Healthcare footprint
The health care sector has a large and costly environmental footprint worldwide.  Hospitals, in particular, are among the most energy-intensive facilities, accounting for a significant percentage of greenhouse gas and carbon dioxide emissions. In the US they produce 6,600 (source?) tons of waste per day and use large amounts of toxic chemicals.
·        According to Rick Fedrizzi , the CEO and founding chairman of the U.S. Green Building Council: hospitals are responsible for almost one tenth of the country´s carbon-dioxide emissions.  
·        The U.S. Environmental Protection agency issued a highly disturbing report: Medical waste incinerators were the single biggest source of dioxin emissions into the atmosphere.
This footprint rises even further, due to the growth of ageing population, the explosion of the so-called lifestyle diseases, rise in public expectations, and lack of value-consciousness among healthcare consumers. On the supply side, the cost of care continues to increase, driven by new therapies and technologies with no cost consciousness.   
Furthermore, according to the U.S. Science Advisory Board’s assessment, the highest global environmental priorities should be given to: global climate change, loss of biodiversity, habitat destruction, and stratospheric ozone depletion. The above indicates environmental health at risk and signals trouble for the human species.
Reducing therefore the environmental footprint demands strong leadership and clarity of priorities. But finally this will also reduce in return the incidence of human disease, thereby saving money for the health care system and society as a whole. As part of a preventive approach to controlling chronic disease, a growing number of hospitals in the USA and Europe have been committed to minimize the adverse environmental effects of their operations serving as role models for the health sector and society.
But how could we reach the reduction of  health care footprint?
By adopting operational interventions in existing buildings?
By adopting retrofit strategies?
By designing new eco hospitals?
By developing a new vision for the hospital of 2050?

1. Operational interventions to improve sustainability, functionality and ensure high level of medical services could be addressed at two levels.
Operational interventions with low investment cost, concerning primarily personnel, patients, and their “energy saving culture”. Some of them are:
  • Ergonomic design for elevators and circulation  inside the building.
  • BMS system for energy saving  of lighting,  heating and cooling.  
  • Change the “stand by” mode to “off mode” for all electrical devices
  • Introduce occupancy sensors for public areas.
  • Unoccupied period controls and off-hours shutdown.
  • Night ventilation of areas with no windows.
  • Efficient purchase of OR supplies through reprocessing and reuse of single-use medical devices.
  • Regular training of personnel related to eco-solutions.
  • Cultivate awareness, stay alert.
  • Change of mentality.
Similar or even minor interventions were implemented at five US hospitals according to a research carried out by the School of Public Health at the University of Illinois in Chicago (UIC). After standardizing metrics and generalizing results to hospitals nationwide, the analysis finds that savings achievable could exceed $5.4 billion over five years and $15 billion over 10 years.
Our estimation for applying in Greece the above interventions will practically mean 20% energy saving annually. However no such initiative has been taken so far…
Operational interventions requiring a cost / benefit approach and concerning the redesign and regrouping of services and departments, based on a new functional prototype.
  • Replacing internal with external departments, as kitchen, laundry room, etc.
  • Moving sections or creating new ones.
  • Upgrading medical and hotel equipment.
  • Enhance waste reduction and waste management: recycling, minimization of regulated medical waste, through improved segregation and reduction in total landfilled waste.
  • Designing training programs for personnel.
  • Extending all Information systems.
  • Upgrading of new technologies. .
2. Retrofit strategies and design of  NEW –so called– Green Hospitals or Energy Saving Hospitals that respond to sustainable principles of environmental quality, economy and welfare, are strategies related to energy consumption and atmospheric quality, water efficiency, indoor environmental quality and comfort, natural and artificial light provided, materials and resources to be used, connecting people with natural environment, etc.  
We will concentrate here on the strategy of:
2.1 Energy consumption, which should be based on energy consciousness, energy efficiency and use of renewable energy sources, which means a common scope with measures concerned with the reduction of medical services and the preservation of better life conditions (thermal, acoustic, visual comfort).
The development of a holistic package of actions towards “green hospital” model should emphasize the following energy parameters:
(a)      Introducing Bioclimatic and Biophilic design tools, such as:  
  • The improvement of the surrounding environment which means, provision of access to views on nature, outdoor and indoor places of respite and exercise, introduction of vegetation, embedded water element as an aesthetic and relaxing feature inside and outside the building, provision of natural cooling., use of colours, sounds etc. 
  • Greener, healthier hospitals offer optimal healing environments for patients. A range of international studies have confirmed that they reduce by 8,5 % the length of stay required in hospital. The Mackenzie Health Sciences Centre in Canada found that depressed patients in sunny rooms recovered 15% faster than those in darker rooms. The Flinders Medical Centre New South Wing in Adelaide, Ausralia, achieved a 5 Star Green Star – Healthcare Design rating in 2011, increasing by 10% the number of babies born, which means increasing their turnover (!). This indicates indicating support of community for such initiatives.
  • Through the Improvement of building shell, by minimizing heat losses, reducing air pollution through proper insulation, and providing natural lighting and shadings together with natural ventilation.The LEED-rated Bronson Methodist Hospital in Michigan found that applying green design principles such as improved ventilation, private rooms, music, light and nature in its redevelopment project, led to dramatic decrease in nursing turnover rates.     
  •  Through the introduction of renewable energy sources, with environmental, aesthetic and cost/ benefits criteria, such as geothermal energy combined with photovoltaic or, sun collectors or wind turbine.
  • Through the use of ecological and cool materials with soft surfaces that improve thermal and visual characteristics, and secure long life circle and recycling according to hygiene standards.
Healthcare architects have begun to explore the physiological benefits of biophilia in the design of indoor environments. For instance, in a recent study carried out by the University of British Columbia, the visual presence of wood in a room, confirms that it lowers SNS activation in occupants.
Furthermore, wood contributes naturally to humidity control by absorbing or releasing moisture from the air according to humidity level in a space.  
 
