This document discusses making hospitals more environmentally sustainable. It notes that hospitals are heavy energy consumers, produce large amounts of waste, and use toxic substances. Going green can improve health outcomes by reducing pollution and accidents while cutting costs. The document outlines a conceptual framework for sustainable healthcare that includes eco-friendly construction, energy/water savings, reducing pollution emissions, sustainable purchasing, and waste sorting/recycling. It stresses the importance of prevention and addressing environmental health risks, and notes the poor are most impacted so regulations and financing need to support sustainable improvements in all facilities.

1. Why “sustainable”
hospitals?
… and what could make hospitals
environmentally sustainable?
Dr. Jean-Jacques BERNATAS ADB, July 2013 1

2. … and why it should be so.
More than just showcasing, health sector is supposed to be a leader and to
bring onboard the other sectors.
A hospital is usually one of the main employers in a community and has a
high economic impact on it.
A hospital has a corporate social responsibilities.
The hospitals are dealing with highly toxic substances.
The hospitals are among the heaviest energy consumers.
The hospitals produce a huge amount of regular and hazardous waste.
• Not a marketing-driven initiative.
• Shared interest between the medical service providers and the users, about a
“development that must allow current generations to satisfy their needs,without
prevening future generations from doing the same”. 2

3. The context of SD in HCF
Input
(equipment,
supply,
consummables,
…)
$ (investment,
capital, income)
People (staff,
patients,
visitors)
Strategy
Management
Process (SOP)
curativepreventive
HEALTH
 Adverse public
health impact:
• toxic substances
• energy and water
consumption
• carbon footprint
 Individual adverse
events:
• nosocomial infections,
• accidental deaths and
disabilities
• work accident and
occupational diseases
Immediate profitability vs. Sustainable
development
Lowest cost vs.
Sustainable input
3

4. Back to fundamental: The
Hippocratic Oath
Better health (patients,
community, country)
Adverse events (patients,
visitors), work accident
(staff), and negative
environmental impact
(indoor/outdoor)
4

5. Conceptual framework of SD in
healthcare sector
Improving
outcomes
Mitigating adverse
events and negative
environmental
impact
Sustainable
management
Ecoconstruction
Saving energy
and water
Preserving the
atmosphere
Sustainable
buying
Sorting, recycling
and re-using
Sustainable
health
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6. Sustainable management
From quality grass-roots:
• Structure/process/outcome Donabedian’s framework and its further
improvements, for evaluation and quality improvement
• Non-quality as a factor of increased costs of healthcare,
• P-D-C-A and continuous quality improvement in health.
to sustainable management:
• Motivate: motivation is the cornerstone
• Link: network of hospitals sharing experience on SD
• Train: knowledge is power; on-site, hands-on and continuous is better
• Validate: certification (ISO14001, LEED, EMAS, …)(*)
• Communicate: creation of SD commissions, sharing experience with a
larger audience, and to convince people on the relevance of SD.
(*): ISO: International Standard Organizatio; LEED (US Green building Council): Leadership in Energy & Environmental
Design; EMAS: European Eco-Management and Audit Scheme. 6

7. Ecoconstruction
•Usually a higher immediate investment for a mid-
even long-term profitability « only ».
•Refers to specific labelling such as LEED, BREAM,
ISO 14001, …
•Starts with a decision-making, then a choice of a
site, and a participative multidisciplinary approach.
•Environmental impact studies to be conducted.
•Energy performance, choice of materials, noise
reduction, choice of light, … among others.
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8. Saving energy and water
• A hospital energy consumtion in France is around 350 kWh/m2/year
(energy efficiency index) where the new low energy building standard
for healthcare buildings in France is now 50 kWh/m2/year.
• Hospitals energy consumption represents an average 11% of energy
consumption of tertiary sector in Western countries.
• A German study evaluated one hospital bed to consume as much
electricity and heating as two households.
• Energy performance assessment applies to hospitals. Benchmarking is
ongoing.
• Water is a finite resource: the estimated average consumption of a
medico-surgical hospital is 300 to 750 liters/bed per day:
• Using less « thirsty » autoclaves, recycling water from hemodialysis
for flushing systems, using bio-digestive membranes 8

9. Preserving the atmosphere
• Carbon footprint: the University Hospital of Geneva (HUG) has evaluated
that it consumes yearly as much energy as a European city of 16,000
inhabitants, and producing 10 tons CO2
• HUG carried out a « life-cycle analysis » showing that 40% of carbon
emission comes from materials and incoming products (mainly from drugs
and textile objects); energy consumption of the buildings counts for 25%;
transport makes 25% of total carbon emission, and infrastructure and
traetment of waste counts for 10%:
 Reducing the impact of transport on CO2 production:
• Hospital better connected to the city
• Green mobility: hybrid engine ambulances, carsharing for
ambulances, staff mobility (car pooling, bicycle, …)
 Improving the hospital functionning in reducing CO2 production:
• Promotion of green spaces
• Shortening of the supply chain
• Energy saving policy 9

