The future of healthcare is green

The future of healthcare is green

Dr Ted Schettler has been a staunch advocate of environmental health and justice for the past 30 years. He is the science director of the American Science and Environmental Health Network (SEHN), and science advisor to Healthcare Without Harm (HCWH) (see box 1 for more information). Specialist Forum spoke to Dr Schettler about his passion for ‘green healthcare’ and why it is important.

Plastic in healthcare

Evidence is mounting that plastic and its additives negatively impact environmental and human health. Additives such as phthalates (notably di-2-ethylhexyl phthalate [DEHP]) and bisphenol A [BPA]) are known endocrine disrupting chemicals (EDCs).

EDCs have been linked to the increased risk of hormone-related diseases such as obesity, diabetes, and testicular cancer to name but a few. Phthalates have also been implicated in the increased risk of allergies, asthma, wheezing, hay fever, itchy rashes, and eczema.

Mass-produced plastic entered the global market after World War II. In the 1950s about two million metric tons of plastic were produced. By the end of 2015, an estimated 8 300 million tons were produced of which about 66% has been released into the environment, according to a 2019 report by the Center for International Environmental Law.

Single-use plastic is the biggest market today, comprising 42% of all products produced. The healthcare sector is one of the biggest users of single-use plastics, which can contain DEHP and BPA.

These include products such as apheresis circuits, blood bags and tubing, extracorporeal membrane oxygenation circuits, drainage and urinary collection bags, catheters, wound draining systems, enteral feeding sets, nasogastric tubes, gloves, a number of intravenous (IV) and dialysis therapy products.

They are also used in the packaging of medical products and devices and in a number of patient products such as ID bracelets, bed pans, cold and heat pacts, compression devices and inflatable splints.

In respiratory therapy products, phthalates are used in oxygen masks, endotracheal and tracheostomy tubes, humidifiers, water bags and resuscitator bags. They are also used in durable medical products, in office equipment and in furniture.

During his career, he has authored or co-authored numerous articles and reports on environmental health including Generations at Risk: Reproductive Health and the Environment, In Harm’s Way: Toxic Threats to Child Development, and Environmental Threats to Healthy Aging.

More recently he published a report commissioned by HCWH entitled Polyvinyl chloride (PVC) in health care: A rationale for choosing alternatives. He has also appeared before the American Senate Committee on Environment and Public Works on two occasions.

Question: Tell me a bit more about your involvement in the green healthcare movement. What motivated you to become involved? What is your vision for the healthcare of the future?

Answer: I have been involved with HCWH https://noharm.org/ since its beginning in the 1990s. We began the campaign to reduce the environmental and public health impact of medical care. We learned that in the United States medical waste incinerators were the leading source of dioxin emissions into the environment. At that time medical waste incinerators in the United States were exempted from regulation and were often poorly designed and operated.

Incinerators were also a significant source of mercury emissions. Dioxins and mercury make their way into the food chain resulting in human and wildlife exposures. Both are highly toxic. It seemed highly ironic that the medical industry was contributing to adverse health outcomes in communities as a result of providing medical care.

While I was still in clinical practice at the time, I had expanded my work into public environmental health. Since then, dozens of medical waste incinerators have been closed and those that remain are far more tightly controlled.

My vision for healthcare of the future includes a greater emphasis on primary prevention and reducing drivers of common chronic diseases that increase morbidity and mortality and are far too expensive to care for. The global pandemic is forcing us to reimagine and redesign ways of delivering healthcare services.

Question: Where did the idea of ‘green healthcare’ originate and can you quantify what it means?

Answer: To my knowledge, HCWH was the first coordinated effort to address the environmental public health impacts of healthcare. Prior to that, there were a few concerned individuals, mostly addressing the enormous medical waste stream.

Motivations varied, but when medical waste washed up on beaches in the eastern United States, it got media attention and raised awareness. Medical waste volume and handling was an entry issue, but other topics followed.

These included healthy food in healthcare (all along the value chain from production to processing to transport to distribution, consumption, waste), green building, energy consumption in healthcare, climate change, transportation, water use, pharmaceuticals in the environment, safer materials, and products, and so on. Healthcare has significant influence in the market-place and in other sectors.

Box 1: About SEHN and HCWH

SEHN was founded in 1994 by a consortium of North American environmental organization who were concerned about the misuse of science in ways that failed to protect the environment and human health. The organisation makes use of science, law and best practices to combat cumulative impacts, especially in matters relating to public health and the environment.

HCWH is an international non-profit network of hospitals and healthcare providers, healthcare systems, local authorities, research/academic institutions, and environmental and health organisations. The aim of the organisation is to transform healthcare sector so that it reduces its environmental footprint, becomes a community anchor for sustainability, and a leader in the global movement for environmental health and justice. To complete this month’s CPD questionnaire, please go to www.medicalacademic.co.za and navigate to the CPD section of the website.

Question: In your opinion, what are the biggest concerns about the use of endocrine disrupting chemicals (EDCs) in healthcare?

Answer: EDCs contribute to a number of diseases and disorders. It is virtually impossible to know what the contribution from healthcare is. And at least for me, it is impossible to name the ‘biggest concern’. Choosing a disease or disorder at the top of the list is completely value-laden.

