Malawi Open Wards Health Infrastructure

Malawi Public Health Infrastructure in times of Pandemic: The Studies of Air Quality, Passive Ventilation and Programmatic Relationships By: Priya Badri, Kaitlyn Cusumano and Alan Davidson

Project presented to the Faculty of the Department of Architecture College of Architecture and the Built Environment Thomas Jefferson University In partial fulfillment of the requirements for the degree of BACHELOR OF ARCHITECTURE Arch-507 / Design 9: Research and Design Faculty Associate Professor Chris Harnish Philadelphia, Pennsylvania December 2020

5 OPEN WARDS

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5.1-INTRODUCTION 5.2-BACKGROUND

5.5-METHODS

- THE SPREAD OF COVID 19

5.3-RESEARCH PROPOSAL

5.4 - INTENTIONS

- ENVIRONMENTAL FACTORS OF COVID 19 - MALAWI’S BASELINE DESIGN FOR OPEN WARDS

5.7-CONCLUSIONS

5.6-FINDINGS - ANALYSIS OF EXISTING OPEN WARDS

- SPATIAL ORGANIZATION

- LITERARTURE REVIEW OF BEST DESIGN STRATEGIES

- CIRCULATION

- SPATIAL ORGANIZATION OF PROGRAM - BUILDING ASSEMBLY

- KASUNGU DISTRICT HOSPITAL ANALYSIS - VENTILATION - PERSONAL SAFETY

5.8-PROGRAMMATIC LAYOUTS

- DAYLIGHTING

5.10-EXPERIMENTAL VENTILATION

- WHO & CDC GUIDELINES

5.9-AIR QUALITY INVESTIGATION IN WALL ASSEMBLIES

- PROGRAM GROUPINGS

- AIR QUALITY IMPORTANCE

- EXISTING KDH LAYOUT VS. IMPROVED KDH LAYOUT

- VENTILATION PROPOSAL 1 COMFORT SCHEME

- WHO AIR QUALITY GUIDELINES

- IMPROVED PROGRAMMATIC LAYOUT 1 - IMPROVED PROGRAMMATIC LAYOUT 2

- COVID-19 WARD GUIDELINES

-MATERIAL INVESTIGATIONS - WALL ASSEMBLY PROPOSAL SET 1 - WALL ASSEMBLY PROPOSAL SET 2

- CONCERNS OF EXISTING AIRFLOW

- WIND TOWER STACK VENTS - HYBRID VENTILATION & WIND TOWER - VENTILATION PROPOSAL 2 NOSOCOMIAL INFECTION - VENTILATION PROPOSAL 3 COVID-19 RISK

5.11-APPENDIX

THESIS STATEMENT AND QUESTION: In Sub-Saharan Africa, the country of Malawi is working on keeping up with their growing population as they continue to make practical advancements forward in expanding their healthcare facilities in sustainable ways, while combating the new development of COVID-19. The issue of airborne infection and transmission has become a heightened concern and obstacle among healthcare facilities such as open wards. This has led to the need for new design strategies involving natural ventilation and better foot traffic circulation.

How are open wards impacted by airborne transmissions and infections, specifically relating to COVID-19?

KDH OPEN WARDS 5.1 Introduction In Sub-Saharan Africa, the country of Malawi is working on keeping up with their growing population as they continue to advance and expand their healthcare facilities in sustainable ways, while combating COVID-19. The issue of airborne infection and transmission, specifically tuberculosis and COVID-19, is a heightened concern and obstacle among open ward healthcare facilities recently.

Tuberculosis (TB) has repeatedly revealed that there is a strong correlation between hospital ward design and infection rates proving it is an inherently spatial issue1.

In 2005, fifty-two out fifty-three patients that entered the hospital with HIV died within two weeks from a rare form of TB that is resilient to most antibiotics. It was discovered that these cases were all contracted at the health facility itself2. With the rise of COVID-19, the need to develop new design strategies involving natural ventilation and improvement of circulation flow within open wards is more crucial than ever.

Longitudinal Section of male ward at KDH

Figure 1: Arial view shows the male ward at Kasungu District hospital as it sits parralel to the rest of the general wards

5.2 Background The Spread of COVID 19: The main issue that persists with open wards is how easily and quickly the infection travels throughout the facility, affecting everyone in its path. Infections such as COVID-19, spread their pathogens in droplet form which are spread through contact, droplet and airborne transmissions. Airborne and droplet transmissions spread through exposure to droplets that are in the air for long periods of time or when exhaled by an infectious person within too close of a distance. Examples of these could be through natural means like, breathing, talking, sneezing and coughing. Contact transmission is when one person has direct contact with an infectious person, surfaces or objects, for example, touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes3. As a result of not only the air droplets being infected,

but also surfaces throughout facilities, leaves the healthcare workers at major risk. A recent study had been done that estimated 49% of healthcare workers had TB infections compared to 25% of the general population4. This should indicate to staff working in healthcare facilities the importance of personal protection equipment (PPE) and the importance of protecting themselves and other patients.

Environmental Factors of COVID-19: •

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1 “World Population Prospects: The 2017 Revision | Multimedia Library - United Nations Department of Economic and Social Affairs.”

2 Philp, Rowan. “Future - Developing World Hospitals Receive Radical Surgery.”

3 Scientific Brief: SARS-CoV-2 and Potential Airborne Transmission 4 Gupta, KB, and A. Atreja. “Transmission of Tuberculous Infection and Its Control in Health Care Facilities.”

5 Gupta, KB, and A. Atreja. “Transmission of Tuberculous Infection and Its Control in Health Care Facilities.”

6 Atkinson, J., Chartier, Y., Pessoa-Silva, C., Jensen, P., Li, Y., & Seto, W. (2009). Natural Ventilation for Infection Control in Health Care Settings (World Health Organization, Department of Global Alert and response).

Exposure in relatively small spaces lacks adequate ventilation to clean the environment through dilution or removal of infectious droplet nuclei and the recirculation of air containing infectious droplet nuclei5.

Within these conditions, for these droplets to live and continue infecting, they need to survive physical challenges such as evaporation, light, temperature and relative humidity6.

5.3 Research Proposal •

The infected airdrops thrive in dry, cool atmospheres with little to no direct exposure to sunlight or other sources of radiation7.

Malawi’s Baseline Design for Open Wards: •

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Single story rectangular form with a double loaded corridor at the center - bays to be double lined with patient beds on each side.

Windows line the two longer sides of the ground floor level for cross ventilation.

This research proposal examines the impact of COVID-19 within open wards in Malawi and of COVID-19 within open wards in Malawi and asks, how can assembly modifications and better spatial organization lower risk factors of airborne transmission, improve ventilation performance and the safety of health workers and patients, when compared to existing models of open wards?

5.4 - Intentions The report begins with analyzing existing open ward facilities in Sub-Saharan Africa, followed by a literature review that examines the best practices for environmental and spatial designs within these facilities to create safer environments. Afterwards, an examination of Kasungu District Hospital open wards will be implemented as a baseline for bettering the conditions of these facilities.

This will include a graphical analysis report of the best spatial, environmental and structural practices to use according to the CDC and WHO guidelines when addressing COVID-19 and TB infection control.

5.5 Methods A literature review was conducted that includes a graphical analysis of the best practices to be implemented within open wards in order to optimize patients’ care and safety, compared to the case study analysis of Butaro District Hospital and Kamuzu Central Hospital.

Following is a graphical analysis of the existing open ward healthcare facility at Kasungu District Hospital, the COVID-19 design strategies they have put into place and the environmental and spatial methods used.

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Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)

5.6 Findings Analysis of Existing Open Wards: An analysis was completed on two different open ward healthcare facilities: Butaro District Hospital and Kamuzu Central Hospital.

• Butaro District Hospital • natural ventilation system involves clerestory windows and ground floor windows that allow for the stack effect • patients beds 1m apart and isolation rooms at the ends • main circulation was outside the building • Kamuzu Central Hospital • Natural ventilation system that includes ground floor windows to create cross ventilation • patients beds 1m apart and isolation rooms at the ends • central double loaded corridor within the building Overall, the design elements of these open wards should be improved upon in order to optimize the environment their patients are living in and staff are working in.

Literature Strategies:

Review

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PPE / HAND WASHING STATIONS

Suggested

This literature review is based off of conducted reports from the CDC and WHO guidelines for efficient methods of environmental and spatial designs within open wards in order to optimize patient care and safety in open wards.

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Natural ventilation systems are recommended by both sources in order to reduce the airborne transmission among staff and patients8. Systems that can be carried out: • combines cross ventilation with stack ventilation; i.e. clerestory windows with ground floor windows9.

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Daylighting is harmful to the airborne bacterias and viruses within the air.

• droplets don’t typically survive long once exposed to sun rays for too long10.

• exposure to daylight helps the comfort of patients by reducing the length of their stays, improves sleep cycles and eases pain11.

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Spatial layouts among patients helps to reduce their exposure of infections between each other and is very important when trying to reduce the spread of airborne infections. Initiatives to take include: • Patient beds need to be at least 2m apart • Physical barriers placed between patients’ care models12.

• The recommended circulation paths for staff and patients include single corridor or courtyard circulation instead of central double loaded corridors due to the efficiency of air flow and cross infection13.

Figure 1:The use of PPE and hand hygiene should be reminded of throughout the hospital facility with the implementation of signage and supply stations to caution and emphasize the importance of these practices.

Kasungu District Hospital Analysis: Upon analyzing the existing open wards at Kasungu District Hospital and others in the Sub-Saharan region of Africa, there have been some design elements that should be altered in order to address the concerns surrounding the airborne transmission of infections like COVID-19 in healthcare facilities.

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Personal Safety: • Masks must be worn at all times on the premises and enter is not permitted unless one is being worn • Hand washing stations outside of every building and at every bay within World Health Organization (WHO) suggest additional practices include: • Appropriate PPE for staff (gowns, face masks, goggles and gloves) • Hand hygiene (either alcohol based hand rub or soap and water) for staff and patients is one of the most useful practices to avoid transmission of infection, seen in Figure 114.

8 WHO guidelines on tuberculosis infection prevention and control 9 Atkinson, J., Chartier, Y., Pessoa-Silva, C., Jensen, P., Li, Y., & Seto, W. (2009). Natural Ventilation for Infection Control in Health Care Settings 10 Ather B, Mirza TM, Edemekong PF. Airborne Precautions 11 Benedetti, Francesco, Cristina Colombo, Barbara Barbini, Euridice Campori, and Enrico Smeraldi. “Morning Sunlight Reduces Length of Hospitalization in Bipolar Depression.”

