In 1994 the genocide had stripped the people of Rwanda from their dignity and destroyed a generation of lives. Fourteen years later, in 2008, after focussed investments on health, education, housing, economic reconstruction and reconciliation, Rwanda was abundant and hopeful. It was shedding histories of colonialism and ethnic division and recalibrating its future towards shared economic and social progress.

To assist in strengthening the country’s healthcare system, Dr Paul Farmer and his organisation, Partners In Health, were asked by the Rwandan government to consult. A key element of this collaboration would be a new purpose-built hospital in the remote northern hamlet of Butaro.

Designing a hospital without hallways to serve patients better

Dr Farmer’s lead engineer in Rwanda, Bruce Nizeye, needed help designing the hospital in Butaro, and Dr Farmer assisted with the new design in 2008. Most of the clinics and hospitals Partners In Health had previously built were additions or renovations to hospitals. At the time, the Butaro hospital was the largest project it had ever designed and constructed.

Dr Michael Rich, an expert on tuberculosis and its multidrug-resistant variants, was then the director of Partners In Health’s Rwanda operations (through its sister organisation, Inshuti Mu Buzima) and an architecture junkie. Hospital hallways, he explained, were the major problem in the transmission of multidrug-resistant tuberculosis.

Patients waiting in these spaces without windows or airflow would cough on each other, become coinfected with drug-resistant variants and then bring them back to their communities. In the hallways of hospitals, buildings meant to heal, the epidemic had begun. “We have been trying to design hallways out of hospitals for years,” Dr Rich explained. “Mechanical systems never work as designed and they are often too expensive to maintain.”

Rwandian hospital

The right to breathe

Dr Edward Nardell, another tuberculosis expert at Partners In Health, pointed to a study in Peru that showed how older, colonial-era hospitals, built with generous windows, tall ceilings and open-air waiting areas, were better able to prevent the transmission of tuberculosis. Dr Nardell also introduced Walls & Roofs to Florence Nightingale’s Notes on Hospitals and her spatial strategies to increase airflow and reduce disease transmission.

In the new structure, all patient, staff and public movement and waiting take place outdoors. Rwanda’s temperate climate allows for comfortable exterior waiting throughout most of the year, but when it rains, covered outdoor areas provide respite. Exterior hallways necessitated a distributed multibuilding design rather than a centrally loaded institution, and the buildings had to be thin for airflow.

Doctors would walk between buildings dispersed in a campus setting, so covered pathways were created, surrounded by cheerful gardens. Elevators often break and in rural areas, there is often not the necessary maintenance for proper upkeep, hence the need for an accessible facility without elevators, which are also essential for patients in wheelchairs. The hospital was layered across the crests of a hill to ensure that multiple storeys would be accessible at ground level.

Nightingale’s design principles 

Nightingale’s design principles were based on wards that could hold a carefully balanced load of 20 to 30 beds. In Rwanda, many wards were designed for two dozen patients holding well over 30, sometimes with two to three people per bed or with patients lying on mats underneath. With few medical facilities in the country, doctors were trying to use all the available space.

As overcrowding is dangerous and on an unregulated scale, it was almost impossible to control infection and isolate patients in single rooms. In rural areas, patients were dying more often in isolated rooms as there was not enough staff to monitor them.

It was essential to ensure that the wards in Butaro would not overfill during times of stress to the system. It was also crucial to have monitoring devices and a visual relationship between the nurses’ station and the patients, hence the necessity to design open wards with nurses’ stations in the centre, low walls to ensure the visibility of the entire room and all the beds, and few corners to block the view between staff and patients.

Glass-doored isolation rooms for actively contagious patients are located at the end of each ward. Adjacent bathrooms are equipped with their own venting and entrances to the wards to reduce the spread of odours and bioaerosols.

Nightingale’s prescriptions were needed to balance out all elements. The new Butaro ward design is written into national guidelines and has been replicated in hospitals throughout Rwanda and beyond. Nightingale changed many things, but most importantly the revelation that architecture is an essential, rights-based discipline.

Full acknowledgement and thanks go to and MASS Design Group for the information in this editorial.

Excerpted and adapted from The Architecture of Health: Hospital Design and the Construction of Dignity, an accompanying publication for the Design and Healing: Creative Responses to Epidemics exhibition, on view at Cooper Hewitt, Smithsonian Design Museum through February 2023

Michael Murphy, Int FRIBA, is a founding principal and executive director of MASS Design Group, a collective of architecture and design advocates dedicated to the construction of dignity. MASS is the recipient of the 2022 AIA Architecture Firm Award.

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