Health Care Without Harm: Nurses Take Action

Richard S. Ferri, PhD, ANP, ACRN, FAAN


May 01, 2007

Editor's Note

Every nurse can identify with the amount of medical waste that is generated in the clinical practice setting. We have all seen, and contributed to, mounds of used and contaminated dressings, catheters, and more. However, what may not be in the forefront is the impact medical waste has on the environment, our own health, and the well-being of the patients and communities we care for. Fortunately, this is exactly what is on Anna Gilmore Hall's mind constantly. Anna's passion about health and the environment are part of her mission as the executive director of Health Care Without Harm (HCWH) Anna has always been interested in environmental issues and now contributes to this effort worldwide. Here is Ann's story.

Medscape: Medical waste is hardly a new issue. However, my sense is that the problem has become more complex and problematic. Do you agree? Would you provide the reader with the some of the major issues HCWH is dealing with today and why it should matter to them?

Anna Gilmore Hall: Hospitals alone generate more than 6600 tons of waste per day or over 2 million tons of waste each year. In the past, many hospitals simply dumped all waste streams simultaneously, from reception-area trash to operating-room waste, and burned them together in incinerators. Now we know that incineration is a leading source of highly toxic dioxin, mercury, lead, and other dangerous air pollutants. Much of what is burned in incinerators are wastes created by physicians and nurses providing healthcare services. Through the very practice of saving lives, many clinicians are unwittingly harming the environment, and in turn the health of the communities in which they live. The link between medical waste and pollution is clear. The Environmental Protection Agency has acknowledged this link between waste and the environment.

'Clean waste' is still waste.

HCWH works to eliminate the dangerous practice of incineration, as well as to minimize the amount and toxicity of all waste generated by the healthcare sector. To fulfill the medical ethic of 'first do no harm,' the healthcare industry has a responsibility to manage waste in ways that protect the public's health and the environment.

The American Public Health Association has taken on 'iatrogenic pollution' or pollution generated from healthcare delivery as an ethical issue. Many nursing organizations like the International Council of Nurses and the American Nurses Association have passed resolutions calling for action by nurses to reduce this threat to themselves and to patients.

Nurses are taking the lead in educating their colleagues and others in the healthcare industry about toxic agents such as dioxin and urging them to take personal responsibility for reducing the amount of medical waste they produce.

The types of waste that healthcare facilities generate vary, which can make their management challenging. Nurses pay a key role in reducing pollution by practicing waste segregation in their workplaces. The first step is waste minimization and segregation. The infectious waste stream must then be treated to prevent the spread of disease. Our group's review of medical waste treatment technologies found that cost-effective alternative technologies are available that are safer and cleaner than incineration, and just as effective at rendering medical waste harmless.

Medscape: Please give provide us with some insight into your professional career and interest in medical pollution. What is the history of HCWH as an organization? What events and experiences led you to get involved? Are you the director for the HCWH global network or just the United States?

Anna Gilmore Hall: Our campaign began after the United States Environmental Protection Agency (EPA) identified medical waste incinerators as the leading source of dioxin, one of the most potent carcinogens known. In response to this serious problem, a group of 28 organizations came together to form HCWH in Bolinas, California in 1996. Since then, the campaign has grown into a broad-based international coalition. By late 2005, more than 440 organizations in 52 countries have joined HCWH. With offices in Washington DC, Prague, Buenos Aires, and Manila, we are working in partnership with governments, non-governmental organizations, and healthcare institutions around the world.

Our partnerships have also created the capacity to transform healthcare practices on a global scale. For instance, we are working in collaboration with the United Nations Development Programme and the World Health Organization to develop a special project involving 7 countries as part of the Global Environment Facility project to demonstrate sustainable healthcare waste management in Argentina, Latvia, Lebanon, India, the Philippines, Senegal, and Vietnam.

In just 1 decade, our campaign has had a significant impact on major health systems, healthcare workers, medical device manufacturers, group purchasing organizations, and government regulators. Our successes include:

  • Virtually eliminating the market for mercury-based medical equipment in the United States, and generating demand for safe alternatives;

  • Closing thousands of medical waste incinerators and promoting safer technologies and waste management practices in the United States and around the world;

  • Creating new markets for safe and healthy products by leveraging the purchasing power of the healthcare industry;

  • Initiating a Green Building program specifically geared to hospitals; and

  • Developing a Healthy Food project that is changing the way hospitals purchase food to support sustainable agricultural practices.

In the United States, HCWH has created Hospitals for a Healthy Environment (H2E) in partnership with the EPA, the American Hospital Association, and the American Nurses Association. More than 2000 US hospitals have joined this program to implement a shared agenda to reduce toxins and protect the environment.

