ARTICLE - ARCHITECTS DESIGNS HOSPITAL

CHICAGO ARCHITECT DESIGNS A BEACON FOR HEALTH CARE IN HAITI
(Chicago Tribune) - By Melissa Harris

Friendship with famed doctor leads to state-of-the-art teaching hospital for quake-ravaged nation

MIREBALAIS — Under a blinding Caribbean sun, far from the sleek Chicago residences she usually designs, architect Ann Clark saw well-laid plans turn to improvisation, yet again.

Overhead, a 2,850-pound ventilation system dangled from a broken crane, hovering over the roof of the national teaching hospital Clark had designed for this impoverished nation.

This was the third crane to arrive broken — not a victim of the twisty, mountainous climb to the site, but of Haiti's general dysfunction. Rarely does anything work properly here.

Before this project, Clark, a slender 51-year-old, mostly worked for Chicago's wealthy. She had never designed a health care facility, much less a hospital. Certainly not in a place where a ventilation system had to be rolled into place using a jury-rigged wood-frame dolly, or where concrete, the most basic of all building materials, was of such dubious quality that samples had to be toted to two countries for pressure-testing.

She also never imagined how this midcareer opportunity would challenge her, even sour her at times, but also inspire her to continue working in Haiti.

Her project was already under way when a 2010 earthquake devastated the country, killing tens of thousands of people. After that came a surprise request from government officials to transform the modestly planned facility into the most sophisticated hospital in the nation.

"I did think, 'Crap. I haven't built a hospital,'" Clark said. "But I realized that designing a hospital in the U.S. wouldn't necessarily help me design a hospital in Haiti."

Clark's journey to Haiti began almost two decades ago. While driving to work at her husband's West Loop architecture firm, she heard on National Public Radio that Paul Farmer, a college friend, had won the MacArthur Foundation's genius grant.

"I was working part time because I had a 3-year-old and a 1-year-old-ish," Clark said. "And I was like, 'Oh my God. Paul Farmer?' So I hand-wrote a letter. Not an email. A letter. 'Hey, I'm in Skokie with two toddlers at my ankles. And you're out saving the world.' I essentially told him I didn't feel very good about myself right then."

Farmer and Clark had corresponded via letter for years after graduating from Duke University in 1982. At some point, they stopped. By then, Clark was an architect but still something of a lost soul, unsure she had chosen the right career.

Farmer, however, had found his obsession: Haiti. While enrolled in Harvard Medical School, he began traveling there, doing everything he could to assign the same value to a Haitian patient as he would an American one, including the deployment of expensive drugs to combat tuberculosis and HIV.

After receiving Clark's letter, Farmer replied that she should never undervalue her role as a mother; she didn't know who her two boys would become. The note was sweet and reassuring. But it didn't change the fact that Clark was unsatisfied with her career.

From that car ride on, Clark paid attention to Farmer's work and sent small sums at Christmastime to his Boston-based charity, Partners in Health.

She joined her husband's architecture firm full time in the mid-'90s, forming Nicholas Clark Architects. While Farmer dedicated his life to the poor, Clark's career was dictated by the whims of the affluent.

Take the young Lincoln Park couple who hired her to design an addition. Without consulting Clark, the wife ordered a $1,200 stained-glass transom window. When it arrived, her clients disliked it and ordered Clark to refund them.

She refused. When the husband wouldn't let up, Clark mailed Partners in Health a $1,200 check with her client's name on the donor form. She told him that an entire house could be built in Haiti for the cost of that window and mailed him "Mountains Beyond Mountains," the 2003 book about Farmer by New Yorker writer Tracy Kidder.

Kidder's book had transformed Farmer from a country doctor into a celebrity, or as much of a celebrity as a doctor can be.

A benefit and a reunion

By 2008, Clark's most high-profile project was a well-received rehab of the Skokie Theatre. Whenever it seemed right, she told clients about Farmer and recommended "Mountains Beyond Mountains."

Then, a client with whom Clark had shared the gospel emailed her, asking if she was involved in an upcoming fundraiser in Chicago for Partners in Health.

Clark hadn't heard about it. She called the charity's headquarters and offered to host the event in her family's 3,100-square-foot Skokie home, which she had designed. In September 2008, about 130 people, including Farmer, mingled in Clark's glass-encased courtyard and spacious kitchen lined with an Italian marble backsplash.

