Introduction
Today we're interviewing Dr. Jeremy Greene, who is the third speaker of the Sawyer Seminar Series at Rice University and he presented his seminar, “After the Single Use: Healthcare Waste and Environmental Justice” yesterday. Dr. Greene, thank you so much for joining us today. Before we begin, could you give us a brief introduction?
I'm Jeremy Greene. I'm a physician and a historian. I practice internal medicine at the Community Health Center in East Baltimore, and I direct the Institute for the History of Medicine at Johns Hopkins University. I also direct the Center for Medical Humanities and Social Medicine. And this year I'm filling in to head up the largest Humanities major at Johns Hopkins, which is a program on medicine, science, and humanities. So I’m very invested in this space of how the world of health and the world of humanities overlap.
Research Journey
What was your journey in getting involved with your current research and work with medical waste?
There's almost two parts to that question. One, how does one find oneself in this space of the medical humanities?
For me, it started with primatology, and I was interested as an undergraduate both in biology–I found the biological world compelling and fascinating–and in anthropology–studying social forms and understandings of the world. Somehow I became briefly deluded into thinking that the intersection of those two would be to actually follow primates through forests. I had this grant the summer of my senior year to live in the Kibali Forest of Western Uganda and study chimpanzees and monkeys in the forest.
But of course, it was 1995, and the AIDS epidemic was devastating in Western Uganda. And in Uganda, homosexuality was then, and is now, illegal. So on the one hand, Uganda had the most important virological laboratories in sub-Saharan Africa, but on the other hand the space to talk about AIDS was incredibly complicated.
Folks who lived in nearby villages and were working in our research station would fall ill, go to local hospitals, and be told they had malaria, which was also true. Malaria was a substantial form of co-infection and presentation with HIV. But other dimensions of their illness was just not being addressed or treated at all in that space.
So for me, what was happening with the lives of people who made our research space possible to study primates was so much more challenging and compelling than actually studying the primates themselves. This is how I then found myself realizing that in the world of medicine, public health was such a necessary and compelling intersection of this humanistic framework of understanding social and cultural forces, and the underlying biological manifestations of disease and how they play out differently in different people at different times.
That's the pivotal moment for me that brought me into both medicine, as I suddenly became pre-med (I had not really considered a career in medicine before), but also found humanities and social sciences as a guiding way through why I found medicine to be a compelling field. That's how I found myself in the space of medical humanities. Then down the road, though, as someone who is a clinician, but also works in libraries and archives and historical research, and then also works with students, this movement between the clinic, the archive and the classroom has always been a space to find topics of research and engaged impact.
As for how I began researching medical waste: in retrospect, my career looks much more coherent than it is in prospect. But I had done a lot of work on medical technologies, beginning with drugs, and my most recent book had been about electronic digital technologies and how medicine was being done through data processing machines. I started looking, in the aftermath of the COVID epidemic, at how much trash my clinic produced and how much trash one just saw through the streets of Baltimore—crumpled face masks or the popsicle stick of a used Binax COVID test were such commonplace objects. And then I started realizing that this was not just a local observation, that actually clinicians across the country, across the world were realizing that they had been producing an excessive amount of trash. The World Health Organization found that only one out of every three healthcare facilities in the world had adequate means of disposing of its own waste.
That was before the pandemic wave of trash came. There's something in these everyday technologies, like the gowns, the drapes, the masks, the gloves, the syringes, the disposable speculum, that we've just come to normalize. For me as a historian, so much of the value of history as a humanities field that gives you method and analytic perspective is taking something that we take for granted, realizing it has a story, that it wasn't always this way, it doesn't have to be this way, that 60 years ago, all of the items I just mentioned would have been reusable.
Then to understand that as we think about the earth crisis right now, and the way that health is a salient mode of understanding the impact of the earth crisis, that healthcare was also contributing to the earth crisis in ways we weren't naming, and that I had a role and a responsibility in trying to tell that story and bring visibility to it.
History of Medical Waste Informing Sustainability
Your work on disposable medical technologies highlights a key environmental challenge of the healthcare industry. How do you think learning from the history of medical waste can help shape more sustainable practices today?
That's a great question. So how does history help us? I think in so many ways.
Scotland has, as a country, the Scottish National Health Service, which is perhaps the boldest plan of developing a green healthcare system of any country that I've seen so far. They've pledged to make the whole health system net zero by 2040. I had a chance to meet the director of sustainability responsible for this transformation, Wendy Raymer, last year.
She was highlighting some of the changes that they've made so far. One of them is the kidney basin, which is a common medical tool used to collect fluids or to irrigate cold saline or other things. Kidney basins just get thrown away all the time.
It's a ton of plastic, or it's tons and tons of plastic being dumped. NHS Scotland realized that you could develop a metal kidney basin that was made of stainless steel, washable, reusable, sterilizable, and perfectly circular. So that's an innovation.
Yet, as a historian, that innovation was common practice in the year 1960. All the kidney basins were made of stainless steel. It's fascinating how the past is a repository of solutions to present-day problems that we forgot that we actually knew about before.
The past is also a way of understanding how we structured our values into our system. This is not to point fingers and say, “this is the person who ruined it all for us in the past.” But if we try to understand why the disposable revolution happened in healthcare supply in the 60s, and you go back to the values that are being promoted by it, it's very sensible.
It's just that there's a reckoning to that transformation of waste producing that wasn't apparent to them at that point. And it is now. In a way, history allows us to re-reckon and re-value.
