Healing under Extreme Conditions

The Challenge of Building Hospitals in Precarious Contexts

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The hospital in N’Djamena, the capital of Chad, where Famou was admitted, was a desolate place: dark, foul-smelling rooms, filled to the brim with patients and their families; airless, unhealthy corridors in concrete wards standing on arid terrain in the suffocating heat: hospital design is not a priority in some countries. In Famou’s case, everything went wrong: prevention, diagnosis, and treatment, but what did not help either was lying in a derelict corner of one of the poorest hospitals on Earth. The story is repeated in many countries where health is precarious and medical care is minimal.

Hospital design in Rwanda helps to mitigate and reduce the transmissions of airborne disease
MASS Design Group’s Butaro Hospital in Rwanda is designed to mitigate and reduce the transmission of airborne disease through overall layout, patient and staff flow, and natural cross-ventilation. Foto © Iwan Baan

“A decent space can make a difference in the quality of health care anywhere in the world.” That is how architect Christian Benimana, director of MASS Design Group, defines his team’s mission. With the Butaro hospital in Rwanda, they proved that designing a hospital is an opportunity to improve patients’ experiences and treatment results. The facility was designed with the goal of mitigating and reducing the spread of tuberculosis by means of a carefully considered arrangement of the structures and the flow of patient and staff movements while providing natural ventilation for the spaces.

Years later, they applied the same principles to the Cholera Treatment Center in Haiti, where they included an innovative system for treating contaminated water, a key element in fighting the spread of the disease. As with the Rwanda hospital design, part of the work was carried out by local professionals using materials that were specific to the area, thus increasing the building’s sustainability and stimulating the local economy.

Hospital design in Léo, Burkina Faso, faced the problem of an extreme climate
Léo Health Care Center by Francis Kéré. Photo © Francis Kére

Resilient Buildings

“In my country, when we talk about sustainability, we’re referring to finding a local material, using it in a sustainable way, and inspiring others to do the same,” explains architect Francis Kéré –born in Burkina Faso– when he describes how he convinced his people to use clay bricks. “For them, being up-to-date means using techniques from abroad, but here, if we use concrete for our buildings, the indoor temperature is insufferable,” he explains in an interview. Now some of Keré’s constructions, such as the Health Care Center in Léo, in the south of the country, are informally known as “refrigerator” buildings.

Local materials in response to an extreme climate. Innovative solutions that can be applied with limited resources. Local labor in combination with state-of-the-art methods. And, above all, resilient structures should be considered in hospital design.

The need for maintenance is another key consideration in architectural and hospital design
Integrated Care Centers under construction in Quissico, Mozambique. Photo © ASF

Salvi Ros, an architect working for Architects Without Borders (ASF) in Mozambique, has first-hand experience of building in a country recurrently hit by natural disasters. “The last cyclone damaged half of the health facilities in this province,” he explains. According to the World Health Organization (WHO), the huge investment that certain countries make in health infrastructures –hospitals account for up to 70% of the Ministry of Health’s budget– can be lost if they are damaged or destroyed. In addition, Ros points out the need for maintenance as another key consideration in architectural design. “There are health care centers in outlying areas that are full of non-functioning solar panels, because if there isn’t enough money for gasoline for the ambulance, there certainly isn’t enough for technical repairs,” notes Ros, who urges professionals to immerse themselves in the underlying reality of the place where they work.

“We have to stop prioritizing material aspects and try to understand the psychology of the space we’re working in, of the place and of its people.”

Integrating the Native Culture

The anecdote of the project in which the latrines were built facing Mecca is an extreme but real case that illustrates the need for architecture to listen to the population, leave preconceived notions behind, and seek a deep understanding of the psychology of the place, especially in foreign contexts. As architect Ole Scheeren explained in an interview, “We have to stop prioritizing material aspects and try to understand the psychology of the space we’re working in, of the place and of its people.”

ASF in Mozambique followed this approach in its project for two Integrated Care Centers for victims of gender-based violence. “We are using brick, straw, and metal sheeting on the roofs, following the structure of traditional houses. We believe that feeling like you’re in a recognizable space can help reduce post-traumatic stress for the victims,” says Ros.

For Paul Cabrera, Construction & Shelter Advisor at the NGO Doctors Without Borders (MSF), it is a priority to design structures that contribute to the quality of service. Considering criteria such as durability, legal aspects, the type of building depending on the type of patients – “it’s not the same to design a nutrition center for highly vulnerable children or a health care center for refugees”– and, above all, the human resources for implementing the projects. MSF teams work in the harshest of settings, placing the emphasis on the facilities’ flexibility.

Buildings in a conflict zone are a big challenge for hospital design
MSF Field Trauma Clinic, South of Mosul, Iraq. The complex includes an emergency room, operating theatre, intensive care unit and in-patient department. The facility was opened on the 16th February in a village south of Mosul. For more than one month it was the closest surgical facility to West Mosul. Foto © MSF

“Any hospital design should take into account the possibility of being extended with tents or modules, or have multi-purpose spaces that can be transformed in the event of an emergency. There should even be plans for the possibility of isolating areas if an epidemic breaks out,” adds Cabrera.

This need for flexibility, both in terms of service and location, prompted MSF teams to design a mobile surgical unit to treat war casualties on site. The result is MUST, a robust trailer with several cabins capable of withstanding harsh conditions in the field. “It only takes a few hours to deploy, allowing surgical procedures to be performed with aseptic protocols that are almost comparable to those applied in Europe,” notes Paul Cabrera.

Architecture, engineering, design, and creativity push all the boundaries to create spaces where people can receive treatment even in the harshest of conditions.

Main image: Butaro Hospital by MASS Design Group. Photo © Iwan Baan