- Good afternoon and welcome to what sadly is our final Friday lecture for the spring 2022 season.

It's been fantastic and thanks George for organizing everything.

Terrific series of speakers, and today will be no different.

It's a terrific conclusion to a wonderful semester of presentations.

So thanks to all who have participated in making that happen.

Our speaker today is Autumn Leveridge.

And Autumn is in the Department of Civil and Environmental Engineering as an associate professor of the practice.

She is also a fellow of the Center for Health Systems and Design which, as this audience knows, lives half in the College of Architecture and half in the College of Medicine.

And recently, I can tell you that Autumn has joined the EXCOM, the Executive Committee of the Center for Health Systems and Design and then is now offering her voice to help lead us into the future so we're delighted to have her with us in that capacity.

She brings 22 years of experience to this conversation today, working in the military and in America and abroad, working with partners in Europe, Asia, and the Middle East.

And I will add, for those of you that follow these things, she deployedboth in support of Operation Iraqi Freedom and Operation Enduring Freedom.

And before any other time passes, thank you for your service.

We love our military and appreciate their contribution.

Professor Leveridge is homegrown.

She's from Brazoria, Texas, commissioned out of the Corps at A&M.

Yes, she was in the Corps here, yay, and she commissioned as a medical service corps officer.

She got her BS in Biomedical Engineering here with a minor in electrical engineering.

She earned a Master of Science in Civil Engineering here from the College of Engineering and importantly, the Certificate in Health Systems and Design from the center by the same name.

She holds a Master of Military Art and Science and a certificate in Europe Regional Studies from the US Army Command and General Staff College.

It is a real pleasure for me to present to you Autumn Leveridge for today's final presentation of the semester.

Please join me in welcoming her.

(crowd clapping) - Thank you, Ray, and George and Zee Ping and Cynthia and Dan and the team in the Center for Health Systems and Design for having me and for inviting me.

I'm very happy to be with be with you all here today.

So we're gonna to talk today about operational health facility planning for the US Army in an international environment aligned with the theme for this semester health center.

So Ray has pretty much said about me.

Other than that, some of the countries that I have been around and had the opportunity and fortune to work with has been in Korea, South Korea, although we did get to step in at the UN tables around the table to technically the North Korean side.

Kuwait, Iraq, Afghanistan, Germany, Italy, Israel.

And then in hobbies I've had the opportunity and fortune to travel to many more countries.

I do enjoy photography.

I asked my engineering students who is the artist?

Go talk to the artists.

You need to be more well rounded as an artist and I truly truly have a passion and belief for for lifelong learning, which is largely what brought me back here to College Station.

So why are we talking about the Department of Defense in a class for health systems design?

Well it kind of links into the national defense strategy and, you know, we have different priorities in the national security and national defense strategy, and they do link to protection.

They link to promoting prosperity, preserving peace and advancing influences.

Sound kind of similar to the themes of health and health design?

So these are in a regional strategy and our defense helps support that.

We operationalize that through the joint force employment, and we do that through joint publications, and that includes health facility planning.

So that links, what the Department of Defense is aiming to do and is tasked to do in support of our nation is linked to what the center is trying to achieve this semester in celebrating the global agenda to protect, develop and restore human health, preserving peace through strength.

The integrated deterrence campaigning and building enduring advantages is executed across geographic combatant commands across the world.

And Ray had mentioned, I gotten the opportunity to work at the United States European Command, so enjoyed doing that.

And in order to execute those priorities and the requirements, the DoD and the United States Army, have a process for the health facility planning through the organization and management of the lifecycle of the medical facilities.

Now, the medical facilities that we use, across the globe and in different mission sets, they're not necessarily the brick and mortar.

Sometimes they're tents, sometimes they're trucks.

But in either way, it's about the delivery of those health services.

In wartime, it's largely or it can be largely trauma and also disease and non battle injuries.

And it also says in compliance with applicable national standards.

So we know what that means in the United States, but I think we've got quite a few at least in the audience here who are from other nations.

And each of your countries also has its own national standards.

So when there is a situation in which you would invite the United States to come and participate in a operation or an activity in your country, typically, we would follow also along with what your nation is asking to comply with as well.

