The difficult thing now is there’s no [longer any] low-hanging fruit.
– Roger Elliott1, St. Joseph’s Hospital, Chippewa Falls, Wis. on efforts to reduce hospital energy costs.[A]ny field … should be judged by the degree to which it understands, anticipates, and takes action in regard to changes in society.
– Bernard Sarason2. The Making of an American Psychologist.
With few exceptions3, medicine is not preparing for global warming and the approaching zeniths in the extraction of oil,4 natural gas5 and coal6 from the earth (often referred to as peak oil). The implications of these intertwined socioeconomic7 and geopolitical8 perils are stupefying, with global warming calling for radical reductions in the use of fossil fuels to reduce carbon emissions9 – most estimates10 calculate 80%11 or more12 by 2050.
Throughout society, the meaning and scale of peak oil is misconstrued as a temporary concern over “energy prices” or “addiction” to foreign oil. Here lies our predicament: not only are these health dangers, they could undermine our ability to sustain health care systems.
We must explain the dangers of global warming and peak oil to medicine. Recently the CDC13 listed the health hazards created by global warming. We will see an up-tick in numbers of heat stroke, frostbite and hypothermia. This particularly will distress the growing elderly population of baby boomers and other physically weakened or susceptible cohorts.
In general, warmer temperatures and greater moisture will favor extensions of the geographical range and season for vector organisms such as insects, rodents, and water-borne snails. This in turn leads to an expansion of the zone of potential transmission for many vector-borne diseases, among them malaria, dengue fever, yellow fever, Schistosomiasis, and some forms of viral encephalitis. Extreme weather events such as heavy rainfall or droughts often trigger disease outbreaks, especially in economically poorer regions where treatment and prevention measures may be inadequate.
Peak oil complements and exacerbates this list of threats14 and makes dealing with these stressors all the more difficult because it introduces resource scarcity and the possibility of transportation and other social system (electricity, communications, manufacturing, water and sewer) breakdowns or interruptions. Specific to the medical care system, electronic medical records as well as radiology, laboratory and a host of other medical services, which depend upon an uninterrupted power source and low energy costs, will be at risk.
Notably, our dependence on oil is pervasive; petroleum15 “is the world’s most important manufacturing commodity, paramount to most industries, from Pharmaceuticals to Civil Construction, from Electronics to Clothing;” it is the keystone of technologically modern society and, by extension, contemporary medicine.
The hospital is medicine’s largest energy sink, petroleum by-product consumer, and pollution and greenhouse gas producer.
To detail what hospital administrators are thinking about energy and climate change we contacted some speakers at a recent conference16 on the future of hospital care. We queried an economist, did “your presentation included discussion of energy and global warming as factors that will affect hospital costs?” He replied, “It did not cover those topics.” Of twenty-one sessions held at this conference one addressed “green thinking.” This speaker informs us:
I included information …about how climate change will impact disease patterns and therefore seriously strain the health care sector. I also discussed how rising energy costs are already hurting the bottom line for hospitals.
This is consistent with our view that overall health care executives have limited17 cognizance of global warming and even less of peak oil. Importantly, global warming is viewed as an opportunity to “go green” and demonstrate corporate social responsibility. The cost of energy -not peak oil, which is a large bitter pill- is a relatively low-level agenda item which is not integrated into long-range planning.
In the context of planning for the future, any business professor will tell you that executives are expected to anticipate social change. This is evident but it is rarely done because upper echelon administrators have an embarrassing conflict. On the one hand innovation, which requires flexibility, a good deal of reading, speculative judgment and risk taking, is idealized as the path to organizational success. On the other hand, the mandate facing most leaders is to produce short-term financial gain; this requires risk avoidance and conservatism, typically while paying lip-service to creativity, strategic thinking and innovation.
When all is said and done, the diffusion of innovative18 ideas initially is undertaken by about 2% of leaders in any given field. And compounding our case is the issue of the misdiagnosis of climate change and peak oil. Therefore, it is not surprising that this green conference speaker took the go-slow approach to energy and climate change just to get executives thinking about them.
A given in hospital operations is unlimited inputs of energy and resources; this results in waste in the name of hygiene, insurance and regulatory considerations, and “the best” care. However, the fact that worldwide energy demand19 is accelerating and on its current pace “will double by the year 2050” will soon burst upon medicine.
Turning specifically to energy usage, the Health Care Energy Project20 tells us that hospitals “use twice as much energy per square foot as office buildings…” In addition, hospitals consume large quantities of petroleum-based, processed, and transported products ranging from aspirin to jells and lubricants to plastic dinnerware and gloves to pharmaceuticals, syringes, IV and dialysis tubing, to name but a few. And most of these items are produced for one-time, non-recyclable21 use. Petroleum derivatives are also found in many computer parts, electronic equipment, furniture, and so on.
As noted, hospital administrators are somewhat aware22 of and responding23 to the rise in energy24 costs for heating, cooling, and lighting, primarily by locating the problem in the domain of facilities management. Therefore, controlling energy costs in a hospital largely is confined25 to electricity and natural gas bills.
