Following ancient advice first, do no harm hospitals are being transformed from danger zones to healing environments  

A flotilla of medical syringes washed up on the New Jersey shore 15 years ago and awakened the world to the hazards of medical waste. Since then, thousands of health care practitioners, scientists, ecologists, designers, architects, and activists have been trying to figure out what to do with the 2.4 million tons of medical waste the health care industry generates each year. Their efforts have gradually shifted from cleaning up the mess to examining its cause. Now they're scrutinizing the entire environmental impact of hospitals-and what they've found is troubling. Those needles were only a small part of a much bigger problem.

The health care industry is now awakening to the deep irony that while people go to hospitals to get well, hospitals themselves are making people sick. In addition to the well-documented threat of hospital infections-now the fourth leading cause of death in the United States-patients in hospitals may be exposed to a host of dangerous materials: dioxins, phthalates, mercury, and the volatile organic compounds (VOCs) found in many solvents and paints. In fact, potentially harmful substances can be found in everything from IV bags to carpeting to the very walls of the facilities in which healing is supposed to occur. Patients, many of them in vulnerable conditions, are inhaling poisons-and, in some cases, receiving them directly into their blood.

But a revolution is underway that not only will lead to a safer and radically different hospital in the future but also could point the way to a healthier world.

Walk into the Continuum Center for Health and Healing, a two-year-old Manhattan medical clinic that's part of Beth Israel Medical Center, and the first thing you notice is how much it doesn't feel like a hospital. Everything in the clinic, from chairs to curtains to plumbing, has been designed and constructed with a healing environment in mind. The offices are filled with natural light, plants, stone, and cork flooring. The air smells of wood and wool rugs.

This approach is aimed at something deeper than creating an inviting environment: It is meant to support the health of patients and hospital employees. The Continuum Center's focus is "integrative" healing-an approach that combines the best of mainstream medicine with alternative practices. Many of its patients come in search of help for what they believe are environmentally related illnesses that Western medicine has not been able to treat, like chronic fatigue syndrome and multiple chemical sensitivity. Those patients' needs, along with evidence of the wider effects of buildings on people's health (as many as one in five office workers report symptoms associated with either sick building syndrome or other building-related illnesses) helped determine the clinic's construction plan, which reveals a central tenet of the green health care movement: detoxify.

While the planners of the Continuum Center may have been ahead of the curve in using environmentally sound architecture because of its medical philosophy and patients, the growing trend toward sustainably designed health care facilities is in the interest of everyone who wants to avoid poisons.

As buildings are tightened up to improve energy efficiency, ventilation decreases. So at the Continuum Center, materials were selected to keep the air clean with low VOC levels, no formaldehyde, and no polyvinyl chloride (PVC), a petroleum-based material. PVC piping is illegal in New York City, but Robin Guenther, the New York architect who designed the center, had another reason for excluding PVC in the plan: "I tell my clients I don't want to put PVC in my building specifications because I don't know what they're going to do with it in 20 years," she says.

Polyvinyl chloride has become a focal point of the movement toward safe and healthy hospitals. A highly adaptable material used to make shower curtains, plastic wrap, children's toys, piping, and other familiar products, PVC is ubiquitous in most modern health care facilities-a key ingredient in medical devices, furniture, building materials, a wide variety of other products. But it poses so many environmental risks that the staff of the Ecology Center in Berkeley, California, calls it "Satan's resin."

From the toxins released when petroleum is extracted from the ground to problems associated with manufacturing, installing, using, and disposing of it, "PVC is in a class of chemicals in which there is no threshold for safety," says Tom Lent of the Healthy Building Network.

Polyvinyl chloride didn't really become an issue until hospitals, attempting to solve the medical waste disposal problem, which came to light with those needles on New Jersey beaches, started to burn their waste. "Most of us thought that the more we burned, the safer we were making our patients," says Charlotte Brody, a former nurse who now co-coordinates the Washington, D.C.-based campaign Heath Care Without Harm. But in 1996 the EPA released a study showing that medical incinerators were one of the nation's largest sources of dioxin. A known carcinogen that also affects reproduction, dioxin is emitted when products containing chlorine, like IV bags made of PVC, are burned. "That was a big wake-up call," says Brody. "We didn't know that medical waste incineration was making people sick."

While the number of medical incinerators in operation has decreased rapidly in the last few years, medical devices made from PVC are still causing problems in hospitals. In July 2002 the Food and Drug Administration released a report noting that DEHP, a softening agent used in pliable PVC products like IV bags and tubing, causes a range of adverse effects in lab animals, most notably to "the development of the male reproductive system." DEHP is a phthalate, a type of chemical that can leach out of PVC-based products into fluids that are then introduced into the blood during medical procedures. The FDA has yet to receive reports detailing a similar threat to human males, but the circumstantial evidence for such a risk is strong. In response, the FDA has instructed doctors not to use devices in various procedures that could lead to DEHP exposure in male infants, boys near puberty, and pregnant women carrying male fetuses.

For health care activists like Charlotte Brody who have been warning about phthalates for years-in the face of industry resistance-this public health notification was a major turning point. According to Brody, the FDA alert helped expand the way we think about toxic exposures-and the design of medical products. "To protect boys before puberty, you have to protect women of childbearing age, because exposures start in the womb," she says. "Thinking about the world with women of childbearing age in the center gives you all the arguments you need for clean production."

