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.

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)

Just Read: How to mutate your DNA, and how health systems can heal the planet, with American University’s PUB115 students

Because we are The Center for Total Health (@KPTotalHealth), everything health related is in scope. Because we are Kaiser Permanente, healing people and the planet is in scope.

With that in mind we were happy to tour American University’s Professor Lynne Arneson and students in her undergraduate course “PubHealth 115: Why Aren’t We Dead Yet? Role of Public Health in Society

The readings she provided were illuminating, so I’m sharing them here.

In Samet JM, Spengler JD. Indoor environments and health: moving into the 21st century. Am. J. Public Health. 2003;93(9):1489–93, there’s a fascinating history of the evolution of mechanical building design, from the need to reduce human odors, to today’s need to do that plus reduce contaminants and infection threats. It’s definitely a science that’s as vital to health as what physicians and nurses do inside our medical buildings.

In Lanphear BP. The impact of toxins on the developing brain. Annu. Rev. Public Health. 2015;36:211–30. there’s a very robust discussion on the impact of widely used chemicals in society and the impact on our children. They produced a very accessible video which I’m reposting here; it does a great job of showing the impact:

As I read both papers, I was able to easily connect the threats discussed to the work that Kaiser Permanente is doing to eliminate them in our health system and in the environment. It was one of those, “we’re doing the things they are mentioning are the best for health.” And that’s a good feeling – everything from a mercury-free health system, a flame-retardant-free health system, to a PVC and DEHP-free IV-tubing and bags health system (see: #greenhealthcare Part 2: Safer Chemicals (what’s dripping in that IV besides medicine?) ).

The great thing for total health is that all of these concepts are accessible to everyone in the health system. My colleague Erin Meade (@erinm81) remarked as we prepped for the tour that our endocrine systems are better off without disruption. I agree, so I’m glad we’re doing all the things we are to allow people’s hormones to work as intended.

Kathy Gerwig (@KathyGerwig), our environmental stewardship officer for Kaiser Permanente – wrote this blog post which was perfectly timed for the students’ experience: 10 ways hospitals can heal the planet | OUPblog

Joel Sigler, CSP, HEM, from Kaiser Permanente National Environmental Health & Safety, discussed KP’s efforts to remove harmful chemicals and reduce waste in the Kaiser Permanente System, a good family doctor knows what they don’t know, and invites those who do know to join the conversation…

I’m really glad that we’re able to tell a story about how public health and health care work together to heal people and communities at Kaiser Permanente – it’s something that didn’t seem possible during my medical training, and now it clearly is. One more reason why I love this century :).

2015.11.16 American University Class PubHealth 115- Why Aren't We Dead Yet? Role of Public Health in Society at Center for Total Health 00150
2015.11.16 American University Class PubHealth 115- Why Aren’t We Dead Yet? Role of Public Health in Society at Center for Total Health 00150 (View on Flickr.com)

2015.11.16 American University Class PubHealth 115- Why Aren't We Dead Yet? Role of Public Health in Society at Center for Total Health 00146
2015.11.16 American University Class PubHealth 115- Why Aren’t We Dead Yet? Role of Public Health in Society at Center for Total Health 00146 (View on Flickr.com)

Photo Friday: Our cities are changing – North Capitol Street, Washington, DC USA

North Capitol Street, Washington, DC USA 09770
North Capitol Street, Washington, DC USA 09770 (View on Flickr.com)

I found this scene fascinating because it’s a snapshot of how are cities are changing, in multiple dimensions. This is the NoMA (North of Massachussetts Avenue) neighborhood, in Washington, DC. Destroyed once in 1968, and then again 20 years later.

On the left is the LEED Gold headquarters of National Public Radio (@NPR). The middle building is empty. If you take a closer look (see the other photos) you can tell what it used to house (hint: “thrive”), and if you think the building on the right will contain luxury condos (which has been my thought as I walk past the high rise modern structure on most days), you’d be wrong.

The building on the right is The John and Jill Ker Conway Family Residences which is

a landmark tower in Washington, DC that will provide permanent supportive housing for 60 veterans who currently sleep on the streets along with 64 low-income DC residents. Built from sustainable materials and designed by one of the top architectural firms in Washington, the new John and Jill Ker Conway Residence will include community gathering spaces, ground floor retail, and on-site supportive services to help its formerly homeless occupants remain stably housed. (Breaking Ground on New Housing for Homeless Veterans | Community Solutions)

Did you guess what the middle building used to be?

It was the Kaiser Permanente North Capitol Medical Center, which has since been replaced by the Kaiser Permanente Capitol Hill Medical Center (read on).

By the way, do you know what the NPR Headquarters building was?

Communications workers picket Western Electric: 1950

…it was a Western Electric Plant that built telephone booths.

