- Well, good afternoon and welcome to the Architecture for Health lecture series.

My name is Ray Pentecost and it's a pleasure to have you joining us.

Those of you here in the studio and those of you joining us online, welcome.

We have a special treat again for you this week.

Remember, our theme for this semester is Designing for Health Internationally.

Our guest lecturer today lives in Paris, and we're going live to connect with him in Paris, so that's gonna be fun.

Our speaker today is Thomas Schinko.

Thomas is the lead architect and owner of Vasconi Architects in Paris, founded in 1973, but now it is Thomas' practice.

I had the pleasure of visiting Thomas Schinko and his lovely wife, Aten, who by the way, was an Aggie '96.

Can I give it up?

- [Audience] Woo woo.

- There it is.

There's the whoop, Aten, just for you.

I had a chance to visit with them earlier this past summer.

Had a wonderful time, and continued to remember that visit fondly.

Thomas' practice has been all over the world.

Some of the highlights of his practice: they have branch offices in Hong Kong, and also in Luxembourg, and they've done projects in Hong Kong, Toulouse, Kazakhstan, Paris, and recently a huge project in Riyadh.

We actually have somebody here in the audience, Thomas, from Saudi Arabia, and I mentioned to her that you had that project, the Riyadh International Convention and Exhibition Center, which for those of you that may not have seen it yet, the pictures online are stunning.

I highly recommend at least a virtual visit if you can't get there in person, but Thomas has a strong background in health design, healthcare design as well, and that's one of the places where we've connected.

Thomas represents France to the International Union of Architects Public Health Group where I also have a volunteer activity, and we have served together and gotten to know each other through that venue.

I won't continue with the introduction at this point.

Thomas, we are ready to hear from you.

Thanks so much for joining us and welcome.

Would you help me welcome Thomas?

- [Thomas] Thank you very much.

When we acknowledge that today is a very sad day for Texas A and M, as you're remembering the bonfire accident 23 years ago.

All my apologies.

I want to start to bring to you a French vision and a French experience in healthcare.

The French healthcare system is based on the Beveridge system that was developed in the 1940s by Lord Beveridge, and that was giving a universal healthcare by the state.

The state directly finances and organizes the delivery of health and social services.

All this is done in France by the Assurance Maladie.

That is materialized by the Carte Vitale.

This card gives every French citizen access to the healthcare he needs.

He can freely choose his doctors.

When in 2000, the World Health Organization distinguished France as the best healthcare system, maybe the French were the first one to be astonished, because they never estimated their healthcare system to be the best one.

But in fact, delivering healthcare in France is driven by very passionate and very insighted doctors.

And so, I wanted to start with a small project that we were starting at the very beginning of our healthcare experience.

It was a project for Professor Henry Bismuth.

Henry Bismuth was premier in transplantation with his Hepatobiliary Institute for Liver Transplantation.

He was looking for an architect to help him and to build.

All hospitals in France are done, or most of them by public authorities.

There was a public competition, and our office was invited, and the professor immediately was astonished by the approach that was very not healthcare oriented.

It was an approach that was more industrial oriented.

And Claude was explaining that he used only half of the hospital site, because he wanted keep it open for future extensions.

The next point was that he immediately was working with the director already on the section when the professor said, "We have to integrate research facility inside of the hospital."

So, the ground floor became a research institute.

Then he said, "I want my students to participate into the surgery."

And so, they decided right the day to integrate above the operation theater, a place for the students, so they can participate from above and look into the operation theater, and see exactly what Professor Bismuth was doing.

Then there was a very new approach for patients, because it's a very traumatizing operation, and so the professor said, "I don't want only wards for the patients.

I need for their family too, that they can come and stay with the patient."

And so, this way this project was developing in a very interesting way, and as the professor wanted a new approach and said, "I don't want a white hospital.

Please make everything but a white hospital.

Make me a hospital that is really looking and showing the technology and expressing what we are doing, but at the same time has a welcome experience," because he said, "The welcome experience is the first act of treatment for my patients."

We were luckily having a huge problems with the financing of the hospital, but the professor was quite finding private sponsors, and we even found a way to make the facade.

We took from another project the same facade, and we could so cut down the price for the project, and so this hospital could be built within the very harsh constraints of a limited budget.