As the costs of oil and natural gas have risen in recent years facilities managers are trying to make their buildings more energy-efficient, hoping that such savings will offset price rises. Yet, a 2006 survey of hospitals26 found:
More than 90% … reported higher energy costs over the previous year , and more than half cited increases in double-digit percentages.
The facilities management response is to replace, retrofit or upgrade inefficient infrastructure – boilers, lighting fixtures, building insulation, windows, etc. and in general to “modernize” facilities – in accordance with the Energy Star Program.27 Some of the newest “green” hospital building approaches promise to reduce energy consumption by as much as 60%28 below code mandates; this is encouraging, but only a beginning. However, new construction is done only when it makes “economic sense”, leaving many older hospitals and kindred structures too obsolete to “economically” justify retrofitting or demolishing and replacement – again energy is presumed to be plentiful and cheaper than upgrading – and no consideration whatsoever is given to its scarcity. Moreover, the costs for new hospital construction are soaring,29 another factor traceable to increasingly expensive fossil fuels.
Dave Carpenter,30 summarizing a 2006 energy survey of hospitals, comments on the constraints facilities managers face:
Money-related reasons were among those given most often in response to a … question asking why recommended energy-saving measures hadn’t been implemented, including 37 percent who reported a lack of funds. Additionally, 31 percent cited other priorities, 26 percent said the payback period was judged to be too long, 23 percent said operations and maintenance budgets were underfunded and 16 percent cited lack of senior management commitment and support.
Given these constraints:
Facilities managers have little choice but to stay on the lookout for energy savings wherever they can be found. [One manager] says “it’s going to get worse before it gets better…”
We would argue that it – energy costs – will not get better. The entire health care industry will be forced to accommodate to dwindling fossil resources while simultaneously begin facing the consequences of global warming.
This is stark because the health care system – already stressed in other ways—could begin to fail and even collapse for want of energy coupled to a concomitant surge in patients.
Finally, a word is needed on the third so-called “fall-back” fossil fuel we have barely mentioned, coal, since many energy experts offer it as a painless fix for peak oil. While the high levels of greenhouse emissions of coal are well known, what is less appreciated is that carbon sequestration – to control greenhouse emissions – is expensive and stills an unproven technology.
Second, recent reviews31 have concluded there are substantially less coal reserves than the commonly accepted estimates of 200 to 300 years supply, perhaps as little as a few decades of recoverable coal remains, much of it low-grade and high in pollutants.
The dimensions of what we face are uncertain, but the major question undeniably is How will hospitals change given the ecological (global warming as well as multiple sources of pollution and resource scarcities) and geological (twilight of fossil fuels) state of affairs the world now faces?
At the macroeconomic level, recession32 or economic depression appear likely while simultaneously generating enormous demand for hospital treatment many people will be unable to afford. Add to this the likelihood that basic medical resources periodically will become scarce.
The fundamental choice coming is between attempting to perpetuate the current version of the market economy health care system and developing an ecological perspective within which to operate a unified and lower energy consuming public health and health care system.
At the existential level, the guiding questions to pose for hospital executives are uncomplicated: How are you going to heat these hospitals? Run the electronic equipment that has replaced so much experiential and tactile medical knowledge? What can you do about supply interruptions? Will you face the issues of rationing and prioritizing medical procedures?
Based on this, we can suggest a few guiding principles: Community focus and attention to preventive and public health measures are indispensable. Techniques for guaranteeing health services while using fewer resources are imperative, with a transition to alternative models of comprehensive health care – rooted in preventive medicine and public health – delivery that are lower energy-intensive than those in place today.
Our personal view is that the classical ideal of medicine is to improve health and well-being of all, regardless of ability to pay, and to reduce suffering while first doing no harm. Through our unrestricted use of energy and resources in the health care industry, as well as our production of greenhouse gases, we are actually contributing to the ill-health of our planet and ensuring certain future suffering of the Earth’s inhabitants.
The above focus is on the internal operations of medical care. Externally, at the societal level, medicine has a critical role – for its survival – to play in the nation. To do this the medical industry will have to suspend much of its competitive politics and establish cooperative relationships among its members.
How to do this? The meta-theme of medicine’s posture toward society should be to develop a gospel of conservation and sustainability; in economic terms: to advocate throughout society lower demand on energy and other resources. This will require a consortium of medical leadership—probably that 2% to begin with—to promote social change beyond the confines of medicine.
We refer to such thing as endorsing forms of mass transportation, eating local, seasonal foods, and addressing the oil we eat33 dilemma, calling attention to the fact that Americans consume twice as much oil per capita as do Europeans, among others. There is also a societal role for medicine to play on the supply side, especially in terms of sorting through all the hype and false hope about various energy alternatives.
If medicine would regard peak oil as likely to occur within 12 years, in line with most predictions, then it will choose strategies which automatically address climate change as well. If the health care industry fails to lead, it will suffer the draconian consequences of having ignored the driving forces of the opening decades of the 21st century.