Josh Karliner, international coordinator for Health Care Without Harm (HCWH), shared the organization’s perspective on healthcare sustainability activities worldwide. Facilities across the world have varying levels of sustainability engagement, from being nonexistent to leading the way. One hospital can literally throw garbage out the back door and less than a mile down the road could be a high-end, world-class facility with the latest in technology and systems.

Approaches to sustainable design and operations in international settings can benefit from work being done in the United States, but they may also teach us new strategies, as I shared in a recent blog post for Practice Greenhealth titled “Poco a Poco.” We can look to our international partners for their leadership in energy and water conservation, use of safer materials in both building materials and in medical supplies, and their material/waste management.

With the engagement both in the United States and internationally, next steps could include increased communication, information-sharing, and collaboration —including at CleanMed Europe to be held September 26-28, 2012, in Malmo, Sweden.

Health Care Without Harm’s international structure
Health Care Without Harm offices in Asia, Latin America, and Europe (see sidebar) work directly with health professionals, hospitals, health systems, and ministries of health. They also connect to regional partners for projects ranging from medical waste treatment to mercury elimination, climate mitigation, and public policy, to name a few.

Health Care Without Harm Europe, which has members in a number of different countries, is running a regional effort to address the health impacts of climate change and mobilize the health sector to advocate for sound climate policies.

A regional headquarters in Buenos Aires, Argentina, partners with Latin American healthcare and environmental organizations in Argentina, Mexico, Brazil, Costa Rica, and Chile and works with members in several other countries. The dynamic work includes an EPA-funded initiative to substitute mercury-based medical devices with safe, affordable, accurate alternatives in these countries.

A Southeast Asia office in Manila, Philippines, works with health sector partners in the Philippines, Thailand, Indonesia, and Vietnam on sustainable healthcare waste management and mercury substitution.

HCWH’s Global Team, based in San Francisco but spread out around the world, works with partners in countries such as South Africa, Tanzania, Nepal, India, and China. It also manages projects with the World Health Organization, United Nations Development Programme, and a number of global health non-governmental organizations (NGOs).

Around the globe, HCWH shares strategies and resources, helps raise money for efforts, and develops tools for hospitals and health systems to create a broad environmental sustainability and public health agenda.

Medical waste treatment project, Nepal
Ruth Stringer, international science and policy coordinator for HCWH, explains that her organization has been working closely with Health Care Foundation Nepal (HECAF) in Kathmandu. Their flagship project is with the National Hospital, Bir, where HCWH staffers have helped design and set up a waste treatment center and manage the data gathered by the team.

As is common in Nepal, all of the hospital’s waste had been piled in the yard before being collected and taken to the city dump. Rag pickers would search through it looking for recyclables, including syringes, which are often illegally rinsed and repackaged for sale. Now, mercury thermometers have been eliminated, all infectious waste is autoclaved, and over one-half of the waste is being recycled or biodigested.

Biodigesters are common in Nepali farms, but this is this first time that one has been installed in a hospital. The new system is extremely popular, the patient experience is improved, the staff has increased pride in their work, and even the prime minister recognized the work that HECAF and HCWH have done.

More projects in Nepal are under way and in development to create safe and sustainable systems for healthcare facilities across this diverse country.

Stringer says what must be in place to consider undertaking these types of campaigns include a good partner on the ground, long-term funding beyond a simple two-year project, supportive political and policy structures that can benefit from the results, and replicability—is it something that others can use and/or learn from? If those elements are in place, a project has potential to succeed.

Mercury elimination
On the international level, Health Care Without Harm worked in both Argentina and the Philippines piloting mercury alternatives to demonstrate the accuracy and affordability of mercury-free equipment. These pilots led to national phase-out policies in both those countries and a global initiative between HCWH and the World Health Organization.

As a result of these efforts, there are national policies in a growing list of municipalities and countries—Sao Paulo, Brazil; Mexico City, Mexico; Dehli, India; Chile; Mongolia; and pilots in dozens of others around the world—to implement the phase-out of mercury. It is a movement that began with a single thermometer in a single hospital and is leading to global phase-out.

New construction
Health Care without Harm international staff are seeing healthcare facilities around the world designed and built with environmental health criteria in mind and are developing strategies to replicate and scale-up some of the best practices that are emerging. Increasingly sophisticated healthcare facilities are required and constructed in places with virtually no energy or water infrastructure, leading to innovative solutions that can influence more developed regions.

