August 12, 2014

Excerpts from book by environmental stewardship officer

Kaiser Permanente’s environmental stewardship officer, Kathy Gerwig, offers timely insight into the movement to ‘green’ the health care system.

The following is a Table of Contents from the book, "Greening Health Care: How Hospitals Can Heal the Planet" with excerpts lifted from each chapter.

All proceeds from the sale of Greening Health Care: How Hospitals Can Heal the Planet will go to Health Care Without Harm.Visit Oxford University Press to learn more about the book and purchase a copy. Electronic and print copies of the book are also available on Amazon.


The very nature of health care is changing. Health care reform, clinical innovations, electronic medical records, social connectivity, technological advances, baby boomers’ expectations about quality of life, demands for price to align with value, and ways the environment contributes to disease are some of the factors behind the changes. These changes offer profound, new opportunities to address environmental issues across the health care sector and beyond… Read More

Chapter 1: Launching a Green Revolution in Health Care

I tend to date the beginnings of the environmental stewardship movement in health care back to the mid-1990s, in my case, precisely to the day when I first met Gary Cohen of Health Care Without Harm in the lobby of the Royal Sonesta Hotel in Cambridge, Massachusetts. It was 1996, and I had flown in from Oakland, California, to attend an environmental conference sponsored by Tufts University. Kaiser Permanente’s environmental stewardship strategies and goals were taking shape just as some important information was emerging that had direct relevance for health care, specifically involving the harmful health impacts of dioxin, mercury, and other chemicals. The conference promised to be a good opportunity for hearing the latest expert thinking on these and other issues I knew I would be dealing with, and for establishing a network of professionals with a shared commitment to environmental health.

Cohen, who was also attending the conference, had called me before that trip to introduce himself and tell me about plans for a new advocacy group called Health Care Without Harm that he was forming with Charlotte Brody, a registered nurse. I knew almost nothing about Cohen, except that he had a reputation as a committed activist with a focus on toxic chemicals. Health Care Without Harm, he explained, would be dedicated to cleaning up and limiting the use of toxic materials in the health care sector. This agenda seemed ambitious for someone who had no experience in health care. In fact, as I later learned, Cohen’s formal training was in Eastern philosophy.

Nonetheless, a series of life-altering experiences, including Cohen’s work on behalf of survivors of the 1984 Union Carbine pesticide factory explosion in Bhopal, India—which killed 3,000 people and sickened a half million more—had focused his activist’s passions on the growing dangers of toxic chemicals. When the US Environmental Protection Agency (EPA) issued a series of alarming reports in the early to mid-1990s on the carcinogenic, reproductive, and immune system effects of dioxin, one of the most toxic human-made pollutants, Gary set his sights on the health care industry. Health care, after all, had been identified as the biggest emitter of dioxins into the atmosphere in the United States, due to the routine burning of thousands of tons of chlorine-based plastic medical waste and trash at an estimated 5,000 onsite or remote incinerators.

Chapter 2: The Health Implications of Climate Change

Anthony Costello, the lead author of the exhaustive 2009 Lancet study on climate change and its health consequences, proposed that health professionals should be spearheading three areas of action: First, they should be speaking out forcefully about “the threat to our children and grandchildren from greenhouse-gas emissions and deforestation”; second, they should be addressing and mitigating the “massive inequality in health systems throughout the world” in their ability to deal with climate change; and third, and most optimistically: “We must develop win–win situations whereby we mitigate and adapt to climate change and at the same time significantly improve human health and wellbeing.”

Dr. Dana Hanson, the incoming president of the World Medical Association, seconded those views in even stronger terms: “Climate change represents an inevitable, massive threat to global health that will likely eclipse the major known pandemics as the leading cause of death and disease in the 21st century. The health of the world population must be elevated in this discussion from an afterthought to a central theme around which decision-makers construct rational, well informed, action-orientated climate change strategies.”

Chapter 3: The Business Case for Total Health

In the beginning of Kaiser Permanente’s environmental stewardship efforts, our cost structure was less of a driver than our health care mission, so long as our program was cost-neutral in the long run. Actually, what we had in the early days was not so much a stewardship “program” as a shared understanding about the link between environmental health and human health and a belief that, as a major health care provider, we had a great opportunity, and a responsibility, to act on that link. We understood that the health and sustainability of the environment—the natural environment, the built environment, and even the social environment—is a necessary condition for human health and well-being. We think of our mission in terms of what we call “total health,” which has multiple, interrelated dimensions. It includes the physical, emotional, and spiritual health of every individual supported and sustained by the health of our total environment—our families, neighborhoods, workplaces, cities, the air we breathe, the food and water we consume, and all the delicate ecological balances that sustain life on this planet. While medical care is typically focused on the physical health of patients and members, our approach to health and wellness must support this larger reality.

