Innovation, Infection, and Poverty Eradication: Partners In Health Style

View from Butaro Hospital, Burera District, Rwanda

View from Butaro Hospital, Burera District, Rwanda

 Two types of medicine are being practiced at the Butaro hospital in northern Rwanda; one treats diseases of infection, the other treats the disease of poverty.Using local building techniques, materials, and labor, construction of a new hospital building is now underway  in northern Rwanda’s Burera district, near the border with Uganda.Lush terraced hillsides, subsistence farming, and Lake Burera dominate the one hour drive from the nearest paved road – less than 15 kilometers as the crow flies.

Lake Burera, Rwanda

Lake Burera, Rwanda

In a joint venture with the William J. Clinton Foundation, and Rwanda’s Ministry of Health, the Boston based Partners In Health (PIH) is overseeing the building of an innovative hospital designed to control infectious diseases like tuberculosis, as well as nosocomial (hospital-induced) infections common to hospitals in sub-Saharan Africa.”

Workers digging foundation, Butaro hospital, Rwanda

Workers digging foundation, Butaro Hospital, Rwanda


 With a local contractor, and a construction crew hired from the local population, PIH is implementing their proven model of community-based care to serve a population of over 500,000, in a region reaching from northern Rwanda to southern Uganda.PIH fundamentally believes health care is a right not a privilege. Community-based care is based on five fundamental principles[i]:1. Access to primary health care, 2. Free health care and education for the poor, 3. Community partnerships, 4. Addressing basic social and economic needs, and 5. Serving the poor through the public sector.

Ambulance and Butaro hospital, Rwanda

Ambulance at Butaro Hospital, Rwanda


An existing facility, in the process of being updated, treats the three most common ailments – upper respiratory infections, malaria, and gastro-intestinal problems. It also includes maternity, pediatric, HIV/Aids, and other treatment wards.  Equipped for x-rays, minor surgeries, C-sections, and physical therapy, the present hospital can handle most medical issues.Conditions requiring major surgery are transferred to larger facilities.

Butaro hospital ward, Rwanda

Butaro Hospital ward, Rwanda

Butaro’s  new hospital building was conceived by a team of architects from Harvard’s Graduate School of Design, working in conjunction with PIH.  Lead architect, Michael Murphy, began preparations after being contacted in 2007 by Paul Farmer, the founder of PIH.Farmer challenged Murphy to generate an architectural solution to the medical problem of infection transmission in sub-Saharan Africa.Of particular concern, halting the spread of recalcitrant airborne infectious diseases, such as tuberculosis, where a patient can come into the hospital for an easily treatable condition like a broken bone or the stomach flu, and leave with TB.

Michael Murphy, MASS, Butaro Hospital, Rwanda

Michael Murphy – Architect, Butaro Hospital

  “The problem of airborne disease in developing countries is so huge and complex that a multidisciplinary approach is the only way to address these issues,” states Murphy. “We believe that architecture can save lives through effective healthcare design.”[ii]The Butaro project inspiredMurphy, along with ten other students, to  form the non-profit MASS (Model of Architecture Serving Society), in January 2008.

Transferring supplies between buildings, Butaro Hospital, Rwanda

Transfering supplies between buildings, Butaro Hospital, Rwanda


Rather than depending on high cost and high energy intake methods like the negative pressure air evacuation systems more common in wealthier countries, the new Butaro hospital relies on simple design features to reduce the spread of airborne pathogens. Open wards with natural ventilation allow air exchange rates on par with western hospitals. A hill top cite provides the advantage of increased wind and air flow, and high permanently open windows amplify ventilation.Interior hallways, where close patient to patient contact is frequent, are eliminated.Exterior walkways and courtyards with wards built around the perimeter also reduce the risk of disease transmission.