Before you decide that Kaiser Permanente’s time has come and gone in this part of Washington, DC, all you have to do is walk around the corner, where it’s an anchor tenant in the now-healing H Street, NE:

DC People and Places 09709
DC People and Places 09709 (View on Flickr.com)

…and delivering unheard-of-incredible patient outcomes in its quality of care.

It’s highly likely that at some point in the near future, the vantage point from where I took this photograph won’t exist because yet-another-huge development is being planned for the site.

If you know the history of Washington, DC, you know that it was a city, ironically, that once lacked hope, as it led the nation. That’s starting to change, and it’s becoming healthier, more inclusive, and solving problems, and leading in how it is as well as in what it does.

If you’d like to see the view from a different vantage point, including the data about the people on both sides of the North Capitol Street census tract: Photo and Map Friday: The Social Determinants of the NoMa Neighborhood, Washington, DC USA

Photo Friday: 7th Street, NW Rising, as taken from the beautiful LEED Gold AAMC headquarters, Washington, DC USA

7th Street NW Washington DC USA 08531
Association of American Medical Colleges Headquarters Washington DC USA 08531 (View on Flickr.com)

This week’s photograph was taken from the roof on top of the beautiful, LEED Gold-certified Association of American Medical Colleges (@AAMCtoday) headquarters, situated in historic Mt. Vernon Square, in Washington, DC.

The view itself is a brand new vantage point (since 2014) of a historic street, destroyed once in 1968 following the assassination of Martin Luther King, Jr., and devastated again in the late 1980’s and 1990’s by an uncontrolled drug and murder epidemic, just 1 mile from the White House.

I’ve posted photos of 7th Street and the 1968 damage here: Photo Friday: Progression Place, Washington, DC.

This book, by Ruben Castaneda (@RCastanedaWP) tells the story of 7th Street in the Marion Barry era (see: Just Read: S Street Rising: Crack, Murder, and Redemption in D.C.)

In the upper left is the 7th and O market, where 8 people were shot and 1 killed in 1994, and now houses the largest grocery store in Washington, DC. Catholic University is in the upper right. On the left is the Washington, DC, Convention Center. In the foreground is an area cleared for new development, that can only be appreciated from this vantage point.

I was at the AAMC because I am a member of the Axis Committee, (I said yes: AAMC Advisory Committee on Sexual Orientation, Gender Identity and Sex Development) whose work is getting under way, and holds great promise for a future health system that’s respectful of all.

Thanks Tiffani St. Cloud (@TStCloud) for the tour and for supporting this work. The rest of my photos are below, showing the majestic parts of the city. I always prefer the parts where people learn and grow the most, though 🙂 . Enjoy, comments always welcome, and Washington, DC never stops being beautiful.

You can read more about the headquarters and the AAMC here: AAMC Dedicates New Headquarters, Learning Center for America’s Medical Schools and Teaching Hospitals – News Releases – Newsroom – AAMC

Presentation: Walls, Ceilings, Closet Doors (Things Worth Shattering): Total Health and Social Innovation

This is a 2015 Update on the Kaiser Permanente Center for Total Health (@KPTotalHealth)  the Social Innovation Center of Kaiser Permanente.

There’s a short description of social innovation and examples of social movements and interventions that have been born or amplified since 2011.

It has been an impactful 4 years! Come by for a tour, and arrive by #activetransportation please. There’s now a Capital Bikeshare (@bikeshare) station right in front for your convenience 🙂 .

Enjoy, let me know what you think in the comments.

Dog Parks & Coffee Shops + Leadership Networks

This week I got to go see a screening of DogParks & CoffeeShops: Diversity Seeking in Changing Neighborhoods on the invitation of Professor Sonya Grier, on the campus of American University, at the Metro Policy Center (@MPC_AU) which addressed a ton of interests of mine all in one.

First, the trailer:

DogParks & CoffeeShops: Diversity Seeking in Changing Neighborhoods (Trailer) from Sonya Grier on Vimeo.

In no particular order:

  • I love Washington, DC and have been posting about our changing cities and Washington as the ultimate laboratory
  • I am a fan of diversity and all that it does to support a healthy and resilient community
  • Storytelling and images are a big part of my existence. I’m more of a still photo person because video is challenging for me – so I watched with extra respect 🙂
  • The screening itself was in the American University School of International Service, a beautiful building which is famous for its LEED Gold Certification, and I got to meet its architect, Carl Elefante, FAIA, LEED AP O&M, in October (A bunch of doctors, an architect, and a bridge builder: Designing for Health)

So, of course I was going to go, and enjoyed every step that I took on my #activetransportation journey from downtown Washington, DC .