We see that we have a nice entrance area with a gallery, and trying to integrate green.

So he said, "I want my patients to come into the hospital like in an airport, in any public building.

They have a pizzeria at the entrance."

He wanted everything to be nicely finished, because he said, "This building will last for a long time.

We have to cut in the quality of the materials.

With my work in the public healthcare group, we were debating about what makes international hospital architects different from other architects, and I think we are working in very complex buildings but we have as well, healthcare is always a problem of budget, and there's a big budget.

But finally, it's decided in France by the Minister of Health.

He's decided for the budget, and then it's run down by different agencies.

We have regional healthcare agencies who adapt all the healthcare to the different regions.

In our healthcare group, we were debating about what is really the impact of a hospital of cost, and we see here little sketches we were doing during the workshop that we had in Florence, and we see that initial cost of a hospital is insignificant when we look at the overall operating cost and the lifecycle cost the hospital is getting.

It means the building itself, it's a small investment compared to the operating costs of the hospital, and there's a bigger bubble of the cost that's a social cost of a hospital that is most time neglected, because most people don't see this cost.

If you put in a hospital on the wrong place, and have to provide all infrastructure to bring people to the hospital, this is an immense amount of money that many times is not considered.

Another point is the network of hospitals, and we call it in our group the Hospital Without Walls.

And so, I want to show you today some ways of how to master cost in hospital design, because this is the key for us in our experience for hospital design.

We see that, in a hospital, the cost of supplies are not as important as the labor cost.

Still, the people working is the major part of the budget, but if we look at it, we have that the labor costs, the secondary processes are only 70%, while the major goes really to the doctors and healthcare givers.

If we look at the breakdown of cost for cost materials, we see that primary care is still the primary cost.

Medical supplies is still the biggest part of the cost.

Then we have maintenance, housekeeping, administration, energy, food supply and other costs that is as well fees for consultancies.

And we see that the only place where real architects can interfere is place of energy, and energy represents 6.6% of 35% of maintenance costs.

Finally, it's on the overall budget round about 2%, and now you might ask why 2% its worth.

Well, it's the way where we can interfere as architects, where we can do a tremendous job, because we can bring down these costs by 50%, and nowadays in Europe, we are facing that energy prices go up three times the price before.

This is now represented nearly 20% of a hospital the energy prices.

Cutting this down is a tremendous achievement for a hospital to save costs.

I want to show you in three ways how we approach the cost issue in hospitals.

We have the green hospital approach in our office.

The lifecycle hospital that we were developing together with our partners, and then the Hospital Without Walls approach.

The master plans we are doing for big projects like here, it's a competition we were entering and winning in Astana for the expo 2017, and it was always when we do big master plans or big projects, we have a energy master plan behind to see how we can provide sustainable energy, and so fight climate change and help to master costs in the developments.

The same for project here at Kal Tak Fantasies, where we in Hong Kong as well provided a way how to provide sustainable energy, and cost savings and energy for the cool master plan.

We were putting this approach for the first time in the competition, and we want this competition for the hospital for Princesse Grace in Monaco, where we as well develop energy master plan, and show the client how he can cut down cost for energy.

The hospital is placed in the wonderful Bay of Monaco, where we have a wonderful site, and the site is cut down by a road.

It's an existing hospital, so it will be built in stages.

The hospital itself is around about 100,000 square meters, 400 rooms, and we have a whole site very innovative.

It should be a showcase in hospital design.

So, we wanted to promote photovoltaic, and you see where the helicopter platform.

It was aiming for the whole region besides its for the city of Monaco.

It was reaching the whole southern France.

It's situated on a very steep slope of a big hill going right into the water down.

We have a road crossing through the hospital, we have a logistic to parkings, and we have a lot of wards all facing the seaside where the secondary services are behind.

I run quickly through the plans, because this is not the major issue of today.

We had a portal-like management certification level, where managers come just to have a check up.

And on the other side, administration.

In the lower levels, we have the wards facing the seaside, and behind some offices for the doctors, and we had the psychiatric hospital a little bit hidden behind the wards, with a nice garden that is giving them free access, and we had the whole operation theaters behind on two levels, totalizing 15 operation theaters and delivery room, ICU.

Then, we had the outpatient department and the ER unit with the wards for the caregivers, and so the yard department, a wonderful gallery, and a wonderful Belvedere with a restaurant sitting here.

