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For much of 2007, the main thing on Berkeley resident Lisa Wilson’s mind was the health of her premature baby. But as she spent seven months at the hospital bedside of her delicate daughter Samantha, Wilson couldn’t help but notice the trash. “I remember thinking, ‘Oh my God, look at all we’re throwing away.’”

At home, Wilson had been waste-conscious, choosing products with less packaging to reduce her impact on the environment. At the hospital, she found that approach impossible to maintain. As Samantha’s stay dragged on, the piles of supplies the doctors needed to keep her healthy kept multiplying: diapers, bandages, oxygen tubes, feeding bags. “Everything from gauze squares to little plastic fittings for this or that hose comes packaged in big plastic containers that are sterile,” recalls Wilson.

The waste bothered Wilson, but it seemed inevitable. “How can you not [create trash]?” she asks. “Because of course you can’t reuse this. They [the doctors] are there to fix kids, so they’re going do whatever the protocols say they have to do.” Because Wilson’s first priority was her daughter’s health, her environmental unease slipped into the background. Besides, she didn’t have solutions. “My thinking didn’t go much beyond, ‘This is a situation that needs to change at some point.’”

Many people who work within the hospital system agree that things need to change. Because of their efforts, a new, greener mindset has been creeping through the bright corridors of California’s healthcare establishment, as administrators reconsider everything from the trash hospitals create to the cleansers on their floors to putting solar panels on the roof. But reducing the ecological footprint of healthcare isn’t easy; hospitals’ efforts to treat the sick can affect the world beyond their walls in many ways. For one thing, hospitals are big energy users: An average hospital consumes twice as much energy per square foot as a commercial office building. Hospitals deal with toxic substances including pharmaceuticals, medical waste, laboratory chemicals, and radioactive waste that take extra work to dispose of and that can contribute to environmental pollution. Hospitals buy and use vast quantities of supplies—not just specialized medical equipment, but electronics, paper goods, food, and bed linens. To prevent disease, they use chemicals and packaging to keep things sterile.

All these aspects of a hospital operation add up to a big environmental footprint, and it’s one that is likely to grow. Nationwide, more than 100 million square feet of medical building space are constructed every year, and experts predict that healthcare’s share of the economy will continue to expand. In 2004, spending on hospital care made up almost four percent of California’s total economy.

Hospitals have an important role to play as California works to cement its status as a leader in environmental responsibility. But can they get there?

An uphill climb
As Wilson experienced, hospitals often face conflicts between reducing their environmental impact and delivering state-of-the-art care. “Patients are the top priority, so whatever we do we have to make sure to protect quality, to always have the patients in mind,” says Dominican Sister Mary Ellen Leciejewski, the ecology program coordinator for Catholic Healthcare West (CHW), a San Francisco-based nonprofit that operates the state’s largest system of hospitals.

Other challenges to going green include hospitals’ tendency to operate on tight budgets without a lot of wiggle room for extra costs or investments, the sheer size and complexity of hospital operations, and the tangled web of health-related regulations hospitals must navigate. Then there’s mindset: “There’s a high burden of proof for us,” explains Dr. Preston Maring, a gynecologist and administrator with Oakland-based nonprofit healthcare giant Kaiser Permanente. Health providers make decisions based on proven science, and that same way of thinking can permeate decisions about running hospitals. Even a facility that’s actively working to be more sustainable is likely to shy away from any unproven, cutting-edge ideas, like an eco-friendly flooring material that one hospital rejected because administrators doubted it would last long enough. “Within a healthcare institution, you have to know ahead of time that what you’re doing is the right thing to do,” says Maring. With such a risk-averse attitude, hospitals tend to lag behind when it comes to making green choices.

Healthy earth, healthy people
Despite the obstacles, over the past decade a growing number of hospitals have begun to view a concern for the environment as inseparable from their main mission of promoting good health. Because of their position in the community, hospitals can play a leadership role. “As a healthcare facility we have the opportunity to model health and healing,” agrees CHW’s Leciejewski. “We help people continuously make the connection that our health is aligned with good soil, pure water, clean air.”

Spurred by the largely successful campaign in the late ‘90s to eliminate toxic mercury from hospital waste, several national organizations have made cleaning up healthcare their mission, including Health Care Without Harm, a global coalition working to reduce pollution in the healthcare sector, and Practice Greenhealth, a nonprofit that provides information and support on topics such as clean energy, green building, and waste management. These organizations, both based in Arlington, Virginia, serve as clearinghouses for ideas percolating through the hospital community: that health extends beyond the hospital doors; that what hospitals do affects the larger world; that the environment matters.

