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Chen H. Wen and Jesse Eaves The healthcare sector in the US generates almost 2.5 million tonnes of waste a year, some of it toxic. A partnership effort between the Environmental Protection Agency and several healthcare bodies is greatly reducing the amount of healthcare waste and making the variety of waste streams easier to deal with. The healthcare sector, which operates round the clock, is one of the top waste-generating industries. In the United States, the healthcare sector generates over 2.4 million tonnes of waste per year. A 1998 report to the US Congress indicated that the healthcare sector was the fourth largest source of mercury release into the air. The sheer quantity of waste and the variety of waste streams, as well as the toxic chemicals contained in the waste, all impact on the environment and human health. A study by the National Academy of Sciences estimated that, as a result of the mercury pollution in the environment, nearly 60,000 newborn children per year will have elevated levels of mercury in their blood. As the general public becomes more aware of the links between medical waste and public health, national and local environmental regulations have begun to focus on the impact of the healthcare industry on the environment. Some examples of the changing regulatory landscape include the following: the 1999 Medical Waste Incinerator Rule, requiring medical waste incinerators to improve their performance, has effectively closed some 80% of all medical waste incinerators in the US many states across the US have banned the sales of mercury-containing thermometers the regulations introduced by the Health Insurance Portability and Accountability Act of 1996, protecting patient confidentiality, will have a huge effect on how information about patients is disposed of. A hospital waste manager must continue to deal with this changing waste management landscape, in order to be in compliance with the multiple layers of laws and regulations. Healthcare sector takes action In 1998, the US Environmental Protection Agency (EPA) approached the American Hospital Association (AHA) to find a way to help the healthcare sector reduce its waste. The result was a landmark agreement, 'Hospitals for a Healthy Environment' or H2E, a voluntary partnership between the AHA, American Nurses Association, the EPA and Healthcare Without Harm, a non-profit advocacy group. The goals of this partnership are to: virtually eliminate mercury-containing waste from hospitals' waste streams by 2005 reduce the overall volume of waste (both regulated and non-regulated waste) by 33% by 2005 and by 50% by 2010 identify hazardous substances for pollution prevention and waste reduction opportunities, including hazardous chemicals and persistent, bioaccumulative and toxic pollutants. The H2E effort has been gaining strength over the past two years. A few indicators of success to date are listed below: H2E has 398 partners representing 1329 facilities - 442 hospitals, 719 clinics, 28 nursing homes and 140 other types of facility. H2E has 39 'champions' - organizations that help healthcare facilities achieve national H2E goals and improve their own environmental performance to meet national H2E goals - representing approximately 3893 facilities. H2E maintains an active listserv (an automatic mailing list server) for healthcare professionals, which now has over 700 subscribers. The H2E website - www.h2e-online.org - receives over 1500 hits per month. Finally, there is an H2E award programme, designed to recognize H2E participants and their work to achieve the programme's goals. Many H2E award winners have undertaken innovative waste reduction work to improve the environment and to reduce cost of waste disposal. Programmes such as H2E not only help healthcare facilities comply with regulations - and can help them exceed the required standards - but provide waste companies with new ways of helping their healthcare industry clients reduce waste and save money, all the while improving the environment. H2E Environmental Leaders University of Rochester's Strong Memorial Hospital The University of Rochester's Strong Memorial Hospital in New York was one of only three winners of the Environmental Leadership award in 2002. Strong Memorial began a small programme in the early 1990s to eliminate mercury sphygmomanometers, which eventually became an aggressive and successful mercury elimination campaign. The hospital is now a national leader in becoming mercury-free while bolstering its financial bottom line and protecting the environment by reducing the risk of accidental spills. In 1997, the hospital used 8500 mercury thermometers; by the end of 1998, the number had dropped to 499. In 2001, the hospital replaced all mercury thermometers with non-mercury ones (electric, tympanic and alternative alloy). The facility also replaced more than 900 mercury-filled sphygmomanometers with non-mercury aneroid units, saving 255 lbs (115.5 kg) from disposal each year. Tungsten tubing replaced mercury-filled gastrointestinal tubing, preventing the disposal of 45 lbs (20.4 kg) of mercury annually. Strong Memorial also focused on mercury-containing laboratory waste, and eliminated mercury products when viable substitutes were found. In 1997, the hospital's labs disposed of 51 lbs (23.1 kg) of mercury annually; by 1998 the amount was down to 11.2 lbs (5.1 kg). In December 2001, the labs recorded zero mercury disposal. Overall, waste disposal costs for mercury and mercury spill debris dropped from $24,000 in 1997 to below $1200 in 2001.The hospital eliminated 351 lbs (159 kg) of mercury per year, not including mercury found in thermometers. In addition to saving thousands of dollars in disposal costs, the hospital's mercury elimination programme has resulted in a successful educational programme for employees, the elimination of disruptions related to mercury spills, and improved safety for patients and staff. Kaiser Permanente Northwest Region Kaiser Permanente Northwest Region (KPNW) in Oregon was recognized as an Environmental Leader in 2002 for its multi-faceted programme to minimize waste, prevent pollution and conserve natural resources. Within the system, the amount of virgin paper consumed is reduced by the use of cut sheet paper with 30% post-consumer waste content and recycled paper envelopes, and reuse of inter-office