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Mission statement

The changing planet

The Intergovernmental Panel on Climate Change (IPCC), a scientific, multinational body, operates under the auspices of the United Nations (UN). It was established in 1988 by two UN organizations, the World Meteorological Organization, and the UN Environment Program. To date, the IPCC has produced five reports in support of the UN Framework Convention on Climate Change (UNFCCC), which functions as the main international treaty on global climate change. The aim of the UNFCCC is to stabilize greenhouse gas concentrations in the atmosphere at a level preventing dangerous anthropogenic, i.e. human-induced, interference with the earth’s natural climatic systems1. Each IPCC report contains a “Summary for Policymakers,” subject to line-by-line approval by the delegates from all participating governmental jurisdictions, a protocol typically involving nearly 120 countries. The IPCC is regarded as the preeminent international authority on climate change, its causes, and its future. For this, in 2007, it was awarded a share of the Nobel Peace Prize2.

The fifth assessment report, published in October 2014, contained the perspectives of 800 authors. Findings included the following: the warming of our planet is unequivocal, and since the 1950s many now-observed changes have been nearly unprecedented in history. High atmospheric concentrations of carbon dioxide, methane, and nitrous oxide have increased to levels more dangerous than at any time in the past 800,000 years3. Human influence on the climate is now an incontrovertible fact and there is a 95-100 per cent probability that human influence was the dominant cause of global warming from 1951-2010. Many ills of the modern world — starvation and poverty, flooding, intense hurricanes, heat waves, droughts, war and disease — are likely to worsen as the world warms further. The word “exacerbates” was used repeatedly in the 2014 assessment report to describe climate change's deleterious effects on poverty, water supplies, the rise and spread of pandemics, and military conflicts, including "water wars"4.

Without effective policies to mitigate the vast changes underway, current scientific projections suggest an increase in global mean temperature by 2100 of 3.7 to 4.8 degrees Celsius, relative to pre-industrial (pre-1850) levels5. The 2014 report anticipated that throughout the 21st century, climate change impacts will exacerbate global desertification, and hence, serve to begin to dangerously erode food supplies, resulting in further magnified socio-economic inequalities and population dislocations. Risks include increased deaths occurring from atmospheric warming, combined with sea level rise and attendant flooding, especially in large metro aggregations situated on coastlines and along other vulnerable bodies of water. With an increase in famine rates, infrastructure failures will mount because of the effects of such extreme weather events, with heat waves becoming commonplace and entire ecosystems becoming subject to extinction6. The collapse of the Antarctica ice sheet is well underway. This, feared by scientists for decades, portends a rise in global sea levels of as much as 10 feet over a period of many decades7. Although this rise in sea levels is predicted to occur gradually, in time it will reach a crisis level. The continued release of greenhouse gases will likely further destabilize the Greenland ice sheet as well8. By 2014, it was clear the rate of upper ocean warming had been grossly underestimated9. The World Bank estimates natural disasters have cost a total of $3.8 trillion since 198010. The consequences of coastal flooding will cost coastal cities $60 billion per year by 2050 if current unchecked urban development patterns are not mitigated. Of these projected loses, $52 billion will have been the result of continued population growth. By 2050 as much as 80 per cent of the world’s population will reside along coastlines11.

How can architecture for health more effectively contribute to the strengthening of existing health care facility networks, particularly in the aftermath of disaster?

In 1973, C.S. (Buzz) Holling defined resilience as "the measure of an engineered system’s ability to rebound to its operational integrity after having sustained sudden shock"12. In the context of rapid response frameworks, system breakdowns occur when the disaster response system is pushed beyond its accepted, normative performance metrics13. Resiliency, at present, is trending strongly across a spectrum of disciplines, including macroeconomics, psychiatry, robotics, the health sciences, military tactical planning, global public health, the engineering disciplines, urban and regional planning, and in disaster mitigation and risk management science14. And yet resiliency and rapid response continue to be dismissed as opaque, strangely underappreciated propositions in architecture15. From a review of published papers in the ecological and social sciences, researchers at the University of Melbourne recently assembled a list of a dozen different definitions for the term resilience, reporting descriptors ranging from coping, recovering, adapting, withstanding, to self-organizing16. Psychiatrists use the term to describe a patient’s mental diversity, flexibility, and rebounding strength relative to one’s personality type, and in the diagnosis of neuropsychological disorders17. Engineers compute an eigenvalue — a mathematical construct for measuring the long-term probability of a particular event occurring or reoccurring, such as when the routine vibration of a bridge might lead to its collapse18. The inequitable distribution of global wealth and the ramifications of climate change call for new conceptualizations in architecture and health design19. Problems must be approached as complex and interconnected rather than as stand-alone phenomena, and interdisciplinary approaches will be essential if response discourses are to be broadened to ensure improved outcomes20. Discourses centered on eco-humanism (of equivalent ecological-humanist concern) in the realm of design and health are needed that are resilient to unforeseen externalities, while centered on the conservation of finite ecological resources, all in sync with the maximization of human health and well-being21.