12 Severe acute respiratory infections treatment centre: practical manual to set up and manage a SARI treatment centre and SARI screening facility in health care facilities 13 WHO 2009

Circulation: Also, findings from WHO suggest Kasungu’s circulation routes within the open wards aren’t effective because their double loaded corridors aren’t as effective as single corridors or courtyard circulation due to the efficiency of air flow and cross infection, seen in Figure 215

Figure 2: Double loaded corridors increase the risk of cross infection, whereas single corridors and courtyard circulation are exposed to more fresh air resulting in lower risk of cross infection

14 Severe acute respiratory infections treatment centre: practical manual to set up and manage a SARI treatment centre and SARI screening facility in health care facilities 15 WHO 2009

Spatial Organization: Findings from WHO reports also suggest Kasungu’s spatial organization within the open wards aren’t practical because single-row ward layouts are more effective than double-row layouts, seen in Figure 315; the patient beds need to be at least 2m apart, seen in Figure 4; and the lack of use of physical spatial barriers such as, glass or plastics, seen in Figure 516. In addition, another reliable source, HERD, suggests that centralized nursing stations could be beneficial for the comfort levels of patients and family, seen in Figure 6 17.

NURSE STATION

NURSE STATION

Figure 5: By having physical spatial barriers implemented it can help to reduce patients and staff from exposure to the infections.

Ventilation:

Figure 3: Double row ward layouts aren’t as efficient as single-row ward layouts because patients close together and facing each other aid in the spread of infections.

In addition, findings from WHO suggest Kasungu’s ventilation system within the open wards is problematic because solely using cross ventilation isn’t the best system, by combining it with stack ventilation allows for the most airflow and circulation, seen in Figure 7 19. Cross ventilation can be effective if there is an ability for the air flowing through the space to move upwards and outwards. In this case, the heat in the air travels up and becomes trapped with a lack of an escape thus causing the space to heat up and become a heat trap. Using stack ventilation will allow the air to move upwards thus regulating the internal temperature of the ward.

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Figure 4 When patient beds are less than 2m apart the potential for transmission of infections increase due to their infected air droplets spreading amongst others.

Figure 6: Decentralized nursing stations distances staff from patients and increases their anxiety for care whereas centralized nursing stations allow for better circulation, improved visibility of the patients, and reduce patients anxiety of not being seen or cared for when needed.

16 Atkinson, J., Chartier, Y., Pessoa-Silva, C., Jensen, P., Li, Y., & Seto, W. (2009). Natural Ventilation for Infection Control in Healthcare Settings 17 Severe acute respiratory infections treatment centre: practical manual to set up and manage a SARI treatment centre and SARI screening facility in health care facilities 18 Zborowsky T, Bunker-Hellmich L, Morelli A, O’Neill M. Centralized vs. decentralized nursing stations: effects on nurses’ functional use of space and work environment 19 Atkinson, J., Chartier, Y., Pessoa-Silva, C., Jensen, P., Li, Y., & Seto, W. (2009). Natural Ventilation for Infection Control in Health Care Settings

Figure 7: Stack and cross ventilation allows for fresh air to come in through the ground floor windows, then replacing the contaminated and hot air as it rises to the top and escapes through the stacks/windows.

Daylighting: Lastly, findings from Harvard Health suggest Kasungu has relatively useful daylighting within the open wards because the nine windows that line each side of the open ward help to kill bacteria in the air and allows for patients to have exposure to natural light, helping their bodies produce Vitamin D, which boosts their natural defense against viruses and bacteria, seen in Figure 8A-F 20. Each of the daylighting models distinguish the amount of daylight entering through the four main months of the year in Malawi’s seasonal pattern: March, June, September and December. As shown in the diagrams, there is a constant change of daylighting levels specifically within the open ward space of this unit, especially being the space with the least amount of structural interference. In contrast, the other closed programs show the constant change in lighting and solar insolation based on these seasonal times throughout the year.

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Figures 8A: Daylighting in January

Figures 8C: Daylighting in September

Figures 8E: Daylighting Insolation in July

Figures 8A-F: The use of daylighting not only creates a comfortable environment for patients, but also helps to quicken their healing process.

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Figures 8B: Daylighting in April 20 Preventing the spread of the coronavirus”

Figures 8D: Daylighting in December

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Figures 8F: Interior Daylighting in June

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5.7 Conclusions This report presents a set of design guidelines for underdeveloped healthcare systems that helps advance the progression of needing to control airborne infections, specifically COVID-19, and provide safer environments for patients and staff. When looking at the WHO and CDC reports along with other credible sources and comparing their information to the existing open wards at Kasungu District Hospital, a few design goals were developed.

Building Assembly:

Spatial Organization of Program: •

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Modify circulation from being a central double loaded corridor to either a single corridor or courtyard circulation for better airflow in the building for patients and staff Modify circulation of staff with a hybrid centralized nursing station, which entails a more private room for their equipment and supplies and a centralized station to stay in close range to their patients.

Patient beds spaced at least 2m apart from each other in order to safety distance them from spreading infections Barriers between patients in order to prevent patients from being too close to each other and exposing each other to the airborne transmissions •

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Creating a private and covered waiting area outside in the back of the facility for guardians and patients (plantings acting as a perimeter)

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Creating a public and covered waiting area outside by the front of the building for patients waiting to come into the open ward

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Expanding out on a side of the building for more ward space to accommodate not only the correct 2m distancing, but also make room for more patients

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Modify the roof assembly so there is no drop ceiling, exposing the structure above it and adding stack vents to add stack ventilation with cross ventilation.

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Implementing a drainage system with the stacks

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Implementing some kind of screening or shading device over windows to avoid direct sunlight

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Wall assemblies should be lightweight and insulated •

The surface temperature of a lightweight construction or a wall with internal insulation will respond rapidly to changes in air temperature, limiting the rise of surface and internal relative humidity when the sudden warm and humid air comes in contact with the wall (e.g. in the transient spring season)21

Doubles as seating and storage for each patient and guardian, while giving a bit of privacy and shielding from patient next to each other

21 Atkinson, J., Chartier, Y., Pessoa-Silva, C., Jensen, P., Li, Y., & Seto, W. (2009). Natural Ventilation for Infection Control in Healthcare Settings

INDIVIDUAL ANALYSES COMBINED MOVING FORWARD: After the initial case study and research examination of Kasungu District Hospital’s open ward, three main areas of improvement were programmatic development, air quality and natural passive ventilation strategies, which focus on bettering the quality of experience and safety for users. Beginning the individual studies of these topics, the intentions were to reconnect and bring all three improved areas together to create one cohesive designed project in the end.

INTRODUCTION: Open Wards are key components of the district and central hospital tier of the MOH health infrastructure.

This project examines open wards and their preparedness and responsiveness related to COVID-19.

The work to consider other factors in open wards including poor air quality and circulation, high risk of airborne infection transmission and overlap of user circulation paths.

THESIS STATEMENT & QUESTION Malawi’s open wards can be more programmatic efficient and can approach a more transmission free infection rate through better performing wall assemblies, air evacuation strategies and programmatic layouts.

How can redesigning programmatic relationships, wall assembly systems and passive ventilation strategies reduce transmission of infectious diseases effectively while providing safe healthcare environments for all users?

5.8-PROGRAMMATIC LAYOUTS

RESEARCH STATEMENT & QUESTION: In Sub Saharan Africa, the issue of COVID-19 transmission has become a heightened concern and obstacle among healthcare facilities such as open wards. This has led to the need for new design strategies involving better foot traffic circulation and organization methods.

In Malawi’s open ward healthcare facilities, how can bettering different spatial organization and circulation systems aid in transforming a normal open ward to a COVID-19 ward resulting in lower risk factors of airborne transmission and improved safety of health workers and patients, when compared to the WHO standards and facilities designed by leaders in the profession?

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WHO & CDC GUIDELINES

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When analyzing open ward, it was crucial to take into consideration the guidelines formulated by the World Health Organization (WHO) and the Center of Disease Control (CDC) in redesigning healthcare facilities.

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Floor plans shaped as I, H, L, T or U in combination with open courts and maximum window sizes in order to get the fullest effect of natural ventilation and daylight1 2

A few fallbacks that were discovered among the guidelines inlcude: • Overlapping of user circulation throughout the facility in I, H, L, T and U shaped plans, seen in Figure 5. This means that the transmission of infectious diseases is much more likely to spread rather than reducing • The use of long corridors with no cross ventilation (Figures 5, 6, and 7) result in lowering the chances of having the best natural ventilation outcome and raising the spread of airborne infections

STAFF OFFICE

STAFF RESTROOM

STAFF OFFICE

CONSULTATION ROOM

5.8-PROGRAMMATIC LAYOUTS

Natural ventilation corresponding to interior organization, a single-row ward layout works better than a double-row layout with a central corridor due to the efficiency of the air flow3 Useful types of natural ventilation include combining cross-ventilation with stack ventilation through corridor vents or shafts in multi storey structures, as seen in Figure 14 Cross ventilation works with windows being on opposites of the room (Figure 2) and wind tower ventilation allows positive pressure wind coming in to then extract air out on the negative pressure side (Figure 3) Placing patient beds at least 2m apart and having physical barriers between them (Figure 4) in order to lower the risk of spreading infectious diseases through direct contact, long distance and short distance5

PROCEDURE ROOM

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DONNING ISOLATION RESTROOM

EXHAUST INTAKE

DOFFING

NURSE STATION

ISOLATION ROOM

OPEN WARD OPEN WARD DOFFING

WARD RESTROOM

STORAGE

NURSE STATION

ISOLATION RESTROOM

DONNING

NURSE STATION

ISOLATION RESTROOM

WARD RESTROOM

DONNING

NURSE STATION

STAFF RESTROOM

WARD RESTROOM

OPEN WARD

EXHAUST

CONSULTATION ROOM

STAFF STAFF STORAGE OFFICE RESTROOM

PROCEDURE ROOM

DOFFING

OPEN WARD

STORAGE

DONNING

DOFFING

ISOLATION ROOM

Figure 2: “L” section showing cross ventilation

DOFFING

DONNING

STAFF OFFICE

DOFFING

STAFF RESTROOM

ISOLATION ROOM

DONNING

Figure 4: Physcial barriers and appropriate spacing between patient beds

STAFF OFFICE

PROCEDURE ROOM

INTAKE

CONSULTATION ROOM

EXHAUST

ISOLATION ROOM

OPEN WARD

CONSULTATION ROOM

PROCEDURE ROOM

Figure 1: “I” section showing cross and stack ventilation

INTAKE PATIENT STAFF GUARDIAN

PATIENT STAFF GUARDIAN

Figure 3: “T” section showing wind tower ventilation

Figure 6: “T” shaped floor plan with user circulation paths

Figure 5: “I” shaped floor plan with user circulation paths

1 Atkinson, J., Chartier, Y., Pessoa-Silva, C., Jensen, P., Li, Y., & Seto, W. (2009). Natural Ventilation for Infection Control in Health Care Settings (World Health Organization, Department of Global Alert and response).

