“A mind is like a parachute, it only works when it is open.”

Today the population of planet Earth is approximately 6.6 billion people. By 2050, the population is projected to be 9.5 billion people. The needs for appropriate health and hospital facilities will be enormous and unprecedented. There is no question that a very significant and growing percentage of an Architecture for health practice will be its international component.

Undertaking an international Architecture for health practice sounds glamorous and exciting, but it is and will be brutally difficult to achieve. Please note that some firms have bankrupted themselves by making unfortunate decisions and/or being at the wrong place at the wrong time. Nevertheless, international practice is happening today and will grow significantly in the years ahead.

Texas A&M University has undertaken over 500 Architecture for health projects and/or programs all over the world since the program was established in 1966. Over those 40 years I have had the privilege and opportunity to travel all over the world, advising various groups and countries on how to develop and improve health facilities. In the process I have encountered many varied and challenging situations and have also learned a great deal.

In undertaking international efforts, there must be a desire to be adventurous, curious, and sensitive to differences. We live in a country of great wealth, luxury, and tremendous resources. That situation is not true in many areas of the world. Most people and most countries have to accomplish much more with a great deal less. In turn, we can also learn from these societies as to how they accomplish this.
George J. Mann, AIA

George J. Mann, AIA

Moreover, leaders of international Architecture for health practices will need to be aware of the broader context of their practices, including population and demographics. Worldwide, the age structure of national populations is changing. Many societies, especially in more developed regions, have already realized a larger percentage of older populations than have ever been seen. Many developing countries in the midst of demographic transitions are experiencing rapid shifts in the relative numbers of children, working-age, and older people. In many countries, the changing age structure is becoming a major concern and the focus of heated political debate, as governments struggle to reign in the rapid growth of aging-related expenditures. A few countries are actually projecting declining overall populations, but a rising percentage of aging populations.

The following are some thoughts I've developed on random key topics to consider for successful international design.

Environmental health issues

Much of the world lives with substandard housing, poverty, poor sanitary conditions, lack of potable water supplies, lack of sewage systems, substandard education, and lack of knowledge of health maintenance. Widespread air pollution adds to the dilemma. In some large cities, the infrastructure supporting basic human health is not capable of sustaining the population.

Toward healthy cities and new communities

In China, new cities and communities are rising everywhere. The government of China is very concerned about related pollution and congestion. Officially, it wants to promote the concept of “Healthy Cities.” In 2004, Tsingua University and Texas A&M University partnered to undertake an international conference in Beijing to promote the “Healthy Cities” concept.

Diseases and disease strategies

Focusing on the statistical facts and incidence of causes of illness and death is a vital first step toward developing a disease strategy. Why build a huge gleaming white hospital where malaria was a leading cause of illness and death? Would it not make sense to eradicate mosquitoes instead?

Transportation

Health facilities need to be located for ease of access. Internationally, this may range from pedestrian access, horse-drawn carts, bicycles, scooters, autos, buses, trains, helicopters, and airplanes. People should be able to reach their healthcare facilities in simple ways.

Energy realities and sustainability

Healthcare facilities are enormous guzzlers of expensive and ever scarcer nonrenewable resources. Designing for energy efficiency and sustainability will be critical. Use of solar and wind power wherever possible will be essential.

Communications

Recently I traveled to Australia, South Africa, Israel, Japan, and China. My Blackberry was able to send and receive e-mails and telephone calls in all of these countries. It seems that the whole world is being wired. Understanding this fact is essential to improving Architecture for healthcare design around the world.

Technology and technology transfer

As we move forward in using technology in less developed parts of the world, there will still be enormous gaps. One of these gaps is trained manpower. What good is the technology without electricity or a properly trained staff to operate and maintain the technology?

Imaging

Because of constantly improving communications technology, X-rays, CT scans, MRIs, sonograms, and other critical diagnostic tests have the possibility of being read remotely—even from thousands of miles away.

Medical records

Our airline itineraries can be accessed all over the world. Why (with appropriate privacy protections) can't our medical records?

Strategic components of an international Architecture for health practice

Some firms moving in this direction are dividing their efforts into two basic components:

1. Health Planning Consulting Services. This component will include interdisciplinary teams of statisticians, doctors, nurses, healthcare administrators and architects. After an in-depth analysis of a country or region, this group will determine needs and priorities and make specific recommendations, which may or may not include a building.

The Health Planning Consulting component will address such questions and issues as:

Is the project needed and feasible? There are many instances when well-intentioned healthcare facility projects were just not properly and critically analyzed in a feasibility study. Analysis of health problems and health needs were not undertaken. Issues of staffing, medical technology, and total life-cycle costs (construction plus operating costs over time) were not addressed.

Aligning resources, staff and facilities. An important part of feasibility studies will be to determine whether the resources are available to successfully undertake the project. It is not enough to plan, design and build a hospital or other healthcare facility. Human and financial resources must be considered in a holistic approach to design, build, and operate a facility.

White elephants. Indeed, too many healthcare facilities have been designed and built but cannot be used because of a lack of operating funds or medical staff. In another country in which we worked, the President wanted to build a 1,000 bed hospital in his home town. Even though the Ministry of Health usually ran out of funds in November—the beginning of flu season, yet they were not able to purchase antibiotics—the President wanted to superimpose a 1,000-bed hospital on an already failing health system. He also didn't want to consider the life-cycle costs of operating the building over time. He wanted an expensive, ill-thought-out monument to himself, which would have wiped out the Ministry of Health's budget for years to come. Fortunately, his advisors finally convinced him of the need for further planning, using tough, hard construction and operating costs figures.

