What else would you have health workers do? The housing crisis is a health crisis. People who are chronically unhoused live half as long as others. When a patient’s major concern is where they’re going to sleep at night, it’s hard for them to follow a medication regimen. With chronic conditions like cardiovascular disease or diabetes, tragic outcomes — from amputations to heart attacks to strokes — are far too common. People who are unhoused are in hospital two to three times longer than other patients. There’s a revolving door of people coming in and out of emergency departments because they have nowhere else to go. Our downtown hospitals are at 105 to 120 per cent occu­pancy. And there’s no pathway for humane discharge.

It costs the system over $30,000 a month when an individual is admitted to any down­town hospital. It’s around $13,000 a month in the prison system, which has become the de facto mental health system. People ask, “Can you afford Dunn House?” My answer is, “We can’t afford the status quo.” But the issue is not just one of health economics. It’s one of life expectancy. If there was a drug that could stop people from losing 20 to 30 years, you’d hope that every policy-maker, funder and investor would be racing to pay for it.

Using hospital data, we identified individuals who have high medical risks, high num­bers of total visits to the ER or high numbers of days in a hospital bed. We also looked at how long people have been unhoused. There’s no perfect algorithm. What’s unique about Dunn House, though, is that it’s a permanent solution. It’s not transitional housing where, after 60 days, people are discharged onto the street.

With modular construction, you’re building whole boxes — with interiors, windows and most of the cladding — off site in a factory. You then bring the boxes, almost fully complete, to the construction site for assem­bly. Dunn House has identical 275-square-foot studio units. Buildings like that, with lots of repetition, are best suited for modular construction.

It has two advantages. One is speed. You can do much of the on-site and factory work in parallel. The final assembly, then, might be completed within weeks. When modular construction goes smoothly, we can get an entire building done in nine to 12 months, as opposed to 20 months. The second advantage is the lower carbon footprint. Factory fabrication reduces waste, particularly when it comes to transport. You’re only trucking the final product to site, not the other materials.

We have a diminishing workforce available to us. We’re seeing smaller construction crews on sites in general. With modular construction, you can find workforce efficiencies. For example, if you’re install­ing plumbing in a washroom on site, you’re on a ladder up in the ceiling. But in a factory, you’re lifted on dollies, so you’re sitting in a chair comfortably working at chest height. A factory setting is more attractive to the labour force. It’s a more climate-controlled, technologically enhanced environment.

In the Durham Modular Transitional Housing project [a suite of modular homes for unhoused people in the town of Beaverton, Ontario], we had 47 units and three storeys. For much of the building, we leaned into the repetition. In the middle, though, there’s a cut-out where we used two shorter modules, creating a forecourt for the entry. We weren’t doing anything complex. We were just saying, “Let’s put a bunch of shorter units here to create a cut-out. And let’s line the inside of the cut-out with wood to have a contrast to the dark siding.” To create a community hub, we put a smaller building in the front of the residential section, and we gave that building a distinctive roof shape. We were being selective. We were allowing repetition, but also intro­ducing moments of variety to create contrast.

At Dunn House, the length of the building is shorter than at Durham. So naturally, we have less repetition. And the repetition we do have is quite nice.

Each individual has their own bed and bathroom. The building is pet-inclusive. And there are embedded healthcare supports that have not been standard for supportive hous­ing. As a physician, I’m at Dunn House every Monday, offer­ing primary care. There are also community health workers and caseworkers. A colleague of mine, Vicky Stergiopoulos, has a weekly clinic addressing mental health needs. And we have access to the UHN virtual emergency department.

One is “Where are the opportunities to scale up? How can we make the model more accessible, so that cities customize it for their own patient populations or neighbour­hoods?” It’s important to build up a cadre of design and architecture expertise. The second question is “What should housing look like for people who have high health needs, high degrees of social deprivation, and mistrust of the health system?”

