ANMJ Featured Story

Green Healthcare: Our environmental warriors

Friday 23rd June, 2017

Extreme weather patterns, global warming and air pollution are increasingly becoming the norm, the consequences of which are being felt across the world. Climate change is being touted responsible, compelling a commitment from world leaders to reduce emissions in an attempt to curtail the impact. Yet to ensure environmental sustainability everyone must play a role including nurses, midwives and healthcare facilities. Natalie Dragon investigates the progress healthcare has made to this end.

Garden development and spaces don’t just happen”, says Melbourne Clinical Nurse Specialist and Horticulturalist Steven Wells.
“And they have to be sustainable with low water use requirement; they have to survive on rainfall.”

Steven is Australia’s first Gardens and Grounds Project Officer at Austin Health, in Melbourne’s north.

A “collection of pots and some nursing time” to support patients with acquired brain injury started in 2003. Steven now creates gardens for respite, recovery and restoration.

“The use of plants and garden-related activities assist with achieving patient goals and promote physical and emotional wellbeing needs.

“While tinkering and chatting we are making a difference to our patients. It’s a moment of normality. Patients are not sitting in a hospital bed but reconnecting with their world, the natural world.”

Austin Health’s master plan was to develop gardens to patient areas for their health benefits and also for staff. Since 2011, $754,000 has been spent, largely philanthropic, on garden projects. Some 23 diverse projects include 6,700 plants in garden spaces in acute care, mental health, rehab, child care, and various courtyards over Austin Health’s three campuses. 

An impressive 19 metre wide Jessie Mary Vasey Labyrinth at the Heidelberg Repatriation Hospital is a tool for personal, psychological and spiritual transformation. The ‘Sensory Gardens’, a green refuge includes areas of privacy. 

“It’s a place to chat with families who are going through tumultuous times of uncertainty and anxiety in whether a loved one can walk again, talk again - essentially recover.”

Steven says there’s a strong link between environmental sustainability and embracing nature to improve health outcomes for patients.

“For everyone, it’s how we can make a difference to the core business of patient care and duty of care. Dream big, start small. Keep creeping and creeping,” he says.

Duty of care

Crowds marched in more than 600 cities worldwide for Earth Day in April amid growing concerns of US President Donald Trump’s stance on climate change and cuts to research funding.

Think globally, act locally, Australian of the Year and prominent scientist Professor Peter Doherty urged delegates at the ANMF Victorian Branch Health and Environmental Sustainability Conference in Melbourne. “Duty of Care is at the heart of what you do. That must be extended to the natural systems that sustain us and to the other complex life forms. 

Climate change is the most serious human health problem of today, says Professor Doherty. “Greenhouse gas levels are at the highest they have ever been for 500 million years. We are on an inexorable path to two degree warming. We will have warming by three to five degrees by 2100. It’s really dangerous yet we are doing relatively nothing.”

The UN’s Sustainable Development Goals will be extraordinary difficult to meet, he says. “However we need aspirations to work towards and we have got to move forward to have pragmatic solutions. We have to tackle climate change with the best science we have got.

“This is an extraordinary time. We need to act – there is no place for despair. We must change our ways of doing things if future generations are to enjoy a green, clean and liveable world. It’s up to us.”

2015 Paris Agreement

At the 21st United Nations Conference of the Parties meeting in December 2015, countries agreed to increase their level of commitment to limit climate change. Australia ratified its commitment last year to reduce its emissions to 26-28% on 2005 levels by 2030.

“Paris was great but it’s not enough – it’s not compatible with life,” Climate and Health Alliance (CAHA) President Dr Liz Hanna says. 

“CO2 is right now 410ppm so we know the temperature is going to rise again. Not only are our emissions increasing, they are accelerating. We have been way too much asleep at the wheel.”

If all 195 countries signed up to the Paris Agreement adhere to their commitments, there is a 50% chance of staying under two degree warming, Dr Hanna says. “Because the pledges are not strong enough and they’re not binding.” 

