A world unbuilt: The moral implications of design

Imagine you are designing a hospital for one of the poorest communities in the world. There is no infrastructure for water, power or waste. Roads are rough and unreliable. Medical supplies disappear in the dead of the night to be sold on the black market.

The average life expectancy of residents here is 42.5 years old, and 257 out of every 1,000 children born here will die before they celebrate their fifth birthday. Now imagine you are designing this hospital over a bad Skype connection, without ever stepping foot in the country where it will be built.

This was Troy Hoggard’s reality in 2009 while working with a team of fellow CannonDesigners to develop a 100-bed prototype hospital in rural Afghanistan. Says Troy, “It’s surreal. You never get to meet any of the people you are designing for. You quickly realize that the people on the other end of the phone are relying heavily on what you recommend, because they have minimal clinical expertise. It was very empowering and very scary.”

The communications challenges don’t even begin to compare to the inherent challenges of designing for a developing nation. “We had to design a three month fuel and water supply because in the winter, fuel trucks may not be able to reach the hospital and all power is created by on-site generators,” Troy explains. “There are no building codes. They would just ask ‘well, what do you use there?’ Suddenly I’m modifying U.S. codes for a country that I’ve never even visited. There would be these moments when we’d ask something simple like, ‘Can we talk to your anesthesiologists about where to put the gas lines?’ and there would be a long pause on the other end of the line. Finally they’d say, ‘Well, we don’t have any physicians yet. We don’t know who our anesthesiologists are going to be.’”

His experiences working in Milot, Haiti had similar challenges. Haiti ranks just eight spots above Afghanistan on the United Nations’ Human Development Index (#163 and #171, respectively— the US is #8) but after the devastating 2010 earthquakes, they saw an influx of support from international relief organizations and US hospitals, including Holy Name Medical Center in Teaneck, NJ. In 2012, Holy Name Medical Center assumed control of The Crudem Foundation, which has been providing financial, volunteer and medical resources to Hôpital Sacré Couer since 1986. Following the change in leadership, a team from CannonDesign, including Troy, has been engaged in planning and design work ranging from small modifications to existing facilities to a complete replacement hospital that could triple their site capacity.

Rendering for the new Hôpital Sacré Couer.

“Hôpital Sacré Couer stands out in northern Haiti because it is well-managed through its partnership with Holy Name, so it attracts a high caliber of talent. The medical staff is actually a level above what the facility can support. With a better building, they can quickly improve both quality and quantity of care.” Troy returned from his first trip to Haiti with a wave of motivation and sense of duty to design for these caregivers. “I knew they needed a design that was not only buildable and appropriate for the climate, materials and culture of Haiti—but it also had to inspire people to donate so that The Crudem Foundation can fund the construction.”

The lack of government-funded infrastructure also poses a challenge, as it does in Afghanistan. “Many roads in Haiti are basically a riverbed. There’s no ambulance service, no police force, no fire codes—instead of saying ‘where do we put the fire extinguishers?’ it’s ‘where do we put the bucket of sand and who’s going to be the bucket brigade?’” Troy recalls. “I tell my friends: ‘Don’t complain about paying taxes.’ Say what you want about waste in U.S. government, but no government at all is a much bigger waste.”

When asked for his final thoughts on his experiences in Afghanistan and Haiti, he evokes an idea from international strategies leader Carson Shearon: “Working with Carson in Haiti, he often used the term ‘global best practice’—meaning, what is our position on minimum standards for healthcare, no matter where you are in the world or what your GDP? What do we believe in as a firm? Our work abroad has taught me how important it is to have a philosophical underpinning behind your design. When you design a hospital in a developing nation, you have to be serious about your priorities.”