- [Ray] Howdy?

- [Audience] Howdy.

- Welcome to the Friday architecture for health lecture series.

It's great to have y'all here.

We got a good studio audience here today.

Thank y'all for being here.

I want to briefly introduce our speaker because I know there is a lot to cover and you're gonna want to hear it all.

Our speaker today is Brad Perkins.

That may be a familiar name.

We're gonna walk through that here in just a minute.

Brad is the founder and chairman of Perkins Eastman Architects.

Perkins Eastman is a New York based architecture, interior design, planning, urban design, and strategic consulting firm based in New York.

And he founded that firm in 1981.

So do the math 40 years, 41 years-ish.

Perkins Eastman now has almost 1200 staff in 24 studios around the world.

The firm has built around 15 specialty practice areas.

The two largest ones are healthcare and senior living.

Perkins Eastman has worked in 60 countries, 6-0 countries, and has full service offices in China, Singapore, India, Dubai, and Ecuador.

Brad is third generation architect.

The apple didn't fall far from the tree.

His grandfather had a major firm in Chicago that also worked in China.

His father founded Perkins&Will.

In addition to his architectural degree, he has a BA from Cornell in Latin American history and an MBA from Stanford.

Nice.

He is the author and co-author of nine textbooks, over 100 professional articles on architectural topics.

He's also been on the faculty of Cornell's College of Architecture for the last 10 years, and he does have a life outside of practice.

He's lectured before at A&M and his wife, June.

His wife is a regular student at the barbecue boot camp here on campus in June.

So with that introduction to Brad Perkins, please help me welcome him.

(audience clapping) - Thank you, Ray.

I'm really very pleased to be down here again and I look forward to coming back in June, accompanying my wife and learning the fruits of what she learns here each time she comes down.

So today I've been asked to talk about some of the challenges and opportunities about doing healthcare and senior care in countries around the world and in particular in developing countries.

I got a lot of material to cover so I'm gonna go relatively rapidly.

And to start, many countries I found in our practice, even ones with better health statistics than the US currently has do look to US models when they're planning the modernization or expansion of their healthcare and senior care systems.

As a result, the US firms with an established reputation for designing hospitals and/or senior care facilities are finding some of their most interesting opportunities in countries around the world.

My firm, for example, in recent years has worked on healthcare and senior living in Japan, Korea, China, Kazakhstan, Thailand, Singapore, India, Saudi Arabia, Kuwait, the UAE, Turkey, Israel, Morocco, Uganda, Ecuador, Mexico, and Peru.

In the course of that work and my 50 years of working internationally, my firm and I have learned many lessons.

And in my talk today, I would like to talk and discuss 10 of the most important of the lessons we've learned over the years.

Since I assume that many of you may not know that much about Perkins Eastman, I thought I would just give two minute introduction.

While we are now 40 years old we're actually the youngest of the 10 largest firms in the US.

We are the youngest and the only one that is still run in part by its founding partners.

While we now have many partners, Mary Jean Eastman, and I are still very active and are involved in running projects both here and overseas.

We are sometimes as Ray pointed out confused with Perkins&Will, which in the early years was to our great advantage.

But Perkins&Will was founded 87 years ago and even I couldn't claim any authorship there.

And he too, as was pointed out did not join his father who had a major firm that was founded 128 years ago.

And as I sometimes point out, I have managed to show very little creativity in my choice of a career.

Perkins Eastman was founded in New York in 1981 as Ray mentioned in one small office with staff at 27 and we had no built work.

I had been the managing partner of some offices of two other large international firms before founding the firm.

And after building the foundation of our practice during the first 12 years, we began a period of rapid growth.

And as Ray mentioned, we now have 24 offices, 19 of them in North America, including two here in Texas.

Our staff is very diverse.

We come from over 60 different countries and several of our healthcare and senior living leaders over the years have been graduates of A&M.

So I don't know whether... Yeah, those are some of the general statistics showing where the offices are and the people.

And as Ray mentioned two of our largest practice areas are healthcare and senior living.