The film and discussion afterward, attended by Professor Grier and her collaborator Professor Vanessa Perry, from George Washington University further extended my interest:

  • “faux” diversity – when people are attracted to a diverse neighborhood but pick and choose the diversity they associate with, resulting in a divided community
  • Our changing cities – becoming more sustainable, with more amenities and health infrastructure, with tension around displacement
  • The work itself and what’s considered “scholarly” in academia. I didn’t anticipate this conversation at all.

Films and scholarship

Is a film, in this case peer reviewed (and Winner, “People’s Choice” Award, 13th Annual Association for Consumer Research (ACR) Film Festival) that generates portable knowledge and connects leaders and future leaders considered scholarly? Vanessa and Sonya mentioned that this would be a risky endeavor for a junior faculty, not tenured as they are.

I’m not surprised, but I am surprised in 2015 that this is still the case in academia. I thought things would have changed by now.

When I left academia (or should I say, I never joined it), I was producing “work” in my Robert Wood Johnson Foundation Clinical Scholars Program that included news stories and action to improve health on the campus we were learning on. I was allowed to present it at our annual meeting, but it was clearly different than everyone else’s project.

And here I am, now, in a non-profit health system that regularly engages in video ethnography. I am also embedded in a design consultancy right now to understand the health experience of some of the most special people we serve. This work is changing health. I know it.

I hope someday any body of work, no matter what the medium, is recognized for its value in (a) igniting the passion of its creator and (b) changing the thinking of the people who experience it with the result being a better society (as judged by the people in that society). As Vanessa mentioned, a recent screening to a group of economists probably generated more conversation than ever would have via a manuscript placed on their desks in front of them.

Leadership Networks

Sonya and I are part of the Robert Wood Johnson Foundation Leadership Network (@RWJF). There are a ton of people on it/in it, which reflects the size of the scholarship created and supported by the Foundation. She contacted me after seeing this post on the network, and we corresponded after that.

It reminds me of a concept that goes unrecognized when people learn that social networks are about having a lot of followers (they aren’t). That type of learning encourages people to think of these networks as one-way mass communication mediums, which disappoints. Instead, they are about meaningful connections with people who you might not say hello to while walking through the boulevards and picturesque circles of your communities.

My HHSIgnite teammate/lead Sabrina Matoff-Stepp, PhD (@SabrinaMatoffSt) asked me a question I haven’t heard in a long time which was about why I spend time doing these kinds of “things.” My response is that they save me time by discovering things sooner that I don’t know, and if someone knows how to do something better, I want to know about it (“Proudly discovered elsewhere”).

My suggestion, then, is post away, and then listen and engage afterward. You never know what you’ll learn. 1 to 2 great connections every 6 months is the goal of gaining followers and friendships, in social media and in life.

Our cities are changing

Today’s Photo Friday is about changing Washington, DC, which I’ve been reading and experiencing. Destroyed by riots in 1968, destroyed again by drugs that consumed people and communities, now just becoming a walkable, sustainable place, in some places.

Composite - 14th and T  Streets Then and Now - 2010 - 2014 49694

Thanks for the great networking experience and more knowledge that will help us create a place where everyone has what they need to be successful.

Car-Free Generation Y, Washington, DC #ActiveTransportation

Young Adults, Then and Now – Census Explorer (View on Flickr.com) – Source: Census Social Explorer

Far fewer young adults commute to work in Washington, DC than do in the rest of the United States, with a much bigger drop compared to the rest of the country. You can access the full report here: Young Adults Then and Now – Census Explorer

Thank you @census and @socialexplorer


Sustainable DC Plan 33800
Sustainable DC Plan 33800 (View on Flickr.com)

see: Now Reading: The Sustainable DC Plan | Ted Eytan, MD

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.

Don’t forget about sustainable Information Technology: ENERGY STAR Low Carbon IT Champions

I posted earlier today about sustainable food. There’s also a thing called sustainable (low carbon) Information Technology, and it matters for health.

Data centers are one of the fastest growing energy uses in the country. Health care has to heal across all dimensions…

EPA ENERGY STAR (@EnergyStar) recognizes Low Carbon IT “Champions” who are cutting costs and saving energy in the one of the fastest growing energy uses in the country – information technology. Please see the case studies and public service announcements (PSAs) recognizing their efforts below.

Kaiser Permanente — the first health care provider to earn ENERGY STAR building certification for their data center — implemented a raised floor optimization (RFO) program, diagnosed their efforts with a unique computer room functional efficiency (CRFE) metric, and optimized cooling during a large expansion

via ENERGY STAR Low Carbon IT Champions : ENERGY STAR.

For more information / why this matters: #greenhealthcare part 4: Health Information Technology helps health care be green | Ted Eytan, MD