More worrying is that there is only a 50% chance of staying under 3.6 degree warming - a world we cannot imagine, she says.

“By 2045, today’s extreme summers will be the norm – every second year half the world’s population will experience the hottest year. 

“Australia’s 2013 hottest year should occur one in every 12,000 years. We know it’s not going to be another 12,000 years before we have another hottest year on record like 2013.”

The impact of climate change will incur injuries and deaths caused by conflict and war, warns Dr Hanna.

“There are 7.4 billion people on this planet and conflict is very problematic. Climate change is really going to interrupt the fundamentals that we really need. Existing wars in Sudan and Syria were precipitated by droughts, hunger, and migration exacerbated by existing cultural tensions. There is going to be more of this.” 

Health professionals need to lobby for urgent and deep mitigation as a health issue, Dr Hanna says. “For us in the health sector we have to adapt. Mitigate, educate and adapt.” 

A national strategy 

The gap in climate policy in Australia includes the lack of a national climate change strategy.

A national strategy would help the government meet its international obligations under the UN’s Framework Convention on Climate Change (UNFCCC) Paris Agreement and its commitments to the Sustainable Development Goals, argues CAHA’s Founder and Convenor Fiona Armstrong.

“Without a national strategy, Australia lacks any mechanism to ensure this occurs.”

There is overwhelming public support with 98% of respondents to a national survey indicating Australia needs a National Strategy for Climate, Health and Wellbeing.

CAHA released a discussion paper in June last year, followed by a Health Leaders roundtable convened in October.

All three major political parties jointly hosted the launch of a proposed framework for a national strategy at Parliament House last month as the ANMJ went to print. Parties indicated they may develop policy positions using the framework, says Ms Armstrong.

“It will also deliver ‘win win’ climate change mitigation and adaptation strategies, which both reduce greenhouse gas emissions and the social and economic burden of ill health in the population.”

Key areas of policy action include: health-promoting and emissions-reducing policies; supporting healthy communities; education and capacity building; government collaboration; leadership; emergency and disaster-preparedness; a sustainable and climate-resilient healthcare sector; and research.

Climate reality

Scientists argue climate change is about ‘extremes’, not necessarily always about warming. Such as the recent unprecedented thunderstorm asthma outbreak in Melbourne which resulted in eight deaths and 8,500 hospitalised. Asthma attacks increased by more than 300% during the 2014 heatwave in South Australia. The ‘Ash Fly Crisis’ in SA’s Port Augusta in January led to severe health effects, particularly for those with asthma.

The 2015 Lancet Commission on Health and Climate Change was formed to track progress every two years on the effects of climate change until 2030. The direct effects of climate change will include increased heat stress, floods, drought, and increased frequency of storms. Indirect threats to health such as changes in air pollution, spread of disease vectors, food insecurity and under-nutrition, displacement and mental ill-health.

Two of the Lancet’s proposed indicators measure energy access for health facilities and the greenhouse gas emissions of healthcare systems. 

Green Healthcare

The Global Green and Healthy Hospitals (GGHH) is a worldwide network for the health sector. Globally there are almost 800 members with a reported 25,000 hospital and health services.

GGHH connects people doing vital sustainability work, says Project Officer Pacific Region Carol Behne. “It also shows the broader community that the health sector is concerned about its environmental impact.”

GGHH focuses on 10 action areas: waste; energy; water; chemicals; transportation; food; pharmaceuticals; buildings; purchasing; and leadership.

“There is a lot of opportunity for reducing what ends up in waste landfill, energy use and greenhouse gas emissions,” says Ms Behne.

“Installing solar panels and more energy efficient systems are outside the realm of nurses and doctors, they don’t have that level of operational control but they have a role in advocating behaviour change.”

“It’s simple things done often, such as closing doors, turning lights off, reducing and disposing of waste correctly,” says Ms Behne.

“Our health is so dependent on our environment but it’s not always foremost in people’s minds.”

Focus on something within the realm of the workplace which is easy to fix, she says. 