So that very, very quickly becomes quite complex.

Anybody who's looked at the requirements of the Joint Commission already knows that that's complex but then having to bring together how do we align that and synchronize and coordinate that with what another nation is requiring us to do as well.

Two big examples, the facilities that we operate in Korea, the facilities that we operate in Europe.

So in the execution the operation of the facilities and I think a lot of folks have seen this before, is the facility lifecycle.

So starting from the idea and need through the planning, design and construction and then long term, the operations and maintenance is that from Department of Defense and Department of Army perspective, it has to link to the operational mission need.

It's not just that you've got little green men who show up and decide to build a hospital.

There is some overarching need that brings those requirements to that location.

We're also required, the DoD is also required to comply with congressional OMB and budget constraints.

So this is different than a private partnership or a partnership where you're able to, you know, perform fundraising and raise funds to build a hospital to design a a health facility.

That is spectacular and beautiful and truly beyond measure.

With the congressional and the the funding constraints, there has to be evidence for those design.

In planning for the design, it's many stakeholders, right?

You've got the from the American perspective in a DoD project, but when we're operating in an international environment, again, you know, the the European case for the percentage of lumens in two different rooms, it is a law in those countries, and as we are building facilities in those countries, we have to comply with those laws and that brings it into the design.

Having different standards in complying with.

In Germany, you have to have the (speaks in German) must sign off on everything and similar for other countries.

In construction, and we'll talk a little bit more about this today, we have different DoD construction agents and sometimes national or multinational contractors involved in the construction.

And the case study we're going to talk about today, we had many different stakeholders.

And then down the road, the operations and maintenance.

How are we able to balance the operational funding with defense health program funding?

And that is certainly a challenge in the DoD in the United States Army.

So beginning with the need, the operational support, to ISAF was the 2001 mandate.

So there was a request for assistance from the Afghan authorities to the United Nations Security Council mandate.

They originally brought in forces into Afghanistan in 2001.

From 2003 to 2014, the UN and the Islamic Republic of Afghanistan, again, requested US presence.

NATO took command of the International Security Assistance Force there in Afghanistan and of course, service members from many different countries participated in that mission.

From 2015 to 2021, the Afghan government in accordance with the United Nations Security Council resolutions, again requested that that mission change, but that there still be a presence, and that new mission was the Resolute Support mission.

This was still NATO lead and this portion was a non combat mission.

So during this timeframe, all was the operational need, justifying the health care facilities that we needed and had to build and required and used to save lives.

And it's the missions that we have been doing in Iraq and Afghanistan, very largely different from World War I and World War II, in the fact that we were able to save so many lives, so many lives, very high percentages.

And this is not the case of World War I and World War II.

And so some of the concepts and y'all may have talked about this in your classes is the golden hour.

And actually, NATO has adopted some of that language into their documents, although the United States still caveats and says this is a nice to have, but we realize and acknowledge that it's not possible in every situation.

In addition to the golden hour, the design here across this geography was also to have what they called the platinum 10 minutes, and that was with the early surgical interventions.

So moving on from the idea into the planning, the idea need into the planning phase of the cycle.

OMB funding was achieved for the Bagram project.

It was in an emergency wartime supplemental appropriation and that was with the Combine Forces Land Component Command.

So there is a Land, a Maritime and Air Command, they work together and this was through this supplemental.

It was designed for a NATO Role 3, right?

Because this was a NATO mission.

And the Southern European taskforce had been utilizing an army, a US Army Combat Support Hospital, which was at that Role 3 level.

So Role 1 with your initial Medicare, Role 2 maybe having some initial life saving trauma care and then Role 3 more of that stabilization care.

The construction agents that the DoD uses are the US Army Corps of Engineers.

They have districts across the world.

And in Afghanistan was the Afghanistan Engineering District.

They were responsible for the contract management and they also brought in experts, like from Vicksburg, Mississippi, out of Attic for geotechnical for other support.

In the planning process, of course, with the hospital truly complex, everything from how are we going to manage this, you know, project execution?

How are we going to communicate?

What is our letter of intent for us to share the design to get through the submittals?

What is the concept of operation?

