This article is part of our new series on the Future of Healthcare, which examines changes in the medical field.
As climate change evolves from a model of the future to a reality of the present, health systems across the country are facing tough questions. What should doctors do when forest fires, rising floods, or other natural disasters endanger their ability to care for patients? How can these institutions be resilient in the face of these disasters?
For Ramé Hemstreet, these are not abstract questions. Mr. Hemstreet is Vice President of Operations and Chief Sustainable Resources Officer for Kaiser Permanente, the California-based healthcare system. The state is already addressing the effects of climate change: During the Northern California wildfires in 2017 and 2019, Kaiser Permanente had to evacuate more than 100 patients from a Santa Rosa facility and find a way to care for the surrounding communities.
"The climate crisis is a human health crisis and we already live that in California," said Hemstreet.
For the past decade, Mr. Hemstreet and his colleagues at the company have attempted to remove it from fossil fuels in an attempt to largely reduce the company's contribution to climate change. However, it has also become clear that fossil fuel dependency is an obstacle to health care as the effects of climate change are increasingly part of the lived experience of many Americans.
Hospitals and health systems across the country are trying to answer the key question of how to care for patients when climate change threatens their ability to keep hospitals open. Many of the changes to improve resilience are not streamlined, technically advanced responses to crisis. Rather, it is often a question of sensible solutions: moving technical equipment from basements, in which floods could damage them, to higher floors; Arranging patient transfers before disasters; Improving energy efficiency; better air filters; and more backup systems and redundancies, just in case.
Since 2012, Boston Medical Center has reduced its energy use by nearly 40 percent and its greenhouse gas emissions from all energy sources by 90 percent while caring for more patients. Some of these savings can be attributed to a combined heat and power plant for electricity and heat, which works 35 percent more efficiently than the electricity supplier, which uses its energy needs separately. The hospital also bought enough solar power from a solar farm in North Carolina to cover all of its electricity.
BMC, the largest New England safety net hospital serving the uninsured and underinsured community in the Boston area, has expanded its sustainability efforts beyond renewable electricity and heating, including a rooftop garden in the hospital that grows about 6,000 pounds of food annually for its pantry, inpatient meals and a hospital farmers market, and a biodigester that converts food waste into water
Robert Biggio, an engineer who served in the Merchant Navy and is now senior vice president of facilities and support services for the hospital, learned resilience on the high seas. "People can't reach you on a ship in the middle of the sea," he said. "You have no choice as to whether you are resilient."
While it is often argued that sustainability and climate friendliness are too expensive, all system upgrades – including a cogeneration power plant and a chilled water circuit cooling system in place of an expensive new tower – have saved BMC, a non-profit, significant amount of money.
"Waste reduction is more efficient and also improves resilience," said Biggio. "They go hand in hand."
The health sector in the United States is responsible for an enormous amount of waste and a significant amount of greenhouse gas emissions. For every hospital bed, the American healthcare system produces about 30 pounds of waste every day. Overall, it accounts for around 10 percent of national greenhouse gas emissions.
Much of the waste comes from the shift towards single use disposables, apart from personal protective equipment which is single use only. Many hospitals use outside companies to clean and reprocess many of these items. Kaiser Permanente is committed to recycling, reusing or composting 100 percent of its non-hazardous waste by 2025.
In terms of greenhouse gas emissions, hospitals need to have backup power, usually provided by diesel generators. These run on fossil fuels and produce particulate matter known as PM 2.5, which contributes to asthma and other diseases. The air quality in hospitals, which have to test their generators regularly, is often poor.
A recent study found that colored people are more exposed to PM 2.5 than whites from all sources, and black Americans are most affected. As a result, these communities, which often do not have access to health care, are more likely to suffer the health consequences of this exposure. PM 2.5 is also responsible for 85,000 to 200,000 deaths per year in the US (according to the study), and long-term exposure to PM 2.5 correlates with hospitalization for Covid-19.
During firelight and heatwaves, power may go out or utilities may turn off power to avoid sparks or system-wide blackouts. Both mean that hospitals have to run on their generators.
That hospitals are partially responsible for this pollution is an unacceptable irony, said Hemstreet.
Kaiser Permanente has been buying supply-scale renewable energy since 2015 and signed a contract in 2018 to purchase 180 megawatts of wind and solar energy and 110 megawatts of battery storage, which is currently under construction. Since 2010, the company has installed 50 megawatts of solar power in its systems and is installing a 9-megawatt-hour battery on the company's campus in Ontario, California, which can be used to completely disconnect most of the system from the grid.
In New York City, space constraints and less sunshine make ambitious installations difficult, but heatwaves present a similar challenge – the possibility of power outages and rolling outages that turn off air conditioning, with higher temperatures putting some elderly adults and the sick in particular at risk.
Like B.M.C. NYU Langone Health built a CHP power plant for air conditioning systems powered by electricity, heat and steam. It's 50 percent more efficient than electricity, according to Paul Schwabacher, senior vice president of facility management at NYU Langone.
Construction of the cogeneration plant was underway prior to Hurricane Sandy in 2012, which was an eye-opening experience for the hospital system. During the storm, the flood reached the lower floors of the hospital, leaving 15 million gallons of contaminated water. More than 300 patients had to be evacuated from the hospital, including newborns in the intensive care unit who were carried down many flights of stairs by doctors and nurses.
The hospital was closed for two months after the storm. During that time, about 100 electricians were working on repairs, Schwabacher said. "We made lemonade," he said, adding that they did repairs that would have been much more difficult with the hospital open, like cleaning all of the air ducts. They also rebuilt and expanded the emergency room, which was flooded during the storm.
Since then, the hospital has built a new building and restored older ones.
However, NYU Langone's greatest effort towards resilience is new flood barriers around campus designed to protect against a storm surge seven feet above the level caused by Hurricane Sandy. The campus also has a 12 foot steel storm barrier on the loading ramp that can be raised hydraulically or manually. Valves on drains and sewers to prevent backflows off-road from being flooded; and steel gates and doors to contain the flood at critical points throughout the facility.
However, building walls doesn't keep the effects of climate change at bay. This will be due to the reduction in greenhouse gas emissions across society, Schwabacher said.
"We are very, very confident that we will be protected, but we know that the next disaster will be different from the last."