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1AFGHANISTANAND BEYOND Developing a prototype for community healthcare in the World’s most challenging environments
2 3 Afghanistan and Beyond Where do we start? Developing a prototype for community healthcare in the World’s most challenging environmentsTable of Contents1.0Introduction1.1A Scalable Idea Through a modest project for the International Or-1.2Case Study- Afghanistan ganization for Migration and USAID we were given1.3Case Study - Zambia the chance to design multiple hospitals to serve1.4Case Study - St. Lucia the people of Afghanistan. At first glance these1.5 are basic structures built locally by tradesmenCase Study - Guizhou Province China1.6 and staffed in their final forms by local healthcareAffiliations workers. Western ideas of how healthcare is deliv- ered are only as relevant as their ability to be suc- cessfully implemented. In areas of cultural or political transition, basic needs like healthcare serve as the building blocks for new communities. Our permanent, scalable and expandable strategies for these facilities reflect the values of cultures and access to natural resources that each context has to offer in Afghanistan and beyond.
4 5Off the Grid: A Different Direction inBringing Healthcare to Developing Nations As the team was developing the design for the Afghan 100 bed prototype, there ap- T peared to be a specific niche that the project was addressing. A confluence of a particular need, a particular quantity of services, and an architectural solution that is simple, flexible and transferable to many sites. We recognized that the model being he idea is a healthcare prototype that bridges a designed can fill a void in the healthcare fabric of many developing nations; and that if this void is filled, it could bring a leap in the quality of life of thousands at a minimal gap in the society of developing nations. The gap be- investment. So when an ideas competition was announced within the firm, we start- tween rural clinics and urban hospitals. The gap that is ed discussing what made this project different from similar efforts in the past: stranding millions, especially women and children, on the When aid agencies build healthcare clinics, they tend to be either for immediate di- wrong side of history. By providing right sized, flexible, saster care, or urban settings. They are either small and temporary, or large and in- frastructural. The 100 bed model is something else, but has the flexibility to provide simple hospitals that can bridge this chasm, an entire na- both experiences. It is large enough to demonstrate a permanent commitment to the tion can stabilize its population and move up the hierar- community, yet small enough to be placed in villages, near rural areas. There have been many architectural competitions about bringing, small, portable, often temporary, chy of security and wealth. It’s not just about access healthcare facilities to underserved populations. This project takes another approach to care; it’s about access to the future, by putting down by proposing a permanent, site-specific building that encourages the participation and investment of the locals. It is not trying to import Western solutions, it is using uni- roots and investing in local, long term growth. The no- versal techniques to adapt to the cultural, and medical needs of the visitors. grid hospital is the seed that stabilizes the shifting sands Size is key in another critical area: utilities. In Afghanistan and other developing con- of the community, allowing time for the grid, and educa- texts, there is no “grid” for water, power and waste. The ability to package these im- tion, to take hold. provements at the right scale is one of the vectors via which these projects can trans- form the community. They must be small enough to operate off the grid, yet large enough to achieve an economy of scale in water and power production. We think of these buildings as more than health centers, but rather social centers: places for edu- cation, security, and employment. By providing a hub of infrastructure, the 100 bed hospital becomes a community catalyst, an engine for change.
6 71.0 World Health IndicatorsThere are literally hundreds of sites in need of permanent, scalable healthcare. Using World health data, we selected four sites including Afghanistan forfurther study. Using indicators including infant mortality, life expectancy and skilled professionals at live births a picture of need begins to evolve. More Newborn life is fragile.than half a million women die every year of complications during pregnancy or childbirth. Most of these deaths can be avoided as the necessary medicalinterventions exist and are well known. The key obstacle is pregnant women’s lack of access to quality care before, during and after childbirth. Investing Almost four million childrenin health systems - especially in training midwives and in making emergency obstetric care available round-the-clock -- is key to reducing maternal mortal-ity.Nearly 10 million children under the age of five die every year - more than 1000 every hour. These children could survive and thrive with access tosimple, affordable interventions. Helping countries to deliver integrated, effective care in a continuum, starting with a healthy pregnancy for the mother,through birth and care up to five years of age is crucial. Investing in health systems is key to delivering this essential care. die every year within a monthWe have identified 3 other case study sites in addition to Afghanistan to further explore the implications of our strategies. of their birth. Afghanistan Afghanistan St Lucia St Lucia Guizhou Guizhou China China Zambia Zambia
8 91.0 World Bank Data 257 babies per 1000 bornThe World Bank tracks data related to World economies. Overlaid with health data from these countries a picture emerges of high mortality rates and highbirth rates in countries like Afghanistan and Zambia.”Developing” countries like India, China and in this case St. Lucia, represent the middle of the packwhile the United States, not surprisingly, consistently ranks near the top of all categories related to health of its citizens will die in Afghanistan be- fore they reach their fifth birthday.
