Health without harm

Prescriptions for the heathcare industry's ills


Prescriptions for the heathcare industry’s ills

sharps container with biohazard loop symbol and skull and crossbones symbol

First do no harm—the motto of the healthcare industry. Few other industries can claim such a noble maxim. In fact, not only does the healthcare industry aim not to harm, but it aims to heal. It seems especially ironic then that the healthcare industry produces two million tons of medical waste each year. That medical waste incinerators are a leading source of air pollution. That thousands of toxic chemicals are used and disposed of in medical facilities every day. That PVC plastics are the most common plastic used in medical devices. That pharmaceutical drugs are being flushed down the drain and into our waterways, polluting the water with chemicals that kill aquatic organisms.

But now healthcare administrators, physicians, and nurses are recognizing that “do no harm” applies not only to individual patients, but to the environment at large. They are looking beyond individual health to community health and acknowledging the inherent connection between the two. Today many hospitals are taking it upon themselves to go beyond the bare minimum environmental standards. They are setting new standards for themselves, since few environmental regulations apply specifically to the healthcare industry.

They are building new “green” hospitals following sustainability standards drafted by healthcare insiders. They are setting best management practices for the disposal of drugs that are not federally regulated. They are purchasing products that have less unnecessary packaging, more recycled content, and are more energy efficient. They are serving sustainable, locally grown food to patients and in their cafeterias. Amazingly, these commonsense solutions are quite revolutionary in an industry filled with disposable plastics and individually wrapped… well, everything.

Until the summer of 1988, the environmental impact of the healthcare industry did not really enter the public’s consciousness. But that summer thousands of syringes and vials of blood washed up on the beaches of New York and New Jersey, and with them brought new diligence in the handling of medical waste. The issue was not particularly new among healthcare professionals, but it took beach closures and swimming bans during the height of summer to bring about public awareness. The incident alerted government and health officials to the increased production of medical waste, the problems of illegal dumping, and the need for stricter regulations on the disposal of medical waste.

Out of this incident came the Medical Waste Tracking Act, a federal law that required the EPA to develop a program to define medical waste—infectious material including syringes and needles, scalpel blades, blood-saturated bandages, human tissues and body parts—and create a system for sorting and tracking the waste from cradle to grave. The law has since expired, and regulation of medical waste is largely left to the states’ discretion.

At that time, incineration was the primary mode of medical waste disposal. While widely unpopular today, incineration had a few advantages that made it the disposal method of choice—complete destruction of the waste, sterilization of infectious material, and significant volume reduction of the waste. Over 2600 incinerators were in operation, and many hospitals had their own onsite incinerators. Prior to the Medical Waste Tracking Act, all waste from a hospital—everything from bloody bandages and removed spleens to cafeteria scraps and office paper—was dumped together into an incinerator to be destroyed at temperatures that exceed 1000°F, resulting in a pile of ash that would then be landfilled.

But the advantages of incinerators were soon overshadowed by the pollution they produced. Studies found that medical waste incinerators were a leading source of dioxin—a highly toxic family of chemicals and known carcinogen—into the atmosphere. No less dangerous were the emissions of mercury, lead, and other harmful pollutants. The studies came as a shock to hospitals, who were appalled they were responsible for releasing so much pollution. “It was rather distressing, to say the least, that in their own back door they were producing harmful toxins,” said Tom Lent, Technical Policy Coordinator at Healthy Building Network and co-coordinator for the Green Guide for Health Care.

In 1997, the EPA recognized the danger of these incinerators and enacted strict regulations on emissions from medical waste incinerators. Rather than pay for costly upgrades to meet new EPA standards, most of the incinerators cooled their fires and closed their doors. Today only 100 medical waste incinerators remain open.

The closures of so many medical waste incinerators marked the first major step in the environmental movement within the healthcare industry. The second was the Memorandum of Understanding (MOU) between the EPA and the American Hospital Association. MOU was a shared commitment to reducing hospital pollution, which focused especially on eliminating mercury from the medical waste stream and reducing the overall volume of medical waste.

The agreement had a number of beneficial effects. It showed people, especially hospital administrators, that the push to clean up the healthcare industry was not just a radical environmentalist idea. It was a practical approach to reducing the footprint of the industry that had the backing of two major players. MOU marked the first large scale efforts by hospitals to clean up their act and demonstrate their real commitment to health.

