This interview was conducted by Jon Shaffer on behalf of the Boston Network for International Development and first published on 8/14/2017.

JON: Obviously I have gotten to know you a bit over the last few years and I am quite familiar with your work especially in connection with Partners in Health (PIH), but I wonder if we could maybe start fairly broadly, and I would love to know a bit more about you, Jim, and what your background is, where you grew up, what has influenced you, and how you, as someone with a construction background, found yourself invested in global heath and international development.

JIM: Right, so, I grew up in Boston/Cambridge and my family, my mother in particular, was very progressive politically, especially for the time, which had a great influence on our whole family. I am the youngest of four and most of my siblings have gone into some sort of social or political action work. I ended up on a different path. I was very focused in high school and college initially on playing sports and having fun. I started at Brown University and lasted almost one semester, and then dropped out and played hockey on a minor league team for a year and a half. I was then accepted to Amherst College and went there and lasted a year and a half there! At the same time, I met Karen [my wife and co-founder of the Ansara Family Foundation] and found myself back in Boston needing a job, and talking my way into work as a carpenter. This then started a long adventure in construction for me. Very quickly I began working for myself doing small projects in Dorchester and Roxbury and started a little company which became a little bigger and eventually grew to become a very large company, Shawmut, which we sold in 2006 to the employees. Our family had had a small foundation which we started in 1999 but, with the sale of Shawmut, we took half the proceeds from that sale and started a much larger philanthropic foundation.

Also, we had adopted 4 children, 3 from South America and had traveled a lot, and especially throughout Latin America, and had become much more involved in international development. My wife Karen had a background in international development which began at Wellesley where she went to college. My interested in international development really came from our travels and from my children. I began to think about key issues of women, children, poverty and equality which is how Karen and I began to shift our focus from domestic giving to a more international focus.

JON: I am interested to know a bit more about how Build Health International came to be, it makes sense and I definitely understand the progressive roots and the interest in international engagement but Build Health International in particular, how did that originate?

JIM: For many years my wife Karen was involved with Oxfam America where she worked very hard on a capital campaign. Through Karen’s work with Oxfam, we met Cate Oswald and Paul Farmer and others involved in an economic development project in the Central Plateau of Haiti. In traveling to Haiti, I was really shocked by the level of poverty, injustice and inequity. At this time I was no longer running Shawmut and was really trying to find something to plug into that was of real value. I had tried a number of things – boat building, fishing, etc. – but it was sort of indulgent and wasn’t adding a lot to the world. I was really looking for something deeper in which to become involved and make a significant contribution. Then, in the summer of 2009, Dr. David Walton from PIH called and said PIH was building a community hospital in Mirebalais in Haiti’s Central Plateau. David explained that my background in construction could be of great help for the project, after which I immediately became involved. I then started traveling to Haiti in September of 2009 with David working on plans for what was then a 100-bed hospital in Mirebalais. Then…in January 2010, the earthquake struck in Haiti, and everything changed.

So that is how I became involved in PIH and in Haiti. The hospital in Mirebalais was finished in late 2012 and officially opened in May 2013. At that time, I began thinking I was going to be a part-time volunteer who would maybe travel to Haiti once a month. But, over the course of the Mirebalais project, I didn’t realize I was going to be essentially living in Haiti and building a team of people who would work together to complete the project. I often say it would be a completely separate interview to discuss the process experienced in the Mirebalais project and touch on the mistakes and lessons learned which were numerous, but very helpful. The entire project was a very unique situation.

As we continued work in 2011, Haiti was still very much in the vortex of the earthquake. There were really good and bad parts of the Mirebalais experience, but it was a very unique way to learn how to approach building in such a unique environment with a very distinct set of circumstances at play. The project was funded and collaborating with David [Walton], who had worked in Haiti for so long, was a really direct way in which to learn, and re-learn, everything I thought I knew about planning and design and construction and hospitals. I also had to quickly unlearn ways in which we had operated at my company for so many years. I had an unusual background where I had started my career in the building trades during which time I gained direct hands-on experience. I then had experience running a large company which provided another set of skills in terms of management and project overview. As it turned out, I was also uniquely well suited for the work we were doing in Haiti – because I had been an electrician, plumber and carpenter and had also worked on large-scale projects as well, I could see the overall project from both the macro and micro levels.

JON: So how did you go from constructing the Mirebalais hospital, a huge endeavor with many challenges and many successes, to founding Build Health International and creating the organization that it is now?

JIM: My plan was to finish the Mirebalais hospital in the spring of 2013, stay for the inauguration in May of 2013, and then re-retire. I was thinking to continue working with PIH as a consultant on different projects. However, we came to the realization that there was a lot more work to do in Haiti for PIH, a lot more to do at Mirebalais, and so much more to do in the rest of the health care delivery system within Haiti overall.

We had also learned so much, and survived so many mistakes and missteps that I felt like we couldn’t let those lessons learned go to waste. At the same time, other organizations working in Haiti, like the Saint Boniface Haiti Foundation were coming to us for help. These organizations were telling us that they just couldn’t figure out how to move forward on infrastructure, planning, design, and construction to ensure their essential health care delivery programs could be executed in the most impactful way possible. On the surface Mirebalais is such a big success, there are a lot of things I’d do differently, but to people looking from the outside, it’s sort of unbelievable. Here’s this huge hospital that was done so quickly for comparatively far less cost than other big development projects and, from that, other organizations were hoping to learn how to move ahead with their own projects.

