Healthcare should link social determinants with environmental sustainability

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.”

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.

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.

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.

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.