The good news is that alternatives to several PVC-based medical products are now available, as are alternatives to other devices with toxic substances that are common in hospitals, like blood pressure monitors and batteries made with mercury, a well-known neurotoxin. The bad news is that medical devices account for only 5 percent of PVC production in this country. Another 75 percent goes into building materials like flooring, window frames, and piping. Additives used to harden PVC in construction materials include lead, known to cause brain, kidney, and nerve damage, and cadmium, which is a carcinogen. As the toxicity of such materials becomes more widely documented, disposal costs are bound to rise. If health care companies end up picking up the tab to remove these harmful substances from existing hospitals and clinics, incentives to avoid using them in the first place will grow.

The effort to turn these ideas about green health care into actual building codes for medical facilities has just begun. Last February, the American Society of Healthcare Engineering released a groundbreaking statement calling for environmentally friendly construction practices that will protect the health of building occupants, the surrounding community, and the larger world. The U.S. Green Building Council has begun discussing construction guidelines for health care facilities. But some clinics and hospitals are not waiting for regulations before they act. Like Beth Israel's Continuum Center, they are making construction decisions that reflect a growing awareness of the health risks, and the long-term costs, associated with toxic materials.

The design of the Marshall Street Addition at Legacy Good Samaritan Hospital in Portland, Oregon, completed in 1998, called for no PVC and low or no VOCs as well as views of a garden, preservation of old trees, and a designated "urban wildlife habitat" on the grounds. The School of Nursing at the University of Texas in Houston, now under construction, is being built with 50 percent recycled materials, 50 percent sustainably harvested wood, a roof planted with trees, and no PVC piping. Green housekeeping-using cleaning materials that are low in solvents and other potentially toxic substances-is part of the construction plan. In addition, medical schools at Harvard University and at Emory University in Atlanta have green building projects in the works.

And at least two large national health care networks, Catholic HealthCare and California-based Kaiser Permanente, are starting to act as well. In addition to addressing dioxin, mercury, and phthalate concerns, Kaiser, a nationwide network that includes 29 hospitals and 423 medical offices serving 8.4 million members, is interested in phasing out the use of PVC materials, including vinyl-backed carpeting, in its buildings. Health considerations help inform the company's construction decisions as it prepares to build 12 new hospitals in the coming years. "The main thing that drives our decisions is quality of care," says Kathy Gerwig, Kaiser's director of environmental stewardship and national environmental, health, and safety operations. "If we have less toxic materials in our facilities, that helps the healing process. People intuitively get that connection. And people want to work in a greener environment."

One person in every nine in the United States works in health care, including more than 2.5 million registered nurses and more than 756,000 physicians. The industry accounts for roughly 14 percent of the nation's gross domestic product. If the health care sector as a whole moved toward using greener practices in design and building, it would generate the economic power to drive changes in product design and construction materials in many other fields.

What will the hospitals of the future look like? They could be quite different from today's giant, impersonal facilities, which operate more like megamalls or airports than neighborhood institutions. They promise to be smaller, healthier, more local in focus, and more inviting for patients and visitors. "Unlike other industries, health care is rooted in communities," says Health Care Without Harm co-coordinator Gary Cohen. "It's not picking up and moving to China or Mexico." So, as the greening of health care takes hold, it will move the industry toward an even deeper interdependence with local economies and concerns.

At the University of Nebraska Medical Center, an interdisciplinary working group has spent the past four years developing a model for a future facility they've named the Green Health Center. Two members of the group, bioethicists Andrew Jameton and Jessica Pierce, speculate that materials at such a clinic would be bought locally as much as possible, that therapies and medications would be ecologically sustainable, and that costs would be low to maximize everyone's access to care. Inside the facility there might be windows that actually open, an information center with brochures for local bike trails, and no blaring TVs or annoying Muzak.

For Tracey Easthope, who works with both community groups and hospitals as the environmental health director at the Ecology Center in Ann Arbor, Michigan, a truly green hospital is really more about biology than about architecture. "Instead of a vast, imposing structure set on a hill and bounded by walls," she says, "I see the architecture more like a cell in an organism, inviting in the surrounding landscape and people." The water treatment, cooling, and waste systems would be visible. The center would buy local organic food, provide transit options, and help efforts to revive local streams and lakes. It would also work to change the social systems-political and economic-that threaten health.

"Right now, we talk about people's health within the walls of a brick building," Easthope says. "But people come into the health care setting affected by the world. If we really want to talk about well-being and appropriate responses to disease, it means we have to go to where people live and work. In order to really address people's health, you have to engage outside of those brick walls."

This idea is a common theme in both the new green health care movement and wider efforts to bring an ecological awareness to all of society. As a recent statement from the Science and Environmental Health Network noted, "Whether it is in the way we build clinics and hospitals . . . or choose the means of maintaining our own health, we must do so with a commitment to enhancing life on this precious planet." The ultimate goal is not to turn hospitals into enclaves of healthy practice in an otherwise dirty world. It is much broader. Only by healing our relation to nature will we fully address the deeper ills that afflict us. 

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