But as is the case even here in the US, but particularly overseas, we find more and more projects are drawing upon other capabilities that we have because of their scale or because of the relevant other skill sets that are required.

So it's very common, particularly overseas for projects to require urban planning expertise, our hospitality, workplace, science and technology and higher education.

Very often all of these are brought to bear on a single project.

Now we branded ourselves human by design because the focus of our practice has been to work on projects that have a direct... Have the potential for a direct positive impact on the lives of the people that are going to use or visit the facilities.

And we do believe in the old time religion that good design really does have the potential to change people's lives for the better and that's...

Nowhere is that more clearly that demonstrated than in healthcare and senior care.

The cross section of some of our recent projects, three of the most recently completed, the white building in the center is the David Koch Center for Cancer Care in New York city for Memorial Sloan Kettering, which has been winning a lot of awards over the last two years.

And second project is we've been working for the last 12 years to rebuild the Stanford University Medical Center, a place where my wife worked while she was supporting me when I was getting my MBA.

And then the MarinHealth Medical Center, and these three projects led healthcare design magazine to name us the firm of the year last year, something we're very proud of.

We were also active in medical education.

So this is both academic and cancer care for Washington University.

And this is a new school of nursing for Rutgers University.

Our senior living practice includes over 600 completed projects, such as Newbridge on Charles, which is a Harvard affiliated continuing care retirement community near Boston.

And then four of our recent projects in Texas.

This is a domain in Maravilla in the domain in Austin and Hallmark, this is in Dallas, Overlook.

And this is Blue Skies, which is an air force retirement community in San Antonio.

But this talk is focused on what we've learned working on healthcare and senior living, working on the youth projects outside of North America.

I brought and am leaving with George two of the books that I've written recently.

This is one on practicing internationally and let's see if it can be seen.

And then a second on a basic textbook on the planning and design of senior living.

I'll be leaving these for either George to take home or to be generous and give to the library.

- [George] To the students.

- Yeah.

- [George] Thank you.

- So, as I mentioned, I wanna talk about 10.

There are many, many less sense to be learned, but I wanted to talk about 10 of the most important.

Sorry.

Oh, and this is a picture of about half of the New York City staff standing on what is probably the smallest project I've worked on in the last 20 years, but probably one of the best known, which is the TKTS Boot in the middle of Times Square and all glass... At the time, the most complicated all glass building built to date and something we're quite proud of.

So the first as I said is the size of the need.

The worldwide I need for quality healthcare and senior care is enormous.

The current pandemic has made the need even more transparent, more apparent, and cute.

Though through our work we know we have the potential as well as the responsibility to improve the quality of tens of thousands of people's lives and a few statistics might help illustrate this.

Is this readable by the way?

- [Audience] Yes.

- Yes, okay.

New cancer cases in the US these days are reported to be about 1.7 million a year.

China, where there very large percentage of the cancers are not caught in screening, which almost doesn't exist in rural areas, still reports 4.6 million new cases per year.

In India which is now almost the same population as China and where the data is even more unreliable they don't really publish a reliable estimate, but we can assume that just these two countries that their need alone is a vast multiple of the US.

The projected population over the age of...

The population over the age of 65 in China is projected to top 250 million by 2030 and a similar total is projected for India.

The US total population is projected to top 70 million, but just these two large countries will have seven times the number of seniors that we do and virtually no infrastructure to support them.

And remembering that we are a rich country that is struggling to properly house and care for our seniors you can imagine what the challenge is in the developing world.

The second major point that we have learned over the years is the scale of some of these international expansion and modernization programs is something that doesn't really exist anywhere in the West anymore as if it ever did.

Now, while some of our projects, not very many of them are very small scale interventions, such as this rural surgical center in Uganda, which is not even on the electrical grid.

And therefore the whole ceiling system is a series of photovoltaics to provide something that approximates a reliable electrical source for this surgical center.

But most of what we see are vast camps that are larger in scale than anything being planned or built in North America.

One of our first clients, this wasn't technically a medical project, but it gives an idea was the Chinese academy of sciences, which is located in Northwest Beijing.

