Humanitarian architecture inherently embodies concepts of risk, with building designs reflecting perceptions of surrounding dangers and environmental threats. The spatial configuration of humanitarian facilities directly correlates with security assessments - the more violent the environment, the more likely operations occur behind reinforced walls, barbed wire, and metal-shuttered windows. However, architectural solutions have limitations, as some environments become too dangerous for any physical barriers to provide adequate protection.
The Médecins sans Frontières (Doctors Without Borders, MSF) hospital in Cité Soleil, Haiti, exemplifies this challenge. Originally designed in 2011 with earthquake resistance as the primary concern, the facility found itself a decade later confronting entirely different security threats as two rival gangs engaged in violent territorial battles directly outside its walls. The hospital's evolution illustrates how humanitarian architecture must adapt to changing risk landscapes.
When construction began in 2011, Haiti was experiencing one of the largest humanitarian interventions in modern history. The devastating January 12, 2010 earthquake that destroyed large portions of Port-au-Prince and killed over 100,000 people was followed by a cholera outbreak. The humanitarian response faced numerous scandals, including widespread inefficiency, sexual misconduct allegations, and the UN's importation of cholera without subsequent accountability or reparations.
MSF deployed extensively following the earthquake and cholera outbreak, treating 53 percent of the more than 200,000 Haitians infected with the disease. The Cité Soleil hospital opening was part of several new MSF facilities established during the post-earthquake period. Its original design prioritized earthquake safety, featuring single-story structures built from lightweight plastic materials to minimize crushing injuries in case of structural collapse during seismic events.
The hospital occupied a large rectangular site measuring 360 by 124 meters in a mixed industrial and residential area. During the 2010s, the facility specialized in burn treatment - a complex medical specialty requiring extended hospital stays, multiple surgeries, and strict hygiene protocols to prevent infection. Simultaneously, Haiti's political situation deteriorated dramatically, bringing unprecedented levels of gang violence.
Gangs have long influenced Haitian political life, beginning as small groups of lightly-armed individuals called "baz" in Créole. These groups functioned as conduits for political power and sources of neighborhood criminal control, channeling government resource distribution, defending territories from rival groups and police, organizing demonstrations, and ensuring proper electoral participation. Throughout the 2010s, gang numbers and strength increased significantly due to greater political instrumentalization, expanded high-caliber assault rifle smuggling from the United States, and new inter-gang alliances.
Cité Soleil had been gang-controlled since the early 2000s. Originally planned as middle-class factory worker housing, it rapidly became an impoverished slum where residents faced violence from both gangs and police while experiencing state neglect. Despite being only kilometers from Port-au-Prince's main airport, aid took over two weeks to reach the area following the 2010 earthquake.
In 2020, Jimmy "Barbecue" Chérizier formed the G9 alliance, a federation of twelve gangs, prompting Jean Pierre Gabriel ("Ti Gabriel") to create the opposing G-Pep alliance. Ti Gabriel previously controlled Brooklyn, Cité Soleil's central neighborhood. The rival alliances triggered intense combat for territorial control, with neither side achieving decisive victory. This resulted in G9 controlling central Cité Soleil while G-Pep held surrounding areas.
The area became effectively besieged, with all roads except one permanently blocked. The remaining route was dangerous and frequently closed during fighting. G9 cut electricity and water supplies to Brooklyn. Civilians were regularly targeted and killed during combat, with widespread sexual violence. The United Nations reported that in one six-month period, 262 people were killed, 285 injured, and four went missing, while hundreds of women and girls were raped - likely underestimated figures given UN access difficulties.
A retrospective mortality survey by Epicentre, MSF's epidemiology center, found violence was the leading cause of death in Cité Soleil, accounting for 40.9 percent of deaths overall and 57.7 percent in the south, the area most exposed to fighting. Within this violent environment, the MSF hospital occupied a strategic location. The sole road allowing Brooklyn residents to access the rest of the city passed by the hospital's P3 gate, while gates P1 and P2 opened onto G9-controlled areas.
This positioning allowed residents from both gang territories to access the hospital through different entrances, even though the P3 road frequently witnessed civilian killings and rapes. By 2020, the hospital had operated for nearly a decade, during which staff developed positive relationships with all local actors, including gang leaders. These relationships initially enabled continued operations within a relatively secure space despite dramatically increased area violence.
However, in February 2021, particularly intense combat between G-Pep and G9 focused around "Carrefour de la mort" (Crossroads of Death), located just 550 meters from the hospital's southwest corner. The fierce exchanges of high-powered weapons created significant stray bullet risks for the hospital. This risk was amplified by the buildings' poor ballistic protection - lightweight plastic construction ideal for earthquake safety offered minimal protection against falling assault rifle bullets.
