It’s noisy in the building systems control room at Boston Medical Center, the largest safety-net hospital and busiest emergency services operation in New England. Computers chime alerts, phones ring, and walkie-talkies crackle with updates about the systems that keep the air clean, the temperature consistent, and other functions needed for the well-being of thousands of patients and roughly 6,000 clinicians and other staff who work there. Planning for a large surge in COVID-19 cases adds an electric sense of urgency in the control room — and throughout the hospital.
In addition to helping ready facilities for the outbreak, the dispatchers are on a mission to eliminate energy waste in the massive buildings, some of which are over a century old. Thousands of sensors spread across the 1.9 million square feet of building space on the hospital’s South End campus signal the dispatchers if a steam valve registers hotter than it should, a cold stairwell threatens to burst a water pipe, or if something else requires immediate repair or maintenance by a technician. If someone opens the door to the rooftop farm, where the hospital grows thousands of pounds of produce annually to serve patients through its kitchen and food pantry, they’ll know.
Bob Biggio, the buoyant former merchant marine who oversees facilities and support services for BMC, likens a hospital to an oceangoing ship: Both need to be self-sufficient and resilient in extreme weather and unexpected disasters. Years before the coronavirus pandemic was upending life around the world, Biggio was preparing for crises by changing the sprawling campus to work more efficiently. The efforts are paying off now as the hospital works to keep patients and employees safe by erecting tents outside facilities to screen for possible cases, conserving protective equipment, and reducing clinical traffic through telehealth, among other measures. Unlike a hurricane or other natural disaster that clinicians have to react to, BMC is dealing with the virus “much more proactively,” Biggio says. “It’s all hands on deck.”
Biggio’s no tree hugger; he’s been driving the bulk of the emissions reduction and other sustainability efforts he initiated as part of a campus consolidation effort about a decade ago because they make financial sense, especially at a hospital like this one, where more than half of the patients are from underserved populations. Along with a deal to offset its fossil fuel use by buying solar power from North Carolina, these moves have made BMC about 96 percent carbon neutral for energy, and it’s on track to become New England’s first carbon-neutral hospital by year-end, Biggio says. He’s quick to acknowledge that BMC is still using fossil fuels but offsets them with renewable energy credits.
Every day, in the course of providing medical care, the global health care industry is also making people sick. That’s because it’s one of the biggest polluters in the world. Compared with many other industries, it emits a disproportionate amount of greenhouse gases and other harmful pollutants into the air. Thousands of hospitals around the United States rely on fossil fuels night and day to power equipment and to heat, cool, and light buildings, contributing to the pollution and global warming that, in turn, can cause or aggravate maladies. For years, medical waste incinerators were considered the top source of dioxins — the harmful result of burning chlorinated IV bags and other materials that once conveyed lifesaving treatments to patients. (Advocacy efforts and US Environmental Protection Agency regulations shrank the number of such incinerators from 2,400 in 1997 to around 30 as of 2013, which is the last time the agency says it updated its inventory.)
Exposure to dirty air, carcinogens produced by burning waste, and neurotoxins such as mercury has caused significant harm to people, including birth defects, brain damage, and learning disabilities. Given the health care sector’s enormous impact, its healing mission, and its Hippocratic oath, hospitals “have an extra responsibility compared to other industries to kick their addiction to fossil fuels,” says Gary Cohen, who cofounded the nonprofit advocacy group Health Care Without Harm in 1996 and was awarded a MacArthur “genius grant” in 2015.
“If the global health care sector were a country, it would be the fifth-largest greenhouse gas emitter on the planet,” estimates a September report from Health Care Without Harm. In the United States, the industry accounts for 10 percent of greenhouse gas emissions and 9 percent of other types of harmful air pollutants, according to research cited by a Journal of the American Medical Association commentary published in August. “Ironically, modern health care is a major contributor to pollution that adversely affects human health,” it warned. As the health implications of climate change have become clearer, prompting clinicians to push the entities they work for to green their operations, BMC has emerged as a national leader.
Kate Walsh, BMC’s president and chief executive, cochairs a working group of 20 health care entities tackling climate change that is part of the Boston Green Ribbon Commission. Besides BMC, the group includes Brigham and Women’s Hospital and Massachusetts General Hospital, which are part of the Partners HealthCare system, and other heavy hitters such as Beth Israel Deaconess Medical Center, Boston Children’s Hospital, Dana-Farber Cancer Institute, and Tufts Medical Center. Collectively, they’ve cut their greenhouse gas emissions by one-third since 2011, the group estimates, exceeding city and state targets. Boston, “seen all over the world as a medical mecca,” is likely the only city in the United States that collects such data from its health care sector, says Paul Lipke, a senior adviser to Health Care Without Harm, which coordinates the effort. “It’s quite unusual even to know what an entire metro health sector’s greenhouse gas progress has been.”
