Greening Health Care
Mark Ballard, former Medical Student Rep for PGS ( Canada)
Good Afternoon DPAS co-coordinators
So to start, my name is Mark Ballard and this is my advisor and group member Dr. Lisa Mu. I spoke to some of you before about what I wanted to speak about today, but just to re-iterate I am here to speak to you about the possibility of integrating Sustainable Healthcare (SH) education into the DPAS Medical school curriculum.
Currently, many Health Authorities look at SH from a purely economic perspective, they gage the cost of the treatment vs the patient care. For example the Northern Health Authority values makes no public mentioned of environmental sustainability (see quotation).
We must be wise in balancing the services we provide with the resources available in order to ensure a sustainable system. We invest in what is effective in meeting needs, and we ensure that services are managed with efficiency. (Vancouver Island Health Authority website)
However over recent years groups have proposed that a SH should contain three key factors: patient care, responsible fiscal budgeting and minimizing environmental impact (Jameton, McGuire, 2002). It is this vision of SH that I would like to focus on and I would like to propose that the UBC medical school DPAS program take a first step in BC and Canada in introducing SH information to medical students.
Over the next 20 minutes I would like to share with you why I feel it is important that we teach Medical Students, future physicians, about environmental sustainability, in addiction to fiscal and patient sustainability. My talk will start with a brief introduction to global warming and how hospitals fit into the picture, Canada’s current commitment to the environment, why should hospitals teach sustainable healthcare, what the manufacturing and retail industry is doing about sustainability, what other hospitals in Canada are doing about sustainability, what are the local health authorities current standpoint on sustainability, how would DPAS fit into the Environmental Science Center Model, what are the important objectives to teach to medical students, who are the potential teachers, followed finally by the conclusions and questions period.
Global Warming and Hospitals
Many of you have likely watched the film An Inconvenient Truth by Al Gore. It gives a fairly good overview of the global warming situation. Essentially, the film, which has been well received by scientists within the global warming field, states that humans are the cause of global warming (1, 2). Other sources state that solar radiation and volcanic eruption encompass the leading natural contributors to global warming (3, 4) but still do not contribute as much as human causes.
Healthcare in Canada is second only to the manufacturing industry in its generation of pollution. Canada’s healthcare system and hospitals make up 10% and 3% respectively of the GDP thus is a substantial consumer of renewable and non-renewable resources including energy, paper and water. Additionally, as any other major economic player it is also a producer of a wide variety of toxic and non-toxic wastes that can contaminate the air, the water, the earth and last but not least, people and patients.
Ecological foot print studies, ie studies to determine the amount of land required to support a person or an institution, have compared a hospital’s land consumption to a variety of other entities. As a basis of comparison, the average Canadian requires 7.66 hectares, the average American requires 12.22 hectares, and the average Asian requires 1.78 hectares. Thus an American consumes 60% more resources than a Canadian and a Canadian consumes 400% more than an Asian living in a developing country. At a more macroscopic level Vancouver city requires 180 X more land space to sustain itself than its political boundaries allow and finally a hospital requires 700 X more land space than its actual size.
In regards to the above, Energy use contributed to 88% of the ecological footprint compared to 50% for the national average in a developed nation. 8.2 pairs of gloves per patient per day were worn, in other words 1.75 million pairs over the year in a hospital with an average in-patient count of 591 and of 220 tonnes of paper consumed only 97 tonnes were recycled. It should be noted though that the ecological footprint mentioned above is by far a conservative estimation as it was not possible to get product composition information from companies, hospital food consumption was not calculated and finally building maintenance was not calculated.
To this point we have looked at the amount a hospital consumes, a quick point should be mentioned on how much pollution a hospital produces. First, the negative impacts of a hospital, or any institution, can be measured by looking at the ecotoxicity, to the resource depletion, changes in climate and atmosphere to finally an overall ecosystem health.
Specifically healthcare produces: clean general waste, recyclable waste, biomedical waste, chemical and liquid waste, radioactive waste, pharmaceutical waste and miscellaneous waste.
