Gary Cohen always found it odd that the healthcare system didn’t focus more attention on the health impacts of its own industry. Of course in the developed world, we are thankful to live in a society where most people have access to expert medical care when they need it, but what about the hospitals themselves and the medicines, foods, and other products consumed within them—what externalities do they create in regards to human and environmental health? What about the paint on the walls, the wood in the floors, and the power they pull from the grid? As a physical, social, and economic institution, does the healthcare system embody the well being it seeks for its patients?
These are some of the tough questions that Cohen, president and co-founder of Health Care Without Harm (its membership organization Practice Greenhealth includes roughly 1,400 hospitals—almost 20% of the market), has explored in his 30-plus year career as an environmental health advocate. He says that while much has improved, the healthcare industry still contributes significantly to public health problems, which the earliest impacts of climate change are beginning to magnify. “We have to educate the one sector of our economy that actually has health as its mission: healthcare,” Cohen says. “And if healthcare itself is one of the largest polluters, then there is no hope of building a healthier society.”
Hope in that department has grown considerably since Cohen first began knocking on the doors of healthcare providers and asking them to take a hard look at their own practices in the mid-1990s. This was when he discovered that medical waste incinerators were the largest source of dioxin emissions and a significant source of mercury emissions in the United States. Since then he has unraveled a laundry list of environmental hazards, and associated health hazards, stemming from the healthcare industry—work that has brought him recognition from both the public and private sector as a leader in the field of environmental health. He was named a MacArthur Fellow in 2015 for his efforts.
As president of Health Care Without Harm, Cohen leads an international coalition of more than 500 members in 53 countries that work to promote safe and environmentally healthy practices, processes, and products in the healthcare sector. He recently sat down with gb&d to discuss the evolution of his career and why climate change is as much a health problem as it is an environmental problem.
PART 1 ENVIRONMENTAL TOXINS: THE DAWNING OF PUBLIC AWARENESS
gb&d: What first drew you to look at the intersections between healthcare and the environment?
Gary Cohen: It’s a funny roundabout story. My first job out of college was writing guidebooks—restaurants in Paris, pubs in London, walking tours of New York City, that kind of thing. After that, I went to India for almost two years, and when I came back, a close friend of mine from college who had gotten involved in supporting communities that were impacted by toxic chemical threats said to me, ‘You’re a guidebook writer Gary, why don’t you write a guidebook to toxic chemicals?’ I’d come back from India right at the time of the Bhopal chemical disaster, and people were realizing there were all these toxic waste sites around the country, people’s health was being impacted, and that there were no ‘right to know’ laws. People were worried a similar accident could happen in their community.
gb&d: What was your response to your friend’s suggestion?
Cohen: I said, ‘What do you mean? Nobody wants to go visit those places.’ He said, ‘No, no, it would be a how-to guide.’ So if you’re a mother in Pittsburgh, and you have some toxic waste site down the street, or an incinerator, or a chemical factory that is spewing all sorts of toxins into the air—how do you address that stuff? How do you organize your neighbors? How do you access whatever data might exist that the government has? How do you use the media to draw attention to the problem? How do you negotiate with the company?
gb&d: What did writing that book, Fighting Toxics, open your eyes to?
Cohen: I had a chance to start to meet all these mothers and fathers that were sitting around kitchen tables wondering why their kids had rare forms of cancer, or woke up choking at night, or had strange skin rashes after bathing. I was so moved by their bravery, their tenacity, and their willingness to go up against the most powerful companies in their communities because they were defending their family’s health. I also got involved with the National Toxics Campaign that was instrumental in winning the first community ‘right to know’ law in the country, which required companies to disclose the chemicals that were coming out of their stacks and being dumped in the water and on the land.
gb&d: What then inspired you to focus on the healthcare system?
