STEVEN ROSS JOHNSON October 19, 2019 01:00 AM
Addressing the social determinants of health is
hot in healthcare right now, while preparing for climate change is not.
Most providers fail to make the connection
between the two issues. And experts say providers who don’t see the link risk
slowing progress toward solving both.
“These two issues have to be very closely
integrated in order for hospitals to be effective, and I think the fact that
they haven’t been doing that is a real problem,” said Dr. Ashish Jha, dean for
global strategy at the Harvard T.H. Chan School of Public Health and director
of the Harvard Global Health Institute. “Environmental sustainability has not
been understood as a health issue.”
If they fully understood the connection,
providers would integrate the concept of addressing social determinants into
their environmental sustainability policies and make the latter a part of their
population health management plans.
“I think that still in the minds of many here
and throughout the healthcare industry, not everybody makes the connection,”
said John Leigh, director of sustainability at Virginia Mason Medical Center in
Seattle. “Our systems aren’t integrating those two approaches all that well.”
Making the connection
Despite being recognized as one of the country’s
leading health systems for environmental sustainability, Virginia Mason has yet
to fully integrate its sustainability program with its population health
strategy, Leigh admitted.
He said more needs to be done throughout the
healthcare industry to help meld the two concepts into a singular cause. “One
of the things we have to do is help people understand that this (environmental
sustainability) is a population health strategy,” Leigh said.
But attempts to link environmental
sustainability with population health remain in their early stages even among
health systems considered at the forefront of the sector’s effort to address
both issues. “This is one of those things where this is a natural for hospitals
to do, and yet I’ve seen so few hospitals actually do it,” Jha said.
Addressing environmental factors can have a
large impact on improving patient care and outcomes. Consider air quality, a
known driver of respiratory illnesses such as asthma and chronic obstructive
pulmonary disease.
Such conditions have been a major public health
concern that combined affect nearly 40 million Americans and cost the U.S.
roughly $20 billion a year in healthcare expenditures. Indoor
air pollutants, which are a leading cause of respiratory disease, are found in
homes in many poor neighborhoods; experts say that pollution can make the
indoor air quality worse than it is outside.
The health effects caused by poor air quality
have prompted a number of providers to invest in initiatives to improve the
environmental conditions of patient homes.
One of the largest came in 2018 from Oakland,
Calif.-based Kaiser Permanente when the health system launched its $200
million Thriving Communities Fund to address housing stability
and homelessness. Funding went toward procuring new housing as well as repairs
to existing housing units to remove toxic substances such as mold and lead
paint.
Gary Cohen, president and co-founder of Practice
Greenhealth, an initiative that serves as an information resource for
healthcare on sustainability initiatives, said a big part of his organization’s
efforts in the last few years has focused on raising awareness among healthcare
providers about the increasing health impact of environmental conditions.
“Sustainability has started to merge with
broader community health and planetary health dimensions,” Cohen said.
Why it’s important
Experts rank environmental factors among the
leading causes of poor health around the world, along with risky health
behaviors and social and economic determinants.
Preventable environmental factors are
responsible for an estimated 23% of all deaths globally, according to the World
Health Organization, including 26% of deaths among children under the age
of 5.
Some providers have continued or expanded their
efforts as the federal government’s views about the effects of climate change
have shifted in recent years. In 2017, after the Trump administration pulled
out of the Paris climate agreement, several of the country’s largest health
systems reiterated their commitment toward environmental stewardship with or
without federal support.
Yet the healthcare sector itself is a major
contributor to pollution as the world’s seventh-largest producer of carbon
dioxide; it’s also responsible for nearly one-tenth of
all U.S. greenhouse gas emissions. Healthcare also produces large amounts of
waste. The average hospital generates more than a pound of hazardous waste per
bed a day, according to the World Health Organization.
The environment’s impact on public health is
expected to only grow as a result of climate change. Heightened temperatures
caused by greenhouse gases have led to increases in the frequency and intensity
of extreme weather events, which were responsible for more than 600,000 deaths
globally over the past 20 years, according to a 2015 report by the United Nations.
In recent years a growing number of providers
have set audacious goals for achieving greater environmental sustainability with
initiatives to massively lower their energy and water consumption, improve
their waste disposal practices, and reduce their greenhouse gas emissions.
Cohen said such social determinants as housing
instability and food insecurity among patients along with hospitals’ energy use
were a few of the biggest areas of focus for those healthcare providers who
have begun to examine how to link environmental sustainability with their
population health strategies.
Arguably the most popular trend hospitals pursue
involves how they purchase food. Cohen said Practice Greenhealth works with
several hundred providers as part of its Healthy Food in Healthcare Program,
getting them to commit to buying portions of their food supply from local and
sustainable growers.
The goal of the initiative is for hospitals to
create a “sustainable food system” that promotes healthy food access, diet
education and economic development in low-income communities.
Among the one-third of providers in the country
that follow Practice Greenhealth’s sustainable food criteria is Kaiser
Permanente, which has set the goal of buying 100% of its food from local or
sustainable producers by 2025. In 2017, 28% of Kaiser’s food budget went toward
sustainable food, with its hospitals collectively hosting more than 50 seasonal
markets and farm stands a year.
“We’ve defined the criteria of healthy food to
include sustainable food,” said Kathy Gerwig, vice president of employee
safety, health and wellness and environmental stewardship at Kaiser. “That’s
how you begin to make it seamless.”
The pledge is part of the health system’s
broader environmental stewardship effort that includes becoming carbon-neutral
by 2020 by purchasing most of its energy through renewable sources, reducing
water usage by 25% per square foot of its buildings, and recycling or reusing
all of its non-hazardous waste by 2025.
“These are all things that in and of themselves
are important environmental issues but combined create a very effective climate
action strategy,” Gerwig said.
Going beyond your walls
Traditionally many of the efforts that hospitals
have engaged in to become more environmentally sustainable have centered around
making their facilities or campuses “greener.” Such initiatives have included
substituting renewable energy sources for fossil fuels, resulting in lower
consumption and carbon emissions.
But connecting those efforts to a broader
population health strategy requires providers to think about how their energy
consumption affects the health of nearby communities.
Like other environmentally conscious health
systems, the Cleveland Clinic has for more than a decade committed to becoming
carbon-neutral, which has so far resulted in a 19% reduction in energy use per
square foot toward its goal of lowering it by 20% by 2020.
But according to Jon Utech, senior director of
Cleveland Clinic’s Office for a Healthy Environment, the health system’s
efforts reach into the community with policies and programs designed to lower
the air pollution caused by employees’ commuting. Utech said Cleveland Clinic
offers discounts for employees who buy fuel-efficient vehicles, rebates for
purchasing hybrid cars and incentives for workers to carpool.
“Our direct commuting actually has a population
health impact,” Utech said.
Gundersen Health System CEO Dr. Scott Rathgaber
said he saw real population health benefits in the health system’s
environmental stewardship efforts. Its energy conservation initiatives include generating
wind power and using solar and geothermal energy, which have led to the system
lowering its carbon dioxide emissions by more than 80% and its mercury levels
by 86% from 2008 to 2018.
“Those are real environmental improvements that
will improve the health of our community,” Rathgaber said.
Dollars and sense
Justin Graves, director of materials management,
logistics and sustainability at the University of Maryland Medical Center, said
it was important to convey to the community why the system works on
environmental sustainability by connecting those actions to their health
outcomes.
In terms of impact, Graves said leveraging the
system’s tremendous purchasing power to buy environmentally preferred products
has reduced the likelihood of getting items that contain hazardous chemicals or
aren’t recyclable. “The effort is to green that supply chain,” Graves said.
Rathgaber said the system’s purchasing has been
leveraged to not only buy locally but to form community partnerships on
projects designed to improve the fiscal health of the local community, which he
said will reduce the impact of poverty and unemployment as health determinants.
Such initiatives can have a reciprocal effect.
The amount of pollution a health system produces is largely based on the number
of clinical procedures a hospital performs.
Providing the community with economic stability
through its purchasing means residents will be more likely to have the ability
to cover the cost of medications and tests to better manage their chronic
conditions, making it less likely they will need to come to the hospital. Less
healthcare utilization means less pollution is produced.
“This money stays in the community and
circulates in the community with each dollar spreading from business to
business, improving jobs and people’s stability,” Rathgaber said.
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