10 111.0 Hierarchy of Health AccessThe development of responsive building solutions is inextricably linked to the social conditions and the aspirations and limitations of the individuals thesebuilding’s serve. Our projects serve a population that in in transition. A population whos upward mobility is being severly limited by a lack of primaryhealth services. Understanding the development of stable communities is essential in setting the right expectations for the projects and evaluating pos- Our projects bridge this gap. Bringingsible sites. We call these sites “Permanent and Disconnected”. “ resources where needed, linking the the hierarchy of development Resources 1 Meaning Fulfilment Sustainable Medical Growth Capitol School & Research Creativity Esteem & Achievement Needs: Responsibility, Status, Reputation City Grid & Backup 2 Nursing School & Elective Social & Emotional Needs: Family, work, Relationships Town Grid Intermitant 3 Acute & Specialty Care Safety & Stability Needs: Security, Law, Protection Village Permanent Disconnected 4 Primary Care & Public health Biological & Immediate Needs: Clinic Portable, Mobile / Air, Water, Rural Emergency Disconnected Shelter Shelter Individual Needs Group Infrastructure Level Trauma Level Facility Level Growth Growth
12 13 1.1 A Scalable Strategy“... freedom translates into having a supply of clean water, having electricity on How do you create an affordable, sustainable,tap; being able to live in a decent home and have a good job; to be able to sendyour children to school and to have accessible healthcare. I mean what’s the and locally viable healthcare solution that canpoint of having made this transition if the quality of life ... is not enhanced andimproved? “ become a building block for healthy communi- ty growth?— Desmond Tutu
14 151.1 A Scalable Strategy Areas in crisis in need of healthcare resources need to balance the immediate needs of care with the rebuilding of physical com- munities. We believe that the community hospital built to reflect the communities needs through expedient and simple construc- tion can serve as the rebuilding blocks needed. The fundamental planning modules represent a simple and achievable outcome for areas of the world most in need of quality, permanent healthcare. An expandable strategy of building in rural areas accomplishes this. Mobile units circulated from clinic to community hospital as bridge between expansion strategies Clinic with Mobile Care Units 20 Bed Hospital 50 Bed Hospital Flex into Mobile Units 100 Bed Hospital 150 Bed Hospital
16 17 1001.1 A Scalable Strategy THE FULL TEMPLATE: The 100 Bed Hospital is the starting point for consideration of this Bed Hospital strategy. One can subtract elements but keep the essential drivers of Mobile surgery support interface services the ED Surgery and Outpatient keeping places for support and administrative functions to begin and expand as need increases. E.D. A key difference between this and other solutions implemented is Generators the clinical model. The prototype can provide all the basic services needed for community health and education, with enough space to house a couple of key specialties. In Afghanistan, the need for train- Mech. Bedded Care ing mid-wives and female care-givers is essential to lowering infant mortality rates. Orthopedic services are also in high demand due to land mine injuries. The 100 bed module provides enough space for basic medical-surgical services, as well as an emphasis on O.B. and Ortho. In other parts of the World, other specialties would be de- Ambulance Sterile livered, along with training and public health. One of the planning Port Pharmacy Process Outpatient Clinic innovations proposed is a six bed unit that can be operated as a 3- bed unit when staff levels permit. By dividing the units into gender- specific wards of 24, then into rooms of 6, then into groups of 3, there is tremendous flexibility. Depending on care model, service Food line, staff level, and cultural preference, the units can be managed in Service many configurations without renovation. Outpatient Exam Diagnostic and Treatment Because the project is site specific, and expandable, it uses a univer- sal module, and is buildable with any common material. The 15 me- Staff Courtyard: ter clear span, single story, single slope roof, provides an architectur- 50 Female Bed Unit al building block, a "widget", that can accommodate many types of space, in any part of the World. The walls can be built from brick, Lab P.T. & Prosthesis adobe, concrete, or sandbags. The roof trusses can be shipped as a kit of parts and assembled on site. High windows encourage natural Support Space ventilation and daylighting. X-ray We know that education, especially for girls, is the key to stability and wealth in the long term. In places like Afghanistan, rural India, Dental and central Africa, poor healthcare is preventing the education gap from closing. Education and Administration Public Courtyard: MAIN Cultural & ENTRY Educational Events 50 Male Bed Unit Classrooms
18 19The 100 Bed Prototype- Design ProcessOn the way to the simplest solution, we ex-plored schemes based on an original layoutfrom our client. By standardizing the 15 meter width throughoutthe building in the final scheme we were able to radically simplify construc-tion and build the conceptual basis for our scalable hospital.