10. Sustainable buying
• Appropriate purchase is of utmost importance to:
• Getting rid of toxic substances
• Reducing waste and energy consumption
• Decreasing greenhouse gas production
• About toxic substances:
• endocrine disrupters (transgenerational effect of Distilbene; BPA and
feeding bottels; DEHP and nutrition pockets, tube, transfusion packs)
• Nanoparticulated titanium in wall paints (production of titanium dioxide
under UV exposure with antibacterial effects, but nanoTiO2 has possible
adverse effects on membrane blood-brain barrier)
• Ethylene oxide sterilization, including bottle teats: listed as carcinogen to
man, but still in use to sterilize enteral feeding devices.
• Solutions:
• Responsible and professionalized purchase based on transparent
information made available, traceability of the products to face the
fragmentation of internal and external purchases, purchasing centrals,
pooled purchases ...
• Substitution of toxic/carcinogenetic substances (Karolinska Hospital in
Huddinge, Sweden: list of 100 substances to be abolished).
Bisphenol A
Phtalates
nanoTiO2
10

11. Sorting, recycling and re-using
• Chemical releases
• REACH regulation (European Community Regulation on chemicals and
their safe use): guidelines for identification and substitution of
chemicals
• Effluents:
• Effects of low concentration persistant residues in discharged water:
drugs, radioactive substances, antibiotics,
• Possible bioaccumulation in aquatic organisms.
• Reduction of drugs in effluents requires better prescription (less
/appropriate prescription of antibiotics), specialized treatment plants,
separate sewage network for hospital.
• Substitution of reagents (cyanide for blood count),
• Issues in disinfection/sterilization: place of incineration? Substitution to
autoclaves for some mediacal waste (grinding and chlorine dioxide
treatment)
• Sorting channels and recycling: up to 30 channels in some hospitals, with a
specific lifecycle for each type.
• Chasing any unnecessary packaging.
Waste reduction and recovery policy in
place. 11

12. Sustainable health (1)
• Taking care of employees:
• Occupational health improvement, based on prevention: back pain
prevention, tobaco-free environment/smoking cessation support, ...
• Psychological stress, specific issue of HCW: counseling, adapted innovative
management (decentralized management unit providing more autonomy
for nursing staff). Experience of « magnetic hospital » keeping low attrition
rate among workers in providing better conditions at work – ARIQ label in
Canada (attractiveness of a hospital/ ability to keep staff/ involvement of
nurses/ quality of care)
• For patients
• The International Declaration on Diseases due to Chemical Pollution, known
as the Paris Appeal, launched at the Paris conference on Cancer,
Environment and Society on 7 May 2004: an agenda to deal with
environmental health.
• Implementation of environmental medicine services in hospitals: multiple
sensitivity, low fertility due to endocrine disrupters, ...
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13. Sustainable health (2)
• Prevention is the cornerstone of sustainable health, but:
• Can hospitals shift to prevention+care, when they primarily exist for care
only and when the competition is based on the scope of services and
cutting-edge technology access? For private sector: Is prevention a good
business??
• Another reason to rethink care more globally and to revisit the primary health
care concept = PHC as the grassroots of sustainable health in all development
setting (LIC/MIC/HIC) = essential health care based on 8 components through a
transversal and intersectoral approach.
• Was considered as cheap basic – and then affordable - quality medical services
• Now comes back on our radar, brushed up (see Jim Yong Kim’s Speech at World
Health Assembly: Poverty, Health and the Human Future, May 2013)
• Addresses not only Health for All (in 2000 …) but quality of care and universal
coverage
• Is a strong rationale to bring hospitals on board of SD
• The diagonal approach: sustainable development of hospitals will support health
system strengthening.
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14. WHY the poor must benefit from such
an approach?
When it comes to saving money, the poor
are the first to be affected:
• Similar to double-burden of nutrition: the poorest
are more often sick and will have only access to the
cheapset care, which includes the use of the
cheapest materials.
The poor are more exposed to
environmental risks.
• This includes risks generated by the hospitals in the
neighborhood: unsafe waste management,
incinerator producing dioxines production, for
exemple.
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15. HOW the poor must benefit from such
an approach?
Environment regulations to be reinforced
• and to apply to all healthcare facilities, including
public and decentralized.
Adequate financing and existing agenda.
Promotion of projects or projects components
adressing this issue:
• just to incorporate the hospital in the picture and see
what can support its sustainable development.
An assessment is necessary in public healthcare facilities. Possibility to start
with a version of an autodiagnostic tool, implemented already in more than
1,200 hospitals in Europe, now in Canada with the support of C2DS.
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16. • No way to escape
• Asian/South-East Asian countries are more
exposed to the environmental risks and
should take up the lead in developing
sustainable healthcare facilities.
Finally …
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17. Acknowledgements
• Olivier TOMA, C2DS (www.c2ds.eu )
• Health Community of Practice, Asian
Development Bank, Manila.
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