As guardians of the health status of Earth's inhabitants, the healthcare industry should be leading the charge for increased environmental stewardship, improved indoor air quality and energy efficiency in buildings. Instead, this sector is characterized by poor waste management practices and enormous appetites for fossil fuels and petrochemical materials. At a minimum, the industry should be engaged in serious consideration of the health effects of compromised indoor air quality and the levels of potentially toxic chemicals that pervade the building and medical product industries today. As design professionals, we should carefully examine those products we routinely specify in the creation of “healing environments” for our healthcare clients.

The Industry Today

In the last decade, the healthcare industry underwent major changes in waste management protocols. Following reports of beaches littered with medical waste, hospitals instituted strict protocols for the disposal of potentially hazardous materials. Clean air regulations forced many individual hospitals to shut down older incinerators. Today, most medical waste is transported to larger, modern incineration plants, at an ever-increasing cost to institutions.

Many hospitals incinerate upwards of 50% of their waste stream, while the CDC (Centers for Disease Control and Prevention) estimates that as little as 2% of medical waste requires incineration. IV bags, tubing and packaging go “up in smoke” along with true medical waste. Ultimately, the EPA contends that the incineration of medical waste (particularly from items made from polyvinylchloride [PVC]) is the second largest source of airborne dioxins and the fourth largest source of mercury-which ultimately settle and are absorbed in the food chain.

In 1996, in response to this growing issue, an international coalition of healthcare organizations formed Health Care Without Harm. They pledged to reform the environmental practices of the healthcare industry through the following specific initiatives:

  • reduction in incineration through improved waste management practices and alternative technologies

  • phase-out of mercury and PVC plastics in medical products

  • education of the industry

Their self-described mission is to assist the industry in developing strategies to reduce use of disposables, segregate the waste stream and increase recycling and reuse. They have been joined by a growing number of other organizations and initiatives, including the Healthcare Resource Conservation Coalition and the Environmental Protection Agency/American Hospital Association's “Hospitals for a Healthy Environment,” both national and international.

To date, these organizations have seen major reductions in the use of mercury, accompanied by more modest improvements in waste management practices. As hospitals realize the cost savings through - reduction in medical waste incineration, the overall industry improves.

While the issues surrounding sustainable building practices have not yet surfaced with these organizations, I believe it is only a matter of time before their achievements in the arena of waste management will allow a refocusing of their agenda to the built environment. Increasing energy costs might hasten the shift.

The Buildings

The healthcare construction industry is amajor consumer of chemical products. In the last 50 years, more than 80,000 new chemicals have been developed by man to answer every material need-stabilizers, plasticizers, fire retarders, adhesives, etc. The petrochemical industry, in its quest to use every component of a barrel of crude oil, as well as the waste from the refinement of gasoline, has evolved a complex and far-reaching range of plastics. In addition, there are significantly more building products that embody large quantities of volatile organic compounds (VOCs; the most commonly known VOC is formaldehyde).

At the same time, Americans now spend 90% of their time indoors. Increasingly, buildings are sealed for thermal efficiency and year-round mechanical conditioning. The inevitable result of chemicals in confined spaces is compromised indoor air quality. The inevitable result of poor indoor air quality is chronic illnesses in building occupants. The seriousness of this issue cannot be underestimated. Witness Business Week's cover feature by Michelle Conlin, with John Carey, “Is Your Office Killing You?” in the June 5, 2000, issue.

Indoor air quality issues first surfaced in superinsulated houses in the early 1980s and office buildings in the 1990s. Healthcare institutions, with their massive mechanical systems and enormous volumes of outside air, have not been at the forefront of this problem, but at the same time, construction practices in healthcare facilities with regard to toxic materials have been similar, if not worse, than those in the office sector.


Building materials affect the indoor air environment primarily through off-gassing-that is, continuous release of chemical compounds into the air, where they are either absorbed by other porous materials in the indoor environment or removed-either by natural or mechanical ventilation means. The resultant VOCs vary widely in their toxicity and emission profiles over time.

Many “wet” products containing high levels of VOCs-e.g., paint, adhesives, sealants-release the vast majority of VOCs as they cure (i.e., within the first 24 hours). The profile for vinyl is also a steep curve, with most emissions occurring in the first seven days after installation. Other materials, such as the formaldahyde-based adhesives in plywood and fiberboards, release VOCs at a much more continuous, low level over an extended period. As these are emitted, they are easily absorbed by other elements in the interior-furniture, fabric-covered furniture panels, acoustic ceiling tiles, etc. Once absorbed, VOCs are re-emitted, but always at a lower level over a much longer period.

The risk of compromised indoor air quality can be reduced through careful use and management of these materials: The keys are separate and ventilate. On a construction site, installation and curing of “wet” materials should precede the installation of other absorbing materials. “Flush-out ventilation” should be provided while major wet materials cure and for two weeks prior to occupancy. Finally, for those materials with sustained VOC emissions, substitute products should be sought.

