by Gary Cohen and Robin Guenther
Gary Cohen and Robin Guenther propose a new approach to healthcare, moving away from a treatment centered approach to a 360 degree approach where environmental factors are considered in the cause of health issues and in the contribution to patient healing in health care facilities. Looking at trends in ‘green initiatives’ they propose new approaches to healing both ourselves and the planet through our practices.
One of the greatest challenges facing humanity in the coming decades is the reinvention of the relationship between industrial civilization and the environment that sustains it. The healthcare “industry” itself is a major industrial enterprise—in its quest to heal it embodies all the same contradictions of an industrial system powered by fossil fuels and toxic chemicals. It is a significant source of pollution and related public-health impacts. In the context of this larger reinvention, the role of healthcare needs to be transformed and enlarged. Not only do we need to heal individual patients, but also the surrounding environment and the communities that are served by health care delivery systems.
This disequilibrium must be rectified at a scale that matches the social and ecological crises facing the planet. Increasingly, the healthcare sector must be viewed as a key component in actualizing this transformation. The healthcare industry has both the scale to exert upstream leverage to reinvent material supply chains around sustainability, and the downstream influence on citizens to induce fundamental behavior change toward healthier, more sustainable lifestyles.
CATALYST Insight: Health care should place an emphasis on design solutions for preventive care as opposed to treatment.
How will healthcare be “reinvented” for this important global catalyst role? First, health care professionals around the world must be educated to understand the importance environmental conditions in disease onset; second, the health care sector should “clean up its house” by reducing its environmental and public-health footprint; third, the enormous purchasing power of health care should be harnessed to drive markets and create stimulus for greener energy, greener chemicals, and safer products and technologies. Finally, health care leaders must be activated to advocate for broader societal policies which increase wellbeing and are more protective of both humanity and the ecosystems that sustain all life.
Identify: from your industry how are you affecting global warming?
Understand: recognize what items within your enterprise can be modified.
Calculate: be aware of how any modification will impact the triple bottom line.
Apply: set up a plan of implementation having in mind your resources, time, budget and human power will be of major influence.
Evaluate and maintain: measure the impact at different levels.
Communicate: be clear with your message, involve as much as possible companies from your industry. Inform them about your processes and results.
The ‘green tsunami’
One can barely move in contemporary culture without encountering “green initiatives.” Mainstream media are relentlessly reporting on environmental leaders and laggards, and – industries that are slow to respond are increasingly vilified. Three distinct but interconnected factors are propelling this movement: mounting climate change concern, increasing scientific linkages between environmental degradation and human/ecosystem health, and global resource competition. Together, these issues will change the way both life and business are conducted. They will have profound impacts on healthcare delivery—as each of them in turn impacts human health. Moreover, these factors are fundamentally changing economics as previously “externalized” costs to society are monetized and valued.
CATALYST Insight: Shifts towards more environmentally conscious healthcare models will produce economic benefits.
First, there is growing scientific consensus around climate change impacts and the need for rapid global action to reduce greenhouse gas emissions associated with the burning of fossil fuels. NASA scientist James Hansen writes: “We have at most ten years – not ten years to decide upon action, but ten years to alter fundamentally the trajectory of global greenhouse emissions.” The building sector is by far the largest emitter of carbon, outpacing both transportation and industry. U.S. Energy Information Agency data (EIA 2003) rate acute care hospitals the second most energy intensive building type, just below food service. The data show that hospitals use twice the energy of commercial office buildings. Across the United States, in the absence of federal action, states and municipalities are enacting legislation aimed at achieving rapid reduction of greenhouse gas emissions through public transportation investments and green building programs. In 2006, Architecture 2030 launched the 2030 Challenge with the goal of achieving carbon neutrality in the built environment by 2030. Soon after, the American Institute of Architects adopted the challenge as its own, who spread the word to their 80,000 member base. At the same time, the healthcare industry is just beginning to articulate the impact of climate change on healthcare services delivery. As average temperatures rise, heat island impacts in dense urban areas will exacerbate chronic respiratory conditions in the elderly and children. More extreme weather events – hurricanes in coastal southeast, tornadoes and floods in the Midwest, fires and drought on the West Coast – will require a more resilient emergency care infrastructure capable of delivering potable water as well as healthcare. Grid reliability is likely to continue to be an issue in unstable energy markets.
