More than 40 influential healthcare leaders gathered in September 2006 at an invitation-only conference entitled “Designing the 21st Century Hospital: Environmental Leadership for Healthier Patients and Facilities.” Supported by a grant from the Robert Wood Johnson Foundation and convened by The Center for Health Design and Health Care Without Harm (HCWH), the event challenged participants to advance strategies for transforming the healthcare system through bold commitments to environmental sustainability.

For the healthcare industry, environmental stewardship is fundamentally about creating the conditions for health, according to a series of white papers released at the meeting. “For the past decade, the healthcare industry has been engaged in a transformation of design, construction, and operational practices with a goal of reducing environmental impacts,” writes Robin Guenther, FAIA, in a paper entitled Values-Driven Design and Construction: Enriching Community Benefits Through Green Hospitals, cowritten with Gail Vittori and Cynthia Atwood. “Quietly and without much fanfare, early industry leaders have begun a radical journey toward a new vision of the industry's health mission. …With early adopters having completed their first sustainable buildings, this is a pivotal moment to assess the state of sustainable design and construction in the healthcare industry from a leadership perspective. Why have organizations taken this on?”

Guenther's paper explores this pivotal question through the stories and perspectives of prominent healthcare CEOs who have been early adopters in sustainable design—leaders who are “reaching beyond measures that have economic payback and who are achieving community benefit beyond their four walls.”

These early adopters, the authors write, “are not primarily motivated by pristine wilderness and resource conservation for its own sake, but for the sake of their mission to serve and steward resources and health. For them, it's more than saving energy. It's fundamentally connected to health or to a basic human value.”

As Michael Covert, CEO of Palomar Pomerado Health in Escondido, California, put it at the conference, “We have an obligation to do it. People want us to do it. Green building is essential for good health. And the indoor environment is intrinsic to our whole mission of healing people and allowing them to do that in a better way. So it works to our benefit and the benefit of the larger society as a whole.”

The white papers in the series explore how and why hospitals are taking this “radical journey toward a new vision of the industry's health mission” through such bold efforts as moving markets toward safer and nontoxic materials, creating cleaner indoor environments, and redefining healthy food.

The first paper in the series, First Do No Harm by Health Care Without Harm's Gary Cohen and excerpted here, lays the foundation for this new journey by exploring how healthcare has traditionally been a polluting industry, contributing to the very diseases it works to cure. In the next several issues, Clean Design and Operations will run excerpts from other papers in the series. The full set of papers is available online at and Other titles:

  • Toward an Ecological View of Health: An Imperative for the Twenty-First Century by Ted Schettler, MD, MPH, of the Science and Environmental Health Network

  • Redefining Healthy Food: An Ecological Health Approach to Food Production, Distribution, and Procurement by Jamie Harvie, PE, of the Institute for a Sustainable Future and HCWH

  • Creating Safe and Healthy Spaces: Selecting Materials That Support Healing by Mark Rossi, PhD, of Clean Production Action and Tom Lent of the Healthy Building Network

  • Preventative Medicine for the Environment: Developing and Implementing Environmental Programs That Work by Laura Brannen of Hospitals for a Healthy Environment (H2E)

  • Values-Driven Design and Construction: Enriching Community Benefits Through Green Hospitals by Robin Guenther, FAIA, and Cynthia Atwood of Guenther 5 Architects and Gail Vittori of the Center for Maximum Potential Building Systems

    —The Publishers and Editors of Clean Design and Operations

The challenge intrinsic to healthcare is how to provide high-quality treatment in an ever-changing environment. New science and technological innovations constantly require healthcare providers to transform the way they deliver services. Over the last ten years, the new science linking chemical contaminants in the environment and the incidence of disease has created an additional impetus for the transformation of healthcare practice.

Our rising disease burden

Chronic diseases and disabilities now affect more than 90 million men, women, and children—nearly one-third of our population. In spite of the many advancements in medical practice, the best available data show an increase in the incidence of asthma, autism, birth defects, childhood brain cancer, acute lymphocytic leukemia, endometriosis, Parkinson's disease, and infertility.

The lifetime risk of getting cancer is 1 in 2 for men and 1 in 3 for women. The risk of breast cancer has almost tripled from more than 1 in 20 to 1 in 8 in the last 40 years. Asthma rates doubled between 1980 and 1995. Non-Hodgkin's lymphoma has nearly doubled since the 1970s.

In America, 127 million people are overweight; 60 million are obese. Between 1997 and 2004, diabetes incidence increased 45% among 18- to 44-year-olds. Endometriosis, linked to dioxin exposure, now affects 10-15% of the U.S. female population.