Question: In your report Polyvinyl chloride in health care: A rationale for choosing alternatives, you briefly allude to safer alternatives. Has any progress been made in the development of other safer alternatives?

Answer: There are alternatives to PVC and DEHP on the market right now. Some manufacturers have chosen to continue using PVC in medical devices and supplies while using alternative plasticisers. Others are moving to alternative polymers that do not require plasticisers.

Box 2: Kaiser Permanente’s ‘green healthcare’ campaign

Founded in 1945, Kaiser Permanente is one of America’s leading healthcare providers and not-for-profit health plans. To date, they have achieved the following: » Eliminated triclosan and triclocarban from soaps, lotions, and sanitisers

» Eliminated PVC and DEHP from IV solution bags

» Prohibited the purchase of building products containing PVC in resilient flooring, carpet and carpet backing, cove bases, corner guards, wall protection, handrails and bumper guards, perimeter edging on tables, signage (vinyl lettering), and above-ground piping

» Prohibited the purchase of fabric, furniture, finishes and building materials containing fluorochemical additives or treatments

» Prohibited the purchase of fabrics, furniture, and finishes containing added anti-microbial agents in all large projects

» Prohibited the purchase of upholstered furniture containing chemical flame retardants

» Conducted studies that found that exposure to BPA could cause harm to human reproductive health and increase the risk of obesity in children.

By 2025, the group plans to increase their purchase of products and materials meeting environmental standards to 50%.

Question: Can all products containing PVC and DEHP be replaced or are some products more problematic than others eg single use syringes versus IV bags that leach?

Answer: Most PVC/DEHP products can be replaced with alternatives. Performance of course is an issue, but generally alternatives that perform equally well or better are available. The one product that has been difficult to replace so far is PVC/ DEHP blood bags. When the DEHP leaches into stored blood, it actually prolongs the shelf life of red blood cells to some degree. Efforts are underway primarily in Europe to explore alternatives.

Question: In your opinion, has the healthcare fraternity embraced the idea of ‘green healthcare’? If not, what do you think the main stumbling blocks are?

Answer: The concept of green health care is gaining traction around the world. Stumbling blocks are lack of awareness, resistance to change, busy schedules of health professionals.

Question: Again, in your opinion, how urgent is it that PVC- and DEHP-containing products are phased out in healthcare?

Answer: Probably the most urgent change needed is reducing and eliminating DEHP exposures in foetuses, infants, and children who, because of their age and developmental stages, are more vulnerable to adverse impacts.

Beyond that, as explained in the PVC/DEHP report, PVC is a problematic plastic for a variety of reasons. We should be moving toward safer materials and products more generally and HC has an opportunity to show leadership in that regard. The PVC industry is trying hard to make PVC recycling easier but the reality is that co-mingled waste streams containing a mix of PVC and other plastic polymers are a nightmare for recycling.

Question: Are you aware of any facilities around the world that have been successful in phasing out these products?

Answer: Kaiser Permanente and Dignity Health have made great strides in this direction in many or most of their large facilities (see box 2 and 3, respectively). A number of members of Practice Green Health have taken steps to eliminate some PVC/DEHP products in certain categories.

Question: One of the main concerns about phasing out these products are cost constraints. What is your response to this?

Answer: There is no single answer. For some kinds of products, alternatives are costcompetitive. Others are not.

Box 3: Dignity Health’s approach to ‘green healthcare

Dignity Health was founded in 1986 and is the fifth largest healthcare system in the United States. Some of their project include:

» In 2005, the group incorporated the use of PVC- and DEHP-free IV bags, solutions, and tubing

» In 2011, they started using reusable sharps containers, eliminating more than a million tons of red plastic and 73 098 tons of corrugated packaging containers. As a result, carbon dioxide emissions equivalent to 118 313 litres of gasoline were prevented

» In 2012, the group became the first healthcare system in the United States to begin using pigment-free patient plastics in all of its hospitals and other care centres to reduce its impact on the environment. They started by replacing everyday products that are used at the patient’s bedside, such as bed pans, wash basins, water pitchers and drinking cups, with pigment-free products. Pigment-free products support greener manufacturing because they eliminate the need for potentially harmful chemicals during the manufacturing process.

Question: If you could give healthcare facilities (with limited resources such as southern Africa) advice on how to phase out these products, what would it be? Where should they start?

Answer: Neonatal units are a good place to start because of the vulnerability of neonates to DEHP exposures mentioned above. Many hospitals also do a PVC/DEHP inventory, simply to see what their product choices look like now. From that they can begin to prioritise beyond neonatal units.

Question: How long do you think it would take a healthcare facility to complete eliminating the use of PVC- and DEHP-containing products?

Answer: Complete elimination will take some time. It would depend on contracts that they have already entered into. When contracts come up for renewal on various product lines they can begin a transition. But the time will vary considerably from place to place.

Question: What do you think individual healthcare professionals can do to promote ‘green healthcare’?

Answer: Get involved in HCWH’s efforts in their region or country. Take advantage of the many resources already available. Choose a topic of personal and professional interest and go to work on it… as much or as little as time allows. Build collaborations. SF