20 21 501.1 A Scalable Strategy GENDER SEPARATED HOSPITAL: The 50 Bed Hospital accommodates the separation of sexes, a critical Bed Hospital feature in Muslim culture and in a multi-patient wards. From the main Mobile surgery support interface entry, men and women can reach the inpatient services along separate routes. At this scale, specialty hospitals are ideally suited to address major y er rt needs. Afghanistan is planning 50 bed women’s hospitals to target pre- v po co RI p natal care, and blunt the momentum of high infant mortality. By desig- CT M Re Su E.D. nating the entire facility for women, cultural boundaries in education and access are removed. Education facilities are expanded, to train specialty Ambulance Bedded Care care givers. Port Generators The main courtyard creates a secure, public space and orients visitors to Surgery Recovery circulation flows around it. Mech. Sterile This scheme is the lowest level of fully “permanent and off grid”. Process Power generation and sterile processing are brought into the building, no Outpatient Clinic longer using mobile resources. Staff Courtyard: Lab Lab Diagnostic and Treatment Dining/ Waiting Outpatient Exam Public Courtyard: Cultural & 25 Female Bed Unit Educational Events Support Space X-ray Dental Reception 25 Male Bed Unit Education and Administration MAIN Classrooms ENTRY
22 23 201.1 A Scalable Strategy DAY HOSPITAL: Mobile surgery support interface Bed Hospital At the 20 bed scale, the facility can swing between outpatient day hospital, and inpatient care. The inpatient exam rooms receive the rush of visitors in the morning, then convert to extended recovery for the last rt Ambulance surgery cases of the day. po RI p Port Su R CT M O The classrooms can be leveraged as public health screening and inocula- tion places. This modest hospital can grow to the 50 Bed and then the Mobile 100 Bed by: Utilities Bedded Care E.D. Generators 1. Building some shell treatment spaces and using the space for Surgery Recovery interim support Mobile 2. Reserving places for future functions like bedded care Sterile Process Mech. Outpatient Clinic 3. Reusing public health spaces in the future in new programs like healthcare workers training classrooms Endo. Scopes 4. The use of mobile modality trailers and trucks can greatly lever Staff Courtyard: Lab age staff and resources across large distances. X-ray Staff support Diagnostic and Treatment This scheme allows the sterile processing to be accomplished with mo- & Housing bile units, as an interim step between, bulk storage and an SPD dept. MAIN Dining/ ENTRY Waiting Reception As the number of highly trained personnel increase for inpatient services, the need to recruit and train staff from the community must be accom- modated. This scheme uses on-site housing, built to house the trades Public Courtyard: during construction, as a dedicated dormitory. Together with the educa- Cultural & Support Space tion and administration spaces, a complete school of nursing is possible. Educational Events OUTPATIENT EXAM & EXTENDED RECOVERY Education and Administration Dental Physical Classrooms Therapy
24 25 Clinic1.1 A Scalable Strategy No inpatient beds, the basic care hub THE HUB: Mobile mass casualty The no bed “clinic” is the most basic building block. The fundamental structure that houses the kernel of a much larger structure, but can also stand alone. This kernel is uniquely adapted to support major surges due to catastrophic events. This allows the dual mission of primary and routine surgical care during normal periods, and triage cen- ter during mass casualty. Surge triage Mobile surgery support interface Bedded Care The building is divided into high and low acuity from top to bottom. It is further divided into public and support function from side to side. This allows every side of y the building to specialize to a group of functions, based on access and privacy. This er al g t v Ambulance in organization creates a hub for the addition of future expansion, or mobile units. Tre- or ic co ag rg pp mendous flexibility is permitted, depending on the medical and financial needs of the Re Mobile Port Su Im Su community, to configure the facility over time. Decon. Mobile Outpatient Clinic Bulk Utilities Storage Generators Recovery Surgery Med-Surg Hub ED High Acuity Mech. Equipment & Staff Diagnostic and Treatment E.D. & O.R.’s Out Patient Open Court: Light/ Air / Security Clinic M or Screening gu X-ray Education e Support Space MOBILE UNITS: Su pp As an outpost in a developing nations health network, the “hub” clinic is the ideal le Dining/ docking platform for mobile medical units. These units may reside at other facilities, s MAIN Waiting St Mobile or in storage, but would be installed here to respond to a temporary or overwhelming ENTRY Reception af Surge need. The mobile units can also serve as an interim step prior to a permanent addition. fs up Support po Shown here are the seven basic families of mobile units and how they interface with Classrooms rt Education and Administration the clinic. Mobile These units provide developing governments the ability to leverage their resources Pandemic across much larger areas, and react to catastrophe. They also allow outside organiza- tions an opportunity to contribute with a proprietary platform and controllable logistics. testing & This means that imaging equipment companies, for example, could access markets that Vaccination are not currently available. Services that are highly technical, such as cardiac cath., can be brought to many new patients. Services that are too specialized for wide use, such as lithotripsy and cataract surgery, can be brought to rural areas. The “Hub” clinic provides an interface for the local and international community to interact, via technology and expertise. It is the beginning of new expectations for both the patient and the care industry. A higher expectation, that suffering is no longer acceptable, that medicine is not just for the urban and the wealthy.
