by
|
by |
|
Abstract
When it comes to the environment, some health-care providers are realizing that pollution prevention is not only better than a cure, it's also an obligation.
| Many hospitals are going "green." |
According to the 1998 report Greening Hospitals - an unprecedented survey of 50 top U.S. hospitals by Health Care Without Harm (HCWH) and the Environmental Working Group - some hospitals are changing to greener ways, while the lack of "basic" environmental practices at many other hospitals is causing serious pollution problems that impact public health.
Since the 1950s, the convenience of disposable medical products has led to overfilled landfills and has resulted in the contamination of land, seashores, water, and air. Hospitals such as New York City's Beth Israel Medical Center have rightly concluded that they could be defeating their own purpose of providing health care. "We now better understand that health-care environmental management is a public health issue," says Janet Brown, medical waste manager at Beth Israel and recipient of the Citizen's Award from the EPA in April 2001. Under Brown's management, Beth Israel has also won numerous awards for waste initiatives.
Clinical medicine had once been closely linked to public health. Health practitioners since the time of Hippocrates knew that the understanding and treatment of illness required a holistic approach - one that weighed environmental factors along with others. Somewhere along the rapid path of progress in developed countries, the focus on individual cures occurred at the expense of public harm. Now, we're forced to deal with the irony.
In June 1998, the American Hospital Association, in partnership with the U.S. Environmental Protection Agency (EPA), set a goal to eliminate mercury from hospitals' waste streams by 2005; reduce waste volume by 50 percent by 2010; and identify hazardous substances for pollution prevention and waste reduction opportunities.
| The Sustainable Hospitals Project provides free advice. |
A commitment to the environment requires "green" thinking - policies that place a core value on green practices and products. Hospitals can turn for free technical help to the Sustainable Hospitals Project, which is funded by the National Institute for Occupational Safety and Health. The project's goal is to study the occupational health and safety impact of hospitals' pollution prevention initiatives. According to Tom Fuller, project manager, some hospitals have opened their doors, while others are reluctant to participate.
At CleanMed2001, a recent conference in Boston coordinated by HCWH, environmental stewards such as HealthcareWest, Kaiser Permanente, and Beth Israel Medical Center shared model hospital practices in sync with environmental management guidelines under ISO 14000. Scandinavian hospitals also shared model polyvinyl chloride (PVC) plastic reduction practices.
Hazardous/Nonhazardous Waste Reduction
| Hospitals generate 2 million tons of waste per day. |
The estimated medical waste generated overall is about 2 million tons per day - an average of 15 pounds per patient per day. Regulated medical waste (RMW), the infectious or "red bag" waste, is about five times more costly than regular waste to dispose of and constitutes about 10 to 15 percent of total hospital waste.
By segregating red-bag waste and recycling, Beth Israel has managed to cut nonregulated medical waste fees by as much as $800,000 yearly. Brown states that waste segregation is a public health issue.
| Kaiser launched a national effort four years ago. |
Kaiser Permanente's successful sustainability efforts at the facility level for 20 years prompted the launching of a national effort four years ago. Its Environmental Stewardship Program's goal is to minimize waste, prevent pollution, and conserve natural resources, while reducing cost and modeling responsible environmental practices for the health-care industry.
Kaiser Permanente's "take-back" purchasing program addresses the life cycle of the product through environmentally preferable purchasing (EPP). It is set up to take back the old product automatically. Life-cycle purchasing is based on choosing products after considering their cradle-to-grave impact. The responsibility for a product does not end with its use. Buying products that can be recycled, or are less harmful if they have to be dumped, is the basis of EPP.
By setting up a recycling program last year, Kaiser Permanente saved $7,000 in purchasing and disposal costs for hazardous xylene and alcohol - cutting the alcohol disposed of by more than 75 percent from 1998 levels. "We frequently find that what's good for the environment is actually smart for the business as well," says Kathy Gerwig, Kaiser Permanente's national manager for resource conservation.
| What's good for the environment is good for business. |
Albany Medical Center (AMC) recycles 20 to 25 percent of its waste stream. This current figure dropped from a 50 percent recycling effort in 1998, primarily due to the loss of composting in New York State, explains Russell Mankes, assistant professor in pharmacology and neuroscience. Through CURE Waste, an integrated waste management program, the poundage of all red-bag waste was reduced from 3 million pounds yearly to 900,000 pounds in 2001, after segregation and packaging changes.
