ERI Home IRR Home Last updated 3/27/03
A hospital combines the environmental impact of a full-service hotel and restaurant complex, a paper-intensive service industry, a warehouse and dispensary dealing in particularly potent and toxic reagents, a meat processing operation (smallish-scale and highly specialized, to be sure), and a waste treatment facility dealing in particularly toxic precursor materials and infectious agents.
This document will focus on those impacts and risks that are specific to the health care sector. Not surprisingly, the root cause of many of the risks is the infectious nature of many types of health care waste, sometimes exacerbated by the measures taken to deal with them. There also appears to be a significant level of public scrutiny directed toward the use of hazardous materials in hospitals and health care facilities. It is unclear why the health care sector should be held to higher standards than manufacturing sectors in this regard. Perhaps the fact that members of the general public are much more likely to pass through hospital wards than shop floors increases the perceived risk level. In any case, hospitals seem to be under more direct pressure by interest groups than most manufacturing sectors to find substitute materials for some specific, high profile toxics.
Environmental impacts and risks
Effects of existing and future regulations on impacts
This sector falls under NAICS code 62, Health care and social assistance. At the three digit level, three categories are relevant:
Code 621, the "ambulatory" category, as the name implies, includes service facilities for patients that are generally all capable walking in and out without a lot of assistance. It includes doctors' and dentists' offices covering a wide range of specialties in addition to general practice, plus outpatient and dialysis clinics, and the like. It also includes medical laboratories and blood banks, presumably the immediate supply chain for the ambulatory service providers. (It also includes ambulance services, in seeming contradiction to the name.) The 1997 Economic Census lists 455,381 establishments in this category.
Code 622, hospitals, in addition to general hospitals, includes psychiatric, substance abuse, and other specialty hospitals. There were 6,685 such establishments counted in the 1997 Economic Census. Of these, 1,345 were taxable institutions, and 5,340 were tax exempt.
Code 623 includes nursing homes, homes for the elderly, and residential mental health and substance abuse facilities. The 1997 Economic Census lists 57,359 establishments of this type.
The corresponding SIC categories are generally of the form 80xx. The SIC breakdown does not exactly track the three digit NAICS level, but some generalizations may be made. The three digit SIC level 806x covering various types of hospital corresponds generally to the NAICS 622 level, and the three digit SIC 805x level covering nursing facilities corresponds to the NAICS 623 level. The 621 NAICS level includes the categories from the three digit subsets of SIC 80xx other than 805x and 806x. The Census Department's "bridge" web page comparing the NAIC and SIC systems provides details.
A web page provided by the American Hospital Association divides hospitals into "registered hospitals" and "community hospitals", the former being larger, general purpose institutions, and the latter being smaller or special purpose facilities. Examples of the latter include obstetrics and gynecology, eye, ear, nose, and throat, rehabilitation, and orthopedic clinics. According to this source, there were 5,810 registered hospitals and 4,915 community hospitals in the United States in 2000. There were also 245 federal government hospitals, 631 nonfederal long term care hospitals, and 19 hospitals associated with institutions such as prisons and university infirmaries. These numbers do not correspond to the Economic Census numbers in any obvious fashion, although they are of the same order of magnitude. This may indicate a general ambiguity of definition that may show up generally in statistical summaries, or it may simply be an artifact of which categories meet AHA's particular definition of "hospital".
A links page provided by AHA lists literally hundreds of health care associations in every imaginable specialty and concern.
