Eco‐conservation and healthcare ethics: A call to action

I would like to thank Dr. Myles Pensak and the Triological Society for the honor of delivering the 2009 Ogura Lecture. Dr. Ogura's legacy as an innovative thinker, as a distinguished clinician-scientist, as an outstanding teacher, as a prolific author, and as a superlative leader is indeed humbling. He provided us with a gold standard of personal and professional achievement in our field, and served as a role model and source of inspiration for seeking new knowledge and new solutions to improve the lives of our patients. More specifically, Dr. Ogura made great strides in the treatment of head and neck cancer, developing many of the principles of conservation surgery of the larynx that remain the foundation of current surgical practice. In honoring Dr. Ogura, I would like to expand upon the topic of conservation, discussing it not in the familiar context of surgical practice, but rather in the broader and much less familiar context of the role that we, as physicians, should be playing in the “greening” of our hospitals and in the global conservation movement. As physicians, we have historically considered ourselves as healers rather than “polluters,” and have upheld the Latin maxim primum non nocere (first, do no harm). We have largely focused on interventions to improve the lives of our individual patients, and have generally distanced ourselves from the problems and politics of industrial pollution and its impact both on public health and global warming. Although we are well aware that healthcare has burgeoned into an enormous industry, we have collectively been either unaware of or indifferent to the incongruence between our guiding ethical principle of taking care not to harm patients or put them at risk, and the environmentally irresponsible behaviors that pervade an industry in which we are key players. Buildings are often old and inefficient, and too little attention is given to low-energy alternatives to medical equipment, lighting, and heating and cooling systems. Overconsumption of water generally goes unchecked. Toxic chemicals are sometimes used in cleaning, disinfection, and exterior pesticides. Often unknowingly, hospitals purchase items that are toxic and that ultimately have a negative effect on the health of patients, workers, communities, and the ecosystem. Hospitals generate thousands of tons of waste each day, including toxic materials and chemical waste. They heavily rely on the incineration of this waste, which is a major source of toxic air emissions. In essence, hospitals paradoxically enable individuals to heal, and yet often create an environment that is deleterious to public health and destructive to our ecosystem. This paradox raises two critical questions: 1) What is the underlying function of the healthcare sector? and 2) What role should we as physicians play in effecting change? My interest in these issues was sparked several years ago during visits to the Arctic and Antarctic, where I saw the effects of pollution firsthand. My objective today is to present information that serves as a “going green” primer for physicians. In briefly describing a number of key environmental issues, I would like to lay the foundation for further exploration of these issues. My hope is that this information elicits interest in expanding our professional role as healers, and plants the seeds of activism in environmental conservation both within and beyond the walls of our hospitals. This would be a wonderful tribute to the far-reaching impact of the Ogura lectureship. The conversion in healthcare from reusables to disposables from the late 1970s through the 1980s resulted in a rapid and significant increase in medical waste. In 1998, the US Environmental Protection Agency (EPA) issued a landmark report exposing that medical waste incineration was a major source of toxic air emissions in the US.1 This report laid the groundwork for international consensus regarding the link between healthcare, environmental degradation, and health. Over the past decade there has been a steady growth of governmental and nongovernmental agencies (NGOs), institutions, and professional groups worldwide that have worked collaboratively to change environmentally irresponsible practices of the healthcare sector. Not surprising, discussion and debate have been influenced as much by economic and political interests as by science.2 The reduction of toxic emissions has been high on the international agenda. Attention has focused on three toxins: dioxin, polyvinyl chloride (PVC), and di (2-ethylhexyl) phthalate (DEHP). The 1998 EPA report identified medical waste incinerators as the leading source of dioxin. The term dioxin refers to a group of complex, highly toxic chemicals that are waste byproducts of industrial processes such as combustion, chemical manufacturing, and chlorine bleaching. It is one of the 12 chemicals covered by the United Nation's Stockholm Convention on Persistent Organic Pollutants, which the US signed in 2001.2 There is a direct association between the chlorine content of combusted material (e.g., bleached paper products) and dioxin formation. Upon incineration of such products, dioxin is released into the atmosphere. Rain, snow, and dust carry it to the surface of the earth. Deposition of dioxin emissions on fields and gardens brings it into the human food chain. Dioxin bioaccumulates in fatty tissues and is magnified in concentration