2 World Health Organization, District Hospitals: Planning and Design.” District Hospitals: Guidelines for Development.

3 Atkinson, J., Chartier, Y., Pessoa-Silva, C., Jensen, P., Li, Y., & Seto, W. (2009). Natural Ventilation for Infection Control in Health Care Settings (World Health Organization, Department of Global Alert and response).

4 Atkinson, J., Chartier, Y., Pessoa-Silva, C., Jensen, P., Li, Y., & Seto, W. (2009). Natural Ventilation for Infection Control in Health Care Settings (World Health Organization, Department of Global Alert and response).

5 Severe acute respiratory infections treatment centre: practical manual to set up and manage a SARI treatment centre and SARI screening facility in health care facilities

PATIENT STAFF GUARDIAN

Figure 7: “L” shaped floor plan with user circulation paths

PROGRAM GROUPINGS

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Upon analyzing case studies and precedents such as Kasungu District Hospital, an analysis of each programmatic space was broken down individually and categorized into programmatic groups based on their function. The importance of this analysis was to improve the base understanding of what goes on within each program, the significance to them, the user groups that occupy the spaces and finally the needed spatial relation they have to other program spaces throughout a healthcare facility.

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Clinical spaces (Figures 7, 8, 9) are highly infectious areas where transmission could occur • Open wards, isolation rooms, consultation and procedure rooms • These need to be close in proximity for staff to circulate quickly

Programmatic Layouts Support spaces (Figure 10, 11) • Nurse station is crucial to not only be close to the clinical spaces, but also in direct sight of them for the patients comfort and alertness to what’s going on • Donning and doffing stations are recommended to have at the entrance and exit of each clinical Figure 10: Support - Nurse Figure 11: Support - Donning space in order to best practice PPE Station & Doffing rooms • Only staff such as doctors and nurses would have access to • Outdoor spaces (Figure 13) • exposure to the natural environment • private ward space for patients and guardians • public waiting and screening areas for potential patients need to be close to the consultation, procedure and offices so staff can have easy access without potentially spreading infectious Figure 8: Clinical - Isolation Rooms Figu diseases

Figure 7: Clinical - Open Ward

Figure Figur 9: Clinical - Consultation & Procedure Proce Rooms

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S Service spaces (Figure 12) • Only staff can access storage, staff offices and restooms • Storage facility should be relatively close to the nurse station and donning and doffing stations for easy access to supplies when needed

Figure 13: Outdoor - Public Waiting & Screening Areas and Private Ward Access

Figure 12: Service - Staff Offices, Storage & Staff Restrooms

EXISTING KDH LAYOUT VS. IMPROVED KDH LAYOUT

Programmatic Layouts

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• When analyzing Kasungu District Hospital and its effectiveness on transmission of infectious diseases, new design implementations need to occur based on the guidelines suggested by the WHO and CDC and the • analysis of each programmatic space needed within an • open ward healthcare facility.

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Issue of overlapping circulation among all user groups is a major concern in terms of transmission of • infectious diseases (Figure 14) Additional entrance and exit at the other end of the • facility will allow patients and guardians to circulate more efficiently without travelling through the entire facility (Figure 15)

Lack of outdoor access for patients and guardians (Figure 14) Implementation of outdoor circulation for all users and resting areas for patients and guardians would allow for more access to outdoor air and daylighting for all users (Figure 15) Absence of donning and doffing stations (FIgure 14) Implementation of donning and doffing stations in order to properly prep and dispose of PPE when treating patients (Figure 15) Absence of a nurse station near the isolation rooms (Figure 14) Nurse stations by both the isolation rooms and open ward so patients feel comfortable knowing staff can see them at all times if they’re in need (Figure 15)

Figure 18: Existing KDH Open Ward section showing cross ventilation

Figure 19: Improved KDH Open Ward section showing cross & roofing strategy ventilation

Figure 14: Existing KDH plan and user groups’ circulation paths

Figure 16: Existing KDH Open Ward patient bed spacing

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Figure 17: Improved KDH Open Ward patient bed spacing Figure 15: Improved KDH plan and user groups’ circulation paths

Current KDH patient beds are spaced 1.4m apart, (Figure 16) Patient beds need to be spaced at least 2m apart to reduce the transmission of infectious diseases, shown in Figure 17 Current source of natural ventilation is cross ventilation, seen in Figure 18 Need for a roof ventilation system to better the air circulation and filtration of infected air, seen in Figure 19

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IMPROVED PROGRAMMATIC LAYOUT 1 When considering the guidelines given by the WHO and CDC and analyzing existing open ward case studies, two new ward facilities were designed to best reduce the transmission of infectious diseases.

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First Improved Scheme: • Service spaces at the front of the facility by the consultation and procedure spaces, which back up the public outdoor waiting and screening area • Nurse station is central to the facility so staff can be close to the major clinical spaces, while also having access to the front of the facility for meetings with potential patients • Private outdoor areas for patients and guardians are at the back of the facility for privacy from the public in the front (Figures 20, 21)

Figure 21: Axonometric view showing spatial relationships between programs

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Seen in Figure 20, all circulation paths are open to air and under a roof All patient and guardian circulation stays on the exterior for the most part while staff circulates the inside of the facility. Separating the staff from the patients and guardians help in the reduction of spreading infectious diseases.

Clinical spaces and donning and doffing stations are exposed to the prevailing winds on the east side of the site to help increase the air flow and filtration within those highly infectious areas of the facility.

All patient beds are 2m apart from each other to aid in the reduction in transmission of airborne infection, seen in Figure 22.

Programmatic Layouts

Figure 22: Appropriate spacing between patient beds

Figure 20: Plan view with circulation paths of all users

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IMPROVED PROGRAMMATIC LAYOUT 2 •

Second Improved Scheme:

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Importance of separating staff circulation from the patients and guardians in order to reduce the risk of cross infection Majority of the staff circulation stays on the left inside of the facility, whereas the patient and guardian paths stay on the right outside of the facility (Figure 23).

Public waiting and screening area is in the front of the facility close to the services programs, consultation and procedure rooms Private outdoor ward area is in the back of the facility close to the open wards for patients and guardians to access Nurse station is central to the facility and close to the service programs, seen in Figures 23 and 24.

Figure 24: Axonometric view showing spatial relationships between programs

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Clinical spaces and donning and doffing stations are exposed to the prevailing winds on the site to help increase the air flow and filtration within those highly infectious areas of the facility.

All patient beds are 2m apart from each other to aid in the reduction in transmission of airborne infection, seen in Figure 25

Programmatic Layouts

Figure 25: Appropriate spacing between patient beds

Figure 23: Plan view with circulation paths of all users

Programmatic Layouts

COVID-19 WARD GUIDELINES When needing to adjust and adapt to pandemics like COVID-19, healthcare facilities need to address this forcefully. Leaders in the healthcare industry and architecture field have made suggestions and guidelines based on COVID-19 to help reduce the transmission of diseases in open wards.

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Healthcare workers need to be wearing appropriate PPE, perform hand hygiene and put on and dispose of it properly once finished6. This should occur within the donning and doffing stations at the entrances and exits of the clinical spaces (Figures 26-A, 27-A) Hand washing stations should be implemented at entrances, exits and ends of all open ward bays as well to encourage the use by all and reduce contamination, as seen in Figure 27-B Wayfinding clues such as highlighting thresholds with tape or paint and using signage can help users who may be entering or exiting an area identify where contagion risk is high or where they may encounter people who are vulnerable7 (Figures 26-C and 27C) Physical spatial barriers such as, glass or plastic is important in reducing exposure to the virus8 (Figures 26-D and 27-D). Although studies have shown that COVID is more stable on plastic and steel (up to three days) than on porous fabrics like cotton, leather, and even cardboard (less than 24 hours)9 Patient beds should be at least 2m apart is extremely important to reducing the spread of infection airborne transmission (Figures 26-E, 27-E)

Figure 26: Scheme 1 A: PPE and hand washing should occur within donning & doffing stations.

C: Highlighting thresholds and using signage.

D: Implementing physical barriers E: Separation of patients’ beds

C D

E

A C

C A Figure 27: Scheme 2 A: PPE and hand washing should occur within donning & doffing stations.

B: Hand washing stations at entrance and exit doors to encourage all users.

C: Highlighting thresholds and using signage.

D: Implementing physical barriers E: Separation of patients’ beds

6 Mass Design Group. “Carceral Environments and COVID-19.” The Role of Architecture in Fighting COVID-19 (2020) 7 Mass Design Group. “Carceral Environments and COVID-19.” The Role of Architecture in Fighting COVID-19 (2020) 8 Severe acute respiratory infections treatment centre: practical manual to set up and manage a SARI treatment centre and SARI screening facility in health care facilities 9 Mass Design Group. “Carceral Environments and COVID-19.” The Role of Architecture in Fighting COVID-19 (2020)

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D E

5-8 PROGRAMMATIC LAYOUTS

CONCLUSION: THESIS: This investigation was based on the current heightened concern and issue of COVID-19 transmission in Sub-Saharan Africa among healthcare facilities like open wards. The goal was to analyze existing open ward healthcare facilities and review suggested implementations made by the WHO, CDC and leaders in the architecture field in order to redesign ward facilities to help reduce the spread of infectious diseases like COVID-19. These design schemes were focusing on better user circulation and program organization methods.

MOVING FORWARD, design schemes should be explored in how existing open ward facilities can prepare and react to pandemics such as COVID-19. This would be more relatable to healthcare professionals and facilities rather than starting new and rebuilding. Analyzing existing case studies and redesigning them while keeping their building shell would be the most efficient, cost effective and time saving option.

5.9 - AIR QUALITY INVESTIGATIONS THROUGH WALL ASSEMBLIES RESEARCH QUESTION: In sub-saharan Africa, COVID-19 and other airborne illnesses such as Tuberculosis create issues of proper ventilation and air quality within a space. This is calling for new design needs, better and more affordable and natural materials in order to create an ideal environment and system to reduce the risk factors and improve air quality.

In Malawi’s open ward healthcare facilities, through what methods and interventions can air quality be improved through use of financially feasible, organic materials to reduce the risk and impact of infections from airborne contaminants and illnesses like COVID-19 and promote a healthier environment within and outside of the open wards?