How are we going to long term maintain this program for design?

So the project management plan went through the different roles and responsibilities, and some of that included the general contractors project managers on site the United States Army Corps of Engineers also had project managers that had more than one project.

So that was another challenge in that they had to look for what was happening with the hospital, but also the construction of the airfield, the construction of other projects as well.

From the owners rep side, the help the US Army Health Facility Planning Agency provided project officers, 'cause this went through multiple years through the planning, design and construction.

and I had the opportunity to be there from zero to 80% construction completion.

It was on site and certainly the planning and the design process is extremely important.

But I think some of the most fun is actually getting to be on site during the construction.

It was medical modular.

So what is medical modular mean?

There's a typical concrete masonry unit, CMU construction.

So those were two of the what we referred to as blocks.

We had five blocks, A through E, and three of the blocks were constructed off site in modular fashion.

So I think y'all had a lecture with the Aggie BUILDs, so similar has kind of come down through the years.

Previously, prior to this company, the company that was selected for this modular construction was PKI.

But in previous projects, Cadolto out of Germany was also another modular built for the Kosovo hospital.

PKI out of England, worked with different subcontractors throughout the Middle East region.

So they were actually working through construction in Dubai.

So yes, we had to go and inspect the modules under construction in Dubai.

And that was certainly interesting, very interesting.

So the design was for Role 3 hospital 45 bed at Level 3, three operating rooms full outpatient ancillary support, 73,000 square feet.

The project amount, the PA was 17 million with an additional $9 million or so of equipment, you know, major medical equipment.

And that package, you know, similar with it, you had the funding for construction, but then the funding for the equipment also had to go had to go through the operational channels.

The multinational piece was, I think really, one of the best experiences about this project.

Because bringing so many people together, you know, trying to share perspectives and bring together cultural norms.

You know, the British think differently.

The third country nationals that work in Dubai think differently.

They Afghanis think differently, our general contractor was from Turkey.

And certainly there are similarities, but bringing together and working through dialogue, so that way, we could decrease the misinterpretations, right?

Work through conflicts, to make sure that we were achieving the design.

So this is the overall site layout and then in gray here, these are the three modular blocks that were brought in.

So on the upper side, the top side of the slide is where the emergency department is, and below that is the operating theaters, and then the intensive care.

So I won't say that there was nothing on this site when I got there.

There had been use of this base before the main drive was called Disney Drive.

And it had, you know, started out when everybody kind of first went in and everybody put a little fence around their own part off a Disney Drive and they had to check for things like ordnance.

There was a lot of unexploded ordnance.

There was trash, I think, you know, it's a typical for Army, okay, here's the hospital, okay, you get an old trash sight.

So that had to be cleared through.

We had to call EOD to come and check and make sure that there weren't any, you know, that it wasn't going to be ordnance, it was going to explode.

There were concrete pads already in place that had to be demolished.

So certainly not a greenfield site.

And then the crew management and local national labor.

We're in 2022 now, this was 2005.

But, you know, as we advance forward in technology, there are still places in the world that relies on hand tools, hand excavation, and that's the norm and in different regions.

So excavating out, you know, probably a little bit different than how we might do it here in the States.

As we were placing the different footings, you know, you can see here, they're trying to bring in some concrete, almost maybe, I don't know about halfway across the jobsite, and trying to extend the boom to get it across well it wasn't quite far enough.

So you know, I don't know if we would call this Aggie engineering or Afghan engineering, but somehow, they were able , Turkish engineering was a general contractor, Zafar Engineering, but made it work made it work with the manpower and the materials and the machinery that they had available.

And you saw one of the previous slides, the geography, this was not along the coast, not easy access, you know, bringing in materials and supplies, you know, even for the US and NATO partners, who could use portions of the airfield to bring in materials was still not easy.

And then you know, how the general contractor would bring in items, you know, sourcing locally where they could, but not always an easy situation.

As we worked through, there were challenges with quality assurance and testing, you know, the concrete slump tests, the concrete was not always where it needed to be.

And there was a batch plant at the end of the base.

And they, you know, sometimes would have to go back and try their mix again.

The Corps of Engineers set up a soils laboratory and then, like I said, brought in folks from Attic.