Aside from being green because it seems like the right thing to do, many hospitals realized that cleaning up health care was really in their best interest. If hospital administrators weren’t convinced by the environmental savings, they could certainly appreciate the monetary savings. For example, the cost of replacing mercury thermometers with mercury-free alternatives may seem like a great cost, until one considers the even greater cost of cleaning up a mercury spill. Reducing energy usage and waste disposal are two other ways that hospitals fulfilled sustainability commitments, while cutting costs—a high priority for cash-strapped hospitals. “It helped to get hospitals to recognize that it’s a good way to do business,” said Janet Brown of Hospitals for a Healthy Environment (H2E), a group that formed out of the EPA-AHA alliance.

H2E has been at the forefront of the movement to “green” hospitals. Perhaps one of the greatest successes of the movement has been the elimination of mercury from hundreds of hospital facilities across the country and the thousands more who have pledged to eliminate it. H2E did not meet the original goal of completely eliminating mercury in hospitals by 2005. In fact, only about 170 of the nearly 6000 US hospitals have applied for H2E’s mercury-free award. But Brown said it’s a slow process, and the results are nonetheless promising. “We focus more on the goals and not the timeline.”

As was the case with dioxins, the healthcare industry is also a leading source of mercury pollution. The harmful effects of mercury exposure have been well documented. Studies show that exposure can result in serious brain damage. (The term “mad as a hatter” came from the trembling and delirium often seen in felt hat makers exposed to mercury.) Because the fetal nervous system is especially at risk to damage from mercury, pregnant women are warned to avoid tuna and other fish that contain high levels of mercury. But according to Janet Brown and H2E, that’s the backwards approach to solving the problem of mercury exposure. “Rather than avoid fish, it makes more sense to stop it from entering the waste stream,” Brown said.

marked refuse containers on a concrete dockChrisClarkeBiohazardous waste containers on a hospitalloading dock

One of H2E’s greatest success stories is Kaiser Permanente, the country’s largest nonprofit health plan. Since 2005, all of Kaiser’s facilities are virtually mercury free. The group made a formal pledge in 1997 to eliminate mercury. Around that time a study by the EPA came out that found high quantities of mercury emissions from medical waste incinerators. (In fact, according to the EPA the healthcare industry was the fourth largest producer of mercury emissions. Emissions have decreased in recent years with the closures of so many medical waste incinerators.) “We didn’t want to be part of that problem,” said Lynn Garske, environmental stewardship manager at Kaiser Permanente.

Kaiser has made preventative care a major part of its mission. According to Garske, environmental protection is really not so far removed from patient care. “Clean air, land, and water are intrinsically linked to health,” Garske said. The health of the environment directly affects human health. For example, the incidence of asthma increases with greater air pollution, and lead exposure has been shown to have serious neurotoxic effects. Western medicine has always focused on the repair model, rather than the preventative model, Tom Lent said. That focus has changed finally, as people look at the role environmental pollutants play in causing disease. “It only recently that leaders in the healthcare industry have made the connection,” Lent said.

Kaiser is not the only one jumping on board. Over 1300 hospitals in the US have joined with Hospitals for a Healthy Environment, pledging to eliminate mercury and reduce overall waste. H2E has given out a number of awards to hospitals that exemplify the healthy hospitals mission.

Mills-Peninsula Health Services in Burlingame, CA (just south of San Francisco) was one medical center singled out for its commitment to a healthy environment. In 2006, the hospital received H2E’s Environmental Leadership Award for its extensive recycling programs—the hospital reduced solid waste disposal costs by $97,000 and recycled 90% of the building material when an old hospital facility was torn down.

“Hospitals are notorious for being the biggest waste generators,” said Gail Lee, director of Environmental Health and Safety at Mills-Peninsula. “Everything is disposable.”

While disposable, individually wrapped products may be an easy way to ensure sterilization, they create an incredible amount of waste. At Mills-Peninsula and other hospitals around the country, administrators are looking to reprocessing companies to take used products—often catheters, surgical instruments, drills, bits and blades—and remanufacture them to make them “new” again. The items are cleaned and sterilized (sharpened if necessary), then returned to the hospital ready to be used again. This is a controversial option since some have raised concerns about the safety of reusing medical devices, but Lee said it is a great way to reduce unnecessary waste.

