This document discusses the environmental impacts of the healthcare sector and the role of nurses in promoting environmental health. It notes that nurses understand the link between environmental factors and health outcomes. Approximately 25% of the global disease burden is attributable to environmental factors, including air pollution which causes over 7 million deaths annually. The healthcare sector generates significant waste and pollution, for example through the use of mercury, chemicals, and medical device manufacturing and incineration. The Global Green and Healthy Hospitals initiative works to transform the sector to be more sustainable and advocates for environmental health and justice. It has over 750 member hospitals and organizations worldwide working towards its 10 goals for more sustainable practices.

1. Nurses No Harm
Faye V. Ferrer
Coordinator, Global Green and Healthy Hospitals
Health Care Without Harm – Asia
PHICNA Convention, 17 May 2017

2. • Nurses have long appreciated that a
healthy environment impacts upon
the health of individuals, families,
communities and populations
• This understanding is an essential
underpinning of nursing practice

3. “No amount of
medical knowledge
will lessen the
accountability for
nurses to do what
nurses do, that is,
manage the
environment to
promote positive life
processes.”

4. • Published 1995:
Pope, Snyder,
Mood.
• General
environmental
health
competencies for
nurses
– Basic
knowledge &
concepts
– Assess and
refer
– Advocacy,
ethics, and
risk
– Legislation &
regulation

5. Definition of
Environmental Health
Freedom from illness on injury related to
exposure to toxic agents and other
environmental conditions that are
detrimental to human health
Source: Institute of Medicine (1995): Nursing,
Health and the Environment

6. The Environmental Crisis is Global

7. Environmental Factors
= ¼ of global burden of
disease (GBD) – WHO, 2006
Pruess-Ustun et al.
Preventing disease through
healthy environments:
Towards an estimate of the
environmental burden of
disease
www.who.int/quantifying_ehimpacts/publicati
ons/preventingdisease/en/

8. Environmental factors cause over 25% of global burden of disease
– important determinants for the largest diseases
Communicable
Diseases
Noncommunicable
Diseases & Injuries
Share of burden of disease
Lead-caused MMR
Cancers
Road traffic injuries
Chronic respiratory diseases (COPD, asthma etc)
Cardiovascular diseases (IHD, CVD etc)
Other unintentional injuries (excl. road traffic)
HIV/AIDS
Childhood cluster
Perinatal conditions
Malaria
Respiratory infections
Diarrhoea
Source: WHO Burden of Disease statistics
Environmental Fraction Total
0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10%
Share of burden of disease
Lead-caused MMR
Cancers
Road traffic injuries
Chronic respiratory diseases (COPD, asthma etc)
Cardiovascular diseases (IHD, CVD etc)
Other unintentional injuries (excl. road traffic)
HIV/AIDS
Childhood cluster
Perinatal conditions
Malaria
Respiratory infections
Diarrhoea
Source: WHO Burden of Disease statistics
Environmental Fraction Total
0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10%

9. GBD Air Pollution:
WHO reported that in
2012 around 7 million
people died - one in eight
of total global deaths – as
a result of air pollution
exposure.
• 3.3 million deaths
linked to indoor air
pollution
• 2.6 million deaths
related to outdoor air
pollution
who.int/mediacentre/news/releases/2014/air-
pollution/en/
Outdoor air pollution-caused
deaths – breakdown by
disease:
• 40% – ischaemic heart
disease;
• 40% – stroke;
• 11% – chronic obstructive
pulmonary disease (COPD);
• 6% - lung cancer; and
• 3% – acute lower respiratory
infections in children.
• And linked to Dementia

10. • An international environmental
and health organization and a
global coalition of more than 500
organizations in 52 countries
• Working to transform the health
care sector worldwide to be
ecologically sustainable
• Health sector as a leading
advocate for environmental health
and justice
• Two core principles:
– The right to health
– The right to a healthy
environment

