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Engineers and architects extend hope through design.

By Robert Donahue, AIA, LEED AP

Having particular interest to our civil and structural engineers, the existing water tower provided about one day of storage capacity for the hospital campus. With a defunct borehole pump, the hospital is completely dependent on city water with no redundant supply.

Seasoned with skeletal reminders of our architectural and engineering history, our cultural world savors residual remnants of our past that echo in cathedrals, pyramids, and aqueducts. Previously reverberating acoustics, some ruins now simply resonate craftsmanship of stone masonry, structural stone rib vaults, or graceful architectural proportions.

Devoid of those skeletal ancient ruins, Malawi is a country whose past becomes synonymous with the present. Simple sunbaked clay brick homes topped with shaggy grass-thatched roofs slowly melt in the rain, eventually returning to the earth from whence they came. Villages organically develop along shop-laden roads backed by homes with neatly swept bare dirt yards and goats milling around central maize granaries. The Malawian landscape looks virtually the same as the British explorer Dr. Livingstone encountered in the late 1800s when exploring interior Africa and discovering the lake now bearing the country’s name.

Beit Cure International Hospital

Beit Cure International Hospital (BCIH), a teaching hospital specializing in the orthopedic treatment of children and adults, was established in Blantyre, Malawi, in 2002 by The Beit Trust, a UK-based charity, as a gift to the people of Malawi. BCIH is part of an international non-denominational Christian network of eight surgical hospitals and other clinics serving in 26 developing countries.

Specializing in pediatric orthopedic total hip and knee replacement surgeries, club foot, and bowleg deformities, BCIH offers free medical services to the poorest of the poor. Portable clinics travel throughout Malawi and adjacent countries offering medical consultation and selecting children in the most need for services, developing schedules and travel arrangements for children and their families. The existing hospital campus includes a 50-bed children’s ward and an adult ward with eight private rooms. While adult patients pay for services, all medical surgeries and procedures for children are free of charge.

BCIH also serves the local medical community, the adjacent College of Medicine, and other neighboring hospitals in Blantyre through partnerships, training, and other shared educational opportunities. Visiting expat surgeons offer training and clinicals to help educate Malawian medical students and professionals. Partnerships are also fostered by medical referrals to/from neighboring hospitals and collaborative sharing of equipment when needed. In developing countries, hospitals often struggle to provide even minimal care, let alone specialize in multiple facets of medical services.

The in-country rendered site master plan, illustrating existing buildings without color, future demolished buildings as dashed with red inner lines, and proposed new buildings/additions as solid red.

An initial conceptual elevation sketch shows a potential two-story addition with connecting balcony to provide accessibility to the upper floor in the existing building.

Hope through design

I eagerly joined a diverse 10-person team recruited by Engineering Ministries International (eMi; https://emiworld.org) to provide design services for BCIH. eMi is a nondenominational Christian development organization with offices in 10 countries whose vision is to foster God-inspired restoration and hope through design, discipleship, and diversity. eMi partners with indigenous and expat ministries to analyze, design, and improve their facilities, helping them become better stewards of natural resources and improve the livelihood of people on their ministry campuses. eMi’s tagline is “Designing a World of Hope.”

On Aug. 31, 2018, our design team assembled at the Blantyre International Airport. Most of us were mentally and physically exhausted, with some enduring a 48-hour plane trip. Despite having never met one another, our team quickly joined together in a common purpose of serving alongside BCIH.

Several weeks before our primary team assembled, two Ugandan surveyors traveled to the site to survey the entire hospital campus in addition to three other satellite properties with support housing. Our primary team, led from a field office in North Africa, included three architects, two architectural interns, two civil engineers, a structural engineer, mechanical engineer, and electrical engineer (see “Malawi design team”). Our diverse design team included two from North Africa, another from the UK, and the remaining from San Diego, Phoenix, Denver, Houston, and Austin, Texas.

Understanding the hospital vision

During our first full day, we met with Mark Deysher, the executive director of BCIH, learning about local culture, the vision and history of the hospital, and touring the main campus facilities. We heard several amazing stories of physical healing, struggling families, and the tremendous impact of children returning to their villages with prior deformities removed. Many families tend to hide children with deformities out of shame or an unwritten sense of the “sins of the father.” Spiritual pastors accompany village reuniting experiences to explain and minister to returning families now unashamed of previously hidden and outcast children.

After enjoying a worship service at a local church and touring some of downtown Blantyre, our team spent most of our second day sketching and measuring buildings on multiple sites to create accurate as-built drawings.

Throughout our time in Malawi, we shared how each of us felt compelled to volunteer for this project, focusing on our common purpose of serving the people of Malawi, and enjoying our week and a half of divinely intertwined life paths.

Our third day in Malawi coincided with the weekly arrival of incoming patients. After a relatively quiet weekend, the hospital suddenly became a beehive of activity. Some children were admitted while others were prepped for life-changing surgeries. Day clinics, x-ray, ultrasound, pharmacy, and other hospital services provided care to out-patients.

Unique to Malawi, BCIH provides three meals per day for all patients and one family guardian. Some children require supplemental nourishment to physically withstand surgery. The hospital kitchen was abuzz with meal preparation throughout the day while spiritual leaders offered counseling to patients and families, many having traveled great distances from all over Malawi and even some neighboring countries. Our team enjoyed traditional Malawian dishes cooked in the hospital kitchen.