26 27 Clinic1.1 A Scalable Strategy No inpatient beds, the basic care hubClinic OutpostsThe clinic module of the scalable hospital is atonce the basic building block to the future and animportant destination in and of itself for those inneed. The facility can operate in it’s most basic clini-cal care configuration as permanent built spacesas well as allowing the mobile care units to dockinto the core care spaces of the facility in clearlydelineated areas.
28 29 1.2Afghanistan is not kind to children. AfghanistanThirty years of war have marred the land, decimated Afghanistan, with a per-capita income of less than US$ 200, is among the least developed countries in Total population: 26,088,000the economy, and exposed Afghans to human loss the world with 70% of the population living in extreme poverty and health vulnerability. The social indicators,on a grand scale. The country ranks second to last on which were low even before the 1979 Soviet invasion, rank at or near the bottom among developing countries, Life expectancy at birth m/f (years): 42/43the United Nations human-development index, and preventing the fulfillment of rights to health, education, food and housing. Since the fall of the Taliban almost Healthy life expectancy at birth m/f (years, 2003): 35/36for children, the consequences have been especially five years ago, important progress has been achieved in all sectors, but much remains to be done in order to Probability of dying under fiveacute. Afghanistan has one of the worlds highest reach a significantly strengthened social infrastructure, realize the rights to survival, livelihood, protection and (per 1 000 live births): 257maternal mortality rates, according to UNICEF, and participation, and reach the Millennium Development Goals (MDGs). Probability of dying between 15 and 60 years m/f (per 1 000 population): 500/443a child mortality rate second only to Sierra Leones. The health of women and children is among the worst in the world. One woman dies in Afghanistan every 27 Total expenditure on health per capitaMore than 2 million Afghan children are orphans. minutes from pregnancy-related complications, 25,000 every year. Morbidity and mortality among children are (Intl $, 2006): 29More than half are malnourished, and one-third are due to measles, diarrhea, acute respiratory infection, malaria, malnutrition and poor sanitation. 20% of chil- Total expenditure on health as % of GDPunderweight. dren have a low birth weight and 85,000 children under five die from diarrhea each year. Anaemia prevalence is (2006): 5.4 high among women and children.
30 311.2 Case Study - AfghanistanAfghanistan’s ethnically and linguistically mixed population reflects its location astride historic trade and invasion routes leading from Central Asia intoSouth and Southwest Asia. While population data is somewhat unreliable for Afghanistan, Pashtuns make up the largest ethnic group at 38-44% of thepopulation, followed by Tajiks (25%), Hazaras (10%), Uzbek (6-8%), Aimaq, Turkmen, Baluch, and other small groups. Dari (Afghan Farsi) and Pashtoare official languages. Tajik and Turkic languages are spoken widely in the north. Smaller groups throughout the country also speak more than 70 otherlanguages and numerous dialects.Afghanistan is an Islamic country. An estimated 80% of the population is Sunni, following the Hanafi school of jurisprudence; the remainder of the pop-ulation--and primarily the Hazara ethnic group--is predominantly Shi’a. Despite attempts during the years of communist rule to secularize Afghan society,Islamic practices pervade all aspects of life. Islamic religious tradition and codes, together with traditional tribal and ethnic practices, have an importantrole in personal conduct and dispute settlement. Afghan society is largely based on kinship groups, which follow traditional customs and religious prac-tices, though somewhat less so in urban areas.
