Primum non nocere,

deinde curare also

applies to hospitals.

Disclaimer: The views expressed in this paper/presentation are the views of the author and do
not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board
of Governors, or the governments they represent. ADB does not guarantee the accuracy of the
data included in this paper and accepts no responsibility for any consequence of their use.
Terminology used may not necessarily be consistent with ADB official terms.

Dr. Jean-Jacques BERNATAS

ADB, May 2016

Negative global public health

impact of HCF
Uncontrolled development for immediate profitability in health care
facilities causes collateral damages:
Direct: malpractice, higher rate of unavoidable side-effects of
treatments;
Indirect:
To the patient: stress, disruption at work/family life; exposure to
hazardous components (air pollutants, utilization of potentially
harmful device or material - IV lines/phtalates/newborn ), risk
of hospital-acquired infection including with resistant bacterias
To the visitors: same as for patients, except care-associated risk
To the community: spread of communicable diseases, outbreaks
of emerging diseases (SARS, EBOV, CCHF, ); environmental
impact (water, energy, effluants, carbon footprint).
2

The context of SD in
HCF
People (staff,
patients,
visitors)

$ (investment,
capital,
income)

Lowest cost vs.

Sustainable
input

Adverse public
health impact:
toxic substances
energy and water

consumption
carbon footprint

Individual adverse
events:
nosocomial infections,
accidental deaths and

Input
(equipment,
supply,
consummables,
)

disabilities
work accident and
occupational diseases

Immediate profitability vs.

Sustainable development
Process (SOP)

preventive
Management

curative

HEALTH

Strategy

Back to fundamental: The

Hippocratic Oath
Better health (patients,
community, country)

Adverse events (patients),

exposure to hazard (staff,
visitors), work accident
(staff), and negative
environmental impact
(indoor/outdoor)

Conceptual framework of SD in
healthcare sector

Sustainable
health

Improving
outcomes

Sustainable
management

Ecoconstruction

Sustainable
procurement

Mitigating adverse
events and
negative
environmental
Saving energy
impact
and water

Sorting,
recycling and
re-using

Preserving the
air quality

Sustainable management
From quality management basics:
Structure (=ingredients)/process (=recipe)/outcome ( the cake!)
Donabedians framework and its further improvements, for evaluation and quality
improvement
Non-quality as a factor of increased costs of healthcare,
P-D-C-A and continuous quality improvement in health.

to sustainable quality management:

Motivation: embracing this vision relies on real understanding of its rationale. Wellinformed staff makes a positive choice. Patients motivation++
Cooperation: network of hospitals sharing experience on SD
Training: part of the remediation process; on-site, hands-on and continuous education
Validation/good practice: certification (ISO14001, LEED, EMAS, )(*)
Communication: creation of SD commissions, sharing experience with a larger
audience, and to convince people on the relevance of SD.

ISO: International Standard Organizatio; LEED (US Green building Council): Leadership in Energy &
6
Environmental Design; EMAS: European Eco-Management and Audit Scheme.
(*):

Ecoconstruction
Usually higher immediate investment for a mid- even
long-term apparent profitability only .
Refers to specific labelling such as LEED, BREAM,
ISO 14001,
Starts with a decision-making, then a choice of a
site, and a participative multidisciplinary approach
(ex. /Location).
Requires multiple kinds of specific expertise.
Energy performance, choice of materials, noise
reduction, choice of light, among others.
7

Saving energy and water in

hospitals has a global impact
A hospital energy consumption in France is 350 kWh/m2/year
(energy efficiency index) where the new low energy building
standard for healthcare buildings in France is now 50
kWh/m2/year: long way to go
Hospitals energy consumption represents an average 11% of
energy consumption of tertiary sector in Western countries.