Another area where forward-thinking hospitals are employing their green ideas is the building of new hospitals. California, for example, is witnessing a flood of new hospital construction, as new regulations require hospitals be able to withstand an earthquake of magnitude 8.0. It is a great opportunity for hospitals such as Mills-Peninsula and Kaiser to showcase their commitment to the environmental movement.

“People are recognizing that all that new construction could have an impact on the environment,” Lee said. “The purpose and goal of building a hospital is patient care. But on the other hand, if you look at the environmental issues, you have to see it as how it affects the patient, and sometimes we don’t link the two. “

Hospitals have a unique challenge when it comes to green building. LEED (Leadership in Energy and Environmental Design) standards—a set of requirements to be considered a “green building”—are based on the model of an office-type building and often don’t apply to healthcare facilities. A hospital that operates 24 hours a day is going to have a hard time meeting LEED requirements for energy efficiency and water conservation, for example. Infection control requirements and heavy chemical use also impede LEED certification. But proponents of green hospitals have come together to develop a version of the LEED requirements that better suits the healthcare industry.

Known as the Green Guide for Health Care, it is a set of recommendations for the healthcare industry that combine the duel missions of human health and sustainable development. “The Green Guide came out of an acknowledgement within the design community that LEED was not being used by hospitals. They started questioning why LEED was not applicable to hospitals,” said Adele Houghton, pilot coordinator for the GGHC. They took the basic structure of LEED and designed a model for acute care hospitals that stresses not just the importance of sustainable design, but also its beneficial effects on human health. So far there are about 100 green hospital projects in the US and around the world—28 million square feet of green hospital construction, said Tom Lent. “We’re just scratching the surface,” Lent said. “We have impressive numbers, but there’s an even more impressive amount of [non-green] construction going on in the world.”

Hospitals can get credits for providing alternative transportation for employees and patients, water-efficient landscaping, using healthier building materials, nontoxic paints, and energy efficient medical equipment, or designing patient rooms with more daylighting to reduce lighting costs and speed up patient recovery.

The beauty of this collective effort to clean up healthcare is the enormous potential for real change, due in large part to the magnitude of the healthcare industry. This market power can have a huge effect on the environment.

“[By buying products with PVCs or toxic chemicals,] we’re creating a market that creates that pollution that other people are impacted by. So from the big scheme of things, if we truly care about health and we truly care about people and how the environment affects people, we have to think about things in a more global perspective,” Gail Lee said.

Fortunately, hospitals are beginning to recognize their ability to shape the market. While only a fraction of hospitals are currently “greening” their hospitals, their market power can already be felt. When Kaiser Permanente was looking for an alternative to vinyl-backed carpeting for its new hospitals, the building designers found nothing on the market that would suit their needs. They put the word out that they were looking for a PVC-free carpet, and eventually a company stepped forward with a new type of carpet named Ethos. Made of recycled materials with a backing made from windshield safety glass, Ethos is 100-percent recyclable.

Ethos is just one example of the environmentally preferable products (EPPs) that are available to hospitals today. Almost all products on the market have environmentally preferable alternatives; it’s just a matter of changing the mindset of the purchasing departments away from the bottom line. “We need to be concerned about the upstream impact of what we buy,” Garske said.

According to Sarah O’Brien, of Hospitals for a Healthy Environment, buying EPPs is an easy way to reducing toxic exposures in the healthcare setting (by avoiding PVCs and other toxic chemicals), encouraging sustainable manufacturing, and reducing waste by purchasing products with less packaging. Conscientious purchasers are buying EnergyStar equipment, less toxic cleaning products, recycled paper, reusable sharps containers, or organic food for the cafeteria.

The healthcare industry has been slower to adopt EPPs than other industries because most medical devices must be approved by the FDA. Any changes to these devices would require new approval. “In the world of health care, EPP is relatively new as a concept, but has grown rapidly as more and more facilities embrace their environmental responsibilities and work to reduce their impacts and to eliminate toxic exposures and unnecessary waste generation,” O’Brien said. For example, mercury-free blood pressure devices were once difficult to find; today they are very common.

Yet despite all these improvements, new challenges continue to surface. Pharmaceutical waste is the hot new buzzword among the green hospital crowd. In recent years, studies have found evidence of pharmaceuticals in American waterways. Presumably there have been pharmaceuticals in the water as long as the drugs have existed, but only recently have scientists had the tools to measure such trace amounts. It’s hard to say exactly what effects these pharmaceuticals have on wildlife and the environment, but laboratory studies have found some drugs that are implicated in endocrine disruption and behavior changes in aquatic organisms.