“The data show that hospitals use twice the energy of commercial office buildings.”
The science linking industrial chemicals with human health impacts continues to provide new information about our toxic body burdens – ranging from the effects of low-dose exposures on both a developing fetus and young children to the cumulative impacts on people and wildlife of an environment rife with persistent bio-accumulative toxic industrial chemicals. The recent market reaction to bisphenol A (BPA) in Nalgene athletic water bottles and baby bottles – in which products literally disappeared from stores in a market stampede – is only one of a growing number of consumer product issues around toxic chemicals. In the medical device markets, movement away from PVC devices containing DEHP plasticizers represents a similar adjustment. This simple idea: “imagine a cancer center constructed without materials that contain known or suspected carcinogens, or pediatric clinics without asthma triggers,” is driving market transformation of building materials and medical devices. The linked movements of “green chemistry,” “clean production,” or “cradle-to-cradle thinking,” are ushering in a materials revolution that is producing a range of alternative healthier products. Healthcare organizations, and their design professionals, are utilizing a growing number of alternatives to long-established materials and products like mercury thermometers and PVC medical devices.
“Imagine a cancer center constructed without materials that contain known or suspected carcinogens, or pediatric clinics without asthma triggers,” is driving market transformation of building materials and medical devices.
Another important factor in the ‘green tsunami’ is global resource competition. There is growing consensus that we are consuming natural resources faster than the planet can replenish them – the World Wildlife Fund’s Living Planet Report (2005) estimates that we are consuming global resources at 30 percent above carrying capacity. However, if the planet consumed at the level of present U.S. consumption, more than three planets would be necessary. This is reflected in construction cost escalation that outpaces the rate of U.S. inflation, as we compete in a global materials marketplace for diminishing natural resource base. It is clear that demand for oil outstrips global extraction and refining capacity (and probably basic supply) – the end of cheap oil is driving focus on reduced consumption and improved efficiency/ reduced waste.
What does this mean for healthcare? Lee Jong-Wook, MD, former director general of the World Health Organization, in the Millenium Ecosystem Assessment (Corvalan 2005), notes, “Nature’s goods and services are the ultimate foundations of life and health, even though in modern societies this fundamental dependency may be indirect, displaced in space and time, and therefore poorly recognized. This [is] a call to the health sector, not only to cure the diseases that result from environmental degradation, but also to ensure that the benefits that the natural environment provides to human health and well-being are preserved for future generations”.
“This [is] a call to the health sector, not only to cure the diseases that result from environmental degradation, but also to ensure that the benefits that the natural environment provides to human health and well-being are preserved for future generations.”
In summary, these seemingly disparate trends signal a fundamental shift in economics and cost accounting, as well as overall business conduct. Once upon a time, we could dispose of things “away” – the seemingly limitless air and water. The impacts of using our air and water as dumping grounds for waste – species loss, air pollution and toxic contamination – are moving into economic cost accounting models. Carbon trading models and life-cycle assessment (LCA) methodologies are in their infancy, but ecological economics is gaining momentum. A recent issue of Harvard Business Review (2010) proclaimed that society has a new era of leadership in an age of transparency – “Consumers now know everything about your company – not just its carbon emissions but its countless other “invisible” effects on the globe. That has changed the rules of business forever.”
Sustainable action and human health
The connection between sustainable action and human health has been at the root of healthcares response to these issues from the start. The American Society of Healthcare Engineering (ASHE 2002) first framed green building initiatives around “protecting health at three scales: the immediate health of building occupants, health of the surrounding community, and health of the larger global community and natural resources.” Environmental scholar David Orr (2004) writes: “The standard for ecological design is neither efficiency nor productivity but health; beginning with that of the soil and extending upward through plants, animals, and people. It is impossible to impair health at any level without affecting it at other levels.”
