Healthcare Quarterly

Healthcare Quarterly 8(1) January 2005 : 40-41.doi:10.12927/hcq..16950

Green Healthcare: Looking Back, Looking Forward

Trevor Hancock


For the past three years, I have written this column on green healthcare, but this will be my last one. My work now has moved on - or back, to be more precise - to focus on public health services, away from green healthcare. In this final column, I want to reflect on the progress we have made and the challenges ahead.
When we began the Canadian Coalition for Green Health Care in 2000, the topic was very peripheral to healthcare providers. It came in part out of a concern by some environmental organizations (notably Great Lakes United, the Toronto Environmental Alliance and the Canadian Centre for Pollution Prevention) with the environmental impact of the healthcare system, and partly out of concern on the part of several health professional organizations (notably the Canadian Association of Physicians for the Environment, the Canadian College of Health Service Executives, the CMA and the CNA) and a few hospitals (notably Toronto's Hospital for Sick Children and Cambridge Memorial Hospital) with both the practical benefits of "greening" the healthcare system and with the ethical duty of healthcare professionals to do no harm to people, and by extension to the environment within which people live. This, in turn, came in part from a concern with the health of the environment itself and the many species that live within it, and in part from a recognition that doing harm to the environment results in doing harm to people.

At the outset, although a group of (mainly) national organizations helped establish the coalition, much of its work became focused in Ontario. In particular, the Ontario Hospital Association became a willing and enthusiastic partner (and more recently, a member) and this led to three of the key activities of the coalition at the OHA annual convention: The Green Lane in the exhibits area featuring environmentally responsible products and services, an annual educational presentation featuring high profile speakers (Bob Rae this year, Ontario's Environment Commissioner before that) and the Green Health Care Awards, which recognize outstanding achievements in Ontario in the areas of energy efficiency, pollution prevention, individual leadership and overall leadership.

In addition to this set of annual events, the coalition has maintained a website ( and developed some key resources - notably a 70-page resource on many different aspects of "greening" healthcare (Doing Less Harm) that was funded by the Office on Sustainable Development at Health Canada - and a checklist for building green hospitals. The membership has slowly expanded to include a number of hospitals (several of which have attained ISO 14001 certification) and has some members beyond Ontario, notably in Winnipeg, Edmonton and Vancouver. A firmer base has thus been established for the next, necessary phase of the development of the coalition and its expansion to become a truly national organization that will play a key role in the greening of the Canadian healthcare system and the attainment of its vision, which is that "Canada's healthcare system operates in an environmentally responsible manner." If this bold vision is to be achieved, there are a number of challenges that need to be addressed.

1. Incorporate "Greening" as a Routine Part of Addressing the "Triple Bottom Line" of the Healthcare Business

It is increasingly common practice in the corporate world to recognize that business needs to address a "triple bottom line," which considers not only the economic but also the environmental and social costs and benefits of doing business. In the case of the "greening" of the healthcare system, the impact is not only on the environment, there are also the economic benefits of environmentally responsible behaviour to be taken into account. That positive impact comes chiefly from more efficient energy use, but there are also economic benefits of environmentally responsible solid waste management, more efficient use of water and other resources, reduction in the use of toxic substances and control of air pollution, to cite but a few. Conversely, there may be economic costs of failing to act in an environmentally responsible manner, including administrative fees and penalties, legal costs associated with lawsuits, fines and so on.

There are also social benefits to consider: local and planet-wide health benefits that flow from being environmentally responsible; the boost in staff morale that may accompany "greening" efforts; and the improved image of the organization in the community. I look forward to the day when all healthcare facilities formally address and incorporate the triple bottom line as a routine part of their business.

2. Link Green Hospitals to Healthy Hospitals

As a general rule, anything that is good for the environment is also good for human health, and that is especially true in a healthcare setting. So being "green" is one part of being a healthy hospital. But as I have noted elsewhere (Hancock 1999; Hancock 2001) a healthy (and health-promoting) hospital has four main components. The first two components occur within the hospital: A healthy hospital strives to create both a healing environment for patients and healthy workplace for staff - indeed, the two are usually mutually reinforcing approaches. The Planetree model, developed in the US by Susan Frampton, Laura Gilpin and Patrick Charmel , provides one of the best examples of how to create this kind of healthy hospital environment. Frampton and colleagues' (2001) accumulated experience over the past 25 years is summarized in their recent award-winning book, Putting Patients First. The third and fourth components of a healthy hospital occur outside hospital walls: A health-promoting hospital tries to be an environmentally responsible corporate citizen and to become a partner in the process of creating a healthier community, notably by applying the strategies of the Ottawa Charter for Health Promotion.

