Environment

Big Medicine's Malignant Growth

Some medical professionals say the only way to rid ourselves of medicine's vast piles of waste is to shrink the health care industry itself. Are they heretics or visionaries?
Andrew Jameton dug through the clutter of his bookshelf and pulled out a flexible plastic ventilator circuit. "This is used by a patient for two days, and we throw it away," he said. "In the past, they were used for just one day, so we're making progress, I guess."

He handed me a thin, colorful cardboard box, about half the size of a sheet of paper. "Pharmaceutical samples came in this. It holds three pills."

Jameton is a professor and section head in the University of Nebraska Medical Center's Department of Preventive and Societal Medicine. He's not a medical doctor but a philosopher, and he's tackling a subject few dare discuss: how to shrink medicine's big ecological footprint by shrinking the medical industry itself.

He showed me a diagram illustrating the vicious circle that he sees as the heart of the problem: "Big Medicine: Big Economy: Death of Nature: Poor Public Health: Big Medicine."

"But," he told me, "if you try to talk about ecological limits in the medical professions, it's not a welcome conversation."

Growing pains

From 2001 to 2004, the U.S. health care industry grew at an annual rate of 3.6 percent, easily outstripping the rest of the economy's 2.1 percent rate. And as 2006 began, the medical industry had $22 billion worth of buildings under construction or renovation -- the biggest boom in half a century, predicted to last through the coming decade.

A hospital bed in America, on average, generates an estimated 16 to 23 pounds of waste every day, seven days a week. That includes office paper, food, IV bags, gauze, syringes, human body parts, drugs, toxic agents used in chemotherapy, heavy metals, radioactive wastes and much more.

Then there are "upstream" eco-costs; for example, the long, toxic history of one pair of latex or vinyl gloves that may be used for only a few seconds and discarded. U.S. hospitals used 12 billion such gloves back in 1994 alone -- almost one pair for everyone on earth.

And despite some environmentally friendly construction projects in recent years, the current hospital-building frenzy is having an environmental impact like that of any construction boom. A 2006 report in the trade magazine Health Facilities Management summarized a nationwide survey of the "red-hot construction market that's reshaping the face of health care delivery." It extolled trends toward larger, more soundproof patient rooms, nurses' computers in every room, wireless infrastructure plus extra cabling and conduit, and of course, more and bigger electric power plants. But read through the report's 2,700-plus words, and you'll find not a single mention of energy conservation or other environmental issues.

In medicine, as in war, urgent questions of life and death can lead the participants to overlook the resulting ecological impact, or to treat it as a necessary evil. But Jameton insists there is no real conflict between saving lives and preserving the planet. Rather, he says, it's money hunger that's making medicine unsustainable. "Rescue can be a beautiful thing. We all need heroism. But people in the back room are gaming that system."

Economic fairness, Jameton says, aligns with ecological responsibility in demanding that we cut back: "Each year, we spend $5,500 to $6,000 per person in this country on health care. Who in the world can afford that?"

"Everyone has to learn to live on less -- and the rich will have to give up more than the poor. I looked at the global distribution of wealth and income and calculated that I'm something like the 50 millionth richest person in the world!" he said. "But does that entitle me to any treatment I demand, whatever the cost to the earth?"

Curbing medical pollution

A growing number of medical professionals recognize the irony of an industry dedicated to health that threatens the natural environment on which human health depends. Among the impressive array of groups working to address the problem is the network Health Care Without Harm, which is in the forefront of the longtime battle to eliminate use of the neurotoxin mercury.

A 2005 study by the American Hospital Association and Hospitals for a Healthy Environment found that 80 percent of hospitals surveyed had stopped using mercury fever thermometers, and more than 54 percent had established a policy to virtually eliminate mercury facilitywide.

Hospital wastes contain three times as much plastic as household trash, and much of that plastic is polyvinyl chloride (PVC), which can leak toxic chemicals into patients via intravenous drips or emit highly carcinogenic dioxins when incinerated. In response, the list of cities and organizations formally aiming to eliminate PVC, dioxin, and/or incineration in medical facilities is getting longer. In recent years, local battles have shut down medical waste incinerators or won commitments to stop incineration in Maine, Illinois, Michigan, Missouri, California and the Gila River Indian Community Reservation in Arizona.