In California, those ideas have received a warm reception, and a number of local institutions are working towards sustainability. “These are our recycling bins,” says a smiling Sister Leciejewski, pointing at the large containers lined up along a back driveway at Dominican Hospital, a CHW affiliate in Santa Cruz and Leciejewski’s home base. The bins are standard blue trash containers, but Leciejewski is clearly proud of them. “We recycle all our paper, after we print it double-sided,” she says. Next she points out the spots for collecting metal furniture, light bulbs, food waste, batteries, electronic waste, and plastic wrap.

There’s nothing unique to a hospital about these waste streams, even though they can make up 95 percent of what a facility throws out. But managing it right is important, something Dominican recognized in the ‘90s when employees pushed for recycling programs like the ones they used at home. (Today, Dominican has won almost a dozen awards for waste reduction and environmental leadership.)

Keeping track of which waste goes where is especially crucial when it comes to “the bloody stuff,” as Leciejewski puts it. Disposing of medical waste is expensive and energy-intensive; anything that goes in one of the red biohazard bags has to be treated as possibly infectious and either sterilized or incinerated. Dominican makes sure that employees know exactly what goes in the red bags (used bandages, for example) and what shouldn’t (pizza boxes). “The first year we started emphasizing that we saw a real drop in cost and waste. Now it’s just how we do business,” says Leciejewski.

Being mindful of what comes into the hospital is just as important as dealing with what leaves it. “We’ve been trying to redesign things, talking to vendors to figure out what comes through the front door,” Leciejewski explains. A hospital system of CHW’s size has enough leverage to influence the marketplace. For example, when nurses at Dominican got sick of opening three separate packages of supplies every time they delivered a baby, they convinced their supplier to consolidate the packs into one, reducing the amount of trash.

Still, challenges abound. In 2001, Dominican set up a program to recycle the special “blue wrap” plastic packaging that keeps surgical and medical supplies sterile before use. It was a great success, diverting eight tons of the stuff from the landfill in its first year, but the company Dominican had been working with shut down. The hospital couldn’t find a replacement that wouldn’t ship the waste to China, something Leciejewski is reluctant to do. Now it goes back in the trash.

In spite of the setbacks, Leciejewski remains optimistic. “We realize we can’t do everything. Sometimes it’s baby steps, and we just keep on the journey. Sometimes it’s leaps of faith, and we move ahead.”

An apple a day
One place where Leciejewski is moving ahead fast is in Dominican’s vegetable garden. Tucked on a small plot of land bordered by the cafeteria and a parking lot, the garden, now in its sixth year, offers a touch of serenity amidst the bustle of the busy hospital complex. By summer, the thirty raised beds will brim with onions, tomatoes, eggplants, pepper, carrots, cauliflower, and herbs, lovingly tended by volunteers from the staff and the local community. The organic bounty will head straight to the plates of employees and visitors. (The garden isn’t big enough to provide for patient meals.)

The idea of serving fresh, organic, locally grown foods is one that’s gaining popularity throughout the hospital community. In 2007, the California Medical Association passed a resolution encouraging hospitals to promote a healthier and more sustainable food system. As of May 2008, over a hundred healthcare facilities had signed a pledge, sponsored by Health Care Without Harm, committing to the goal of providing local, nutritious, and sustainable food. Local signers include all of CHW’s facilities, the St. Joseph Health System in Sonoma County, and the John Muir Health System hospitals in Concord and Walnut Creek.

The idea behind both the resolution and the pledge is that the negative impacts of industrial farming—pesticides, overuse of antibiotics in livestock, land degradation, high fuel use for transporting food, to name a few—are not just an environmental but a public health issue, and one in which hospitals need to take an active role. For many hospitals, though, that’s a big leap: A 2005 survey by the Physicians Committee for Responsible Medicine found that only sixteen percent of hospitals used organic ingredients, and fewer than a third were even consistently offering meals that were healthful for people, much less the environment.

But change is on its way. The Kaiser hospital system, for example, is working to source food for patient meals from small and mid-sized local growers, to provide hormone-free milk, and to offer healthy options in its vending machines. “There’s so much room for connecting people to good healthy food,” says Kaiser physician Preston Maring.