How can an architecture for health anticipate unexpected externalities? One way for first responsiveness to occur in architecture for health is to perform research that funds advancements in pre-manufactured modular health care clinics. Transportable clinics and trauma centers can be mobilized quickly to disaster sites and can help establish baseline care in communities where conventional hospitals and related facilities have been damaged or destroyed. A resilient architecture for health, not unlike a resilient local economy, employs strategies for self-detecting unwanted intrusions and then minimizing potential damage, even if this requires isolating already-damaged segments within the system or landscape22. The system must be capable of continuously operating in a reduced state, if necessary, in the wake of any breach to its pre-impacted state of well-being. As such, a lightweight, transportable facility can complement the land-based permanent infrastructure in a community. Because architecture is too often surprisingly fragile and rife with indeterminism, a resilient architecture for health, like life itself, must be at once flexible and strong, capable of helping a community and its inhabitants bounce back to some pre-condition of relative functionality.

Mental health

Poorly designed and built hospitals contribute to medical errors and care delivery inefficiencies that can result in injury and even death during hospitalization. This trend has been well documented in recent years and itself is worthy of much additional evidence-based health design research. Physical health has been the predominant focus of prior health design research and the need for continued research on the relationship between the architectural environment and physical health is not disputed here. However, the global mental health landscape at this time is experiencing dislocations caused by climate change, further exacerbated by population growth. In developing regions, where four-fifths of the world’s population reside, non-communicable diseases (NCDs), including diagnosed and undiagnosed mental illnesses, are supplanting traditional (physical) diseases as leading causes of disability and premature death.

NCDs account for seven out of every 10 deaths in developing regions, due in large part to an aging global population combined with declining birth rates. These rates of change, combined with the absolute numbers impacted, are posing serious challenges to existing health care systems, requiring difficult decisions. Worse, many governments lack the basic health status population data so necessary in effective policymaking23. Recent reports in The Lancet and The Lancet Psychiatry have underscored the gravity of the situation, concluding that the growing burden of, for instance, untreated mental disorders in the world’s two most populous countries, China and India, cannot be adequately addressed without fundamental changes to their complete internal health care systems24. In these two countries alone, less than 10 per cent of those who suffer from a mental disorder ever receive treatment, and the burden of disability is higher in these places than in all Western nations combined. These two countries account for one third of the world’s entire population and are in the midst of major economic transformations; they will need to invest significantly beyond than the less than one per cent they currently devote to mental health care services, including architectural infrastructure.

China is especially ill prepared for the coming tsunami of physical and mental health needs as its population ages. In the realm of psychiatric health care alone, the central government started a program in 2004 that to date has trained 10,000 psychiatrists and built hundreds of outpatient community mental health centers, representing an unprecedented national investment in psychiatric care facilities25. In addition, folk medicine is an integral if unorthodox component of the health care system in numerous countries. This includes the work of traditional faith healers, herbalists, and spiritualists who have continued their traditions for centuries. In China, many doctors receive some exposure to the traditional healing arts, i.e. herbal treatments, acupuncture and qigong. In India, similarly, many physicians incorporate yoga and Ayurveda traditions in their practices, with medical doctors and folk healers just now beginning to collaborate. In Nigeria, folk tribal healers are becoming ever so slightly willing to treat conventional diagnoses such as depression and anxiety, although not schizophrenia or bipolar disorder, both traditionally considered demonic afflictions26.