So becoming a "green" hospital or healthcare system is but one step along the path to becoming a healthy and health-promoting organization. I hope that in the years to come, Canada's healthcare organizations will take up the challenge of becoming models as the healthiest workplaces in their communities, the most environmentally responsible corporate citizens and organizations dedicated both to creating a healing environment for their patients and helping to create a healthier community for their citizens. This should be the ideal to which all healthcare facilities and health authorities aspire.

3. Make "Greening" or ISO Certification Part of Accreditation

There are ethical, health, environmental, social and economic benefits that result from environmentally responsible behaviour, and this should be part of the routine business of a healthcare organization. One way to ensure that healthcare organizations are environmentally responsible is to make such behaviour one of the key measures to be incorporated in accreditation. In time, every accredited facility should have an environmental management system in place - with accountable staff and an accountability mechanism - and should be able to show its progress in reducing energy and resource use, preventing pollution, managing and reducing solid waste, using less toxic substances and so on. One way to ensure that organizations meet these goals (which might be considered as sufficient to obtain accreditation in this area) may be for a hospital to have to become ISO 14000 certified, as a few hospitals have done to date.

4. Change Provincial Policies That Prevent "Greening"

One of the challenges (noted by some hospitals as they attempt to construct more energy-efficient buildings or to operate in a more environmentally friendly manner) is that environmentally responsible behaviour is not always encouraged, and indeed may actually be discouraged, by provincial policies. Spending additional money on architects' fees, construction or equipment costs to create a more environment-ally friendly and energy-efficient building, may save far more money in the long run than what is spent on these up-front costs. Yet, such extra up-front costs may not be allowed, or construction guidelines and requirements may not encourage or permit such construction. These systemic barriers need to be removed. Perhaps a federal/provincial report on "green" hospital construction policies and practices is a useful place to begin. Such a report could be expanded to include, or be complemented by, a similar report on designing and building hospitals that establish a healing environment for patients and a healthy workplace for staff.

5. Update Professional and Ethical Codes to Include a Responsibility to the Environment

The CMA's ethical code refers to ethically responsible behaviour towards patients, other professional colleagues and the community. It does not refer to the profession's ethical duty to the environment. Yet, at a time when we have a growing understanding of the impact of healthcare on the environment, and thus on human health (both locally and globally - now and over the long term), surely it is time to expand the ethical precept primum non nocere to include doing no harm to the environment. This ethical duty, of course, should not be limited to physicians but should also include nurses, healthcare administrators and others. Such a revision to their ethical codes would be timely and welcome.

6. Establish a Fully Functional National Coalition

The healthcare system is 10% of the Canadian economy, and bringing the message and the tools for greening to this huge economic sector requires a well-resourced national coalition, ideally with chapters in every province or region of the country. A national office could do many things: develop and provide national resource materials and training; link the provincial or regional chapters; link with both national organizations (e.g., the CHA, the CMA, the CNA, the CPHA and various national environmental organizations) and relevant federal government departments (Health Canada, Environment Canada, Energy Mines and Resources Canada and so on); and link with international organizations, especially the international coalition Health Care Without Harm.

At a time when huge amounts of money are being transferred from the federal government to the provinces as a result of the recent Health Accords and the First Ministers' Agreements, surely it is not too much to expect that a tiny portion of these funds be dedicated to supporting a coalition that will benefit the environment, human health and the bottom line of the healthcare system?

No doubt there are other challenges, but these are the main ones, as I see it. I will continue to observe with interest, and encourage when I can, the ongoing and accelerating "greening" of Canada's healthcare system.

About the Author(s)

Dr. Trevor Hancock is Healthcare Quarterly's environmental editor. He is a founder of the Canadian Coalition for Green Health Care and of the Canadian Association of Physicians for the Environment. He was formerly a Principal in Planetree Canada.


Frampton, Susan, Laura Gilpin and Patrick Charmel. 2003. Putting Patients First: Designing and Practising Patient-Centred Care. San Francisco, CA: Jossey Bass.

Hancock, Trevor. 1999. "Healthy and Health-Promoting Hospitals." Leadership in Health Services/Intl J Health Care Qual Assurance 12(3): viii-xix.

Hancock, Trevor. 2001. "Moving Beyond Healthcare: The Role of Healthcare Organizations in Creating Healthy People in Healthy Communities in a Healthy World." Hospital Quarterly (Summer): 20-26.


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