In the early 1990s, James Childers attended the groundbreaking of the Redbird Smith Health Clinic in Sallisaw, Okla., five miles north of the little town where he lived. Redbird Smith was the first clinic built from the ground up by the Cherokee Nation and—Childers was surprised to see—it was a huge improvement over the typical Indian clinics he was used to.

As an architect, Childers had been doing healthcare projects primarily with the Sisters of Mercy system since 1980. He’d never pursued any government- or publically funded healthcare projects—but the Redbird Smith project got him thinking.

“The architect for that clinic was out of New Mexico,” Childers says. “And that’s what caught my attention. I thought, there’s no need for them to be going to Albuquerque to do clinics in Oklahoma.”

The building, staffing, and maintenance of healthcare facilities for federally recognized Native American tribes have fallen under the jurisdiction of Indian Health Service (IHS) since that department was established in 1955. Traditionally, these IHS clinics haven’t exactly been design-driven, nor have they been particularly reflective of the cultures they serve. Built to meet strict federal guidelines that could be easily replicated from site to site, most of these clinics “were just boxes,” Childers says. “They’re just very functional government buildings.”

Over the past two decades, however, tribes have begun investing more and more money earned through their businesses in improving healthcare for its members. Fueled by joint ventures between the tribes and IHS, healthcare facilities are getting the attention they deserve, with bigger footprints (to better serve the number of patients and house more varied services); thoughtful innovations based on wellness research; and culturally significant touches to celebrate the rich histories of the tribes and provide a positive community resource.

Since 1992, Childers (a member of the Cherokee Nation himself) has been a prolific contributor to these new facilities. Of the 19 joint venture projects between IHS and tribes across the country, Childers has designed seven of them—all publicly bid and awarded separately by each tribe.

Healthcare Design spoke with Childers about the legacy he’s building, as well as the process behind designing facilities that proudly demonstrate the tribal values and cultural wealth of a historically underserved population.

Healthcare Design: Your first tribal project was the Wilma P. Mankiller Clinic in Stilwell, Okla., in 1992. How did you approach that job?
James Childers:  That was an Indian Health Service facility. And as we went through the IHS program, we figured out that what it produced was the typical Indian clinic you might walk into anywhere: too small, overcrowded, no waiting room, no people amenities. Indian Health Service did a fantastic job of getting the most out of its square footage, but there were really no provisions for waiting areas.

We’re in a very rural area here in Oklahoma; these people might drive 40-50 miles for healthcare. And when they did, they brought Grandpa and Grandma and the kids. Everybody came. As a result, you’d go into these clinics and the corridors would just be lined with people.

The IHS design guidelines dictated that you be within 10 percent of their square footage limitations. So what we ended up doing was reducing the square footage in the mechanical rooms. By selecting the right kind of systems and putting a lot of this equipment on the roof instead of on the floor, I ended up under their program on total square footage.

So what they allowed me to do—after many meetings and discussions—was to take that additional square footage and put it into circulation. We increased the widths of corridors and increased the size of waiting rooms. This was all an effort to get Indian healthcare environments compatible with private care.

Were there cultural elements built into this first facility?
One of the things [then-]Chief [Wilma] Mankiller wanted was for the entry to face east. The way the building was set, it wanted to face the highway, to the north. But we reworked the design.

All traditional Cherokee buildings would face east and would be built up on a mound. East is a rebirth; it’s the rising of the sun every day. West is death. You or I might walk up to a facility and say, well, it faces west because that’s the primary circulation route and it’s the logical place for it to be, facing the highway, etc. But to Cherokee people—and many Native American people—it has significance.

Did that experience affect your future Native American projects?
It did. We always ask to meet with a tribal representative to learn about the culture and history. We do as much research as we can into what’s important to that particular tribe. Every one of our clinics is very different in appearance, but that’s all a function of the people we’re designing for.

The next facility [after Mankiller] was the Idabel Health Center; that was the first IHS joint venture project for the Choctaw Nation of Oklahoma. And what’s significant about the joint venture projects is that up until that time, most of these tribal clinics were in a size range of 10,000-12,000 square feet. Once these joint ventures started happening, these tribal clinics jumped to 50,000-100,000 square feet.

That size is based on population area served. And they always knew these facilities needed to be that big—but IHS never had the money to build them. So they only built to fill the basic needs.

With the joint ventures, the tribes stepped in and said, we’ve now become self-sufficient enough that we have our own incomes. We’ll use our funds: We’ll build the facility to IHS standards, if IHS will come in and simply provide staffing dollars for it.

So the Idabel project was much larger (more than 55,000 square feet). Were there cultural differences as well?
The Choctaw Nation is one of the three largest tribes in Oklahoma; it’s very progressive. And they wanted their building to be very modern, to capture the feeling within the Choctaw Nation of their pride of growth and accomplishment. We went around with them and they’d point to buildings they liked, and they would be corporate offices.