As mentioned, the consulting group's recommendations may or may not include a building. If a building is recommended the consulting report should include:

  • Statement of need

  • Scope of services to be provided

  • Staff requirements

  • Project size (in net square feet or net square meters and/or in gross square feet or gross square meters)

  • Cost of construction

  • Costs of operation

  • Sizes of Phase 1 (including building and parking), Phase 2, Phase 3, etc.

  • Site size required

2. Architecture for Health Practices. Some firms include landscape Architecture, engineering, interior designers, physicians, nurses, and healthcare administrators; others include constructors and others involved in the design/build approach). Such practices consider:

Appropriateness of planned healthcare facilities. We know that design needs to be developed appropriate to the location's unique site and context. It cannot and should not be a “canned” product brought in from the outside. Within this, careful consideration should be given to:

Available power and utilities. Availability of water, sewage treatment and power—things we take for granted in our own country.

Climate and culture. An understanding of the climate and the culture of a region is vital. For example, we have planned and designed in countries where separation of males from females was a given within their own cultural/religious framework.

Natural ventilation. Is the building design properly oriented or sited for optimum natural ventilation? Should only certain areas be climate controlled?

Local materials and methods of construction. Understanding and working with local materials and methods of construction just makes very good sense, with or without politics.

Use of local architects, engineers, and constructors. It is essential to collaborate with local architects, engineers and constructors involved in a project in another country. They have knowledge of local conditions, policies and procedures and can help avoid serious miscues.

In one very small country in Asia we planned a multistory hospital, only to find that the only crane on the island was committed to the construction of a high-rise hotel to promote tourism. The hotel got the crane. In yet another country, international aid agencies provided computers, but there was no electricity.

Deciding on labor intensive versus prefabrication. Shipping in prefabricated components from western countries may be very profitable for the western economies, but this will not create much needed local jobs.

Contracts and legal issues. Contracts in the United States are complicated enough. Be sure and get expert legal advice for overseas contracts. No one knows the rules better than the local attorneys working together with your attorneys.

Currency fluctuations. Foreign currencies and U.S. currencies fluctuate in value. It may be best to predetermine with your client which currency will be used for payment.

Innovative and creative methods of delivering healthcare. Some underserved areas use interesting innovative ways of delivering health care, including hospital trains in China and India, flying doctor service in Australia, Mercy hospital ships in various countries, and Project Orbis, a flying eye hospital in a DC-10 in which numerous physicians around the world have been trained

The Architecture for Health Firm of the Future (AFHFF)

Like Boeing or Airbus, the AFHFF will have to have the capability and the expertise, as well as the will, to work anywhere in the world. Meeting the challenge will encompass:

Regional offices. The AFHFF might have regional offices in such cities as London, Washington, D.C., Paris, Moscow, Cairo, Brazzaville, Johannesburg, Abu Dhabi, Karachi, New Delhi, Tokyo, Seoul, Sydney, Manila, Mexico City, Buenos Aires, and Sao Paolo.


Organization. Multidisciplinary teams will be the norm, and might include physicians, nurses, public health professionals, healthcare administrators, architects, interior designers, engineers, technology, and communication experts.

Language capabilities/fluency. Professionals who speak the local language fluently, perhaps raised and educated in that country, will be essential. In larger firms, there may be teams concentrating on certain countries, such as India and China.

Diversity. AFHFFs should employ males and females, professionals and staff from many countries. This diversity will enable it to more easily navigate through diverse parts of the world.

Links to universities. A flow of young, energetic people to AFHFFs from focused graduate Architecture for Health Programs will be essential to the long-term growth of the these firms. These firms will develop close links to universities.

AFHFFs are already working with universities on joint studio projects, mentoring students, giving lectures, and touring faculty and students through completed or under-construction health and hospital facilities, providing summer internship, scholarships, prizes, and endowing Chairs and Professorships.

Networks of firms. It's a small world, but it is also at the same time a very large world. AFHFFs will seek out joint ventures, alliances, and mergers in order to respond to a variety of needs and opportunities.

GUPHA: Global Universities in Healthcare Architecture

One of the greatest mysteries of my career is why there are not 20 Architecture for Health programs in the United States. The demand for our graduates far outstrips the supply. In fact, in 1999, Texas A&M University, The University of Tokyo, and South Bank University in London founded GUPHA in order to jump start other universities. It has grown to more than 130 members from architectural firms and 30 universities in countries all over the world. Dr. Yasushi Nagasawa is Secretary General and I am President of GUPHA. On Nov 11-13, 2007, GUPHA will have its 5th meeting at the University of Tokyo. You are most welcome to join us. Visit http://www.Gupha.info for more information.

The future

The future belongs to those who prepare for it. The challenges and possibilities to effect positive changes for those in need around the world are enormous. HD

George J. Mann, AIA, is the Skaggs Sprague Endowed Chair of Health Facilities Design at Texas A&M University. He is also President of GUPHA and founder and Chairman of the RPD (Resource Planning and Development Group). He has recently been appointed Liaison, AIA to the UIA/PHG (International Union of Architects Public Health Group)

He can be reached at 979.845.7856 or e-mail gmann@archone.tamu.edu. To comment on this article, visit http://healthcaredesi.wpengine.com.