A Position Paper: ‘Expect the Unexpected’

By Ronald L.Skaggs, Joseph G. Sprague & George J. Mann

Our country has suffered a tremendous unprecedented shock that has rocked the very foundations of our society. Plain and simple, we have been attacked by a virulent deadly disease. It has been a medical Pearl Harbor or World Trade Center tragedy, which are dwarfed by the COVID-19 pandemic. How can we defend ourselves against the unexpected? What have we learned, and how do we recover? What do we need to do? What can we do?

Note how our society had to change and adapt, after the Pearl Harbor and World Trade Center attacks. This pandemic likely will move up to first place in its traumatic impact on our society. Certainly, the mortality rate has mushroomed, as well as having a very negative impact on our economy. It caught us all off guard, and was totally unexpected.

Leading the defense

Our U.S. Public Health Service has to become more like the Defense Department and our Defense Department has to become more like the U.S. Public Health Service. An outbreak of disease anywhere is an outbreak everywhere. We have developed a global economy, corporations, communications, universities, airlines, military, global thinking but not global health. How can these other global initiatives work without global health? They cannot.

We just were not prepared. We need an integrated interdisciplinary approach to be properly prepared for all possible and imaginable natural disasters, tornados, tsunamis, cyclones, hurricanes, typhoons, floods, fires, pandemics, as well as for all possible shocks both biological and manmade accidents, radioactive accidents, military attacks, bioterrorism warfare and any other conceivable threats.

Clarity and continuity in decision making

We need a strengthened administrative structure that can quickly recognize and then legally organize a response to all kinds of unexpected disasters. To a great extent, our country was in denial when the pandemic got underway. Plain and simple, this even, was outside the frame of reference and experience of most Americans. Nevertheless, the results are here to stay with us.

We need to further develop community emergency plans that connect with state and federal agencies that are prepared for any possible scenario.

In 2004, Dr. P.K. Carlton, M.D., FACS, Lt. Gen.  USAF, (Ret) and former Surgeon General of the USAF, proposed the concept of “surge” hospitals to Texas A&M University’s College of Architecture, and initiated a collaborative exploratory research and design project that explored what a surge hospital should be. We give credit to his great humanitarian vision. Seventeen teams of students then presented their architectural ideas for surge hospitals to Dr. Richard Carmona, surgeon general of the United States on Dec. 1, 2004, at Texas A&M University.

We need an alternative system of health and hospital facilities that can handle sudden surges of patients in disasters, epidemics or other unforeseen events. Such surge health and hospital facilities need to be organized in every U.S. community. Examples of existing buildings that could quickly become surge health and hospital facilities include hotels, motels, high school gymnasiums, warehouses, churches, convention centers and other appropriate buildings.

However, buildings alone cannot save lives or heal. They need to have qualified medical, nursing and allied health staff prepared with beds, blankets, linens, food, water, medicine and medical supplies, caps, masks, gowns, ventilators, emergency power and security. Infection control is a key concept, and can help lower the death rate.

More research and development need to be done on special protective masks and clothing that caregivers must wear. We cannot risk losing vital health professionals to the extreme demands on them, both physically and emotionally.

We should not bring patients with known highly infectious communicable diseases into a hospital, which could bring the entire hospital down, taking patients, staff and families down, along with the downed hospital.

Developing a plan

Legal agreements with hotels, motels convention centers, sports arenas, high schools and community centers need to be reached ahead of time, so that flipping them into surge hospital facilities could be accomplished quickly and seamlessly.

Surge health and hospital facilities will need to be staffed. That staff could be organized as a surge health auxiliary, and include groups such as physicians, nurses, other allied professionals like qualified retired and qualified staff, so the existing health and hospital facilities are not overwhelmed and/or contaminated. We watched as medical staff has been overwhelmed and too many contracted COVID -19. One doctor in New York City contracted COVID-19 and, after recovering, committed suicide.

Planning for such unexpected events must begin on a grassroots level, but be coordinated with regional and statewide planning, neighboring states and other countries.

New planning, design & construction program

We will need a new surge program (similar to the Hill Burton program) for planning, design, construction, operation and maintenance of appropriate health facilities.

Sheltering-in-place orders need to be followed in a pandemic, or our entire population can be placed at risk.


We need to develop new guidelines for surge health and hospital facilities. This effort needs to be coordinated with experienced groups, including American Medical Association, American Nurses Association, American Society for Health Care Engineering, Facilities Guidelines Institute, American Society of Heating, Refrigerating and Air-Conditioning Engineers, among others, as well as universities and architectural and engineering firms.

Ventilation and air exchanges

One of the most important areas to focus on, in both existing health facilities and proposed surge health facilities, relates to fresh air circulation and exchanges so the virus is not spread throughout a health facility, thus contaminating it. Experienced mechanical engineers who understand healthy airflow is vital to the success of the team.

Technology utilization

The experience of not having enough ventilators on hand is a case in point. Another example is the importance of telemedicine in patient care, whether in a densely populated area or in a remote area. Mass testing for COVID-19 must happen quickly, and new technology can make that happen. Perhaps mobile phones or smart watches could be developed to detect when one is near a person who is infected.

Establish an interdisciplinary surge health and hospital facilities taskforce

An interdisciplinary taskforce should be assembled to undertake further development of the surge health and hospital concept. It should consist of representative agencies such as those listed above.



What we propose needs to happen—as quickly as possible—as we are woefully unprepared for future pandemics and disasters, or even the likely resurgence of COVID-19.

As we have spent billions of dollars on developing defense systems to prevent future Pearl Harbor and World Trade Center events, we need to rethink the defense and health of our people, in the context of new threats, and invest accordingly.

Author: Ronald L.Skaggs, Joseph G. Sprague & George J. Mann
Ronald L. Skaggs, chairman emeritus, HKS Inc., FAIA, FACHA, FHFI, LEED AP, is an adjunct professor of architecture at Texas A&M University. He can be reached at rskaggs@hksinc.com. Joseph G. Sprague, FAIA, FACHA, FHFI, is a former principal and senior vice president, HKS Inc.; past president, FGI Facility Guidelines Institute, American College of Healthcare Architect and the AIA. He can be reached at jsprague@hksinc.com. George J. Mann, architect, AIA, The Ronald L. Skaggs, FAIA, endowed professor of Health Facilities Design, College of Architecture, Texas A&M University and founder and advisory board chairman of the Resource Planning & Development Group. He can be reached at gmann@arch.tamu.edu.

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Posted May 14, 2020

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