In summary, hospitals are major contributors to global warming and more should be done to reduce their impact.
Canada’s Commitment to Pollution reduction
On the 11th of December 1997 the Kyoto Protocol to the international Framework Convention on Climate Change (UNFCCC) was agreed upon to reduce greenhouse gases that cause climate change. The Protocol did not enter into force until the 16th of February 2005. Canada’s general public met the protocol with great optimism, with support for the protocol at around 70%. However, the governing Conservative Party and some business groups argued that the protocol would generate energy and economic concerns. In particular, Canada was concerned about its ability to compete with the US as the US companies would not be impeded by the protocol whereas the Canadian companies would. Despite Canada’s signing of the protocol, its greenhouse emission rates increased by 62% in contrast with a 21% increase by the US, who did not sign the protocol. As of May 2006, funding has been cut to fund the Kyoto protocol.
In response to the Kyoto Protocol’s failure the conservative government signed on to the Asia Pacific Partnership on Clean Development and Climate. Along with the US, the partnership permits the sharing of clean technology, but does not put caps on carbon dioxide emissions. The governments that have signed on to this treaty have felt that it is “fair and effective”, but the World Wide Fund for Nature and other advocates for the Kyoto Protocol have deemed it ineffective citing that “a deal on climate change that doesn’t limit pollution is the same as a peace plan that allows guns to be fired.”
Regardless of the lack of government support for the Kyoto Accord, many private institutions, even Wal-Mart, and cities across North America are attempting to cut emissions, with many of them citing that they want to meet Kyoto Protocol standards. Canada’s Healthcare system should jump on the bandwagon too.
What other places have done
Over the past few years there has been growing recognition among northern developed countries, including Canada that healthcare’s environmental impact must be reduced. In the US many health authorities, in response to this realization, have begun to develop their new hospitals to leadership in energy and environmental design (LEED) standards. LEED standards encompass 12 criteria that are used to determine the quality of a “green hospital”. These standards include waste disposal, to water and energy efficiency to whether the staff members receive “green education” and to finish off with eight other criteria outside of the scope of this presentation.
These changes within the US lead the Ontario Health Authority (OHA) to create the Canadian Coalition for Green Healthcare and recognize the environmental impacts in the 2000 Health Canada Sustainable Development Strategy. Ontario subsequently improved the LEED standards of Toronto’s Hospital for Sick Children and the University Health Network (encompassing three different hospitals) where the waste disposal was improved. The South Riverdale Community Health Centre has enacted policies in disposal, safe cleaning supplies and air quality. St. Michael’s Hospitals took yet another approach to hospital greening and implemented a new heating system that saved 30% in both water and energy consumption. Finally, the OHA is planning to build a hospital within the William Osler health system entirely to LEED standards.
British Columbia has made a few motions towards sustainable healthcare the interior health authority has built three different LEED hospitals and one green friendly hospital. As of February 13, 2007 a Speech from the Throne announced that “New strategies will be launched to promote Pacific Green universities, colleges, hospitals, schools, prisons, ferries, and airports.” In fact it goes so far as stating that health authorities will be required to ensure that their health care facilities are healthy. Further research will also be done in BC on preventing the adverse effects of the health care system. Finally, the Capital Services division has a draft White Paper on hospital construction with 10 principles, one of which refers to sustainable design. In summary the health authorities are starting to catch up on the building design, but education is still lacking in all centers.
The Positions of selected Medical Education related Institutions within British Columbia
Specifically attempts were made to contact the British Columbia Northern Health Authority (NHA), Vancouver Island Health Authority (VIHA) and the College of Physicians and Surgeons (BCCPS) to determine what there standpoint on sustainable healthcare is. Of these groups only NHA returned a definitive response and they stated that they make attempts at purchasing items in bulk to reduce the amount of packaging they receive.
Web searches of the fore mentioned organizations returned no mention of any position on environmental sustainability in any of the publications. Additionally, there was no reference to environmental sustainability on any of their respective websites.