Foundation construction, Butaro hospital, Rwanda

Foundation construction, Butaro Hospital, Rwanda

 Eloquent solutions, appropriate technology, and determination are all in play, but the design and it’s structural endpoint are only the beginning.Construction techniques and applications are the unexpected story.In a country where 60% of the population earns less than one U.S. dollar per day (88% earns less than two dollars per day),[iii] the Butaro hospital project directly treats the disease of poverty.All labor comes from the local population where subsistence is a way of life, and a full stomach is never guaranteed.Typical of Rwanda, people living in this area have no electricity and no running water.

Woman hauling dirt from construction site, Butaro hospital, Rwanda

Woman hauling dirt from construction site, Butaro Hospital, Rwanda


The construction crew works in one week shifts, then a new group comes on.Work groups cycle once every six weeks, spreading employment to six times as many people than if only one crew were hired.Local building techniques are the rule; earth moving machinery is all but absent.Foundations are dug with pick and shovel. Dirt is removed on foot, in large bowls atop a woman’s head.

From cement to cinder blocks - mixing, molding, and drying, Butaro hospital, Rwanda

From cement to cinder blocks – mixing, molding, and drying, Butaro Hospital, Rwanda


Cement is mixed by hand, and cinder blocks molded and driedon location. Furniture and other finished wood products are constructed on site. Anything that can be dug, mixed, cut, formed or fashioned into shape is done by the local people with local means.

Woodworking at Butaro hospital site, Rwanda

Woodworking at Butaro Hospital site, Rwanda


Meals are fed to all, clean drinking water is readily available, and health care and education are provided.Construction of the new hospital is as much about development and poverty reduction as it is about improved health care. Work is one of the treatments.

 “It’s a clear example of how you could rehabilitate an entire community by investing in one infrastructure.” Michael Murphy.

Worker at Butaro hospital construction site, Rwanda

Worker at Butaro Hospital construction site, Rwanda

 All photography copyright 2009 Adam Bacher.  Absolutely no usage without prior authorization.

[i] Partners I Health,

[ii] “GSD Students Design Hospital Prototype in Rwanda to Reduce TB Epidemic,”

[iii] UNDP, 2007/2008 Human Development Report,

Adam Bacher
Adam Bacher
When your vision becomes a reality, how will you tell your story? I’m a commercial photographer and photojournalist based in Portland, Oregon, since 1991. I specialize in commercial location photography for businesses. The majority of this work is for architectural, corporate, editorial, and public relations clients, and appears in a variety of print and electronic media. You can view samples online at: Since 2007 I’ve been taking a month each year to devote my time towards humanitarian missions. Three trips have taken me to Rwanda, for a project documenting the countries recovery from the genocide in 1994, which claimed the lives of one-million people in the course of 100 days. Images and stories from the places I visited are featured on my blog site at: This November, I’m going to Haiti for 4 weeks, to help two non-profits working tirelessly to save and rebuild lives following the earthquake in 2010. As well as donating my still and video images, I plan to create a traveling print exhibit, and a multi-media educational presentation to build awareness and remind us of Haiti's needs. If you’re interested in project please see this link: My commercial work makes this humanitarian effort possible. I exhibit and speak nationally, offering a provocative visual and journalistic insight into contemporary Rwanda and the recovery, reconciliation, and reconstruction of the of the country. This message of hope, peace, and diversity, has been enthusiastically received at peace conferences, corporate gatherings, and in public schools. Specialties All aspects of location photography including: Architectural, Corporate, Editorial, People, Public Relations, Travel and Photojournalism. .
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  • Evelyn Sharenov

    I work in the health care delivery system and I have to say that the PIH approach is informed and cost-effective. I think that we in the USA have become spoiled and cynical when it comes to health care, inured in the belief that health care must be costly to be effective and accept what is handed to us in terms of medical care: high costs, ineffective delivery, elitist delivery. Where else in the world would tylenol cost $5.00/tab.

    Can anyone think of a hospital in the USA that has a TB patient walk around a facility in order to get where he needs to go, rather than go through a draconian system that cost millions to construct? Let me know through Adam’s blog.

    Fantastic reporting – a true photojournalist!

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