5.9 - AIR QUALITY INVESTIGATIONS THROUGH WALL ASSEMBLIES

nervous system and even as much as the cardiovascular system - each of these creating a chain effect which have a negative impact on the structure of the whole system.

When analyzing the existing building’s facade details and wall assemblies, there are minimal conditions which promote air filtration to reduce the particle matter present in the air. The primary existing construction is based on cast in place concrete with kiln fired bricks sourced locally. This leads into the discussion of developing and using organic, sustainable material which also have properties to aid in air filtration.

Without proper air quality and air ventilation, especially in the open ward of a healthcare facility, patients and healthcare workers can develop symptoms solely from poor air quality. Some examples of these symptoms can include: • Headache • Extreme Fatigue / Dizziness • Coughs • Effects on Cardiovascular Performance • Effects on Nervous System/Circulation System

Based on a study done by a collection of professors sponsored by the University of Milwaukee, there have been a series of air pollution testing sites around the major cities to determine the primary causes for the pollutants and carbon particles within the air. Air pollution and air quality is ranked in the top nine environmental issues which are of utmost importance to the Malawian government and country. WIthout the proper care for air quality, this can have lasting, detrimental effects on the population as a whole and therefore must be engaged with in any manner possible.

Within this specific study, a series of material investigations and experimental assembly systems will be proposed as a primary start towards bettering the architectural infrastructure to battle the needs in improving air quality, even in the slightest attempt.

W.H.O GUIDELINES

Figure 3.1 - EXISTING WALL ASSEMBLY & STRUCTURE

IMPORTANCE OF AIR QUALITY Within open wards of healthcare facilities, air quality is a major factor which can have direct affects in on an individual’s health condition. This investigation of air quality takes into account, the existing structure’s effects on regulating the quality of air within the open wards systems. As shown in Figure 3.1, the existing structural system is composed of a simple brick layer atop a concrete slab system connected to a corrugated metal roofing system. With these existing materials, and the existing organization of the wall systems, the air quality has minimal regulations on the particles entering the open air space within the open ward facilities.

Poor air quality can prove to have detrimental effects on the existing health conditions of patients and even the healthcare workers. With poor air quality comes additional health symptoms

Poor air quality can develop these symptoms, and while some could be temporary based on the location and condition of the patient, but in some cases, it could also promote lifelong health complications.

If the air quality is monitored and tested regularly with the necessary changes applied, this can greatly reduce the risk factors of promoting more health concerns for patients being tended to and the health workers.

AIR QUALITY GUIDLINES In Malawi, most of the cities and more commercialized areas are what prove to have more of a threat in regards to air quality.

1. Mapoma, Harold & Xie, Xianjun. (2013). State of Air Quality in Malawi. Journal of Environmental Protection. 4. 1258 - 1264. 10.4236/jep.2013.411146.

According to the WHO Guidelines, maintaining proper air quality to reduce health impacts relies on decreasing the factors of ultrafine (UF) particles of harmful chemicals and pollutants which travel through the air. It is imperative for these UF Particles and fine particulate matter to be monitored on a regular basis to know the conditions of the existing air quality. Aside from the particulate matter in investigation, other chemicals that additionally must be filtered through include Nitrogen dioxide (NO2) and Sulfur dioxide (SO2). The levels of these airborne chemicals and particulate matter may change based on the density of the population as well as the setting in which these particulate matter are being analyzed.

MATERIAL INVESTIGATIONS Through a series of material investigations, these selected materials can be assembled in multiple manners and aid in reducing risk factors to promote a healthier air environment. There were a total of 6 types of materials in investigation to promote healthier air quality.

The chosen textile here is cotton fabric sheets which could be coated in a hydrophobic material like ethically sourced beeswax or even the TiO2 ( to act as a moisture barrier). This would promote the regulation of particulate matter - the air quality could be significantly better even with just a physical barrier that collects the toxins and chemicals in the air.

PHOTOCATALYSTS - TITANIUM DIOXIDE ( TiO2 ) Titanium dioxide (TiO is a chemical which is available in a pastelike form, or powdered and can be applied to any surface or fabric. The properties involved with titanium dioxide allows for the pollutants and contaminants

STRAW BALE STACKS Straw bale construction is a material that is readily available in Malawi with many structural and thermal advantages. In quite a few settings, straw bale has been used as a primary wall structure system framed by wood beams and girders.

Oftentimes it can also act as a major thermal insulator giving strong support for internal temperature control.

Figure A: This graph shows the differences in thickness of cotton textures in relations to different treatments of the material as it is processed into fabrics.

Because of the nature of straw bale, it must also be treated on the exterior especially to prevent any moisture from running through and corrupting the system.

This material can also be used in aiding with air quality control, however it is imperative to make sure moisture does not enter the straw bale stacks in any stage of construction before and after.

Moisture entering this system can easily cause the exact opposite effect and decrease the quality of air even more.

BIOPLASTICS/FABRIC MESH - COTTON Bioplastic and fabric textiles can be systems placed within walls or implemented in building openings (meaning windows and vents) to act as regulatory factors that maintain the air quality and reduce particulate matter levels within a space.

Thinned cotton fabric could be an ideal material to improve those internal air quality conditions, as it has a high water and air filtration capacity. One of the few negative traits with using cotton includes visibility of the collection of matter on the actual fabric. This could be prevented through use of Photocatalysts or implementing a hydrophobic barrier, but it would still need to be maintained and cared for.

1. Mapoma, Harold & Xie, Xianjun. (2013). State of Air Quality in Malawi. Journal of Environmental Protection. 4. 1258 - 1264. 10.4236/jep.2013.411146.

2. Garger, Mark, and Evan Marhon. Tech. THE USE OF TITANIUM DIOXIDE IN CONCRETE MATERIALS TO FILTER SMOG POLLUTION FROM AIR. University of Pittsburgh, n.d.

in the air to oxidize with the TiO2. The properties in TiO2 neutralizes the majority of these contaminants on impact and immediately makes them less harmless. This material would be applied as an external layer of wall assemblies, manufactured into textile fabrics or be designed in wall paneling systems which can be placed along an exterior facade.2

MATERIAL INVESTIGATIONS HEMPCRETE Industrialized hemp creates many health benefits both directly and indirectly. Within this circumstance, hemp would be mixed in with concrete to develop masonry units that would allow for air filtration through the direct passage of air through the hemp fibers.

Hempcrete is an effective thermal mass as well. The fibers are thick enough that it allows the heat to become trapped, thus becoming a factor allowing regulation of internal air temperature.

This can be crucial especially inside a healthcare facility where temperature of the space can affect the health conditions of patients. Additionally, the fibers from the hemp hurds in hempcrete have a high moisture tolerance and are the most effective method of cleansing the air of any pollutants and contaminants. Replacing the existing brick walls with even just a few of these hempcrete masonry units can be effective in improving internal air quality.

Figure B: This table dervied from a study of hempcrete’s material properties shows is feasibility. It verfies hempcrete as one of the best materials to use in industrial construction as a masonry unit with its sustainable environmental properties3.

Rammed earth is another effective material, similar to hempcrete. Although this system does not use fibers or the mixture of organic material, it does have some qualities that can aid in reducing particulate matter within the air.

Figure C This shows the initial process in which hempcrete is cast into a system with a timber frame and lined with lime plaster on the exterior this can similarily be done to systems for Malawian hospitals by substituting red bricks with hempcrete masonry units.2

Hemp is a financially feasible material with a very short harvest time.

Within Malawi’s lush conditions, hemp can be grown but only to a certain extent to where it buds flowers. For hemp to be harvested for industrial use, it must continue to grow in a larger scale. It has a harvest time of 120 days from the day it is planted to the day that is fully grown, allowing this to be a sustainable material that can be grown and harvested in abundance.

The use of hemp can also promote environmental conditions and reduce carbon footprint on the site as well - it acts as a carbon scrubber from the air while it is in growth.

RAMMED EARTH

Figure D: To aid in regulating temperature, rammed earth can also have a layer of insulation added between the layers and surrounds the insulation to prevent heat loss.

Hempcrete is an effective thermal mass as well. The fibers are thick enough that it allows the heat to become trapped, thus becoming a factor allowing regulation of internal air temperature, where temperature of the space can affect the health conditions of patients. Fibers from the hemp hurds in hempcrete have a high moisture tolerance and are the most effective method of cleansing the air of any pollutants and contaminants.

Replacing the existing brick walls with even just a few of these hempcrete masonry units can be effective in improving internal air quality.

1. Mapoma, Harold & Xie, Xianjun. (2013). State of Air Quality in Malawi. Journal of Environmental Protection. 4. 1258 - 1264. 10.4236/jep.2013.411146.

2. Bedlivá, Hana & Isaacs, Nigel. (2014). Hempcrete – An Environmentally Friendly Material?. Advanced Materials Research. 1041. 83-86. 10.4028/www.scientific.net/AMR.1041.83.

3. Bedlivá, Hana & Isaacs, Nigel. (2014). Hempcrete – An Environmentally Friendly Material?. Advanced Materials Research. 1041. 83-86. 10.4028/www.scientific.net/AMR.1041.83.

Park, S. H., & Mattson, R. H. (2009). Ornamental indoor plants in hospital rooms enhanced health outcomes of patients recovering from surgery.

This material’s ability to filter air relies mostly on its property to filter air through collecting the humidity in the wall system. Since rammed earth is compacted earth mixed with concrete, it also does have an ability to collect and have resistance to any moisture. This could be an ideal material for use during Malawi’s humid, monsoon months during the year.

MATERIAL INVESTIGATIONS RAMMED EARTH (CONT.) Similar to hempcrete, rammed earth is a great solution to help regulate internal air temperature. In Malawi’s conditions, it can collect the heat during the day if placed at lower levels along the wall assemblies, and release the heat during the night time as temperatures decrease to provide a better thermal comfort space for the healthcare workers and the patients1.

BIOWALLS & VEGETATIONS Biowalls and using plants are beneficial to reducing the impact of illnesses, especially within hospitals. These systems would be mostly implemented in the external conditions of the healthcare facility acting as the primary barrier between particulate matter and other chemicals. It would then be followed by a series of additional filtration levels implemented in the biowall and within the wall system of the existing building structure.

Vegetation can be applied to internal environments in hospitals but it is extremely important to remember to maintain those plants to prevent any sort of harmful bacterial or fungal growth.

Plants are systems that must be cared for and maintained.

Without the proper maintenance, similar to straw bale stacks, it can have a negative impact on patient health.

