Humanitarian architecture always carries within itself an idea of risk. The spatial configuration of the buildings that humanitarianism is practiced within reflects a perception of the surrounding environment and the dangers that it might pose. The more violent the environment, the more likely the work is to take place behind thick walls topped with barbed wire and windows reinforced with metal shutters. Yet design cannot mitigate all risks: at some point, the surroundings might become too dangerous for any walls to protect against. Of course, the physical layout of any humanitarian institution, like a hospital, is only one part of how risk is managed: equally, if not more, important are the relations that one has with armed actors and other important members of the community in the area in which one is working, as well as the usefulness of the services that are being provided. However, discussions about the construction and use of buildings can, in some cases, become an important cipher for how the management of risk in a project is viewed more generally. One of those cases is the Médecins sans frontières (Doctors Without Borders, MSF) hospital in Cité Soleil, Haiti, which was initially designed with the risk of an earthquake in mind but found itself, a decade later, contending with very different questions of physical protection as two gangs battled outside its walls.1
When the hospital was first built in 2011, Haiti was the site of one of the largest humanitarian interventions in contemporary history. The huge earthquake that flattened large parts of the capital, Port-au-Prince, and killed more than 100,000 people on January 12, 2010, was followed by a cholera outbreak. The humanitarian mobilization was dogged by scandal: from the inefficacy of large parts of the response, issues of sexual misconduct, to the UN’s importation of cholera and its subsequent failure to admit responsibility or make reparations.2
Immediately following the earthquake and the subsequent cholera outbreak, MSF deployed massively: the organization treated 53 percent of the more than 200,000 Haitians who were infected by the disease.3 The opening of the hospital in Cité Soleil was one of a number of new MSF-run facilities that marked the post-earthquake period, and its design reflected the risk that was still the freshest in everyone’s mind: that of another earthquake. Consequently, the hospital was designed as a series of single-story structures constructed from lightweight plastic material that would minimize injury were there to be an earthquake powerful enough to cause structural collapse. The site of the hospital was a large rectangular lot, 360 by 124 meters, in a mixed industrial and residential area.
The activities of the hospital evolved during the 2010s to become specialized in the treatment of burns—a complicated specialty that involves long hospital stays, multiple operations, and very strict hygiene conditions to avoid infection. Concurrently, the political situation in Haiti was also evolving, bringing with it vastly increased levels of gang violence. Gangs have long been a feature of Haitian political life. They started as small collections of lightly-armed individuals known in Créole as a baz. The baz acted both as a conduit of political power and a source of criminal control within each neighborhood. They channeled the distribution of government resources, defended the neighborhood from rival groups and the police, organized and participated in demonstrations, and ensured that the neighborhood voted for the “right” party during elections.4 During the 2010s, the number of gangs and their strength greatly accumulated in a climate of their increased instrumentalization by political forces, expanding smuggling of high-caliber assault rifles from the USA, and creating of new alliances amongst them. 5
Cité Soleil had been controlled by gangs since the early 2000s. Although it had originally been planned housing for middle-class factory workers, it had rapidly become an impoverished slum whose inhabitants were subject to violence by gangs and the police and neglect by the state. It took more than two weeks for aid to reach the area after the 2010 earthquake, despite being just a few kilometers from Port-au-Prince’s main airport. In 2020, the formation of the G9 alliance, a federation of twelve gangs, by Jimmy “Barbecue” Chérizier, led to the creation of an opposing alliance, G-Pep, by Jean Pierre Gabriel, a.k.a. Ti Gabriel. Before this, Ti Gabriel controlled Brooklyn, the neighborhood at the heart of Cité Soleil. After the two alliances were created, intense combat started for the control of the area, with neither side able to decisively impose their control. This led to a situation where the center of Cité Soleil was controlled by one group, and the surrounding areas by the other. The area became effectively besieged, with all roads to the outside—apart from one—permanently cut off. That sole remaining route was dangerous and often closed during fighting between the two groups. The G9 cut electricity and water into Brooklyn. Civilians were often targeted and killed during fighting, and the use of sexual violence was rife. The United Nations reported that in one six-month period, 262 people were killed, 285 injured, and four reported missing, in addition to “hundreds” of women and girls being raped, though these numbers are likely an underestimate given the difficulty for the UN to access the area.6 A retrospective mortality survey carried out by Epicentre, MSF’s epidemiology center, found that violence was the leading cause of death in Cité Soleil, with 40.9 percent of deaths being caused by it. That figure rose to 57.7 percent of deaths in the south of Cité Soleil, the area most exposed during the fighting.7
Within this new, violent environment, the MSF hospital found itself located in a strategic location. The one road that people from Brooklyn could use to access the rest of the city ran past one of the hospital’s gates, P3. The two other gates, P1 and P2, gave out onto areas controlled by the G9. This meant that people from areas controlled by either of the two gangs could access the hospital, using different doors, even if the road by P3 was often the scene of killings and rapes of civilians from Brooklyn.