A view into this gallery, as we imagined it, and a view over the bay with the restaurants from the Belvedere.

This hospital is split in two levels, with a logistical level below, and we have green gardens and green facades to cool down and to fight the heat island effect.

Another big issue was we had very high end facilities for medical imagery integrated into the hospital as well.

Radiotherapy and nuclear medicine, and then all the logistical departments, like pharmacy and everything, was of course with robots in the pharmacy, and we had a independent robot-driven transportation system inside of the hospital.

Coming to the main issue of our hospital.

It was to develop a view how to create.

Of course, this hospital was created in stages, so it was planned till 2028.

But for us, the main issue was the wish of the French government to bring down energy consumption of buildings that still represent 43% of all energy consumption in France.

And so, they had the plan, and the COP25 in 2025 was confirmed, we want to cut down by four the energy consumption in our country.

We have a powerful tool, that's the HQE Haute Qualite environmentale, that is a certification label that helps us to get more sustainable buildings, and the number four level is energy management.

We wanted to focus on the energy management.

Where HQE lets help is in all social economical concerns.

It's only focusing on environmental aspects.

We have as well a very ambitious task to only have a 25 kilowatt per hour per square meter.

This is a very ambitious task for a hospital, and when we were looking at the energy task, the first one is to reduce energy demand of buildings by architectural design, limit the consumption, use of sustainable energy, and reduce polluting emissions into the atmosphere.

These are the four main tasks, and we do these environmental profiles.

We were pushing the task number four to the limit, so that we are beyond the certification, and as we look already in the competition, we were saying, "We want to reach the level of Swiss hospitals that are the benchmark in Europe," and we wanted even be twice as much better than the Swiss hospitals, and cut down by four the energy consumption of our hospital.

When we achieve and we look in on environmental gain, we see that how we place the building is the biggest impact.

And then, we have passive system like blinds.

They are costly, and they have an impact on cost, but less effect on the sustainable environmental gain.

While very active systems like photovoltaic had a very high cost, and finally a very small impact.

The first thing is then, we have to see how we can, by placing and making the right decision for the building, to place it in its environment.

We were looking at the site, and we were deciding to use the up winds in the evening to cool down the building.

We had to as well to open the building, so that the wind can go through the technical rooms and innovate perfectly our project.

We had to look at the sun studies, and we saw that of course we have a full south orientation, so we had to work on how to protect from the sun, and how our envelope design with the passage system we can optimize this.

We were looking, "Okay, we can make lodges."

The lodges will help not only to give patients a wonderful outside area of the patient room, but to actively protect from the sun.

But as well from the wind, because we can create a shelter.

And of course, we can actively use it in the summertime to heavily ventilate the lodge here.

And in wintertime we gain even from the sun, some energy to heat the room.

This way was so introduced into the room, and we were making these lodge here, getting wonderful access to the outside for the patients.

We see the facade that can open and close.

Like we put on clothes in winter, I can take them off in the summertime.

And so, we have a very rough facade that is even breaking the winds, so that we have less impact on the facade.

We were developing this facade with our facade designers, and we were of course trying to optimize and minimize the cooling loads we have in the rooms.

There was a lot of studies done for how to reduce the loads inside of the rooms.

Different rooms were analyzed, different orientations.

For every orientation, we were looking what will be the best way to develop and to protect from the sun, while allowing as well to have the daylight, and use daylight for most of the parts, and to have the right way to use the daylight?

Because not always we want daylight.

We were looking at different facades with different U values.

For different glass systems, and of course the facade is the most important part of building, having the biggest impact on transmissions, even if it's only a small part in the square meters of the building.

We had to look on different ways, and we were analyzing, and we found out that sometimes, things we didn't of course understand had a huge impact, like the side walls on each lodge had a very valuable impact on reducing the cooling loads inside of the building.

This way, we were developing our wards, offering the patients well-tempered environment where they can directly choose and interfere and actively participate to choose the right ambiance for their rooms.

We studied different parts of the building.

Here, we had the part in the lower part, where we had green facade, and we were trying to optimize using grades, using the plants and calculating what will be the best way to make this facade, and to have the best achievements, because we needed a better protection for the wards from daylight, because we had laboratories and pharmacy who are not part of the hospital that should be really exposed to too much daylight.

