The innovations have not ended with Butaro. MASS Design has just completed plans for a dedicated TB clinic in Haiti, Gheskio Hospital, and Murphy says one of the new design innovations is to include external doors to patients' bathrooms, so that cleaning staff do not have to risk walking through the wards. Family visiting areas have also been created beneath patios outside the wards.
And Murphy believes the designs are not only of use in the developing world. “I do think that if we can produce an alternative model, then that might be a huge innovation for the future of healthcare buildings,” he says. “If we could build a huge, naturally ventilated hospital in the US or Europe, with better outcomes and at a fraction of the usual cost, that could offer a new way to think about these things in the west as well.”
But he faces an uphill struggle. Even amongst the proponents of these new designs, questions remain about the benefit of some of the concepts.
Take one of Butaro's most simple but striking innovations: ward beds that are back to back and arranged down the centre of the room so that patients are facing a window, not each other. Paul Farmer, co-founder of Partners in Health, believes this can have a psychological effect that speeds recovery. “I can't show you a study which proves that patients are better off because they can see beautiful things,” he said in an interview for the NGO. “But I believe it.”
Designer Murphy says that there are also other benefits: central beds allow windows to be larger, and lower on perimeter walls, which promotes cross-ventilation. It also saves a little on service lines to bedside oxygen nozzles and electrical devices, which would otherwise have to extend around both walls.
Harvard’s Nardell agrees that there are psychological benefits, but cautions that the overall merits have not yet been established: “Florence Nightingale believed very strongly that beds should be as close to windows as possible, and there are merits to that view as well.”
Other design tweaks are also questioned. Some believe strongly in the benefits of bactericidal ultraviolet lights, of the type now used in Butaro's wards. But not everyone is convinced. “We have a lot of dust here in Africa, and UV cannot penetrate this dust. Also, it cannot go around corners,” says Professor Shaheen Mehtar, head of Infection Prevention and Control at Tygerberg Hospital in South Africa. Nardell argues that this is “a silly reason to avoid UV. In any hospital you have to keep things clean, and the same applies to the lights.” Other administrators complain that unscrupulous salespeople have sold fake UV lights to clinics that are simply blue in colour, and that their deception was difficult to determine.
Even something as simple as washing hands is the subject of debate. This remains the most important infection control measure of all, but there is no consensus on how staff and patients should safely dry them afterwards. “Electric hand drying systems of the kind you see in airport bathrooms are absolutely the worst solution for hospitals,” says Joseph Neethling, former chief architect for South Africa's Western Cape government. “They stir dust around, and pathogens stick to dust.”
But perhaps the biggest struggle for this new wave of design is overturning entrenched views.
“Copycat architecture” of western plans still continues, says Mehtar, and there are still economic pressures to purchase expensive ventilation machines, even in inappropriate settings. “Sometimes, people are getting their designs from Google, or via fax,” she says. “A week ago, I was shown a hospital in which the administration block was actually placed above the outpatient department – and they were wondering why their staff were contracting TB! You don't have to be an Einstein to figure out that air conditioners will draw in contaminated air.”