This is the academy of chemistry and physics and pretty much everything else.

And we were retained to do a master plan for their main campus about 100 acres of the core campus, which and this master plan once we had submitted it stalled in the approval process.

Even in China, if you're trying to redevelop an area that's populated by tenured professors at the adjacent Chinua and Beta Universities.

It's not always easy to get them underway.

So our client, the chairman of the academy asked if we would mind in the interim doing a small project, and I asked how small was small.

I mean, we wanted to do whatever they wanted but you know it limits how small you can handle if you're flying 8,000 miles to come visit it.

So they said, "Well, we apologize, but it's only 100,000 square meters."

Well, that's 1.1 million square feet.

I said, "I thought we could fit it in."

So this was the first project and it was an incubator building for science startups.

But an extreme example of how big these projects can be or three projects that we designed and documented for the all India Institute for Medical Sciences, or usually called AIIMS.

AIIMS is the premier academic medical center, public academic medical center in Delhi, the capital of India.

Prime Minister Modi felt that each state in India should have a similar high quality academic medical center and ordered that 17 more of these campuses be built.

And the first four were designed and built by all Indian teams working under the direction of a development subsidiary of the ministry of health and family welfare and all four projects were problematic.

And the prime minister's office was unhappy and directed that the next three should be led by foreign healthcare or design firms, including they were all the usual suspects, mostly from the US.

We proposed on all three hoping that maybe we would get one and for whatever reason, we were awarded all three, we were obviously extremely excited until we quickly learned that the agency that had been running the first four was to be our client and their feeling was that if we were successful their failure on the first four would look even worse.

So they were intent on trying to make sure we did not succeed in which... And we went through probably one of the most difficult project development periods I've personally been through.

But the main point of this was the scale.

First phase scope for each of the three campuses was to master plan, program, design, document, and get under construction three Greenfield 150 acre campus and that each would have a new 960 bed teaching hospital, new medical and nursing schools, and all the related development, such as student and staff housing.

The first phase of each campus was 2.5 million square feet and the schedule called for all three to be planned program designed, documented under construction within 12 months of our being commissioned.

To our clients, dismay in spite of all the obstacles they put up we met this deadline, but it took large teams drawn from seven of our offices as well as the support of 14 Indian sub consultants.

Healthcare projects in China are the same.

They rarely go for hospitals of less than 700 to 1,000 beds.

And men many are entirely new campuses.

So these are just illustrating those three Indian campuses, the master plan and then the development.

All of these are now nearing completion of construction.

So doing new hospitals of 700 to 1,000 beds.

I mean, there are not even very many hospitals in the us that have 1,000 beds.

And that to be the routine in China gives you an example of the scale.

So, for example, we have been working on three public hospitals in Hong Kong.

The bed count, the three that we're working on is 2,356 is the one that's on the screen.

2,389 is the second one and we have a nice modest one at 840 beds that are underway right now.

But China also has commissioned the planning for entire destination medical centers, the medical zones.

We were the master planers for this one, which is one of the largest.

This is the Shanghai International Medical Zone.

This is an 11 square kilometer campus and it's right next to Disney Shanghai.

So in case you get upset on one of the rides you can come over here and get treated.

Anyway, this 11 square kilometers not only includes a major international hospital, it had initially planned for four specialty hospitals, a senior living community, and then a large tech park where the headquarters of Siemens and various pharmaceutical and medical equipment manufacturers are basing their operations in China.

And one of the reason we now have a Singapore Office is we have just begun work on a 1400 bed hospital in Singapore.

And we are also working on a $4 billion medical campus for Kuwait University.

The size of senior living projects can be equally challenging.

Our first projects were in Japan, international projects were in Japan, which is...

Probably most people know the world's most aged country and the Japanese have embraced some of the American senior living concepts.

The size of the need.

However, is meant to scale of some of our projects far exceeds anything we do in one phase the US.

This is a picture of a high rise in Tokyo called, Sun City Ginza and it's a continuing care retirement community.

And it has over 550 residents in the first phase and this is just give you feel of this is a very high end project.