Then we had the wish to integrate as well in the operation theater daylight, but with a real heavy control not to have any bad impact on the light situation inside of the room.

This was giving us the opportunity to bring daylight with a controlled system of blinds and the double facade, so that we can be sure we have air proof airlock facade while we have absolute control of the daylight.

People in the operations here still have a view outside.

And as well for the emergency department, the ER unit, we had the same studies.

This was getting for us a very valuable analysis of the facade.

Then we have to split down the energy consumption.

We have to get the profiles.

What are hospital users in energy, and where are the big consumptions where we can interfere?

We found out that of course, cooling loads in summer are beyond everything that is impacting energy consumption in the hospital.

But we were as well amazed to see how much impact we have by humidification of air.

While heating the hospital, this is the record here, it's not as important as we imagined, and ventilation as well is not so big issue as we were thinking.

We were splitting off all this project in different.

And so, the hospital was really analyzed from department by department, and we were very amazed to see that still administration is the biggest consumer of our cooling loads.

We were doing this for different humidification as well, already shows that the big departments asking for humidification is the ICU and some other heavy integrated departments.

Very easily, we were as well looking for how to bring active systems like solar thermal collectors, and how to use them.

We found out as well that it makes perfectly sense to use them, because even on the weekends, the consumption of the hot water is high enough to justify to have a permanent production of hot water, because hot water and the solar thermal collectors, we cannot cut them off.

So, we needed to prove that we have a permanent demand for hot water to be able to use it.

We were using as well, and optimizing the way how to incline these solar thermal collectors.

The cooling terminals inside of the patient room was another study we were pushing very much forward to see how we can make the most energy saving cooling, and with the best comfort, and we found out that cooling ceilings are extremely efficient, and as well energy saving for patient rooms.

We were looking then, because many doctors said, "We don't believe that the cooling ceiling is very comfortable when someone's laying the whole day."

So, we were making very many thermodynamical studies to prove that the comfort of the patient is given filled with a cooling ceiling.

This is a view in how we imagine one of these rooms, and in the night with a view on the wonderful Bay of Monaco.

How we produce the energy.

And so, we were going, and as we are close to coastline, we were saying, "From 100 meters depth in Monaco, we have permanent 13 degrees of water temperature that we can use."

We have heavy need, even in summer it's very efficient to use this.

And so, we came up with an energy plan where we use the sea water to cool down, and we can use the cooling energy directly in the cooling ceilings, because we don't need very low temperatures.

Then, we had of course some chillers and some heat pumps to use for the more cold uses inside.

We had a tree generation, where we used bio ethanol biofuel to create steam, because steam seems to be the best way for anything to transport energy for the big demands of a hospital, in the hotel, or in the planching suite where we had in the laundry the big demand for.

We use steam, it's much better than using hot water, and we were using photovoltaic, of course, and as we said as well, the solar collectors.

This gave the opportunity to break down the energy consumption by half.

And so, we were analyzing and finding, by using seawater cooling, tree cool generation, solar thermal panel, solar photovoltaic, cooling ceilings, we have the active systems, but we reduced as well significantly the energy demand by increasing the performance of the envelope facade design, by improving daylight so we have less artificial light, limited solar loads by the better protection of the facades and all technical systems, to put them high performance, but as well to put them the possibility with the water, with air cooling to cool down, and to give up the energy they save.

We found out with the overall estimate of the hospital of 340 millions, we only needed investment of 3%.

3% met on the return of investment in 20 years.

Unfortunately, the client decided not to share our vision, and so this was the very sad story of this hospital, because the client decided 20 years is not enough and we are over budget, and so we want to shrink down the hospital, make it cheaper.

But looking now again at the energy savings we had, nowadays with the price going up three times, return of investment comes back to five years or six years, and this is practically nothing for a hospital, in the life cycle of a hospital.

Sadly, this wonderful hospital did not happen the way.

Now it's another hospital project, but still I wanted to show you this to understand how important it is to work on a holistic way on the hospital, and how sustainable hospital design is an important factor for the hospitals.

We have now a quick look at our lifecycle approach.

I want to show you we have a wonderful project in Strasbourg.

It's a medieval city, but in the 12th century decided to make a civil hospital, and it was built over the centuries.

