Design for Good: A New Era of Architecture for Everyone

Design for Good: A New Era of Architecture for Everyone

by John Cary


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Product Details

ISBN-13: 9781610917926
Publisher: Island Press
Publication date: 10/03/2017
Edition description: None
Pages: 280
Sales rank: 992,354
Product dimensions: 8.00(w) x 10.00(h) x 0.80(d)

About the Author

John Cary is an architect, writer, speaker, and curator focused on design and philanthropy. Consulting principally for TED, he is also an advisor to Aspen Global Health & Development and an array of foundations and nonprofits globally.

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If It Can Happen Here

The Improbable Story of Rwanda's Butaro Hospital

Michael Murphy remembers the night well. On the eve of his final semester presentation during his first year at the Harvard Graduate School of Design, Murphy quietly ventured across campus to sit in on a lecture unrelated to his pressing schoolwork. It was December 1, 2006, World AIDS Day.

The lecturer was the global health pioneer Dr. Paul Farmer, cofounder of Partners in Health (PIH), an international nongovernmental organization. A year earlier, while living in South Africa, Murphy had read Mountains Beyond Mountains, Tracy Kidder's popular book on Farmer, an uncompromising humanitarian, and the organization he cofounded. Before ultimately deciding to go to architecture school, Murphy had even researched job openings at PIH. Then and now, he faced the dilemma many of us have — how do you get access to an organization that you admire? A friend who wasn't even in graduate school with Murphy had alerted him to Farmer's lecture, so off he went.

Murphy was preparing to pull an "all-nighter," a rite of passage in architecture school, to work on his final project. He had done so innumerable times that semester, and each time, he had a little ritual of wearing his father's old Poughkeepsie High School Crew sweatshirt. Murphy recalls: "I looked terrible, ragged, unkempt, wearing this paint-covered sweatshirt."

Soon after Murphy settled into his seat, Farmer said, "We're building housing." Murphy had never thought about housing as a health-care priority before. "That really piqued my interest, and I sat up, thinking, 'Wow, this guy is building housing for people in really poor communities because he wants to provide better health care.' It instantly made sense: housing is a social determinant of health."

Farmer has a practice of patiently hearing out every person in line to talk with him after a lecture or panel discussion. "He's very, very kind," Murphy tells me, "and I think he was really energized that night by all the students who came up to him afterward, saying 'I want to mention my project to you.' He just waits for everyone to finish. That access was surprising; he was just so receptive."

Eager to work for any architecture firm working with Farmer, Murphy asked which firms Partners in Health had experience with. After all, Farmer had described building clinics, hospitals, housing, even roads. "I drew the last clinic on a napkin," Farmer told him. Here was a pioneer in global health who was undertaking significant building projects, and he had effectively never worked with an architect. Murphy was astonished, unaware at the time how little the practices of architecture and design intersected with global health and development work such as Farmer's.

At the end of their conversation, Farmer gave Murphy his e-mail address. By 9:30 p.m., Murphy was back at his desk and writing an e-mail to Farmer rather than working on his final project. "I sent him a message, and he wrote right back to me. So I sent him another e-mail, and he wrote right back again," Murphy recalls. "We were e-mailing about gardens and fishponds at his hospital in Haiti, and just talking about the beauty of gardens. I couldn't believe that this guy was writing back to me." Murphy remembers feeling a little star-struck but also inspired by the access to Farmer.

Murphy finally turned back to his studio project. He was tasked with squeezing a public pool into a bizarre, awkward site near a train station in Brookline, Massachusetts. "It was meaningless. I was also totally failing on the project," he recalls. But Murphy finished the project, and kept in touch with Farmer. In the summer of 2007, just six months after meeting him, Murphy accepted Farmer's invitation to visit Rwanda, one of the countries in which PIH had recently started to work.

Twenty-seven at the time, Murphy had never been to Rwanda, a landlocked East African country known for its gorillas and volcanoes and for the brutal civil war that had led to a horrendous genocide in 1994, just over a decade earlier. In its healing and under the leadership of President Paul Kagame since 2000, Rwanda had been transforming itself into a center for innovation in health-care delivery. PIH signed on as a crucial partner of Rwanda's Ministry of Health in 2005.

Mere hours after Murphy arrived in the capital city, Kigali, a doctor named Michael Rich picked him up for the two-hour drive to the organization's main office in Rwinkwavu, a town in eastern Rwanda. As he drove, Rich effectively said to Murphy, "What are you doing here? You're clearly not here for long enough to make a difference."

Murphy would learn during their drive that Rich's father was a contractor who had done huge building projects. Rich himself had built his own house out of mud bricks. So Rich uniquely understood construction and building and had done a lot of thinking about the planning of PIH's medical campus in Rwinkwavu.

Speaking of Rich, Murphy tells me, "Michael is very talented in a design sense. He was understandably asking, 'What's this twenty-seven-year-old architecture student with barely one year of experience doing here for a few weeks? What value is that going to provide?'" Murphy concedes, "He was very skeptical. I would have the same feeling if I was bringing on someone like that today."

