[Globe and Mail, March 3, 2007]

Hospitals do a good job caring for patients, but as CHRISTOPHER FREY reports, they often have less than a healing effect on the planet. Can an emerging movement cure health care facilities of environmental ills?

Employees at Toronto General Hospital were cleaning out a little-used research lab in a wing slated for renovations when they made a grisly discovery in one of the freezers reserved for test subjects: 20 human heads.

“Actually, they were half heads. You could see all the soft tissue,” Ed Rubinstein clarifies during a recent stroll through the corridors of TGH. “I didn’t try matching them up, so who knows? Maybe it was just ten heads.”

Either way, as the man in charge of waste disposal for the University Health Network—which includes three Toronto hospitals— it fell to the 36-year-old to properly discard the strange trash in accordance with laws governing biomedical refuse. As such waste could potentially contain infectious pathogens harmful to humans it must be put into its own stream for eventual incineration.

He started by asking around the hospital to find who had, quite literally, lost their heads. But he soon discovered it was “one of those ‘they’re not mine’ situations.” When nobody claimed the leftover subjects, he figured they must have belonged to a researcher who decamped without alerting anyone to his stash of part-subjects.

That meant it was up to him, after donning rubber gloves, a gown, goggles and a mask, to move the heads to one of the bright red, double-lined garbage bags marked for anatomical waste and burning. All of which, however oddly, puts him at the vanguard of heath care’s greenification.

Hired seven years ago for a new position as manager for energy and the environment at UHN, Mr. Rubinstein is part of a nascent movement to reduce the environmental footprint of Canadian hospitals—to uphold the Hippocratic oath to “above all, do no harm” not only to people but to the planet. In addition to overseeing the proper treatment of waste into streams—including biomedical, anatomical, chemical and radioactive refuse, as well as good old office rubbish—he is one of the few hospital employees dedicated to tracking energy efficiency.

“It’s anything to do with the outside environment,” he says of his job. “If you spill some nasty chemical on yourself, you don’t call me. But if you spill something nasty on yourself, then it hits the floor and trickles down the drain… you call me.”

***

It’s hard to imagine another institution that handles such a diverse array of waste materials. On an average day, UNH throws out 3,000 pounds of potentially hazardous waste, from medical equipment tainted with blood to toxic chemicals such as disinfectants or the formaldehyde used to store human organs. There is also a small amount of radioactive and pharmaceutical matter in the trash. And with about 11,000 employees, there’s the non-hazardous refuse and recycling to be dealt with—at about 23,000 pounds per day at UHN, it’s on par with an industrious small town.

Yet hospital waste disposal and energy usage have historically escaped close scrutiny by government regulators because they were perceived as being preoccupied with the good work of patient care. It was only in the 1990s, when it was still standard for hospitals to put all their waste into one stream for on-site burning, that incinerators became a lightning rod for protest in some municipalities and organizations like the Canadian Centre for Pollution Prevention (C2P2) began examining the cumulative effects of health care on the environment.

“Ontario was probably one of the worst back then,” says C2P2’s Chris Wolnik. “Almost every health care facility had an incinerator, simply putting stuff in big plumes up the stack. That’s changed since, but it was the driver that also got us looking at other avenues, such as waste water, waste management and greenhouse gas emissions.”

In 2003 the Ontario government finally banned the use of hospital incinerators. Now, most of the waste produced by the province’s health care facilities is handled and processed by certified contractors. “Must burn” materials (such as anatomical waste or waste potentially infected with harmful pathogens) is sent to facilities such as Medical Waste Management, a state-of-the-art commercial incinerator in Brampton, or shipped to the northern United States by Stericycle.

Meanwhile, biomedical waste such as medical instruments that have come into contact with blood or human cultures and specimens, is now put through a process of autoclaving—a high-pressure, high-temperature treatment that sterilizes the materials so they can safely be deposited at approved landfill dumps.

And yet, despite these moves, there is still much about hospitals that can make people sick, and there is a long way to go before health care is “green”. According to the U.S. organization Health Care Without Harm, medical waste contains 50 per cent more mercury than regular municipal waste. Mercury—found in thermometers, blood pressure cuffs and lab chemicals—can cause neurological, liver or kidney damage when inhaled from a spill or when dispersed in the atmosphere through incineration.

Polyvinyl chloride or PVC, the most commonly used plastic in medical instruments such as intravenous sacs, blood bags and tubing, can produce the carcinogen dioxin during both its manufacture and its burning.

As a result, not only do hospitals often suffer from poor indoor air quality, but they are a leading contributor of dioxin and other dangerous pollutants to the atmosphere. For activists such as Mr. Wolnik, this means the health sector has an obligation to become a leading player in environmental management.