When we were winning the competition of the hospital, we were very amazed to see this museum of all typologies of hospitals.

We created a machine for healing authority, right in the same industrial spirit we had.

If we look at the site, we have here from the 12th century now till the cutting edge new NHC hospital, whole collection of hospital design and layouts from old past.

The project, it's a very simple 500 bed hospital with 18 operations theaters.

It has all kind of services.

We call it in France MOC.

So, you have the child clinic, the pediatric clinic, you have cardiology, have all services, and we wanted it to be the most modern, and it was the first hospital in France integrating robots for the transportation system.

And so, the waters oriented to the south with a wonderful galleria all linked together.

Here, we see a link in the galleria that still has an industrial look, but brings some green, and it's a long way to walk, so people in hospital, especially patients, should have the opportunity to walk and to move.

We had the 18 operations theaters that we had of course in an industrial approach extension space integrated into the hospital.

This in order to create a hospital that it's future proof and can develop further.

Here's some views of this very huge hospital, a view on the helicopter platform.

But this was as well start of where we were a little bit amazed, because we were thinking we were making a flexible hospital.

But finally, with all typologies of hospitals that then developed from over the 14th century till today with the Hopital Monospace in France, for instance, we still have a problem with whenever it phases to come to integrate something new in the hospital.

And so, we were finding out that, when the professor were coming and saying, "We want to integrate imagery driven surgery," that our extension spaces were not fit for this, not the loads, not the height, and they were on the wrong place.

So, we decided to make a new building close by.

Again, we have a building that is not easy.

During a visit in Japan, we were seeing this Izu Shrine.

We were amazed, because they are building a shrine every 20 years, completely the old way.

They way the old temple was built, they built the new temple, and then they burned down the old temple in three years' space.

This space in the future will be the place where they built the new one.

What we were asking what is the specificity of the buildings of hospital?

Of course, it's a very complex program.

We have a lot of technical installation, we have a very challenging supply and disposal logistic.

There are very varying demands in the hospital.

Then there are challenges in the design of hospitals, like the specialization in medicine where you have a high demand on innovation coming the hospitals, so you have to always keep up with the innovation.

Then, you have the technological process.

You have the new desires of patients, who have their demands too, and you have an intensive collaborative use of space.

This means that, for instance, the patient room is not used only by the patient but by the doctor, by the healthcare givers, by the cleaning woman, and by the maintenance.

Everybody has a difference vision how this should look like.

Then, we have in hospitals big deficiencies are that of course we have that they're calling the envelope is a big issue, with that we have problems to reach the lifespan, that whenever we do changes in the hospital, we have to apply new regimentation comply to regimentations and building regulations.

There are big changes whenever we touch the shell, and the carcass of the buildings.

We have that room sizes are changing, they're getting bigger, especially patient rooms.

We have the different floor level and tides, and all this is meaning, like here in Valence, for a hospital where we are making the extension, we find finally always fragments of visions for a holistic hospital, for something that is the perfect shape, and it ends up in a big amalgam of mesmerizing, and units that are interconnecting, and we make them work.

But they will not work in a perfect way.

These upfront investments I was showing, like providing space to absorb things, will not work unfortunately, because the problem is that we cannot envision how things will look in 20 years.

These investments in providing space for future extension, most of the time it's kind of a future exercise, like we showed in Strasbourg in our hospital.

Then, the hospital has different life cycles.

They are parts of the hospital who have the very high technical parts of the lifespan of 10 to 15, 20 years, like operations theaters.

Then you have to change the technical floors, you have to change the whole machines.

Then you have outpatient clinics with a lifespan of 30 years.

You have an administration that even some wards can be 40 to 50 years of lifespan.

But this means that life cycle of the buildings and the contained services are not identical.

This means that the life cycle of the whole building complex will be determined by the unit with the shortest useful service line.

It means that, after 20 years, you're impacting your hospital, even services who functioning perfectly, because you have to refurbish another part of the building that has reached the end of its life cycle.

Especially if we think in hospitals about nesting everything of the functions together to make the short ways, and to have everything close together, and not considering the different life cycles makes hospital very expensive on a long run.

And so, we had some exercise here in Switzerland, with (indistinct), who is our hospital designer, and we were debating with him.