Chapter 4: Food for Health

In many ways, the farmers’ markets are symbolic of a broader movement in health care, closely related to other green health initiatives, to promote healthy and more sustainable food systems. Through their substantial purchasing power and health focus, health care systems are ideally positioned to create change within the wider food system, not only within the hospital walls but throughout the entire food enterprise, from agriculture to food processing, distribution and sales, and preparation and consumption.

Our local hospital farmers’ market is just one example of work going on at hospitals and clinics across the country to support local farms and producers, serve healthier, more sustainable offerings to staff and patients, and to make over a tired, industrial food system that until recently served up Jell-O and canned peaches as appropriate hospital food. This work not only seeks to improve health of patients and entire communities but also to improve the well-being of the environment that produces that food.

Chapter 5: Managing and Minimizing Hospital Waste

Anyone who works in health care or wants to understand how it operates should spend some time at the back door of a hospital. There, in the hospital’s underbelly, one can observe a constant stream of trash—from bottles, cans, and cardboard, to pharmaceuticals, sharps, and used lab solvents. At many hospitals, you will also hear the regular humming of the autoclave, a giant furnace-like apparatus that steam-sterilizes medical waste all day and night, preparing it to go to a landfill. But that is not all. Containers of hazardous waste, such as expired chemicals, chemotherapy, spent silver and lead, and diesel oil await pickup from specialized handlers. It is a surprising and even shocking scene to some, and one that goes on at every hospital across the country.

As health care providers, we are responsible for promoting health. Yet, in the process of delivering health care, US hospitals produce more than 2.3 million tons of waste annually. That means hospitals generate an average of 26 pounds of waste per staffed bed in the course of a day. The US health care sector is second only to the food industry in contributing to waste production. Clearly, hospitals have a garbage problem.

Chapter 6: Green Chemicals and the Detoxing of Health Care

Ironically, the health care sector, with its commitment to “do no harm,” is a large user of chemicals, spending more than $100 billion a year on chemicals and chemical products annually (excluding pharmaceuticals).9 Adding to the irony, these chemicals include a host of products used to treat us when we are ill and to maintain a clean and safe environment for patients and staff at all times—cleaners and disinfectants; flame retardants and formaldehyde in furniture; chemicals of concern inside medical devices, like IV bags and tubing; solvents and formaldehyde in laboratories; noxious emissions from anesthetic gases; prescription antidepressants, anticonvulsants, steroids, chemotherapy drugs, antibiotics, and other biologically powerful medications that, improperly disposed of, end up in our drinking water. They include chemicals with known or suspected life-cycle impacts, capable of harming patients, health care workers, and communities from the day they are manufactured until decades after their disposal.

Chapter 7: Environmentally Preferable Purchasing: What We Buy Matters

The health care industry was not far behind. Purchasing departments at a handful of major health systems, including Kaiser Permanente, had been including language on specific environmental attributes, such as recyclability, in their requests for proposals (RFPs) to product suppliers on a selective basis since the mid- to late 1990s. But the first really large-scale achievement for EPP in health care began with the 1998 mercury elimination campaign by Hospitals for a Healthy Environment (H2E), the predecessor of Practice Greenhealth.

As part of that multiyear campaign, H2E worked closely with the nation’s largest group purchasing organizations (GPOs), third-party entities that today aggregate, negotiate, and manage more than 70 percent of all product purchasing for more than 95 percent of all acute care hospitals.6 H2E helped to inform the GPOs about the health impacts of mercury-containing products and the availability of alternative products with equal or superior clinical performance. Meanwhile, a small number of large health systems, including Dignity Health, adopted purchasing policies that required their GPOs and other suppliers to identify all products that contained mercury and PVC and to purchase alternatives whenever possible.

By 2005, three of the five largest GPOs implemented mercury-free purchasing policies for all contracts in which an acceptable alternative product was available, while others focused specifically on eliminating mercury thermometers and sphygmomanometers (blood pressure measuring devices) from all their contracts. The result was a dramatic shift in the entire mercury medical product line, with the GPOs reporting that total sales of mercury devices were steadily decreasing while sales of mercury-free products were increasing. At the same time, as demands for environmentally preferable products grew, the GPOs working with H2E expanded their EPP focus to target products containing latex, glutaraldehyde, ethylene oxide, and toxic cleaning chemicals, plus reprocessing and waste management services, and energy and water efficiency equipment.

