Second Week in Sagam, Kenya

It took me about a week to get accustomed to the culture here in Kenya but when I did, it made life much easier. The second week of my stay here started off really well. On Monday, I had the opportunity to meet Deborah Rogo, the daughter of Khama Rogo, who owned the hospital. Deborah is the acting General Manager of Sagam Hospital and was a great source of knowledge in terms of hospital operations. Seeing from her point of view gave me very useful insight of operations from the local context. I then presented my analytical findings and masterplanning to her. She had a few comments on things that I may have misunderstood due to the difference in context but overall she agreed with my analysis. From her feedback, I went back and worked on my traffic flow analysis of the hospital to prepare for my presentation with Khama Rogo.

Deborah Rogo

The next day, Deborah gave me a tour of the entire hospital and the sites for expansion. Sagam Hospital has a lot of plans for expansion including housing for their workers. They have been having a difficulty recruiting new members because of the hospital's remote location. I learned that provincial hospitals need to be built with housing in mind to encourage healthcare workers to work there. Since the housing were still under construction, I got a sneak preview of how they locally construct buildings. For most one story buildings, Kenyans use a combination of mud bricks and concrete to build load bearing walls, which are approximately 200mm in thickness. For every 4 layers of bricks, they use a metal bar or "wall pass" to add strength. The bricks are made by simply digging up their abundant soil, pouring that in a mold, then leaving it to dry in the sun. This makes their wall construction very affordable. After the tour, I got back to work on the designs for the 3rd level and the masterplan for the hospital including its expansion.

I then got a call from Khama who told me to observe some masons working on the flooring for the entrance of the ER to see if I can get inspired by local craftsmanship. They used the thin stone and placed it on top of cement mixed with rough sand. Their methods of making the path were simple and rudimentary but highly effective.

On Wednesday, Khama finally arrived and I was able to meet him for a quick update of what I was doing. I presented my analysis and designs. He agreed with me that the old building has poor access to natural light and air ventilation. After the discussion, he told me that he was going to be in Kenya for 5 straight weeks and that he wants a lot of construction done before he leaves. Apart from the 3rd level, he wants to implement what I had proposed for the OPD in class last semester. What I have noticed so far was that construction only really happens when Khama is present on site. He is very hands on with construction and spends a great deal amount of time to make sure everything is moving.

Khama then shared his plans for the second level of the hospital. He wants to add another level above the old building and asked me that if I was not working on the 3rd level, that I should be "dreaming about the 2nd level". I took that as a call to action that I should design the second level. Currently, the doctors in the hospital did not have their own office space. The expansion of the second level would provide them with just that. Designing the second level also gave me the opportunity to give the first level more access to natural light and improve passive ventilation.

Original Building First Level

I felt accomplished that Khama had asked me to help him design the second level and that he trusted me as a designer. It was not part of the initial responsibilities that I was tasked with but am happy to accept more work while I was there. Like I said in my last post, I want to make the most of my trip here. After conversing with Khama, my tasks now included helping implement the 3rd level of the ER, masterplanning the entire hospital, landscaping, redesigning the OPD, and now designing the second level of the old hospital.

Thursday started off really interesting because I volunteered to be a patient for a medical simulation. The MGH fellows hold simulations every Monday and Thursday to better equip the Sagam Hospital healthcare workers. My role for this simulation was a construction worker that had fallen off a ladder and was then unconscious. I was instructed to lay down at the waiting room. I was then transferred to a gurney and brought to the resuscitation room. I cannot recall the last time I was being transferred using a hospital bed. It was quite unnerving. After several physical exams, they then had to put a neck brace. Overall, the fellows and I were impressed with the performance of the doctors and nurses.

After the simulation, Khama called me asking me to meet a man named Werewn who was in charge of construction for the steel roof. I had to then explain to him what was happening for the second level. It was a strange feeling being depended on like that in spite of my recent arrival. On my way back to the house, I bumped into Khama who asked me if I could present all my work to him. I then proceeded to present my traffic flow analysis, masterplan, and landscaping.

Traffic Flow Analysis

Throughout the presentation, it was very exciting seeing his eyes light up and that my work resonated with him. He then went on approving my designs and saying that he will work on it within his 5 week stay to make them a reality. It left me in a state of both giddiness and fear because I am finally getting work out in the real world. I have designed quite a bit of built projects but all of them were personal work for my own business. This was the first time that it was for someone else.