Groups such as Sustainable Hospitals have developed highly detailed guides to "environmentally preferable purchasing." The Nightingale Institute mobilizes nurses and clinicians to push for more environmentally sound products and procedures in their own workplace.

Research is showing that many drugs, including anticancer agents, psychiatric drugs, anti-inflammatories and even caffeine can pass, still in an active form, through our bodies and into sewers and waterways. The sewer lines under hospitals and clinics are teeming with such compounds. Toilets aren't the only source; unwanted or expired medications are often just dumped or flushed. The company PharmEcology Associates is working with some success to reduce drug pollution from medical facilities.

Ted Schettler is science director of the Science and Environment Health Network. Although, he told me by phone that "there's plenty of work yet to be done," he has been pleased to see a growing list of hospitals strive to reduce or eliminate mercury, PVC, waste incineration and drug-dumping. And he's encouraged by a trend in some areas toward green medical buildings. "When a hospital is under construction," he observed, "that's a real opportunity to get it right."

Another big topic, Schettler said, is the food served in hospitals. "Some are transforming their food purchasing procedures, concentrating not only on nutrition but also on the way the food was produced. This is an issue that really gets the industry to look more at public and environmental health."

I asked Schettler about Andrew Jameton's argument that any environmental gains achieved by using better materials and methods would be eaten up quickly by an industry that at its current growth rate will double in size in less than two decades.

Schettler knows Jameton and agrees with his analysis, but, he said, "That's a tough one. People are not going to give up access to expensive medical care."

Michael Gillespie, senior lecturer at the University of Washington, Bothell, has written about a discussion that occurred in one of his classes several years ago, following a visiting lecture by Jameton. One young woman, a mother, said she agreed with his ecological arguments but that if her own child was stricken with a potentially fatal disease, the environment would have to take a back seat. "I would do anything to save my daughter," she said. As Gillespie notes, few in our society would criticize her for that, however contradictory her stance.

In the belly of the beast

Jameton realizes that he's poking at sacred cows. Nevertheless, he argues, there is an ethical imperative to rein in a system whose rapid growth seems to be producing more profit but less health.

To illustrate, he took me on a short tour of the University of Nebraska Medical Center in Omaha. Like any major hospital, UNMC packs an environmental wallop that Jameton likens to a 24-hour hotel, restaurant chain, office building, university science department, big-box retailer and transportation company rolled into one.

jametown
A storeroom at the University of Nebraska Medical Center in Omaha. Hospital wastes contain three times as much plastic as household trash. (Credit: Andrew Jameton)


We peered into a dim room lit only by video monitors, where banks of computers were being fed by imaging equipment like CT scanners, PET scanners, MRIs, and good old-fashioned X-ray machines. Increasing numbers and varieties of such diagnostic devices not only suck hard on the power grid but also require huge computational power, heavily braced walls, vibration-resistant floors and/or lead shielding.

A nearby storeroom was filled floor-to-ceiling with surgical gowns, disinfectant soaps and a host of other items. This and another storeroom are restocked from a huge UNMC-owned warehouse a few miles away by the center's own fleet of trucks.

"You can think of a hospital as a big retail merchandiser of pharmaceuticals and other medical supplies," Jameton said. He showed me a "personal" can of shaving cream the size of two thumbs, just one of 85,000 items the hospital keeps in stock. That doesn't include pharmaceuticals, where the issues become even more bewildering and the economic stakes higher.

We descended into the basement, passing from the high-tech 21st century to a scene from the mid-Industrial Revolution, complete with boilers; distillers; water treatment tanks; massive, old gray GE and Honeywell electrical controls; a rank of backup batteries and ductwork that looked big enough to drive a Nebraska corn picker through.

In the maintenance staff's work area, we peeked into a room with so many bookshelves it might have been mistaken for a branch of the medical center library, yet the volumes were all equipment manuals and spec books. "With this level of complexity," Jameton said, gesturing toward shelves groaning under the bulky manuals, "any system becomes more and more fragile."

Another sign of fragile complexity is the amazing proliferation of pipes throughout the building. And plumbing's not just for water anymore; the circulatory system of UNMC's gleaming new Durham Research Center is a tangle of pipes carrying eight different kinds of liquids throughout the building. Spaces between floors and ceilings of most medical buildings are especially large, to make room for the extraordinary amount of plumbing needed.

