COMMENTARY: THE WESTERN MODEL HOSPITAL IN HAITI, Fall 2012

Among signs of modernity in any given country figures the presence of an organized healthcare system. In the third world, the latter manifests itself in the built environment through the rise of hospitals modeled after architectural precedents in Europe and the United States.  However, in the 19th century, due the industrialization of the western hospital, its shift from humane-care focus to a financial revenue generator revolutionized the patient -caregiver interface and the architectural environment accommodating such interaction. Therefore, the successful implementation of the western model hospital in countries such as Haiti calls for a nurturing and culturally sensitive environment adapted to the medical, economic, and psychological needs of the patients.

The religious affiliation of health care delivery during the medieval period established the model of the humane-centered hospital. In its most vernacular forms, the modern hospital emerged from the Christian monastery as a ministry of service providing medical care to the sick and hospitality to the pilgrims. In the case of the hospice of Turmanin, Syria (A.D 475), as an early example, the patient care was distributed across a campus of buildings accomplishing various functions such as a church, a tomb, a covenant and a house, catering the medical, spiritual and physical needs of the sick, free of charge ( Thompson and Grace, 6 – 7). Therefore, in its earliest forms, although its functions were rather accomplished and dispersed throughout existing building structures, the hospital reveals to be a place of mercy which embraced the spirit of service; a humane-centered place catering the needs of the sick.

The emergence of the modern hospital shifted the latter’s aim from a humane-centered place to a capital revenue generator. In the modern age, the hospital developed into its own architectural typology; a health care institution providing medical treatment for patients by specialized medical staff and technologically advanced equipments; therefore evolving from the concept medieval Christian care to a medical institution sponsored by private organizations, government administration and non- profit organizations. The American Hospital Association reported only 3% of hospitals in the United States are funded by the federal government and provide free medical care, while 87%   are part of networks of healthcare providers and insurance companies requiring annual or monthly memberships. The financial burden causes 1/4 of US population to be uninsured and don’t have access to medical care. Therefore, the industrialization of the hospital transformed the human -centered nature of the sick – hospital relationship into a commercial exchange, providing medical services only those are can financially afford it.

The capitalist nature of the western hospital reveals to be economically unsuitable for a third world country such as Haiti. Being the poorest country in the western hemisphere with 77% of the population living on less 2 US dollars a day, the western model of the hospital has greatly failed to provide medical services due to its economic unaffordability. According to the World Health Organization, 46% of the population does not have access to healthcare because they can’t pay for it, while the General Hospital HUEH, which is the largest hospital of the capital managed by the Haitian government, provides medical care at extremely low prices; however inefficiently due to the overflow of patients, the lack of financial, medical and human resources (Sanjay). Moreover, private hospitals are creating  a “brain drain” into  the public system by recruiting the best doctors, while providing medical services at high prices for the other 23%; thus, revealing the problematic nature of the western model hospital and its  economic and medical ineffectiveness to provide medical care to the Haitian population.

Furthermore, The lack of basic infrastructure of Haiti greatly reduced the impact of the technologically advanced western hospital. In Haiti, 50% of the major hospitals are forced to be located in the capital of the country, while the rest are distributed across 8 other major cities. The basic infrastructures are inexistent in rural areas, therefore unable to support the electrical and mechanical needs of the modern hospital. This lack of medical access in those rural areas along with other factors such as poverty, unemployment, and drought are causing a great wave of migration into the major cities. In 2010, the urban population of the country rose to 52%, with 22% living in the capital city of Port au Prince only. Since they are deemed impractical to the other 48% of the population who live rural regions of the country, their location in urban areas transformed those modern hospitals into major contributors of migration. Thus, their inaccessibility to rural communities due to the lack of resources has greatly reduced their projected impact on the health of the Haitian population.

The characterless architecture of the modern hospital is an antithesis to the recovery of the patient. The industrial revolution and the architectural modernist movement of the early 20th century have greatly impacted the envelope and the interior of the modern hospital. The Beaujon Hospital at Clichy near Paris built in 1935, the first major vertical hospital, consists of a solid brick cladding on the facades contrasting with the colorless character of interior units (Thompsonet al. 197). In her description of the interior of the modern hospital, Susan Mazer, president and CEO of Healing HealthCare Systems stated: “Upon entering the alones of the hospital room, the sounds continue to intrude beyond the four visible walls. The noises are exaggerated, distorted and unending. The din coming from everywhere soon blends into the characterless walls, never yielding to the fear it creates and its relentless chorus (4).” She reveals the unpleasantness of the overbearing noises of hospital environment which are then amplified into those white walls. She is not only suffering physically from her pain, but also psychologically due to its spatial surrounding. Thus, the characterless environment of the modern hospital can worsen the medical conditions of the patients, since recovery requires the rest of the body and the mind.

