Gary Cohen is on a mission to make the health sector live up to its ethical responsibilities by addressing the use of toxic chemicals, waste incineration and mercury, he tells Claire Read.

The World Health Organization gives a clear, concise definition of dioxins. These chemicals are, it says, “persistent environmental pollutants… of concern because of their highly toxic potential”. As that toxic potential includes human cancers and harm to the reproductive, immune and endocrine systems, it might be expected that healthcare providers would have been aware of, and concerned by, dioxins. Yet, until relatively recently, medical waste incineration meant that hospitals were actually one of their biggest sources.

It is an example of what Gary Cohen says is a frequent and uncomfortable contradiction: that the healthcare system, designed to help and heal, is often involved in actions that cause harm. An environmental health activist since 1984 - the year leaking gases from a chemical factory in the Indian city of Bhopal caused thousands of deaths - it was in 1996, confronting what he felt was a tipping point of evidence, that he became the founder and president of US-based non-profit organisation Health Care Without Harm.

“There was important new information coming out which identified chemicals that could disrupt the developing endocrine system of children in the womb,” he explains. “So we said at that time, ‘Well, who needs to understand this science, who needs to really take it in and change their approach?’ And we said it’s got to be the healthcare sector - the one sector of our society that lives within an ethical framework of first do no harm.”

Ethical viewpoint

As Mr Cohen began to take his message to managers and clinicians in the US, he found he was largely met with ignorance. Those in healthcare were not only unaware of the new evidence about chemical harm, they were also ignorant of the role they were playing in the problem. Focusing on medical waste incineration, Mr Cohen attempted to overcome that ignorance with an argument he says was strong not only from an ethical viewpoint but, crucially, from a practical one as well.

“It’s impossible for the healthcare sector to say they’re poisoning their patients in the name of healing them,” he contends. “The moral contradiction of this situation was very potent. Secondly, we could show the hospitals that there was an alternative way of managing their waste: to reduce, reuse, recycle, repackage, multi-use and isolate infectious waste and autoclave it where possible. Then there were all the savings. To treat infectious waste costs maybe 20 times as much as disposing of normal waste. So if you can reduce the volume of it, you’re going to save money.”

Health Care Without Harm is set up as a coalition, with hospitals and other interested parties invited to become members and commit to addressing the environmental impact of their actions. The arguments around incineration proved so compelling that a number of US health organisations agreed to change their practice and, over seven years, the number of medical waste incinerators fell from 5,000 to just 83. The success led to similar campaigns to bar the use of mercury-based measuring devices and reduce pesticides and toxic chemicals in healthcare.

Today, it has 470 member organisations in 52 countries and an approach as broad as its geography. “We started out asking how you could deliver quality care without doing environmental and public health harm,” explains Mr Cohen. “But we think the proper role of healthcare is to heal, it’s to be regenerating, it’s to be repairing what has been wounded both in people and our society. We want healthcare to go beyond the four walls of its institutions and intervene in communities.”

That, says Mr Cohen, means projects like the one undertaken at the children’s hospital in his hometown of Boston. Staff in the emergency room were seeing certain youngsters with asthma again and again. Rather than continuing to invest in sometimes costly treatment, staff visited the homes of these patients to determine if they contained any known triggers for the condition. Where pesticides, toxic cleaning chemicals or mouldy carpets were found, the hospital paid for safer alternatives. “In this way, they reduced emergency room visits by 65 per cent and hospitalisations by 81 per cent,” says Mr Cohen. “That’s what healthcare should do - it should be intervening to prevent chronic disease. It should be supporting people to eat healthily, to live healthy lives, be educating mums about how to protect their kids from toxic exposure.”

This overarching approach is at the heart of the organisation’s Global Green and Healthy Hospitals Network (known in the US as the Healthier Hospitals Initiative). It is designed as an overall sustainability programme for the healthcare sector and presents six key challenges: to provide healthier food for both staff and patients; to use energy more efficiently; to produce less waste; to use safer chemicals; to procure more environmentally friendly products; and to engage healthcare leaders in the issue of sustainable, environmentally sound healthcare. “[This kind of strategy] is more likely to succeed if you embed it as a part of the core operating strategy as opposed to having it be some sort of ‘do-gooder’ add-on,” comments Mr Cohen.

The initiative has drawn widespread interest. The NHS Sustainable Development Unit is a founding member and has committed to involve 200 British hospitals in the network to add to the 12 UK trusts that are already members. They join organisations from countries including Australia, Indonesia, Mexico, Brazil, China and Argentina, and 700 US hospitals that have signed up. Members share their strengths and address their weaknesses. In the case of the UK, Mr Cohen argues there is impressive leadership on ethical procurement and much best practice on carbon reduction. There are other parts of the sustainability drive where he believes the NHS could improve significantly, however.

NHS challenges

“There’s really a lot of learning that needs to be done around issues such as pharmaceuticals, chemicals and food,” he argues. “Britain has super high obesity and diabetes [rates] and yet it hasn’t quite sunk in to the NHS yet that if it could totally transform the way it serves food, it will reduce both of these and it will support more resilient, less chemically intensive agriculture that has got other benefits.

“The hope with the network is that we can accelerate the adoption of best practice in these areas, develop a common research agenda and really move a lot further, faster, to position the sector as the leader for a healthier economy around the world.”

Sometimes that may mean healthcare workers and organisations taking a political role. While Health Care Without Harm is trying hard to influence politicians - Mr Cohen had to delay the interview with HSJ by a day because commitments had arisen in Washington DC - it seems that the most effective campaigners are often those from within the healthcare sector. He cites the example of the American Lung Association, which he says played a leading role in opposing politicians who argued the US Environmental Protection Agency should not be setting rules about coal-fired power plants.

“When you take it out of the realm of short-term economic benefit and put it into that health frame it changes everything,” argues Mr Cohen. “It’s very difficult for a politician to be confronted by the parent of a kid who has learning disabilities and say, ‘No, we’re not going to address mercury’.” He believes healthcare will, in particular, have to lead on the issue of climate change, becoming what he characterises as “an anchor for resiliency.”

“For example, take a community where there is flooding. Maybe the healthcare institution is the one place with a water filtration system so people can get clean water; it will prevent the spread of cholera. Or in a disaster like Hurricane Katrina - maybe the hospital is the one place that is off the main electricity grid and so can keep critical medicines refrigerated. Healthcare is going to have to really be the front line of being prepared and resilient.”

There may be lots of challenges but Mr Cohen believes the potential rewards are immense. “If you can use the purchasing power of this critical sector to drive green chemistry, renewable energy, sustainable agriculture, then the transformation goes way beyond making hospitals greener,” he argues. “It actually makes people healthier and makes communities healthier.”