11. Extent of the problem of medical waste
“Over half of the world’s population are now at
risk from occupational, environmental or public
health threats from improperly treated medical
waste.“
Harhay et al. (2009)
Tropical Medicine and
International Health
14(11): 1414-1417

12. International guidance
on waste treatment technologies
World Health Organisation
• 2004 policy: scale up steam-based treatment
• Blue Book Second edition, 2014: priority for non-incineration
Stockholm Convention:
• waste incinerators are specifically identified as potential sources of highly toxic
dioxins and furans.
• guidelines on medical waste states that “priority consideration should be given
to alternative processes” that do not generate dioxins and furans
Basel Convention:
• 2003 Guidance: prefer steam based treatment
Human Rights Council 2011
• Substitution of incineration with alternatives wherever practicable

13. Examples of Non-Incineration Technologies Demonstrated
by the GEF/UNDP Project in Different Countries
Vietnam: large autoclave
Lebanon:
hybrid autoclave
Latvia: microwave
Latvia: rotating autoclave

14. Biomass fired autoclave
• Gasket-less aluminium autoclave set into a
high efficiency biomass cook-stove
• Potential for disinfecting waste in remote
areas and post-disaster situations
• Being tested in Kathmandu May/June
2014
• Effective with wood, and various biomass
briquettes
• 60 litres of waste can be disinfected with
as little as 800g of fuel.

15. Biodigestion
• Breaks down organic waste to
produce methane- a renewable
fuel
• Bir hospital uses biodigestion
for food waste
• Potentially able to dispose of
pathological waste
• Pilot in development for
Kathmandu Maternity Hospital
• -2 chamber design to maximise
reaction time
• Will monitor pathogens, temp
pressure, pH etc, to prove how effective the technology can be and optimise conditions

16. Mercury

17. Hospital Uses Health and Environmental Concerns
Disinfectants &
Sterilants
• Glutaraldehyde is a potent occupational skin irritant and causes
asthma.
• Ethylene oxide is flammable and explosive, a probable human
carcinogen, a toxic air contaminant, and an ozone depleter.
• Chemicals designed to kill biological organisms like pesticidal cleaners
can be very toxic to humans and ecosytems.
Hazardous Chemicals in HeaIth Care

18. Hospital Uses Health and Environmental Concerns
Cleaning
Agents
• Chlorine bleach (sodium hypochlorite), can in some circumstances
liberate chlorine gas, a respiratory irritant and sensitizer.
• Surfactants such as alkylphenol ethoxylates degrade into nonylphenol,
which is toxic to aquatic wildlife; ethanolamines can cause asthma.
• Some cleaners may contain chemicals that cause cancer, reproductive
disorders, respiratory ailments, eye and skin irritation, central nervous
system impairment, etc.

19. Hospital Uses Health and Environmental Concerns
Laboratory
Chemicals
• Toluene is neurodevelopmental toxicant.
• Formaldehyde is a carcinogen.
• Laryngitis, bronchitis or bronchial pneumonia, conjunctivitis may be
developed through chronic exposure to laboratory chemicals.

20. Hospital Uses Health and Environmental Concerns
Medical
Devices
• PVC manufacture and incineration generate dioxins, chlorinated
organochlorines.
• DEHP, an additive to PVC, can damage the liver, kidneys, lungs and
reproductive system, particularly developing testes, according to
animal studies.
• In animal studies, BPA is associated with alteration in breast, prostate,
and brain development, changes in behavior, and susceptibility to
breast and prostate cancer. Human studies find a direct association
with risk of diabetes and heart disease.

22. Global Green and Healthy Hospitals
10 Agenda Goals
Leadership Chemicals Waste Energy Water
Transportation Food Pharmaceuticals Buildings Purchasing

23. 10 GGHH Goals

24. 24
GGHH Objectives
1. To serve as a vibrant virtual community for hospitals and
health systems seeking to reduce their environmental footprint.
2. To chart progress in achieving measurable outputs, while
sharing best practices, finding solutions to common
challenges, and raising the bar.
3. To mobilize health care around the world to work together
toward and advocate for greater environmental health, locally
and globally.

