Completed in 1932, Alvar Aalto’s Paimio tuberculosis sanatorium’s programme was revolutionary

Tuberculosis may have blighted mankind since at least as far back as antiquity, but when the AR devoted its September 1933 issue to a survey of recent tuberculosis sanatoriums, it turned its attention to a building type with a far shorter history. The sequestering of TB patients only became common practice after the disease was discovered to be contagious in the 1880s. An argument for the rehabilitative effects of exposure to light and air lent weight to the subsequent construction of residential facilities in often very remote locations. However, the success of such treatment was at best partial: to enter a sanatorium in the first decades of the last century was to face a 50 per cent likelihood of death within five years. It was only with the discovery of the antibiotic streptomycin in 1946 that patients finally began to have access to an effective cure.

Among the buildings featured in the AR’s survey, none was of more pioneering design than the facility that Alvar Aalto had completed earlier that year at Paimio in Finland. In an article that concludes by lauding the project as ‘the most revolutionary hospital building erected within the last decade’, P Morton Shand catalogued its numerous technical innovations, from its optimisation of daylight, heating and ventilation to its structuring of the patient’s social interactions over the course of what would frequently prove a stay of years. This was a work of architecture that addressed its programme with quasi-scientific rigour. As Aalto himself would later explain: ‘The main purpose of the building is to function as a medical instrument.’

Kauria colour chart credit artist eino kauria. Source: Eino Kauria

Having secured independence from Russia in 1917, the Finns rapidly committed themselves to a nationwide programme of public construction in which regional hospitals, old people’s homes, mental health facilities and tuberculosis sanatoriums featured prominently. By the early 1930s, the country had established 3,700 patient places for victims of lung tuberculosis. Such projects not only represented the building blocks of an aspiring welfare state but provided one of the central means by which Finland consolidated its nascent national identity. A progressively minded young architect could hardly wish for a more sympathetic environment in which to embark on a career.

Aalto was 30 when he won the competition for the Paimio Sanatorium in 1928, by which point he had already secured a substantial reputation within Finland through projects such as the Workers’ Club (1924-25) and Defence Corps Building (1926-29) both in his home city, Jyväskylä. These employed a spare Neoclassical style that related closely to work being built by Asplund and Lewerentz across the border in Sweden. However, with the design for the concrete-framed and strip-windowed headquarters of the Turun Sanomat newspaper in Turku (1927-29), Aalto had recently undergone a Damascene conversion to the Functionalist cause. At Paimio that newfound enthusiasm came into full bloom.

Paimio sanatorium2 Source: Leon Liao

Lying a two-hour drive west of Helsinki, Paimio is a rural municipality that coalesces into something that might plausibly be termed a town only for the extent of a couple of intersecting streets. The sanatorium stands a judicious three kilometres away, set within a vast encompassing swathe of forest. Original photographs show distant views of the main seven-storey building towering above the treetops like a fairy-tale castle. However, the forest has long since grown to approximate the level of its uppermost storey, effectively concealing the facility from visitors until they have progressed part-way up its drive.

Aalto remained closely involved with additions and alterations to the building throughout his life, the most substantial being an operating theatre built in 1955. However, in the 1970s the building was converted for use as a general hospital and was earlier this year taken over by an agency that helps children dealing with mental and physical handicaps. Both functions necessitated changes to the fabric but, thanks to the close monitoring of Finland’s National Board of Antiquities, its external aspect and communal interiors survive in remarkably good condition.

Paimio sanatorium interior 2 Source: Leon Liao

Approaching through the woods, the visitor passes between brief outlying terraces housing the sanatorium’s senior staff, planned so as to present no view of the main building. They share this very much larger structure’s expression in white-painted concrete offset by brightly coloured metalwork and projecting blinds – a treatment that contrasts dramatically with the trees. The main building stands on the highest part of the 40-hectare site and takes the form of a free composition of linked wings. Each serves a distinct function – an arrangement intended to minimise the spread of disease and disruption to patients – and is distinguished formally by its unique orientation, massing and fenestration. We first encounter three of these blocks ranged around an entrance forecourt, its deep and splaying plan seemingly offering a gesture of embrace.

To one side lies the wing housing the wards and to the other that containing communal facilities including a dining room, library, recreation space and workshops. At the far end they intersect with the central block in which the foyer and principal means of vertical circulation are contained. Paimio is a transitional building in its architect’s development, offering little indication of the romantic form-language of Aalto’s mature style. However, the curvaceous, black-painted concrete canopy that cantilevers over the entrance door offers one significant departure from the orthogonal. The associations evoked by such forms in Aalto’s later work are to elements of the natural world but, if an anecdote relayed to me by the building’s current caretaker is to be believed, the canopy’s form derives from a more ghoulish source: a bisected blackened lung.

The seven-storey wing housing the wards is by some distance the largest. Accommodating 145 rooms ranged along single-loaded corridors, it is startlingly tall, long and skinny. The wing is oriented so that each room enjoys a south-south-west orientation through a deep-set window that extends from floor to ceiling. A central line of concrete columns allows the corridors to be cantilevered: a feat registered by the continuous strip window that extends along each one. The wing’s more prominent end is given particularly dynamic expression through the provision of a glazed lift – the first use of such technology in Finland – bracketed by cantilevered balconies to either side. These represent the most intimately scaled of a range of terraces to which patients had access. The average temperature in Paimio drops to -6°C in February but fur-lined sleeping bags were on hand to encourage use of external areas across the year.

The wing’s other end terminates in a stack of dramatically cantilevered decks – originally open but now glazed in – that cranks in plan to face due south. Here, weaker and more infectious patients spent part of the day lying in groups of 24. Those in better condition gathered – as many as 120 at a time – on the wing’s full-length roof terrace. Stripped of its soundtrack of coughing and the unfortunate fibrous cement canopy that was added later to fend off snow, the space encountered in the original photographs conjures an ocean-liner glamour. It was even equipped with a flag that was raised whenever a patient returned to health. Aalto developed the building’s unusual variety of communal spaces – both internal and external – with the aim of offering patients control over their relationship to the wider community. ‘The idea, it is perhaps hardly necessary to add, was an architect’s not a doctor’s,’ he observed in the Morton Shand article. ‘The doctors fail to understand it. Whether the medical profession will end by adopting it remains to be seen.’

200px paimio hospital 1978

The building is a true gesamtkunstwerk, every detail from door handles to lighting to furniture having been custom-developed by Aalto, working in close collaboration with his wife, Aino. The most celebrated product of that endeavour remains the Paimio chair which was designed for use in the recreation area and which is still produced by Artek. Inspired by Marcel Breuer’s tubular steel Wassily Chair of 1927-28, Aalto’s version represented an innovative demonstration of the possibilities of bent plywood technology. Although famed for its dramatic sculptural form, the design was closely wedded to considerations of comfort. The choice of plywood was led by the material’s natural feel and insulating qualities, while the angle of the seat and back were intended to aid patients’ breathing.

The most ample evidence of Aalto’s attention to detail was to be found in the wards of which only one now survives in its original form. Their principal innovation was their scale: accommodating two patients each, they were significantly smaller than the norm. However, the architect’s care for the wellbeing of patients was imprinted on every last component of these intensely conceived interiors. In response to Finland’s punishing winters, each window was designed as an assembly of two individually framed layers separated by a wide gap. The offsetting of their opening casements enabled ventilation to be introduced without generating a draft. The beams picking up the edge of the slab were inverted, allowing the windows to be set flush to the ceiling and thus to provide the deepest possible penetration of daylight. At the base of the window, the floor was curved up to cover the resultant upstand – a detail that provided better light reflection and facilitated cleaning. Despite the presence of the upstand and that of a built-in plywood desk, the window extended sufficiently low so as to allow patients a view of the surrounding grounds while lying in bed. Now sadly erased, the lawn outside featured a serpentine path that wove repeatedly back and forth with fountains located at the turning points.

50 950 Source: Alvar Aalto Museum

The window’s asymmetrical siting within the wall was also carefully considered to maximise morning light while restricting the admission of the sun during Finland’s long summer evenings. Heating panels were ceiling-mounted so as to be located at the greatest possible distance from the recumbent patients while one wall was lined in a soft insulation material to enhance the room’s acoustic. Wall-mounted sinks – paired to either side of a conical glass sputum cup – were also designed with noise in mind: their rear surface was set at a 30 degree angle, chosen after tests established that it resulted in the quietest performance. The walls and the equipment that they supported were white but the floor, ceiling and other furnishings offered a heightened restatement of the colours of the surrounding landscape. Pistachio green extended across the ceiling save for a half-circle of white that provided a reflective halo for the room’s principal light. Wall-mounted behind the patient’s heads, it was located so as to impact minimally on their field of vision.

‘The sanatorium cannot easily be characterised as an embodiment of the CIAM doctrine of pared-down standardisation’

In 1929, the year in which the construction of the sanatorium commenced, Aalto became a member of CIAM and attended the group’s second meeting at Frankfurt-am-Main. The appropriate standards of the Existenzminimum was the theme under discussion but Aalto proved one of a small number of vocal dissenters from such a reductionist mindset. Throughout the Paimio building we find evidence of his embrace of the possibilities of industrialised mass production and his belief in a design methodology rooted in scientific analysis. Yet for all that it deserves to be viewed as one of the principal monuments of the International Style, the sanatorium cannot easily be characterised as an embodiment of the CIAM doctrine of pared-down standardisation.

Paimio sanatorium 2 credit gustaf welin alvar aalto museum Source: Gustaf Welin / Alvar Aalto Museum

Paimio sanatorium 1 credit gustaf welin alvar aalto museum Source: Gustaf Welin / Alvar Aalto Museum

The similarly heliotropic arrangement of white concrete volumes that constitutes Duiker and Bijvoet’s 1925-31 Zonnestraal Sanatorium at Hilversum has often been claimed as an influence on Aalto’s building but, as Edward R Ford argues in The Details of Modern Architecture Volume 2: 1928 to 1988, the relationship between structure and programme adopted at Paimio is markedly dissimilar from that of the earlier project. Zonnestraal’s structural frame follows an insistent and unwavering module dictated by an ambition to minimise the use of concrete while near continuous bands of glazing maintain a reading of the frame at all times, admitting no ambiguity about its autonomy from the non-loadbearing envelope. At Paimio, each wing employs a different structural grid in response to programmatic needs, while a far from continuous glazing treatment sacrifices structural purity in the interests of enabling each space to be oriented to a particular aspect. Aalto argued that the varying orientation of the communal spaces was especially valuable as it ensured that patients could find a place to rest either in or out of the sun at all times of the day. The architect was even content to abandon the structural logic governing each wing when the occasion demanded: the library in the communal block is hung from steel posts to allow the dining room that extends beneath it to remain column-free. The contrast between Paimio’s long-established adaptability and the near terminal dereliction into which Zonnestraal fell within 30 years of its construction speaks volumes about the relative robustness of the two approaches.

In his 1955 essay ‘Art and Technology’, Aalto relates the story of his participation as a juror at a student’s presentation of the design for a children’s hospital. The hapless speaker spent a considerable length of time detailing the myriad technical criteria that had informed his project. Aalto then responded: ‘You have apparently still left out at least one possibility. How would the building and the sick children in it function if a wild lion jumped in through one of the windows? Would the dimensions be suitable in such a case?’

As of yet, the Paimio Sanatorium has been spared trial by marauding predators but 81 years of varied use have proved it to be much more than a precise answer to a set of reductive functional requirements. Privileging the individual’s experience in his approach to every design problem, Aalto produced a building that transcended the brittle architectural doctrines of its period and which continues to radiate a profound sense of human empathy today.