The new field of environmental health is linking each of these diseases and disorders to exposure to toxic chemicals. The old way of looking at chemical risk and safety would have missed these links, as they are not as simple as cause and effect. But through the new lens of environmental health science, we are learning that exposure to toxic chemicals, at levels thought to have been safe, is increasing the chronic disease burden of millions of Americans.

The new findings in environmental health science show that:

  • Chemical exposure at incredibly small levels can impact the hormonal system and disrupt the body's normal development, including interacting with genes that can damage the delicate balance in the human body. New science is revealing that genes and chemicals work together to contribute to disease onset.

  • Babies in the womb and young children are more vulnerable to chemical exposure than average adults.

  • Chemical exposure at important windows of human development can set in motion changes that only manifest themselves as health impacts later in life.

  • Chemicals can interact in a synergistic way in our bodies to contribute to a health impact or exacerbate a health problem.

Healthcare's contribution to chemical contamination

Dioxin and mercury are two chemicals that new environmental health science has shown to be unsafe at levels previously thought benign.

According to the U.S. Environmental Protection Agency (EPA), in 1995, medical waste incinerators were the largest source of dioxin air emissions and contributed 10% of the mercury air emissions in the United States. Processes such as combustion, chlorine bleaching of pulp and paper, certain types of chemical manufacturing, and other industrial procedures that include the combustion of chlorine produce dioxin as a byproduct.

The EPA estimates that humans receive more than 95% of their dioxin intake through food. People eat dairy products, meat, and fish and take the dioxin into their bodies, where it is stored in fatty tissue for years and builds up over time. Dioxin's global distribution means that every member of the human population is exposed. This is especially problematic for childbearing women, who pass dioxin to a child in utero and when breastfeeding. The EPA also estimated, in its 2003 Dioxin Reassessment draft, that the average levels of dioxin in all Americans is “at or approaching levels” where we can expect to see a variety of adverse health effects. Health effects linked to dioxin exposure in humans and/or animals include cancer, endometriosis, testicular atrophy, increased miscarriages and birth defects, damage to the immune system, neurological damage, and alterations in hormone function.

Dioxin is one of the most infamous of the persistent bioaccumulative toxins (PBTs), one of the most potent carcinogens known to science, and one of the few targeted by international treaty for elimination.

Intimately linked to the dioxin issue is polyvinyl chloride (PVC), used widely in the production of IV and blood bags, plastic tubing, and an array of other hospital products. PVC (because of its high chlorine content) contributes to dioxin formation when it is manufactured and incinerated. Flexible PVC often contains a chemical, DEHP (Di[2-ethylhexyl]phthalate) that can leach out of products and enter the bodies of patients receiving fluids through PVC tubing. In 2000, new environmental health science led the National Toxicology Program to conclude that DEHP is a reproductive toxicant and that infants in hospitals are at risk from exposure to this chemical. The Food and Drug Administration followed with a health advisory to hospitals, urging healthcare facilities to seek safer alternatives, especially for vulnerable patient populations.

Medical waste incinerators are also a source of mercury and other heavy metal emissions into the environment, although their numbers have been drastically reduced. Mercury is a toxic metal that affects the human nervous system, liver, and kidneys; mercury-contaminated fish eaten by pregnant women can affect fetal development. In the United States, 42 state departments of health have issued warnings against eating fish caught in all or some of their states' water bodies because of mercury contamination. The EPA estimates that 1.6 million pregnant women, children, and women of childbearing age are exposed to unsafe levels of mercury from eating contaminated fish. An estimated 630,000 newborns are threatened with neurological impairment due to in utero mercury exposure, or one in six children born in the United States.

In addition to dioxin and mercury contamination, there is a variety of other environmental exposures in the hospital environment that can lead to compromised health for both healthcare workers and patients. Some of these issues arise from hospital design and materials used in building healthcare facilities. For example, 75% of PVC is used in construction, which outgases DEHP into the air. Four studies have linked interior PVC exposure to asthma. Other exposures are tied to day-to-day hospital operations, such as the use of toxic cleaners and pesticides in healthcare facilities.

According to research conducted by the Massachusetts Department of Health, poor air quality has been identified as the most frequent cause of work-related asthma in healthcare workers.

Hospitals are also energy-intensive institutions. After the food-service industry, the healthcare industry ranks second in energy-usage intensity. In 2005, each square foot of healthcare space cost an average of $2.15 in electrical and natural gas expenses. Some of these costs can be addressed by energy-efficiency upgrades and smart design. Additionally, many hospitals are located in communities where public transit either does not exist or the hospital is inaccessible to the public transit system. Until recently, hospitals paid little attention to the energy performance and efficiency of their building infrastructure.