The rate of occurrence of depression, alcohol dependency, and schizophrenia tends to be underestimated by researchers who take account of only a nation’s physical death rate, and not the occurrence of mental disability. The reasons for this bias are many, but one reason has been an overarching focus on infectious disease. This has accounted for historically blasé attitudes toward the study of mental health in many parts of the world. While psychiatric illnesses are responsible for little more than one per cent of all deaths worldwide annually, they account for nearly 11 per cent of the total global disease burden. Adults under the age of 70 in Sub-Saharan Africa now face a higher probability of death from NCDs than adults of the same age in highly developed societies. How are various disease burdens comparatively measured? Research in the past two decades has identified a set of metrics for documenting health outcomes associated with disease and disability. This research has yielded a metric widely known as the Disability-Adjusted Life Year (DALY) index. The DALY index documents the total years of life lost due to premature death as a fraction of the total years lived with a disability. One DALY is therefore the equivalent of one lost year of a healthy life. A premature death is defined as one that occurs before the age a dying person could have been expected to live if she or he were a member of a standardized population with a life expectancy at birth equivalent to that of the world’s longest-surviving population (Japan).

The unseen burdens of psychiatric illness are omnipresent, and epidemiological research on the quantification of the disease burden index has until recently been rather undependable. Of the 10 leading causes of disability worldwide in 1990 — as measured in years lived with a disability — five were psychiatric conditions: unipolar depression, alcohol and substance abuse, bipolar affective disorders (manic depression), schizophrenia, and obsessive-compulsive disorders. Unipolar depression alone is responsible for more than one in every 10 years of life lived with a disability worldwide. Altogether, psychiatric and neurological conditions account for 28 per cent of all years of living with a disease, compared with only 1.4 per cent of all deaths globally. That said, mental illness and other NCDs are rapidly emerging as dominant causes of ill health worldwide and this trend shows no signs of diminishing. In 2010, mental and substance abuse disorders accounted for 183.9 million aggregate DALYs, translating into 7.4 per cent of all DALYs worldwide. Overall, these types of disorders are the fifth leading disease category of all global DALYs, with such disorders having increased by 37.6 per cent in a 20-year period between 1990 and 201028.

Urbanization

The world’s population as of 2015 was 7.3 billion, a number expected to rise to 8.5 billion by the year 2030. By 2050, 66 per cent of the world’s population is expected to live in urbanized regions29. Globalization, combined with advancements made possible by telecommunications, air travel, and the Internet, is fuelling ever-accelerated rates of urbanization. Rural-to-urban migratory shifts are occurring with increased frequency as people relocate to cities in unprecedented numbers. By comparison, in the mid-1970s less than 40 per cent of the world’s population lived in cities30. Back in 1950, 41 of the world’s 100 largest cities were located in less developed countries. By 1995 this statistic had risen to 64 cities and it keeps arcing ever upward31. Rapid urbanization warrants examining the complex interrelationships between the experience of living in increasingly dense environments, and residents’ mental health and physical well-being. In one nationwide study in the Netherlands, hospital admission rates were twice as high, per capita, in the most highly urbanized municipalities compared to the least urbanized municipalities in the country32. In another study, of 4.4 million persons living in Sweden, a similar rural-versus-urban pattern was detected, with higher incidences of psychosis occurring in latter contexts33. This pattern was consistent across all major psychiatric disorders and across children and adolescents, the aged, men and women, married couples, and unmarried individuals34.

Systematic research on mental illness among urban residents dates from the 1950s, stemming from findings showing that first-time hospitalization rates for schizophrenics were higher in the densest inner urban neighborhoods of Chicago, with comparable admission rates gradually decreasing outward towards the urban periphery35. It was concluded that population density per se, combined with an inadequate social and physical infrastructural support network, is associated with a higher level of mental illness, irrespective of ethnicity, race, or income level36. From the 1970s to the present, the work of psychiatric researchers has focused on further understanding this interrelationship. Urbanization in many less developed countries has been linked to increasing occurrences of depression and anxiety disorders, and particularly among low-income women37. Not until 1991 did the World Health Organization (WHO) officially acknowledge this pending crisis, and only then did it define eight specific disease types believed to be deserving of particular attention and policy action in cities38.