After the house emptied, Farmer stayed behind to reminisce with Clark; her husband, Peter Nicholas; a Partners in Health doctor named David Walton; and a Partners in Health staff member. They sat on Clark's sofa, drinking wine in front of the fireplace, listening to Farmer tell stories about their days at Duke and of dining out with his new friend Bill Clinton.

Clark told Farmer. "Look, every year I send you guys money. What else can I do?"

Farmer replied: "Well come on down to Haiti and build some sh--, Ann."

First impression

The day after Christmas 2008, Walton, a Harvard-educated Farmer protege who grew up in Skokie, returned to Clark's home. The charity had never before hired an architect, and Walton knew its building practices desperately needed to be professionalized.

Walton asked Clark to design Partners in Health an 82-bed community hospital in Mirebalais, a 45-minute drive from Port-au-Prince. She accepted the job pro bono.

On Jan. 12, 2009, one year to the day before the earthquake, Clark flew to Haiti for the first time.

Partners in Health dispatched a driver and SUV to pick her up at the chaotic Port-au-Prince airport. After escaping the capital's open sewers, dust and trash, Clark rode past huts, one-room concrete-block homes, grazing goats, broken-down cars and gravel soccer fields.

The epicenter of Partners in Health's work is Cange, the site of Farmer's first clinic. Over decades the clinic had mushroomed into a maze of more than a dozen concrete and stone buildings perched on a steep hill wholly unsuitable for medical care. To get from the emergency room to the tuberculosis ward, for instance, one must ascend a steep ramp and dozens of stone and concrete steps.

Clark's first stop was Lacolline, then the newest of Partners in Health's clinics. It had been built with $640,000. Farmer didn't involve an architect until two years after the building opened — "just so we had documentation and could share the plans with others," he said.

Walking into the waiting area there, Clark saw women wearing dresses and men in dusty pants or jeans. Everyone's shoes were beaten up. Clark was immediately struck by how close the people sat next to each other in the waiting area and how sandwiched they were in line at the pharmacy window.

And people walked everywhere, even in rural areas. Clark marveled at how women balanced jugs of water and baskets of supplies atop their heads. She wondered how far these women had walked, and how far they had to go. And she noticed they were often smiling. Given their ragged clothing and signs of malnutrition — poverty unlike anything she had ever witnessed — she wondered what Haitians had to smile about.

"If anything, in a feeling sense, you learn to put up some kind of a shell or barrier, as a protective membrane," Clark said after her fifth trip. "The whole country is such an assault on your senses. Everything is in your face all the time. And if you don't do that, you're just going to get taken down."

Clark quickly gleaned that there would be no room for an architectural flourish in Mirebalais.

"I always get asked, 'So what's the architectural statement?'" Clark said. "The big architectural statement is called healing people."

Thinking it through

Back in Chicago, around the birch Parsons conference table at her West Loop office, Clark and Walton thought through health care in Haiti. It would be other people's jobs — plumbers, general contractors, electricians — to build the hospital; it would be Clark's job to think it.

How could they allow natural light into the wards, yet prevent people from being able to peer inside? How could they keep the rooms cool without air-conditioning? And how could they, in a country where electricity is notoriously unreliable, ensure the power wouldn't go out?

Partners in Health expected the hospital to draw patients from all over. Clark planned for a minimum of 250 Americans, enough space for 400 Haitians, in each of the hospital's larger waiting rooms. The most significant challenge was figuring out how to arrange the buildings so patients could move easily from one step to the next, from registration to the pharmacy. Signs wouldn't suffice. Walton estimates that 70 to 80 percent of the population of Haiti's Central Plateau is illiterate.

By August 2009, the Haitian Health Ministry had found Partners in Health a larger, 13-acre site in a rice field less than a mile down the road in Mirebalais. Clark flew to Haiti again.

There, she pulled on borrowed black rubber boots and, with Walton and a Japanese-American doctor, trekked through chest-high reeds and swampy rice paddies with a measuring wheel. By the end of the land survey, Clark's gray T-shirt was soaked in sweat.

For months, Walton had repeated, "Welcome to Haiti," every time Clark questioned why he wanted things done a certain way,a gentle reminder of the limitations there. By the end of the second trip, Clark said she was "ready to roll with the punches."