Green Guide for Health Careh issue” statements that introduce each construction and operation topic – the Green Guide is the foundation for the U.S. Green Building Council’s LEED for Healthcare. Providence Health and Services CEO John Koster, MD, in describing their new LEED® Gold Certified hospital in Newberg, Oregon, summed it up this way: “In healthcare, sustainable building represents a bold move toward precaution and prevention. The building stands for health. In creating it, the organization is essentially saying, ‘We’re investing in keeping people healthier.’ Being attentive to sustainability, wellness, and resource stewardship presents a holistic view of healthcare that has an impact. We may not be able to measure or test, but I’m convinced it has a tremendous impact on a person’s ability to attain health. Not just to be not sick, but to be in health” (Guenther and others, 2006).
CATALYST Insight: The impact of buildings materials on human health and the environment needs to be considered when constructing medical care facilities.
Finally, the healthcare sector is realizing that green construction and operation makes business sense. Leaders engaged in green building and operations delineate three major benefits: reduced operating cost, avoided risk, and tangible impacts on employee satisfaction, recruitment, and retention. Reducing energy demand is increasingly seen as not just about dollars saved today, but is a “risk avoidance” strategy in a time of uncertain energy economics. Likewise, green strategies aimed at improved indoor air quality – from using building materials that emit less fumes to cleaning with greener products – reduce occupational health and safety risk.
Almost without exception, hospitals that undertake green building and operation strategies report improved worker recruitment, satisfaction, and retention. Green building is viewed as a major catalyst for organizational culture transformation – by connecting with employee values, the work experience is transformed. Moreover, the completion of a green building is really only the beginning of organizational transformation. Once the building is in place, new green programs and initiatives are implemented. Boulder Community Hospital installed solar PV panels nearly four years after achieving their LEED® certified building, and continue implementing operations programs that earn them environmental excellence awards each year.
Reducing healthcare’s public health footprint
Collectively, pioneers and early adopters of green building practices in healthcare have reported energy demand reductions ranging from 15 to 30 percent, potable water reductions in the range of 30 percent, successful integration of local and regional materials palettes alongside a host of environmentally preferable material choices, and improved indoor air quality through enhanced ventilation and occupant controls, low-emitting materials, and an increased focus on using more natural light and connecting to nature (often through the integration of outdoor places of respite, or healing gardens). While the majority of LEED-certified projects are new construction, a number of major renovations or adaptive reuse projects have achieved certification. They range in size from 25,000 square feet to 500,000 square feet – in the second wave of registered projects, many are in excess of one million square feet, are geographically dispersed, and are located in urban, suburban, and rural settings.
Many have included unique, community-based regenerative design strategies in their projects, moving beyond simply LEED points in the service of a larger community health vision. Parrish Medical Center, in Titusville, FL, rehabilitated 6 acres of degraded wetland habitat for the endangered scrub jay as a cornerstone of its 30 acre development. Thunder Bay Regional Medical Center, Thunder Bay, ONT, uses a series of stormwater retention ponds to hatch fish and return them to the adjacent stream – part of the community project. Gundersen Lutheran Medical Center, LaCrosse, WI, partnered with an adjacent brewery to harness the brewery waste methane to supply thermal energy for their nearby hospital – and sell power to 500 homes. These community partnerships for environmental and social benefit signal a move beyond simply “using less resources” to a vision of a restorative and regenerative community.
The Power of Purchasing
Healthcare is currently the largest service sector of the US economy, representing 17% of the US GDP; healthcare organizations are often the largest employer in the communities they serve. The UK National Health Service estimates that close to 60 percent of its carbon footprint is embodied in its supply chain, with almost one third the result of pharmaceutical manufacture and transport. US hospitals are beginning to use their market predominance to drive environmental health improvements – for example, phasing out PVC plastics and phthalate plasticizers. They are strengthening electronic waste recycling infrastructures in their communities.
Perhaps the most visible aspect of healthcare purchasing shifts is in the realm of food. More than 300 hospitals have signed Health Care Without Harm’s Healthy Food in Healthcare pledge, with commitments to take action on a range of food supply issues. Strategies include organic food purchase, 20% less meat on menus, antibiotic free meat and poultry, and hormone-free dairy. Hospitals are implementing composting and hosting farmer’s markets in underserved urban communities. These actions model healthier living to staff and patients, and move markets in the process. Widespread elimination of growth hormones and antibiotic use in meat and dairy production is only possible as large-scale purchasers demand it.