By 2020, the hospital had been open nearly a decade. Over this period, the team had developed good relations with all of the local actors, including gang leaders. Despite the drastic increase in violence in the area, this led to them being able to keep open, to a certain extent, a secure enough space to work in. In February 2021, however, a particularly intense period of combat between G-Pep and G9 focused around an area called “Carrefour de la mort” (“the Crossroads of Death”), which is located just 550 meters from the hospital’s south-west corner. Given the intensity of the exchanges of fire, and the power of the weapons being used, there was a significant risk of stray bullets hitting the hospital. The gravity of this risk was increased due to the poor protection offered by the construction of the buildings. Lightweight plastic, while ideal for mitigating the risk of crushing injuries in an earthquake, offers little protection from an assault rifle’s stray bullet falling from the sky. Given the complicated needs of burns patients, and the extreme difficulty to move them given the hygienic conditions that are needed to prevent infection, the hospital was no longer judged suitable for their treatment, and all burns activities were transferred from Cité Soleil to another MSF hospital, Tabarre, which was situated in a more stable area.
While in 2021 the fighting was around half a kilometer away, 2023 saw the frontline move even closer, with a fighting position just outside the hospital’s P1 gate, marking the limit of one gang’s territory and the beginning of another’s. This meant that during fighting, the hospital was in the firing line, even if it was not a target of the gangs themselves. During the previous years, MSF teams running the hospital tried to adapt its built environment to the new risks associated with the fighting by planning and constructing new concrete structures at key points. These included shelters for the watchmen positioned at each gate, a shelter for the drivers and for the radio operator, and safe rooms for staff and patients. The fact remained, however, that these safe rooms were not big enough to hold the hundreds of patients and staff present each day, and that the site was difficult to protect in its entirety. Its size, surface area, and the number of buildings meant that moving between different parts of the hospital complex required crossing large open areas. At the same time, it was impractical to consider building concrete structures to house all parts of the hospital, partly because of the scale of the construction required, and partly because it would quickly have increased the risk for staff and patients from falling masonry in the event of an earthquake.
On March 7, 2023, MSF teams present in the hospital judged that the situation had become too intense and too violent to continue to run operations safely. Work at the hospital was suspended while negotiations with the armed actors proceeded. The hospital briefly reopened on March 22 before closing again on April 7; a closure that would last until mid-June. During this time, the hospital team worked on a detailed analysis of the risk posed by stray bullets. This involved going around the hospital and up on the roof (when it was safe to do so) to count the number of impacts. Sixty-five bullet holes were identified at various points around the hospital, with around half at P1—the gate next to the fighting position—and most of the rest in the roofs of different buildings, including the ward building, the intensive care unit, and the operating theatre. Thirty-five bullets were recovered from various points around the site. However, given the site’s size and the fact that it is largely outside, it is likely that more bullets fell into the hospital grounds without being counted. During fighting, staff often reported being able to hear bullets passing close by, whooshing through the leaves of trees and whistling by them. None of the bullets that were found, however, had traversed through the material and into the interior of the rooms themselves.
Thus began a debate between different parts of the organization about if and how to continue working in Cité Soleil. These discussions happened between the team on the ground; the logistics coordinator and head of mission in the coordination office elsewhere in Port-au-Prince; the security focal point in Paris; and the cell manager in Paris who was responsible for Haiti, amongst a number of other countries such as Afghanistan and Palestine. There were a series of different questions being discussed. Was it reasonable to keep exposing staff and patients to the risks associated with such intense combat in close proximity to the hospital? Which operations—and therefore which medical benefit for the population—could justify those risks? Which physical measures of protection could be put in place in order to allow some activities to continue? Which buildings were too risky to use, and which might still be used safely? Could another, safer, location for the hospital be found, given that fighting was becoming generalized in the city? How far could we trust the assurances of protection that were being given by the gangs, despite the fighting advancing, becoming uncomfortably close?