Why Teach Sustainable Healthcare
Primum non nocere- First, do no harm, is a statement that encapsulates the ethical duties of healthcare in a nutshell. Patients come to hospitals for help because they are sick and it is healthcares duty to heal them. Additionally it is healthcares duty to ensure that healthcare providers are not making the patients ill in the first place and if these healthcare providers are causing illness it is their responsibility to reduce there contributions to illness generation. As mentioned above, healthcare is the second leading cause of pollution and it is a well known fact within the medical community that pollution leads to illness. During the UBC medical curriculum pollution has been cited to contribute to atherosclerosis, asthma, cancer, mercury poisoning, lead poisoning, the energy hospitals use to global warming and to too many others to continue naming. Therefore it is the ethical duty of healthcare to attempt to reduce the generation of many of the fore mentioned problems.
One of the problems encountered though is a lack of formal training in sustainable healthcare among healthcare workers. From a mass e-mail sent to the UBC medical school numerous UBC medical students from the 2008 to 2011 classes and even a few residents cited insufficient knowledge of how they can be of help in the defense of the environment. Another group of students cited lack of foresight in the work-life balance, many young physicians over consume when they are not at work, and although they have the financial ability to over-consume, for the environments sake, should they? A commonly brought up concern by all members of the class is the excessive use of paper by healthcare and the lack of electronic resources, in fact numerous initiatives have been attempted and failed to reduce the amount of paper used during medical education. This comment was reinforced by the statement that society focuses too much on recycling and not enough on the other two “R’s”, reusing and reducing. Finally many students have noticed that many of the hospitals have environmentally poor building standards, reduced recycling capabilities, no water fountains, cafeterias that serve unhealthy food with plenty of packaging. All in all, some students have some idea on what to do about the environment, but many do not.
How DPAS fits into Healthcare provider education
The UBC Medical School DPAS program is strategically position to provide a substantial amount of education on sustainable healthcare to students. The Environmental Science Center in Augsburg Germany has done a substantial amount of work in developing environmental management systems for hospitals. In there major publication, Greener Hospitals, they bring up the idea of a triad of important aspects to create and maintain a healthy sustainable healthcare system (see Figure). This triad’s pillars include environmental protection for sustainable healthcare in the long term, economic considerations for the sustainability of healthcare in the short term, and finally education and efficient organization of healthcare staff and patients to ensure that the above two objectives are met.
Environmental protection is the most new of the concept sustainable healthcare and takes into account the negative effects that a hospital has on the surrounding world. To this point we have mentioned many of the toxic effects that healthcare has on the patients, workers and world. To address this pillar of SH, healthcare needs to reduce its use of resources and reduce the harm of its waste, as mentioned above.
Luckily many of the goals of environmental protection can also be achieved by simply looking after healthcare’s economy. If hospitals can purchase fewer resources, whether they are energy, water or even disposable equipment, it will not only reduce the costs to the hospital, but also reduce the number of resources used from the environment. As mentioned earlier, Hospitals in Ontario enjoyed a 30% reduction in the costs associated with energy and water use, simply by installing a new heating system. This reduction in costs could then be further used to benefit the patients and make the hospital more competitive in respect to the services that it provides.
However, to sustain any of the above mentioned thoughts the healthcare staff, and even patients, need to understand how the hospital and family offices fit into the larger environmental picture. Staff need to understand that although the hospital is saving lives, they are also harming lives if they are wasteful in their use of resources, or if they use resources that are toxic to the environment when non-toxic resources are readily available. For example many hospitals still use many toxic cleaners that pollute lakes and streams when they are permitted to go down the drain. Additionally, new family doctors that set up their offices in places difficult to access by local transit or pedestrians may save money in rent, but in turn would be costing the environment a substantial amount in terms of the amount people have to drive to get to the office. For example, hospitals within the United Kingdom’s National Health Service have stated that patients, staff and visitors drive an average of 25 billion kilometers a year to access a particular hospital, 80% of which was by car. Now if this hospital was located in a more transit friendly location that number could be reduced substantially, a reduction that even family doctors should consider in the setting up of their practices.