What lies ahead?
Imagined futures are always more about where we have been than where we are going. The challenge for all of us is to look back at history while focusing on the path ahead. There seems to be no question that our future depends upon this vision. The green tsunami will continue to strengthen as public policy aligns and comes to bear on the sector through mandatory green building requirements and carbon taxation. The challenges ahead are daunting: carbon neutrality, toxic-free, water balanced and zero waste are already emerging as the BHAGs (big hairy audacious goals) of sustainable healthcare (Guenther and Vittori, 2008). While this may seem an impossible undertaking for an industry with so many fundamental economic, occupational, regulatory, and safety challenges, healthcare leaders are nonetheless embarking on this journey. It is a journey beyond “doing less harm,” to a world of “doing no harm” and “healing.” It is a journey beyond treating illness rooted in a vision of supporting health and community. It is a quest for a regenerative health system.
“It is a journey beyond “doing less harm,” to a world of “doing no harm” and “healing.”
As important local employers and service providers, the healthcare industry is uniquely positioned to support the resurgence of support for local green economies and green jobs. Recent changes in the Internal Revenue Service definition of “community benefit” are increasing the ability for healthcare organizations to invest in sustainable programs that benefit community health and healthy communities as part of maintaining their non-profit status. This prediction is taking shape: hospitals can situate themselves within the ecology of their communities and act as a force for healing.
The sector should not need to argue that delivering high quality healthcare requires excess waste production and energy usage – or that saving lives is somehow outside of broader ecosystems and ecological concerns. “The healthcare industry is in a pivotal position to lead the twenty-first century reintegration of environment, health, and economic prosperity. By critically reinventing the hospital as a regenerative place of healing, marshalling purchasing power, and modeling health and wellness within a society in critical need of alternatives to fast food and retail culture, the healthcare industry can signal a new relationship to healing and health” (Guenther and Vittori 2008).
The hospitals leading the sustainability movement in healthcare are acting as if everything they do matters and makes a difference. They have begun to heal the split between what they believe and what they do, to commingle their identities as consumers, industries, and citizens. They are exerting both upstream leverage on their supply chains, and downstream influence on their employees and patients. Through their green construction and operations initiatives, they demonstrate a broad commitment to more than high quality patient care – they are committed to saving lives and improving health without undermining ecosystems or diminishing the world.
Guenther, Robin and Vittori, Gale (2008). Sustainable Healthcare Architecture.
Gary Cohen is a founder and Co-Executive Director of Health Care Without Harm (www.noharm.org), the international campaign for environmentally responsible healthcare. HCWH is working to prevent disease and illness in society by assisting the healthcare sector in understanding the links between a healthy environment and healthy people and helping hospitals become more environmentally sustainable while saving money.. HCWH has over 500 member organizations and partners in 50 countries, with offices in Washington, D.C., Brussels, Buenes Aires and Manilla.
Cohen is a co-founder of Green Harvest Technologies, a bio-based green chemistry company, working to replace toxic products with safer alternatives. Mr. Cohen was awarded the Skoll Global Award for Social Entrepreneurship in 2006 and the Frank Hatch Award for Enlightened Public Service Award in 2007.
Robin Guenther FAIA, March is a Principal of Perkins+Will. She co-coordinates the Green Guide for Health Care, serves on the LEED for Healthcare Committee, and co-authored “Sustainable Healthcare Architecture,” with Gail Vittori in 2007. She is a board member of both the Center for Health Design and Healthy Building Network.
In 2005, she received the Center for Health Design’s Changemaker Award for her leadership and innovation in the design of sustainable healing environments. Author and Designer Rosalyn Cama describes Robin as “a pioneer who defied the odds.” Healthcare Design magazine named her the “#1 Most Influential Designer in Healthcare” in 2009. Robin’s work has actively addressed the need for transformation of the industry and the profession, utilizing sustainability as a guiding framework for design.