As one of the primary spaces of the modern hospital, the semi-private clinical ward presents a threat to the health, safety, and right to privacy of patients, primarily in Haiti. The multi-patient room has been a spatial requirement for inpatient care since the medieval period and has  been the subject of controversial debate for the last decades in the United States. According to research conducted by Arup, a global firm of consulting specialist and engineers, the semi- private room, while economically efficient, provides a friendly atmosphere by  providing exigent care and  promoting the patient culture of taking care of one another in  company of room-mates; therefore creating a sense of security for  both patients and nurses. In the other hand, the all-private room assures patient confidentiality along with  reducing slips, trips and falls, due to the reduced patient movement associated with their close proximity to in-suite bathroom facilities (Stephen, G.Todd, 10). One of main disadvantages of the semi-private is the cross infection rates which are amplified in the hospitals of Haiti due to lack of hygiene and cleanliness of the spaces. Private rooms are primarily reserved for inpatients who can afford it and those whose medical conditions absolutely require such spatial requirement. Therefore, the semi-private rooms are germs carriers, often causing diseases to visiting family members and worsening the medical state of existing patients.

On the other hand, in its architecture, the success of the western model hospital lies in its adaptation to reflect the vibrancy found in the modern Haitian vernacular architecture. The use of rich and vibrant colors in Haitians homes is a reflection of the spirited, energetic and lively character of the island and the Caribbean basin (Fig 1). Thus, in contrast to the whiteness of the walls, introducing vibrant colors as elements to improve the spatial experience can animate the interior spaces of the modern hospital. The modern Haitian tap taps constitutes a great precedent to the application of color into architectural space. Handcrafted with typical plywood, glass and metal, vibrant colors are used in their envelopes and interiors to portray patriotic, international and local icons and create writings which either welcome passengers or communicate moral values  to passenger and the general public (Fig 2). They are symbols of creativity and ingenuity of Haitians and iconic representations vehicular transportation typology. Therefore, color is a major constituent in adapting the modern western hospital to the culture of the people of Haiti and it can be used to express the vibrant character of a cultural and architectural condition. 

As an alternative to the western model hospital, the community-based care hospital developed by Partners in Health/ Zanmi Lasante bridges the gap between healthcare and economic disparity. Founded by Paul Farmer in 1987, PIH, a non-profit organization based in Boston, implemented a community- based approach hospital which provides educational assistance and advocates free universal primary care to the poor in rural communities. In contrast to modern hospital, it reaches out to the population by adding through its mobile component of community health workers, who regularly visit clients in their homes in order to identify and treat diseases at their early stages.  According to the 2011 annual report, PIH/Zanmi Lasante in Haiti currently employs about 5411 individuals, which includes 2, 378 community health workers. They provided educational assistance to 13,784 children and had encountered about 2.8 million patients including 75,000 cholera treatments (Partners in Health).  Its success had caused its proliferation in several rural regions of Haiti and 10 additional countries during the past 25 years. Therefore, it not only relieves the economic strain imposed by the modern hospital, but also creates job opportunities for locals. Since the economic burden does no longer exist, its location in the extreme rural areas brings free healthcare to about 48% of the population. Its medical efficiency relies greatly on its economic affordability and physical accessibility.

The western model hospital reveals itself to be medically inefficient, culturally irrelevant and economically unsustainable to respond to the needs of the Haitian population. The high poverty rate of the population makes it financially unaffordable, its inaccessibility to due to its sole location in major metropolitan areas reduces its medical impact and the characterless nature of their interior spaces does not cater to the psychological needs of the patients which prolonged their recovery period.  Its impracticality reveals a lack of adaption to the local culture of the population, a lack of consideration of the local economy and a lack of knowledge of the physical infrastructure of the country.  Thus, the new model should consist of a patient- nurturing and culturally sensitive environment which consider and prioritized the medical, economic, and cultural psychological needs of the patient; and the community- based approach model by PIH is a successful example of such implementation.

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