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In Depth

Developing world hospitals receive radical surgery

  • Design for life
    After a spate-of deaths in developing world hospitals, Butaro Hospital in Rwanda was designed to reduce transmission of deadly infectious diseases. (Copyright: Iwan Baan)
  • Radical redesign
    To reduce infection transmission risk at Butaro Hospital, designers removed enclosed corridors in favour of open-air walkways connecting buildings and wards. (Copyright: Iwan Baan)
  • Rooms with a view
    You will not find beds against walls at Butaro. Beds are positioned in the centre, allowing patients to look out across the surrounding green landscape. (Copyright: Iwan Baan)
  • Clean air
    To reduce infection risk in wards, a natural ventilation system operates instead of air conditioning, changing the air up to 15 times per hour. (Copyright: Iwan Baan)
  • Harnessing the Sun
    One idea for improving natural ventilation in wards is to use solar chimneys that funnel hot air upwards, which increases air flow through buildings. (Copyright: MASS Design)
A new design movement is taking developing world hospitals back to the drawing board, and it has already resulted in some simple, innovative changes that are saving lives.

In 2005, 53 patients with HIV entered a relatively well-resourced hospital in the rural town of Tugela Ferry in South Africa. Within weeks, all but one were dead. Their death certificates would record that they died from a new drug-resistant form of tuberculosis. But behind the diagnoses lay a more shocking truth: they were killed by visiting the place where they had hoped to find treatment.

The incident at the Church of Scotland hospital was an enormous wake-up call for public health officials across the world. Experts like Paul Farmer at Harvard University are convinced that life-threatening microbes, allowed to thrive in congested, dirty hallways and waiting rooms, are turning countless hospitals into deathtraps. “Millions of people die each year from diseases for which safe and effective treatments exist,” says Farmer. “In Haiti, these are known as ‘stupid deaths’. Among the stupidest deaths are those caused by illnesses acquired in the clinics and hospitals intended as places of healing.”

The problem is that hospitals in the world’s poorest countries have been generally built in the image of their western counterparts, and this was making them dangerous to patients’ health.

But now a new school of thinking aims to make events like this a thing of the past. It is being driven by a small band of academics, architects, NGOs, the World Health Organization and a new breed of architects, and their chief weapon is simply a matter of better, intuitive design.

A room with a view

Forget the traditional image of a stark, multi-storey hospital. From Pakistan to Haiti and from Sierra Leone to South Africa, hospital buildings are being constructed that look to all intents and purposes like safari lodges. Patients enter single-storey buildings dotted between lush, green courtyards. Wards have towering ceilings, there are no hallways and waiting areas are breezy and open plan. On the wards, patients recuperate in beds that face out towards giant, open windows, and feel natural ventilation on their face.

“We have to change the way we think about these buildings completely,” says Michael Murphy, co-founder of the not-for-profit Boston based architect firm MASS Design. “Successful health architecture is going to be rated not on how great the building looks, but by how many lives it improves.”

Most hospitals in poorer countries are based on designs from other countries, regardless of whether or not they are appropriate, according to Matthew Salt, a co-author of the WHO’s new guidelines on design for infection control. For instance, despite their warm climate, Africa’s sick have generally been crowded together in waiting rooms and enclosed hallways designed for the colder winters of rich, northern hemisphere countries. The problem is compounded by a desire to fit them out with complex technology, but without the resources for its upkeep.

“Ventilation solutions used for the developed world were simply applied to places which did not have the resources or skills to maintain that equipment,” says Salt. With slow diagnostic systems and high co-infection rates with HIV, Salt says this creates “a perfect storm” for diseases like TB to become a lethal threat. “Twice the ventilation at the Church of Scotland Hospital would have halved transmission,” adds Professor Edward Nardell, associate professor of immunology at the Harvard School of Public Health.

Nardell is another one of the proponents of this new wave of thinking. In response to the Church of Scotland incident, he helped to set up the world’s first programme aimed at preventing disease through design. “One of our first students was a designer who came over from Pakistan with plans for a new hospital in Karachi,” he says. “After the course, he tore up the plans and redesigned it. The Indus hospital now features some of the best principles of infection control.”