And then we have a second project for the same client nearby Yokohama that has over 1,000 residents in the first phase.

These are much larger than any continuing care retirement community.

Certainly, anyone that we do in one phase.

The scale issue is even more extreme in China.

This is the overall plan for a large senior living community on the north side of Beijing in a district called, Changping.

In the US our typical first phase for many of the continuing care retirement communities we might do is 250 to 300 seniors.

But in a lot of our early work in China, our clients always talked in thousands.

This one is a community of 5,000 for one of the big insurance companies.

And it includes the CCRC, the first phase of our CCRC that has accommodates 1,000 residents.

But it's this entire part of the district is has 5,000 in the first phase and this is the CCRC portion of the project and (indistinct).

The third major lesson we have learned is the need for the design team to provide more than just design services.

Many of our clients do not have the experience to guide the planning and design process.

They hire us as international experts to help them with the strategic planning, the programming, and even their market positioning.

And sometimes the recruiting of an operations team and even their business plan.

They're often very interested in our experience with other healthcare and senior care providers that they consider to be leaders in the field.

The is the first comprehensive cancer center in the middle east.

It's in Petah Tirva, which is a suburb of Tel Aviv.

We were hired by actually one of the leading medical centers in Israel, Rabin Medical Center to plan this.

But one of the main reasons that we were hired was that we had this close relationship with the leadership of Memorial Sloan Kettering.

And as part of the deal, that sealed the deal was the administrator for Memorial Sloan Kettering, as well as one of the clinical leaders agreed to be part of our team when we were doing the initial planning for this cancer center, which is now actually being doubled in size.

In other cases, there are often no user groups to meet with since the...

This is one of the infusion areas of that hospitals.

As I said, so in other cases, there are no user groups to meet with since the staff will often be hired as the project is being built.

And many of our assignments begin with our ranging tours for the sponsors of new medical center or senior living developments.

In addition, we are all often asked to introduce our clients to potential management and operations partners.

Well, and our client for this hospital and senior living campus in Guayaquil, Ecuador found and hired Miami Baptist as their operations partner.

Our initial assignment was to introduce them to other possible operators.

So this is a campus that is being developed, which includes a senior living community, a hospital, and then a variety of other complimentary uses.

In this project in Bangkok, we did in the introduce them to a Canadian company that is a client of ours to act as their operator for the first years of operations.

And this project is now under construction.

This is a part of a very large scale development, most of which is being done (indistinct) and Partners, but they carved out a section to do a very high end retirement community, which includes skilled care and dementia care and a variety of other programs in addition to independent living.

Then there's the issue of speed.

The clients in many development countries do not want to wait seven or eight years for care environments that they know they need now.

In major markets, such as China and India it's not unusual for the initial goal to be to start construction within one year of hiring the design team.

I've already described that in the case of the three aims projects.

But in China, most projects that have any government funding start with a design competition, where each of the invited design teams is expected to plan program and develop a complete concept design in English and Mandarin within 30 to 60 days from authorization to proceed.

Even when the project is a complex hospital or an entire senior living community.

I'm about to click through a project that we just did last month, where we had four weeks to do the effort I'm about to show starting with a relatively vague program of a hospital that was to have the high end private hospital in Xian, which was the first unified capital of China.

And it was to be built around four centers of excellence.

We had a blended team from our New York, Dallas, and Shanghai offices, but this is just one of the dozens of competitions we've done over the last 20 years.

I'm gonna go through fairly quickly 'cause there are a lot of slides.

So one was trying to demonstrate our understanding of the site and the healthcare market in china and as related to the centers of excellence.

I'm just giving you a sense of what the output and presentation needed to be in order to be selected for this project, which happily we were.

And it included...

So as you can see everything is in two languages, there's reference to images to show how we selected the character of the architecture.

I mean, you're doing all this in sort of a vacuum and you're trying to guess what the final decision makers are gonna find appealing and whether you really wanna reference traditional Chinese, traditional design vocabulary.

But in this case we chose it 'cause it was going to be a low scale project.

And so this is... And the presentation went on for two hours and (indistinct) at 10 o'clock at night.

It included test plans and...

But as I said, it's sort of an extreme case and the issue of speed is not always an issue.

There are parts of the Middle East where we joke that the common Arabic phrase (speaking in a foreign language) that is invoked many times when discussing things such as schedule means exactly the same thing as (speaking in a foreign language) means in Mexico without the sense of urgency.

And we are working on a large medical center in Kuwait as I mentioned earlier.

We pursued it for years then waited to start for another year after being selected before we were authorized to proceed.

Now five years after we first began discussing the project with the client we were finally finishing concept design.

So the next of the lessons and I'm gonna see we have what 10 minutes left.

I'm gonna fly through this.

- [Ray] It's 10 minutes, yeah.

- Yeah.

So the next is the barriers to change.

They're are all sorts of (indistinct).

Sometimes they could be local building codes and some others are harder to identify.

And the thing that we always run up against the developing countries and senior care is people say, "We don't need that here.

Our families look after their aging relatives."

And while that's true to some extent is not true to a very large extent.

In China, the one child policy gutted the ability of families to look after their early parents and there's something called the two, four, eight problem in China, which is two working adults might have four living parents and eight living grandparents.

In India and many other countries, a lot of the children live overseas or near their parents and one of the big needs is finding a place for aging parents, where they could be safe and that their family who might live in New York or Dallas or Austin knows that they're being well taken care of.

The second thing is we don't... That's not how we do things here and in that Israel project I mentioned.

In this country, we typically one doctor or a team might have three exam rooms at their disposal.

So if a patient is getting ready for exam or in the middle of exam or is just getting dressed afterwards, so the teams can move from one to the other.

Whereas in Israel, each doctor has their own dedicated exam consult room, which makes much less efficient throughput, but we argued that it was not an efficient way to do it.

And they said, "No, we couldn't sell that to the doctors."

And then of course in many cases there's vast investments in what we know are going to be obsolete or not where the leading edge is and that our work with Memorial Sloan Kettering and other cancer centers, all the real growth we're seeing is in ambulatory settings and with the growth in treatments that are based on medical oncology and yet in China and other places, it all the treatment is, and work very often is all focused on inpatient and radiation oncology and surgery.

And then there are issues with how doctors are compensated and in China they tend to be poorly paid and their priorities are influenced by who will pay them supplemental income.

And it's very hard to put it on a completely efficient model.

And then, of course, corruption is unfortunately a significant issue in some countries.

And one of the countries where I loved working and I spent a lot of time, I was gonna open an office until I found out that we were being advised that our fee proposal should include the soft payments.

And I asked what they were and they said, "Well, that's for the minister and his wife to go shopping in Paris."

And I said, "Well."

They said in other countries there's no... People from other countries there's no problem.

I said, "Well, it's against the law in the US and we actually can go to jail for doing it."

And then there are unique cultural and religious issues and it's very hard to generalize about anything.

There's a steep learning curve for US trained architects in each country and what works in China does not work in Korea or Japan and certainly not Thailand or India and each country is... And the first task is to understand how these unique characteristics are in some parts of China, vanchuai can be a major planning influence while in parts of India, the comparable but very different influence is vastu.

And even in China, even where vanchuai is not of a major belief, other traditions such as the need for passive solar for heating and clothes drying has meant that there's a very, very strong preference for surfacing which is very often built into the codes.

Vastu which is the equivalent of...

The Indian equivalent of vanchuai can have a huge influence this large retirement community in India that I did up in Dehradum, the North of India.

The whole plan had to be signed off by Vastu master.

The floor of the client would approve the plans.

And, of course, in the more observant Muslim countries, all the planning is very often starts with a separation of the male and female on the campuses while in Japan it's very common for us to have communal mixed gender bathing facilities as an amenity.

Market expectations.

Yeah, this is India.

Market expectations are also a big deal in places that are prosperous like Japan where the seniors have money.

They expect a very high quality lifestyle.

Whereas first projects we did in China, even if the people had the money, they had grown up in very spartan conditions until the recent years and they said, "We don't need all this."