By December of 2013, the team that had worked on Mirebalais had sort of disbanded, a few people had gone to work for PIH and I was continuing to help in directing them. Eric Benson [Build Health International’s Director of Construction and Senior Project Manager] was working at Saint Boniface with me at this point but I had no office and we had no infrastructure, no team. Carroll Huss [Build Health International’s Director of Internal Operations and Finance] who had worked with me on the Mirebalais project was interested in continuing the work as well, so that was really the genesis of Build Health International. From there, we rented a little office and warehouse in Beverly and began working as BHI in early 2014. At that point, we were still working as the infrastructure arm of PIH which continued until about a year ago. Since then, BHI has really taken on a life of its own.

JON: It seems like it! I wonder if you could talk about some of the other projects you have been engaged with, and what else you are excited about within Build Health International.

JIM: During 2015, BHI was pretty well focused on doing work almost exclusively for PIH and Saint Boniface, with the majority of work concentrated on PIH in Haiti, Malawi, and West Africa. For example, we helped organize a logistics team during the Ebola response. During this time we also had people consistently reaching out to us for help. We continued working with St. Boniface and experience success replicating what we had done in Mirebalais and improving on it. We focused on how we could even further improve, while also simplifying, the facilities we were constructing, looking at sustainability, not just in the green sense, but from an operations and maintenance management perspective. This extended to work on renewable energy sources, especially in Haiti where energy is such a huge operating expense. We continued to take lessons learned from Mirebalais, such as best practices for operating budgets, and examined ways to challenge preconceived notions of building in resource constrained settings. By looking at ways to build ‘less’, we could examine impact on both budgetary planning and also facility longevity, allowing resources to be allocated to towards maintenance and repairs, rather than just on the initial cost of the capital investment. These are certainly challenging, but important, conversations to have.

JON: It’s almost unimaginable, it’s a huge amount of work and really incredible to hear the breadth of it, honestly. I am interested to know what your view is on the broader field of global health construction and infrastructure. Obviously, players like the World Bank and USAID have some funding and have done infrastructure projects in the past, but do you see other organizations perhaps taking on the work of designing and building appropriate health oriented infrastructure?

JIM: That is a very good question and a very important one. Within the sector it appears there are two extremes…there are the large organizations such as the USAID contractors. There seems to be a struggle to clearly define the role of these companies in terms of mission and ability to deliver sustainable facilities that meet the needs of the communities in which they are constructed. That then becomes one type of international development delivery in which European and North American style hospitals and clinics, which are often very expensive capital costs and usually don’t have much funding for sustained operating budgets, become the norm in places like Haiti. As it happens, the buildings constructed in this model don’t really end up being sustainable for geographic locations like Haiti, given its climate and the feasibility of continued operating support. We have certainly experienced some of these same challenges in our past projects, and have learned from our experiences as we try to match the capacity of the community in which we’re working with the scale of the project.

So there is a huge void between the widely accepted status quo, and what BHI is trying to address. There are definitely other organizations also trying to fill this void. Organizations like MASS Design are addressing the design and architecture challenges – BHI is currently working with MASS Design on a number of projects such as Redemption Hospital and JFK Hospital in Liberia. Another organization, Construction for Change in Seattle, is a spinout from a foundation working with PIH on projects in Malawi. And there are organizations such as Building Goodness who BHI is working with in Haiti. The central point which I keep returning to is that if you amass all of the work done by these various organizations, it can still feel that the work is only a tiny drop in the bucket of what is needed. There are thousands of facilities globally (in places such as Haiti, Sub-Saharan Africa, parts of Asia, etc.) which are operating in rapidly declining conditions and are in need of equipment, infrastructure, running water, sewage, improved ventilation systems and so on.

Keeping all of this in mind, one of the larger scale questions that I am always trying to address is: beyond the immediate work we do, how our organization Build Health International can have greater, more direct impact. I recently turned 60 and was reflecting that if I work like a maniac for another 20 years until I am 80, I still really believe we will only accomplish a tiny fraction of the larger scope of the work that needs to be done. So, the continuing challenge is to try to figure out how to capture what we are learning in each of our projects and disseminate this information to help other organizations leverage their impact as well. To this end, we are currently working with a number of universities on a range of projects so that students at the forefront of their academic training can begin to interface with ideas of best practices in architecture, engineering, design and so forth. We are also just finishing a pilot project examining the Emergency Department at Mirebalais where Drs. Reagan Marsh and Shada Rouhani from PIH just did a presentation at a national emergency medicine conference around that project and what we have been doing. BHI has also started a pilot project that we are calling, for lack of a better title, the Mirebalais Learning Project, in which we are documenting the vitally important lessons learned from Mirebalais as well as the other facilities in which we have been involved. Rather than sort of just celebrating what we did right, it is so important to really look at what could have been done differently and learn from those challenges moving ahead.

JON: It is a fascinating thing. I mean, how do you digest the deep lessons that you all have learned along the way while continuing to pioneer this work to galvanize more support and encourage more people to take it on. It is a really fascinating challenge. As we wrap up, it would be great to learn a little about the BHI outlook as you move ahead into the future.

JIM: Certainly a great question – I think at this stage looking ahead, BHI is in a unique position to continue pushing forward. We will continue focusing on individual projects while also contributing to the larger conversation about health care delivery, infrastructure frameworks and ways in which building and design can impact successful outcomes. Together with our partners, we are certainly looking forward to this next phase of Build Health International’s evolution.