Nestled into a hilltop in Butaro in the Burera District of Rwanda, a white plaster-and-stone structure stands as a beacon for the improved well-being of the community. Completed earlier this year, the Butaro Hospital is drastically changing healthcare delivery to this rural countryside.
One of the most impoverished areas of Rwanda, this region had a highly inadequate care environment before the hospital was built with sometimes two or three patients per bed, some laying under a bed, and some on rows of mattresses on a floor. Overcrowded conditions not only deprived patients of decency and dignity, but also exacerbated infection control problems.
Partners In Health (PIH), led by Dr. Paul Farmer, had worked to improve healthcare delivery in Rwanda, but did not have architectural staff or expertise. Then, in 2008, PIH began a collaboration with Michael Murphy and Alan Ricks, who founded MASS Design Group (MASS) while they were still students at Harvard GSD. Murphy and Ricks were brought in by Farmer and PIH to help plan and design a first-rate healthcare facility for Butaro, and their Butaro Hospital opened in January. The jury of Contract magazine's 2011 Healthcare Environment Awards named this hospital the winner in the Acute Care Facility category (see coverage and jury comments).
The Clinton Health Access Initiative (CHAI), founded by President Bill Clinton, was an early partner for this project. CHAI assessed the Rwandan regions and national need, and brought expertise to understanding the scope of required work. CHAI identified Burera to be the most underserved district.
A new model for architectural practice
"At the most basic level, this project represents the will of a few groups who are committed to providing top medical care to communities in need, no matter what the constraints," Murphy says. "To me, it represents a new practice model in architecture, where we seek clients and communities that have not benefitted from the value of architectural service, and do whatever it takes to make that commitment a reality."
The 140-bed hospital wraps around and is embedded in a hilltop that had been used as a military base. It is designed as a campus of buildings--separate structures to help isolate and limit the possible transmission of disease--connected by outdoor circulation and loggias. The campus includes an emergency room, two operating rooms, internal medicine ward, maternity ward, intensive care unit, and pediatric clinic.
Air circulation was highly considered in the design, maximizing air mixing. Six huge 24-foot-diameter ceiling fans, produced and donated by Big Ass Fans, pull air up within the wards to then escape through louvered clerestory vents. Natural air ventilation, with a mix of operable and inoperable windows, helps to both reduce energy costs and lower the risk of infection. MASS worked with experts in infection control at the Harvard School of Public Health, namely Dr. Edward Nardell, a pulmonologist, to plan for this. With Nardell, MASS strategized a natural ventilation concept that would get enough air changes per hour to reduce transmission rates of airborne disease, and additionally implemented germicidal ultraviolet lights to inactivate microbes and sanitize air that is filled with tuberculosis particulates.
Without enough trained healthcare staff to have individual rooms for patients, open wards are the norm in Rwanda. In the Butaro Hospital, beds are positioned at the center, against a wood-paneled wall that has electrical outlets. With this configuration, the exterior windows can be larger than if beds were placed against the perimeter walls. Floors are a continuous single epoxy surface, which is best to mitigate the possible spread of infection. Renowned graphic designer Massimo Vignelli donated his graphic design services for the hospital's signage.
Significantly, the process to build the $4.4 million, 65,000-square-foot hospital involved the training of 3,898 laborers, including about 3,500 local residents who worked in shifts around the clock. Those trained as masons built the volcanic stone wall by hand and are now highly sought-after in the area after gaining incredible skills. Other walls of the buildings were constructed with CMU blocks, a reinforced frame, and a plaster coating. All rainwater is collected and reused.
Ricks points to this project's wider lessons for the role of architects. "For me, this project demonstrates the instrumental role that architects provide as translators and planners," Ricks says. "Architects are uniquely capable of studying and interpreting what the problem is, as well as how the well-built environment plays a role in addressing it."
MASS now has 10 architects in Rwanda and is building housing for the medical staff. "The hardest challenge was in executing this, realizing that drawings alone wouldn’t be enough to provide complete architectural service in this community," Murphy says. "That is why we moved to site and established a team there to complete the project."
Butaro Hospital. Architect MASS Design Group. Client Rwandan Ministry of Health, Clinton Health Access Initiative, Partners In Health. Where Butaro, Burera District, Rwanda. What 65,000 total square feet on two floors. Cost/sf $70.
Photos by Iwan Baan
Michael Murphy, Alan Ricks, Sierra Bainbridge, Marika Clark, Ryan Leidner, Garret Gantner, Cody Birkey, Ebbe Strathairn, Maura Rockcastle, Dave Saladik, Alda Ly, Robert Harris, Commode Dushimimana, Nicolas Rutikanga
PIH/IMB, Bruce Nizeye, Felix Ndagijimana
Vignelli Associates, MASS Design Group
Big Ass Fans
SIKA Epoxy Flooring
DOORS, WINDOW TREATMENTS, SEATING, TABLES, SHELVING, WOODWORKING
Custom, fabricated onsite