At home, things were not going as well.

The global recession was sending the architecture industry into a tailspin. For a while, Nicholas Clark, a five-person firm, made due with pre-recession assignments. But by mid-2009, the real estate crisis had killed new business. Rather than fire anyone, Nicholas and Clark cut everyone's hours to four days a week.

Not to mention that their marriage had been under strain for several years and was now breaking.

The earthquake

By January 2010, the Mirebalais hospital team was in place. Marjorie Benton, a former Partners in Health board member and Evanston resident, had signed on as the lead volunteer fundraiser. Walton would co-manage the project with Jim Ansara, a stocky, Boston construction magnate. Ansara had sold his company in 2006 and was struggling with retirement.

Clark, Walton and Ansara spent Jan. 12, 2010, reviewing electrical and engineering drawings at Ansara's Boston office.

That evening, a 7.0 earthquake knocked down Port-au-Prince.

Haiti's National Palace, its White House, folded in half, its four-sided dome pitching forward like Humpty Dumpty. The nursing school at Haiti's General Hospital collapsed during class, killing students and faculty.

Money began pouring into Partners in Health's headquarters, and Haiti's Ministry of Health saw an opportunity in Mirebalais.

"You need to set your sights higher," the health minister told Farmer, according to his book "Haiti After the Earthquake." "The hospital needs to be a place that can train young doctors and nurses. ... It needs to be bigger, many times bigger, than what we agreed upon."

Ansara worried the project had grown too big for Clark. In February 2010, he called her to say he wanted to hire the Boston office of Chicago-based Perkins+Will, the world's second-largest architecture firm by revenue that year, to assist pro bono. Ansara flew Clark and her then-26-year-old designer, Jacob Wahler, to Boston for a brainstorming session.

Clark, no doubt, felt threatened.

"It wasn't a particularly comfortable meeting," Ansara said. "It became fairly territorial pretty quickly."

Still hopeful a partnership could form, Ansara told Clark and Perkins+Will's Dennis Kaiser to collaborate on a design scheme. Ansara asked to see their plan when he returned from Haiti. Ten days later, the two architects hadn't reached an agreement, and Clark was still tending to her previous plan.

Farmer, meanwhile, said he had been "cajoling, guilt-tripping, begging and employing all of the usual Catholic stratagems" to get the project moving. Ansara felt the pressure. Over the phone, Ansara ordered Clark and Kaiser to go to lunch, come back and work out their differences.

"The marriage between Ann and Perkins+Will was not clicking or working," Ansara said. "The cultures, the sizes of the firms, everything was at opposite ends of the spectrum. That was one issue. The other issue is we had to sort of start all over again with Perkins+Will and negotiate what was possible in Haiti and what wasn't possible."

On that point, Clark's inexperience proved an advantage — she couldn't tell Ansara or Walton, "That's not how it's done," or, "You shouldn't do that," because she didn't know how things should be done. And she had seen enough of Haiti to know that monumental ideas couldn't be executed there. The equipment and skilled labor didn't exist.

"They didn't have to reprogram me," Clark said. "I knew this couldn't be U.S. hospital redux."

That afternoon Ansara called Perkins+Will. He wanted to find a support role for the firm but made it clear Clark would lead the design. And with that, Perkins+Will departed.

Getting paid

Clark would need to quickly generate about 100 drawings plus revisions and clarifying sketches. She believed she could do it, but not for free. She asked Ansara to pay her to finish the project at 40 percent her normal rate.

Ansara agreed. In fact, he said it was his idea.

"She didn't actually ask," he said. "I insisted on it. I knew what she was getting into, and what she had initially committed to. ... Initially she was reluctant because she had made a commitment to Paul Farmer to donate her services."

Clark doesn't remember it that way. In fact, she said she has had an epiphany about pro bono work: She won't do it anymore.

"Because I can't live," she said. "I'm now realizing I undermine my own value by doing that."

Clark's new model is to help charities raise the money to pay for their building projects, including a reduced fee for her design services.

"I really think architects are the worst businesspeople in the world because they will do business for free ad nauseam," Clark said. "There are competitions nobody gets paid for. There are requests for proposals that nobody gets paid for. In a small office, I can't really afford to do that."