1. Stone, Clayton & Bagoňa, Miloslav & Katunský, Dušan. (2012). EMBODIED ENERGY OF STABILIZED RAMMED EARTH ENERGIA ZAWARTA W STABILIZOWANEJ ZIEMI UBITEJ. Czasopismo Techniczne - Technical Transactions. 109. 395-400.

2. Park, S. H., & Mattson, R. H. (2009). Ornamental indoor plants in hospital rooms enhanced health outcomes of patients recovering from surgery.

WALL ASSEMBLY PROPOSAL SET I

Figure 3.2 - SCHEME 1

Within the proposal sets of wall assembly schemes, are two sets of proposals based on typologies of the wall assembly structure. This initial set intends to investigate wall assembly systems which introduce a vegetation free system that relies solely on the material properties of the wall materials selected for each wall system. Each material selected contributes to the layer of air filtration, providing an intermediary layer to filter the air of any pollutants.

These systems also aim to add to the thermal comfort and use of the space through the use of natural, organic materials that are also ethically sourced. Figures 3.2 3.4 are the primary examples that depict these wall assembly systems. Each material selected for each wall assembly system have been selected carefully with the best

Figure 3.3 - SCHEME 2

Figure 3.4 - SCHEME 3

possible material pairings in order to achieve full function. Each assembly system takes into account the different materials that were investigated. With each proposal An additional factor going into each of these designed is a scheme developed using different combinations schemes is the external interaction for users outside of the selected materials and implementing multiple of the space as well. Each of these schemes progress interventions within the wall systems to create a series in terms of interaction with the external environment, of effective and efficient systems to improve the air Figures 3.2 and 3.4 are examples of peak interaction on quality conditions both inside and outside the healhcare an external basis while Figure 3.2 showcases the least facilities. amount of interaction.

Part of the approach in these schemes also takes into account providing a space for guardians, or other family members that may be visitng to to take care of the patient within the facility.

WALL ASSEMBLY PROPOSAL I - SET 1

Figure 3.2 - SCHEME 1 Figure 3.5 - SECTION DETAIL

Scheme 1 proposes a system that is composed of: • Rammed earth • Plastic/fabric mesh - Composed of Cotton • Titanium Dioxide - Photocatalyst The materials in this scheme were selected to create an earthy tone and environment to the exterior shell and extended space of the open ward facility. The rammed earth material is used in the primary barrier providings space for both main circulation paths and private seating areas. Within Malawian culture, specifically in hospitals, each patient is designated a guardian or family member to look after them to supply foods and medicines when health workers are not present.

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Oftentimes, these guardians also stay the night with these patients but are not provided adequate staying areas both during the day and night. This provides an external seating space which can be implemented by any type of ward to provide that necessary designated space.

The first layer of filtration comes from the first main rammed earth separation wall composed of rammed earth and a fabric mesh held taut between the layers. The physical wall assembly uses a series of interventions that allow the air to be filtered through both directly and indirectly.Within this wall assembly, The materials within this wall assembly also uses quite a a series of stack vents can be implemented with a layer of few different elements to filter the air. Scheme 1 without operable vents along the bottom to further help regulate the the vegetation aims to use passive methods through organic internal temperature of the internal environment. material selections. The main element in use here is Rammed Eart units which can be cast in place. Rammed Earth materials acts as an effective thermal insulator which can regulate internal temperatures within the open ward.

Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)

WALL ASSEMBLY PROPOSAL II - SET 1

Figure 3.3 - SCHEME 2 Figure 3.6 - SECTION DETAIL

Scheme 2 proposes a system composed of: • Straw Bale Stacks in a Wooden Frame • Lime Plaster Finish - coated in Photocatalyst (Titanium Dioxide) • Hempcrete sitting space • Clerestory Windows Lined with Fabric Mesh

It measures out to be a total of 20 cm (8 in.) This will be lined with a layer of lime based plaster coated in a layer of Titanium Dioxide to neutralize the particulate matter within the air. Additionally, this will be applied on the inside as well to control the internal air quality of the open ward.

Figure 3.6 shows a scheme composition implementing straw bale stacks as the main air filtration element with a clerestory window lined with a fabric mesh along the top portion of the wall assembly. This allows for air and light to be filtered into the space through an additional light shelf on the interior to diffuse the light even more. The straw bale stacks allow for air quality to be regulated through the thickness of the physical wall assembly itself.

Again, it is incredibly important to remember that using straw bale stacks need to be composed incredibly carefully. It is of utmost importance to prevent any sort of moisture from entering the bales, otherwise it becomes a growth area for molds and other harmful fungi that can affect the quality of the air.

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Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)

The straw bale stacks can additionally be treated on the external layer with a hydrophobic material to prevent any sort of moisture from seeping through as well. If not treated properly during construction phases, this material can cause an opposite intended effect on the health for patients. The hempcrete sitting space attached to the outside can be used as a space for guardians and for patient visitors which simultaneously filters the air from above and the air from the drains that it covers. This space has minimal private settings with no separation barriers.

WALL ASSEMBLY PROPOSAL III - SET 1

Figure 3.4 - SCHEME 3 Figure 3.7 - SECTION DETAIL

Scheme 3 proposes a system composed of: • Hempcrete bases for • Plastic/Fabric Mesh - Composed of Bioplastics & Cotton • Concrete pilasters to connect fabric meshes • Titanium Dioxide Panelling on exterior Figure 3.7 shows a schematic approach which is similar to the first proposed scheme. The main difference here is the use of fabric and bioplastic meshes to create thermally regulated external space outside of the open ward. This system is mainly composed of hempcrete, a material with fibers that hold a strong filtration capacity as well as some of the best thermal massing.

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This provides an external seating space which can be implemented by any type of ward to provide that necessary designated space. Hemp material can collect heat during the day and store it within the heaviness of said material to keep cool during the daytime. However during the night, when guardians need a space of rest and shelter, these spaces can release that heat to keep a comfortable environment without becoming too cold.

Additionally, using hempcrete provides the best level of air filtration through the wall assembly system, directly collecting particulate matter and transferring the cleaned air into the open ward facility.

Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)

As mentioned in the material investigations, hemp has a high tolerance for moisture and is mold and rot proof in essence.

This would be one of the safest materials to use in a building system as it has high air quality control properties, strong fire resistance, and thermal regulation for internal termperatures.

WALL ASSEMBLY PROPOSAL SET II

Figure 3.8 - SCHEME 1

This secondary set of wall assembly systems is based on the typology of using vegetation systems integrated into the wall assembly structure. All three of these sets use different progressing methods of intervention as both physical changes to the wall assembly systems and as structures added on to the external frame of the building facade system. Plants and other native vegetation can be used in correlation with the different materials involved in building. Vegetation has been proven to have a positive effect on human health especially within the hospital setting.

Some of these positive health benefits include: • Quicker progression of health conditions • Cleaner air

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• •

Figure 3.9 - SCHEME 2

Stress reduction Improved mental health

While plants also do have these improvement factors to health, they also can pose some serious threats if not attended to properly. Plants, if not cared for properly can begin harboring bacterias and other fungi.

According to Dr. Edward Green, a medical doctor and researcher based out of Chikwawa, Malawi, mentions that certain plants can develop fungi and harmful bacteria that can be carried through the air and cause health issues with patients in more serious health conditions like cancer or with those who have recently received transplants.

Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)

Figure 3.10 - SCHEME 3

Vegetation can be applied to internal environments in hospitals but it is extremely important to remember to maintain those plants to prevent any sort of harmful bacterial or fungal growth.

As shown above in Figures 3.8 - 3.10 the following three schematic approaches are designed to be external additions to the building assembly, using vegetative systems as the primary method of air filtration. Each system has a different level of interaction with the building facade based on proximity and intensity of plant use. It uses a similar strategy to the previous wall assembly proposal set in determining how some spaces function through different separation of spaces.

WALL ASSEMBLY PROPOSAL I - SET 2

EXTERNAL METAL/WOODEN STRUCTURE FOR VEGETATION GROWTH

MANUALLY OPERABLE LOUVERS TO BLOCK RAIN/ ALLOW SUNLIGHT

13’ - 0”

6’ = 0” RAMMED EARTH WALL FOR PRIVACY SCREENING AND THERMAL HEAT GAIN

SHELTERED WALKWAY FOR GUARDIANS/OTHER USERS (EXTERNAL CIRCULATION)

SHELTERED OUTDOOR PRIVATE SEATING AREA FOR PATIENTS ACCESS TO WATER SOURCE FROM WASTE DRAIN - ALLOWS THE VEGETATION TO CLEAN THE WATER AS WELL

5’ - 0”

Figure 3.8 - SCHEME 1

Scheme 1 is composed of: • Native vegetation like ferns and ivys • Rammed earth • External metal/wooden shelter structure Figure 3.11 investigates a scheme which heavily uses a plant system to filter the air of particulate matter in correlation with rammed earth.

This system similarly follows figures 3.7 and 3.5. These materials are used to create an external environment that simultaneously cleanse the air as well as providing a private space for guardians and patients connected to the wards.

The external side also offers an additional sheltered space for exterior circulation.

9’ - 0” 12”

This approach also uses a series of operable louvers to deter rainwater from falling through as well as to improve lighting and air flow conditions within the external sheltered space.

The rainwater can be captured and collected by the plants to act as a water source, and storing any excess water in a space beneath the plant roots in the rammed earth separation wall.

The vegetation wall also acts as a barrier for the drainage system, collecting and purifying any chemicals or particles that may be travelling through the water. One of the concerns that must be taken into account with this is the open air in regards to

Figure 3.11 - SECTION DETAIL

the water from the drains being a grounds for mosquitos.

Additional elements like fabric meshes lining the windows and opening can prevent those mosquitoes from entering the internal space.

WALL ASSEMBLY PROPOSAL II - SET 2

Figure 3.9 - SCHEME 1

Scheme 2 is composed of: • Metal rods for external structure • Rammed Earth/Hempcrete planter base • Biowall attached to roof Another approach provides a medium level of intervention with the building facade. This again is just an additional layer to the building’s composition, providing an external structural layer to create space for the biowall. This biowall is then attached to a thermal mass layer which also acts as a planter base.

The thermal mass could be composed of Hempcrete or as shown in the image above, it could be rammed earth coated in a layer of hydrophobic materials to prevent the water from damaging the mass.

While the biowall uses the mass material (rammed earth or concrete) this can also provide an external seating space for nearby users and the patients as well. This screening method also develops a system of privacy screening for the wards as they act as shield to prevent direct view into the facility from the outside. This method is a more open approach to determining the indoor/outdoor relationship to the space.