Often, the risk factors become magnified as a function of the size and density of the city and its surrounding region. Length of residence in a large city has been linked with higher probabilities for developing psychosis within one’s lifetime39. In a recent meta-analysis of numerous research studies, the occurrence of schizophrenia in dense cities was found to increase by as much as 72 per cent. It is now estimated that urbanization accounts for nearly 30 per cent of all reported cases of schizophrenia in all Western countries40. Effective social and architectural support infrastructures, for their part, are necessary ingredients to help in early detection. By contrast, socially fragmented urban communities — i.e., ones with high social and income inequality, pervasive crime, poor, ineffective neighborhood-level social supports, and a lack of mental health clinics and 24/7 psychiatric/substance addiction hospitals — are in general associated with higher rates of psychosis. Beyond, the concept of urban social capital has become widely known in the past 15 years as a way to perhaps help further explain these patterns and associated outcomes. Urban areas with relatively high levels of intrinsic, or built-in, social capital tend to report lower rates of mental illness and substance addiction, a fact attributed to a higher overall social cohesiveness quotient as defined by the existing physical, i.e. architectural, environmental, and socio-cultural infrastructures41.

While specific definitions of social capital are many, the sociologist Robert Putnam postulates it consists of five key characteristics: (1) Viable community social networks; (2) Active civic engagement and participation; (3) A shared collective sense of civic identity and of belonging to something larger and more important than oneself together with a sense of solidarity and social equality; (4) Reciprocity and effective, normative communication channels to achieve mutual cooperation, a shared sense of purpose and a sense of obligation to help others in need (with the confidence this will be reciprocated if and when needed); and (5) A general presence of trust within the community and its constituent social networks42. This social capital construct has been extended more recently to include the impact of urbanization on individuals’ mental health status, with higher levels of social capital associated with lower rates of mental illness and addictive disorders. Restated, cities with more in-place "bridging" social capital infrastructure (reinforced by therapeutically designed health facilities) will more naturally produce and sustain the types of social safety nets necessary to buffer the psychological impacts of adverse life events43.

Urban communities such as these are also better positioned to more successfully acquire and retain educational, health, and housing resources that are linked with improved mental health outcomes. Urban social capital is relatively easy to destroy but tediously slow to build back up, once lost. It takes so much time to re-establish trust and rebuild social structures that previously fostered positive life outcomes before having been disrupted by adverse impacts such as climate change. Unplanned urban sprawl severely undermines the development of social cohesiveness because it destroys innumerable social (and physical infrastructure) bonds. Predictably, this results in the greater propensity for mental illness because needed social (and architectural) buttresses and buffers erode, becoming dysfunctional. Cities with a low level of social capital tend to be associated with a high level of mistrust and crime, resulting in the need to look out for oneself above all else. This results in a toxicogenic psychological environment of high stress compounded by low mutual social support, and a feeling of disconnection from one’s neighbors, the people one works with, one’s spouse and children, and even friends from years ago44.

The United Nations (UN) asserts that strong, effective government at all levels is the necessary foundation for building positive urban social capital in the world’s burgeoning cities45. A recent UN report concluded that good governance must be genuinely participatory, drawing into the manifold of concern the best interests of all stakeholders in a society, especially the interests of those who have been historically marginalized and economically disadvantaged (and medically underserved). The UN views the prerequisites as consisting of transparency, responsiveness, consensus orientation, and mutual accountability. A prior WHO report on this same subject in 2003 concluded the fundamental premise of urban planning and development at all levels must be to promote and implement policies and built initiatives that serve the best interests of all, in one way or another — because a city and its surrounding region is a human as well as environmental ecosystem, and must be predisposed to provide positive social supports on multiple levels including physical, social, economic, and psychological. To this end, the most recent WHO guide to planning for urban communities has listed among its key health objectives the establishment of policies to encourage and promote social cohesiveness, on the premise that hyper-urbanization itself is often traumatic with far reaching unhealthful consequences46.