Chapter 8: Greening the Built Health Care Environment

Architects and health care professionals had long been interested in sustainability, but it was mostly thought of as an environmental issue. It was not until the 1990s that we began to link environmental stewardship to human health, which seems remarkable today, given how obvious that connection is. Vittori took the connection even further by asserting that sustainable design and green building practices should be fundamental to hospitals and other health care facilities as an extension of the industry’s “first, do no harm” principle.

“I was stunned to realize that having worked in green buildings for twenty years, I didn’t know anyone who had applied a green way of thinking about building design to health care,” she recalls. “At the time I thought: ‘How have we been so completely missing the sector that should be the poster child for green building?’ ”

In a paper presented at the second CleanMed conference in 2002, Vittori advocated for a lifecycle approach to facilities, merging capital and operations costs into a single budget to break owners from their strong tendency to focus only on initial costs when making building decisions. Hospital owners and providers, she wrote, “must learn that budgeting needs to change from first-cost to full-cost accounting that, for example, extends a conventional balance sheet to include a value for health impacts and the environment. They must grasp the concept of preventive maintenance and integrated anticipatory design. And finally, they must embrace the concept of partnering with their suppliers and design professionals to continue to explore the linkages between the nature of the physical environment and the impact the environment—including the built environment—has on medical outcomes, user satisfaction, and productivity.”

Chapter 9: Measuring and Reporting: Sustainability Gets Sophisticated

In one of my first discussions with Kaiser Permanente’s senior vice president for Community Benefit, Research and Health Policy, Dr. Ray Baxter, he shared a vision in which the organization would be “accountable for all of our impacts.” That is saying a lot, and we agreed that part of being “accountable” meant credibly improving our environmental performance and publicly reporting our progress in a transparent way. And “all of our impacts” meant not cherry-picking the easiest or most obvious “greening” activities, but rather doing the following:

  • Rigorously inventorying the many activities of our organization
  • Identifying their corresponding environmental impacts
  • Prioritizing our improvement initiatives based on evidence of significance
  • Establishing measurable targets for initiatives
  • Implementing improvement programs
  • Reporting progress to both our own staff and the public

When we first set out to achieve this agenda in 2008, I tapped into the knowledge of an in-house sustainability expert, Joe Bialowitz, who had experience helping large organizations implement environmental management systems based on the ISO 14001 standard. ISO 14001, developed by the International Organization for Standardization, provides a framework for what organizations need to do to systematically identify and control their environmental impacts, and constantly improve their environmental performance. We completed a planning exercise that, borrowing from the ISO 14001 approach, considered all of Kaiser Permanente’s activities and known impacts, and using that information we created SMART (specific, measurable, attainable, relevant, and time-bound) targets in the priority areas, where we could have the most impact on five environmental forces that shape human and environmental health:

  • Finding safe alternatives to harmful industrial chemicals
  • Responding to climate change
  • Promoting sustainable farming and food choices
  • Reducing, reusing, and recycling to eliminate waste
  • Conserving water

What target-setting tools did we settle on, and how have they evolved over the long haul?

Chapter 10: Community Benefit and the Determinants of Health

Coming under the umbrella of the Community Benefit program may sound like a simple bureaucratic redrawing of the reporting hierarchy. In another organization, it might have been just that. But for us, it meant something much more profound. It meant that our environmental sustainability efforts on greenhouse gas emissions, toxic materials, waste minimization, healthy and sustainably produced food, green buildings, and other objectives would become formally integrated into a vast range of community-focused programs that address the soul and substance of the organization’s historic mission to improve the health of our members and the communities we serve. By aligning our various environmental workstreams with the Community Benefit department’s multiple initiatives—totaling $2 billion a year by 2012—it also helped to more clearly frame our environmental work in the context of community health as opposed to the less specific objective of “saving the planet,” however commendable the latter might be. As Dr. Ray Baxter, the senior vice president of Community Benefit, Research and Health Policy put it, the convergence of the environmental and community health work “helped us to make connections among all the various assets we have across the organization”—from clinical expertise in our medical centers to population health initiatives in our communities to our environmental stewardship work inside and outside the hospital walls. “By utilizing all these separate levers of health,” says Baxter, “we can create a concentrated focus on what we’ve all been calling ‘total health,’ by which we mean going beyond the doctor’s office to schools, workplaces, and community environments that have such a big impact on health.” Dr. Baxter is a big-picture visionary, and environmental stewardship fits nicely into that picture of total health.