Figure 3.12 - SECTION DETAIL

entering the internal space and protecting the patients and workers of any harmful exposures.

The biowall in this case also connects down into the drains to act as a secondary purifer for the water travelling down. The biowall can serve a dual purpose in cleaning the contaminated waters and absorbing all harmful chemicals that may be airborne and can travel into the open ward space or any One of the concerns that must be taken into account with patient space. this is the open air in regards to the water from the drains being a grounds for mosquitos. Additional elements like fabric meshes lining the windows and openings between each structural opening for the biowall can prevent those mosquitoes from

WALL ASSEMBLY PROPOSAL III - SET 2

SLOPED ROOF RUN-OFF COLLECTS INTO BOTTOM DRAIN

EXTERNAL METAL/WOODEN STRUCTURE FOR VEGETATION GROWTH

HEMP BASED CONCRETE MASONRY UNITS / HEMP BASED BRICK UNITS HEMP BASED BRICKS ARE FIBROUS ENOUGH TO ABSORB ANY TYPE OF AIR QUALITY AND PURIFY IT - SUSTAINABLE

HARSH VOC/ORTHER CHEM. ABOSRBED & CLEANED THROUGH VERTICAL PLANTER

PLANTER ABSORBS DIRTY WATER & CLEANS AIR AS WELL

Figure 3.10 - SCHEME 1

Scheme 3 is composed of: • Hempcrete Masonry Units • Biowall • Metal frame structure attached to roof assembly This final proposal suggests making a much more direct impact on the physical wall assembly in terms of using vegetative material.

Throughout parts of the wall assembly, sections of the wall can be remodeled using hempcrete masonry units which are closely connected to the metal frame structure to line the vegetation. Having the bricks physically installed into the building assembly

Figure 3.13 - SECTION DETAIL

provides a much better method of air filtration for the space as this is very direct without relying on multiple layers. This system uses just two layers: the bio wall and the hempcrete.

The fibers in the hempcrete promote direct filtration in correlation with the use of the vegetation.

This system also has the least amount of interaction with the users of the space and directly focuses on the sole purpose of air purification. This can be beneficial visually for the external users and act as a shading device on occasions for the users within the space.

The vegetation is also connected to the drainage system, using it as an additional water source. This can also cleanse the air and the waters of any volatile organic compounds (VOC’s) or particulate matter that collects in the water. Additional elements like fabric meshes lining the windows and openings between each structural opening for the biowall can prevent those mosquitoes from entering the internal space.

The overall goal for this schematic approach is to develop a quick and efficient system that can be implemented sectionally throughout a selected healthcare facility - in this case, the open wards.

5.9 - AIR QUALITY INVESTIGATIONS THROUGH WALL ASSEMBLIES

CONCLUSION This investigation was developed on the factors of taking in air quality control within healthcare facilities specific to airborne infections and diseases like COVID-19. The final goal was to create a series of wall assembly structures to improve internal conditions of air quality and investigate the relationship with the outdoors based on guidelines and research from the W.H.O and existing air quality conditions of Malawi.

Moving forwards, these designs can be modified and implemented in healthcare facilities that are in need of systems to improve air quality and regulate internal air temperature to improve comfort of space for all users. For existing systems or newer systems, these proposals can provide simple additions to the building assembly to promote a healthier air quality and environment for the patients and workers using the space.

5.10 EXPERIMENTAL VENTILATION

RESEARCH STATEMENT: By sustainably modifying roof assemblies and incorporating passive ventilation strategies in open wards of Malawi, increased and specifically directed airflow will improve comfort and reduce the risk of nosocomial infections among patients and staff.

INTRODUCTION Intentions & Methodologies: In Malawi’s open ward healthcare facilities, how can passive strategies be used to control ventilation thresholds of both positive and negative pressure, allowing for air flows to be predictively designed for, to increase comfortability and or reduce risk of disease transmission?

This recommendation proposal set explores three different levels of interventions that are all aimed at improving the quality of airflow.

•

Roof replacement for comfort only

•

Upward flowing wind towers for reducing the risk of nosocomial disease transmission

•

Downward flowing wind towers for reducing the risk of COVID-19 transmission

The ultimate goal for this exploration is the hope that one to one scale prototypes can be developed and tested for their effectiveness. With multiple testing methods including; Compound Fluid Dynamics1 (Figure 1), tracer gas detecting2 (Figure 2). With numerical data new iterations could be designed to improve the quantitative and qualitative outcome of the interventions.

TRACER GAS BALLOONS LOONS CO2 2 CENSOR

Figure 1: Simulated airflows using Compound Fluid Dynamic analysis software within a 3D modelled massing of the Kasungu District Hospital open ward.

Figure 2: Tracer gas experiment set up for Kasungu District Hospital open ward.

Constraints:

Figure 3: Left: Site adjacency of wards surrounding Kasungu District Hospital open ward. Right: Proposed area of intervention isolated to roof, preserving the orignial walls.

The proposals consider the universality of application to existing open wards in an effort to maximize sustainability and maintain embodied energy (Figure 3). This reuse of existing structure also reflects different site constraints; in the case of the Kasungu District Hospital, the male open ward sits surrounded in the middle of other wards. This creates a limitation of accessibility to the ward in terms of demolition/removal and new construction. Cost and constructibility were also taken into account in terms of readily accessible materials and ease of assembly.

1

Lai, Alvin C.k., and Y.c. Cheng. “Study of Expiratory Droplet Dispersion and Transport Using a New Eulerian Modeling Approach.” Atmospheric Environment 41, no. 35 (2007): 7473-484. doi:10.1016/j.atmosenv.2007.05.045.

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Ai, Z., Mak, C.M., Gao, N. et al. Tracer gas is a suitable surrogate of exhaled droplet nuclei for studying airborne transmission in the built environment. Build. Simul. 13, 489–496 (2020). https://doi.org/10.1007/s12273-020-0614-5

CONCERNS OF EXISTING AIRFLOW Initial analyses of ventilation strategies within the Kasungu District Hospital male ward concluded that there are numerous potential immediate health risks for patients and staff. The main issue to be addressed is the drop ceiling (Figure 4), which prevents warmer, rising, waste air from exiting the ward. That warmer air then cools and recirculates within the ward before slowly exiting. The only form of ventilation the ward uses is a two window, cross ventilation set up that only works when the windows are opened (Figure 5). This becomes an issue for the double loaded open ward, as clean air on one side increasingly becomes poorer quality as it is consumed, expelled, and drafted towards the opposite side3 (Figure 6). This waste air can potentially carry airborne pathogens such as tuberculosis and COVID-19.

This creates an uneven risk of infection for patients on one side of the ward. This also puts staff and guardians at a heightened risk while traveling along the interior corridor.

Figure 5: Existing single direction, two window cross ventilation.

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Figure 4: Warm air from patients breathing rises and is stopped by drop ceiling.

Figure 6: Risk disease transmission increases across the ward.

Todd, Mark Cohen, and Marco Vinicio Flores Belteton. “Factors Involved in Aerosol Transmission of Infection and Control of Ventilation in Healthcare.” Noninvasive Ventilation in High-Risk Infections and Mass Casualty Events, 2013, 269-77. doi:10.1007/978-3-7091-1496-4_30.

VENTILATION PROPOSAL 1 COMFORT SCHEME Complete Roof Replacement While considering ventilation for open wards one cannot just consider disease spread as risk can ultimately only be minimized. This scheme proposal is solely meant to improve the thermal comfort and breathable air quality. In doing so the goal is for the staff to be more comfortable working in a normally unpleasant, stuff y, and hot work environment.

This scheme uses the positive pressure of the wind coming in from the right side of the ward, and it guides the air into the clerestory level. From there the wind travels down funneling out of the left side of the clerestory creating negative pressure in the ceiling4 (Figure 7). Warmer air rises out through the ceiling. In this scheme the normal windows can be left open to increase the airflow.

With this proposal, the roof is completely removed, and replaced with a shed roof that overhangs off both sides. The main materiality of the roof itself is corrugated metal decking which is readily available and widely used in the region. The anchoring and structure of the roof is a tapered truss structure that rests on the existing cross members spanning the ward. Angled vents were added to guide the flow of air directionally up and out of the other side of the ward. There becomes a clerestory right below the roof that uses vented windows to maximize the enclosure of the ward.

Figure 7: A negative pressue zone created in the ceiling draws air out from the space below using inducted wind.

Figure 8: Angled vents in the ceiling direct waste air in the direction of the airflow.

4

Atkinson, J., James Atkinson, and World Health Organization. Natural Ventilation for Infection Control in Health-care Settings. Geneva: World Health Organization, 2009.

WIND TOWER STACK VENTS Forced Induction Ventilation: Wind is not a guaranteed constant at grade, so in order to guarantee that ventilation remains continuous, air needs to be moved not just guided. In certain precedents wind towers are implemented to reach more constant winds are higher altitudes.

How They Function: The main principle of this wind tower is creation of positive pressure5 using the turbine action of an internal impeller. It uses an external set of vertically oriented fins that catch air in 360 degrees and spins the impeller (Figure 9) . The fins are aerodynamically curved and slightly extended out allowing air to be passed into the area of the impeller. The impeller uses scoops that cause the air flow to accelerate as it travels towards the center. The scoops are attached onto an exponentially tapered funnel which directs the airflow either up or down depending on the orientation of the stack (Figure 10). This curved funnel sheds water inherently down and off the slope. In cases when the stack is inverted a lip is used in combination with weep holes to expel water.

The assembly is designed to be simply built using modular components (Figure 11). The tower uses light weight aluminum for all components. They are made up of stackable units, with the more being added, the more air is captured and the higher up the tower reaches.

Figure 9: Airflows pushing external fins that turn an impeller which catches and forces air inwards.

Advantages of Stack Vents:

Figure 10: Left: Isometric view of stacks. Right: Sectional view showing how air is inducted and forces waste out using negative pressure.

The introduction of these towers removes the need to completely replace the roof structure. They are meant to be inserted into existing roofs, attaching to the internal structure with light modifications. This brings the overall cost of the intervention down, and allows wards to keep drop ceilings which are considered a status symbol for healthcare facilities in Malawi. They can be potentially passively powered by kinetic or solar energy harvesting machines to stay in use when there is no wind. Lastly, by being modular these towers can be applied universally to all wards in need.

Figure 11: Exploded assembly of a single stack unit.

5

Bouchahm, Yasmina, Fatiha Bourbia, and Azeddine Belhamri. “Performance Analysis and Improvement of the Use of Wind Tower in Hot Dry Climate.” Renewable Energy 36, no. 3 (2011): 898-906. doi:10.1016/j.renene.2010.08.030.