Over many months and years, the two developed a strong relationship built on trust, hard work, and mutual commitment to PIH's goals. Murphy now counts Rich as one of his dearest friends and biggest advocates. "It was in that first couple of weeks, living with a bunch of doctors, trying to make myself useful, that I really built these relationships," Murphy explains. "It also helped me at least start to hone in on what would be useful for me to do."

Murphy's time in Rwanda that summer was spent between Kigali and Rwinkwavu, with visits to other PIH field sites. The organization had an array of projects and facilities, and Murphy tried to help out wherever possible. Perhaps most significantly, it was then that he met a Rwandan builder named Bruce Nizeye, PIH's head of infrastructure at the time. Nizeye was doing everything from building a large training center and a laundry facility to putting in a garden and a fishpond in one of the other health centers. Murphy recalls innumerable small projects that Nizeye, his brother Fabrice Nusenga, and an army of local artisans tackled day in and day out. They were working out of a few old warehouses on the PIH campus, left over from a mining company that used to be there.

"I was just so inspired. Bruce and his crew were thinking about architecture completely differently from how I ever had. He was literally making everything — working with carpenters to make furniture and metalworkers to weld windows, among many other things," Murphy recalls. "But being so young and so new to architecture, I wasn't burdened by the way architecture is made in the U.S. enough to understand exactly how different it really was. There, if someone needed a chair, Bruce made a chair."

Nizeye's focus on local labor and local materials made a profound impression on Murphy, and it would become a hallmark of Murphy's work and the nonprofit he would go on to found. Murphy stuck close to Nizeye, working on the laundry facility and other small projects, before returning to the United States and to school.

I met Michael Murphy shortly after his return from that first fateful trip to Rwanda, for no other reason than that he was dating a summer intern at the nonprofit I directed in San Francisco. I had heard a lot about Murphy by the time the pair waltzed into the fourth-floor loft that our organization occupied.

When Murphy and my intern, a Bay Area native named Marika Shioiri-Clark, told me they were returning to Rwanda to design and build a hospital, my first thought was, "This is a terrible idea." In my work domestically and knowing of innumerable other examples internationally, I had seen well-intentioned designers parachuting into unfamiliar places to "help," only to be crushed by the complexity of conditions they never could have anticipated from a distance. This seemed all the more probable for a couple of Ivy League graduate students. What could they possibly have been thinking?

At the time, most work of this type was conceptual, and much of it was small in scale, if it had even reached the point of construction. Schemes for shipping-container clinics were especially prevalent. Again, all well-intentioned but difficult to execute for a whole host of reasons.

Thank goodness Murphy and Shioiri-Clark didn't listen to me.

The pair and a group of classmates launched MASS Design Group, with MASS standing for "Model of Architecture Serving Society." Along with classmate David Saladik, Murphy and Shioiri-Clark went to Rwanda that winter. They spent their school break sketching possible schemes for a hospital in the Burera District, which at the time was home to over 340,000 people and barely one functioning clinic. They then returned to Harvard, recruited a larger group of students, and spent many cold Boston nights and weekends designing the hospital.

After weeks of work, the team settled on a barrack-style building for the hospital. Even Murphy was underwhelmed. "It was not a good design; we just didn't know what we were doing," he recalls. Murphy shared the design with Michael Rich, who told him, "I really don't think this is what you want to show. It's not the kind of inspiring architecture that we were hoping for." Murphy knew Rich was right. He and his classmates were designing far from Rwanda; they needed to be back there, living on-site, working side by side with PIH and the community.

Murphy and Saladik moved to Rwanda in the summer of 2008, living on what is now the Butaro Hospital site. The hilltop where the hospital stands was itself a contested site and a prison during Rwanda's civil war in 1994; PIH had converted an old jail building into its quarters. Murphy and Saladik shared bunks with PIH staff and immersed themselves in the community and the site.

"We were drawing all day in our room or elsewhere and, at night, showing plans and interviewing nurses and doctors," Murphy recalls. "We presented the various layouts and went back and forth with them. It was this very, very intimate, iterative design process, happening with medical professionals on a day-to-day basis. It was so ideal." More than designing the building together, Murphy, Saladik, and PIH were building relationships rooted in trust and understanding.

Because of its connections with Brigham and Women's Hospital in Boston and other major medical systems, PIH was able to attract some of the world's best-trained doctors to Rwanda. "They knew how an operating theater at the Brigham should be configured," Murphy recalls, "but no one knew how it should be configured in this remote context, which didn't even have reliable electricity at the time. There was an expectation that it had to be different. Because of that, I think, people were willing to go along with us on this journey."

A young physician within PIH, Dr. Peter Drobac, would come to play an important role in this project. A native of my hometown, Milwaukee, Drobac had led a parallel life to Murphy's in some important ways. Drobac took his first trip outside the United States at age twenty-one, when he visited the African country of Tanzania to study primate ecology and behavior. While the primate study didn't convince Drobac of a future in that particular field, he fell in love with the people and culture of Tanzania and returned the following year.