DPAS is strategically positioned to teach medical students, future physicians and leaders of tomorrow, to understand how healthcare fits into the sustainable healthcare triad. As mentioned before many students are concerned about the environment but do not know how they can help within their profession. Further to this many students are not aware of what impacts their extracurricular activities will have when they finally start receiving income. Depending on the specialty and the number of hours worked, future physicians will have the financial ability to purchase items such as suburban utility vehicles and high end sports cars, two luxury items known to consume a large quantity of fuel. The majority of medical students should already have a good grasp on how to think about purchases and business from an economic perspective, but a minority of students will be able to think from an environmental perspective. When setting up a new office down town, a physician who thinks strictly from an economic point of view will consider the high cost of rent vs. the number of patients that can come in on a particular day vs. the amount of patients the physician would ideally want to see in a day. If the physicians would like to see a large number of patients in a day, downtown would be economically worth it, but if a physician would like to have a quieter practice it may be more logical to set up a practice outside of downtown. However, if the physician was also thinking from an environmental perspective, consideration would also be placed on how far the physician has to drive to work and how far do the patients have to drive to work in addition to the previously mentioned considerations. With the addition of this perspective, it is easy to see that a large proportion of the patients would have less distance to travel to get to an office downtown because it is easily accessible by foot and transit, whereas an office in the outskirts of Surrey or Victoria may require more patients to drive. A DPAS lecture would facilitate the students thinking on environmental cost-benefit scale in addition to an economic cost-benefit scale.
In addition to generating a methodology of thinking about decisions a DPAS lecture would be optimally positioned within the healthcare field to provide ideas on what students and physicians can do practically. A physician that enters rural practice may have the opportunity to engage in healthcare worker training programs on sustainable healthcare. Additionally, work can be done on purchasing non-toxic cleaners and encouraging staff to dispose of trash in the correct waste, as unnecessary waste in biohazard bags costs more money to the hospital and generates more pollution because this waste must be incinerated. In fact it has been estimated that only 15% of all waste within a biohazard container actually needs to be eliminated by incineration. A physician on a Hospital advisory board may sway the decision makers in building the next hospital to LEED standards, or to simply be role models for the next generation of medical students. These are but a few examples of many areas that need practical solutions.
In summary, DPAS would be ideally suited to provide students with reasons why healthcare needs to become more environmentally sustainable. DPAS will be able to provide a theoretical tool kit on how to reason environmentally in addition to economically. Finally, DPAS plenary will provide an excellent opening to have students, in tutorial, discuss what they can do practically as medical students and as future physicians to help make healthcare more environmentally sustainable.
As for who could teach sustainability in DPAS every year, our group has taken the liberty to contact Dr. Trevor Hancock, Dr. Warren Bell, and Dr. Bob Wollard. As of this point, Dr. Hancock has expressed interest in teaching this lecture. Much of the material for this presentation was provided by articles that Dr. Hancock has published, thus he would be an excellent choice as a future sustainable healthcare lecturer.
At the current moment many healthcare institutions, especially in Ontario, have realized that healthcare needs to be environmentally sustainable in addition to economically sustainable, but, not much action towards this realization has been done. The UBC Medical School DPAS program sits in an optimal position to be the first in Canada to teach environmentally sustainable healthcare. A decision to teach sustainable green healthcare is very important to the future of our planet, to our patients, and to our families.
Students across Canada have realized this and are taking action. Students are approaching the University of Ottawa Medical Faculty, selected hospitals in Victoria and Vancouver Coastal Health to ask for their help in redefining the word sustainable healthcare from a purely economic concept to one that that includes the environment.
Jameton A., McGuire C. (2002). Toward sustainable health-care services: principles, challenges and a process. International Journal of Sustainability in Higher Education. Vol 3 (2): 113-127
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4. ^ Robock, Alan, and Clive Oppenheimer, Eds., 2003: Volcanism and the Earth’s Atmosphere, Geophysical Monograph 139, American Geophysical Union, Washington, DC, 360 pp.