HYBRID VENTILATION & WIND TOWER INSTALLATION Passive Energy Capture Winds can be inconsistent, which causes the towers to become inactive and ineffective6. It is therefore recommended that for instances when ventilation needs to be consistent that forms of renewable energy are implemented to create a hybrid system that remains passive.

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Solar panels are placed on the roof to store backup energy for wind tower motors.

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Kinetic generators within wind towers can convert the rotational energy of the impeller into stored energy for wind tower motors

Wind Tower Implementation Spanning beams between roof trusses allows the wind towers to sit right above the drop ceiling of the open wards and are spaced out over the middles of each bay. Vented distribution ducts can be attached to the bottom to evenly spread the flow of air infiltrating the space or increase the volume of air exiting (Figure 12).

Figure 12: Ghosted axonometric view of Kasungu District Hospital male ward roof strucutre showing wind tower tectonics.

6

Atkinson, J., James Atkinson, and World Health Organization. Natural Ventilation for Infection Control in Health-care Settings. Geneva: World Health Organization, 2009.

VENTILATION PROPOSAL 2 NOSOCOMIAL INFECTION While there is no existing data to show that good ventilation can actually reduce the risk of disease transmission, there is data showing that poor ventilation increases the risk7. By increasing the air changes per hour through the ward using wind towers combined with opened windows, airflow becomes dramatically better.

Waste air is forced through the ceiling vents and out through the towers including a passive central tower.

Negative pressure zones are created in the ceiling vents by the wind towers, causing the air to be sucked out through the top. Fresh air coming in through the window makes the open ward a positive pressure zone, simultaneously pushing waste air out while it’s being removed.

In all this proposal aims to do the most with as little intervention as possible.

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Double stacked wind tower above each ward bay

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Continuous central stack vent along circulation

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Maintains drop ceiling and operable windows

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Wind towers oriented up with solar back up

Atkinson J, Chartier Y, Pessoa-Silva CL, et al., editors. Natural Ventilation for Infection Control in Health-Care Settings. Geneva: World Health Organization; 2009. 3, Infection and ventilation. Available from: https://www.ncbi.nlm.nih.gov/books/NBK143278/

VENTILATION PROPOSAL 3 COVID-19 RISK COVID-19 is a highly infectious virus that is passed from person to person by either airborne droplets, or contact with an infected surface. There are almost no known ways to reduce transmission. With what little is known, by attempting to divert droplets out of the air as quickly as possible hopes to reduce the risk of transmission8.

Negative pressure is created by inverted wind towers to force air downwards into the ward. A cross ventilated floor duct system creates a negative pressure suction that aids in moving air down and into the floor as fast as possible.

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Double stacked wind tower above each ward bay and along circulation

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Windows fixed, drop ceiling preserved

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Subterranean sloped vent pipe with drainage and exit wind tower

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Wind towers oriented down with no distribution ducts, with solar back up

Wan MP, Chao CY. Transport characteristics of expiratory droplets and droplet nuclei in indoor environments with different ventilation airflow patterns. J Biomech Eng. 2007 Jun;129(3):341-53. doi: 10.1115/1.2720911. PMID: 17536901.

5.10 EXPERIMENTAL VENTILATION

CONCLUSION: This recommendation set explored the issue of COVID-19 an other infectious diseases on open wards in Malawi. Through architectural interventions on roof assemblies of these wards in combination with other safe practices the hope is that transmission of the disease will be less likely than if no interventions were made at all. COVID-19 and other infectious diseases are almost impossible to completely prevent, but with these improvements patients, staff, and guardians will have a greater chance on different levels

5.11 - APPENDIX

SITE ANALYSIS

DRAWING ANALYSIS

APPENDIX 25% SUBMISSION

Kaitlyn Cusumano

CASE STUDY - TROPICAL WOMEN’S OPPORTUNITY CENTER SHARON DAVIS DESIGN Location: Kayonza, Rwanda Date Built: 2013 Typology: Educational Community Center Photos: Elizabeth Felicella

Spirit of Site through Auras

Public vs. Private

Community Composition

Context Aware

Scale

APPENDIX 25% SUBMISSION

Kaitlyn Cusumano

CASE STUDY - TROPICAL WOMEN’S OPPORTUNITY CENTER SHARON DAVIS DESIGN Location: Kayonza, Rwanda Date Built: 2013 Typology: Educational Community Center STRUCTURAL ANALYSIS

APPENDIX 75% SUBMISSION

Kaitlyn Cusumano

CASE STUDY - HEALTH INFRASTRUCUTRE GHESKIO TUBERCULOSIS HOSPITAL This tuberculosis hospital was built in 2015 after a devastating earthquake in the tropical savannah capital of Haiti, Port-au-Prince. MASS Design Group was brought in along with many other stakeholders to create a facility that minimized the risk of transmission, while creating a more comfortable space to receive care. They were able to “respond to both the surrounding culture and climate and show a sensitivity to the patients with an organization of rooms and courtyards that reaffirmed hope and healing, while serving to build a community”1.

Seen in the diagrams below, the importance of community and being outdoors for while doing so were very important aspects as well.

Building Section (ArchDaily)

Ventilation and Circulation

Summer Solar Path

Community

Winter Solar Path

Outdoor Green Space

Site / First Floor Plans (ArchDaily)

Graphics: Kaitlyn Cusumano Group: Kaitlyn Cusumano, Ariana Rosario, Ronaldo Desiderio

APPENDIX 75% SUBMISSION

Kaitlyn Cusumano

PRIOR TO 3/4THS REVIEW PROCESS

APPENDIX 75% SUBMISSION

Kaitlyn Cusumano

STAKEHOLDER PRESENTATION PROGRAMMATIC LAYOUTS Before the development of schemes, the individual programmatic spaces were analyzed and categorized into four main groups, treatment (purple), support (blue), services (red) and outdoors (green). Three differing programmatic layouts were developed for the stakeholder presentation.

SCHEME 1 Treatment

Support

Services

Outdoor

APPENDIX 75% SUBMISSION STAKEHOLDER PRESENTATION PROGRAMMATIC LAYOUTS SCHEME 2

NATURAL VENTILATION

N

Kaitlyn Cusumano

APPENDIX 75% SUBMISSION

Kaitlyn Cusumano

STAKEHOLDER PRESENTATION

COVID-19 GUIDELINES The analysis of guidelines specified for COVID-19 were investigated as well to better understand the implementations that need to be made to help reduce the spread of this airborne disease.

Some of those suggestions (seen in the diagram below) include, hand washing stations (A), signage and highlighting thresholds (B), patient beds being at least 2m apart (C) and physical barriers between patients (D).

PROGRAMMATIC LAYOUTS

B

SCHEME 3

D C B

NATURAL VENTILATION

N

A

APPENDIX

Clinical - Open Ward

Kaitlyn Cusumano FINAL CRITIQUE PROGRAMMATIC LAYOUTS

PROGRAM GROUPINGS

Outdoor - Public Waiting & Screening Area and Private Ward Access Clinical - Isolation Rooms

Support - Nurse Station

Support - Donning & Doffing Stations

Clinical - Consultation and Procedue Rooms

Services - Staff Offices, Storage and Staff Restrooms

APPENDIX Kaitlyn Cusumano FINAL CRITIQUE PROGRAMMATIC LAYOUTS

IMPROVED LAYOUT 1 The first scheme (crucifix) focused on keeping the nurse station central, exposing the open wards to the prevailing winds for best ventilation and keeping the outdoor private ward spaces far from the front of the facility. Both these schemes were focused with the goals of prioritizing the nurse station to be central, separation of circulation with the use of exterior facility paths and clinical spaces being exposed to the prevailing winds as much as possible.

APPENDIX Kaitlyn Cusumano FINAL CRITIQUE PROGRAMMATIC LAYOUTS

IMPROVED LAYOUT 2 The second scheme (“L”) focused on keeping the clinical spaces exposed to the prevailing winds and separating the circulation of users as much as possible.

APPENDIX FINAL CRITIQUE

E E Kaitlyn Cusumano

D

PROGRAMMATIC LAYOUTS

C

B A

IMPROVED VENTILATION & COVID-19 Scheme 1

When analyzing the guidelines of the WHO, CDC and leaders in the architecture field, a few suggestions were made and can be seen in both schemes open wards. These suggestions include hand washing stations (A), signage and highlighting thresholds to indicate to users the risk they may be entering into (B), patient beds being separated at least 2m (C), physical barriers between patients (D) and staff using and disposing of appropriate PPE when in contact with patients (E).

E

B

D

A

C B Scheme 2

Scheme 2

Scheme 1 Section with roof ventilation

APPENDIX 25 % SUBMISSION

PRIYA BADRI

CASE STUDY - VILLA SARABHAI

VILLA SARABHAI LE CORBUSIER LOCATION: AHMEDABAD, GUJARAT, INDIA TYPOLOGY: FAMILY RESIDENCE DATE: 1951 - 1955

Madame Manorama Sarabhai commisioned Le Corbusier to design and construct a home in Ahmedabad, Gujurat, for her ever growing family. Like many South Asian cultures, the home is centered around a common space for family to be together. It is very family centric, only using personal chambers for periods of rest. This could be the living room, kitchen, a serises of outdoor spaces , and any other place promoting congregation.

APPENDIX 75 % SUBMISSION

PRIYA BADRI

CASE STUDY - HEALTH INFRASTRUCTURE

BUTARO ONCOLOGY SUPPORT CENTRE MASS DESIGN GROUP

Located in the Butaro District of Rwanda, this oncology support center brings in patients from various regions for cancer treatments. Rather than being design as a hospital, MASS Design Group took this initiative to create a space with a more residential feel. This allows for patients to bring along their respective family members.

The building is designed to mold the circulation with the external spaces to maximize the wind flow and provide ample access to the outdoor views. The only sheltered spaces include the areas of shelter and rest like bedrooms and cafeteria spaces.

APPENDIX 75 % SUBMISSION

PRIYA BADRI

CASE STUDY - HEALTH INFRASTRUCTURE

BUTARO ONCOLOGY SUPPORT CENTRE MASS DESIGN GROUP

APPENDIX 75 % SUBMISSION

PRIYA BADRI

PROJECT PROCESS VENTILATION INVESTIGATION

This investigation intially looked at possiblilitys for bettering the air flow and conditions within the open ward space of the open ward facility. These series of diagrams investigate the different aspects of air flow such as heat rising and cool air settling and travelling between the spaces. These could come from human movement, heat rising off the materials and other elements as well as collection of heat towards the higher points of the structure.

