Health care is a capital-intensive business. Its environmental impacts, flowing both upstream and downstream from the facilities where the services are delivered, offer myriad financial opportunities that -- until recently -- have been largely ignored. By Cate Gable


The physician’s oath is to “First, do no harm,” yet some of the side-effects of hospitals and the health care industry can make people sick.

Health care is a capital-intensive business. Its environmental impacts, flowing both upstream and downstream from the facilities where the services are delivered, offer myriad financial opportunities that until recently have been largely ignored. Cost externalities for materials manufacturing, waste disposal, energy use, water inefficiencies, and the effects of poor design on working conditions are starting to factor into a holistic health care equation by a range of dedicated individuals.

Room with a View

Environmental innovation in health care seems to be starting with brick and mortar.

“There is an obvious connection between health care and green building,” said Gail Vittori, co-director of the Center for Maximum Potential Building Systems in Austin, Texas. “We have a heightened awareness now of what buildings do to people. There were 100,000 deaths related to being in a hospital last year.”

The ways a building can be lethal are various. Building materials used in construction — carpets, adhesives, paint, pressboard, tiles, flooring — can give off toxic vapor and particulate matter that contribute to indoor air pollution. Since humans spend almost 90 percent of their time indoors — and health workers and patients have few options — the seriousness of indoor air quality is nothing to sneeze at. Hospital air can aggravate asthma, allergies, and even deliver air-born carcinogens.

Polyvinyl chloride (PVC) is a particularly lethal and prevalent building material. Its production creates dioxin (one of the most potent carcinogens known), ethylene dichloride and vinyl chloride. Eleven million pounds of PVC materials are used in the construction industry, 75 percent of all the PVC manufactured in the United States.
Reducing the use of PVC in health care structures is the goal of a variety of new policies.

Vittori is chair of the U.S. Green Building Council’s Leadership in Energy and Environmental Design (LEED) committee, which is drafting an Application Guide for Health Care. The document, due out in late 2004, will recommend green building certification standards for health care facilities. Only one hospital has been LEED certified - Boulder Community Foothills Hospital in Boulder, Colo. — but there are over 25 registered health care projects in the pipeline. Four are on the West Coast.

The need for replacement hospitals is growing. Many hospitals, especially small, rural ones, were built in the 1950s and 1960s. Medical technology innovation and changing patient demands have poised the nation for a health care rebuilding and renovation boom.
Buildings are not the only area of concern, however, in the health care industry. Another major source of pollution is the incineration of medical waste.

Turn and Burn

Every bed pan, set of gloves, syringe, swab, pill tray, blood bag, and intravenous tube used in a health care or medical research facility gets jettisoned directly into a hazardous waste bin to be hauled off-site, where in most cases it is incinerated.

The volume of biomedical or infectious solid waste has grown as hospitals cope with a growing array of infectious diseases. Since sterilizing and reusing supplies can provide an invitation for litigation, most medical tools and equipment get dumped in the trash.
It’s estimated that for each 4 kilograms of waste generated in a hospital, only 1 kilogram is infected. Yet unless a hospital facility properly sorts its waste, everything goes into the incineration can. As the United Nations Environmental Program health care guidelines attest, “Separation is possible only when there is significant management commitment, in-depth and continuous training of personnel, and permanent supervision to ensure that the prescribed practices are being followed.”

Since most medical equipment is made of some variety of PVC, incineration delivers a silent killer into the air — the carcinogens dioxin, hydrogen chloride, and hydrochloric acid (the incineration and collapse of the World Trade Center, for example, sent a potent dioxin plume over all of lower Manhattan.)

Reducing PVCs is one of the fights taken up by Tom Lent, executive director of the Healthy Building Network. “Health care industry solid waste incineration has been one of the largest contributors to dioxin pollution in our environment,” said Lent.

Due to the efforts of Lent and others, however, the issue is now being addressed. “We’ve gone from 4,000 incinerators five years ago to under 100 now,” Lent pointed out. “The momentum building for greening the health care industry is exciting and heartening in light of the challenging political environment.”