“We have over 1,000 hospitals in Canada… and they’re usually leaders in the community,” he says. “If they’re not taking the environment seriously then who else can?”

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Mr. Rubinstein claims there’s no such thing as a typical day on the job, although head removals are fortunately the rare exception. Some days he can be found at his computer filing manifests with the Ministry of the Environment or tracking the various waste streams produced by the hospital. Others he might devote solely to educating staff on the quotidian ways they can reduce their impact—a process he credits with increasing UHN’s recycling rate and saving an average of $125,000 per year.

But the road to greener hospitals is still being mapped, and incineration is but one issue of many. Thus, Mr. Rubinstein keeps abreast of emerging practices and technologies that will benefit UHN, most of which are coming out of the United States.

There, established advocacy groups such as Hospitals for a Healthy Environment and Health Care Without Harm have been pushing for medical supplies that don’t contain mercury and PVC, and the elimination of toxic chemicals in cleaning agents. They also want hospitals to embrace sustainable building practices, alternative energy sources and locally-grown organic foods in their kitchens.

An equivalent movement has been slow to take root in Canada, which Rubinstein blames on a lack of information and co-operation. With the assistance of Environment Canada, C2P2 is now working to replicate many of the resource materials and guidelines created for the U.S. to make it easier for Canadian hospitals to identify and support possible improvements.

And some Canadian hospitals have risen to the challenge on their own. When Bluewater Health in Sarnia began planning an addition in 2002, it was one of the first facilities in Ontario to design a new building according to Leadership in Energy and Environmental Design (LEED) certification standards—which promote energy efficiency and limit the use of potentially harmful materials.

To reduce reliance on artificial light, for instance, Bluewater bucked the typical hospital floor plan of double-loaded corridors. Instead, they opted for more ceiling wells over nurse stations and hallways with walls of glass windows on one side and patient rooms on the other.

The plan met with resistance at the provincial Ministry of Energy. Officials argued that it would necessitate more floor space—and a bigger budget—than the traditional floor layout. In the end, the revised drawings actually required more square footage and cost more. It may also cost Bluewater it’s LEED silver rating.

Four years later, however, the government is taking its cue from facilities such as Bluewater. Legislation passed last year requires that all new provincially-funded buildings, such as universities, colleges and hospitals, meet LEED’s minimum standards.

Overall, though, while Canadian hospitals appear to doing better than their U.S. counterparts when it comes to diverting more waste away from incineration, there’s a noticeable lag in other areas that underscores the difference between the public and private health care systems, and the critical role government must play here toward greening hospitals.

“The bottom line is a bigger issue in the U.S.,” says Mr. Wolnik. “But rather than cutting back, they’re embracing efficiency and new technologies and group purchasing policies that are greener and less wasteful.”

Donald Hall, Bluewater’s vice president of facilities and planning points out that the smaller scale of Canadian hospital networks means they lack the buying power to force vendors to change their practices or materials.

“What really supports progress there on moving forward with more green design is that they see the financial benefit in it,” he says. “Here, the dollar isn’t driving it enough. We need more leadership from the government to promote these changes.”

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A simple step would be for more Canadian hospitals to hire people like Mr. Rubinstein—full-time managers dedicated to improving environmental sustainability.

The new position has clearly made a difference: By encouraging researchers to reuse and recycle chemicals, Mr. Rubinstein has cut UHN’s chemical waste sharply. New energy efficiency programs and technologies, such as the retrofitted steam boilers used to heat buildings and sterilize equipment, has saved the network about $6.4 million since 2002 and reduced its annual energy usage by 130,000 gigajoules.

In spite of these gains, many hospitals claim they can’t afford to hire environmental managers. When Rubinstein meets at conferences with colleagues they typically commiserate over weird discoveries, mishaps and the challenges of “fighting to raise the profile of garbage.” Some of them have had to make trips to the dump, donning full-body suits and wading into an ocean of refuse to retrieve materials that were improperly disposed. Discarded teaching skeletons occasionally create problems—although they are now made from plastic, the sight of rather authentic-looking leg bone or skull can send dump workers into a tizzy.

“They’re not anthropologists,” laughed Rubinstein. “You can’t blame them for freaking out.”

Still, as Mr. Rubinstein walks the corridors of TGH—showing off new motion-sensor lighting and “auditing” garbage bins—he is optimistic about the hospital’s green future.

“Sometimes people around the hospital will go, ‘Hey, it’s Ed the garbage guy,’” he says, “On a good day they’ll call me ‘the recycling guy.’ The thing is I fortunately don’t have to go digging through the trash that often. Or throwing out heads.”