as it moves up the food chain. Breast milk, which has a high fat content, passes large amounts of dioxin to infants. Dioxin is also extraordinarily persistent in human tissues, with an estimated half-life of 5 to 10 years. Exposure in humans has been linked to a remarkably wide spectrum of serious adverse effects, including cancer, and reproductive, cardiac, hepatic, and developmental disorders. Although the precise extent to which these toxins have contributed to the increased incidence of many types of cancer or other disorders is unknown, it is undisputable that exposure represents increased risk to the ecosystem and to public health.2-4 PVC is a plastic that is widely used in making synthetic medical devices, including blood, intravenous, and total parenteral nutrition bags and tubing, nasogastric, hemodialysis, and endotracheal tubing, examination gloves, respiratory masks, and plastic food wrap. As PVC is inherently rigid, it requires the addition of softening agents, referred to as plasticizers, to make it flexible. DEHP is the dominant plasticizer used in PVC medical devices. It is one of a family of chemicals known as phthalates, and is a known reproductive and developmental toxicant. DEHP does not bond to the PVC, but floats within its structure, and can leach from medical devices. Because the increased metabolic demands of children heighten their absorption of DEHP, they are particularly susceptible to DEHP toxicity.4, 5 Neonates in intensive care units are known to receive the highest exposure in hospitals. Many of these infants are exposed during blood and other intravenous infusions, respiratory therapy, enteral feedings, and extracorporeal membrane oxygenation.2 Children with tracheotomy tubes are chronically exposed. There is also a growing body of evidence indicating that phthalates used in building materials and interiors (e.g., vinyl flooring, carpet backing, wall coverings, window treatments, and electrical cables), migrate into the dust of buildings, triggering asthmatic and allergenic reactions in children.4 Unlike PVC, other plastics, including polyethylene, polyurethane, polypropylene, and ethylene vinyl acetate, are not manufactured with chlorine and do not require plasticizers for flexibility. PVC is thus uniquely hazardous among plastics. Nonetheless, it maintains a ubiquitous presence in our hospitals and clinical practices. Through collaborative international efforts, significant strides have been made in reducing dioxin generated by waste incineration. In the US, thousands of hospital incinerators have been closed and stricter toxic emission regulations have been put in place. Nevertheless, incineration continues to be widely used, though alternatives are available.6, 7 Effecting change in the manufacturing of PVC products has been slower and more complex, though progress has been made. Based on the consensus of the international scientific community, the US Food and Drug Administration; the European Union; Health Canada; the Japanese Ministry of Health, Labour, and Welfare; as well as many other governments and NGOs have called for the use alternative DEHP-free medical devices, particularly for vulnerable patient populations such as children and pregnant or lactating women. The ultimate goal is the complete elimination of these products. Due to persistent pressure exerted on manufacturers, PVC- and DEHP-free alternatives are available for almost every use of PVC in the healthcare setting.4 Of particular importance to otolaryngologists, Bryan Medical, Inc. of Cincinnati, Ohio has been proactive in having DEHP removed from its neonatal and pediatric tracheostomy tubes made by Trachoe (Frankfurt/Main, Germany), and plans to do the same with their adult tracheostomy tubes by early 2010. Although initial costs of alternative products are currently higher, industry analysts expect that alternatives will become increasingly cost-competitive as demand increases to protect patients from unnecessary exposures. (Due to manufacturing responsiveness to demands in Sweden, polyurethane tubing is now being used to replace PVC tubing at virtually no increased cost).5 PVC-free construction and furnishing products are also widely available.4 The challenge is to work towards a shift in medical culture, changing a collective medical mindset based on noninvolvement in such issues to a mindset based on a higher ethical standard. This involves educating our medical colleagues and working towards a purchasing shift that reflects a commitment to do no harm. As an initial step, we must be adamant about the need for hospital-wide PVC audits. Hospitals alone in the US generate more than 7,000 tons of waste per day. Perhaps surprising, some hospitals reportedly throw up to 70% of their waste into the biohazardous waste stream, although much of this waste is similar to that generated by a hotel or large office building (i.e., mostly paper, cardboard, and food waste). In fact, The Centers for Disease Control and Prevention suggest that only 2% to 3% of the waste in our hospitals needs to be disposed of as infectious waste. Moreover, hospitals often pay up to 10 times as much to dispose of infectious versus solid waste.8 Waste reduction and waste segregation programs are thus not only environmentally sound, but also represent cost savings.9 The often-heard argument that the depressed economy and concomitant escalation in healthcare costs preclude a commitment to greening is inherently