On Friday, Tim Duchenness, my first teammate from RISD finally arrived. After giving Tim the tour of the hospital, we then got working on the 3rd level designs to make it ready for implementation. Now that Tim was present, I was able to spend more time on the other designs that needed doing. As per Khama's instructions, we needed to start construction. So Tim and I met the masons that were going to build the curved walls that's part of our 3rd level designs.

We spent the weekend working at the hospital. For Saturday, we were instructed to foresee the beginning of construction at 7:30 in the morning. When Tim and I arrived on time, we had to wait for a couple of hours until all of the workers had arrived. It turns out that just like the Philippines, Kenya had their own sense of time. When they actually started construction, it felt great because we were finally getting physical work done. We started with clearing the floor debris and then we started constructing the curved walls using brick.

On Sunday, I prepared a construction schedule for us. Another aspect of design that I had to learn on the spot. Thankfully, everyone seemed to be on board with the schedule that I had proposed. Overall, the week was a pretty productive one.

DESINELab Student Lecture

I was recently invited to give a student lecture on healthcare as part of an ongoing series by DESINELab here in Rhode Island School of Design. I wanted to share what I talked about here in this blog to extend the conversation to a wider audience. Any kind of feedback or comments would be much appreciated.

My interest in healthcare was sparked in an advanced studio class I took with Nathan King and Olga Mesa called Future Health Systems. In this class, I realized that most of my personal efforts in trying to affect positive change, within systems like business, the food industry, agriculture, and education were all connected with healthcare, or at least my own vision of healthcare. For that studio, I proposed an ideal healthcare system for the Philippines through architecture, which you can find here. I am currently writing a manifesto for it, in the hopes of making it a reality. 

This narrow focus on a specific area of design has opened many doors for me. I recently did an internship in MASS Design Group, as one of the first RISD students to do so. I have been asked to start consulting with a group of doctors in Manila who are building about 40 hospitals and clinics across the country. The pace of my understanding and knowledge on the field has been increasingly fast due to my niche interest in specializing coupled with the demand of good designers in the field. 

Paradigm Shift in Healthcare

Healthcare has long been ignored by the majority design community. Yet, it is currently experiencing a paradigm shift in where designers are crucial components. This shift is in response to a universal effort of decentralizing and defragmentizing traditional healthcare: from reactive to preventive, from medicine to wellness, from the hospital to the home, from the wealthy to the masses. Therefore, the definition of healthcare is as complex as ever.

Traditionally it is defined as the diagnosis, treatment, and prevention of disease, illness, and other physical and mental impairments in human beings. However, a lot more attention has been focused on just diagnosis and treatment. It is traditionally delivered within primary, secondary, and tertiary care, as well as public health. 

However, projecting forward this definition, as I have mentioned, will change. Therefore, looking forward, my own definition of healthcare is the maintenance of a persons complete wellness system, which includes social, spiritual, physical, occupational, intellectual, emotional, and environmental.

For this lecture, I will be using the lens of architecture in talking about design in healthcare but I want to emphasize that any field of design is just as important. To help understand the current context of healthcare architecture, I want to quickly talk about its history. Just like design movements, healthcare has gone through several revolutions since its inception. 

Prehistory of Western Hospital Architecture

Prehistory of Western Hospital Architecture began in Ancient Greece where the concept of health was closely linked to religious rites and rituals. It emulated the model of their classical temples. In the middle ages, monastic hospitals were built that resembled monasteries like Hotel Dieu. Most hospitals until the 1700's were designed in parallel to the architecture style of their time. They were rarely designed with the pure intention of being a place for treatment. In the renaissance, hospitals were designed according to the geometrical principles that were popular at the time like the Ospedale Maggiore in Milan in 1468. Then in the 70's western countries started producing statistics that triggered the first revolution in hospital design

Ancient Greece

Middle Ages

Renaissance

First Revolution: Built Natural Healing.

Hospitals were the first buildings that were completely determined by scientific and philosophical concepts. It was inspired by the poor outcomes of existing hospital designs that pushed designers to rethink hospital design. Two concepts were brought forth in Paris: the radial system and the pavilion system. Both systems believe that healing is not derived from medicine but from being in a purified, natural environment that provided clean air. The Hopital Lariboisiere by M.P. Gauthier built between 1839 and 1854 is credited as the first pavilion hospital. Pavilions maximized sunlight and windflow. Apart from designing hospitals using the beneficial effects of nature, architects designed hospitals to become iconic. By housing medicine in such a way, it influenced the public to believe that it was important and thus provided more investment, which drove medical science. 