Clinicians recognize the most vulnerable populations are the least equipped to cope with the illnesses, injuries, and diseases caused or exacerbated by climate change, Lipke says. “The urgency comes from what we see in our emergency rooms every time there’s a heat wave or extreme weather.”
For Lilliana Arteaga, 46, who oversees a Boston public schools playgroup program for toddlers and their parents, the health effects of fossil fuels and climate change are personal. She and two of her three children suffer from asthma that gets worse when the air quality is bad or the temperature swings significantly. When her asthma kicks in, “It feels like I have ropes tying my lungs and I cannot stretch them to catch the air,” Arteaga says.
Her youngest son, Damyen, used an inhaler three times a day for a year until his doctors at Massachusetts General Hospital recommended he start taking a chewable pill daily and stay indoors as much as possible. Damyen’s medication doesn’t stop the 7-year-old from “coughing and coughing until he feels like he’s going to pass out” from bus exhaust and other triggers, Arteaga says.
In January, doctors found a third tumor in Arteaga’s right lung. Like the colon cancer for which she was diagnosed five years ago and successfully treated, these tumors are likely linked to environmental, not genetic, factors, her doctors say.
Arteaga joined the East Boston chapter of the advocacy group Mothers Out Front in November to connect with others affected by the climate crisis and to help spread the word about the health impacts of burning fossil fuels. “When it touches you is when you really get into learning more about it,” she says. “Whenever their kids are coughing too much, people come and ask questions. They want to know more about the environmental cancer and asthma.”
In mid-January, the Boston City Council unanimously passed a resolution, offered by Councilor Matt O’Malley, “affirming that the climate crisis is a public health emergency,” echoing the conclusion reached by more than 100 health groups, including the American Medical Association and the American Academy of Pediatrics.
Six stories above Massachusetts Avenue, on the rooftop of BMC’s massive Yawkey Ambulatory Care Center, nine air handling units are pumping fresh air into the building 24-seven. The air needs to be filtered, changed regularly, and warmed or cooled depending on the department — the babies in the neonatal unit need warmer and moister air than a standard patient room, for instance. Heating and cooling systems are hospitals’ biggest “energy hogs,” accounting for far more total consumption than lights or medical equipment, says Jack Nelson, managing partner of the Boston office of engineering firm CMTA. Biggio credits Nelson with helping mastermind BMC’s efficiency overhaul. Making these systems less hoggish involved modifying and increasing the size of the ductwork throughout the building to reduce the engine power needed to push the air into the building. The changes save BMC around $1.3 million annually on energy that Yawkey used to require, Nelson says.
On the same rooftop, a cogeneration plant a bit bigger than a tractor-trailer hums, burning natural gas to generate electricity. Most of the plant’s waste heat, rather than escaping into the crisp blue sky, is being used to supplement the building’s heating. If a storm causes a blackout in Boston, the hospital can operate for months as long as its natural gas supply is flowing. Biggio traces his experiences on ships operating on the high seas and his visits to hospitals recovering in the aftermath of Hurricane Katrina and Superstorm Sandy to the investment in the plant, which was installed in 2017.
About 10 years ago, BMC’s Walsh bet on Biggio’s plan to consolidate the hospital’s sprawling campus, reduce its energy use, and make it more resilient to severe weather. At the time, BMC — the result of a hard-fought merger of two hospitals, orchestrated by Mayor Thomas Menino in 1996 — was facing receivership. “We were, frankly, looking for savings,” Walsh says.
The consolidation, renovations, and efficiency improvements cost about $400 million. BMC’s footprint shrank by 400,000 square feet, but its patient volume is up 20 percent and its energy and operations savings top $30 million annually. To pay for the projects, BMC issued green bond offerings totaling over $200 million, sold real estate, and got grants. The bonds were three to four times oversubscribed, suggesting their environmental nature increased investors’ appetite and likely shifted the interest rates in BMC’s favor, Biggio says.
Dr. Jennifer Tseng, BMC’s surgeon-in-chief and chair of the surgery department at the Boston University School of Medicine, recalls meeting Biggio when she was being recruited four years ago and being struck by the hospital’s quiet commitment to shrink its environmental footprint. Today, sustainability is a concern for many of the medical students, residents, and faculty Tseng recruits. It may not be at the top of their list, “but it matters,” she says. “Residents talk about this stuff all the time.” Tseng, a cancer surgeon, has also noticed patients seeking hospitals trying to be green. “It matters to them that it matters to the hospital.”
BMC’s sustainability commitment attracts climate-conscious clinicians and visitors seeking to green their facilities. Most come from around the United States — even as far away as Alaska. But, last summer, Emmanuel Kamanzi traveled all the way from Rwanda to tour BMC and other area institutions. After living as refugees in Uganda, Kamanzi’s family had relocated to their home country of Rwanda shortly after it was ravaged by the 1994 genocide. He eventually made his way to Boston, where he got a job at nonprofit Partners in Health, and completed courses at Harvard School of Public Health and Harvard Business School. In 2017, wanting to give back, he moved his family to Rwanda and became director of infrastructure for the University of Global Health Equity, which is owned and operated by Partners in Health.
