When doctors in Wuhan, China (where COVID-19 first emerged) studied 138 early cases, they concluded that 41 per cent of patients had most likely contracted the disease in the hospital. 
This is not a new dilemma. The problem of containing infectious disease in the very setting that is supposed to treat sick people is as old as hospital design itself.
When the statutes of the hospital of St John Bridgewater were developed in 1219, Bishop Joscelin of Bath reportedly commented: “No lepers, lunatics or persons having the following sickness or other contagious diseases are to be admitted to the house, and if any such be admitted by mistake, they are to be expelled as soon as possible”. 
Fortunately, people who have contracted infectious illnesses such as COVID-19 are no longer unceremoniously thrown out of hospitals, but most modern healthcare facilities still have a long way to go before they will be able to handle pandemics more effectively.
A medieval approach
For hundreds of years humans have looked to physical space to treat and cure sickness and almost every big pandemic has led to changes in city planning, infrastructure, architecture and interiors. One example is London’s famous mid-19th century sanitation system that was developed in response to the cholera outbreak of the time.
Social distancing might be a new concept to many of us, but it is a tried and tested solution to curb the spread of diseases for which there is no cure.
In the Middle Ages, sufferers of leprosy were segregated and detained in institutions. In 1916, a polio outbreak in New York led to the closing of movie theatres, cancelling of meetings, banning of public gatherings, and restrictions on accessing amusement parks, swimming pools and beaches – measures that sound all too familiar now.
There may have been huge advances in healthcare since the Middle Ages, but when faced with an unknown infectious disease for which there is no known cure, we resort to this medieval approach of first changing the physical environment. The goal is simple: to separate the sick from the unaffected and thereby, stop the spread of the disease.
Implementing social distancing in big hospitals, where thousands of patients present each day with a range of illnesses and injuries, is naturally not as simple as the goal, but it remains the first strategy to stem the spread of infectious disease.
SARS and Singapore hospitals
Public hospitals in Singapore got a wake-up call in 2003 when the viral cousin of COVID-19, SARS, spread across 29 countries, including the island city-state. Singapore was one of the hardest hit by the SARS epidemic. Of 238 cases, 33 people lost their lives – 40% were healthcare workers.
Local authorities then realised that it would be only a matter of time before the “next big one”, and history would prove them right.
Various strategies were developed under Singapore’s Disease Outbreak Response System Condition (DORSCON), a national prevention and response plan and framework that includes the redesign of hospitals.
According to a blog by global design firm Stantec, some of the design strategies that were employed at the Singapore General Hospital (SGH) in terms of DORSCON and the SARS outbreak include:
- Facilities have to prepare for “surge scenarios” – a sudden and huge influx of patients. Block H9A Emergency Department at SGH (scheduled to open in 2023) has been designed to manage a big “national health crisis”, whether it is a mass-casualty incident, pandemic, or mass exposure to hazardous materials requiring a hospital decontamination station.
- In a surge situation, patient flows at SGH are segmented before they enter emergency departments, splitting patients with symptoms (such as fever) from those without. This concept has already been implemented by Sweden’s Skane University Hospital, which opened an infectious-disease building in 2010. In the emergency department and the outpatient clinic, doors lead directly from the outdoors to several private isolation rooms so patients suspected of being contagious can bypass the communal waiting areas. 
- Compartmentalised design is also being implemented at the SGH, allowing the facility to isolate and lockdown the emergency department by identified zones when required, preventing the spread of high-risk infectious diseases to the entire emergency area.
Read more about the changes that have evolved at SGH to face emerging infectious situations in this research paper.
Singapore has not been spared an outbreak of COVID-19, but the country has been praised by an infectious disease expert working with the World Health Organisation.
“All the things that Singapore has in place, any country under lockdown will need to do these, or implement these during lockdown, so that they can be safe afterwards,” said Dale Fisher, chair of the World Health Organization (WHO) Global Outbreak Alert and Response Network. 
We are still in the early stages of the conversation of how COVID-19 will influence hospital design, but as we learn more about dealing with health crises of a global scale, designers and architects will likely add surge control and many other infection control strategies to this field.
And it is a complex field already.
Apart from strategies to stop a pandemic, healthcare architects and designers have to consider acoustics, healing architecture, fire protection, strength of construction material, hygiene, building health, environmental protection, energy saving, durability and utilisation rate, to name but a few.
The research paper mentioned above suggests that a hospital building should always be a work in progress: “Even after initial completion of the hospital building, systematic data collection and feedback for addition, modification and upgrading of the infrastructure must be ongoing. Built-in flexibility in design is becoming more crucial, mainly because technology is quickly obsolete and patient population is constantly changing.”
The healthcare designer and futurist Dr Leland Kaiser would have agreed. He once said: “The hospital is a human invention and, as such, can be reinvented at any time.”
It is quite possible that the COVID-19 crisis will force us to completely rethink how we design for the healthcare sector.
- Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China
- Hospital design for better infection control
- Pandemics spread in hospitals. Changes in design and protocol can save lives
- Countries in lockdown should do what Singapore has done, says coronavirus expert