I joined HCWH as Executive Director in September of 2004 and I oversee HCWH initiatives worldwide. However, we are very fortunate to also have regional executive directors who manage the day-today operations in each of our regions. Previously I had been on staff at the American Nurses Association as the director of the Center for Occupational and Environmental Health and was involved in the nurses work group of HCWH. The campaign is very unique because rather than developing a large staff structure we do most of our work through work groups of committed individuals and organizations who have the same concerns about health as we do.

Anna Gilmore Hall, RN, Executive Director, HCWH.

As a nurse, it is easy for me to understand the link between healthy people and a healthy environment. You can't raise healthy children in a sick environment. You can't be a healthy employee in an environment that routinely exposes you to toxic chemicals. As a nurse who has always wanted to encourage people to be as healthy as possible, I think it is part of my role as a nurse to make the healthcare industry as healthy as possible.

Medscape: What can the practicing/clinical nurse do in his/her institution to bring about change and awareness?

Anna Gilmore Hall: There are many things that nurses can do in their facilities.

When faced with increasing work loads, nurses may not want to add these concerns to their already overflowing plate, but that is not a really an option anymore. The healthcare industry shouldn't be on the list of the major contributors to toxic pollution, and nurses need to support that.

Nurses can help their facilities understand that by reducing the volume and toxicity of waste in their facilities they can also generate savings. Because red bag waste is 5 to 10 times more expensive to dispose of than regular waste, segregation programs can save hospitals thousands of dollars each year.

Here are some steps nurses can take:

  1. Establish a 'Green Team'-- convene a task force of administrators, nurses, housekeepers, and others who are responsible for waste handling. Add directors of purchasing and environmental services and someone from the product selection/safety team. This group can then determine strategies for courses of action for the facility from input from all sectors.

  2. Conduct a waste audit -- tools and resources are available from HCWH and H2E Waste segregation. Use the results of the waste audit to identify wasteful practices and design a waste management strategy that incorporates waste reduction, reuse, and recycling measures.

  3. Educate nurses and others the proper way to segregate waste.

  4. Recycle -- don't throw out what you can recycle safely.

  5. Purchasing practices are often where nurses can make a huge difference. Get involved in the process of acquiring products used in healthcare. Develop environmental criteria for products being purchased. Evaluate the type of packaging that products come in. Work with your risk manager to choose products that don't have a negative impact on worker or patient health and safety. Implement a purchasing program that favors products made of recycled paper that has not been bleached with chlorine. Communicate with suppliers about the need for recyclable or reusable packing materials.

  6. Find out how your hospital is handling its waste. Seek companies that offer alternatives to incineration whenever possible and appropriate. Specify autoclaving or an alternative technology.

Medscape: How can RNs get involved with HCWH? Do you have a membership base?

Anna Gilmore Hall: Membership in HCWH is based on an organizational commitment to the mission and goals of the campaign, and a desire to participate fully in helping to achieve them. Groups that join the campaign do not contribute dues. HCWH does not accept financial support from manufacturers or endorse specific products. Our work is totally supported by funding from foundations throughout the world that share of vision in healthcare and environmental issues.

Organizations become members of the coalition by:

  • Having a thorough discussion within their membership to make certain that they support the mission and goals of HCWH and want to actively participate in accomplishing them;

  • Getting approval from their board of directors or other governing body of the organization; and

  • Sending a letter, on the organization's letterhead/stationery, that states the group's support for HCWH, its desire to participate fully in the work of the campaign, and provides contact information for a designed main contact person with the organization.

Nurses are the key activists in this campaign. As frontline healthcare workers, nurses have a unique role as champions within healthcare facilities, creating positive environmental change from the inside. The HCWH Nurses Workgroup represents a community of nurses who are dedicated to implementing environmentally responsible practices in their hospitals, and who have developed a Nurses Welcome Kit that is available at our Web site.

In addition, there is a special nurses section on the Web site with many tools and resources available. One of the newest is the Luminary Project: Nurses Lighting the Way to Environmental Health . This is an effort to capture the illuminating stories of nurses' activities to improve human health by improving the health of the environment. The Luminary Project, with financial support from the Beldon Fund, is the collaboration of the Nurses Workgroup of Health Care Without Harm, and the nurses and nursing organizations who are the Guiding Lights and Beacons for this Project. The shining stories on this Web site show how nurses are creatively and strategically addressing environmental problems and illuminating the way toward safe hospitals; communities with clean air, land, and water; and children born without toxic chemicals in their bodies.

HCWH's work affects the health of every person in every community. All of us -- nurses, physicians, patients, families, and community members -- have a role to play in transforming the healthcare industry so it is no longer a source of harm. By choosing to use safe, sustainable products and practices, the healthcare professionals can reduce disease and be a catalyst for healing, not only in healthcare settings, but in society at large.

To learn how nurses from around the world have taken on the issue medical waste and protection of the environment, read their stories at


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