I can live in 100 square foot room that'll be just fine for me 'cause that's how I've lived most of my life.

But then those things will change as a new prosperous middle class of China is coming along.

And then in many countries there's such a strong preference to own so that in this project in Bangalore in India we plan this as a senior living community, but families...

Younger couples were coming in and buying not only a unit for their parents, but a unit for themselves to live in the same development.

And this complicates the economic model, which has made senior living work in much of the west where there's a turnover, but the unit mix is still controlled by a fairly homogenous senior community.

And then, of course, there's the ability to deliver quality care environments.

In the Middle East you can get high quality projects built and they can hire good medical staff, but you're usually working in a vacuum while the project to just being designed.

This is one in the United Arab Emirates in one of the Emirates called, Ras Al Khaimah.

But it's not always the case in smaller countries.

This happens to be the largest public hospital in Guayaquil, Ecuador.

It's 800 beds.

When I was touring it for the first time when we were starting the master plan, they had reasonably good ORs and imaging and other departments are basic, but using reasonably good equipment and with pretty good doctors.

And then I went into the woman's ward in one of the buildings and it was 40 women in a large room with no privacy curtains, no bathroom, just one common bathroom and ceiling fans as their HVAC system.

And then touring in another part of my life as chairman of Helen Keller International, I was touring the National Eye Hospital in Hanoi, and there were six patients crammed into small rooms and then all the excess patients lying on mattresses in the public hallway.

And that was considered what was the feasible and affordable standard.

And that, of course, comes to the other thing that is a challenge.

Everywhere, which has scarce resources and it's obviously an issue in places like Ecuador and Vietnam, but it affects things in this country as well.

Construction costs are, of course, considerably lower but medical staff often and leadership and as well as equipment all have to be imported and are very expensive on a relative basis.

And then, finally, the 10th lesson is that we are planning and designing in a time of rapid change in both healthcare and senior care and this is probably the biggest challenge.

This is particularly challenging in healthcare where the perceived need in many countries is for more inpatient beds while as I mentioned earlier the general perception here and in Europe is that more and more care can be delivered in outpatient settings using technology to minimize inpatient stay.

We are seeing new models of care and virtually every a aspect of the healthcare delivery.

And most of these changes will eventually make their way into the next generation of healthcare facilities in developing countries.

But at this time too much of the investment is being made in facilities that will be partially obsolete when they open.

And in senior care projects are being shaped too often by government funding.

I mean, one that just drove me nuts really last year was in a response to the pandemic, Ontario, which has really a very good health system.

Their response to the high death toll and long term care facilities was to build more of them to the same old semi-private model.

That was one of the major contributors to the very, very high death toll across the world in long term care facilities.

But the good news for those of you who are focusing on healthcare and senior care planning and design, is that your skills are likely to be in high demand in the decades ahead.

Just remember, however that working internationally in these large con complex building types comes with many additional challenges.

I have found it very rewarding, but it is very complicated.

I'm still learning new lessons on how to deliver care environments internationally every day.

But when you do it right you make really important difference in the lives of thousands of people.

Thank you.

(audience clapping) - Thank you, Brad.

Wonderful to hear life lessons from the perspective that you can bring to us.

Thank you for that.

Are there questions?

If you have a question, would you make your way to the corner of the stage and use the microphone.

- Brad, I thank you so much for the wonderful lectures you've given today and it's your third time visiting Texas A&M, right?

- [Brad] I think third or fourth.

- Third or fourth and then George, can you remember?

- [George] Yeah, give us a pass.

- Yeah, that was wonderful and each time we hear a new things.

You're introducing a new project, that's incredible.

And we really appreciate that support to Texas A&M program.

And also I want to introduce the Mr. Carlos Moreno and then he's in charge of the Perkins Eastman Austin Office.

- [Carlos] I oversee the healthcare part.

- The healthcare part, yeah.

- [Ray] In Dallas.

- In Dallas as well.

Thank you so much for coming and then- - [Carlos] Thank you.

- Yeah, so any question from the students.