Purchasing Clout

Kaiser Permanente, a private nonprofit health care provider serving 8 million members in 11 states, is regarded by many as the West Coast industry leader in environmental innovation. Kaiser has established its own guidelines for clean and ethical operations and an executive-level position for resource conservation. Additionally, the Kaiser “green team” put its purchasing clout to work by collaborating with manufacturers on targeted products.

Carole Antle, co-chair for the LEED health care committee and director of capital projects at Kaiser, heads up the efforts. “We wanted a cradle-to-cradle assessment of the most polluting, commonly used hospital products,” Antle said.

They started by looking at carpets, vinyl composition tile, and particleboard. After a detailed selection process, Kaiser identified manufacturers to work with on new product research and development.
Some of the material challenges have provided opportunities to source cheaper as well as less toxic products. They found a particleboard without formaldehyde that was below the previous price point. Though finding a less expensive alternative isn’t always possible, non-toxic products often have cost benefits in other areas. For instance, Kaiser discovered a non-toxic flooring that was more expensive upfront but was less expensive over the life of the product because less cleanup labor and cleaning supplies were needed.

Antle calls their selected manufacturers “Alliance Partners.” The partnerships represent a growing trend of supply chain collaboration between high-volume health care providers, or purchasing co-ops, and savvy manufacturers.

The Bottom Line

Major stakeholders in the health care industry include discriminating consumers, environmental activists, standards organizations, government regulators, and visionary corporate leaders. Many companies acknowledge the importance of stakeholder collaboration in refining their business strategies. In a recent white paper called “A Synergy of Nature and Science,” Dow Chemical states, “Green building practices such as those defined by the LEED rating system have helped to establish the direction for product research.”

Antle said it helps when activists get out in front of the issues. Activists provide an early-warning system by identifying corporate vulnerabilities, places where the consumer demand will emerge, she said. Then regulators must do their part. As Vittori said, “Regulatory structure needs to be responsive. The integration of systems will provide the Big Leap in greening health care.”

Tom Paladino, president of Seattle green building consulting firm Paladino & Company, said he has worked on many projects with complex and interconnected hierarchies of power. Building owners want more beds for the buck. Contractors must follow regulations. Financiers want fiscal accountability. Green architects want eco-friendly contractors. Patients and nurses want a pleasant environmental where healing can take place.

Said Paladino: “There is no extra money for green building. The game is how to maximize the effectiveness of the enterprise within the budget we have. Typically the person buying the building is a head doctor. They already have an office with a window so they’re not really worried about windows at the nurses’ station. So how do you compare losing one bed versus improving a 40 percent turnover for nurses?”
Paladino’s firm helped design a recent renovation of Ocean Beach Hospital and Medical Center in Ilwaco, Wash. The seven-year endeavor, from bond issue to opening, provided the peninsula community hospital 19,000 additional square feet of space.

At Ocean Beach, natural light from large skylights floods the nurses’ work station. Hallways are generously wide and adorned with art. The new hospital entrance is a three-story atrium, airy and bright, with a seascape mural by a local artist.

The old work station, still in use, is enclosed in the middle of a windowless room circled by dim patient quarters and tapered by low ceilings. The contrast is palpable. Nonetheless, some patrons were concerned about what looked like money wasted on luxury.

“How can I put a price tag on our entrance lobby?” said Ocean Beach CEO Jim Roberts. “I just ask people, ‘How do you feel when you walk in?’”
Many environmental innovations in the health care industry appear to benefit both patients and the bottom line; but that doesn’t mean there won’t be struggles on the horizon.

“The health care industry is dominated by big projects and big money, which is all about the bottom line,” Paladino said. “Green building is about the user experience, for workers and patients. Getting those to meet in the middle is the challenge.”

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This article has been reprinted courtesy of Sustainable Industries Journal. It first appeared in the August 2004 edition of that publication.