As the environmental and health effects of global warming become more pressing, healthcare, like other major sectors, will need to reduce overall energy use and move to cleaner energy sources. Indeed, they have a responsibility to do so.

Pharmaceuticals are also emerging as another major environmental and public health threat that until recently was virtually unknown. Many pharmaceuticals contain hormone-disrupting chemicals, which migrate from hospitals and homes to water bodies, negatively impact aquatic life, and wind up in our drinking water. Additionally, many drugs contain compounds that persist in the environment or bioaccumulate in the food chain. As more drugs are consumed by Americans, more of these biologically active agents are building up in our environment. More than 100 pharmaceuticals or their metabolites have been found in water bodies in Europe and the United States, some of them in drinking water supplies.

Evolving the Hippocratic Oath

Since physicians and other healthcare professionals take an oath to “First, do no harm,” healthcare institutions and the industries that support them have a special responsibility to ensure that their operations are not major sources of chemical exposure and environmental harm. But, until recently, healthcare professionals and hospital administrators were unaware of their contribution to chemical contamination and broader societal disease burdens. The educational curriculum for physicians, nurses, and hospital administrators does not provide the latest scientific information on the environmental consequences of healthcare delivery.

In the last 10 years, however, the information gap has begun to close. The healthcare industry has begun to expand its definition of health to include environmental health—the body of scientific evidence that links the health of the environment to the incidence of human disease. With the emergence of Health Care Without Harm (HCWH), hospital leaders have learned about their industry's contribution to chemical exposure issues and made steady progress to solving some of their environmental problems. For example, due to the rising costs of complying with dioxin emission regulations and the educational work of HCWH, more than 5,000 medical-waste incinerators have closed since the mid-1990s. In response to the changing regulatory climate, hospital administrators chose to reduce waste and adopt safer waste-disposal and treatment technologies.

In 1998, the American Hospital Association and the EPA entered into a memorandum of understanding to eliminate mercury-containing products from the healthcare sector and reduce waste volumes by 50% in 10 years. To accomplish these ambitious goals, these organizations joined with the American Nurses Association and HCWH to form Hospitals for a Healthy Environment (H2E). Over the past several years, H2E has grown to include more than 1,206 healthcare partners representing 6,700 healthcare facilities.

During this period, virtually all the major pharmacy chains in the country eliminated the sale of mercury thermometers, while major cities and at least 10 states have banned their sale as well. At the same time, the nation's largest hospital systems have adopted mercury phase-out policies in their procurement specifications. The largest group purchasing organizations (GPOs)—Premier, Novation, Consorta, Amerinet, Broadlane, and MedAssets—have committed to eliminating mercury-based products from their catalogs. Mercury elimination in the American healthcare sector, although not yet complete, is a powerful success story about how hospitals can collectively use their enormous purchasing power to reduce their environmental and public health footprint and also drive markets for safer alternatives to problematic chemicals and technologies.

There are additional components to this success story. First, healthcare leaders occupy a highly respected place as trust-holders in American society. If hospitals eliminate mercury from their operations, it creates the political momentum to eliminate mercury from other sectors and other products in our economy, thus improving the safety of the food supply and public health. Since hospitals began moving to remove mercury from their operations in 1998, more than 29 states have passed laws restricting mercury-based products in their states.

Moreover, since leaders within the American Nurses Association and affiliated organizations learned about mercury, dioxin, and other environmental threats linked to hospital operations, they have become active in more than eight states to support policies to phase out chemicals linked to cancer, birth defects, and genetic damage. In 2005, HCWH launched a Web site called the Luminary Project ( to honor those leaders in the nursing profession who are expanding their understanding of the Hippocratic oath and engaging in preventive medicine through environmental activities in their institutions and in society at large.

Ecological medicine

Once the link between healthy people and a healthy environment is made, wonderful opportunities present themselves for hospitals that want to model environmental responsibility. See the full paper online at for more about the opportunities for healthcare to help heal via the environment.

Gary Cohen, Codirector of Health Care Without Harm, has been working on environmental health issues for more than 20 years. He is also the executive director of the Environmental Health Fund, which works on domestic and global chemical safety issues. Cohen is a member of the International Advisory Board of the Sambhavna Clinic and Documentation Center in Bhopal, India, which provides free medical care to the survivors of the Union Carbide gas disaster in Bhopal.

For further information, phone 617.524.6018 or visit


Editor's note: The bibliography forthis white paper can be found atthe end of the full article, availableat and


…until recently, healthcare professionals and hospital administrators were unaware of their contribution to chemical contamination and broader societal disease burdens


If hospitals eliminate mercury from their operations, it creates the political momentum to eliminate mercury from other sectors and other products in our economy, thus improving the safety of the food supply and public health.