Health in the Green Economy

How Carbon Reduction May Impact Health in Health Sector Services

Amy Jarvis

Amy Jarvis

More about Author

Amy Jarvis has developed an internal sustainability plan to include large-scale sustainable solutions, such as renewable energy installations and the purchase recycled products, as well as metrics to evaluate these solutions. Amy's internal sustainability efforts in the Portland office culminated in earning the first-ever Portland Climate Champion Award awarded by the BEST (Businesses for an Environmentally Sustainable Tomorrow) Business Center.

Walt Vernon

Walt Vernon

More about Author

Walt Vernon is an electrical engineer with over 20 years of experience in the design and construction of healthcare facilities across the country. He is the Vice-Chair for the ASHRAE 189.2 Standard for Green Healthcare Buildings and provided leadership for sustainable healthcare facilities at both the state and national levels serving as one of three Co-Coordinators for the Green Guide for Healthcare (GGHC). Walt serves the World Health Organization as a consultant in helping with greener healthcare buildings around the world and founded the consulting group BLUE.

In 2010, the World Health Organization launched a series of reviews of carbon mitigation strategies in five key economic sectors. The health sector paper focuses on carbon mitigation measures that provide significant carbon reduction benefits as well health benefits for healthcare facilities. This article summarises key findings from this paper.

The provision of accessible, affordable and quality healthcare is directly dependent on the efficient performance of healthcare facilities. Modern healthcare facilities, and procedures, however, require many costly and energy-intensive processes - in terms of the use of water, lighting, heating, cooling and ventilation, as well as waste disposal. These are part of the overall cost of healthcare, whose expenditures in 2007 totalled $US 5.3 trillion, or US$ 639 per person per year, roughly 8 to 10 per cent of global GDP.

There is also increasing evidence that more climate friendly and energy efficient provision of healthcare services may also improve aspects of healthcare service functioning, safety, and climate change/emergency resilience. These same strategies may also improve aspects of healthcare access, particularly for the poor and vulnerable. And, there is evidence that some strategies can reduce risks of certain diseases, or otherwise directly improve certain health outcomes. These positive impacts are commonly called "co-benefits."

In light of this growing body of evidence, more climate-friendly and energy efficient healthcare facilities may yield a double or triple benefit in terms of patients, healthcare workers, and the communities served.

The work of the United Nations Intergovernmental Panel on Climate Change (IPCC) represents the largest body of global review of climate change mitigation strategies, by sector. Many of the strategies for industry and commercial buildings covered by the most recent IPCC review, the Fourth Assessment Report, Working Group III (IPCC, 2007), are also highly relevant to healthcare facilities. Additionally, the health sector is worthy of special attention insofar as healthcare facilities may also offer some unique opportunities for mitigation overlooked by other mitigation reviews, including the IPCC.

And, as perceived leaders in health-promoting activities and behaviour, health policy decision makers carry a responsibility to assess such evidence systematically, and assume a role in leading initiatives that address global environmental health for the future and present-day generations.

For these reasons, the World Health Organization (WHO) is currently undertaking a review of potential health co-benefits of mitigation strategies by healthcare facilities, with reference to mitigation strategies considered by IPCC and, where relevant, other key summaries of evidence. In some cases, health risks are also identified, so that they may, too, be mitigated, in the context of sustainability.

The WHO review evaluates IPCC-reviewed mitigation strategies for buildings and industry in the healthcare facility context - with a particular focus on mitigation measures that have direct impacts on the delivery of healthcare services, environmental and occupational health for healthcare workers, patients and the communities; and indirect benefits such as improved resilience of healthcare facilities due to more reliable energy provision. In addition, this review looks at how health equity is impacted by certain mitigation strategies. For instance, in energy-poor settings and off-grid rural clinics, more use of renewable energy sources, and better management of energy may increase access and reliability of healthcare services. While most of the focus is placed on mitigation strategies considered by the IPCC, some strategies not mentioned by IPCC are also considered, if they take advantage of some of the unique opportunities offered by the healthcare sector to generate health and environment co-benefits.

WHO defines the healthcare system as "all organisations, institutions, and resources that are devoted to producing health actions." In reality, the healthcare sector includes such a wide variety of practices and activities that precise definition of the sector boundaries across countries and cultures can probably never be conclusive. Therefore, the WHO review focuses on healthcare sector facilities, including those that provide direct, health treatment procedures to patients. That includes hospitals and healthcare clinics, not health clubs, nor pharmaceutical manufacturing facilities. Home-based healthcare and outreach programmes, such as vaccine and bednet distribution campaigns, are not explicitly considered, except as relevant to facility management, such as vaccine and bednet distribution campaigns. All the same, healthcare facilities can be considered as comprising a major element of the overall sector's activities and its climate and environment impacts.

Health Gains/Risks

WHO has identified the following gains and risks in the adoption of more sustainable practices by healthcare organisations:

  • While hospitals and health clinics are not a specific focus of IPCC's mitigation review, adoption of 'green' designs by health facilities may offer more health co-benefit than the same measures applied to other commercial buildings. This is partly due to the large demands for reliable energy, clean water, and temperature/air flow control in treatment and infection prevention within healthcare facilities. This is also due to significant health gains that can be expected from mitigation interventions, for instance the use of natural ventilation is both an effective energy-saving and infection-control measure.
  • Resilience of healthcare services may be enhanced through use of (clean) onsite energy co-generation that insures more reliable energy supply in areas where frequent energy outages may occur and in emergencies.
  • Access to healthcare can be enhanced and made more reliable through off-grid renewable energy systems coupled with on-site energy storage systems. Particularly in remote, resource-poor settings, renewable energy sources can supply basic electricity for vital life-saving procedures that might otherwise not be feasible.
  • Health risks to health workers, patients and communities will be reduced, from reduced and improved management of healthcare and waste, and so will the carbon footprint. Some 15-25 per cent of healthcare waste is infectious waste, 3 per cent chemical or pharmaceutical waste, and radioactive/cytotoxic (less than 1 per cent). Scavenged needles and syringes from waste areas and dump sites and reused represent a health threat as do dioxins, furans and other toxic pollutants emitted by poor incineration. Better management of solid, liquid and gaseous healthcare products, and emissions from infectious, chemical, and radioactive agents, can reduce exposure to risks of hepatitis B/C and HIV infections as well as to asthma, respiratory disease, reproductive problems and cancers. Improved waste treatment measures can reduce the carbon footprint of such treatment and of water extraction.
  • The healthcare sector is well-positioned to "lead by example" in terms of reducing climate change pollutants and also by demonstrating how climate change mitigation can yield tangible, immediate health benefits.

The following mitigation measures have particular relevance to the healthcare sector because of its unique needs and features:

  • On-site energy generation and storage.
  • On-site rainwater capture and water treatment for re-use and on-site sewage treatment.
  • Appropriate use of natural (mixed-mode) ventilation and natural daylighting.
  • Intensified development and use of low-energy medical devices.
  • Expanded use of telemedicine and other home-care strategies.
  • Reduction in use of nitrous oxide, and capture/reuse of other inhaled anesthetics.
  • Other mitigation measures that can generate significant health and environment co-benefits include.
  • Siting of health facilities to improve access to healthcare by mass transport systems, and also minimize fossil-fuel required for transport, e.g. for health workers and visitors..
  • Building-related energy efficiencies .
  • Materials procurement and waste reduction/management strategies

Health co-benefits of specific strategies:

The WHO review has also identified a number of opportunities for co-benefit strategies that apply to healthcare facilities, healthcare staff and surrounding communities. A selection of those strategies is detailed below.

Water conservation, safe onsite water storage and rainwater harvesting. Large quantities of water and special water treatment procedures are required for many healthcare procedures (e.g. renal dialysis, burns, cleaning of specialized medical devices.) Many rural health facilities lack piped water. Water management is thus important to reduce specialized health risks in healthcare facilities, as well as waterborne-disease more generally. Water efficiencies can help improve water access while reducing carbon-intensive water extraction and ecosystem degradation. Rainwater harvesting is one conservation measure widely promoted in WHO's South-East Asia Region - and also used in large urban hospitals recognized for their 'green' design.

Improved recapture and reuse of waste anesthetic gases can provide significant climate and health co-benefits. Waste anesthetic gases are not only powerful global warming pollutants, they are associated with reproductive risks of (spontaneous abortion and congenital abnormalities); and headache, nausea, fatigue, cognitive impairment to exposed health workers. Strategies for reducing impact from these gases widely used in medical procedures requires greater examination.

Well designed telehealth schemes may reduce the travel-related carbon footprint of all patients, reduce certain needs for facility space, and improve healthcare access and outcomes, including for vulnerable groups. Simple cell phone applications supporting emergency assistance and long-distance consultation for healthcare workers in remote areas are being used in many developing countries with good results. Systematic review of telehealth, telecare and home monitoring schemes has found evidence of effective management for the frail and elderly for diabetes, mental health, high-risk pregnancy monitoring, heart failure and cardiac disease. Meta-analysis also found evidence of health benefits for patients with lung diseases, diabetes and chronic wounds.

Procurement of products that subsequently are not used, particularly pharmaceuticals, was estimated to represent 60 per cent of the carbon footprint of the National Health Service-England. Better managed procurement saves healthcare resources as well as reducing unnecessary exposures to chemical and biological agents and their waste products. In the case of NHS-England, it was estimated that a 10 per cent reduction in pharmaceuticals procurement would lead to a 2 per cent reduction in the system's carbon emissions.

Health equity

Finally, the WHO review has uncovered ways for healthcare facilities to address equity gaps in the provision of healthcare to low-income populations:
Location of health-care facilities near major public transport arteries, and safe cycling/pedestrian routes. Siting of health-care facilities is critical to healthy equitable access to healthcare facilities and related employment opportunities. Since hospitals are typically large employers, public transport and active travel routes can also minimize travel-to-work emissions, and enhance opportunities for active travel among healthcare workers and visitors.

Development and expanded use of low-energy and no-energy medical devices in tandem with expanded use of renewable energy sources (e.g. photovoltaic (PV) solar panels), could further improve access to vital health services in many poorly resourced settings. Inadequate power supply was the single most common cause of medical device failure found by a university training programmes that collected data from 33 hospitals in 10 developing countries: nearly a third of equipment failures were due to power problems. Examples of devices already in use include solar-powered LED lights; LED microscopes for improved TB diagnosis , ; solar-charged, direct current (DC) refrigerators for vaccine storage , and a wide array of rapid diagnostics that can be used in settings without electricity. The US Department of Energy is currently sponsoring a US$ 1.2 million global survey of use and development of DC-grids and devices for residential and small commercial applications.

The WHO review also uncovers a need for healthcare organisations to perform more systematic measuring and benchmarking health sector energy consumption and emissions, as well as address overall environmental performance, in the context of 'greener' facility designs and use of renewable energy sources. In tandem, there needs to be systematic assessment of the actual health impacts and economic impacts of energy-saving technologies, designs, and devices, to identify strategies most cost-effective and practical for scale-up, particularly in poorly resourced settings. Major health organisations in the world, beginning with the WHO, have affirmed that climate change is a public health concern.

Given the leadership role of the health sector, it must lead by example and demonstrate to the world that we also can, we must, and we will, do something about it.