The movement has also resulted in projects like Kenema Hospital's Lassa Isolation Ward in Sierra Leone; the Brooklyn Chest Hospital in Cape Town, South Africa; the redesign of the Nyanza maternity wing in Rwanda; and the 320-bed Mirebalais Hospital in rural Haiti, which is due for completion in July this year. South Africa – which has the world’s seventh-highest rates of TB – is currently building nine new TB wards in which airborne infection control is the overriding design priority.

Garden living

To see the ultimate representation of future hospitals, Salt recommends a trip to one of the most remote areas in Rwanda. The Butaro Hospital in the Barera District was built in collaboration between the Rwandan government and Partners in Health, an NGO which is headed by Farmer. Murphy’s MASS Design firm has provided the plans. It is built on the site of a former military base that participated in the Rwandan genocide – it had to be cleared of grenades and other munitions before former US President Bill Clinton arrived for the groundbreaking ceremony in 2008. But now it has been transformed into a new and innovative 150-bed hospital. Built for just $4.4 million (£2.8 million), the hospital serves a province in Rwanda that previously had not a single doctor to serve its 400,000 residents.

The cluster of single-storey buildings that now occupy the site include effective but inexpensive design changes that the collaborators hope will be replicated across the developing world. Colour-coded signs for wards greet patients, many of whom might be illiterate, and wards are reached through open-air walkways to reduce transmission of infections. Air-conditioning systems have been discarded in favour of natural ventilation to mitigate the spread of airborne diseases, such as TB. This natural system uses air-pressure differences, wind-funnelling and even patient body heat to get rid of contaminated air. The hospital’s administrator, Dr Peter Drobac, says that a system featuring large windows beneath high wooden louvres and giant industrial ceiling fans changes the air in its wards up to 15 times per hour, with no need for mechanical ventilation at all. Courtyard gardens have been landscaped deliberately to lure patients to exercise outdoors.

For Murphy, his drive to improve health through design was a direct result of his own experience of hospitals: “My father had a terminal illness, and I spent a lot of time in hospitals. I thought they were atrocious, depressing and undignified spaces,” he says.

To take on this challenge he founded MASS Design while he was a graduate student at Harvard.

He said Butaro Hospital was built at a cost of $30,000 a bed, compared with “$3 million per bed for a new American hospital”, and that is for a site that includes three operating theatres, a neo-natal intensive care unit and digital X-ray technology.

Drobac says that another key for future hospitals is to empower local communities. With the exception of a bulldozer used to level the site, the hospital was built entirely without construction machinery – 2,500 Rwandans built the 6,000 sq m facility with hammers, machetes and hoes, a strategy designed to provide both an economic boost and community acceptance. “Every window, rain gutter and door was made on site,” says Drobac. “We brought in a master welder, a master carpenter and a master mason, and established workshops at the site. There are now a number of Rwandans skilled in those areas as a result.”

Butaro Hospital celebrated its first anniversary in January this year. It has yet to record a single case of hospital-acquired infection.

As a result, Rwanda's Ministry of Health has asked Drobac to do something which no hospital in the country had been able to do before: offer treatment to cancer patients. He said the immune systems of patients under chemotherapy were generally considered too weak to risk the threat of infection in traditional hospitals.

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.

Transferable benefits

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.”

But the radical hospital redesigns are beginning to receive plaudits. Butaro Hospital was a finalist for the 2011 World Architecture Festival Awards in Barcelona. The hospital was also named Acute Care Facility of the Year by the trade magazine Contract, and in January this year, the magazine also named MASS Design its 2012 Designer of the Year.

Murphy admitted the commercial market for architects in developing world hospitals is small, but added that the potential for impact was “fantastic – and humbling”. One MASS Design architect, Sierra Bainbridge, returned to the US in December after living on site in Rwanda for two years, in a process Murphy calls “immersive design”. During her tour, Bainbridge also launched Rwanda's first school of architecture. Murphy said that the country's first class of 25 architecture students were due to graduate this year – all of them trained in the principles of design for infection control.

All of which will be good news to Pamela Richards. As a South African government health official, she witnessed the lethal TB outbreak at the Church of Scotland Hospital in 2005. “I have never been so upset in my life,” she recalls.

For her, the new movement to rethink hospitals means one thing: “It’s hope.”

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