During spring 2010, Nicholas Clark Architects hired a temporary employee, then dedicated everyone at the firm, except Nicholas, to the hospital. Wahler served as the point man.

More than architecture

Nicholas Clark's contract with Partners in Health states that from January 2009 to February 2010, the firm donated 570 hours of pro bono design work. Ann Clark estimated the firm billed an additional 3,000 hours to finish the job.

Clark would spend that time pondering the substantial, such as the composition of the walls in the radiology room, to the unsubstantial, such as where a donated video art installation would hang.

Drawings continued to be updated, but by August 2010, Wahler had transmitted the bulk of them. The most difficult challenge — building the 205,000-square foot, 320-bed facility — would fall to Ansara and Walton.

If this were a Chicago hospital, Clark would visit the construction site weekly to answer questions and inspect the work. But Clark couldn't afford to fly to Haiti regularly, nor could Partners in Health afford to pay her to do so. So Ansara adopted that role, and Clark contributed in other ways.

Through Rita Knorr, the same client who provided the heads-up about the 2008 fundraiser, Clark secured pro-bono landscape design work. Then through a relationship with a tile showroom in Chicago, called The Fine Line, Clark secured 80,000 square feet of Chinese porcelain tile and 28,000 square feet of Fiandre Italian tile at steep discounts.

Of the hospital's $23 million budget, about $7 million was covered with in-kind donations. Walton doesn't know if Partners in Health could replicate such generosity now that international interest in Haiti has waned.

"Were the timing different, we would have had much more difficulty finding this degree of enthusiasm for the hospital and for Haiti in general," Walton said.

A new career

Clark's life has changed significantly since construction began. She and her husband are in the process of divorcing. They also dissolved Nicholas Clark Architects and sold their Skokie home.

Clark has launched her own firm, Ann Clark Architects, and hired a 30-something fresh from his licensing exams to assist her.

But she still wakes up thinking about Haiti. The hospital won her a new client: Haiti Sustainable Education, a charity trying to build a boarding school in Grand Bois, a remote, mountainous area two miles from the Dominican Republic border.

Although that site is just 37 miles from Port-au-Prince, it took Clark four hours and 42 minutes to reach. The trip is like going white-water rafting. After nearly getting carsick along the way, Clark turned to her boyfriend, Chicago cardiologist Samuel Dudley, who was in the back seat, and declared, "Mirebalais is for wussies."

In retrospect, she said, the hospital didn't cost her anything. Instead, it afforded her very much.

"It offered me an opportunity to move in a different direction with architecture, which is something that I hoped to do but just didn't know how," she said. "While it is difficult, I relish the idea of doing more work in Haiti or in places like Haiti where buildings are needed and where good construction can improve peoples' lives."

The Mirebalais hospital, scheduled to open this fall, is Haiti's best example of this. It is white and beautiful.

"It's big — just the scale of it, it's so big," Wahler said. He snapped a photo of the hospital's iron gates, which are pinned with Haitian metal drum art.

Clark's plane was delayed. She arrived after lunch, wearing charcoal slacks and a white linen shirt, her long graying hair pulled back in a clip. Her first reaction was to look down at the floor, stomp her foot and shout: "A buck a foot! A buck a foot!" Then she burst into her huge, squawking laugh, thrilled at how cheaply she had acquired the elegant Italian tile.

Clark's next reaction was a testament to Walton and Ansara. The quality of the construction awed her. "Wow," she said, as she walked through the lobby, running her hand along one wall.

When Clark walked in the emergency room, she told Wahler with pride, "This is an incredibly American-feeling room." And when she walked into the labor and delivery ward, she said: "There is no artificial light on right now and look at how it feels in here. It's healing and soothing for people."

For a country that has experienced so much suffering, that was always her goal.

Epilogue

About six months after the earthquake, Clark was doing her morning yoga routine at her Skokie home when her eyes locked on a shoe box. Inside, she found letters, including this long-forgotten one, dated March 15, 1989, the year after she completed architecture school.

Well, Ann, when we last spoke you were teetering between business and art. If business won out, would you please help me to build a hospital for the poor in Haiti? If you stayed with art, would you please send us a painting to cheer up our patients? Seriously, drop a line.

Yours, Paul Farmer