Positions differed widely amongst the interlocutors, revealing not only different personal senses of which risks were acceptable, but also different systems of judging the risk and value of the work that was being done. Some people thought that the location of the hospital, which allowed it to serve the populations living under the control of two different gangs, meant that it was too invaluable to move, despite the risks. Others saw precisely that position as the reason why the hospital was so at risk and thought that it would never be safe for as long as the combat continued. Some staff thought that the hospital’s relations with the gangs meant that it would always be afforded some level of protection, even if incidental risks would remain, while others thought that the gangs could not be trusted. Other discussions hinged on the activities of the hospital, which had been in flux ever since the burns unit had been moved to Tabarre, with questions about what kind of impact it was having and whether that justified the exposure of the teams.
In the end, the solution found approached the architectural. While not rebuilding the hospital totally, the teams changed the use of a number of buildings in order to try and afford more protection to staff and patients. In the hospital’s original design, the inpatient department was situated in a long, low building along the south-west edge of the site, the edge closest to Carrefour de la mort. Under the new configuration, this became a warehouse for sleeping stock—items that are kept in store but do not need to be accessed regularly. Bandages and bedding—instead of living human bodies—were put in this most exposed building. These items had formerly been held along with the rest of the pharmacy in two GAPTEK buildings next to P2, the gate furthest from the majority of the fighting.8 These two buildings were repurposed as the emergency room and the inpatient department, with consensus being that their distance from the main axes of combat and their slightly thicker walls would better protect those within them. A new concrete wall was built a short distance away from the exposed exterior of the operating theater to protect it should it be reactivated, yet surgical activities have yet to restart after the closure in April 2023. Certain solutions, such as the construction of more concrete walls or the placing of solar panels on the roofs of some exposed buildings to provide an extra layer of protection, were not taken forward because of impracticality, cost, or limited benefit.
This concentration of activities in a different part of the complex left many of the buildings in the more exposed half of the site unused: a visible reminder of the reduced footprint of the hospital’s activities and the trouble that it had undergone. Many staff and local people were anxious for the hospital to return to its previous levels of activity: not only so that more services could be provided, but also to ensure the continued running of the hospital and the economic benefits it represented in terms of employment and purchase of services. In addition, reducing the amount of services offered on the site—to reduce exposing the amount of people working or being treated there to risk—meant that during periods of heavy fighting, the hospital team would be forced to risk transferring the most urgent patients to Tabarre for surgery, running the gauntlet of active fighting and barricades manned by police and local people.
The architectural was unable to resolve the deeper issues associated with trying to work in the violence of contemporary Haiti. Yet, the architecture of the hospital in Cité Soleil became a lens through which the question of risk could be read. The use and function of different buildings became physical markers of different approaches to and conceptions of risk. How much danger should teams and patients face in the process of MSF trying to save their lives? Given the continued violence in Haiti, this is a question in a constant process of being re-asked and re-answered, its terms and boundaries constantly shifting.9
The author was project coordinator for MSF in Cité Soleil from August to November 2023 and April to June 2024.
See Justin Elliott et al., “How the Red Cross Raised Half a Billion Dollars for Haiti and Built Six Homes,” ProPublica, June 3, 2015, ➝; Damien Gayle, “Timeline: Oxfam Sexual Exploitation Scandal in Haiti,” The Guardian, June 15, 2018, ➝; and Emmanuel Baron et al., “The Origins of the 2010 Haiti Cholera Outbreak,” Humanitarian Alternatives, March 2024, ➝.
Cholera Outbreak OCG E-Cell response in Haiti, 2010-2011, MSF, ➝.
Chelsey L. Kivland, Street Sovereigns: Young Men and the Makeshift State in Urban Haiti (Ithaca, NY: Cornell University Press, 2020).
“Haiti : A Path to Stability for a Nation in Shock”, International Crisis Group, September 30, 2021, ➝.
The Population of Cité Soleil in the Grip of Gang Violence, Office of the United Nations High Commissioner for Human Rights (OHCHR), February 2023, ➝.
Retrospective Estimate of Crude Mortality and the Level of Violence Suffered by the Population of Cité Soleil, Port-au-Prince, Haiti, Between July 2022 and August 2023, Epicentre, November 2023, ➝.
GAPTEK, ➝.
“Haiti: Violence and Police Threats Force MSF to Suspend Work in Port-au-Prince,” MSF, November 20, 2024, ➝.