Exporting Architectural Services to Haiti: A Case Study

Published on : July 08, 2011

Exporting Architectural Services to Haiti: A Case Study

Exporting Architectural Services to Haiti: A Case Study

Ratcliff, the architecture, interiors and planning firm based in the San Francisco Bay Area, is engaged in a pro-bono effort to bring medical planning and construction to hard hit Haiti.  We were approached by a local pediatric surgeon to consider providing medical planning and design services for a new Emergency Department and Intensive Care Unit at St. Therese Hospital in Hinche (pronounced “Ench” in Creole).  Our team of design professionals assessed existing conditions in a visit to Hinche, located in the Central Plateau of Haiti, approximately 3-1/2 hours northeast of Port au Prince, in April 2011.  

Having seen images after the January 12, 2010, earthquake, my personal impression of Haiti before the April trip was one of trepidation and anticipation of extreme despair, of a country needing our expertise in planning complex healthcare facilities.  Once heralded as the “Pearl of the Antilles”, and now the poorest nation in the Western Hemisphere, Haiti’s lack of basic medical services was greatly exacerbated by the earthquake that left more than 300,000 people dead and 1.5 million homeless. The aftermath of the earthquake included the construction of a new highway connecting Port au Prince to rural areas such as Hinche.  One unintended consequence of this highway building initiative, (that aims to create an infrastructure in a country without basic running water and reliable electricity) is an uptick in automobile accidents; hence, the motive for the ED project in Hinche (planned to be a Level II Trauma Center) and our invitation to help a very deserving people.

Project Challenges

Our team expected to encounter a fractured infrastructure but we were never really prepared for the lack of all basic necessities for constructing an ED and ICU.  Reliable power, clean potable drinking water, sewage treatment and disposal and the ability to control infection with proper mechanical systems and isolation units are all foreign concepts in Hinche and lacking in the present hospital.  Since there were no existing codes in Haiti on which to base our design, we began as we would any other healthcare project, with a program based on Western standards, specifically California and International Building Code guidelines regarding seismic requirements.  We enlisted the help of structural, mechanical and electrical engineers to assist in this endeavor, all of whom graciously accepted our invitation and accompanied our team in April.

Our project must be culturally appropriate (or the community will not use the facility), sustainable (off-grid and using renewable materials), reasonable to construct and maintain, and built with locally available materials and labor.

Keeping it Simple and Sustainable Drives the Design

The essential project driver that will shape all decisions is to keep everything simple. Simplicity is the mantra for our team, difficult to achieve in the often quite complex field of medical planning.  Coupled with the fact that proper Haitian design involves seismic and hurricane structural solutions, the selection of appropriate systems, materials and means of construction are tantamount to getting the project actually built.  Simplicity to our team means planning and designing a project “off the grid” that incorporates:

  • Solar energy: to generate electricity (primary source), with a diesel generator as a back-up (secondary) source. Our project orientation will allow good exposure to the south and west, so capturing solar should not be a major challenge.  Converting it to power and storing energy to batteries will be a minor challenge since space is a real premium at St. Therese Hospital.

  • Water purification: Hinche was the location of a 2010 cholera outbreak, and since many Haitians lack clean, running, potable water, our team was entrusted to devise or find a water purification system.  Clean water is particularly crucial in the ICU.  We hope to install a water purification system that can operate on solar energy through photovoltaic panels.  Our fallback option will be to connect the building to the existing cistern system that relies on rainwater collection and chlorination.

  • Water collection: the existing hospital relies on a system of cisterns fed by concrete walkways and sloping open culverts.  We intend to harvest rainwater to use for toilets and any irrigation needs.

  • Natural ventilation: in the Caribbean, it’s important to realize that the days and nights are warm and humid and since the only portion of our project to have conditioned air is the ICU, the ED will rely on natural ventilation concepts traditionally employed in the islands.

  • Daylighting: we need to anticipate loss of power and since both the ED and ICU are 24/7, 365 day service lines, our designers are incorporating a high-performance daylighting experience that maximizes mid-day sunlight while being cost-effective.  This will include light shelves, solar tubes, clerestory windows and fenestration where possible and at a high mounting height to afford a level of privacy for patients and visitors.  