Specifically, the WHO has identified several high priorities:

Chronic lack of funding: The political will to invest in mental health services is slowly growing but still remains astonishingly low. Currently, in most low and middle-income countries only about two per cent of the total health care budget is spent on mental health services, and this funding is mainly in the form of support for inpatient psychiatric care. Similarly, while global investment in mental health services did increase ever so slightly between 2007 and 2013, in both relative and in absolute terms, reaching $134 million (U.S.) annually (on average), as a proportion of overall support for health it still remained less than one per cent of total health care expenditures.

A global dementia epidemic: Most recent epidemiological incidence projections indicate the number of people living with dementia and Alzheimer’s Syndrome will continue to expand dramatically, particularly among the oldest population cohort in countries already experiencing these dramatic demographic changes. The enormous cost of this trend for health care systems is just one aspect of the myriad challenges to be faced in the 21st century. Family members are often ill prepared to care for these persons, and unaffordable residential alternatives are a worrisome challenge in many countries.

A lack of reliable mental health statistics: On a country-by-country basis, many governmental agencies do not currently have sophisticated health informatics databases addressing mental illness occurrences within their jurisdiction. This unfortunate situation persists in over two thirds of all nations globally, with these jurisdictions neither able to document their own internal needs nor able to contribute reliable information to the global discourse on the extent of service coverage for even the most severe types of mental disorders within their own geographic borders.

Continued stigmatization: Negative stereotypes and attitudes toward people living with a mental and/or substance addiction abound and remain relatively unchecked. These are compounded by a lack of "objective" markers or diagnostic tests which, often, is interpreted as further evidence these cases are somehow not "real" enough or genuinely physical in a classical sense compared to types of physical ailments and diseases far more easily observable. Comorbidities also remain widely misunderstood in many countries, resulting in further stigmatization of those afflicted compounded by cultural barriers continuing to thwart an individual from seeking out and obtaining proper diagnosis and treatment.

Lack of grassroots advocacy: Stronger patients’ rights advocacy groups, such as those that spawned the social movement on the need to research and understand the HIV/AIDS phenomenon, beginning in the early 1980s, are needed. In the case of HIV/AIDS this effort had a profound positive impact worldwide. Further successes in establishing greater societal awareness and the will to take subsequent political action with regards to mental health and substance addiction awareness will be dependent on any success in mounting a comparable movement. The absence of such a movement unfortunately prevents these conditions from receiving the wide attention they deserve.

Health workforce inadequacies: The human resource challenges remain immense with regard to providing effective diagnosis and care for individuals with mental health and substance addictions, including the aforementioned need to diagnose and treat individuals experiencing comorbidity where a mental health disorder is part of a larger equation. Existing social and financial investments need pronounced expansion to provide additional educational opportunities to train more specialists in social work, medicine, nursing, and psychiatry — and in related health disciplines (including architecture and health design). This will result in more interdisciplinary, team-based models of care, and more therapeutically supportive built environments47. What types of therapeutically supportive built environments can best provide effective mental health care support on a rapidly populating, climate-changed planet?

Salutogenic support

In medicine, a prosthesis — from the ancient Greek prósthesis, meaning "addition, application, or attachment" — is an artificial device that replaces a missing body part that has been severed through trauma, disease, amputation, or having never developed due to a congenital condition. Across the millennia, those with severe physical injuries either succumbed to their wounds or were disposed of on the battlefield in the face of the inevitable. It is believed that amputations were performed in Neolithic times, from evidence in saws fabricated of stone and bone, and in amputated bone stumps found in unearthed skeletal remains. The first recorded instance of amputations and prosthetic replacement devices appears in the book of the Vedas, written in Sanskrit, in India. The oldest of the Vedas is the Rig-Veda, compiled between 3,500 and 1,000 B.C. It records that the leg of a Queen Vispla was amputated in battle. Afterwards, an iron leg was fitted to enable the Queen to walk and return to the battlefield. The ancient Egyptians also fabricated sophisticated prosthetic devices48.