25. 25
Hospital Members
Health System Members
Health, Professional and Academic
Organizations Members
Categories of Membership

26. Partners and Relationships

27. Latin America
405 Hospitals , 46 Health Care
Facilities, 35 Health Systems
and 15 Organizations,
representing the interest of
1637 Hospitals and Health
Centers.
Africa
22 Hospitals, 10 Health Care Facilities, 5
Health Systems and 2 Organization,
representing the interest of 1455 Hospitals
and Health Centers.
Asia
94 Hospitals, 3 Health
Care Facilities, 7
Health Systems and
24 Organizations,
representing the
interest of 8229
Hospitals and Health
Centers.
Pacific
6 Hospitals, 20 Health Systems
and 6 Organizations,
representing the interest of
582 Hospitals and Health
Centers.
Europe
21 Hospitals, 1 Health Care Facility, 19 Health Systems
and 9 Organizations, representing the interest of 7213
Hospitals and Health Centers.
USA and Canada
HCWH’s implementation arm, Practice
Greenhealth has 1,401 Hospital members in
the U.S. In Canada, GGHH members include 5
Health Systems and 2 Organizations
representing the interest of 1080 Hospitals and
Health Centers.
Totals: As of March 2017, GGHH has 797 members from 47
countries representing the interest of 25,600 Hospitals and Health
Centers.
Global
1 Health System and 3 Organizations
representing the interest of 1040 Hospitals.
HCWH Regional Offices
Strategic Partners

28. Membership
Asia
• Bahrain, Bhutan, China, India, Indonesia, Kuwait,
Nepal, Philippines, Singapore, Saudi Arabia, South
Korea, Thailand, Taiwan
• Membership breakdown -73 Hospitals and Health Care
Facilities, 6 Health Systems and 9 Organizations,
representing the interest of 8206 Hospitals and Health
Centers

29. Programs and Benefits
Programs and Benefits

30. the 2020 HCCC Challenge
The Challenge is based on three pillars:
• Mitigation – Reducing health care’s own
carbon footprint.
• Resilience – Preparing for the impacts of
extreme weather and the shifting burden
of disease.
• Leadership – Educating staff and the
public while promoting policies to protect
public health from climate change.

32. Forms | Report and track

33. Graphs | Benchmark and Compare

34. Case Studies
• Examples of successful
project implementation
from GGHH members
• Process,
Implementation,
Challenges
• Connect with members
to learn more

35. Webinars
• Water: Methods and Tools for
Sustainable Management and
Conservation in the Health
Sector
• Buildings : Green Design and
Construction of Hospitals
• Ebola and Health Care Waste:
Lessons from West Africa
• Combating Climate Change:
Health Care Leadership and the
#2020Challenge
• Sustainable Health Care Waste
Management: Strategies and
Experiences
• Health and Climate Change: The
Lancet Commission Report
• Health Impacts of Energy
Choices: Opportunities for
Health Sector Leadership

36. GGHH Exchange

37. Nurse No Harm
Train the Trainors
Training Module
• Describe environmental risk factors in the home, school, workplace and
community.
• Demonstrate new skills in community environmental health assessment and
exposure assessment (using the pneumonic IPREPARE).
• Demonstrate knowledge of hazardous materials and their toxic effects on
individuals and subpopulations, including children.
• Discuss the goals of Global Green and Healthy Hospitals and benefits of
membership in the network of 20,000 hospitals and health facilities.
• Identify the health hazards from climate change/instability and describe the role of
nurses as environmental health advocates.
• Discuss environmental health resources and the “right to know” points of access to
information.
• Develop an individual and collective plan of action to apply environmental
knowledge.

39. Faye Ferrer
faye@no-harm.org
HCWH Asia - noharm-asia.org
GGHH - greenhospitals.net