CURE Waste includes recycling of all types of batteries ("more than we use," says Mankes with a chuckle), at a savings of $38,000 annually. AMC also recycle fives different types of waste chemicals - alcohol, formalin, xylene, mineral spirits, and paint thinner - through the first, and probably largest, chemical reclamation facility, into pure products that can be used in its labs. The savings? $1.3 million with 100 tons of chemicals recycled since the program's start in 1996. An added benefit: the conversion of part of the hazardous chemicals storage space into a research lab.
Incineration
| Incineration produces mercury and dioxin emissions. |
A federal report shows that medical waste incineration is a source of 10 percent of anthropogenic mercury emissions. Another federal study, The Inventory of Sources of Dioxin in the United States, has documented that incineration of millions of pounds of hospital waste each year constitutes a major source of mercury and dioxin. (Hospitals are among the top three sources of dioxin.) Dioxins, a class of chemical by-products resulting from the manufacture and disposal of chlorinated compounds such as PVC plastic, and mercury are both highly toxic, persist in the environment, and are bioaccumulative, rising through the food chain.
Dioxin was among the 12 persistent organic pollutants targeted for elimination through a United Nations Environment Programme treaty finalized in December of last year.
| Some hospitals incinerate 75 to 100 percent of their waste. |
The Centers for Disease Control recommends medical waste incineration for certain infectious waste. Greening Hospitals reports that some hospitals incinerate 75 to 100 percent of their waste. Some major hospitals reportedly send their waste to incinerators in low-income areas.
In September 1997 the EPA issued its final standards and guidelines for medical waste incinerators. The rules establish limits on a number of pollutants including dioxin and mercury, in compliance with the Clean Air Act. In addition, they set guidelines for training of operators, monitoring, etc. Each state, however, has the responsibility of determining how those rules will be implemented. Generally, states are more stringent. Incinerators operated by hospitals on-site are exempt from reporting toxics release to the toxics release inventory.
| Pollution control devices can be costly. |
Pollution control devices are one way to regulate the emissions from incinerators to comply with established standards. But, as Albany Medical discovered before rejecting on-site incineration and separating all waste going as red-bag waste, they can be costly.
Beth Israel has rejected incineration for a better alternative - steam sterilization or autoclaving off-site for RMW and sharps containers, making them reusable. Microwaving and chemical treatment offer other choices that reduce the risk of dioxin production - with some disadvantages. With autoclaving, precautions must be taken to ensure mercury does not enter the water bodies around the autoclaving facility; microwaving's one disadvantage is that it does not inactivate some of the most heat-resistant bacteria; chemical treatment is generally not as effective as autocalving and microwaving; and there is always the risk of chemical hazard.
Mercury
| NIH has pledged to use mercury-free products. |
Health Care Without Harm's Mercury Man has increased mercury's visibility through a mercury-free campaign aimed at educating people about how mercury affects wildlife, human health, and the environment. The National Institutes of Health recently pledged to replace mercury-containing products with mercury-free products in its research facilities. Many states are banning retail sales of mercury thermometers.
Since 1995, Albany Medical Center has had a mercury-free policy, and Beth Israel won an award from HCWH for its contribution to mercury-free medicine. Two years ago, Kaiser Permanente pledged to eliminate mercury from its labs. But is that avoiding the hazard problem while compounding that of waste disposal?
| Costs add up with mercury devices. |
"We go beyond unit cost with a mercury device," says Kaiser Permanente's Gerwig, adding that training staff for a mercury spill, downtime, and rooms taken out of service add up to being more expensive. "What you have to balance is patient safety, quality of care, along with environmental considerations."