(b)      Optimization of  E/M installations: According to the European Union directives, every building until 2019 should be energy self-sufficient. This requires reduction of energy consumption through the use of renewable energy sources and CHP or other methods.
According to EPA's findings in the USA indoor air pollution is one of the top five environmental risks to public health. To improve air quality and achieve energy saving in hospitals, fundamental changes are needed in the performance and function of control systems, with more effective technologies.
  • Traditional heating, ventilation and air conditioning (HVAC) systems are energy intensive and can be responsible for over 40% of the hospital’s energy requirements.Alternative HVAC systems, such as displacement ventilation, active chilled beams, natural ventilation (passive) and other hybrid systems can have a profound effect on performance and energy efficiency. In displacement ventilation, outdoor air is pumped in at floor level. The cooler air will force the warm air already present in the room towards the ceiling and therefore towards the exhaust system. This can greatly improve air quality and reduce energy use.In Active Chilled Beam, air-water system is using the energy conveyed by two fluid streams to achieve the required cooling or heating in a room. The advantages are due (a) to the superior properties of water -as a heat transfer medium- and (b) to the use of individual control units.In natural ventilation (passive), the advantage is in air quality with the extent of pressure and energy saving through natural cooling by operable windows. This, in some countries may have an annual energy reduction of 50%.  Natural ventilation could improve the capacity of operating with 100% fresh air in intermediate seasons, especially by allowing flexibility for indoor temperature, depending on seasons or day and night. In parallel the system enhances the use of ceiling fans where possible –in order to provide comfort conditions.
  • Other important energy improvements that I should like to put forward are: 
-  Insulation of piping network - HVAC
-  Heat exchange between fresh and exhaust air.
-  Using the air-conditioning exhaust load for water heating.
-  Maximizing systems COP and system’s efficiency, saving in energy consumption by using BMS systems.
-  Optimizing the combination of renewable and conventional energy systems (Installing solar-thermal panels, photovoltaic panels and geothermal energy systems where applicable). Application of renewable    energy systems and CHP will increase energy saving from 20% to 40%.
-  Hydraulic heating controls (which use water instead of air as the heat-transfer).
-  Using of high efficiency boiler.
-  Central plant chiller replacement.
-  Multistage burners to provide high efficiency on low load.
-  Using combined heat and power (CHP).
-  Embedding frequency converters in electrical motors.
-  Compensation of reactive power.
-  Lighting upgrades.
-  Variable-frequency drives offering significant energy efficiency improvements.
-  High-efficiency electric motors. etc……..
Are these interventions effective for a sustainable wellbeing?.
Should the health system be reoriented and rescheduled in more holistic mechanisms, responding to issues of scale of hospitals, preventive medicine, telemedicine and information technologies, home medical care, etc? 

3. The answer is yes, granted that we develop a new vision for the hospital of 2050: According to the 2012 World Economic Forum, a healthcare system cannot be sustainable unless the growing demand for healthcare is slowed. The key drivers of growth are expectations of health safety allied with a mounting burden of diseases. Expectations are raised as society’s develop. These expectations are independent of the health system. The focus therefore is on promoting healthy lifestyles, leading to longer and more productive lives. World society must build healthy cities and countries that are fit for the future, and they should develop an appropriate lifestyle.  As Dr W. Sittel, Head of Architecture at Asklepios Hospital Group, stated at the Asian Pacific Weeks in Berlin in 2011: ‘Today there is a direct link between healing the individual and healing our planet. We will not have healthy individuals, healthy families and healthy communities if we do not have clean air, clean water and healthy soil.’
What has to be done to develop a common vision towards a sustainable wellbeing?
  • The key challenge is to develop a new social contract by engaging a wider set of stakeholders to contribute to better health for all. Health care leaders must work with policy-makers, industry heads and other multi-sector actors, to reverse the negative aspects of our consumption-based culture.
  • A second path is to promote biophilic urbanism – which means encourage green infrastructure–providing many ecological benefits that will make cities more resilient to climate change impacts, to the reduction of damages from winds, rain, floods, but also strengthen favorable climatic conditions and micro-climate, while enhancing  individual resilience and health –physical and mental.
I would like to share with you a more specific vision for the health sector which, according to Dr Sittel, must:
(a)     downsize and redeploy healthcare, with  functional deconstruction of hospital,
(b)     disperse medical care across a number of small-scale micro-hospitals/ clinics,
(c)     turn the home and not the hospital, into the center of the healthcare universe,
(d)     create eco humanist hospitals,  in carbon-neutral healing environments, in  contact with nature and in more  anthropomorphic and organic forms … advocating  for quality of life issues and sickness prevention.
I hope that such an anthropocentric approach will help us reorient ourselves and our cities into a globalized world. The Emirates, in the heart of avant gard initiatives, and in an area that suffers from global warming, is the place, where such a consideration could be initiated. 
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