At its core, environmentally responsible (or "green") healthcare is an ethical issue. Because of healthcare's ethical duty to do no harm, it is particularly important that the healthcare system do everything in its power to minimize its impact on the environment and on human health. One way to do this is through environmentally responsible purchasing, or green procurement.

The ethical dimensions of green healthcare were vividly demonstrated last year at the CleanMed 2001 Conference in Boston. Senior executives from some of the largest health systems in the United States, such as Kaiser Permanente, Catholic Health East and Catholic Health West, stressed above all that their systems had made a clear and strong ethical commitment to environmentally responsible management. This commitment is incorporated in their values and in their mission statements, in the uppermost levels of their board and senior management team structures, and - in at least one case - in the criteria by which their senior executives' compensation and incentive bonuses are assessed!

At that same conference, senior executives of four large group purchasing organizations (between them representing more than three-quarters of all U.S. hospitals) described their growing commitment to environmentally responsible purchasing. One group, Broadlane, reported that it had switched to PVC-free bags in 1996, while another, Consorta, reported switching to PVC- and DEHP-free enteric feeding tubes. And the largest, Premier, has a section on its website on environmentally preferable purchasing.

In Canada, the Winnipeg Health Sciences Centre was a partner in establishing the Manitoba Green Procurement Network, with support from the provincial government's Sustainable Development Coordinating Unit. The Health Sciences Centre itself has a corporate policy on environmentally responsible procurement. The policy, which is two pages long, reads in part as follows:

1. "Where clinical performance, safety and other factors are equal or better, HSC procurement decision-makers shall give preference for products demonstrating the highest level of environmental sustainability through:
   
2. efficient use of energy, resources and packaging,
   
3. use of environmentally certified products where feasible
   
4. contribution to pollution prevention,
   
5. long service life,
   
6. potential for waste minimization, and
   
7. contribution to HSC environmental performance targets."

One example of environmentally responsible purchasing is the growing emphasis on eliminating mercury, a potent neuro-toxin. A Memorandum of Understanding (MOU) was signed by Environment Canada, the Ontario Ministry of the Environment, Pollution Probe, and six Ontario hospitals to voluntarily reduce and eliminate the use of mercury. A subsequent survey, covering 93 of 188 hospitals contacted in Ontario, showed that approximately 70% of those hospitals had put a formal reduction program in place. The five devices most commonly targeted for mercury reduction are thermometers, sphygmomanometers, pressure gauges, batteries and incubator thermostats.

Another important example is the case of PVC. This widely used plastic is of concern for two reasons. First, both in its production and in its subsequent incineration (particularly when done in older, less efficient incinerators) PVC is an important source of dioxins, which are among the most potent carcinogens we know of, as well as being endocrine disruptors. Indeed, the Austrian Supreme Court, in a case between Greenpeace and the vinyl industry, has recognized PVC as "an environmental poison." Hospitals in Vienna now have less than 1% PVC in their waste stream, at least one Danish hospital is now 90% PVC free, and a MOU between the EPA and the Maine Hospital Association and its member hospitals calls for "the continual reduction in use and disposal of PVC plastic."

Second, and in many ways even more problematic, is the presence in many PVC bags and tubing of a plasticizer, the phthalate DEHP. A recent report from an expert advisory panel appointed by Health Canada has concluded that there is "at least the theoretical possibility of developmental and testicular toxicity, particularly in the young human with high exposure levels." As a result, the panel has made a number of recommendations that include using DEHP-free products for total parenteral nutrition of newborns and infants and the introduction "as quickly as possible" of alternative measures to protect those at greatest risk (the fetus, newborns and infants, and young children receiving transfusions, ECMO, cardio-pulmonary by-pass, exchange transfusion, haemodialysis, TPN and lipophilic drug formulations).

Given the environmental and human health concerns with PVC and DEHP, not to mention the potential legal liabilities, it makes sense to avoid products containing PVC. The good news is that not only are alternatives available, but that -- according to Broadlane and Consorta -- it is also possible to save money while switching to PVC-free products.

As the environmental and related health impacts of healthcare become more apparent, we can expect to see a growing movement towards environmentally responsible, "green" procurement, not only with respect to PVC but also a whole host of other potentially environmentally damaging and health-harmful products used in healthcare, from cleaners to pesticides, from IV bags to mercury-containing products, from disposable products to energy-inefficient equipment. Buying green provides a golden opportunity for the healthcare sector to be seen to be doing good.

For more information on environmentally responsible purchasing, see:

• www.noharm.org
  
• www.sustainablehospitals.org
  
• www.premierinc.com/all/safety/resources/
  EPP/epp_index.htm
  
• www.environmentalchoice.com
  
• www.greenhealthcare.ca

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