Cohen: In the mid-1990s, there were some catalytic events that made me focus on healthcare. There was new science coming out that was showing that chemicals at infinitesimally small doses could impact the developing systems of children in the womb in the first couple years of life. This is where we first started to learn about endocrine disrupting chemicals. The other thing that happened at that time was the Environmental Protection Agency had identified medical waste incinerators as the largest source of dioxin emissions in the United States, and a significant source of mercury emissions. These two chemicals were the poster children for endocrine disrupting chemicals.
gb&d: And from this I gather Health Care Without Harm was born?
Cohen: We thought, ‘If we’re going to change our society so that our economy is not built on toxic chemicals that are poisoning our population, then we have to transform the one sector of our economy that actually has health as its mission: healthcare.’ If healthcare itself is one of the largest polluters, then there is no hope to build a healthier society. So that was the impetus to start Health Care Without Harm.
PART 2 HEALING HEALTHCARE, FROM TOXIC BUILDINGS TO DAMAGED COMMUNITIES
gb&d: Over time, your focus within environmental health has shifted away from the toxins themselves to the healthcare industry and its multifaceted contributions to environmental problems, which in turn become public health problems. What does that look like in the big picture?
Cohen: The collateral damage of an economy that is built on fossil fuels and toxic chemicals are the people who show up at the front doors of hospitals. So the public health damage of this addiction to toxins and fossil fuels is directly related to the cost of healthcare, and to the approach of healthcare.
gb&d: How can healthcare be part of the solution?
Cohen: It’s an enormous part of the economy, and growing. In the United States, healthcare is 18% of the entire economy. Globally, it’s 10%. So it has an enormous impact. The only thing bigger is the military. If you can get healthcare to detox its supply chains and make healthier buildings and change its food purchasing practices—then it can have a broader outside impact on the rest of the economy. It also has a role as a messenger. There is no other sector of the economy that is as trusted. If doctors and nurses advocate for policies around phasing out toxic chemicals, around renewable energy standards, around sustainable agriculture policies that incentivize healthier food systems—it has an enormous impact.
gb&d: What sort of advocacy does Health Care Without Harm do with hospitals and healthcare providers?
Cohen: We’ve been working on waste reduction, as well as mercury and other chemicals in the supply chain. And we focus on the buildings themselves, because they’re also full of toxic chemicals, and full of energy-inefficient technologies. We need to bring this agenda around healthy environments into the facilities themselves. We think healthcare facilities should promote the healing process. We should be building cancer centers without carcinogens and children’s hospitals without chemicals linked to birth defects and asthma.
gb&d: More and more hospitals are LEED certified. Is that enough? Does that lead to the results you’d like to see?
Cohen: In the past LEED was narrowly focused on energy, and the hospitals that we were working with said it didn’t really work for them. It didn’t focus on occupant health, the health of the workers, or the health of the patients. So about six years ago, we helped develop what is called the Green Guide for Healthcare with the Center for Maximum Potential Building Systems. It was based on the LEED framework, but each point had to have a health co-benefit, whether it was directly occupant health, or broader environmental health. It was our attempt to insinuate an environmental health framework into the green building world. Within a very short time we had almost 300 projects that were adopting the guide representing over 40,000,000 square feet of healthcare construction.
gb&d: One of your recent campaigns was against toxic flame retardants in furniture that is commonly found in hospitals. Tell us more about that.
Cohen: In the last 18 months, we’ve been advocating around eliminating toxic flame retardants from healthcare furnishings because of the fact that they are ineffective and incredibly toxic. Our allies were able to convince the State of California to change its regulations to allow buildings to have furnishings that don’t have these flame retardants in them. We were able to get Kaiser Permanente and four other large systems to say they’re not going to buy furniture that has these toxic flame retardant in them, as well as furnishings that have formaldehyde, PVC and some other chemicals of concern. Within a very short time we had created a $50 million demand annually for safer furnishings. That created the momentum to bring the furniture manufacturers to the table and offer these innovations at a cost competitive price.