At the Continuum Center for Health and Healing in New York City, a high level of indoor air quality was an important design goal. The Center features sealed concrete, cork and linoleum flooring throughout (Figures 1-3). There are no building products containing formaldehyde (i.e., insulation and cabinet substrates). Wet finishes were specifically selected withlow VOC content (Safecoat and Benjamin Moore's Pristine EcoSpec paints and sealants, and low-VOC adhesives). Fabrics are natural and untreated with chemical coatings. The mechanical system includes HEPA (high-efficiency par-ticulate air) filters on the air handler.

Continuum Center for Health and Healing, New York City

Continuum Center for Health and Healing, New York City

Continuum Center for Health and Healing, New York City

Controlling the specification of materials with an eye toward improved indoor air quality is only one aspect of “sustainable building practice,” but it is a good place to start. The architecture and design community can assist our clients in making more sound material choices. We can push manufacturers to “come clean and green” with new and better options.

Rating Systems for Materials

Once we move beyond indoor air quality, the task of evaluating materials for their environmentalperformancebecomes substantially more complex. There is no single definitive standard for evaluation. Greenspec, the Building for Environmental and Economic Sustainability (BEES) Overall Performance Rating System and Environmental Building News's Simplified Method are all available methods of rating materials. Criteria include:

  • energy use

  • occupant health/indoor air quality (human toxicity)

  • durability

  • hazardous byproducts (global warming, acid rain, ozone depletion)

  • transportation (from manufacturing location to project site)

  • ability to be recycled

  • resource extraction (renewable or not renewable)

  • first cost

  • life-cycle cost

Navigating these evaluations, and the “greenwash” claims of manufacturers, is a daunting and confusing task for designers. In healthcare design, a good example of this dilemma is the environmental impacts of vinyl and PVC in buildings. On one side, vinyl manufacturers continue to stress its many advantages from both clinical and environmental perspectives, while environmental organizations, particularly Greenpeace, are fervently working toward banning its manufacture and use. The industry cites low first cost and reuse of waste products from gasoline refinement into “inert,” durable products.

Greenpeace argues against the production of hazardous byproducts (notably di-oxin) in PVC manufacture and disposal, its inability to be recycled and its toxicity to humans through exposure or when the material is combusted. Health Care Without Harm cites an increasing volume of research data on negative health effects from human exposure to vinyl medical products.

Building Rating Systems

In May 2000, the United States Green Building Council (USGBC) published the Leadership in Energy and Environmental Design (LEED) Green Building Rating System 2.0, the firstnationallyrecognized standard for the design of “green buildings.” It has been adopted for all new federal construction, and a number of states have already linked grant and/or tax credit programs to LEED-certifiedbuilding construction. At this writing, there are more than 180 structures registered in the LEED program, which is geared toward new building, commercial and institutional construction. A companion standard for commercial interiors and renovation, the LEED-CI (Commercial Interiors), is in the pilot stages.

Under the LEED rating system, points are awarded for building elements that optimize site planning and building envelope efficiency, conserve energy, improve indoor air quality and occupant comfort, reduce water consumption, utilize recycled or rapidly renewable materials, and optimize construction waste management practices.

The Discovery Health Center (Figure 4), a 27,000-sq.-ft. diagnostic and treatment center in Monticello, New York, is the first healthcare building in the United States registered in the LEED program. Thisbuild-ing features ground-source geothermal heating and cooling linked to radiant floor distribution, daylighting in all public areas with photocell controls on lighting and low VOC-emitting materials, and it utilizes a high percentage of recycled-content materials in its construction. It is scheduled for completion in December 2002. At this writing, energy-modeling projections indicate electrical consumption at approximately 40% less than conventional construction (based on DOE2 energy model data).

The Discovery Health Center, Monticello, N.Y.

The Future of Sustainable Healthcare

The moment has arrived for the design community to seize the indoor air quality banner in healthcare buildings, both for the improved health and safety of building occupants and for the future economic health of this sector.

If energy costs continue to rise, the healthcare industry and government will need to consider more radical answers to reducing energy consumption. Healthier buildings might increase the industry's ability to safely implement reductions in overall air exchange rates.

Increasing costs for disposal of non-recyclable building materials might, in the future, eliminate any first-cost savings realized in specifying such materials. Unlike other building sectors, healthcare institutions rarely sell their properties-hence, they pay the cost of removing materials they install. Moreover, designers need to remember that the healthcare industry's core value-“first do no harm”-should manifest itself in the construction of the built environment. The design community must work with industry to help our clients realize that simple, but powerful, goal. HCD



BEES-Building for Environmental and Economic Sustainability

CDC-Centers for Disease Control and Prevention

Environmental Building News

EPA-Environmental Protection Agency



Health Care Resource Conservation Coalition

Health Care Without Harm

LEED-Leadership in Energy and Environmental Design

USGBC-United States Green Building Council

The Center for Discovery Health Center

The Continuum Center for Health and Healing

Business Week