The earliest account of an artificial leg in the West dates from about 300 B.C. based on artifacts unearthed in Capua, Italy, in 1858. This artifact was fabricated of bronze and iron, with a wooden core, worn as a below-knee device49. Hippocrates and Herodotus had written of this practice in the fifth century B.C. in Greece. The latter wrote the tale of Hegesistratus, a Greek diviner who severed his own foot to escape his Spartan captors and then replaced it with a wooden one, in 424 B.C.50 During the Renaissance, prosthetic devices advanced significantly with advancements in iron, steel, copper, and wood fabrication. Functional prosthetics first appeared in the 16th century. The great French surgeon, Ambroise Pare, designed prostheses for both the upper and lower limbs of his patients, using techniques perfected thorough multiple surgical trials. The invention of Morel’s tourniquet in 1674 permitted the control of hemorrhaging, and during the Napoleonic Wars this new procedure was advanced much further.

With the introduction of anesthesia in 1846, followed by Lister’s breakthrough in antisepsis in the late 18th century, further advancements in prosthetics occurred51. The U.S. the Department of Veterans Affairs (DVA) led the way in technological breakthroughs after World War II, and this continued through the Vietnam War and up to the present52. Currently, robotic, high-tech prosthetics such as artificial limbs, smart wheelchairs, person-building interfaces in furnishings, smart walls and stairs, and sensing lighting systems are fabricated in lightweight carbon fibre and extremely durable plastics, including the use of 3D printing technology. Besides being light and flexible, these products are being revolutionized by microprocessors that enable the individual to more resiliently bounce back to an acceptable "new normal."

A living/breathing building for health care, when considered as a bionic prosthetic device and not as a mere physical (brick and mortar) artifact, shares fundamental qualities with advanced, high-tech prosthetic devices worn by humans. Both must be modular, portable, malleable, and adaptable to change in the face of sudden — and at times, blunt — impacts, and capable of returning to a pre-impacted (or approximated) state of functionality in the face of the disruptive event. Both "siting" contexts (whether in reference to a person or an installation site) must maintain reasonable functionality even if one or more modular components (other limbs, or sections/parts of a portable modular structure) become disrupted or go offline for any reason. Both must maintain fluidity with the cap ability of interdependently functioning within a larger system (the human body, or the building as defined by its site context), and finally, both must remain operational in at times stressful, adverse climate conditions. The WHO defines universal access to sickness prevention and primary health care as a basic human right53. In 2012, in the U.S. alone, according to the Health Resources and Services Administration (HRSA), there were an estimated 4,143 medically underserved communities throughout the U.S. In addition, 5,830 communities were classified, geographically, as medical health professional shortage areas, and this included more than 34 million undeserved individuals nationally. HRSA defines these areas as experiencing a shortage of primary medical care providers, and they may be rural, suburban, or urban communities. Architects, landscape architects, engineers, and allied design specialists need new ways to learn from resilient people and especially from the victims of disaster because the status quo is no longer satisfactory.

Aaron Antonovsky, a medical sociologist, has defined salutogenics as the confluence of positive factors supportive of human health and well-being, in direct opposition to prevailing negative definitions of sickness and disease (pathogenesis)54. The term salutogenesis is derived from the Latin salus = health, and the Greek genesis = origin. He asserted humans need and require cognitively supportive, meaningful environments in order to cope with highly stressful conditions, conditions that threaten to destroy our sense of place attachment. Antonovsky defined cognitive coherence as a three-part phenomenon: comprehensibility, the belief that things occur in an orderly and relatively predictable manner as humans are capable of reasonably predicting future events; manageability, the belief that humans possess the ability to successfully problem-solve and any given situation is therefore potentially solvable and within one’s range of control; and life-meaning, a belief that life is intrinsically interesting and a source of fascination, and is therefore worth living, with each human having a unique purpose in life and therefore it is worth knowing and caring about what one’s eventual life outcome will be. Jan A. Golembiewski has examined the importance of salutogenic theory and human well-being in relation to the planning, design and daily management of architectural treatment facilities55. He found that in the face of adversity, individuals with mental illness, for instance, are reluctant to leave that which is familiar and known. Places where we live, work, and accumulate our lifetime of memories and experiences are psychologically enduring. Unsupportive environments, by contrast, challenge our mental health and physical competencies on multiple levels. Comprehensibility is the way a disturbed individual attempts to interpret (or misunderstand) these situations. In a health facility context, this entails being capable of comprehending and to some extent accepting the meaning of why he or she is there, how to negotiate the facility and its interpreted meanings and how to function there on a daily basis. This transcends meaning, or manageability, alone, because coping with stress, uncertainty, and adversity is stressful itself while in treatment. Ideally, the patient becomes empowered to be instrumentally in control of both oneself and in control of one’s physical architectural surroundings56. A therapeutically supportive architecture for health must aspire to achieve this and much more, to proactively respond to the challenges of a rapidly changing world.