Paul Farmer’s Partners in Health, with MASS Design Group, completed a small hospital in Rwanda that is making a huge impact globally. Large, sophisticated regional hospitals in Latin America (see case study at end of article) are being constructed with solar energy systems and innovative on-site wastewater treatment systems, which can both filter pharmaceuticals and provide recycled water for closed-loop sewage conveyance.

From small clinics in some of the poorest regions to large regional hospitals in the biggest cities, healthcare organizations globally are moving toward sustainable design. Many are returning to natural systems and traditional building methods to enhance resilience and build local and sustainable economies, ideas that can and should resonate in the United States.

“There is no single solution for constructing healthcare globally. Health Care Without Harm is in a unique position to gather the best examples of low-energy, sustainable, culturally responsive building and operational solutions, and bring those lessons to a global audience. It is our responsibility, as designers, to learn from them,” says Robin Guenther, Perkins+Will, co-chair, Health Care Without Harm Energy and Built Environment Program.

Global green and healthy hospitals agenda
Health Care Without Harm has just launched the Global Green and Healthy Hospitals Network, a new coalition of hospitals, health systems, and health organizations dedicated to improving the environmental performance of the healthcare sector globally.

Karliner says, “The launch this year of the Global Green and Healthy Hospitals Network is striking a chord. There is so much good work going on around the world already, and what we are doing is providing a way to join all these efforts together, make them greater than the sum of their parts, and scale it all up globally. That’s exciting.”

To date, organizations representing the interests of more than 3,500 hospitals have joined as founding members. The Global Green and Healthy Hospitals Agenda, which forms the core of the Global Green and Healthy Hospitals Network, parallels the U.S.-based Healthier Hospitals Initiative (HHI), which is in the process of becoming a founding member of the network.

In essence, this effort is a global articulation of HHI’s approach and forms the framework for much of Health Care Without Harm’s work around the world. The Global Green and Healthy Hospitals Network covers the following focus areas:

1. Leadership: Prioritize environmental health.

2. Chemicals: Substitute harmful chemicals with safer alternatives.

3. Waste: Reduce, treat, and safely dispose of healthcare waste.

4. Energy: Implement energy efficiency and clean renewable energy generation.

5. Water: Reduce hospital water consumption and supply potable water.

6. Transportation: Improve transportation strategies for patients and staff.

7. Food: Purchase and serve sustainably grown healthy food.

8. Pharmaceuticals: Safely manage and dispose of pharmaceuticals.

9. Buildings: Support green and healthy hospital design and construction.

10. Purchasing: Buy safer and more sustainable products and materials.

For more information, download the agenda at To learn more about Health Care Without Harm’s international work on climate and health, visit

Health Care Without Harm International Work Group

Josh Karliner, International Coordinator

Ruth Stringer, International Science and Policy Coordinator

Merci Ferrer, Southeast Asia

Veronica  Odriozola, Latin America

Anja Leetz, Europe

Case study: Hospital Universitario San Vincente de Paul, Rionegro, Colombia
This 260-bed, full-service acute care hospital is the first LEED-certified hospital in South America. Designed by Condisegno of Colombia in association with Perkins+Will, the project opened in late 2011, expanding available medical treatment to a large community.

Located on a 26-acre site on the edge of Rionegro, Colombia, this building blends state-of-the-art medical care with leading-edge sustainable building strategies. It was designed not only to meet healthcare needs but also was inspired by the spiritual and resource needs of the community.

The hospital cathedral is one example—it is located on the hospital grounds within walking distance of the main complex. The community will use the on-site cathedral for daily religious service.

With an energy intensity of less than 150 kBTU/sf/yr in the most intensively conditioned spaces, the project blends naturally ventilated and passively conditioned same-handed, single-bed patient units with mechanically conditioned diagnostic and treatment functions, such as ORs and diagnostic imaging. Approximately 80% of the building gross area is naturally ventilated, including patient rooms, labs, administrative areas, and public/family zones.

The building uses ground source heat pump systems for cooling; hot water is produced with rooftop solar thermal panels. It also features rainwater harvesting for irrigation and an innovative on-site wastewater treatment plant that re-circulates water for toilet flushing and other process uses.

It is anticipated that the construction of this hospital will become an important local development catalyst for the community of Rionegro, bringing enhanced residential and commercial development to the local community.