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In Haiti, Battling Disease With Open-Air Clinics

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PORT-AU-PRINCE, Haiti — The pictures of medical dysfunction were devastating — broken hospitals in Africa struggling, and largely failing, to contain the Ebola epidemic. As deaths mounted, the problems seemed intractable: no money, no infrastructure, no hope.

But across the ocean, Haiti — a broken country if there ever was one — now has two new clinics, open-air, modest in size and cost, designed to tackle diseases that can be as insidious and deadly as Ebola, but are also more common: cholera and tuberculosis.

The clinics here are simple, even handsome. Instead of constructing hermetic shields in the form of airtight, inflexible hospital buildings, the architects took advantage of Haiti’s Caribbean environment, exploiting island cross breezes to heal patients and aid caregivers.


Ivan Baan for The New York Times

It’s not clear yet how well the clinics will work. They open soon. If they turn out right, they could serve as relatively light-footed models for other struggling countries that lack resources for high-end Western-style hospitals. They might even do a little to nudge hospitals in the United States away from the midcentury model of sealed buildings that rely on imperfect mechanical systems costing a king’s ransom and gobbling up energy. Architectural innovation these days can travel south to north, after all, not just north to south.

The two clinics are by MASS Design Group, a young firm from Boston that won kudos recently for a hospital in Rwanda. Like that project, these capitalize on local materials, labor and crafts. One clinic here replaces a tuberculosis treatment center, run by Gheskio, a Haitian health service and research organization. The center collapsed during the earthquake in 2010. The new two-story structure is roughly a pentagon, with one extra-long end. There are rooms for 35 patients surrounding a landscaped courtyard — “an oasis,” is how Alan Ricks, a partner at MASS, imagines it, and that’s close to how it already feels — with a fountain and bougainvillea climbing up bamboo screens.

It’s a plain but elegant structure whose latticed, sculptured steel roof (a giant woven basket comes to mind) gives it some character and helps hot air circulate up and out of the building. Because tuberculosis thrives in closed spaces, windows are placed on walls directly opposite one another to promote cross ventilation.

The other building, for cholera patients, is a single-story pavilion on a separate Gheskio campus, across a busy, rutted road from one of the largest slums in this city, whose residents it mostly serves. It’s not inside the slum, but nearly. The zigzag roof vaguely conjures up 1950s roadside diners. The vibe is surprisingly playful, welcoming. Sky-blue, hand-punched metal screens, made by local artisans, clad the outside and allude to tap-taps: the gaily colored, extravagantly decorated share-taxis that Haitians ride to get around the city.

Cholera arrived here by way of Nepali aid workers after the earthquake and ran amok through contaminated water. Companies hired to dispose of wastewater safely dumped it illegally instead. At the new clinic, MASS constructed a dedicated wastewater treatment system under the pavilion, safeguarded from floods, the architects say. Many hospitals in developing countries burn waste on site. This takes the approach a step further.

Ivan Baan for The New York Times

To some doctors, a permanent cholera clinic can simply sound wrongheaded. Emergency medical experts told me that outbreaks like cholera, or Ebola, tend to be addressed best by portable, pop-up “camps” erected inside stricken areas, to quash the problem at its source. The real solution to cholera would be fixing the sanitation system in the slums. As one doctor put it: You don’t build a trauma center to address a deadly traffic intersection; you redesign the streets.

But a doctor at Gheskio stressed that the clinic here, conceived around the architectural challenges particular to cholera, can be repurposed after the disease is no longer the problem.

And neither clinic cost an arm and a leg. The tuberculosis clinic was $2 million, or $140 a square foot, according to Adam Saltzman, the project manager for MASS on both sites. The cholera clinic totaled $700,000, or $80 a square foot.

Architecture and engineering helped eradicate these diseases ages ago in cities like London, Paris and New York, which constructed sewers and hospitals, while clearing slums. As postearthquake Haiti proves, absent adequate architecture and infrastructure, the diseases can return with a vengeance. The cholera epidemic has affected an estimated 800,000 Haitians, according to Jean William Pape, the Haitian doctor and Cornell professor who founded Gheskio. (Its full name is the Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections.)

Dr. Pape was among the first to identify H.I.V./AIDS in the developing world. Since the earthquake in 2010, he and Gheskio have employed short-term measures to cut the death rate from cholera by 80 percent, introducing a temporary vaccine and distributing chlorine that Gheskio manufactures on its campus. “Architecture and health are inseparable,” Dr. Pape explained when I dropped into his office one recent morning. “A building that is ugly, with no fresh air, no dignity or common sense, is a place people will avoid, and this encourages epidemics.”

I peered into Gheskio’s provisional tuberculosis treatment site, which the new building will replace: It’s a bare-bones, gated tent village. A tent not far from Dr. Pape’s office now serves cholera patients; a stack of cots teetered in a corner. MASS has enlisted furniture-makers at Gheskio to help design better, more comfortable furniture for cholera patients.

“We have 10,000 people on this campus,” Dr. Pape said, “making bricks, metal working, making furniture, manufacturing chlorine.” There is a preschool, too, and a shelter for abused women, who are provided with on-site infant care and job training. It’s a virtual city within the city.

“Too often, after an emergency, when the aid agencies are done, there’s no more funding, and disease simmers,” Michael Murphy, another partner at MASS, told me. “There’s a real chance to end cholera and tuberculosis, but that can only happen with permanent infrastructure. We are building against the hospital trend of the midcentury in the U.S.” He was talking about buildings that “can cause infections and all sorts of other problems.”

The idea harks back to colonial hospitals in the developing world, which were open-air buildings constructed around courtyards. In the tuberculosis clinic, MASS’s architects have carved vestibules outside patient rooms, along the balcony and around the edge of the courtyard so nurses and doctors can conduct examinations in fresh air, not in the rooms, where they’re most likely to become infected. For that same reason, cleaning crews can also avoid the rooms and enter patient bathrooms through a separate door, a strategy European infectious-disease hospitals have pioneered.

“We believe in context,” Mr. Ricks said. “In Rwanda, we asked, ‘Why not have fresh air?’ It wasn’t a radical question.”

Dr. Pape elaborated: “Doctors treating Ebola in most parts of Africa don’t have facilities anything like the ones in the United States, but they rarely get infected. So clearly the clinical environment doesn’t need to be like Mars.”

I spoke with two local contractors who built the tuberculosis clinic. They told me they had never overseen anything as customized or demanding. Robertho Jean Noel, a young Haitian civil engineer, was enlisted by MASS to ride herd on the contractors, one of whom, Pierrot Coupaud, complained to me about how certain tricky parts of the latticed roof had to be ripped up and redone three or four times.

But then Mr. Coupaud pointed to a plain, windowless new stucco clinic next door. “That box is a joke,” he said. “What we’ve done is something else.”

Listening, silently, Mr. Noel smiled.

Read More at the New York Times

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