He had a project, and he was showing us from a hospital that was built in the 1930s, the Inselspital.

We were analyzing a little bit what happened within 10 years of running this hospital, how many big project changes were giving, how many projects were getting, like adding new floors, building a dialysis center, refurbishments, building floors and extensions on the rooftop, bringing new cabinets, bringing new functions in.

So, it was ongoing construction site.

A hospital is not the one time you design it and build it.

No, it will evolve after you design it, and it'll evolve if you don't have a vision.

It work exactly like all hospitals.

It will end up to be an agglomeration of different buildings that are tied together, but that they're all independently functioning and not functioning in a very efficient way.

It turned out, after 10 years of working on this hospital as a consultancy, we now found out that when they came and said, "Now, we want to make a new outpatient department in the south," that this was not anymore possible.

They reached the end of what they could do and how they could develop their hospital.

Therefore, we made an exercise and said, "Let's see these conversions, the renovations you are doing in an ongoing hospital that is still functioning, still giving care to all the patients.

You have lot of impact on your activity, because you are creating emissions of noise or dust.

You have especially to place services somewhere else."

So you have moving people.

A lot of performance.

All this is very expensive.

It's then not a more economical way if we can harmonize the lifespan of the hospital buildings with their useful life, to anticipate and avoid renovation or conversion and to have a more effective process.

Combining units.

The solution for us was combining the usage in a life cycle hospital approach that should be modular, respect the functionality and cost effect is not of internal processes and provide pickup areas for replacement the fallow land, so that you have the possibility to build up new possibilities, new facilities in the future.

And so, to turn something that is a dead end for future development in a lifecycle hospital.

This exercise we were doing and showing them, by going from the existing hospital and to bring up and build up slowly the new hospital in a more lifecycle way.

It means interlinking by a gallery different parties where the wards are always oriented to the valley, overlooking the valley.

And the backside, we have the different operation theaters and giving a new entrance to the hospital, so that we can slowly move old parts that can be demolished and integrated into the new lifecycle hospital.

We were bringing the mother child clinic here.

That was us freeing space.

Then we were bringing new wards and outpatient department and everything interlinked, allowing us slowly to move everything in the modular approach of the lifecycle hospital, and to free space for future extension on the other side.

And even integrating finally a gerontological center and the logistical center in the center of the hospital.

Transforming the hospital in something that is more future proof, and even providing space for future extensions in the hospital to accommodate new programs.

This is shown in an existing hospital.

We were making the exercise, and the Luxembourg government was amazingly adopting our way and inviting us for a competition for the lifecycle hospital approach, so that we can demonstrate how this would work.

And here, we see a life cycle hospital like we imagine it.

On the one side, the more factory life and industrial parts with a low life cycle, and on the other side, the building that will develop and stay for a long time with wards and administration building.

These hospital projects were going on, and we were debating, and it's an exercise that we are going in all our projects.

And so, we were as well after Luxembourg, where we were showing how this student can develop in the next 40, 50 years the hospital, we were invited to different projects in Morocco, where we had as well the chance to make competitions in Agadir.

We were invited as well in Germany, to participate in (indistinct) clinics competition, then in Rabat and others.

So, it was a nice experience, and still it's a very interesting way for us to work on the hospital.

What we have shown now was working on the initial cost and the operation cost, but now I wanted to show how we imagined the Hospital Without Walls.

We had a wonderful experience in Hong Kong, where we were invited by the YDA, Young Diabetic Action, to work on our Hospital Without Walls approach.

And we explained them that maybe they wanted to be in a hospital to make a place to give care for the children of the hospital, who have diabetes.

They were asking us, "How would you imagine this in the context of out of the hospital?

Because we are interested.

That square meter in the hospital is $5,000, while outside we can make it maybe better, and we are closer to our community, and we are closer to the people we want to get to."

We were making a sketch for them, and we were looking at different locations and we said, "In Hong Kong you have these wonderful factories, you can make something out of this with a minimum amount of money."

And so, we were giving them some images, they were making some factorizing.

After three months they were coming back to us and they said, "We have a place, the B17."

They found a place in an industrial site, and they said, "Can you make here the plans?"

We were looking at it, and we were showing, "We can make a kitchen so that people can learn how to cook the families for the children.