Stephen Verderber *
Toronto
November 2019

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References

1. UNFCCC (2014) First steps to a safer future: Introducing the United Nations Framework on Climate Change. Geneva, Switzerland: United Nations Framework Convention on Climate Change. Online.

2. Environment Canada (2013) Contribution to Intergovernmental Panel on Climate Change. Ottawa: Environment Canada. Online.

3. Intergovernmental Panel on Climate Change (2014) Fifth Assessment Report: Climate Change 2014—Impacts, Adaptation, and Vulnerability. Cambridge, U.K.: Cambridge University Press. Online.

4. Associated Press (2013) "Global warming likely to make bad things worse, scientists forecast," The Times-Picayune. 3 November. Online.

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6. Suzuki, David (2014) "Fighting climate change offers many health benefits," Straight.com. 9 September. Online. Also see Gillis, Justin (2014) "Scientists trace extreme heat in Australia to climate change," The New York Times, 29 September. Online.

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12. Holling, C.S. (1973) "Resilience and stability of ecological systems," Annual Review of Ecology and Systematics, 4(2): 1-23.

13. Walker, Brian and Salt, David (2012) Resilience Practice: Building Capacity to Absorb Disturbance and Maintain Function. Washington, D.C.: Island Press.

14. Lee, James H. (2012) Resilience and the Future of Everyday Life. Shelbyville, KY: Wasteland Press.

15. Ibid.: 26.

16. Downes, Barbara J., Miller, Fiona, Barnett, Jon, Glaister, Alena and Ellemor, Heidi (2013) "How do we know about resilience? an analysis of empirical research on resilience, and implications for interdisciplinary praxis," Environmental Research Letters, 8(2): 1-8.

17. Walker and Salt (2012): 42.

18. Fisher, Thomas (2012) Designing to Avoid Disaster: The Nature of Fracture-Critical Design. London: Routledge.

19. Wilson, George A. (2012) Community Resilience and Environmental Transitions. London: Routledge.

20. Carlson, Scott (2013) "After catastrophe," 6 May. The Chronicle of Higher Education. Online.

21. Fiksel, Joseph (2006) "Sustainability and resilience: towards a systems approach," Sustainability: Science, Practice & Policy. 2(2): 14-21. Online.

22. Lewis, Michael and Conaty, Patrick (2012) The Resilience Imperative: Cooperative Transitions to a Steady-state Economy. Gabriola Island, British Columbia: New Society Publishers.

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24. Anon (2016) "China, India face huge mental health burden: studies," The Japan Times, 18 May. Online.

25. Carey, Benedict (2016) "China and India burdened by untreated mental disorders," The New York Times, 18 May. Online.

26. Ibid.: 12.

27. Sugar, J.A., A. Kleinman and L. Eisenberg (1992) "Psychiatric morbidity in developing countries and American psychiatry’s role in international health," Hospital Community Psychiatry, 43(4): 355-360.

28. Whiteford, Harvey A., Louisa Degenhardt, Jürgen Rehm, Amando J. Baxter, Alize J. Ferrari, Holly E. Erkstine, Fiona J. Charlson, Rosanna E. Norman, Abraham D. Flaxman, Nicole Johns, Roy Burstein, Christopher J.L. Murray and Theo Vos (2013) "Global burden of disease attributable to mental and substance abuse disorders: findings from the Global Burden of Disease Study 2010," The Lancet, 382(3): 1575-1586.

29. United Nations (2016) World Population Prospects. New York: United Nations. Online.

30. McKenzie, Kwame (2008) "Urbanization, social capital and mental health," Global Social Policy, 8(3): 359-377.

31. World Bank (2000) World Development Report 1999-2000. Washington, D.C.: World Bank.

32. Peen, Jaap and Jack Dekkar (1997) "Admission rates for schizophrenia in The Netherlands: an urban/rural comparison," Acta Psychiatry Scandinavia, 96(4): 301-305.