Some of the additional factors propose methods of intervention within the ceiling system and the wall systems to improve the air quality and air ventilation condtions.

APPENDIX 75 % SUBMISSION

PRIYA BADRI

PROJECT PROCESS VENTILATION INVESTIGATION

APPENDIX 75 % SUBMISSION PROJECT PROCESS MATERIAL INVESTIGATION

PRIYA BADRI A series of material investigations began to develop and collect information on different types of wall assembly systems that could assist in air purification and cleansiing. These sketches show the initial studies of what materials were used and how they were composed in a structural manner. Here we see the usage of Hemp Based Concrete, Straw Bale Stacks and a Biowall system all that have properties to filter the air through.

APPENDIX 75 % SUBMISSION

PRIYA BADRI

PROJECT PROCESS MID REVIEW / STAKEHOLDER PRES. The existing building assembly system as mentioned before is composed of a simple brick facade which is supported through a cast in place concrete slab with a tile finish for the interior.

This wall system supports a roofing system that uses wood trusses covered by a corrugated metal roofing system. This existing structure allows for the primary function of providing a sheltered space for the patients however, it does need necessary changes for systems in order to provide better levels of thermal comfort and most importantly, cleaner internal air.

APPENDIX 75 % SUBMISSION

PRIYA BADRI

PROJECT PROCESS MID REVIEW / STAKEHOLDER PRES. Proposal 1: This proposal has the highest level of intervention within the wall assembly through the use of Hemp Based Concrete masonry units directly replacing the brick walls. Additionally, the planter system attaches to the roof and to the drainage system to use as a water source. This allows for all factors to become adjusted and cleaned through the vertical biowall system.

ROOF DRAINS WATER INTO GUTTER THROUGH VERTICAL PLANTER

SLOPED ROOF RUN-OFF COLLECTS INTO BOTTOM DRAIN

EXTERNAL METAL/WOODEN STRUCTURE FOR VEGETATION GROWTH

EXTERNAL METAL/WOODEN STRUCTURE FOR VEGETATION GROWTH

HEMP BASED BRICK & MORTAR

DIRECTLY IMPLEMENTED INTO WALL STRUCTURE AND PASSES AIR DIRECTLY INTO OPEN WARD & OTHER PROGRAM ROOMS

HEMP BASED CONCRETE MASONRY UNITS / H HEMP BASED BRICK UNITS

HEMP BASED BRICKS ARE FIBROUS ENOUGH TO ABSORB ANY TYPE OF AIR QUALITY AND PURIFY IT - SUSTAINABLE

DIRECT CONNECTION INTO DRAINAGE GUTTER

THE WATER BECOMES CLEANER AS IT PASSES THROUGH THE PLANTS ON THE STRUCTURE

HARSH VOC/ORTHER CHEM. ABOSRBED & CLEANED THROUGH VERTICAL PLANTER

EXTERIOR CIRCULATION PATHWAY (MINIMAL PRIVACY SCREENING)

GUTTER/DRAIN COVERED TO PREVENT VOC’SFROM ESCAPING INTO THE AIR

PLANTER ABSORBS DIRTY WATER & CLEANS AIR AS WELL

APPENDIX 75 % SUBMISSION

PRIYA BADRI

PROJECT PROCESS MID REVIEW / STAKEHOLDER PRES. This approach also uses a series of operable louvers to deter rainwater from falling through as well as to improve lighting and air flow conditions within the external sheltered space. The rainwater can be captured and collected by the plants to act as a water source, and storing any excess water in a space beneath the plant roots in the rammed earth separation wall. The vegetation wall also acts as a barrier for the drainage system, collecting and purifying any chemicals or particles that may be travelling through the water. One of the concerns that must be taken into account with this is the open air in regards to the water from the drains being a grounds for mosquitos. Additional elements like fabric meshes lining the windows and opening can prevent those mosquitoes from entering the internal space.

EXTERNAL METAL/WOODEN STRUCTURE FOR VEGETATION GROWTH

VEGETATION BARRIER -

AIR PASSES THROUGH VEGETATION BEFORE ENTERING OPEN WARD THROUGH WINDOWS

ROOF SLOPED GUTTER

MANUALLY OPERABLE LOUVERS TO BLOCK RAIN/ ALLOW SUNLIGHT

- CAN ACT AS COLLECTION POINT FOR WATER FILTERATION

RAMMED EARTH PRIVACY WALL (PROVIDES THERMAL INSULATION)

13’ - 0”

6’ = 0” RAMMED EARTH WALL FOR PRIVACY SCREENING AND THERMAL HEAT GAIN

SHELTERED WALKWAY FOR GUARDIANS/OTHER USERS (EXTERNAL CIRCULATION)

SHELTERED OUTDOOR PRIVATE SEATING AREA FOR PATIENTS ACCESS TO WATER SOURCE FROM WASTE DRAIN - ALLOWS THE VEGETATION TO CLEAN THE WATER AS WELL

DRAIN/SEWAGE DRAIN

CAN ACT AS WATER SOURCE DURING DROUGHT PERIODS

SHELTERED EXTERIOR RESTING AREA - FOR PATIENTS SHELTERED EXTERNAL CIRCULATION ROUTE - MEANT FOR GUARDIANS

5’ - 0”

9’ - 0” 12”

APPENDIX 75 % SUBMISSION

PRIYA BADRI

PROJECT PROCESS MID REVIEW / STAKEHOLDER PRES. Another approach provides a medium level of intervention with the building facade. This again is just an additional layer to the building’s composition, providing an external structural layer to create space for the biowall. This biowall is then attached to a thermal mass layer which also acts as a planter base. The thermal mass could be composed of Hempcrete or as shown in the image above, it could be rammed earth coated in a layer of hydrophobic materials to prevent the water from damaging the mass.

SLOPED ROOF RUN-OFF COLLECTS INTO BOTTOM PLANTER

WATER COLLECTION CATCHMENT

USING PLANTER CAN REGULATE INTERNAL TEMPERATURE HARSH VOC/ORTHER CHEM. ABOSRBED & CLEANED THROUGH VERTICAL PLANTER

PLANTER - ADDITIONAL RAIN COLLECTION CATCHMENT SYSTEM PRIMARY LAYER OF AIR CLEANING INTERVENTION

PLANTER ABSORBS DIRTY WATER & CLEANS AIR AS WELL

APPENDIX 25% SUBMISSION

Alan Davidson

CASE STUDY MAPUNGUBWE INTERPRETATION CENTRE PETER RICH ARCHITECTS LOCATION: [Mapungubwe National Park, Musina Local Municipality, South Africa (-22.231469, 29.333015)] DATE BUILT: 2009 TYPOLOGY: Visitors Center

APPENDIX 25% SUBMISSION

Alan Davidson

CASE STUDY MAPUNGUBWE INTERPRETATION CENTRE PETER RICH ARCHITECTS LOCATION: [Mapungubwe National Park, Musina Local Municipality, South Africa (-22.231469, 29.333015)] DATE BUILT: 2009 TYPOLOGY: Visitors Center

APPENDIX 75% SUBMISSION

Alan Davidson

CASE STUDY KINTOBO HEALTH CENTRE ASA STUDIO LOCATION: Rwanda, Malawi, 1°36’22.4”S 29°33’15.0”E DATE BUILT: 2016 TYPOLOGY: Hospital In Kintobo, in the Nyabihu District of Rwanda, an existing health post failed and providing safe and accessible health care. The post was far from the main community hub.

Expecting mothers were forced to walk long distances on hilly terrains. When finally reaching the Post, finding only a hazardous place with little quality of care. The goal of the Kintobo Health Centre is to provide a safe and welcoming environment that relates the users to their environment.

REFLECTION Kaitlyn Cusumano

Throughout this semester, the process of doing extensive research on the context of Africa, Malawi and the design world of healthcare has been a major eye-opening experience. The extensive research and knowledge gained allowed further development of designing open wards that wouldn’t have been discovered otherwise. Understanding the context of not only the country, but also the continent was extremely useful in dissecting how to approach the design process because without it designing would be done based on the already learned knowledge from a developed country. Designers don’t always realize that the design and construction methods used in developed countries don’t work in underdeveloped and mid-developed countries. Many underdeveloped and middeveloped countries have already produced effective methods that are forgotten about due to developed countries coming in and trying to better them with their methods, when in reality it’s only putting them in a worsen state.

Additionally, having the access to collaborate with diverse stakeholders allowed the design process and methods to become strengthened in many ways. The collaboration allowed student designers to understand communications through architectural drawings need to be simple and concise in order for the stakeholders to comprehend what they were trying to develop. Having clear and straightforward drawings allow for conversation to flow better and more insight to be gained in the long run.

Overall, diving into extensive research and having the collaboration opportunities with diverse stakeholders allowed the student designers to truly understand how the built environment impacts the social equity of any given location. When a designer can fully comprehend the context, history and current conditions of a location and be able to collaborate successfully with stakeholders from other fields, the depth and understanding of the project will only be that much stronger and positively effective the community.

When continuing this semester forward, the development of how existing open wards can transform and adjust accordingly to pandemics such as COVID-19 is crucial and needs to be further explored. Also, an indepth look at specific programs within open wards could be interesting in order to better the overall development of the facility.

REFLECTION Priya Badri

This semester was an eye opening experience when researching and developing designs based on the context of the SubSaharan country of Malawi. Throughout the semester, we were given a wonderful opportunity that educated us about the world of design in its relationship to Malawian cultures. It created an eye opening experience that delved into the contexts of cultural norms and that relationship to how the healthcare system was structured which was very different to what we are used to after being educated in a westernized country. The design ethics and principles differ greatly and have different impacts on how the spaces are used.

Oftentimes, designers are given conditions they are familiar with, but what I enjoyed most about this semester’s studio is how immersed we were able to get with the culture and context despite being a whole world away from this country. As designers, and more specifically as students, we were granted so much opportunity to learn directly from the people who work and live there.

In addition to all the research we were doing, we were also gaining first hand information which is always much more valuable and of use.

REFLECTION Alan Davidson

My concept of what meaningful architectural intervention dramatically changed this semester. Often I search for the right solution when I’m designing, however that is not always possible in all contexts especially when there are really tight limitations on what can be done. Working, within the Malawian healthcare context revealed how different it was to Western medical approaches, and while I may have started off thinking that it was highly ineffective and backwards, I had to realize that Malawi has its own issues that it has to deal with and we have to design for Malawian needs. I also learned some surprising facts about malawians including their high regard for ceilings, which i had to take account of when planning my designs.

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