A German study evaluated one hospital bed to consume as

much electricity and heating as two households.
Water is a finite resource: the estimated average consumption
of a medico-surgical hospital is 300 to 750 liters/bed per day:
8

Saving energy in hospitals :

solutions (1)
1. Carrying out energetic assessment: heating/AC (up to 62%
of energy costs, in Canadian hospitals; energy consumed by
hospital represents 50% of ecological footprint of health
care facilities)
2. Certification: BUND certificate ( Energiesparendes
Krankenhaus, Germany); Energy Star program; ecology
footprint calculation; ISO 50001:2011; ISO 14001:2015
3. Green light program (European Commission) (in 2009,
Virgen de la Arrixaca University hospital, Spain, saved
70,000 kWH)

Saving energy in hospitals :

solutions (2)
Renewable energies:
recovering heat generated by air conditioning systems
decreased the fuel consumption from 1200l to 500l a
month (La Colina Hospital Tenerife, Spain);
steam boiler (Newberg Hospital, Oregon),
geothermal (St Jerome Regional Hospital, Canada:
75 geothermal wells saving 500,000 USD a year on
heating),
photovoltaic panels (Portland OHSU, Oregon http://www.ohsu.edu/xd/about/initiatives/green.cfm
10

Saving water in hospitals:

solutions
1. Using less thirsty autoclaves for sterilization units (new
autoclaves will use 120l per cycle instead of 250l previously),
2. recycling water from hemodialysis for flushing systems
after osmosis treatment (USP Hospital in Santa Cruz,
Tenerife, Spain); recycling water for laundry in using waste
water to heat tap water (CHRU Tours, France: 5.5 l/kg
instead of 12l/kg linen before) halves effluent discharge
40,000 saving;
3. use bio-digestive membranes for filtering water = clean
filtering system
11

Impact on air quality

Carbon footprint: the University Hospital of Geneva (HUG) has
evaluated that it consumes yearly as much energy as a European
city of 16,000 inhabitants, and producing 10 tons CO2

HUG carried out a life-cycle analysis :

40% of carbon emission come from materials and
incoming products (mainly from drugs and textile objects
25% come from the buildings;
25% from transports (patients, visitors, staff)
10% from and infrastructure and waste management

12

Solutions to preserve air

quality
Reducing the impact of transport on CO2 production:
Hospital better connected to the city
Green mobility: hybrid engine ambulances, carpooling for
ambulances, staff mobility (car pooling, bicycle, )
Improving the hospital functionning in reducing CO2
production:
Promotion of green spaces
Shortening of the supply chain
Energy saving policy

13

Sustainable purchase for safe and

sustainable products -1. Principles
Shorter/local supply chain: to reduce environmental impact
and carbon emission; to contribute to positive economic impact
on local communities

Responsible and professionalized purchase based on

transparent and evidence-based information made available,
traceability of the products to face the fragmentation of
internal and external purchases, purchasing centrals, pooled
purchases ...
Substitution of toxic/carcinogenetic substances (Karolinska
Hospital in Huddinge, Sweden: list of 100 substances to be
abolished).

14

Sustainable purchase for safe and

sustainable products 2. example
Chasing hidden dangerous substances, for example:
endocrine disrupters (BPA
http://www.niehs.nih.gov/health/topics/agents/sya-bpa/ ; DEHP
banned in UE (European Directive 2005/84/EC) for all childrens toys and
childcare articles/ http://www.cirsreach.com/Testing/Phthalates_Testing.html)
Engineered nanomaterials (ENMs), and nanoparticulated titanium
in wall paints (antibacterial properties under UV, but may affect the
blood-brain barreer.
Ethylene oxide sterilization, including bottle teats: listed as
carcinogen to man , but still in use to sterilize enteral feeding devices.
VOCs (Volatil Organic Compounds): organic gases found in
ambient air, issued from detergents, cleaning fluids, .
15

Sorting, recycling and re-using

Chemical releases
Compliance to existing regulation or necessity to improve it.
REACH regulation (European Community Regulation on chemicals
and their safe use): guidelines for identification and substitution
of chemicals
Effluents:
Effects of low concentration persistant residues in discharged
water: drugs, radioactive substances, antibiotics,
Possible bioaccumulation in aquatic organisms.
Reduction of drugs in effluents requires better prescription (less
/appropriate prescription of antibiotics), specialized treatment
plants, separate sewage network for hospital.
Substitution of reagents (cyanide for blood count),

16

Using less, using better

Techniques for disinfection/sterilization: place of
incineration? Substitution to autoclaves for some medical
waste (grinding and chlorine dioxide treatment)
Sorting channels and recycling: up to 30 channels in some
hospitals, with a specific lifecycle for each type.
Chasing any unnecessary packaging.

Waste reduction and recovery policy in place.

Improvement/Enforcement of national regulations, global
but also specific to hospitals.
Major concern about antibiotic microbial
resistance: hospitals must take the lead and set an
17
example.

Sustainable healthcare services

delivery Broadening the scope of
beneficiaries.
Taking care of employees:
Occupational health improvement, based on prevention: back
pain prevention, tobaco-free environment/smoking cessation support,
...
Psychological stress, specific issue of HCW: counseling, adapted
innovative management (decentralized management unit providing
more autonomy for nursing staff). Experience of magnetic
hospital keeping low attrition rate among workers in providing
better conditions at work ARIQ label in Canada (attractiveness of a
hospital/ ability to keep staff/ involvement of nurses/ quality of care)
Visitors are actors and vectors
18

Sustainable healthcare services

delivery: Broadening the spectrum
of Heath benefits for the patients.
The International Declaration on Diseases due to Chemical
Pollution, known as the Paris Appeal, launched at the Paris
conference on Cancer, Environment and Society on 7 May
2004: an agenda to deal with environmental health.
Implementation of environmental medicine services in
hospitals: multiple sensitivity, low fertility due to endocrine
disrupters, ...

19

Sustainable healthcare services

delivery figuring out the impact
on the community
1. Positive
1. Providing individual better health
2. generating income and employment to the local community
2. Negative:
1. Pollution (air, water)
2. Exporting diseases: AMR, emerging/re-emerging diseases

20

Sustainable healthcare services

delivery: is it marketable?
Integration of preventive medicine in hospitals services in a context
of biased competition (marketing services with high and immediate
return on investment)? For private sector: Is prevention a good
business?
There are many return of experience from hospitals having
implemented a SD approach, but few global comprehensive
business case studies.
(http://www.hpoe.org/Reports-HPOE/ashe-sustainability-reportFINAL.pdf): Environmental sustainability is also good

business, as it helps lower operational costs and allows

hospitals to direct more resources to patient care. (Health
Research & Educational Trust. (2014, May). Environmental
sustainability in hospitals: The value of efficiency . Chicago, IL:
Health Research & Educational Trust. (Accessed at www.hpoe.org , American
Society for Healthcare Engineering)
21

The poor are more exposed to poor

outcomes of unsustainable care
consequences
When it comes to saving money, the poor are the first to be
affected:
Non sustainable options for immediate profit may also offer health services at
lower cost and higher financial accessibility - but of lower quality and may
expose the poorest users to higher incidental health risks.
Similar to double-burden of nutrition: the poorest are more often sick and
will have only access to the cheapest care, which includes the use of the
cheapest materials and cheapest care that may harm them worse in return

The poor are more exposed to environmental risks.

This includes risks generated by the hospitals in the neighborhood: unsafe
waste management, incinerator producing dioxines production, for exemple.
22

HOW the poor must benefit from

sustainable development in
health care?
Environmental regulations to be extended
and reinforced,
and to apply to all healthcare facilities, including public
and decentralized.

Set up an adequate financing agenda.

Raise awareness,
and make decision-makers bear in mind that sustainable
development for hospitals is an integral part of fight
against poverty, and of climate change management.
23

Finally

Sustainable development= primum non nocere, which

is an action in itself

Asian/South-East Asian countries are more exposed to

the environmental risks and should take up the lead in
developing sustainable healthcare facilities.

Climate change is a driver for change in a sustainable

manner for hospitals since many determinants of CC are
also factors of negative health outcomes from health
care providers

What is expected to apply under COP21 to all industrial

sectors applies also to health sector.
24

Health and SDGs: leveraging

SDG3 will optimize the
outcome and minimize the risk

25

Acknowledgements
Olivier TOMA, C2DS (www.c2ds.eu )
Health Sector Group, ADB.

26