Second Revolution: Medical Science and Technology.

At this time period, we begin to see the shift from using nature to using technology. This shift in balance began with the invention of the x-ray. Pavilion type hospitals were replaced with block hospitals because they thought long corridors made it more inefficient. Block hospitals were good for centralizing common utilities like the x-ray which was too expensive to place in every building/pavilion. The first of this block type was the Columbia-Presbyterian Medical Center in New York by James Gamble Rogers built in 1930. However, with the introduction of the block type, we lost an essential architectural feature: the ambition to create healing environments that emulated nature.

Third Revolution: Hospital for the Masses.

This revolution was the product of WWII and the 'social revolution' which fostered the idea of the Welfare State. Social Security Systems were set up in most countries to safeguard the public from unemployment, disability, old age, and illness. Due to the influx of new patients, technology was focused on treatment facilities and outpatient wards. Hospital architecture became synthetic and a new type of hospitals emerged called Matchbox on a Muffin Type. The idea with this new type was that it is much easier to rebuild and redesign the ground floor than to make changes in high-rise buildings. It combines a flat spreadout building and a high rise building containing the patient ward on top. It allowed changes to occur without disturbing the patient wards. The first of this type was the Hopital Memorial France-Etats-Unis in Saint-Lo by Nelson in 1956. Since hospitals were now open to a larger population patients stopped being treated as people but collection of possible diseases or just data. This ran parallel with the capitalistic trend of the Western culture and the rise of bureaucracy. 

Fourth Revolution: Empowering the Patient.

Hospital embodies conflict between the individual, and the needs of the medical staff and equipment. This led to the invention of a neutral, industrially-built, unexpressive structure that was no longer recognizable as an individual building. An example of this would be the Medical Center of Groningen in the Netherlands which emulated the city by introducing covered streets, a huge hall, and many shops and restaurants. Unfortunately, The transition from a medicine-dominated to a management-dominated hospital has not curbed the process of institutionalization. It failed to return the hospital to the people. Technology and science that was once the main justification for hospital architecture and design is now what is driving it to the opposite direction. 

Fifth Revolution: Returning the Hospital to the People.

This revolution should initiate the return to the basic principles of decent management, empowerment of the patient, de-institutionalization, and the courage to re-conceptualize healthcare and to let it go back to its core business. We are the generation currently undergoing this paradigm shift. Healthcare is shifting from being purely reactive to preventive, but we still have a long way to go. 

Designing Forward

How can we design for this new shift towards preventive healthcare, or what we can even call responsible design? I believe the answer lies in research and evidence-based design. When I interned in MASS Design Group, I learned that there should be 4 stages in design. Traditionally especially in architecture, there are two that we mostly focus on: Design and Construction or Manufacturing. However, there should be two more stages to make design more efficient and effective. 

Prior to the design phase, there should be a pre-design phase in where you research the context holistically. RISD design students are very aware of this and most of us approach projects this way anyways. However, where I think we are lacking are looking at things from a systemic point of view. Here is where ID students do better than architecture students in my opinion. In architecture, we often use the pre-design phase as basis of form and program making, which I think is still very shallow. Pre-design must be thought of from the scale of systems all the way to the people that use the system. 

The fourth phase goes after construction or manufacturing called Impact Analysis. This is often very difficult to do because it costs money outside the traditional budgets that are given by clients. However, it is one of the most important phases because it teaches the designer what actually works and what doesn't outside the theoretical realm. Without Impact Analysis, we cannot achieve a complete feedback loop and that is why history of design has been so inefficient and ineffective. We are currently designing objects and buildings without considering what kind of futures they will create both environmentally and socially. This is a manifestation due to the lack of impact analysis of our designs. 

With all 4 phases completing a feedback loop, designers can truly achieve research and evidence-based design. This means that your design is an efficient use of resources because your design meets a real need and demand rather than a theoretical one. From this we can start designing an environment that actually suits our human needs and prevent us from being unwell and getting sick. We cannot use money anymore as an effective way to gauge the flow of resources. Why not try using wellness as a metric of developing a project and as a way to see its following success?