Most of our core project days involved our architectural team meeting with ministry leadership and hospital staff to learn the hospital’s history, vision, function, challenges, and future direction. Gleanings from these meetings developed the framework for designing a “master plan of hope.”Team at the edge of the plateau before heading into the Shire River Valley on the way to a wildlife preserve. Scottish missionaries in the late 1800s, unable to continue beyond a section of waterfalls and donned with wool clothing, found the more mild temperatures of the plateau a welcome respite. Their settlement became the present-day city of Blantyre.

Developing the master plan

Through the process of talking to nurses, surgeons, cooks, administration, and spiritual staff, we developed a greater understanding and clearer picture of current functions, challenges, and future needs of the hospital. Simultaneously, our engineering team explored existing structural, civil, mechanical, and electrical systems to gain an understanding of current challenges and potential future improvements.

Our team also assessed the existing hospital facilities from the standpoint of building code, accessibility, structural, civil, and electrical conditions to create recommendations for critical improvements.

Our architectural team created a 3D SketchUp model of the existing hospital campus and a potential outpatient and administration addition.

From a civil engineering perspective, the existing water supply system was inspected and mapped. With primary storage in a large water tower, water supply included several smaller tanks scattered around the campus. With a nonfunctional existing borehole pump, the hospital is currently fully dependent on city water, with no backup or alternate supply. Our civil engineers developed a water demand analysis illustrating the current storage capacity providing only a day’s supply of water.

Our civil engineers also analyzed site runoff concerns, measured wastewater/storm inverts, and mapped existing pipe layouts. Civil recommendations included swale diversion of runoff from an adjacent site, addition of another water tower of comparable size (affording two days of capacity), rehabilitation of the existing borehole/drilling a new borehole for redundant supply, and installation of a grease interceptor along the waste line beyond the kitchen.

Our structural engineer analyzed the existing water tower structure, finding it sufficiently braced to support the large dead load of water. Additionally, the engineer examined attics to analyze existing roof trusses, looked at some minor wall cracking as requested by the hospital, made recommendations for column spacing in proposed new buildings, and explored potential solutions for bracing a proposed tall flue stack for a new incinerator.

Exploring surgical theaters and other medical spaces, our mechanical engineer made recommendations to improve air supply, filtration, and conditioning, exhaust, and surgical sterilization. Our electrical engineer looked at panel boxes, switchgear, and a diesel generator, mapped existing wiring, and connected load demand instruments during several of our project days.

This 45-year-old bull elephant expressed his disdain for our boat encroaching on his turf. There are few things that can get your heart racing more than sitting in a boat 15 feet from shore and having a much larger elephant charge you to confirm his larger size.

Hospital staff expressed a desire to lessen the use of expensive diesel generator fuel, detach from the sporadic national power supply, and pursue either solar supply or battery storage to bridge the gap in power drops. To meet this concern, our electrical engineer analyzed existing power demands, future demands, solar panel capacity/sizes, and battery sizes/capacities.

At the end of the week, our team shared a presentation of a schematic hospital floor plan, overall architectural site master plan, civil infrastructure plan, structural analysis of existing water tower and future water tower improvements, electrical system analysis and infrastructure improvements, and schematic architectural building designs for potential future hospital expansions.

Conclusion

After an intense design charrette week, our team enjoyed a couple of days at a Malawian Wildlife Preserve, meeting some of the locals, including lions, elephants, crocodiles, hippos, and warthogs, among others.

Our team continued to serve BCIH this fall as we refined and further developed the hospital master plan. By the end of the year, we will release a design report to BCIH for use as a fundraising tool and strategy mapping for campus improvements.

eMi recently served CURE International with similar master planning projects at other hospital campuses in Niger and Uganda and is scheduling future projects at other CURE hospital campuses. Upcoming projects, along with more information about eMi and how you can serve, can be found at www.emiworld.org.

If design professionals think of nations as involved in a journey along a development ladder rather than being subservient in a first to third grading hierarchy, we can more easily show compassion and see developing countries as having tremendous opportunity to nurture and grow. Having lived overseas, visiting more than 70 countries, and enjoying the blessing of serving on more than 40 projects like this, I see the developing world as having amazing potential while equally mired in a quicksand of challenges.

Serving the developing world as a westerner (especially in an indirect communication culture like Malawi) requires patience, humility, cultural sensitivity, and remembering that we don’t know as much as we think we know — not necessarily an easy task for us architects and engineers!

Malawi design team

  • Trevis Smith, eMi project leader (civil engineer), North Africa
  • Meg Longman, eMi associate staff (architectural), UK
  • Martina Nasser, eMi associate staff (architectural), North Africa
  • Nathan Geier, architect, The Woodlands, Texas
  • John Cooksey, health care architect, Denver
  • Robert Donahue, architect/planner, Round Rock, Texas
  • Eric Lehmkuhl, structural engineer, San Diego
  • Robin Osborne, civil engineer, San Diego
  • Joe Ross, mechanical engineer, San Diego
  • Cassandra Rounds, electrical engineer, Phoenix

Robert Donahue, AIA, LEED AP, is a project architect at Lockwood, Andrews & Newnam, Inc. (LAN), a planning, engineering, and program management firm. He can be reached at radonahue@lan-inc.com.

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