32 33 1001.2 Case Study - Afghanistan Bed Hospital - Site Plan Utility Courtyard Before the first building foundation is poured, utilities must be secured as there Dining Courtyard is no grid or local water infrastructure. A masonry wall is built around the site to KABUL (60 miles) protect resources as well as materials and laborers throughout construction. Water is extracted from a well via deep boreholes, and pumped through a treatment facil- ity. A water tower provides two days of reserves in case of a power failure. Future Ambulance Entrance 12’ Perimeter Security Wall Fuel tanks for the generators are sized for a three month reserve. The building Water Tower must be able to sustain itself in case roads become impassable and and fuel cannot Generators Inside Mechanical Room be delivered to the site. Once the community is on the grid, a power substation will be needed on-site. Underground Fuel Tank Future Electrical Substation Islamic law dictates that wastewater generated from food production is collect- ed and treated separately from other wastewater. The separate treatment tanks EMERGENCY SERVICE ENTRY then discharge effluent into a sand filter bed. ENTRY Courtyards between the wings allow for light and ventilation and add a social and religious component to the plan. The geometry of each courtyard is oriented Separated Grey and Black towards Mecca. Courtyards between the inpatient wings provide views of nature Water Waste Treatment from the beds. South of the dining hall is a courtyard with spaces for eating. The Below Grade main courtyard is situated just east of the main public entrance and provides a cen- tral gathering space for communal events. Filter Bed Public Courtyard MAIN ENTRY Men’s and Women’s areas are separated by a metal screen wall with Islamic in- spired patterns. Gated Entry With Guard House Central paving design to be developed GARDEZ (5 miles) and constructed by the local community. Public Courtyard A steel frame trellis provides a sense of enclosure. Inpatient Courtyards
34 351.2 Case Study - AfghanistanDeveloping nations require multi-patient wards due to resource limitations. Our goal is to maximize staff coverage, while minimizing the privacy andinfection control issues that wards create. An open 4-patient room, with a bed in each corner, is common in these settings. Our scheme improves uponthis model by using a 6-bed space that is subdivided to act as a 3-patient room. Efficiency is increased in staffing and area, with a layout that is easier toflex at night or with low nursing levels. All while maintaining a higher level of privacy because views are blocked from foot to foot. n sicia 1 Phy ist. / ass rse Nu ients /2 Pat es 24 urs 2N day nts es t rs gh atie Nu i Team Station 1 2P -2 rse n 1 u & Support 1N nts atie 6P nts atie 3P Isolation or VIP Room Screened Nursury Porch or Procedure Room Family Room Key features of 6 Patient room layout: 100 Bed Hospital - Courtyard between bed units • Privacy- No casual observation from pillow to pillow, or across the room • Leverage- Nurse can access both sides from central sub-station • Family- Dedicated space for visitors to participate in care
36 371.2 Case Study - AfghanistanReadily available materials and simple construction techniques help make this an achievable strategy. The building forms are compact and repetitive withopportunities for expression of entries and hospital symbolism in key areas. In Afghanistan, large extended families often come to the facility together-flexible and safe interior and exterior space is a priority.
38 391.2 Case Study - AfghanistanA strong connection to place makes these permanent, scalable hospitals a part of the communities that they are built in. Universally understood buildingorganizing principals like courtyards are combined with local influences in color and materials..
40 41re1.2 Case Study - Afghanistan A Simple Approach Knowing that mechanical ventilation would not be maintained or was unavailable, the naturally ventilated architecture responds to both Sum- Summer The roof overhang protects the south facade from direct sunlight during the hottest part of the day. Air mer and Winter conditions. Cooler air brought in off the shaded is brought in from low windows while operable clerestory windows and openings in the ceiling allow warm air to escape. Basic fans in the plenum facilitate air movement. courtyards while the volume of the patient care wings works to draw warm air away form the pa- tients in the summer. Winter conditions allow direct sunlight into the building while basic fans help circulate the air. Winter A lower sun angle allows direct sunlight and heat gain deep into the patient room. Baseboard units provide radiant heat, while fans bring in tempered fresh air and circulate it throughout the building.
42 431.2 Case Study - AfghanistanBecause the project is site specific and expandable, it uses a universal module, and is buildable with any common material. The15 meter clear span, single story, single slope roof provides an architectural building block - a "widget", that can accommodatemany types of space, in any part of the World. The walls can be built from brick, adobe, concrete, or sandbags. The rooftrusses can be shipped as a kit of parts and assembled on site. High windows encourage natural ventilation and daylighting. 1 v 2 100 Bed Hospital - West Elevation 100 Bed Hospital - East Elevation 1 v 2
44 451.2 Case Study - Afghanistan 100 Bed Hospital - Courtyard Eleva- tion - East 100 Bed Hospital - Courtyard Eleva- tion- South
46 47 1.3 Zambia Zambia, a country that has experienced five successful Total population: 11,696,000 multiparty elections since 1991, is a peaceful, democrat- ic country with enormous economic potential grounded in its rich endowment of natural resources. The country has altogether held 10 elections since its independence Life expectancy at birth m/f (years): 42/43 in 1964. Kenneth Kaunda, was the country’s first presi- dent and ruled for 27 years. In 1973, Zambia became Healthy life expectancy at birth m/f a one party state after all the political parties were (years, 2003): 35/35 outlawed. Zambia’s copper dependent economy dete- riorated after the fall of copper prices in the eighties. Probability of dying under five The nationalization of the copper mines and generally (per 1 000 live births): 182 poor economic management turned Zambia into one of the poorest countries in Africa with 64 percent of the Probability of dying between 15 and population living below the poverty line and 51 percent 60 years m/f (per 1 000 population): 644/597 considered in extreme poverty according to 2006 data. Like many mineral dependent countries, Zambia has not Total expenditure on health per capita escaped the global economic crisis. The price of copper (Intl $, 2006): 62 fell significantly at the onset of the crisis, leading to clo- sures of mines and a scale back in investments. Prices of copper have since recovered, although not to historic Total expenditure on health as % of GDP high levels. In order to attain the national vision of be- (2006): 5.2 coming a middle-income economy by the year 2030, the Zambian economy will have the daunting task of accelerating growth to 6-7 percent from existing levels of about 5 percent in order to achieve the Millennium Development Goals, while combatting high levels of pov- erty, insufficient economic diversification, and devastat- ing levels of HIV/AIDS and Malaria.