Kaiser Permanente also substituted mercury-containing fluorescent lamps and is replacing mercury sphygmomanometers with aneroid ones for one-third the cost.
| Resolutions to eliminate PVC have passed. |
"Even in places like a lab, in a solution where you think there isn't much mercury, there is an incredible amount of opportunity," says Gerwig about the decision to substitute B-5 fixative - equivalent to eliminating 4,700 mercury thermometers - in Kaiser Permanente's California labs. B-5 is also ten times costlier than the substitute to dispose of.
PVC Plastic
As a major source of dioxin from manufacture and incineration, PVC plastics, widely used in hospitals since World War II, also contain plasticizers and softeners called phthalates. Di-ethylhexyl-phthalate (DEHP) has been identified as a reproductive toxin. Resolutions calling for the elimination of PVC have been passed by many health-care and public health organizations such as the Minnesota Hospital and Healthcare Partnership, the California Medical Association, and the American Public Health Association. Maine Hospitals have pledged to reduce PVC. Baxter International is going PVC-free. Greener alternatives are plastics from biomaterials, polyethylene, and polypropylene.
Albany Medical recycles PVC and does its best to minimize its use. Beth Israel uses non-PVC IV bags. Kaiser Permanente also aims to reduce PVC through environmentally responsible purchasing.
Green Buildings
| Green buildings reduce energy consumption. |
From land-use to design and construction, sustainable buildings serve to reduce energy consumption and protect ecosystems and occupant health, among their other benefits. Kaiser Permanente's goal of green buildings in all its facilities would include the elimination of PVC in building materials.
Green Cleaners
Chemical cleaning solutions are hazardous and can be a source of indoor air pollution. Some of the pollutants are suspected carcinogens. In waste streams, they can hurt the environment. Cleaning solutions made from natural substances offer a less harmful alternative.
Pesticides
| "Integrated pest management" offers a safer alternative to pesticides. |
Although a 1995 study by the New York Attorney General's Office showed many New York hospitals use less toxic pesticides in food preparation and waste disposal areas, waiting rooms, patient rooms, and treatment areas, a safer alternative is "integrated pest management" - natural pesticides with chemical pesticides as a last resort.
Sure, old habits die hard; time and space are major challenges - training staff to think that they can't chuck all waste into the closest can. There are now many choices: sharps, red bag, recycling, clear bag, chemotherapy, battery, bulb, etc. . . . Educating hard-pressed physicians about the regulations on waste segregation; coordinating; getting all the stakeholders to participate in changing their practices. Nonetheless, environmental stewards are making it their mission to sustain a healthier environment.
Barbara deSouza MacMath is a freelance writer and a resident (alien, if you please) in the American "Constitution State." After majoring in chemistry with a minor in botany (all by default) from Bombay University, India, she found that her right brain seemed to function better than her left, and went on to study mass communication.
Andrzej Krauze is an illustrator, poster maker, cartoonist, and painter who illustrates regularly for HMS Beagle, The Guardian, The Sunday Telegraph, Bookseller, and New Statesman.
Environmental Florence Nightingales: Nursing's New Front Line - argues for an increased emphasis on environmental health in nursing. From Environmental Health Perspectives, March 2001.
Public Health: Things Fall Apart, Turning Engineers into Resource Accountants, Enhanced: Toward Greener Chemistry, and Toward Sustainable Chemistry - several recent articles from Science.
MWRA/MASCO Mercury Workgroup - a joint group of water authority and hospital personnel focused on reducing discharges of mercury from medical facilities. The site contains published reports that cover end-of-pipe issues, operations, infrastructure, facilities loadings, pretreatment, mercury management, as well as a mercury products database.
Environmental Health Clearinghouse - offers information on a variety of environmental health issues. From the NIEHS.
Pollution Prevention Web Site - contains general information about practices, programs, and initiatives. From the EPA.
Massachusetts Toxics Use Reduction Institute - provides resources on technology, policy, learning, management tools, references, and publications.
Related HMS Beagle articles: