Just Read: Environmental Impacts of the U.S. Health Care System – (Carbon as a currency for health)?

This review could be considered an update to the brief analysis that appeared in 2009 describing US Health Care’s contribution to green house gas (GHG) emissions to be 8% of the country’s total.

And now it’s up to 9.8% (or maybe 9.3% since the models used to calculate the number are based on 2002 standards around energy generation).

I took the time in 2009 to review the models used carefully, because in life, I always read the whole paper, not just the abstract, and you should too. It’s fair to say that they are (a) complex, and (b) subject to a lot of uncertainty. I have actually been told that some of the assumptions made may not be correct, however, until I get that info, I’m just going to go with the numbers presented here.

2017.03.23 Impacts of Healthcare on the Environment 0157014
Fig 1. Time series of life cycle GHG emissions from US health care activities. Shown for 2003–2013, in absolute terms (orange bars) and as a share of U.S. national emissions (blue line). Mt = million metric tons.

Eckelman MJ, Sherman J (2016) Environmental Impacts of the U.S. Health Care System and Effects on Public Health. PLoS ONE 11(6): e0157014. doi:10.1371/journal.pone.0157014

2017.03.23 Impacts of Healthcare on the Environment (View on Flickr.com)

This paper goes beyond GHG emissions, though:

These impact categories include global warming; stratospheric ozone depletion (allowing higher levels of short-wave ultraviolet light through the atmosphere, increasing the health risks of skin cancer); respiratory disease from inhalation of primary and secondary particulate matter (PM) and from ground-level ozone (smog) stemming from emis- sions of criteria air pollutants; cancer and non-cancer disease through inhalation and ingestion routes of chemical exposure; environmental effects of acidification (from formation and deposition of acid rain) and eutrophication (algae blooms from excess nutrients) in soils and surface waters; and ecotoxicity that reflects the toxic burden of all emitted chemicals to aquatic organisms.

The tweet being made about the piece is that the US Healthcare System emits more carbon than all of the United Kingdom, but really that’s not a useful comparison because of the population differences.

Carbon as a Currency for Health/Life

It’s probably better to note that the National Health Service in the UK contributes 3-4% of the national GHG emissions, which mirrors to some extent the difference in GDP spend on health care, which was previously highlighted so eloquently to me by Brian Masterson, MD, who was then at the Military Health System in 2014, which I’ll repeat here:

20-20-20, 3-3-3

  • 20: % of GDP spent on health care in the United States
  • 20: % of youth out of high school who are fit for the military today
  • 20: % of the outcomes of health that come from health care

The delta on average between our expenditure on health care and other countries is about 12 %, with which

  • 3: % of the GDP is spent on defense today
  • 3: % of the GDP would fund every eligible student to attend a state university
  • 3: % of the GDP to make Social Security solvent for every American alive today
  • 3: % left over

If carbon emissions parallel use of services/supplies/people, then there’s an interest in using the right amount of these to obtain maximum achievement of life goals for a population (see numbers above). And therefore right amount will result in right amount of GHC emissions.

The physician role

The thing to notice carefully about the GHG emission sources, which are based on the expenditure categories of our health system (Table 1) is that they are 80% directed the things physicians do – not just providing medical services, but ordering tests, pharmaceuticals, hospitalizations.

The group physicians for climate (@DocsforClimate) recently convened in Washington, DC with this understanding:

And I have yet to meet a physician who wakes up hoping to provide too much or the wrong type of health care.

Beyond the right amount of things, there’s the way things are produced

Again the assumption (reality) that physicians work every day to perform well for their patients, it’s easy to walk into any health care environment and see opportunities. From the paint on the wall to the light bulbs in the fixtures, the soap in dispensers, the eventual location of discarded e-waste…

Physicians have a role in this too, as they did in the creation of the new Kaiser Permanente San Diego (@KPSanDiego) Medical Center (click here to see video, – LEED Platinum promotes health and it looks good too) .

Carbon not the goal, a better world is

A simple reminder…

091207usatoday global warming.91

Citation: Eckelman MJ, Sherman J (2016) Environmental Impacts of the U.S. Health Care System and Effects on Public Health. PLoS ONE 11(6): e0157014.

2016 US Climate Leadership Summit, Washington, DC USA

Climate change is a health issue. I’ve known that part for a long time.

In 2016, the economics of fixing this problem have changed so much that producing health and mitigating climate change are actually more economical than not. I learned that yesterday.

2016.09.14 American Climate Leadership Summit, Washington DC, USA 07909
2016.09.14 American Climate Leadership Summit, Washington DC, USA 07909 (View on Flickr.com)

I love people who put all of their knowledge concisely on one slide. Thanks, Joseph Romm.

I am also deeply intrigued by people who learn, grow, and change, and so I was fascinated by Jerry Taylor (@Jerry_Taylor). I kind of thought he could host an all day session on his journey.

Before founding the Niskanen Center in 2015, Taylor was a senior fellow at the Cato Institute, where he previously espoused a skeptical position on environmental issues. Taylor’s case is notable as an example of a former climate-change skeptic who came to embrace policies to address climate change after researching the scientific consensus behind man-made global warming. Source: Wikipedia

There was actually a lot of talk about this, in multiple contexts, about people, policy makers, leaders, who have accepted the science, some publicly some privately. It’s a journey.

Kaiser Permanente was present, in the form of Kathy Gerwig (@KathyGerwig) who spoke about the lever of the Community Health Needs Assessment requirement in the Affordable Care Act, and the platform made available by partners, CHNA.org, which includes metrics relevant to climate and a healthy community.

Oh, and we’re planning to be carbon net-positive by 2025.

The rest of my photos are below. Because I am who I am, I do get to gently point out (as Joseph Romm did in his talk at the front of the room), that:

  • A high indoor CO2 level is bad for cognition
  • Sitting meetings are generally unhealthy (and they are kind of 20th Century)
  • All of this can be solved by arranging walking meetings

Thanks EcoAmerica for the educational experience and connection to so many other dedicated professionals and citizens. And of course we’re here to help you plan the next non-sitting event 🙂 .

Just Read: The WELL Building Standard – promoting health for the people inside

These are the things that doctors with Total Health in their job title keep up to date on 🙂 .

Given that humans spend 90% of their time in buildings, it’s easy to recognize that building designers and developers may have a lot more influence on our health than doctors do, and so why shouldn’t we leverage each other?

WELL is a performance-based system for measuring, certifying, and monitoring features of the built environment that impact human health and well-being, through air, water, nourishment, light, fitness, comfort and mind.

The standard is a 238 page, well referenced, multidisciplinary-developed and reviewed (including physicians) document that describes 7 concepts composed of 102 features that impact the “health, comfort, knowledge” of building occupants. You can see as you review it how each feature if thought through can make a difference in a building occupant’s lives (and buildings can be thought of generically, from hotels to health care).

From ventilation, to food choices, to mental health, I found myself contemplating all the decisions that can possibly made about the environments we inhabit that can have a huge impact on us. Great to see them enumerated and explained here.

This includes things like thermal comfort, not just in accurate temperature control, but with temperature variability and “free address” for workers to find their right zone. For me, this would handle the, “It’s so cold in here I can’t even think” syndrome. Same goes for acoustics, both in noise dampening, but also sound masking – to allow for privacy.

2016.02 Gendered Bathrooms New Hampshire1801
A building feature that shouldn’t exist in a healthy built environment. Gendered Bathrooms – still allowed in New Hampshire (View on Flickr.com)

From my read, there’s also room for innovation and incremental improvement. One thing that I’m aware of that’s an impediment to health is gender segregated restrooms (aka “Men’s” and “Women’s” rooms). These shouldn’t exist anymore, and it was a jolting reminder that they still exist on my recent trip to New Hampshire, since these kinds of bathrooms are no longer legal in Washington, DC (see: Why doctors should care about gender neutral restrooms : health, safety, and equality, in Washington, DC)

WELL is pretty new, and it connects to LEED, which, on my last poll of pretty innovative doctors, doesn’t have a lot of name recognition (see: MakerDocsDC: Introducing doctors to green building and LEED at USGBC World Headquarters). But both should. Which is why I’m writing a blog post about it, since I do live in the future.

At Kaiser Permanente, and actually in a lot of leading edge health systems, there’s pretty good recognition of the importance of the built environment for health, both in the buildings we build, and the buildings built where our patients live, work, learn, and play.

For us, it really is in our DNA. Our founder, Sidney Garfield, MD, wanted to be an architect before he became a doctor, and was passionate about design and the facilities in which he cared for patients. See: Why a health system cares about the buildings it doesn’t build: Moderating AIA-DC Panel 10/8/14.

Check out this newsreel from 1953, when his way-ahead-of-his-time hospital in Walnut Creek opened. You’re going to see some things that are most definitely not allowed in the WELL standard today (hint, the waiting room), and also some things that the rest of health care has yet to embrace – the connection to nature.

I have not yet worked in a WELL certified environment, but I hope to … very soon. Watch this space.

Credit to Whitney Austin Gray, PhD for lighting the fire (or should I say, igniting the LED) – she’s a doctor in design that’s improving health. Leveraging each other….

Whitney Austin Gray at Center for Total Health 03020
Whitney Austin Gray at Center for Total Health 03020 (View on Flickr.com)

Photo Friday: Halfway to worldwide 2 degree celsius rise in Washington, DC USA

Halfway to 2 degrees Centigrade - Washington, DC USA-4-Edit
Halfway to 2 degrees Centigrade – Washington, DC USA-4-Edit (View on Flickr.com)

“Come in from the cold to try our winter menu.”

2015 was the warmest December in Washington, DC, history – “This year is expected to be the first year in which global average surface temperatures are at least 1 degree Celsius, or 1.8 degrees Fahrenheit, above average, meaning that the world is already halfway to the 2-degree Celsius, or 3.6 degrees Fahrenheit, global warming target, and even closer to a more stringent 1.5-degree target mentioned in the recently negotiated Paris Agreement.” – via Mashable.com

#ActOnClimate : First White House Summit on Climate Change and Health

White House Summit on Climate Change and Health 57881
White House Summit on Climate Change and Health – Representatives of the Health Care Climate Council (View on Flickr.com)

Kaiser Permanente (@KPShare) is a member of the Health Care Climate Council and one of the greenest health systems in the world.

It was a great honor to share several rooms at the White House (@WhiteHouse) yesterday with other committed health leaders, at the first Summit on Climate Change and Health.

I was present to give a 4 minute overview of Kaiser Permanente’s renewable energy projects. The text of that overview is below. You can see the infographic version on this post. Additional photos also below. Enjoy, comments welcome.

I’m Ted Eytan,
Here on behalf of Kaiser Permanente, nation’s largest non-profit health system, a member of the Health Care Climate Council

I’m a Kaiser Permanente family physician , I work for our medical groups at the Kaiser Permanente Center for Total Health, which is KP’s social innovation center, based here in Washington, DC

I’d like to tell you what we’re doing and then I’d like to tell you why we’re doing it

We’re supplementing our use of green power with three large renewable energy projects that will come online in 2016

110 Megawatts of Solar Power capacity Blythe solar plant in Riverside, CA
43 Megawatts of Wind power from turbines at Golden Hills wind farm in Altamont Pass, California, where Kaiser Permanente will support the replacement of less-efficient turbines on the wind farm with new, more efficient equipment

Solar arrays that will be added to 170 hospitals and facilities in California, for another 70 MegaWatts of capacity

This is in addition to the 17 Megawatts we’ve been generating in California, and green energy projects across the 8 States and District of Columbia

Here in DC, Wind power purchases match 100% of our electricity use in our DC and Maryland based Medical office buildings and our east coast data center

Similar projects are operational now in Oregon, Washington, and Hawaii

In human terms,
Enough power to supply 82,000 homes, and avoidance of carbon emissions equivalent from 45,274 cars

Will supply half the electricity needs for Kaiser Permanente in California.

To give a sense of the energy intensity of health care, Kaiser Permanente uses nearly 1.5 billion kilowatt hours of electricity a year, and emits 806,000 metric tons of harmful greenhouse gases into the atmosphere

These projects make Kaiser Permanente one of the top users of green power in the country and takes us down to 617,000 metric tons, three years earlier than promised, at the same time we are helping more people and communities achieve their life goals through total health – over 10,000,000 members.

By the way, these renewable energy sources don’t require the transportation, pumping, and heating of water, so we will reduce our water consumption by over 100 million gallons, in a part of the United States where there is a serious drought

Clearly, this investment is better for health because we can provide more preventive and other health services with less resources and less impact on the communities we serve.

I’ve been a Permanente physician for 15 years, and what I’ve learned since I came here is how much can be done by health care. That’s why we’re here.

Much of what we are doing today has been happening long before I was born. Kaiser Permanente was built for health.

Our iconic co-founder, American Industrialist Henry J. Kaiser, ordered the first steel mill west of the rockies to be the cleanest ever built. Physician entrepreneur and co-founder Sidney Garfield, MD, who designed futuristic health facilities that provided the most gentle surroundings for healing, with the least impact on the environment.

we’ve known that greenhouse gas emissions are a known contributor to climate change and the rise of pollution and disease,

our focus on health drives a portfolio of environmental stewardship that includes LEED certified green health facilities, diverting recyclables and compostables from landfills, reducing the use of harmful chemicals, and promoting sustainable food choices – to learn more -> kp.org/green.

These actions help doctors, nurses, and all health professionals to provide nationally recognized, high quality, affordable health care.

Being here with more and more health systems demonstrates that we’re not alone in understanding the link between environmental stewardship, health, and the ability to heal.

This past week was Millennial Week in DC, and Kaiser Permanente was one of the sponsors. There, I was reminded of our responsibility to our future patients and their future doctors, nurses, and other health professionals. They expect that institutions including health care protect the communities’ health.

Of the 16 million people in the Health Care workforce today, 200,000 of them work at Kaiser Permanente – I am very excited that our generation has the ability to think of total health AND do something meaningful for the people who come after us.

Representing Kaiser Permanente’s Green Energy Program at the White House Summit on Climate Change and Health 6/23/15

Renewable Energy Infographic 52943Renewable Energy Infographic, source: Kaiser Permanente Share

As the title of the post says, I will be attending and speaking at the White House Summit on Climate Change and Health tomorrow: Your Health and Our Environment: How Can We Protect Both? | The White House

The event will be livestreamed at the link above.

I’m looking forward to sharing information about Kaiser Permanente’s commitment to green energy: Kaiser Permanente Share | Kaiser Permanente Makes Major Wind and Solar Energy Purchases

Details in the attached infographic. What I’ve learned being a Permanente physician is that there are things that can be done to protect our communities’ health. I’m passionate about this topic because I care about our health system’s ability to heal and not harm, for all humans. Climate change disproportionately affects vulnerable populations and is a powerful social determinant of health.

There’s a hashtag you can use to ask questions: #ActOnClimate. See you tomorrow maybe.

Millennials: Not environmentalists and support environmental protection, for health. Me too.

At the KPCodeYourHealth Code-a-Thon, part of Millennial Week DC (@MillennialWeek), and in prepararing to represent Kaiser Permanente at the National Dialogue on Climate Change and Health at the White House, I did a little research on this generation and the environment.

I asked a group of Millennial colleagues: “Does the term ‘environmentalist’ describe you?”

Here is their show of hands:

KPCodeYourHealth 57822
“Does the term ‘environmentalist’ describe you?” (View on Flickr.com)

Then I asked, “Are Stricter Environmental Laws and Regulations worth the cost?”

see below about why this question is framed in the context of regulation*

Here is their show of hands:

KPCodeYourHealth 57823
“Are Stricter Environmental Laws and Regulations worth the cost?” (View on Flickr.com)

That’s my unscientific version. Here’s more robust data:

2014: Pew Research Center shows that Millennials generally do not identify with the term “environmentalist” in the same proportion that generations before them did:

How the Generations See Themselves

2011: Millennials are more likely to believe that stricter environmental laws and Regulations worth the cost

11-3-11 #102

What does all of this mean? Well for me, this in line with my views. As I have said on this blog previously, I am not an environmentalist, I am a health activist (Just Read: What physicians (and patients) need to know about Climate Change – JAMA | Ted Eytan, MD).

*Although I asked the question (based on the Pew research question) about regulation, that’s not what this is about for me. I am most interested in the things that doctors, nurses, patients, and health systems can do while they heal people to heal the planet. Asking the question in the frame of “regulation” is useful in this case because it requires thought about civic commitment.

If we are here to keep people healthy, we can’t do it if we sicken their communities at the same time.

It’s no wonder, then that I was drawn to the project at the code-a-thon around air quality and health, that was not suggested by me 🙂 .

KPCodeYourHealth 57821
The AirQualityHealth&Me team (View on Flickr.com)

There’s a good discussion of this nuanced view here. We’re unified in our interest in healthy communities 🙂 .

Changing Climate (chart), Washington, DC USA 1871-2014

Average Annual Temperature Washington DC USA 1871-2014 51552
Average Annual Temperature Washington DC USA 1871-2014 (View on Flickr.com)

2014’s average temperature in Washington is below predicted trend, compared to the western United States (see my hometown, Phoenix, Arizona’s Haywood plot below).

The likelihood is that cherry blossoms will eventually bloom one month earlier than present, and there will be impacts on health including seasonal allergies, which are extremely costly to the health system and employers.

Interactive version of the chart below

Justice served: Visa paying for denied Zipcar claims

One of the most popular posts on this blog has been this one: Visa Credit Cards refuse to cover Zipcar rentals | Ted Eytan, MD, probably because this issue has affected so many people.

There’s a long list on the post on why I decided to put this information here, specifically for the purpose of making it searchable online.

In a nutshell, it’s relevant to DC, the sharing economy, supporting healthy communities, and fairness.

So now, justice has been served, a settlement has been reached, and Visa (@Visa) is going to pay for denied claims, and agree to treat Zipcar (@Zipcar) rentals as a covered benefit through April 1, 2015.


Visa: “The rental car you rented is not a rental car” circa 2010

As I said in the original post, Visa’s handling of the matter instilled feelings of shortsightedness and promotion of an unhealthy city/community/economy, by forcing people into traditional rental cars for coverage. Zipcar, much more friendly, supportive of the future. That’s how it comes across.

In any event, putting this up to amend the record and show that the future won.

Photo Friday: Sustainable Washington, DC USA

Yesterday, we had the great honor at the Kaiser Permanente Center for Total Health (@KPTotalHealth) to host Washington, DC’s Mayor (@MayorVinceGray) for a special signing:

On October 23, 2014, Mayor Gray will host a signing ceremony for the Sustainable DC Healthcare Sector Pledge at the Kaiser Permanente Center for Total Health.

The Mayor will be joined by over twenty healthcare sector leaders, hospital and clinic system CEOs, in signing the pledge that will create a resource and idea-sharing working group that meets quarterly to advance sustainability goals. This is the fourth in a series of sector pledges initiated by Sustainable DC, following the Colleges and Universities Sustainability Pledge, the Diplomatic Institution Sustainability Pledge, and the DC Smarter Business Challenge.

Truth be told, we asked to host it, as soon as we learned it was being put together. I read the plan back in 2013 and I agree with the Mayor’s comment that the DC Sustainability plan (@SustainDC) is the most comprehensive in the United States (Now Reading: The Sustainable DC Plan | Ted Eytan, MD). Why? Because it’s not just about the environment, it’s about everything that goes into creating an ‘equiitable,prosperous, society.’

Here are our opening remarks, given in partnership with Keith Montgomery, the Executive Director of the Center for Total Health (@KMontgomeryNDC):

Hi, I’m Ted. (Hi, I’m Keith)
I’m the Physician Director here. (and I’m the Executive Director here)

Welcome to the Kaiser Permanente Center for Total Health. Our name stands for the idea that health is more than excellent medical care, it’s the well being of people, in a healthy community and a healthy environment. AND, doctors, nurses, and health professionals shouldn’t be part of a sector that participates in health, it should lead society in total health, and sustainability is a health issue.

It’s in our DNA. Henry J. Kaiser, our founder, built the first steel mill west of the Rockies in 1942 and ordered it to be the cleanest in the United States. 60 years later, we’ve established a goal to reduce CO2 emissions by 30 percent by 2020.

In this region, Kaiser Permanente has purchased renewable energy certificates for 100% of the annual electricity needs of our facilities in Washington, DC, which reduces 16,000 metric tons of CO2 emissions annually.

Our environmental stewardship work extends to food, with $3M in food-activities in the District, supporting school yard gardens, school salad bars, and universal school breakfast, to name a few things. And one very local impact, the metropolitan branch trail, to your right, provides safe physical activity and access to seven Metro Stations, and was built out with a significant investment by Kaiser Permanente.

As a DC resident, I see the commitment of our Mayor every day on my walk to work all the way from Dupont Circle. Our city is a model for a place that’s safer, greener, and a more loving place for all human beings. And, I have seen it personally in the many places he goes to be with people and empower them to be their best.

We Look forward to continuing to work with the Mayor and with the District Government on this important initiative.

Please join us in welcoming the Honorable Vincent C. Gray, Mayor of the District of Columbia.

I have so many photographs to show our city’s commitment to the future. These are just a few:

I’ve clipped out a few pages from the plan to get a sense of what it covers. I’m proud to say I am car-less, purchase renewable energy certificates, work for an organization that does the same, and regularly celebrate the diversity of our city. It’s all related, and it’s great to be in a place where people believe it’s all related with me.

Another example of the Family Medicine Revolution (#FMRevolution)

I found out during this process that I was the bookend to the passion around this work, with the other being Denton Shanks, DO, MPH who’s a Family Medicine resident in Washington, DC at Unity Health Care, with a Master In Public Health, Global Health & Environmental Health. He’s pictured in the images below with the Mayor as well as Vincent Keane, President & CEO of Unity Health Care. Of course we’re the bookends of passion for societal health – it’s a day in the life of family medicine specialists 🙂 .