mailing envelopes. Biodegradable patient-care items are made from telephone books and envelopes, and only carpet made from recycled content is purchased. Patients use plastic sip bottles instead of traditional disposal pitchers and cups. Plastic totes are reused for deliveries across the region. In addition to recycling paper, cardboard, glass, tin and plastic, KPNW has undertaken innovative recycling ventures. These include alkaline battery recycling, which eliminates 3000 pounds of material from entering landfills annually, and recycling of alcohol and xylene through the use of a still, resulting in a 75% disposal cost reduction. KPNW also recycles toner cartridges, computer disks, CDs, videotapes, dental amalgam, fluorescent light bulbs, Styrofoam packaging and depressurized aerosol cans. The healthcare system requires contractors to recycle construction debris and recycles company assets back into use, reducing disposal costs and saving landfill space. KPNW re-issues used materials to consumers across the region for free. Rounding out its resource conversation programme, KPNW focuses on environmentally preferable purchasing, working with its suppliers and manufacturers to purchase environmentally safe products, develop alternative products, ensure environmentally preferable packaging, and ship goods through transportation networks that have a minimal impact on the environment. University of Michigan Hospitals and Health Centers The University of Michigan Hospitals and Health Centers were together recognized as an Environmental Leader for a comprehensive recycling and waste reduction programme that quickly produced results. The hospital first tackled paper, plastic and glass waste streams. In 2001, it recycled 370 tonnes of cardboard, 300 tonnes of office paper, 2.7 tonnes of telephone books, and 11.3 tonnes of plastic and glass. Turning to other areas, the hospital system recycled 109 tonnes of scrap metal and 25 tonnes of cooking grease. In 2000, it recycled more than 830 tonnes of material from building and demolition projects. Acknowledging the environmental impacts of medical waste disposal, Michigan also instituted innovative programmes to reduce and reuse medical waste. With the purchase of a steam autoclave, the hospital was able to reuse medical tools and supplies, and turn some medical wastes into general waste. The production of general waste from medical waste reduced emissions from waste that would otherwise be incinerated. By 2001, the hospital system had recycled more than 2000 lbs (900 kg) of mercury and 22,300 fluorescent bulbs and ballasts (each containing about 300 mg of mercury).The hospital's pathology department recycled and reused 624 gallons (2362 litres) of alcohol, and also developed a formalin recycling project. Using a still to regenerate more than 80% of used formalin, the department disposed of only 520 gallons (1970 litres) at a cost of $9100 a year. Before the project, the hospital used 2600 gallons (9840 litres) a year, at a cost of $8700 for procurement and $45,700 for disposal. The formalin recycling project saves at least $45,300 annually. Michigan further reduced other waste streams by redirecting instruments, wheelchairs and other medical supplies to other organizations. Revenue from aluminum can recycling goes to children's organizations, while donations of wheelchairs, mattresses, hospital gowns and sheets, and office equipment go to various charity programmes in the Detroit city area. Expired and unused medical instruments are donated to the non-profit organization, World Relief. Leading by example The facilities listed are considered to be the cream of the US healthcare facilities, and H2E hopes to bring all such facilities in the country up to this level. And while the above is anecdotal in nature, H2E is working to create a more systematic measure of the programme's effects over time. H2E expects preliminary results by the end of 2003. What's next in healthcare waste reduction The above examples are just the beginning of what H2E hopes to be a larger movement toward environmental awareness among healthcare facilities. As healthcare facilities begin to re-examine what they consume and throw away on a daily basis, they will realize, as the Environmental Leaders did, that better environmental stewardship translates into real dollar savings. Almost 2.5 million tonnes of healthcare waste is produced in the US each year The next steps in healthcare waste reduction will extend beyond everyday waste reduction. H2E sees two major areas contributing to this trend. Environmentally Preferable Purchasing (EPP) - By becoming smarter consumers of everyday products, healthcare facilities can begin to address waste reduction long before they purchase any products. Attributes such as excess packaging, toxicity of ingredients and reusability and recyclability of products can all contribute to minimizing the amount and toxicity of waste generated. Group Purchasing Organizations in the US such as Consorta and Premier have begun to offer information on the environmental preferability of the products that they sell. Green buildings - The healthcare sector in the US is undergoing a major physical expansion. Whether due to a shortage of bed space, or due to governmental regulations for building upgrades, it is estimated that the healthcare sector build over 1 million sq. ft (93,000 m2) of new healthcare space a year over the next decade. With the renovation and new construction comes a huge amount of construction waste. H2E will promote 'green' buildings, encouraging the reuse of building materials such as doors, windows and fixtures whenever possible and the use the environmentally preferable building products, such as building materials with recycled content, reusability and energy efficiency. By maintaining an increasing level of environmental consciousness, H2E participants protect the health of their patients and staff beyond the direct medical assistance they offer. They improve the financial bottom line while possibly ensuring that some people may never need to walk through their doors.   CHEN H. WEN works for the US Environmental Protection Agency, and is Co-Coordinator of the Hospitals for a Healthy Environment Program. e-mail: Wen.Chen@epamail.epa.gov JESSE EAVES is part of the Program's Environmentally Preferable Purchasing Workgroup. e-mail: Eaves.Jesse@epa.gov web: www.h2e-online.org