Garbage and indoor airat first glance, it is difficult to comprehend what common elements these two critical sustainability issues share. However, hospitals and designers focused on these two areas demonstrate a commitment to improved health—for occupants, local communities, and the planet. And through a variety of built environment and operational strategies, hospitals are celebrating dramatic performance improvements.

The linkage between waste disposal practices and human health has profoundly affected hospital waste management. In 1996, the EPA named medical waste incineration as the second largest source of airborne dioxin emissions. (Dioxin is a potent human carcinogen and persistent bioaccumulative toxic chemical.) Two years later, the EPA and the American Hospital Association called on hospitals to reduce their waste volume and toxicity. Since then, facilities have implemented alternatives to incineration of regulated medical waste, and reduced or eliminated plastics, such as PVC, that produce dioxin when incinerated. As disposal costs rise for medical waste, many hospitals have found that reducing these volumes of waste also has financial payback. On-site hospital incinerators have all but disappeared and, according to the EPA, airborne dioxin levels are trending downwards.

While it may be difficult to imagine a zero-waste hospital, strategies focused on the mantra of “reduce, reuse, recycle” are yielding waste volume reductions approaching 60 to 70 percent below levels found in 2000. These strategies begin with environmentally preferable purchasing strategies that minimize packaging and prioritize end-of-life recyclability. Hospitals are shifting away from disposable products to reusable equivalents. Garbage-free cafeterias focus on compostable foodware, pulping, and composting of food waste. And careful segregation of clinical waste is facilitating recycling programs for paper, cardboard, and clinical plastics, while also enhancing segregation of medical waste for treatment and landfill.

For designers, this poses new requirements on loading docks, particularly trash areas, which now need space for staging recyclables, reusable sharps containers (used for disposing of needles and other sharp medical instruments), and reusable packaging. Additional requirements include balers, shredders, and autoclaves for conversion of medical waste to inert plastic, suitable for landfill instead of incineration. Practice Greenhealth ( offers tools and resources for hospitals engaged in waste reduction practices.

Shifting indoors, it may be surprising to learn that the answer to improved indoor air quality (IAQ) in hospitals, historically, has been simply to increase the air change rates. In an era of cheap energy, that might have been a reasonable approach, but hospital air change rates contribute to their enormous energy consumption—estimated by the Energy Information Agency as an average of 346 kBtu per square foot per year.

In this era of expensive energy and concerns about carbon emissions, design teams must balance energy demand, air quality, sealed envelopes, and pollutant source control. But how? Infection control and pandemic disease concerns are leading many hospitals to provide 100 percent outside air with no air recirculation, coupled with heat recovery technologies. This should lead to improvements in IAQ, but the reality is that hospital interiors are filled with air pollutant point sources, both gaseous and particulates—from the building materials to cleaning products—and these point sources have demonstrable negative health impacts on building occupants. It is imperative to balance outside air delivery and pollutant source control.

Sick Building Syndrome and Building Related Illness are linked to sealed envelopes and indoor pollutant sources—primarily off-gassing from volatile organic compounds (VOCs). Cleaning products, particularly floor waxes and strippers, contain high levels of VOCs and heavy metals, and, given the 24/7 occupancy of hospitals, all cleaning takes place while the building is occupied. Pollutants also come from the building materials themselves—formaldehyde and benzene in adhesives, VOCs in paints and solvents, and phthalate plasticizers in flooring and window treatments.

One provocative question is whether these chemical exposures matter. In May 2010, Environment and Human Health ( released “LEED Certification: Where Energy Efficiency Collides with Human Health,” a study that is critical of LEED certification that prioritizes energy efficiency while not effectively providing equal priority for IAQ threats from chemicals. It cites the National Health and Nutrition Examination Survey analysis of hazardous chemicals in human tissues, begun in 1999 by the Centers for Disease Control and Prevention (CDC), which documents widespread and chronic exposure to pesticides, fire retardants, plastics, metals, and other chemicals routinely found in building products. The CDC’s 2009 assessment of human exposure to chemicals measured more than 200 chemicals in 2,500 participants. Chemicals used in building materials that were detected in human tissues include BPA, metals, VOCs, phthalates, and dioxins, all of which are recognized as being toxic. “Carcinogenic and endocrine-disrupting pesticides were detected in more than 50 percent of those tested,” the report said.

The Green Guide for Health Care ( includes credits aimed at many of these chemicals of concern, and the USGBC is beginning to introduce such credits in its LEED pilot library. And many leading healthcare organizations, such as Catholic Healthcare West and Kaiser Permanente, are implementing standards that phase out building products containing such chemicals.

At 17 percent of the GDP, the healthcare industry is in a good position to drive market transformation to safer, healthier materials. Likewise, innovative waste reduction and processing strategies significantly reduce landfill volumes and incineration of toxic products. Through waste and IAQ initiatives, hospital leaders and designers demonstrate a commitment to more than high-quality patient care—they demonstrate a commitment to saving lives and improving health without undermining ecosystems or diminishing the world. ?

Robin Guenther, FAIA, is a principal of Perkins+Will and author of Sustainable Healthcare Architecture. She is a co-coordinator of the Green Guide for Health Care and is a member of the LEED for Healthcare committee.