48 491.3 Case Study - Zambia Natural ventilation, solar shading,thermal mass and proper building orientation will provide the most benefit to the inhabitants. Buildings cre- ate the potential not only for health services but to generate clean power through building integrated wind turbines, photovoltaics and a biofuel gen- eration system. Africa is the world’s largest consumer of biomass energy (firewood, agricultural residues, animal wastes, and charcoal), calculated as a percentage of overall energy consumption. African nations have made considerable advances in the use of photovoltaic (PV) power. PV’s are readily available in Africa - in 1998, Sweden and Zambia agreed to a PV rural electrification project. In Kenya, a series of rural electrification and other programs has resulted in the installation of more than 20,000 small-scale PV systems since 1986. These PV systems now play a prominent role in decentralized, sustainable electrification. Shaded courtyards create an environmental buffer zone at the perim- eter walls as well as areas for social interaction and cultural use. Water runoff from the roofs is captured for building use or released into natural filtration areas. Waste from buildings can be effectively recy- cled into biogas through anaerobic bioreactor or digester to create electric- ity and even cooling through cogeneration. Evaporative cooling may also be employed. Approximately 5% of Africa’s power generation comes from geo- thermal sources. There are two major geothermal energy developments currently under development in Zambia. One is the Kapisya Geothermal Project, located in Sumbu on the shores of Lake Tanganyika. Geothermal heat pumps use the Earth’s constant temperatures to heat and cool build- ings. They transfer heat from the ground (or water) into buildings in winter and reverse the process in the summer. Organic Waste Stream - Organic wastes are to be collected on-site and composted for integral urban farming or sale to exterior farming cen- tres. Material Resource Recycling Stream - Relatively benign materials such as paper, cotton, plastics are to be collected, sorted and recycled. Ventures may be established with manufacturing industries to create closed loop resource cycles.
50 511.3 Case Study - Zambia The Afghan version of the prototype is designed to resist very high siesmic risks. This resulted in smaller opening in exterior walls, which support the roof. In other parts of the World, the high walls of the patient wards could utilize more open area and increased natural ventilation, as shown here. The shaded courtyards act as green- houses to control sun and water expo- sure. Large gardens in these elevated containers supplement food production and reuse site water. These areas are accessed via doors directly off each of the 6 bed patient rooms. The tend- ing of these gardens by family and less acute pateints creates another venue for healthy distraction.
52 53 1.4 St. Lucia St. Lucia , with a total land area of 238, 616 km2 is Total population: 163,000 an island of the Caribbean. The majority of the popula- tion inhabit the coastal areas and the less mountain- ous regions of the north and south. It has a democratic Life expectancy at birth m/f (years): 72/78 system of government similar to the Westminster model. St. Lucia is a member of the Commonwealth of Nations Healthy life expectancy at birth m/f , the Organization of Eastern Caribbean States (OECS) (years, 2003): 61/64 and the Caribbean Community (CARICOM). Although the official language is English, a French patois is commonly Probability of dying under five used, particularly among the rural population. (per 1 000 live births): 14 Various departments within the MOH are responsible for the implementation of health programs such as health Probability of dying between 15 and education, environmental health, preventive services, 60 years m/f (per 1 000 population): 202/104 hospital and curative services. Primary health care ser- vices are mainly provided at the 34 health centers and Total expenditure on health per capita two (2) district hospitals. In addition to routine general (Intl $, 2006): 421 medicine clinics, special services are offered in obstet- rics/gynecology, pediatrics, surgery, sexually transmitted infections and mental health. Special clinics and basic Total expenditure on health as % of GDP services are offered to diabetic and hypertensive clients (2006): 5.9 at the primary care facilities. Secondary and specialized care and services are provided at the three general hos- pitals and the psychiatric hospital. Although clients may seek care at any facility, the administration and man- agement of health facilities are based on the catchment population.