For this facility, we went two-story and we gave it a very modern appearance. We did face it east. To get light into it, we did a two-story atrium, which was the first atrium I’d done in a tribal clinic, and we had a tremendous amount of positive response.

In addition to the atrium, which was all glass, we had light wells that ran down the corridor, flooding them with light. And by double-loading the corridors, travel distance was as short as possible in getting the patient from the front door to the different departments. They wanted it to be very user friendly. A lot of the people who used the clinic were elderly, and many were diabetic and overweight.

When we had the open house, there were a lot of other tribal representatives, as well as IHS. That facility was so unique to Indian healthcare facilities at the time, and it’s really why I started getting more joint venture projects.

It sounds like a very different experience from your project with the Cherokees.
Yes. And from the Idabel facility, I did one in Coweta, Okla., for the Muscogee (Creek) Nation—and they were just the opposite. They said, we’re people of the earth. We want our building to reflect our culture in as many ways as possible. In that building, even the brick on the exterior façade is striated to pick up the colors of the earth. If you drive through Oklahoma, and you see a bank that’s cut, you’ll see red clays that go from dark reds, to light reds, to blonds. So we picked up on that.

Also, where the Cherokees built their buildings up on mounds, the Muscogee (Creek) Nation traditionally built a lot with wood. So with the canopy structure out front, although we didn’t use wood, we exposed the structural members so it kind of looked like that.

They loved the atrium we did at Idabel, so we opened up a big atrium with a lot of light. This was a single-level building on a nice, big, level site. We were able to get a lot of light in through clerestories, and all the corridors were very well lit. In all these facilities, we started incorporating hard surface flooring, like terrazzo, and we worked in tribal patterns that came from their pottery and other artifacts.

And you’ve incorporated the artifacts themselves into the buildings, as well.
I think Idabel was the first one where we created big display cases off the main atrium and down some of the corridors. A lot of the tribes’ art would just be hidden away in a museum somewhere—many times, [the museum] was the equivalent of an old school building, very dark and hard to see the art.

So we worked with the tribal representatives to display that art, to bring it into the clinics and start rotating [exhibits]. That became a major focus; it’s not just trying to work in symbolic cultural issues into the building design, but to work in actual tribal art and make it part of the building. Young people who come into the clinic for the first time, they start seeing these things and becoming exposed to them, whereas they might not in their regular lives.

Also, beginning with Coweta, I believe, all the signage is bilingual. That’s one of the big issues in most of the tribes in Oklahoma now: They’re trying to revitalize their language. With the Cherokee Nation, many people still speak Cherokee. You can hear it spoken. Some of the elders, it’s actually easier for them to read the Cherokee than it is the English.

I think that has helped a great deal, by getting their art and their language back into these facilities. Most of these tribes now, when I work with them, will have an art budget. If they don’t, we ask for one. We usually try to get at least 1 percent of the cost of the construction to go toward art for the building.

Community is a big theme across the board in U.S. healthcare projects today, so it’s interesting to see how that plays out in this culture.
Let me take that a little further. One of the things I was very pleased with was that I was able to take the wishes of the tribe, and to work with IHS representatives, to take the space we saved for mechanicals and work it into those atrium spaces. After Idabel, people saw what we could do. And with Coweta, they really started to see the possibilities of it.

The next joint venture facility I did was the Three Rivers Clinic for the Cherokee Nation. The chief came in [then-Principal Chief Chad Smith] and said, This building is much more than a health clinic to the people in Muskogee. This is the Cherokee Nation’s chance to make a statement that it’s trying to serve the people there.

He wanted the atrium to be bigger, and to allow the community to come in and have events there after hours. These clinics are open around 8 a.m. to 5 p.m. And the atrium here is an 80-foot-diameter, domed space with seven columns, one for each clan of the Cherokee Nation, supporting that dome. The circular form represents their old council houses. The columns are an exact replica of the columns that supported the old women’s seminaries in Tahlequah, Okla.

That space has been used over and over and over again by the community. I’ve been there for children’s art exhibits and displays for local artists. They’ve even had a wedding in it.

What do you find to be the most satisfying aspect of working on these projects?
What I’m most pleased with is that these are no longer substandard healthcare facilities for an underserved population of Native Americans. Not only has the environment grown in size and come alive, but the quality of the providers has gone up, too. Along with the new facilities came the staffing dollars from the government to staff them. This is truly a success story for the tribes and for IHS.

In the past, you might have had a 5,000-square-foot clinic. You could go there and get a shot, or you could go there and sit in line for four hours to see a provider. Now there’s a 100,000-square-foot Cherokee Vinita Health Clinic where you can get dental work or get your eyes checked. They have wellness programs, they have teaching kitchens to teach people how to cook healthy. It’s given them an environment to better themselves, and at the same time, it’s an opportunity to express what’s important to the tribes about their community and culture. HCD

Kristin D. Zeit is editor-in-chief of Healthcare Design.