- First, I just wanna apologize.

Fridays are my casual days, so the weather was nice so flip flops there you go.

But my name is Evan Kennedy.

I'm a senior environmental design student here In the college of architecture.

So I have two questions.

The first being in terms of master planning, I think here in Texas, I don't think that we see as much of it on the scale to which that you guys are designing in other countries, mainly because there are so few codes that we have to get through.

You can just build if you have a hammer and some two by fours you can build.

You don't have to pass as many hoops.

So what do you see as the benefit of master planning for so much large scale facilities that take years to construct?

And as you had just mentioned that they're rapidly becoming obsolete as they're being built in certain areas.

So what do you see as the benefit of master planning?

- Well, I mean, if it's a good master plan, it's a framework that is flexible enough to adjust as new technologies and other things come in.

You're basically setting a framework to guide the investment.

And I think particularly in the US context, I think we can see far enough ahead to avoid doing that.

It's just that the overseas very often their medical establishment really is 25, 30 years behind what we already know is going to happen to them later.

And so the advantage of the master plan is at least to set a framework bringing international experience to give of them some guardrails so that they aren't going too far down the road.

I mean, I've spent several sessions with one of the major medical centers in Shanghai, trying to just bring the lessons from all the many cancer centers we've done in the US as what is happening here to guide so that they're not putting all their investment into what we thought was not where all the advances were going to be because the places we were working for in the US were 25 years ahead of them in terms we can say, "Look, you're gonna...

There are a lot of really smart people in China and there are a lot of really smart people in India, in other countries.

And then in the end they're going to do what's being done here.

It's just right now all the emphasis has been on what they know and what they see in their own country.

And one of the reasons that we and other leading firms like HKS and others who are very active overseas is that these countries want that expertise and that's why we get hired and that's why... And these projects are big and exciting but you gotta give them a framework within which they can do these large scale projects.

But a lot of what we're doing in terms of the specifics of the design changes over time.

It's just that you're setting them within the right guardrails.

By the way, when I was going to Stanford this was considered well dressed.

(audience laughing) And at a time when our counterparts at Harvard business school were wearing suits to class, you know?

- [Evan] Yeah.

- But it was the weather.

I mean, I came from New York.

You would not be wearing this in New York today.

- No, I would not.

And then my second question is, I think I was honestly a little taken aback seeing your first slide of your projects being built in China and how senior design living is not only one story.

I know that that's not possible in those countries, but here in Texas and Florida you just see these mass cookie cutter houses being custom built.

Do you think that, that has any role or any place in senior design living moving forward that there'd still be a place for these one story mass design houses or do you think that this is more going to be adopted by the United States?

- Well, certainly I don't think there's much of a role for it in high density countries like Japan or China.

In India where it's... And what's more in some parts of the United States, the single family development, if for active adult, the gated communities with golf courses in, yes.

You see all over Arizona and Florida and Texas and there but that once you get most of the senior... Once you get to doing continuing care retirement communities which include skilled nursing and dementia care and assisted living being spread out is not an advantage.

I know from just what my father wanted when he moved.

He wanted to live in one of the single story buildings, but the reality was he was getting into a frail where he needed to be in an apartment building where getting to an elevator and down to dining only required him to walk about 100 feet.

And the average age of people moving into the facilities that we designed from when I started and that was a while ago to today is probably...

The average age has increased by 15 years.

So we had communities where people were moving in their 60s.

Now it's very common for the average age in a continuing care retirement community to be in their 80s.

And at that age, even though some of us George, in a couple years, me fall into that category.

The reality is that biological aging affects people at different rates, but it's real.

And one of the reasons that the need for specialized facilities is to allow people to live independently longer.

And if this walking distances and things like that are a barrier then that's not the future.

In a country where land is scares, just in the years, I've been going to China.

When I first went, Beijing was a city of 11 million people.

It's now a city of 25 million people and they can't afford single family one story houses.

I mean, there are a few, but you better be really rich.

- [Ray] Yes, sir.

Well, thank you for your answers.

- Yeah.

(audience clapping) (upbeat music)