Kamanzi appreciates Biggio’s ability to wrangle grants and squeeze savings from energy efficiency. And, like Biggio, he wants to make the community his facility serves more resilient in the face of extreme weather. “You cannot talk about climate change and exclude health,” he says. His goal is to install a centralized solar power plant on campus to take it off-grid within five to 10 years. Depending on the feasibility study underway, it could also supply power to the surrounding community, including a nearby hospital where University of Global Health Equity students will train.
Gundersen Health System, a nonprofit hospital network in the Midwest, became the first in the country to attain energy independence in 2014 by offsetting its fossil fuel use with renewable energy produced on-site or locally. As the La Crosse, Wisconsin-headquartered organization has grown to more than 100 facilities totaling about 3 million square feet in three states, it has remained energy independent. Reducing reliance on burning fossil fuels “fits our mission to improve the health and well-being of communities we serve,” says Alan Eber, Gundersen’s director of facility operations. “Not only are we reducing our harmful emissions, we’re also reducing the cost of care.”
Interest from health care institutions and others has grown so much that Gundersen offers energy consulting through a separate business it established in 2010. Clients can get energy checkups, help with assessing technologies, and advice on overcoming permitting challenges, among other services. Some talk about wanting to install solar panels, windmills, and other technologies, Eber says. “We say, ‘Stop. Before you do any of that, take care of your house as it is right now.’ ” Like BMC, Gundersen regularly monitors its buildings’ energy consumption, which it reduced by 25 percent in three years by making tweaks.
It’s still relatively early days for substantive change at many hospitals, says Cassandra Thiel, an assistant professor at New York University who researches sustainability in health care systems and coauthored the JAMA commentary. “There are not enough hospitals taking broad enough action on this,” she says, but she’s optimistic more hospitals will come around as pressure mounts. Clinicians are increasingly aware of patients suffering from conditions connected to air pollution and climate change, including pulmonary and cardiac problems and infectious diseases spread by mosquitoes and ticks, Thiel says. Severe weather, food and water shortages, and forced migration take a toll on mental health as well. “It gets pretty dark pretty quickly,” she says.
Health Care Without Harm’s Cohen describes the health worker-driven movement as being at the “top of the third inning.” Twenty health care systems representing 500 of the roughly 5,500 hospitals in the country have joined the group’s climate council. Sustainability data collected from 327 US hospitals last year indicated their sustainability initiatives had saved $68 million and avoided putting 183,000 metric tons of greenhouse gas emissions (roughly equivalent to the annual energy use of over 21,000 homes) into the air in 2018. Half said they’d provided education about the connection between the climate and health to their staff, patients, or community members.
For a hospital — or any entity — wanting to use energy more efficiently, making physical improvements isn’t enough, says Biggio. Buildings need people who can run and maintain increasingly sophisticated systems, or the buildings won’t live up to their energy-efficiency potential. Instead, they’ll needlessly pollute and burn money, he says. But there’s a shortage of technicians who understand HVAC, electrical, and programming basics, and want to commit to a career operating big buildings. As demand accelerates, some 115,000 smart building jobs across the United States could go unfilled by 2022 because of the lack of trained workers, warns Siemens, a German conglomerate that makes building control systems and other technologies.
Training programs are critical, says architect Frank Mruk, executive director of the Center for Smart Building Technology at Roxbury Community College. Just as cars have become increasingly computerized, forcing mechanics to acquire new skills, buildings have, too, and managing them “is a new profession,” he says. The center, which launched in April in a former day-care center, aims to fill what Mruk calls the “huge void” in the field by offering a variety of certification programs in so-called smart building technology. Students can get training in wiring circuits and programming to design, build, install, and operate systems that use sensors, thermostats, and other equipment. More offerings are in the works, including a two-year associate’s degree, Mruk says. Technicians’ salaries start around $50,000, according to the center.
Boston institutions will need thousands of these technicians to meet the city’s goal of becoming carbon neutral by 2050, Mruk estimates. He’s been meeting with Biggio and others scrambling to prime their technician pipelines. “Scientists are saying if we don’t make a significant reduction in carbon emissions within 10 years, it’s almost like game over,” Mruk says. Hospitals are the hardest types of buildings to make carbon neutral, he adds. “If you can figure out how to do this for hospitals, everything else is easy.”
In the meantime, as the connections between pollution, climate, and health become evident, the health care industry is recognizing it needs to reduce its environmental impact to heal the individuals and communities it serves, says Cohen. “Climate is the elephant in the waiting room.”
Nick Leiber is a journalist in New York. He has written for Bloomberg Businessweek, The New York Times, Bloomberg News, and others. Send comments to firstname.lastname@example.org.