The year was 1998, and the HIV epidemic was raging in sub-Saharan Africa. It was just a couple of years after the first effective HIV treatments became widely available in developed countries. "I found myself sitting right at the nexus of this vast gulf of inequality, where most of the kids we were seeing and working with were coming in from villages where they had lost family members to HIV," Drobac recalls. "We were surrounded by communities that were dying." He had read and knew about effective treatments that weren't reaching the immense suffering in Tanzania, and it filled him with anger.

When he returned to the United States to attend medical school, Drobac knew that he wanted to do something about these vast disparities in health and wealth around the world. He was particularly committed to returning to East Africa. But he had no inkling of how to go about it. Global health wasn't such a clearly defined field at that time.

"I went to the Medical College of Wisconsin, and I recall meeting an administrator the first week and telling him what I wanted to do," Drobac says. "The counsel I got was, basically, 'Okay, that's nice. You can do some missions when you finish your residency. But, for right now, just focus on your education.' There were no resources, there were no mentors, there was nothing happening."

In medical school, Drobac was somehow turned on to the writing of PIH founder Dr. Paul Farmer. In Farmer, Drobac found someone who seemed just as angry as he was. "But he had a framework for understanding what was happening and what these dynamics were," Drobac concedes. Shortly thereafter, Drobac moved to Boston, where Partners in Health is based, for a residency at three local hospitals through Harvard University. Work with PIH soon took Drobac to Rwanda.

By 2005, PIH was officially engaged in Rwanda, working with the Clinton Foundation's HIV/AIDS initiative in the southeastern part of the country. The goal was to treat people living with HIV in a place where the disease was rampant and, in so doing, build a bona fide health-care system.

Just a year later, President Bill Clinton was in Rwinkwavu visiting with Farmer and government officials. After seeing PIH's approach firsthand, Clinton declared, "I think this is the model that can save Africa."

That may have been hyperbole, but the endorsement was galvanizing. The entire country of Rwanda would go on to adopt PIH's model of community-based primary health care. It decentralized health services in each of the country's thirty districts, with a designated hospital in each district. Those hospitals would be supplemented by a network of outpatient health centers farther afield, which fed into a network of community health workers who managed to reach patients in even more rural settings. It was called the District Health Systems Strengthening framework.

The first test case was the Burera District, starting in late 2007. "Our notion was, let's go to the worst-off district in the country — the place with the poorest health outcomes and the weakest infrastructure — and make it a proof of concept," Drobac explains. Farmer's theory was "If it can happen here, it can happen anywhere."

At that time, this district of more than 340,000 people had no hospital and only one doctor. There was a small patchwork network of health services, usually with about two nurses, very poor facilities, and often no electricity. Burera was, however, a region that President Kagame had campaigned in, promising to build a hospital. Even with the hospital mandate, PIH and the Ministry of Health didn't set out to build a flagship hospital. They simply set out to build an integrated health-care system with a hospital at its core.

Although Drobac had been stationed in Rwanda since 2005, it wasn't until January 2008 that he went to the Burera District to concentrate his work. It was there that he met Murphy, Shioiri-Clark, and Saladik during another one of their extended visits. Drobac recalls noticing that they were a little younger than he was. "I liked Michael, Marika, and David instantly."

On August 6, 2008, two years after drawing attention to the potential of Rwanda's health system, Bill Clinton spoke at the ceremonial ground-breaking for the Butaro Hospital. "I believe this hospital, sitting in this beautiful, peaceful setting, symbolizes health and hope and peace and unity," he said. "Everything about this hospital, including this beautiful setting, symbolizes the future that I believe we all want for Rwanda, for all of Africa, and for all of the world. It is about everything that is good about our future and overcoming the parts of the past that have to be dealt with."

A few months later, as their families back home were celebrating Thanksgiving, Murphy and the team stood on that lush hilltop as the hospital officially broke ground. In the intervening months, an excavator had proved too costly to bring to the site, a four-hour, dirt road drive from Kigali, so on that day local community members started digging the huge foundation themselves, with shovels.

From that day forward, dozens and often hundreds of people were working on the job site. Under Nizeye's direction, nearly four thousand local people were hired and trained to help build the hospital. Many were entirely new to construction, learning invaluable skills. Construction crews were organized into six teams, each working a two-week shift, enabling six times as many people to be hired. The workers not only were paid for their time but also received food, water, and health care. These efforts didn't cost more; they actually saved money. All told, MASS and PIH were able to reduce the hospital's cost to roughly two-thirds that of comparable hospitals in Rwanda.


Excerpted from "Design for Good"
by .
Copyright © 2017 John Cary.
Excerpted by permission of ISLAND PRESS.
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Table of Contents

Foreword by Melinda Gates
Introduction: The Dignifying Power of Design

Chapter 1: If It Can Happen Here
Chapter 2: Buildings that Heal
Chapter 3: Shelter for the Soul
Chapter 4: Spaces that Enlighten
Chapter 5: Places for Civic Life
Chapter 6: Raising Expectations
Conclusion: A Call to Expect More

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