The gentleman on the bottom left, he actually was from Peshawar and then had moved to America, and then, you know, began to work with the Corps of Engineers and so had worked all over the world.

And came in, you know, close to home for him.

The gentleman on the far right, he was from Alabama.

So you might say, that's another country, right?

And I have to brag on John Bower.

And he said, oh, he was turning 65 in Afghanistan.

And at the time, I thought it was ancient.

And now I think, oh, that's not so far away.

But he said that he had started his freshman year at Alabama when Bear Bryant came to coach there, so to put in context.

And I have trained the trainer up here on this slide.

And you can see, you know, John's showing me how to use some of the tools to test for concrete.

And then in the soils laboratory, you know, how are we checking to make sure that we've gotten, the right the compaction testing, another gentleman from Attic, and, you know, not just teaching the Aggie, but teaching the local nationals.

And I don't know what the figures are today in 2022 but in 2005, the illiteracy rate in Afghanistan was 98%.

So to be able to teach, even if it's vocational, brings a lot, brings a lot.

Formworks, the shear walls, right?

The lateral resistance loads from winds and seismic.

During that time there in 2005, Pakistan had an earthquake.

We could feel the rumbles in Bagram.

So building and designing and constructing a hospital that's gonna be safe, right?

From seismic you know, blast resistance, bomb resistance.

I was telling Cynthia, before we started, I said, we had a really good general that year.

He came in and he brought in all of the local Afghan business people.

And he said, I will let you have a bazaar every Friday.

And I will let my entire base come and shop at your bazaar on Fridays, but if we have a rocket attack, there will be no more bazaars.

So that's a pretty smart general.

We didn't have any rocket attacks the year that I was there.

So you know, they police themselves, and they said, hey, doing business is more important.

And that brought protection, you know, for the Afghan workers it brought protection for Turkish contractors that were there for all of the other the NATO forces, American forces that were there.

But you know, again, putting up formwork, and you'll see some of these things, not necessarily what you would see on an American construction site, but getting getting the job done.

And then, this photo I really liked to kinda just show about how the blocks had to be integrated in.

So you know, you're you're building this CMU construction, but yet you're gonna have to bring in these modules and operating a construction project schedule, you know, you don't have time in the schedule to do all of one events and then come back and do another.

It's got to be, you know, work together in parallel and that created complexities and challenges as well.

Working through the roof preparation.

Now, these were, you know, steel pipes that they were using.

But when you would drive around the countryside, if you would drive around the countryside, you would see some local construction where they would literally be using some type of wooden supports for their placements that they were doing.

And you just think, Oh, my goodness, you could just imagine if one of those had collapsed.

Placing in the roof, the concrete on top of for the roofs, it was a large, a large surface area, so then you have to worry about the cold joints that may be forming, which can cause problems later.

And so having continual concrete, that still passes the slump test that still passes all of the quality assurance and quality control to get delivered in a quick enough time to place an entire room.

Now, the roofs were not placed all at this, you know, it was blocked by block.

but still a couple of those blocks were very, pretty large.

And then, of course, you see the the mountains in the background, that was one of the beautiful things there was every evening, the sun would go down over those mountains and it was gorgeous.

Many, many project activities, right?

So huge complexity, trying to you know, align for, hey, what is the access, not only access on this little piece on the base, but even to get on even to get entry onto the base.

You had to, day workers would come and it would take time to be able to get on site, right?

Because you can't just let anybody come on, right?

It's a military base, there has to be checks and controls and that takes time.

So the general contractor, you know, really, really had to work very meticulously to make sure that there wasn't going to be a problem with access.

And then as more and more materials arrived, managing that space, going to the installation, right?

Kinda like you know, going to city manager and saying, I know this is where I'm supposed to be building but I need more at least for this type and trying to work through that synchronization to get additional space, swing space search space for some of those materials and the logistics issues.

Even mobility around the site, right?

Which can be a huge safety issue can be a challenge at times and then synchronizing all of that together.

The different claddings that were used so the exterior finish and insulation systems to help provide on the vertical walls you know, to help provide insulation but then on you know on the roof as well with additional concrete tiles for more blast protection.