“Effects are known to occur at concentrations that are “relevant” to the environment (e.g., parts-per-billion, micrograms per liter), but this does not necessarily mean that the same effects (or even bona fide exposures) occur in the wild,” said Dr. Christian Daughton, chief of the environmental chemistry branch of the EPA.

Daughton said one of the biggest questions is what happens when the drugs interact. “A major complication regarding the environmental toxicology of these substances is that little is known regarding the effects that might result from simultaneous exposure to multiple chemical stressors at trace concentrations; however, those chemicals that share the same mechanisms of action or mode of action, could prove significant, via additive concentration effects.”

While the major source of pharmaceuticals in the environment is through natural excretion, improper disposal of drugs by individuals, hospitals, and pharmacies is also at fault.

The regulation of pharmaceutical waste disposals falls under the Resource Conservation and Recovery Act (RCRA), a law enacted in 1976 to regulate the disposal of hazardous waste. The law was designed for heavy industrial use chemicals, but in the last couple years the regulations been applied to the pharmaceutical and healthcare industries as well. Nicotine, saccharin, the hormone epinephrine, and warfarin, a drug used to prevent blood clots, are among the common compounds listed as hazardous.

But because they weren’t designed with pharmaceuticals in mind, the regulations don’t quite fit. In some ways RCRA is too strict—any vial or pill bottle that contained one of the drugs on the RCRA list must be disposed of as hazardous waste. Yet in other ways, it is far too lenient. Only nine of the 100s of chemotherapy drugs are deemed hazardous waste. (Because only nine of them existed in 1976.) According to Charlotte Smith, president of PharmEcology, an environmental consulting firm for the healthcare industry, five percent of the drugs on the market need to be disposed of as hazardous waste. Another ten percent should be.

a biohazard refuse container, with a step-on button for the lidChris Clarke

There has been a call from pharmaceutical waste experts for a revamp of the laws as they apply to pharmaceuticals. But so far there have been no moves to change them. “Unless there is a lot of pressure applied, I don’t think there will be [any additional regulations,]” Smith said.

In the meantime, Smith and others are encouraging what she calls “best management practices”. She says hospitals should go beyond the RCRA requirements, treating all drugs as hazardous so they don’t end up in our waterways. Rather than putting drugs in the trash or down the drain (where they make their way out to sea), Smith recommends that these drugs be incinerated, despite concerns over the pollution from medical waste incinerators. Smith admits that it’s not a perfect solution, but she said, “We have compromises to make. We’re worried about the effects on water and aquatic life. Right now almost anything is better than getting it in the water system.”

The management of pharmaceutical waste demonstrates the challenges ahead for the healthcare industry, if they really plan to change tack. As with pharmaceutical drugs, there is often no perfect solution for the environmental problems that hospitals face. (Autoclaves, the most popular replacement for medical waste incinerators, are much safer in terms of emissions but still cannot be used to dispose of hazardous chemicals.) Still a hugely wasteful industry, the healthcare industry’s biggest task will continue to be waste management.

Clearly there have been some major improvements since the heyday of the medical waste incinerators, but for real long-lasting change, the whole industry must really take this movement to heart. In many ways the push toward more environmentally friendly practices still remains primarily within the realm of hospitals’ environmental managers, who have to fight to get their programs through. Hospitals like Kaiser and Mills-Peninsula are certainly no longer the exception, but they’re not yet the rule either.

“Certainly there are role model hospitals that are doing great things,” said Dr. Gina Solomon, senior scientist at the Natural Resources Defense Council. “But it begs the question, why isn’t the whole industry doing this…Where is everybody else? How do we get the entire industry to follow the leaders?”

Hospitals that have so far been slow to act may require a nudge from the outside—pressure from the local community—as well as an advocate on the inside, working in the hospital.

Also, so far the focus of these green efforts has been primarily centered in hospitals for obvious reasons: that is where the greatest concentrations of problems are. “But if you just focus on the hospitals, you are missing most of the healthcare industry,” Solomon said. To radically change the way an entire industry operates takes time. Just removing mercury from healthcare facilities is taking several years.

What will it take for widespread change? “We can’t just be green because it sounds good. There needs to be a long-term culture shift,” Janet Brown said.

Liz Savage is an Earth Island Journal intern. She is studying at Boston University.

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