Air emissions data for certain key criteria pollutants (ozone precursors) are available from the National Emission Trends (NET) database (1999), and hazardous air pollutant emissions data are available from the National Toxics Inventory (NTI) database (1996 is the most recent year for which final data are available). For the SIC codes 80xx (Health services), the total emissions for volatile organic compounds (VOC), nitrogen oxides (NOx) and hazardous air pollutants (HAPs) are as follows (in tons per year):
| SIC | Subsector | VOC | NOx | HAP |
| 8011 | Offices Of Physicians | 7 | 74 | 5 |
| 8051 | Skilled Nursing Care Facilities | 16 | 88 | 0 |
| 8052 | Intermediate Care Facilities | 1 | 5 | |
| 8059 | Nursing And Personal Care, NEC | 9 | 228 | 0 |
| 8061 | Hospitals | 0 | 6 | |
| 8062 | General Medical & Surgical Hospitals | 1,204 | 12,440 | 607 |
| 8063 | Psychiatric Hospitals | 115 | 3,412 | 53 |
| 8069 | Specialty Hospitals, Except Psychiatric | 53 | 760 | 31 |
| 8071 | Medical Laboratories | 17 | 15 | 15 |
| 8081 | Outpatient Care Facilities(1977) | 0 | ||
| 8082 | Home Health Care Services | 1 | ||
| 8092 | Kidney Dialysis Centers | 2 | 126 | 0 |
| 8093 | Specialty Outpatient Clinics, NEC | 0 | 2 | |
| 8099 | Health And Allied Services, NEC | 16 | 68 | 14 |
| 8050 | 0 | 4 | ||
| Total, all health services subsectors | 1,445 | 17,429 | 731 |
None of these are particularly large in relation to other four digit SIC codes, with the possible exception of NOx emissions from the general medical and surgical hospital category (presumably from combustion in boilers and waste incinerators).
A brochure issued by Health Care Without Harm cites a 1998 EPA report (Inventory of Sources of Dioxin in the United States) indicating that medical waste incineration is the third largest known source of dioxin air emissions. It also cites a 1997 EPA report to congress indicating that, of all mercury emissions to the environment from human activities, medical waste incineration contributes a full10%.
Infectious wastes are the "clear and present" danger from the hospital and health care sector, and medical waste incinerators are an effective way to deal with it. But these installations turned out to be significant dioxin sources. Hospitals are often located close to residential neighborhoods, a fact that heightens public concern. Dioxin is formed when organics are burned in the presence of chlorine, and a major source of chlorine in medical waste is polyvinyl chloride. Therefore, substitution with nonchlorinated plastics is a priority for pollution prevention advocates. The realization that a common plasticizer in PVC, diethyl hexyl phthalate (DEHP) can cause adverse reproductive effects in test animals has added even more urgency to that priority.
Specific types of infectious waste are defined in a Glossary provided by the Sustainable Hospitals website. These serve also as a useful categorization of the sources of the associated risks:
The use of mercury in medical devices is also being phased out. Advances in electronic sensor technology have made many former uses for mercury (such as in thermometers) obsolete.
Hospitals and health care providers are regulated, mandated, and sued to a fare-thee-well, but, until recently, more by independent interest groups, or by agencies responsible for medical licensing, and for rates and other financial matters, than by environmental agencies. (Some implications of the explicit regulation, as well as the "hidden regulation" of this sector is discussed in a study available from the University of California at Berkeley, Institute of Business and Economic Research website. The focus is on matters such as rate regulation, and is thus somewhat tangential to the scope of this analysis, but it makes points relevant to understanding some of the unique pressures under which providers in this sector must operate. For example, hospitals are forbidden by law to refuse to treat emergency room patients who are unable to pay for the services. While this may be defended on ethical grounds, from a business standpoint it is hard to distinguish from a law that would make it illegal for a grocery store to give unlimited food to anyone who shows up requesting it, whether or not they were able to pay for it.)
More environmental regulatory attention may be paid to this sector in the future. Apparently, an enforcement initiative in EPA Regions I, II, and III targeting hospitals and health care facilities has recently begun. Several documents from the private sector (for example, a law firm, and an environmental publication) are available describing the initiative, but there does not appear to be too much available on the topic yet (as of 10/27/02) from EPA, even from the Region I sector-based initiative page, which carries extensive information on the enforcement program directed at colleges and universities, which was this program's precursor. (Readers may want to check this Region I page periodically, since it may be an early source of information on the progress of health care initiative. Note that there is another Region 1 page devoted to information on mercury elimination, accessible from the index page for the "New England Environmental Assistance Team (NEEAT)", where it is listed as a "secondary focus". It is possible that the enforcement initiative has devolved into this effort, but it is not clear from the information presented.)
In the area of existing regulation, EPA has established New Source Performance Standards (finalized in 1997) for Hospital/Medical/Infectious Waste Incinerators.
An Effluent Limit Guideline (ELG) for Hospitals appears in Title 40 of the Code of Federal Regulations, Chapter 1, Part 460.
***[RCRA categorical wastes?]
Many environmental assistance providers and state agencies have prepared pollution prevention guides for this sector. Links to a wide variety of these resources can be found at: