The Lived Experience of Hospital Design: A Case Study on Internationalism

Sara Honarmand Ebrahimi, Goethe Universität Frankfurt am Main[1]

A novel aim of historians of internationalism concerned with lived experience is to break down the ‘apparent homogeneity of international organisations and national policies’, unsettling in turn assumptions about the category of ‘international’, about relevant sites of internationalism and even about the relationship between nationalism and internationalism. Far from arguing that anyone is an internationalist or that anywhere can be a site of internationalism, this historiographical shift seeks to collapse the boundaries of what is considered as recognisably international. While it employs a bottom-up, or a ‘history in-between’,[2] approach, and pays particular attention to the intersections of race, class, gender, nation, citizenship and empire, it does not treat local or personal experiences in isolation from the interests of international organisations. In its focus on the encounter between the local, the personal and the international, what might it erase?[3]

This entry takes the form of a critical approach to the outline of a case study concerning the establishment of the Aga Khan University Hospital in Karachi, Pakistan in 1972-73. The Boston-based Payette Associates and Mozhan Khadem, an Iranian architect, designed the Hospital, consisting of a 721-bed hospital with ancillary facilities as well as a school of nursing and a medical college.

Aga Khan University Hospital campus, Karachi. The buildings are oriented ‘inward’ and form ‘an organic whole’. Photograph by Gary Otte. Archnet, Creative Commons Attribution Non-commercial 4.0 International (CC BY-NC 4.0) license.

The hospital was commissioned by the Aga Khan IV, the 49th hereditary Imam of the global Ismaili community and the founder of the Ismaili international organisation, the Aga Khan Development Network (AKDN). Aga Khan’s requirement was that the ‘idiom should reflect the spirit of Islam’.[4] He and his brother, Prince Amyn, also played a significant role in ‘conceptualization and design development’.[5] On their instruction, a design team studied ‘Islamic hospitals’ and undertook an on-site study of ‘historic and vernacular architecture in Spain, North Africa, the Middle East, and Pakistan’.[6] They came to a design solution after much study, many discussions and several revisions. Thomas Payette called their trip to Spain, North Africa, the Middle East and Pakistan a ‘process of discovery’, stating that the ‘results freed us from some of our assumptions about what a hospital ought to be’.[7]

This statement turns the attention from Aga Khan and his brother to the design team and their on-site study and the ‘practical effects and consequences’ of the trip. It suggests an analysis of the design team members’ family backgrounds, training, geopolitical positioning as North American and Iranian architects, beliefs regarding Islamic architecture, and so on.[8] Payette and Khadem were not merely architects employed by the Aga Khan; they were also agents whose experiences on the ground during the study trip fed back into international policies of the AKDN. This in return means that the visit to Spain, North Africa, the Middle East, and Pakistan was not purely a study trip but a set of physical spaces of encounter and negotiation, forming and informing experiences.[9]

A preliminary analysis might tell us something about how it felt for Thomas Payette and Mozhan Khadem to undertake the study trip, but it would not tell us much about how it felt for them to be there as a ‘team’. Published documents and articles from the 1970s and 1980s that discussed the design of the hospital consistently referred to these individuals collectively as the ‘design team’. While the design project and the study trip might have created ‘a common framework of experience’, this common experience did not necessarily equate to a shared experience.[10] Besides Payette and Khadem, the design team included Garr Campbell of Sasaki Associates as the landscape architect.[11] Each member would have experienced the design project and study trip from a ‘partial point of view’ and their encounter would have held ‘considerable potential for misunderstandings and failures of communication’.[12] It might be possible to recognise similarities in the experiences of Payette, Khadem and Campbell that bound them together as a group and helped them to discuss, negotiate and propose a design solution. From here, I might be able to proceed to conceptualise their contributions as agents of internationalism. But what about Bhamani Associates in Pakistan and ‘traditional’ tile makers based in Hala, near Karachi, who were also involved, and whose voices are not recorded in the archive?[13]

Their absence gives me pause. The concept of internationalism might not have been available to Bhamani Associates or traditional tile makers. Examining their experiences through this category would be ‘either simply erroneous or, worse, an implicit endorsement of those exclusionary concepts and politics that underwrites them’.[14] Even if the concept of internationalism had been available to them, it might have been set aside, or relegated to the background, in the interaction among the design team members.[15] There might have even been different collectives at work: one formed by Payette, Khadem, and Campbell during their study trip and the other formed by them and Bhamani Associates and traditional tile makes in Karachi. Internationalism might have been at the forefront of discussions in one but not the other.

I am not suggesting that an examination of lived experience should ‘drag us back necessarily to a deep, local history’.[16] Rather, I argue that a focus on explaining experiences should fundamentally change the questions historians of internationalism should ask. Besides asking who the agent of internationalism was, they should ask whether such a concept was what brought a group’s members together. They should search for the moments when historical actors themselves started to use this concept or used different terms to express it,[17] while being open to the possibility that a group’s members might have been brought together by something else entirely. Instead of asking where the site of internationalism was, they should ask what might be obscured, silenced or misrepresented by labelling a certain place as a site of internationalism.

Probing the lived experience of internationalism in the design of the Aga Khan University Hospital is to shift the attention from Aga Khan IV and his brother to the design team’s members and their study trip and then complicate what it means to attend to this collective. Any analysis of the collective experience of the design team’s members as a group must also account for the experience of those whose voices are silenced or ignored that nonetheless lie within, and are perhaps erased by, this collective experience. To understand the situated experience of individual team members while examining how the design project brought them together (which included agreement, similarities as well as uncertainties, miscommunication and so on), it may be necessary to cast aside internationalism as the idiom or framework of lived experience. There are clear benefits to the analytical category of internationalism but also critical limitations. To recover the lived experience of internationalism requires a commitment to searching for moments when the experiences of silenced individuals might have been framed by or formed through this concept, while being open to the possibility that collective experience may have overridden, hidden or invalidated it.


[1] Research for this article is funded by a Humboldt Research Fellowship. I have been enabled by the inspiring works of researchers at HEX for many years. For this, I express my gratitude to them.

[2] Ana Antic, Johanna Conterio and Dora Vargha, ‘Conclusion: Beyond Liberal Internationalism’, Contemporary European History, 25 (2016), 361

[3] Jessica Reinisch and David Brydan, eds, Internationalists in European History: Rethinking the Twentieth Century (London: Bloomsbury, 2021); Patricia Owens and Katharina Rietzler, eds, Women’s International Thought: A New History (Cambridge: Cambridge University Press, 2021); Jonah Sreinberg, Ismai’ili Modern: Globalization and Identity in a Muslim Community (Chapel Hill: The University of North Carolina Press, 2011), chapters 4 and 5.

[4] ‘The Physical Structure of Islam’, a speech delivered to the Asia Society in New York, 25 September 1979.

[5] Mildred Schmertz, ‘Indigenous High-tech’, Architectural Record (1987), 136.

[6] Schmertz, ‘Indigenous High-tech’, 136.

[7] Thomas M. Payette, ‘Designing the Aga Khan Medical Complex’, Theories and Principles of Design in the Architecture of Islamic Societies, ed. Margaret Bentley Sevcenko (Cambridge: Aga Khan Program for Islamic Architecture, 1988), 162.

[8] Jessica Reinisch, ‘Introduction: Agents of Internationalism’, Contemporary European History, 25 (2016), 202; Glenda Sluga, ‘From F. Melian Stawell to E. Greene Balch: international and internationalist thinking at the gender margins, 1919-1947’, Women’s International Thought: A New History, eds, Patricia Owens and Katharina Rietzler (Cambridge: Cambridge University Press, 2021).

[9] Kristin Roth-Ey, ed., Global Socialism and the Gritty Politics of The Particular: Second-Third World Spaces in the Cold War (London: Bloomsbury, 2023).

[10] Rob Boddice and Bettina Hitzer, ‘Emotion and experience in the history of medicine: Elaborating a theory and seeking a method’, Feeling Dis-Ease in Modern History: Experiencing Medicine and Illness, eds Rob Boddice and Bettina Hitzer (London: Bloomsbury, 2022), 7-9.

[11] Schmertz, ‘Indigenous High-tech’, 148.

[12] Benno Gammerl, Philipp Nielsen and Margrit Pernau, ‘Introduction: Encountering Feelings – Feeling Encounters,’ Encounters with Emotions: Negotiating Cultural Difference since Early Modernity, eds Benno Gammerl, Philipp Nielsen and Margrit Pernau (New York and Oxford: Berghahn, 2019), 4.

[13] Ian Latham, ‘Convincing design of Third World University’, Building Design (15 November 1985), 10.

[14] Rob Boddice and Mark Smith, Emotion, Sense, Experience (Cambridge: Cambridge University Press, 2020), 37.

[15] Here I extend Kiran Klaus Patel’s call for understanding ‘how various and diverse internationalisms intersected and interacted on the ground’ to also include the importance of examining how diverse forms of internationalisms interacted with other ways of being and doing. See Kiran Klaus Patel, ‘Afterword: on the chances and challenges of populating internationalism’, Internationalists in European History, eds Jessica Reinisch and David Brydan.

[16] John-Paul A. Ghobrial, ‘The Secret Life of Elias of Babylon and the Use of Global Microhistory’, Past and Present, 222 (2014): 51-93; John-Paul A. Ghobrial, The Whispers of Cities: Information Flows in Istanbul, London, and Paris in the Age of William Trumbull (Oxford: Oxford University Press, 2013).

[17] Boddice and Smith, Emotion, Sense, Experience, 37-8 and 50-2.