When I asked about hospitals actually making people ill, Jameton acknowledged that problem as yet another sign of the system's fragility -- in fact, it's a big, flashing neon sign. The federal Centers for Disease Control and Prevention estimate that 2 million people per year contract infections in America's hospitals, and that about 90,000 die from those infections.

And all the usual ways of preventing infection -- using disposable supplies and chemical disinfectants, autoclaving, incinerating -- either gobble resources, churn out wastes or both.

Some of the hospital's eco-impact has been moved out of sight. Pictures of the former laundry depict a grim, medieval-looking chamber that was decommissioned a few years ago. Now the hospital's gargantuan daily washload, along with the energy, detergent, water and sewer use it entails, has been turned over to an outside contractor.

Of course, the public face of UNMC, like that of any well-funded hospital, is designed to convey a sense of calm, security and comfort. But a stroll through the more pleasant parts of the complex reveal the tradeoffs that undermine that image. An area that once was a solarium, where patients could bask in the sun's therapeutic warmth, is now completely shaded by the towering Lied Transplant Center. A greenhouse originally intended for growing medicinal plants sits empty atop the pharmacy school. A largely paved-over courtyard known as the Healing Gardens is blasted with air from the Lied Center's massive air conditioning system.

Greener, cheaper, healthier

Solid research, an overview of which was presented at a recent workshop sponsored by the National Academy of Sciences, shows that hospitals built and operated on more environmentally sound principles can actually save money. Costs are recovered quickly, patients get better sooner, patients' families are happier, medical errors are reduced, staff are more satisfied, staff turnover and absenteeism are lower and workers' compensation claims drop.

Those conclusions are reinforced by a 2004 book, "The Ethics of Environmentally Responsible Health Care," which Jameton coauthored with Jessica Pierce, lecturer in philosophy at the University of Colorado, Boulder. In it, Pierce and Jameton described a hypothetical "Green Health Center" that would, they argue, achieve better medical results more cheaply and with lower ecological impact.

The British medical journal The Lancet praised the book for taking on the challenge of defining true sustainability in a medical facility but dismissed the Green Health Center idea as economically impractical. Its practical alternative? "At this juncture, we need simple, tentative, precautionary approaches that cut through the uncertainties revealed by science. We need to buy time to find smarter ways of living while not crippling our economies in the process."

The Lancet reviewer continued: "One wonders what will happen when an elderly, wealthy patient, requiring cytotoxic or radioactive treatment, is effectively offered palliative care?"

Pierce, who was the book's lead author, rejects the argument that medicine in a deep shade of green would have to be economically crippling. "We wrote the book as a utopian vision, and we hope health care will evolve toward that vision," she told me. "But we really are presenting a pretty serious challenge to the economic structure."

In Pierce's view, the ecological damage caused by medicine has grown along with a badly distorted growth in its priorities. "The crux of our argument is that allocation of our spending is misplaced. In the past, the greatest advances in overall health have come from clean water, clean air, public works, public health, preventive care."

Rather than more and more medical care, she says, "We need more 'human care,' before people ever get sick. As it is, the system is undermining the very health it's supposed to be protecting. And a lot of those treatments and technologies have negligible health impacts."

Associating high cost with big benefits is just poor logic, says Pierce. She draws a comparison with another expensive, ecologically destructive technology with little or no useful function: "People have a choice to buy a Hummer, too. But that doesn't mean society should encourage them to do it."

Closing the vicious circle

As we emerged from our tour of UNMC into a light snowfall, Andrew Jameton directed my attention downhill to the hospital's immediate neighborhood, where he located several examples of Big Medicine's vicious circle. There was a plastics company, a dry cleaners, a blood-plasma center across the street from a low-income psychiatric clinic ("so people with possibly impaired judgment who need money badly can sell some blood that just might contain psychoactive drugs"), and three (yes, three) power plants.

Finally, pointing toward Saddle Creek Road, which, like so many urban and suburban artifacts, is named for the natural feature that was destroyed to accommodate it, he indicated a grimy metal-fabrication plant. "Notice where it's located," he said, "between the medical center and a graveyard."
Stan Cox is a plant breeder and writer in Salina, Kan.
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