  • Local materials and craftsmanship: we are identifying materials and building systems that possess the properties required to achieve a bio-climatic responsive building, one reliant on natural ventilation to create a cooler surrounding micro-climate.  These same materials and systems must also be familiar to the community labor force.  Many buildings in Haiti failed during and after the January 2010 earthquake due to poor construction that did not comply with basic seismic requirements.  We need to overcome the lack of training of the local work force to ensure incorporation of structural concepts used in California and elsewhere where seismic is a real issue.  Most existing buildings are non-engineered using lightly reinforced concrete frame and concrete masonry block (typically non-reinforced or minimally reinforced) as infill.  Wood is difficult to find and import since much of Haiti has been deforested over the last 100 years.  Metal requires welding and lightweight metal roofing is vulnerable to hurricanes; furthermore, metal does not weather well in hot and humid climates.  Our solution is leaning toward a concrete structure and CMU infill.

  • Minimize waste: it is our intention to eliminate all garbage, with the exception of medical wastes that are unavoidable in an acute care setting.  In the West, we typically equate a hospital setting with one that is clean, sanitary and devoid of garbage (at least garbage in plain sight).  At Hinche, the campus was garbage strewn, we think due to lack of sanitation disposal stations, services and education of the local community.  Our project will strive to incorporate systems that are conducive to proper waste management.

  • Technology: so essential to new healthcare delivery models, expensive technology is tough to justify in an economy where people live on $1.50 a day.  But the most startling revelation while in Haiti was that despite the poverty, almost every Haitian we saw in urban and rural areas had a cell phone.  With healthcare applications predicted to lead the way to improved connectivity in third world countries lacking basic medical services, wireless technology may prove an answer in connecting St. Therese’s ED/ICU to tertiary and teaching hospitals elsewhere in Haiti, such as the L’Hopital Universitaire de Mirebalais now under construction, located an hour south of Hinche.

  • Future surges: our team must plan for the likelihood of future outbreaks that will compromise the hospital’s ability to treat a large population effectively. Since we are indicating private exam and ICU rooms, the likelihood that those rooms will house more than single patients is great.  Provisions are being considered for double headwalls, twice as many outlets and space for two exam tables and two beds in anticipation of an inevitable surge.

Clearly the biggest challenge is in getting the project actually built and sustained thereafter. Our sponsors intend to train the staff at the hospital in cleaning and repairing headwalls and using and repairing radiology equipment.  Our contractor will include a community training program to educate the locals in construction methods that will withstand future events with minimal damage, aimed at allowing the ED to be functional in case of an earthquake or hurricane.  

Charrette Affirms Benefit to Firm of Pro-bono Effort

Our team recently completed a design charrette where sustainability and simplicity were the guiding concepts.  Our plan is built around a “fast track” program since space is a real premium: we need to enhance patient throughput and avoid clogging the ED with urgent care and clinic type cases that can be seen elsewhere.  Realizing that patients are typically accompanied by their entire families, some of whom travel hours to get to Hinche, space for family waiting is essential.

Senior Designer Jorge Burbano exploring a concept
for natural ventilation and daylighting
Charrette relied on images from Haiti and other Haitian projects for guidance


Our charrette reaffirmed our firm’s commitment to exporting quality services to less fortunate countries, something we are all beginning to affirm as part of any A/E firm’s strategic business development plan; pro-bono work is both a way to galvanize an office around a wonderful cause as well as a way to help people who are truly in need of western technology and services.

In the end, our hope is to have touched the lives of many in Hinche and surrounding communities reliant on St. Therese Hospital for basic and emergency medical care.  It’s difficult to imagine a city like Hinche, (with a population of 104,000, and a catchment area of about 220,000 residents who use St. Therese Hospital) devoid of emergency and acute care services.  All of that is about to change through the valiant efforts of our team and our sponsors, Medical Care for Children of All Races Everywhere (Medical C.A.R.E.), , which embarks on missions to provide proper training, tools, and techniques to local doctors and nurses in developing countries, and Dr. Rick Spurlock of Emergency Physicians International (EPI), a non-profit organization that seeks to improve medical care in developing countries by building EDs and enhancing the clinical skills of local providers.  Our project team is reliant on the generous contributions and donations of industry partners. Construction is slated to commence in early 2012.

** All Pictures were taken by the Author **


About the Author
Steven Steinberg, AIA, is Principal of Healthcare at RATCLIFF.  He has more than 25 years of experience in the architecture and real estate development industries.  He is a member of the American Institute of Architects, The Center for Health Design, American Society of Healthcare Engineers, and the Urban Land Institute.  He may be reached at: [email protected]