Yes and no. I would love to not have the housing crisis being managed through the emergency department. And I would like to see both the public and private sectors do the work of delivering housing. At the UHN, we don’t want to engage in hospital overreach. We want to see more collaboration. We prefer to work with other institutions as partners rather than taking on housing ourselves.

At our firm, we’re trying to make housing that is dignified and durable, where people can live their best lives. We have to do that on a budget that’s two-thirds of the private sector’s budget. That’s where having a good pencil and a good drawing hand is useful. We can’t make things that are flamboyant, but we can make things that are beautiful, elegant and built to last hundreds of years.

We try to make the plans of the building simple, and we try to think about the experience of residents. Everyone should feel dignified, safe and secure, warm in winter and not too hot in summer. Materiality is key. Georgian buildings from 300 years ago are still standing. There’s no reason why the new housing we’re building shouldn’t be standing in 300-plus years.

: In London, we’ve gotten value for money by giving the public sector the support they need to manage the process all the way through. In the past 20 to 30 years, a lot of the public sector has been de-skilled, and it has not had the capability to manage projects. Instead, it has brought on private-sector partners — who want a big piece of the pie — at an early stage in the project. If the public sector manages projects themselves, they don’t have to scrimp later on materials or process specifications.

Yes, because land is finite. We have to make the most with what we have, which means working hard to come up with intelligent spatial planning.

In order to get more value out of sites, you have to break rules. For some sites, you need to under-provide on setbacks and maybe have a different building configuration. In Montgomery Sisam’s forthcoming Kensington Market project [a suite of supportive modular housing units on a parking lot in a storied Toronto neighbourhood], we have an L-shaped courtyard building with two narrow edges toward the street, instead of a traditional street wall. Zoning would have hated that, right? But we were able to achieve a great number of additional units because of an atypical built form.

When we began working with Toronto, we started by asking planners about their favou­rite cities and streets around the world. As it turns out, those very cities and streets broke a lot of the planning rules in Toronto. I understand that, in Toronto, you have a different climate, so I see the need for zoning and coding. But these measures kill creativity. If you have too much blanket zoning, it can lead to dull cities and lost opportunities. When Dunn House was being designed, somebody could have drawn a big rectangle around the prop­erty and said, “This is hospital land. And it can only be hospital land.” Well, actually, there’s a parking lot there. It’s underutilized land in the middle of a housing crisis. So let’s negotiate around the rules. I like this tension. It leads to interesting cities that evolve quickly.

I’m not bashing planners, but the approvals process can be bureaucratic. When you’re dealing with public or City land, the sign-off process for contracts and tenders can be slow. We can all design faster than planners can plan.

The City of Toronto has been evolving its approach. The new “city-builder” process [a program by which the City steps in to develop affordable housing] is interesting, because it has taken rezoning out of the equation. A lot of the engineering reports that require time to prepare, review and revise are now no longer needed at the rezoning stage and are down­loaded to the site plan application process instead.

A lot of the modern housing from the ’60s and ’70s was builder- and engineer-led, as opposed to architect-led. First, you had the original Unité d’habitation [a classic residential housing typology designed by Swiss French architect Le Corbusier]. But then, around the world, the construction lobby went, “Wow, we can make a lot of money by imitating — badly — Le Corbusier’s high-density mass-housing ideas while editing out all the design qualities.” So all of Le Corbusier’s generosity gets stripped out, not by architects but by the construction industry. Decades later, the buildings get torn down. And who do we all blame? Architects!

This time around, the work has to be architect-led, with a focus on quality. Often I say, “Build a bit less, but make it good.” That way, when people see new buildings, they go, “Wow, new can be great.” I worry that, if there’s a rush for numbers, the architects will get squeezed, the industry will take over and we’ll end up repeating the mistakes of the ’60s and ’70s, which would be tragic. Tearing down buildings that are only 40 or 50 years old is the definition of insanity.

Charles and Ray Eames aimed, according to their motto, “to make the best for the most for the least,” meaning the best design for the most people for the least cost. If we can take this same attitude when delivering housing, we have a shot at making a real differ­ence as designers and city-builders.