Maring is also working to bring locally grown food to the larger community; in 2003 he started a weekly farmer’s market at Kaiser’s Oakland Medical Center, where he practices. Staff, patients, visitors, and the community so appreciated having organic, farm-fresh produce at their fingertips that Kaiser has expanded the program to include weekly markets at 32 hospitals in four states. Kaiser found that 71 percent of people who attended the markets said they were eating more fruits and vegetables as a result. “What people eat is the most important thing for their health,” he emphasizes.

Green from the ground up
Changing what goes on inside the hospital, however, is only part of the solution. Hospitals are also starting to consider integrating green designs and technologies into the buildings themselves. For example, green building standards encourage use of interior materials that don’t emit high levels of volatile organic compounds (VOCs). Such materials help keep indoor air healthy, especially important for vulnerable patients. Similarly, buildings designed to provide lots of access to daylight help reduce the energy used for lighting and have been shown to speed patient recovery and improve mood.

Yet certified green buildings have been slow to catch on in the hospital sector. “Part of the issue is that the timeframes are so long,” says Larry Koller, program manager for the Mills-Peninsula Hospital Replacement Project in Burlingame, a new building set to open in 2010. “The idea of green is relatively new to the construction industry, and in 2000-2003,” when the team was designing the project, “a lot of the products were not around.” As an example, Koller points out that if they were designing the hospital today they might include solar panel technology that was prohibitively expensive in 2000.

Still, the new Peninsula Medical Center will incorporate a few green elements. The team worked hard to design a climate control and ventilation system that could pipe outside air into each room separately (to prevent germs from spreading between rooms) without using much extra energy. The system now serves as a model for other facilities.
Kaiser Permanente has also been working to incorporate green elements into its new buildings. In October 2008, Kaiser opened a facility in Modesto that features sustainable details such as a small rooftop solar array, permeable
pavement in the parking area that allows rainwater to filter through it, and low-VOC carpet made with recycled materials, a product that didn’t exist until Kaiser asked manufacturers to design it. Kaiser plans to incorporate green elements into many of its new hospitals.

Money matters
Moving forward, hospitals are bound to profit from the innovations in sustainable technology, from renewable energy to green cleaning products. As more hospitals develop green solutions, even the most conservative institutions will have solid models to follow. For example, the US Green Building Council is currently in the pilot phase of LEED green building certifications designed specifically for healthcare.

Yet the hospital sector is subject to the all the perils of the current economy. While sustainability advocates have worked hard to couch their arguments in terms of long-term cost savings (Practice Greenhealth even has a publication called The Business Case for Greening the Health Care Sector), many sustainability changes require an initial investment that may be unpalatable during a recession.

Even if the progress that many institutions have demonstrated expands, there’s a long way to go before the entire industry is as green as it could be. No matter what percentage of its trash a hospital recycles, or how local its food is, or how sustainable the building, the uncomfortable truth is that modern medical practices have a big impact on the environment, as Wilson saw during her stay with Samantha. Possibly the best way for each of us to reduce the impact of hospitals on the environment is to do our best to avoid using them. That means making lifestyle choices like eating well and exercising, and advocating for better access to good food and laws that clean up our air and water. Environmental illnesses are becoming endemic in our society, and in many cases, the way we treat illness is still bad for the Earth. In the end, the greening of hospitals will need to extend far beyond their walls.

Towards a Greener Practice

Even as many hospitals work to reduce their environmental impact, some activists say the medical community is just scratching the surface. “Primarily the green is going on between the administrators and the support staff, and it’s leaving out the clinicians,” declares Dr. Joel Kreisberg, founder and executive director of Berkeley’s Teleosis Institute, a nonprofit that advocates an eco-conscious medical system.

Kreisberg’s idea is that reducing healthcare’s footprint has to go beyond efficient buildings and recycled paper, straight to the heart of what goes on between doctor and patient. If doctors can help keep people from getting sick in the first place, they can prevent a lot of harm to the environment. That means asking patients about their lifestyle—diet, exercise, exposure to chemicals—and helping them make positive changes.

Doctors can also help reduce pharmaceutical pollution by trying alternative treatments when appropriate and prescribing only as much of a drug as a patient needs. Simply being aware that medicines might someday end up in the ecosystem is a big step for some clinicians. Teleosis offers courses in green healthcare to help practitioners understand how they can protect the environment: “We have to connect all the dots,” Kreisberg says.
To find out more, including how you can safely dispose of unused medicines, visit www.telosis.org