We have a little consultancy area, but this can be opened to host big gatherings where they have conferences.

We have the small office area, the playground, the library and all the sanitary and the storage."

This little exercise was going on for six weeks, and finally we put open the first YDA center in Hong Kong.

Well, we were amazed how quick it was and how cheap, because we built this for $80,000, and their rough estimate was for this in the hospital nearly $600,000.

We had really a chance to make this in a very quick way, and it shows and truths that healthcare doesn't need to be very heavy.

It can be very light, very quick, and can give satisfying results and much better impact, because they are amazed by the people who are coming that never came to the hospital.

The next Hospital Without Walls approach was of course during the pandemic, where we were looking and amazed how badly we were prepared for a pandemic.

And so, we were working on how to give in a container and prefabricated way, together with Turkish partners who were contracting us to work on mobile COVID pandemic treatment center.

And so, we were developing this, and we had as well the chance to be invited to make the competition for the French government that was launching the same competition with the same idea of having modular systems to treat people for COVID in pandemic situations.

This shows that there is a big demand, and a real now chance to implement Hospital Without Walls approach into our thinking, so that we should not focus anymore only on hospitals.

Well, 2022 as many of you know, was the year designed for health by the UIA.

And so, we had the chance to go and to see beyond the border what health means.

I think it was very important to say that health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.

It means every aspect of our life impacts our health.

And so, this is the social cost we are many times neglecting, and we were working on a healthy city with master plans, and we were proposing to implement a healthy city master plan into our project in Ganja.

It's a city in the Caucasus.

It's a 4,000 year old historical place.

And we were amazed to see the city, like all CIS cities, is city of contrast, where wonderful monumental spaces.

And then, on the other side, you have new settlements outside, sub-urban settlements were lacking public space, there's no public space, because the development of these cities cannot catch up.

The city cannot catch up with the quick development.

Things are going that we were giving them a master plan, where we tried to integrate as much as innovative elements that are lacking completely, like sport facilities, green parks, a way of creating green energy, and as well to bring a healthcare master plan for whole city.

And here, we see some visions like we were integrating a sport city.

Because sport is an important factor for life.

As well, having less stress in the city by having a better transportation system, a perfect public transport system, as well to integrate new visions for having green cities.

We are participating in the Green City action plan.

And as well to keep the historical heritage of the city, the work of the identity so that people feel connected with the community and to create space where the community and citizens can meet.

This is for us new approach of this year for the health city of Ganja.

Thank you very much for your attention.

- [Ray] Thank you, Thomas.

That was wonderful.

Beautiful project, well organized into your three areas.

Just terrific the way you walked us through those three different thought processes.

Are there those here in the studio today that have questions?

Do we have any questions online?

Thomas, I'm curious.

You've outlined three different approaches for us.

Which of those approaches offers the greatest challenge to you in communicating with a client to get them to do the right thing?

- [Ray] You still hearing me?

- Yes.

Yes.

I'm muted.

The most challenging was maybe still ongoing is implementing investments that are not immediately answering to the demands of the hospital.

Sustainability still is an issue.

If you debate with your clients to invest more money for a better facade, that is an upfront investment, but will turn out to be a big saving later on.

The life cycle approach, it's a very difficult thing, because people who are not involved in operation of a hospital over a long time, they don't see the interest, because it's a very difficult exercise where you have really to debate and to find the right way to organize your services.

But finally, if you have the right people, and if you have the right visionary, and this is the point, that's why I pointed out about Mr. Bismuth, because Mr. Bismuth was defending this architect.

He said because he was peeking out of the box.

I think this is what we need in healthcare, that we have people to think a little bit out of the box, and we have to challenge ourself as well as architects.

Therefore, I think it's a very important exercise to confront yourself with theoretical work, and I think about and go to the place and to build hospitals not the way you think they should work, but to build hospitals the way they work.

- Great answer.

Thomas, I really appreciate your mentioning the truth that every project that we do impacts the health of the people in it.

We should be mindful of that, and design with health outcomes in mind on every project, not just healthcare projects.

Thomas, we're out of time, but it has been a lot of fun hearing from you.

I appreciate you sharing your presentation with us and your beautiful projects.

Thanks so much.

We look forward to having you another time soon.

Bye bye.

- Thank you very much.

Bye.

(audience applauds)