54 551.3 Case Study - St. Lucia Small developing island nations are among the most impacted by cli- mate change because of their vulnerability to extreme weather and rising sea levels. However, because of their small size and low levels of energy use, they have the potential to convert to renewable sources much more easily and can serve as models for other countries. Saint Lucia’s govern- ment is currently seeking to become the first “Sustainable Energy Dem- onstration Country” amongst small island nations in the Caribbean. The country is hoping to diversify its energy market by ending its nearly exclu- sive reliance on diesel generators for production and rely more on its natu- ral setting that is ideal for solar, wind, and geothermal power. The building’s orientation follows the surrounding village’s NE to SW axis to take advantage of prevailing tropical trade winds. Breezes pass over the sloping roofs and are channeled through wind turbines, then continue on to cool the courtyards. Solar hot water panels take advantage of the abundance of sunlight. Photovoltaics could also be used to assist in power generation. Shaded courtyards create an environmental buffer zone at the perim- eter walls as well as areas for social interaction and cultural use. Water runoff from the roofs is captured for building use or released into natural filtration areas. Waste from buildings can be effectively recy- cled into biogas through anaerobic bioreactor or digester to create electric- ity and even cooling through cogeneration. The Eastern Caribbean has significant geothermal potential since most of the islands lie on dormant and active subsurface volcanoes. Saint Lucia alone has approximately 680 MWe of geothermal power poten- tial. Saint Lucia’s island neighbor, Nevis, has begun constructing a large geothermal plant that will provide 10 MW of power, and the Saint Lucian government is attempting to pass legislation funding similar geothermal endeavors. Organic Waste Stream - Organic wastes are to be collected on-site and composted for integral urban farming or sale to exterior farming cen- tres. Material Resource Recycling Stream - Relatively benign materials such as paper, cotton, plastics are to be collected, sorted and recycled. Ventures may be established with manufacturing industries to create closed loop resource cycles.
58 59 1.5 Guizhou China Guizhou is a relatively poor and undeveloped province. China It also has a small economy compared to the coastal Total population: 1,328,474,000 provinces. Its nominal GDP for 2008 was 333.34 billion yuan (48 billion USD). Its per capita GDP of 8,824 RMB (1,270 USD) ranks last in all of the PRC. Life expectancy at birth m/f (years): 72/75 Its natural industry includes timber and forestry. Other important industries in the province include energy Healthy life expectancy at birth m/f (electricity generation) and mining, especially in coal, (years, 2003): 63/65 limestone, arsenic, gypsum, and oil shale. Guizhou’s total output of coal was 118 million tons in 2008, a 7% Probability of dying under five growth from the previous year. (per 1 000 live births): 24 Guizhou adjoins Sichuan Province and Chongqing Mu- nicipality to the north, Yunnan Province to the west, Probability of dying between 15 and Guangxi Province to the south and Hunan Province to 60 years m/f (per 1 000 population): 143/87 the east. Overall Guizhou is a mountainous province however it is more hilly in the west while the eastern Total expenditure on health per capita and southern portions are relatively flat. The western (Intl $, 2006): 342 part of the province forms part of the Yunnan-Guizhou Plateau. Other cities include: Anshun, Kaili, Zunyi, Duyun, Liu- Total expenditure on health as % of GDP panshui and Qingzhen. (2006): 4.5 Guizhou has a subtropical humid climate. There are few seasonal changes. Its annual average temperature is roughly 10 to 20 °C, with January temperatures ranging from 1 to 10°C and July temperatures ranging from 17 to 28 °C.
60 611.5 Case Study - Guizhou China Because of Guizhou’s mild climate with low seasonal change, an east- west orientation of the inpatient wings is ideal. The taller walls of the wings can face south to maximize daylighting. Roof overhangs and sun- shades further protect the facades from direct solar gain but allow reflect- ed light to enter the rooms. The UN Environmental Program estimates that CO2 levels in Beijing could be reduced by 80% if the city meets its goal of greening 70% of their roofs. Developing areas can be proactive by greening new roofs now rather than retrofitting later. Additionally, as rural farms are lost to urban development, green roofs provide an opportunity for food production. In this application, the roofs could also be used to grow plants for traditional Chinese medicines. Shaded courtyards create an environmental buffer zone at the perim- eter walls as well as areas for social interaction and cultural use. Native plantings can be used to eliminate the need for irrigation. The Guizhou province receives abundant rainfall but lacks the means to provide an efficient and reliable water infrastructure. Managing and reusing stormwater runoff is therefore a key element in the roof and court- yard design. The green roofs slow drainage during heavy rains, and filter the water for reuse in the building. China has been exploring and using geothermal energy for 40 years and its use is currently growing by 10% each year. Uses of geothermal re- sources in China are widespread including domestic heating, tourism spas, and aquiculture. The utilization of a ground source heat pump is a better renewable alternative to photovoltaics given the Guizhou region’s high percentage of overcast days. Organic Waste Stream - Organic wastes are to be collected on-site and composted for roof farming or sale to exterior farming centres. Material Resource Recycling Stream - Relatively benign materials such as paper, cotton, plastics are to be collected, sorted and recycled. Ventures may be established with manufacturing industries to create closed loop resource cycles.