So the United States follows, you can find in the whole building design guide, there are the uniform facility guidelines that talk about the minimum requirements for a lot of the cladding and specifically for blast protection.

Galvanized steel studs on the inside I thought this was kind of a nice photo capturing okay now we're getting past some of the initial construction now walls are going up on the interior.

But yet there were still no modules on site, right?

And this here, I believe they they drilled in these piles into the concrete here getting prepared for bringing in all of these modules to be assembled together.

And then this one what I call Jingle All The Way in Afghanistan and it may be in other places in the region, they utilize transportation that they refer to as jingle trucks.

And literally their bells along the bottom of the front of the trucks, they're painted beautifully.

It truly, you know, there's truly an artist that seems that, you know, they've got pride in their trucks that they bring.

And you can see, and I'm not sure if they took the 23 hour route or the route through Lahore but either way and I think they did go on the western route, they did not fly, but very long routes through the mountains, through very tiny roads, treacherous roads module after module and I do not have the figure of exactly how many trucks but it was a large number.

And so when they arrived, you know, probably needless to say there had to be rework.

It was just, you know, too bumpy of a road and coming from Dubai, bringing in and putting them on ships to arrive in Karachi, Pakistan and then being offloaded onto a jingle truck being driven up to Bagram, there was a lot of rework.

But again, going back to the project need and the planning is that this was part of the approved design was to have what was termed as a relocatable facility.

Now, in reality, I don't know if that, I guess you could relocate something but it might not be the most efficient thing to do.

But it was deemed as a relocatable facility and through these modules, which, like I said, technically could be disassembled and moved to another site, if a permissible environment.

Another complex operation was then the crane operations, and, you know, if some of you may have taken on construction science side of things and looked at crane operations, and crane operations is a dangerous business to begin with, you know, for a variety of reasons.

And, you know, here, there you can see, they're taking one of the modules, it's being lifted from the back of the site, over part of the CMU partition and into the Emergency Department block.

So not an easy job, for sure.

The crane operator cannot see exactly where the module is coming into, they're having to rely upon the director there.

And then placing modules there into the site, then it's, of course, like a puzzle piece.

And then having to connect all of the insides.

So it certainly was long, long days.

The road, the Disney Drive road opened at 7am and that's when I would get in my little truck and take my three cell phones and my Leatherman and everything else in my little belt and go out to the site.

And, you know, we'd work till the sun went down, we'd work when needed to through the night, in the case of having to finish some of the concrete this is another one of the the roof construction.

But everybody worked together as a team, we were you know, it was it was like a family, a team working together.

Because that's who we saw every day.

I mean, where are you going to go?

There's not really any place else to go.

So you can go to the dining facility on the north end of the base, or the dining facility on the southern end of the base and, you know, maybe a Burger King in between the Burger King shack, but not really a lot of places to go.

And so that certainly promoted camaraderie, you know, amongst I think we even had an Kazakhstan worker that was even working on the site.

So you know, Afghans Kazakhs, Turks, Americans, we'd have lots of visitors.

South Korea had a another clinic on the edge of the site on the edge of the airbase.

So they would come over.

Lots of good camaraderie working together.

Safety, of course, paramount.

I partnered with the MEDEVAC, who had to do training in their helicopters and they would were kind enough to bring me up so I could take photographs of our progress.

And this one I caught when they were having a morning safety meeting.

But the whole team together, like I said, looked on, how do we can't take care of each other here on the site and how do we put together the best quality that we can?

Really looking through the specifications, one of the walls as they began to put forward, I was not a contracting officer, I could not direct, you know, the contractor.

But I did ask lots of questions.

And in many of the questions that I asked, they would look and they would say, oh, you're right, we got to fix that.

And they tore down some walls to redo some of the work to make sure that it was done, right.

So really a top notch team.

So really building stronger together, this is just a Wikipedia or something picture somewhere I don't know, might have taken it in the air.

But you know, the construction, local Afghan construction is not the same as what we had planned and designed.

But bringing together different cultures, different nations, to build stronger together for a mission.

They sustained this hospital, like I said, until 2021.

