Before October 2010, Haiti had no documented cases of cholera. Since then, the country of 10 million hasn’t passed a day without it.

While easily treatable, cholera has been responsible for the deaths of thousands, and Haiti and international health organizations are fighting it with few and shrinking resources. During Haiti’s rainy seasons, what would seem like a disease in decline resurges. Cholera Treatment Centers (CTCs), little better than long canvas tents with special beds, swell with patients that doctors scramble to treat, wondering when or if the disease will ever be contained. In 2013, 1100 cases and 9 deaths were recorded, on average, each week–a figure lower than the previous years but woefully far from zero.

In Port-au-Prince and Boston, architects at MASS Design Group are figuring out how to deliver treatment more efficiently, and stomp the disease’s momentum. The nonprofit believes that buildings–in this case, permanent clinics–will play a significant role in this fight.

Meeting the MASSes (Again)

MASS is a (achem) huge advocate for design innovation in medical facilities. Take, for instance, hospitals. In richer parts of the world, these facilities tend to be ‘environmentally controlled;’ in other parts of the world, where fewer mechanical systems routinely purify the air, say, design mimicry may encourage the spread of diseases between patients and healthy visitors[1]. In Rwanda, MASS tackled just such an issue, reforming the hospital layout in their regarded Butaro project by placing corridors outside and ensuring the rooms have plenty of passive ventilation. Adjustments like these become lifesavers, and MASS executes them with an extraordinary grace.

It’s an old friend who’s been co-leading MASS’s clinic projects in Haiti. In fact he’s participated in a range of nonprofits there since the 2010 earthquake. I met Adam that first summer post-disaster, when he was among the first volunteers for Architecture for Humanity Haiti. He was in between a prior volunteer stint raising shelters in Leogane, near the earthquake’s epicenter, and returning to Ohio to finish his Master’s thesis (on emergency shelters). With AFH Adam conducted site visits and interviews, for AFH’s first school projects, and surveyed the longevity of shelters built by other aid organizations.

Towards the end of Adam’s stint, Stacey started at the office. Hearing that he now worked for MASS, she and I were both excited to visit him and hear about their work, and were pleasantly surprised to be given a personal tour of the projects.

MASS’ is a three[plus]-pronged attack on cholera. First: clinical care, manifest in the building itself, which could be composed by designers to become a very clear, bright, healthy and dignified space. That the facility employs on-site waste treatment, thereby halting recontamination, serves the second prong; access to clean water, is closely related by a distinct third prong.

I would contend that MASS is incorporating a forth (or third plus) prong in their pursuit of superior cholera beds.

As a special bonus, Adam drove us to a furniture manufacturer’s to meet his colleague Ben, busy refining a device that could ease the staffing needs of a clinic. We’ll discuss that in the next blog.

Clinic of dignity

The medical complex is, as many things are in Port-au-Prince, tucked neatly into a verdant cul-de-sac just off an extremely busy road. No one was working on site that day – which probably allowed us to make the visit in the first place – but we could easily spot which structure was receiving the MASS treatment, as it were. The clinic’s walls undulated like a metal mountain range, cladding perforated all over with fist-sized diamond apertures. Despite the angularity, the architecture read like a giant lung.

“Ventilation was an important form generator,” Adam noted. Air could very clearly pass right through the building, keeping the space cool and the patients comfortable.

Right past the entrance sits the waiting room, or what will soon be the waiting room. In a cholera clinic this space plays a slightly different function from what you might encounter at the ER – specifically, when it comes to cholera, you can’t wait.

Upon arrival sick visitors will be in a bad state, and will need a place to sit or lie down and evacuate. This should begin before a visitor is admitted: clinicians won’t be sure at first whether the sickness is cholera, or simply bad diarrhea–this can be determined within a matter of hours. Regardless, visitors can get care, not only safely and cleanly, but in a way that promotes dignity–something not greatly considered in other cholera treatment centers (those aforementioned tents).

The roof along either side of the waiting room pitched inward like a V, slopes meeting above a metal trellis that rose from a wide, waist-high concrete planter.

“Below there is a cistern,” Adam explained. “All the roof’s rainwater will be collected there for the clinic’s use. We’ll have plants growing on top here, and climbing the trellis as a living wall.” I imagined bougainvillea softening the space, easing distressed minds. Plus, an opaque, vegetated wall separating two rows of sickbeds is a sensible move.

We enter the patient ward–a large space dotted with benches and sinks sculpted and plastered in concrete, an intricate metal-framed roof hovering overhead, and dappled light lancing in through the metal perforations. Adam indicated how the screen’s punctures were much larger at the top than at the floor. “You want air to escape at the top, where it’s hottest.” And one keeps some privacy from passers-by lower down.

The diamond-shaped screen apertures were all punched out by hand by Haitians, following drawings specified by MASS designers in Boston. (Their Haiti operation is too small right now to support in-country design staff.) Not all the panels had been installed yet – metal components marked in chalk and wooden templates were stacked against the back wall.

Catching the project at this moment was a thrill; Stacey and I could see the entire process before us. We were impressed by the precision and inventiveness in construction fit for a pavilion in metropolitan America executed here through uniquely Haitian means.

Byproduct digester

In addition to the intricate patient treatment zones and the high level of cleanliness practiced by clinicians, the project also provides on-site treatment of the clinc’s contaminated waste.

“We’re building an anaerobic baffled reactor,” Adam says, directing us to a series of hatches in a narrow concrete slab in the ground. Wait…a what?

An anaerobic baffled reactor (ABR) is a multi-chambered septic tank that allows helpful bacteria to process (without the use of oxygen) waste in a kind of microbial disassembly line, separated by walls (baffles) of various clearances. The result is a greatly reduced amount of waste product, and the low-tech construction means it can be replicated in resource-strained parts of the country.

The cholera clinic’s ABR will process the sludge enough that the cholera bacteria die off (“this chamber, 99% clean, after the next one, 99.9%,” etc.). Through this use of simple engineering (a method international aid types call “appropriate technology”), much of the Haitian countryside will be empowered to properly treat cholera waste, and essentially stop the disease in its tracks.

Of course this ideal endgame is still several years out. MASS’s clinic and septic design would need to be repeated strategically around the country. This prototype, as with any piece of architecture, will need to be seen in operation to study how the design performs, and see if calibrations are needed.

Should things go well, however, clinicians will have a rather large and powerful new tool to treat and prevent the spread of a lethal disease, and patients will receive dignified health care in the process.

[1] Holly Jacobson and Alan Ricks. “Architecture’s Direct Impact.” Oz Journal. Kansas State University. 2013.