PART 3 HEALTH CARE WITHOUT HARM AT THE COP21 CLIMATE CONFERENCE
gb&d: Most recently, your attention has turned to the links between healthcare and climate change. How does one impact the other? Is this happening already?
Cohen: We agree with the World Health Organization, which claims that climate change is the biggest public health threat of the 21st century. No one will be immune from the impacts of climate change. If you live in Beijing or Delhi, the air is too poisoned to go outside. Between those two countries, there are almost 2 million people that are dying each year just from air pollution. If you live in low-lying communities, rising water is going to make you an environmental refugee, or contaminate your water supplies. In many places, because of the warming temperatures, mosquitoes that carry dengue fever and malaria are going to travel to your neighborhood. Then there is heat stress; as the Earth gets warmer in many places, there will be more extreme heat days that will have enormous impacts on people’s health.
gb&d: Tell us about the 2020 Health Care Climate Challenge.
Cohen: It’s a way to create a framework for inspiring healthcare institutions around the world to make commitments around climate leadership. One focus is around climate resilience—making changes in building infrastructure and supply chains and developing strategies around community engagement that build and anchor community resilience. So that in the next Hurricane Sandy or Hurricane Katrina, hospitals are able to be the first responders and address the increased medical needs. They need to be the last building standing.
gb&d: How have recent climate-related natural disasters changed the way healthcare facilities are planned and built?
Cohen: What we learned from Katrina and Sandy is that when hospitals fail, it creates chaos. On top of the fact that they can’t address the influx of patients, you’re actually evacuating the place. We want climate resilience to become a standard part of the planning for healthcare institutions around the world, and to leapfrog over current technologies. The more that you have on-site power, the more likely a facility can continue operating when the grid goes down. With both Katrina and Sandy, we saw that play out with hospitals that had combined heat and power generation, for example. They were able to operate for days when the grid was down.
gb&d: So public health goes hand-in-hand with resilient power systems, which go hand-in-hand with renewable energy, right?
Cohen: Yes, healthcare needs to lead by example and make the transition to renewable energy, to distributed energy, to co-invest with communities, and build infrastructure for a clean energy future. They’re not only saying that we’re putting in solar panels or investing in wind farms, they’re doing it because it’s to the benefit of the health of their community. So it’s a rebranding of their efforts within the framework of healthy communities. And rebranding climate change to be a public health imperative.
gb&d: In the way you put it, it’s as if climate change is becoming a platform to address a host of environmental problems, as well as social problems.
Cohen: All the polls say that if you can talk to people about climate change as something that impacts them directly and their families—especially their health—it’s the most powerful way to engage people and reach solutions. We need healthcare systems to act as messengers. Are they engaging in policy to use their political clout in developing policies that support renewable energy, put a price on carbon, include the public health costs of fossil fuels, support the president’s clean power plan? The goal is to get healthcare to weigh in on key policy issues around climate and tip the balance away from the fossil fuel industry and all of its money.
gb&d: You and your colleagues were part of the events in Paris. That must have been an exhilarating experience! What was the result of the conference for the healthcare industry?
Cohen: We were part of a number of events on greening healthcare—with the French Hospital Federation, the Paris Public Hospital Association, the World Health Organization, and with hospital systems, nursing and physician organizations, public health experts, and academics from around the world. We were able to create a lot of momentum for the 2020 Challenge in the lead up to Paris, which was super exciting. By the time the Paris treaty came around, were able to get more than 60 participants from 19 countries, representing more than 8,000 hospitals to join this initiative. We’re collecting information from hospitals all over the world that have joined the 2020 Challenge. They’re telling us how they’re doing it and sharing data with us, especially around their carbon footprint reduction and how they are moving toward renewable energy. It’s creating a set of healthcare players around the world that are setting a high bar for the rest of the sector to follow. We will continue to transform the healthcare sector so they expand their healing mission to heal the communities they serve and the planet that sustains us all.
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