Given burn patients' complicated needs and extreme transfer difficulties due to required sterile conditions, the hospital was deemed unsuitable for burn treatment. All burn activities were transferred to MSF's Tabarre hospital in a more stable area. While 2021 fighting occurred approximately half a kilometer away, 2023 saw the frontline advance much closer, with a fighting position directly outside the P1 gate marking the boundary between gang territories.
During previous years, MSF teams attempted to adapt the built environment to new combat-related risks by constructing concrete structures at key points. These included shelters for gate watchmen, driver and radio operator shelters, and safe rooms for staff and patients. However, these safe rooms couldn't accommodate the hundreds of daily patients and staff, and the site remained difficult to protect entirely due to its size and the numerous open areas requiring traversal between buildings.
Building comprehensive concrete structures was impractical due to construction scale requirements and because it would increase earthquake risks from falling masonry. On March 7, 2023, MSF teams determined the situation had become too intense and violent to continue safe operations. Hospital work was suspended while negotiations with armed actors proceeded. The facility briefly reopened March 22 before closing again April 7, remaining closed until mid-June.
During this closure, the hospital team conducted detailed stray bullet risk analysis, examining the facility and roof when safe to count impact sites. Sixty-five bullet holes were identified throughout the hospital, with approximately half at P1 (near the fighting position) and most others in building roofs, including the ward, intensive care unit, and operating theater. Thirty-five bullets were recovered from various locations, though the site's size and outdoor nature likely meant more bullets went uncounted.
Staff frequently reported hearing bullets pass nearby during fighting, whooshing through tree leaves and whistling past them. Notably, none of the recovered bullets had penetrated through materials into interior rooms. This evidence sparked organizational debates about whether and how to continue Cité Soleil operations, involving ground teams, Port-au-Prince coordination office logistics coordinators and mission heads, Paris security focal points, and Paris cell managers responsible for Haiti and other countries including Afghanistan and Palestine.
Discussions centered on multiple critical questions: Was continued staff and patient exposure to nearby intense combat risks reasonable? Which operations and medical benefits could justify those risks? What physical protection measures could enable continued activities? Which buildings were too dangerous versus potentially safe for use? Could a safer hospital location be found given citywide fighting? How much could gang protection assurances be trusted despite advancing combat?
Positions varied widely among participants, revealing different personal risk tolerance levels and different systems for evaluating work risk and value. Some believed the hospital's unique position serving populations under different gang control made it too valuable to relocate despite risks. Others saw this position as precisely why the hospital faced such danger and would never be safe during continued combat.
Some staff trusted that gang relationships would provide protection despite incidental risks, while others distrusted gang reliability. Additional discussions focused on hospital activities, which had been in flux since burn unit relocation to Tabarre, questioning impact levels and whether they justified team exposure. The ultimate solution was architectural in approach. Rather than completely rebuilding, teams changed building uses to provide better staff and patient protection.
In the original design, the inpatient department occupied a long, low building along the southwest site edge closest to Carrefour de la mort. Under the new configuration, this became a warehouse for "sleeping stock" - stored items not requiring regular access. Bandages and bedding replaced living human bodies in this most exposed building. These items had previously been stored with other pharmacy supplies in two GAPTEK buildings near P2, the gate furthest from most fighting.
These two buildings were repurposed as the emergency room and inpatient department, with consensus that their distance from main combat axes and slightly thicker walls would better protect occupants. A new concrete wall was constructed near the operating theater's exposed exterior for protection should it be reactivated, though surgical activities have not resumed since the April 2023 closure.
Certain solutions, including additional concrete walls or solar panel roof installation for extra protection layers, were not implemented due to impracticality, cost, or limited benefits. This activity concentration in a different complex section left many buildings in the more exposed half unused - a visible reminder of the hospital's reduced operational footprint and difficulties endured.
Many staff and local residents were anxious for the hospital to return to previous activity levels, both for increased service provision and to ensure continued operation with associated economic benefits from employment and service purchases. Reducing on-site services to minimize people exposed to risks meant that during heavy fighting periods, the hospital team was forced to risk transferring urgent patients to Tabarre for surgery, navigating active fighting and barricades manned by police and local people.
While architecture could not resolve deeper issues associated with working amid contemporary Haiti's violence, the Cité Soleil hospital's architecture became a lens for reading risk questions. Different building uses and functions became physical markers of varying risk approaches and conceptions. The fundamental question remains: How much danger should teams and patients face while MSF attempts to save lives? Given Haiti's continued violence, this question requires constant re-examination and re-answering, with terms and boundaries continuously shifting.