flawed. On the contrary, the literature is replete with reports indicating significant cost savings through improved waste segregation and implementation of regulated medical waste reduction programs. In view of time constraints, I will mention just a few such programs that have long been underway and that serve as models. The Mount Sinai Medical Center (New York, NY) began an aggressive waste segregation and staff behavior modification program as far back as 1990, trimming more than $1 million from its costs annually.10 In 1996, the Beth Israel Medical Center (New York, NY) implemented a rigorous program to minimize both the volume and the toxicity of the waste their facility generated. They continue to save up to $600,000 annually.4 The Naples Community Hospital (Naples, FL) reduced disposal operating costs by more than 80% by switching from incineration to autoclaving of medical waste.11 As well, sharing medical publications, eliminating frequently unused items from custom surgical packs, switching from disposable to reusable medical instruments, replacing paper towels with air dryers, purchasing washable surgical and isolations gowns and sterilization trays, and replacing disposable admissions kits, bed linens, bed pads, and emesis basins with reusable products can all reduce waste and cost.12 One of our key tasks is to become knowledgeable regarding goods that are purchased for our clinical practice, how these goods are packaged, how these goods are used, and what is discarded—finding ways to eliminate, reduce, reuse, and recycle.13 Instituting a hospital waste audit is an important first step. Most important, however, if we are to be agents of change, we must adopt a holistic approach that incorporates consideration of product selection, product use, product disposal, and environmental and community health impacts.11, 13 Health facilities are often energy inefficient. They operate around the clock and 365 days a year. Temperatures are kept warm and comfortable, water usage is high, and energy-intense medical equipment is used. As reported by the EPA in 2001,14 hospitals expend about twice as much total energy per square foot as traditional office space. They consume almost 50 billion kilowatt hours of electricity and spend close to $3 billion annually on electricity alone. According to this EPA report, if hospitals improved their energy efficiency by an average of 30%, the annual electricity bill savings would be nearly $1 billion, and 11 million fewer tons of carbon dioxide would be emitted. They state that this would be equivalent to taking 2 million cars off the road—an overwhelming statistic! The key issue here is the direct link between a hospital's energy usage and energy sources and community health. Health impacts result from local air pollution (particulate matter, acid emissions, and heavy metals) and carbon dioxide emissions. Important to note, Europeans have been far more energy aware, and have had a quicker response to the increasing need for energy efficiency. A typical Northern European hospital currently uses half as much energy as a typical US hospital.15 Evidence-based design and sustainable heath care architecture have become more mainstream, but we are slowly catching on. The cost savings associated with re-engineering the way we use our resources go hand in hand with related energy savings. Even simple equipment changes, such as faucet aerators, can reduce water consumption by as much as 50% and reduce energy cost for heating water. Higher efficiency toilets save on water bills. Some hospitals have also considered ways in which they can recycle or reuse water.16 I urge you to read the transcript of a thought provoking radio discussion (Public Radio International show “Living on Earth”) on the greening of hospitals.17 Participating in the discussion, Paul Levy, CEO and president of Boston's Beth Israel Deaconess Medical Center, acknowledges that “much of the energy work and environmental work in hospitals is driven more by cost issues than by a desire to make the world cleaner and reduce carbon emissions and the like, but that's okay because they end up being the same program anyway.” Levy notes that saving energy and water in a hospital is not brain surgery, but rather common sense “kind of stuff.” Art Mombourquette, the vice president of support services at Brigham and Woman's, describes the green design of Brigham's newest 300,000 square feet building (Shapiro Cardiovascular Center) and highlights its impact on both energy savings and health. What personally touched me most when reading this transcript was a comment by architect Robin Guenther: “Buildings ultimately are the clothing that we put on our institutions. Buildings embody all our values, so when you inhabit a green building, it changes how you think about who you are and what you're doing.” We have to transform our vision from that of simply building institutions to a vision of creating environments that are truly healing. In a brilliant and beautifully written book entitled Uncertain Science….Uncertain World, author Henry Pollack refers to global climate change as “perhaps the greatest inadvertent experiment in human history.”18 As Pollack writes, of interest in this experiment is how the global climate is to of carbon dioxide in the emissions are the global will continue to this will the and and public health. In new book and when of global warming. 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