“Look at something glaringly obvious, something that is getting to you. It’s probably getting to other people to. Polystyrene cups, cardboard recycling, reminder notes to switch off the lights - bring it up with other staff members and see what the reaction is. 

“Send out an email and see who comes out of the woodwork. Start a conversation in the workplace, have a look at your organisation’s strategic plan, bring it up at meetings. It could be as simple as collecting the organic waste in one small staffroom and taking it away once a week – it heightens awareness.”

Climate challenge

GGHH’s 2020 Healthcare Climate Challenge highlight three key areas: mitigation – reducing healthcare’s carbon footprint; adaptation – preparing for the impacts of extreme weather and disease; and leadership – to promote public health policies.

Mater Health was recently recognised as a 2017 GGHH champion for climate resiliency and greenhouse gas reduction (energy). The organisation achieved a 13% reduction in carbon emissions; a 40% reduction in transport fuel consumption; and reductions in electricity consumption across its major facilities.

Strategies include infrastructure and lighting upgrades, policies for air conditioning (temperature set points and scheduling) and staff engagement initiatives.

Energy was a big focus with 65% of energy use related to air conditioning, says Mater’s Former Director of Environmental Sustainability Chris Hill.

“Of course the cheapest is not to use it. Adjust to winter and summer set points except for specialised areas. Use air con scheduling so that it isn’t 24/7 at the back of the house or in areas not used on weekends.”

Mater has 199 sustainability initiatives including in water and waste, procurement, service design, and stakeholder engagement. 

“The first initiative was duplex printing – just printing on both sides of the paper saved close to 10 million bits of paper. This was an easy win that reduced paper use by 25%,” says Mr Hill.

Nearly 50 campaigns are based on stakeholder engagement. A ‘voluntary pledge of behaviour’ enables staff to sign up to behaviours in energy, water, and waste reductions. To date 4,000 Mater staff are signed up to 40,000 behaviours. 

Campaigns include a Turn It Off campaign based on behaviour change. A Keep Cup campaign significantly reduced the number of disposable cups. 

“You need champions to harness momentum once you set up an initiative and leaders to take the initiative,” says Mr Hill.

Mater Health also links in with key events, including National Recycling Week and Ride to Work Day. 

The organisation has reduced its clinical waste by about 30% with a management plan that includes avoiding waste. “In avoiding it, we have to look at where it comes in. We have trialled direct ward unpacking where suppliers (Baxter) bring it in themselves, put it on the shelves and take their waste with them,” says Mr Hill.

Mater Health has saved $4.5 million since 2008 with its sustainability plan, says Mr Hill. “We started the journey looking to lessen the impact on the environment - making financial savings was an added bonus. From a patient point of view - $1 million spent less on electricity can go to patient care. That’s the focus and the sell.”

Scourge of plastics

About 100 hospitals across Australia and NZ now participate in the PVC Recycling in Hospitals initiative launched in 2009. Baxter IV fluids, oxygen masks and oxygen tubing are recycled to make garden hoses and outdoor playground matting. 

“We save 6.7 tonnes of PVC IV bags from potentially going to landfill or untreated or even worse,” says RN Zeta Henderson at Barwon Health in Geelong, Victoria.

The project started in three ward areas with five collection bins clearly labelled ‘PVC recycling only’. 

“People monitor the bins for contamination but it has improved dramatically – 90% of what is in the bins is fine. We positively reinforce the message.

“PVC opens up the conversation – to battery recycling, disposable cups, crockery – to get rid of single use products and that’s our goal.”

Epworth HealthCare in Melbourne was announced last month as the first hospital in Australia to recycle aluminium bottles of its gas anaesthesia products. About 3,000 aluminium canisters and 80 cubic metres or enough PVC products to fill an operating theatre are to be recycled.

St Vincent’s Health in NSW, Group Manager of Energy and Environment Matt Power describes the ‘scourge of plastics’. 