62 631.6 Affiliations The True Test The best test of an idea is in the marketplace. JCI has published a new document International Essentials of Health Care Quality and Patient Safety for developing countries. I signed you up for access to that document. You should be receiving an e-mail verification. Questions of universality, scalability and transferability of any idea are tested Here would be points I saw in your presentation. everyday by the world we live in. Ideas are rejected or adopted based on their ability to be relevant to meaningful life improvements. Scalability: The design allows for success to happen gradually. The building is organic in how it allows for evolutionary changes to take place as care provision volumes or needs change. We have tested our ideas with our clients on this modest but far reaching Sustainability: The design uses nature to provide for its energy, water, heating and cooling. In impoverished countries with little infrastructure, this is so vital to success of providing safe patient care. The Joint Commission Standards for healthcare that were created by a multinational collection project. In addition we have also reached out to those who are often the first of health experts require a method of providing potable water as well as electricity 24 hours a day. Using solar energy via the photovolaric cells is call to those countries trying to modernize their Healthcare delivery systems indeed creative. It reminds me of Nicholas Negropontes dream of a "laptop for every child". He had laptops built that recharged from solar power and were impervious to dust due to the often dry and dusty conditions that the children would be in. (See 60 minutes, May 20, 2007) and buildings, The Joint Commission International. Their input seemed like the next logical step in pursuing this truly valuable IDEA. Flexibility: The flexibility offered by mobile type extensions prior to any permanent construction provides a fast, reliable method of expansion. The design also would be applicable to areas ravaged by nature via storms, mud slides, tsunamis, earthquakes or other devastating forces. With the flex- ibility of these designs, much could be constructed off site and dropped in via air lifts quickly and efficiently. It seems we are on to something. The 21st century M.A.S.H. unit for civilians. The article I wrote for Carlo Ramponis (JCI European Managing Director) interview with Prof. Per Gunnar Svensson was published in the journal World Health Design in January 2009. In answer to the question Svensson had sent regarding developing countries, here is our quote: Developing countries are often neglected on the world stage, but it is crucial that as we research the methods being used in newly developed facilities, that we explore what can work in countries where there is limited access to basic infrastructure" (p. 19). I feel your design has incorporated the simplest but best methods. It now is a model to study for how we in the "developed" nations might reduce the stress to our planet in our facility design. Kathy Reno Joint Commission International
64 651.6 Affiliations By MARC LACEY New York Times Published: January 15, 2010 PORT-AU-PRINCE, Haiti — Efforts to deliver desperately needed food, water and medical help to victims of Haiti’s earthquake inten- sified on Friday even as the voices of survivors buried underneath Dear Bill, mountains of rubble began to fall silent. Given today’s events in Haiti, I wanted to reach out to you again regarding the Med-1 mobile Cargo planes and military helicopters swooped in and out of the hospitals. We have two units in Charlotte, NC that are immediately available. Each is capable crowded airport in Port-au-Prince. Hundreds of American troops were WITHIN 30 MIN OF ARRIVAL, of providing two operating rooms, four intensive care beds, and arriving, with more on the way. Some 25 rescue teams fanned out seven emergency department bays. A complete two hundred bed tent based hospital is live in to collapsed hotels, schools and homes, and aid groups said they had another six to seven hours. given food and blankets to thousands of people. Also, since Haiti will eventually need to rebuild its bricks and mortar facility; we But 2 million to 3 million are still in dire need, and patience was wearing thin on the streets as Haiti went another day with no power have partnered with a USAID contractor, the architectural firm OWPP-Cannon. and limited fresh water. OWPP-Cannon is designing developing world healthcare facilities for rural Afghan- istan under USAID sponsorship. They are built to take advantage of the flexible In remarks from Washington, President Obama cautioned that that it would take time to set up distribution centers for assistance, but he capacity that modular/mobile facilities such as the Med-1 offer. Together USAID said American help was reaching the capital city. Mr. Obama said he can have a state of the art immediate solution that blends into a fixed facility de- had spoken with the Haitian president, René Préval, and pledged the signed specifically for resource deprived environments such as Haiti, while con- United States’ full commitment in helping Haiti rebuild from a quake tinuing to take advantage of the mobile facility to maintain the economy of scale. that destroyed at least 30 percent of the capital and leveled half of the buildings in some neighborhoods, according to United Nations Attached is a first draft description of the mixed use concept, plus another copy of the full estimates. suite of mobile facilities. The mobile Med-1, the laundry and shower truck, and the mobile kitchen are immediately available. Please feel free to call or write anytime if you would like to discuss this idea further. Scott R. Scott Altman, MD, MPH, MBA EMerge1st, Ltd. International Healthcare Solutions
66 67The Idea This is a healthcare prototype that bridges a gap in the society of developing nations. The gap between rural clinics and urban hospitals. The gap that is stranding millions, especially women and children, on the wrong side of history. By providing right sized, flexible, simple hospitals that can bridge this chasm, an entire nation can stabilize its population and move up the hierarchy of security and wealth. It’s not just about access to care; it’s about access to the future, by putting down roots and investing in local, long term growth. The no-grid hospital is the seed that stabilizes the shifting sands of the community, allowing time for the grid, and education, to take hold. (in case you missed it)