And interestingly enough, although it was designed for an army cash, it was actually the Air Force that said, oh, we'll come in and take care of this nice, pretty brand new facility.

And so they, they did a phenomenal job, it was Joint Craig Theater Hospitals, is the name of the hospital.

So they treated all service members, regardless of service.

And one of the things that really I had hoped for as we were constructing and may I think got to it a lot sooner, was partnering together with Afghan doctors to bring them in, to, you know, hey, here's how, you know, medical procedures and things, clinical procedures that were done.

Again, you know, teaching and transferring some of that knowledge.

And then from this Air Force website, then is kind of a list of sort of where they had gotten to with, you know, what we like to say in the army is always improve your foxhole.

So, you know, always work to improve your environment.

And I think the Air Force did a great job at doing that.

And then these are my guys, right?

This was part of my team.

And this was actually, folks would walk around in just you know, not very good footwear and they would always look at, you know, oh, can we have your combat boots?

No, I can't give you my combat boots.

But at home we had a family church who got together a donation and they sent a big box of extra shoes.

And so that was actually a hearts pictures was a thank you that they were sending to the church for the shoes that they donated.

So very hard workers, great hearts, and it was, you know, truly an honor to get to build with them.

And and I will ever be grateful to the Afghan people for helping us in our mission that we were there to do with them.

And so I will now pause for any comments or questions.

( crowd clapping) - Thank you Autumn, questions for Autumn.

If you have a question, please make your way to the mic.

- Autumn thank you so much for sharing this wonderful story and experience over there.

And I think you know, it's great for you to work with not only multidisciplinary, but also you know Multi Language, multinational team, just a really, really valuable experience, and I just thought, you know, I was amazed by all the work you have done over there.

So my question is taking us through it that, you know, the time you you spend on this project in terms of programming, the site construction, what was the time span on each phases?

- Okay, so I was there from zero to 80% construction completion.

And so that was about a year, during that timeframe that was in 2005.

Some of the initial planning was, you know, probably started sometime after 2001.

But 2004 was basically when they had kind of the official document to take to Congress to get approval for.

So yes, United States government, DoD, the whole process does take a long time.

It is, I think, different in the private sector, where if you've got money, you can execute yesterday, but we, you know, that part of the constraints is the congressional budgeting and that does take time.

And then the operations and maintenance side I believe, they opened for operations in 2007 and so until 2021 - That's pretty quick.

In terms of the construction, right?

- Well, 2005, 2007 for the government?

Yes.

- Yeah that's pretty quick, that, you know, maybe, you know, because of the modular construction design.

- Absolutely executing in parallel.

- And then the budget is significantly lower as well, you know, 70 million, right?

And not including the equipment, the device.

And so have you had any challenges during the construction process?

And just like, damn I lost, you know, I don't have one container, one container just not there or there.

So that kind of, you know, problem happened?

- Right, and like, I was showing the rework, there would be, you know, mechanical that had fallen on the ceiling.

And so the, the subcontractor PKL, they had technical representatives that came in and then they were able to make those repairs.

But, yes, very, very reliant upon the supply chain and, you know, in an austere environment, it's not easy.

- Okay, that's great.

Thank you so much for answering that.

- Well, it appears that our time has ended.

Thank you, that was wonderful.

I couldn't help but notice, we've often talked about the role of the design professional.

And if he does strip away the traditional labels, what is it that we do?

And one of the chief responsibilities that we have is we are integrators.

You think about the variety of things that we integrate even in a domestic project, there's structural, the other engineering the cost discipline, sustainability, the site conditions, the soils, go through all of the things that get integrated into it, so I'm marveled every time somebody turns the key at a ribbon cutting, that all of that integration happened successfully into a singular solution, it's amazing and overlay that with all of the message that you brought to us about culture and language and skill sets and education levels and terrains and materials.

The integration ratchets to an entirely new level incomprehensible at for me at this moment.

The complexity has to have been overwhelming and kudos for a job beautifully done and all of that in service to our country.

Thank you again.

Let's thank her one more time.

(crowd clapping) And this concludes the Speaker Series , the Friday Speaker Series for the semester.

Thank you all for being a part of this.

Those of you that have watched, thank you for dialing in.

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