33. Sundquist, K. and Frank K. Sundquist (2004) "Urbanization and incidence of psychosis and depression: follow-up study of 4.4 million women and men in Sweden," British Journal of Psychiatry, 184(2): 293-298.

34. Dekkar, Jack, Jaap Peen, Jurrijn, Filip Smit and Robert Schoevers (2008) "Psychiatric disorders and urbanization in Germany," BMC Public Health, 8(17): 1186-1195. Also Kalpana Srivastava (2009) "Urbanization and mental health," Industrial Psychiatry, 18(2): 75-77.

35. McKenzie (2008): 361.

36. Ibid.: 362.

37. Harpham, Trudy (1994) "Urbanization and mental health in developing countries: a research role for social scientists, public health professionals and social psychiatrists," Social Science and Medicine, 39(2): 233-245.

38. World Health Organization (1991) Health Trends and Emerging Issues in the 1990s and the Twenty-First Century. Monitoring, Evaluation and Projection Methodology Unit. Geneva: World Health Organization.

39. Boydell, J. and Kuame McKenzie (2008) "Society, place and space," in C. Morgan, McKenzie, K, and Fearon, P. (eds.) Society and Psychosis. London and Philadelphia: Cambridge University Press: 77-95. Also see Halpern, David (1995) Mental Health and the Built Environment: More Than Bricks and Mortar? London: Routledge.

40. Krabbendam, L. and J. Van Os (2005) "Schizophrenia and urbanicity: a major environmental influence—conditional on genetic risk," Schizophrenia Bulletin, 31(4): 795-799.

41. McKenzie (2008): 364.

42. Putnam, Robert (2001) Bowling Alone: The Collapse and Revival of American Community. New York: Simon & Schuster.

43. McKenzie: 366.

44. Ibid.: 372.

45. United Nations Centre for Human Settlement (2001) Cities in a Globalizing World. London: Earthscan.

46. McKenzie: 373. Also Barton, H and C. Tsourou (2000) Healthy Urban Planning: A WHO Guide to Planning for People. London: E&FN Spon. Also see Barton, H. C. Micham and C. Tsourou (2003) Healthy Urban Planning in Practice: The Experience of European Cities. London: WHO.

47. SAMHSA (2015) Key Substance Abuse and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health. Washington, D.C.: U.S. Department of Health and Human Services. Online.

48. Vanderwerker, Earl E. (1976) "A brief review of the history of amputations and prostheses," The Association of Children’s Prosthetic-Orthotic Clinics, 15(5): 15-16. In many societies, even up to the present, the infant is disposed of to hide the evidence. Others with deformities are warehoused in state-run institutions for the developmentally disabled. Also see Katoch, Roger and Rajagopalan, Samuel (2010) "Warfare injuries: history, triage, transport and field hospital setup in the armed forces," MJAFI, 66(44): 304-308.

49. Norton, Kim M. (2007) "A brief history of prosthetics," inMotion, 17(7): 11-13. Online.

50. Herodotus, as Translated by Grene, David (1987) The History. Chicago: University of Chicago Press. Pliny the Elder (23-79A.D.) wrote of a General in the Second Punic War (218-210B.C.) who had a right arm amputated. Celsius, who lived at the time of the birth of Christ, described amputation as a necessary procedure to combat gangrene.

51. Wilson, Brian B. (1972) "The modern history of amputation surgery and artificial limbs," Orthopedic Clinicians of North America, 3(7): 267-285.

52. Ibid.: 31.

53. World Health Organization (2012) United States of America: Health Profile, World Health Organization, Geneva, Switzerland. Online.

54. Antonovsky, Aaron (1979) Health, Stress and Coping, San Francisco: Jossey-Bass Publishers.

55. Golembiewski, Jan A. (2010): 100-117.

56. Golembiewski, Jan A. (2012) "Psychiatric design: using a salutogenic model for the development and management of mental health facilities," World Health Design, 5(2): 74-79.

*Portions of this essay are excerpted from Innovations in Transportable Healthcare Architecture (2016), and Innovations in Behavioural Health Architecture (2018). Both books authored by S. Verderber and published by Routledge, London, UK (reproduced with permission).