“Plastic recycling is actually down-cycling. Let’s be clear - no modern plastics are truly recyclable. There is a net reduction but there are still additives such as printing inside the protective bag of IV saline. They cannot be re-used as the original product but go to use as a hose etc.”

Ultimately plastics end up in the environment, often as micro-plastics, which can take 1,000 years to biodegrade, says
Mr Power.

“We need to attack the original problem – we need to find an alternative to plastic.” This includes the creation of truly recyclable or biodegradable plastics (starches), he says. “We need to move back to materials that are truly recyclable – metals and paper-based.”

Organisations need to pressure suppliers to use less plastic packaging and ask tenderers to provide life cycle analysis of products, argues Mr Power.


“A discussion of climate change is a discussion of energy,” Mr Power says. “Healthcare is very energy intensive. Healthcare consumes more energy per metre square than almost any other built sector.” 

This means a massive opportunity for healthcare in reducing its waste, he says.

“We changed 9,000 lights in one of our Sydney hospitals.”

St Vincent’s National Energy Action Plan (NEAP) approved in 2015 will be completed this year. It involved eight energy efficiencies rolled out simultaneously: sub-metering; LED lighting; reduction in air con use (65% of the electricity load in most hospitals); solar PV on 16 buildings, equipment control; power factor correction; and voltage optimisation. 

NEAP has seen a total electricity reduction of 35-40% - the equivalent use of a town of 50,000 people and savings of $6.5 million annually in three years. It has projected 10 years savings at $65-72 million and a possible $100 million over 20 years.

The future

Climate change is an intergenerational health equity issue, says Western Australia’s Telethon Kids Institute Dr Brad Farrant. 

“My concern for those growing up now is that climate change will no longer be reversible and we end up with a generation of kids with a lower standard of living and worse health outcomes than the generation before them.” 

Dr Farrant is a passionate advocate for those he says do not have a voice yet. “Those who do not have a say in this and who do not have a vote. They will be the most impacted.”

Dr Farrant says we all have a responsibility to pressure our decision makers into action. “Let’s have an honest conversation in Parliament. That we are in the highest per capita of greenhouse gas emitters in the world instead of bringing in a piece of coal to Parliament saying ‘this is good for humanity’.

“If we were to be a good global citizen then we would have more of a leg to stand on in holding other countries to account. It is disappointing to say the least that Australia reports that it accounts for less than 2% of global emissions. It’s a smokescreen – if all the countries that accounted for less than 2% are added together - that’s 40% of global emissions and clearly not a viable approach.”

Australia should look towards Germany and the UK in the ambitious targets they have set to reduce emissions. “We must play our own part and do what we can to bring about change.” 

A green curriculum: the new normal

Monash University has recently introduced two climate change units into the nursing curriculum. A green curriculum is about increasing sustainability literacy, says Monash University Lecturer and RN Trish Schwerdtle. 

Sustainability literacy includes how climate change affects human health; how the healthcare sector contributes to climate change; and the interconnection between healthcare, adaptation and mitigation.

“Sustainability content must be positive, interesting and relevant,” Ms Schwerdtle says. “People are suffering climate change fatigue. Armageddon is disengaging.” 

The curriculum covers both health sector and climate change preparedness - global citizenship, eco-health, migration, conflict, and carbon mitigation.

Generation Y or the Millennials have the characteristics and skills to combat climate change, Ms Schwerdtle says. 

“Fifty percent of millennials are already in leadership positions which is unprecedented. They are opportunistic and innovative. We need them to know about planetary degradation.”

However everyone needs to prepare for a climate changing world, says Ms Schwerdtle

“Mitigation is a closing window.” She says nurses and midwives need to speak up. Events such as thunderstorm asthma and water quality in the bay were not linked in the media to the effects of climate change. “We have to make those health connections. Why don’t we as nurses and midwives be the voice on climate change? Take it to the next level - nurses and midwives as louder leaders?”

Being a green innovator involves persistence and integrating it in everything you do, she says. “Find ways to make it part of your core business, not an add-on.” 

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