Part of what's exciting being here at Rice is people like engineering professor Sabia Abidi interested in saying “how do we get engineers to think about the broader social values and the way they are built into their products?” History has a role in that, and we can consciously work to engineer sustainability as a virtue in medical product design. We can accomplish some remarkable things.
Ecological Consequences to Medical Waste
In your seminar, you mentioned how a lot of medical waste processing happens “underground” so that the general public and even medical staff don’t see it. From your perspective as a physician, do you think that’s something that all medical staff should be aware of and if so, how should medical staff be made more aware of these processes?
I would love to reach a state in which all medical staff become aware of the ecological consequences of their immediate decisions in usage and also purchasing and demand for circular versus disposable healthcare products. And the point here isn't to build a sense of guilt, but a sense of empowerment, realizing that we are actually all making lots of small decisions every day, and then collectively, we can actually ask for changes. How do we model this?
It's hard because the US healthcare system not only shields users, whether they're healthcare providers or patients, from seeing the sort of wasteful consequences of its action, but also makes it hard to understand even other forms of waste, like economic waste. It's really hard to know the economic consequences, like how much one thing will cost your patients or you as a patient at the time of decision. There have been means of using electronic health records as tools to help when you're prescribing a medicine to actually see the cost to a patient of that versus another in class that might do just as well, but be much cheaper.
Actually making the downstream costs of a decision visible at the point of decision, something like the electronic health care record, can have a role in that. Or if you think about what supermarkets are like in many European countries, you'll actually see the carbon costs to bring this particular fruit to you, even though it all looks good and green (because these are green objects that look natural and healthy). But bringing this pineapple to you at this particular time of year has this carbon cost, whereas enjoying this sweet potato from this farm nearby actually had much less. And it's visible, right in front of you, as you make your decision. It takes a bit of work, but simply making visible the costs of a choice can actually help change behaviors on a substantial scale.
Connections to the Suggested Reading
From the two Sawyer Seminar recommended readings you provided, there was one piece on disposable syringes and one piece on the racial bias associated with pulse oximeters. Could you elaborate on the connection between these pieces and how they relate to the idea of medical waste?
The connection between them might not immediately be obvious. The first piece is pretty clear. This is a piece that I wrote for the Atlantic for a general public, for general readership to use storytelling.
Because these syringe tides in the late 1980s, they became the origin point of the book that I'm writing. Because I remember them. I was there in New Jersey.
I was a middle schooler wanting to use the beach. The beaches got shut down by these waves of syringes. It became a dramatic public spectacle as New Jersey sues the state of New York because they find New York addresses on the syringe and prescription bottles. The administration of the New York mayor, Ed Koch, then says, “New York's not missing any garbage.” That was their line directly. We're not missing any garbage, just give a look somewhere else. It becomes this huge fight that goes to Congress and there's these new laws that are passed. That's what defines medical waste as a regulatory category.
It also leads to this line in the Billy Joel song, "We Didn't Start the Fire." Hypodermics on the shore is one of 11 different things used to describe the 1980s. So it was a signature event.
Or in some ways, it was a spectacle rather than an event. Because it's not clear to me that anyone actually got sick or died, that there was no actual bodily consequence from this massive media spectacle around medical waste. It led to huge political changes and regulatory changes.
Whereas, if you look at the pulse oximeter, which was not immediately a spectacle, it's a rather mundane piece of technology that anyone working in healthcare, anyone who's been a patient in a hospital knows, and it's relatively ingenious. It's spectroscopy. You pinch it over your capillary nail bed and you shoot light through it and you see the absorption spectrum on the other side of it.
It tells you based on an algorithm what percentage of your oxygen, your hemoglobin is oxygenated. Very, very useful. But it took a lot of work to show that people were dying.
That actually thousands of people were dying otherwise preventable deaths in the COVID pandemic, because of the color of their skin, because a racialized bias was intrinsically built into the way the machine was developed and tested. Even once discovered, it was not immediately possible to recalibrate these machines. It's still an ongoing fight to try and get a non-racialized, or rather, a non-demelanized-prioritizing version of the pulse oximeter.
On the one hand, the pulse oximeter becomes such a powerful story. My colleague, Amy Moran-Thomas, who's at MIT and does STS studies there, has told the story very well, but also engaged in a variety of policy endeavors to try and rectify it. But Amy has also been working with engineers in the Boston area at Tufts to try and ask, how can we use this example to teach engineers how to not build racist technologies?
Meanwhile, I think I had mentioned Sabia Abidi here at Rice is an engineer trying to teach engineers, how do we understand that the social impact into what a technology becomes, and the social functions of the technology afterwards, actually should matter a great deal to the profession of engineering. We were talking yesterday about design thinking, which was in vogue, maybe a decade ago, and is perhaps slightly less in vogue, but it's still very important to engineering education. How you can get different steps of design and the different feedback loops where we learn whether something's working or not?
I had taught this design thinking principle to my students, and I'm teaching a first-year seminar for undergraduates at Johns Hopkins on medical waste right now. We had this week where I didn't actually teach them, I basically gave them 15 minutes to Google “design thinking,” look at pictures and diagrams of it, and then go up and try and draw it out on the board and sketch it out. Partly what they generated is the sense that you have these basic concepts of here's where you're getting a sense of the need, and here's where you're ideating and coming up with possible solutions, and here's where you're prototyping, and here's where you're testing—and ask them, what step does the values come in?
When are we talking about cultural factors, moral factors, what we value, and who we value, when we create this technology? One of them mentioned one of the five steps, another one mentioned the other, and then another one mentioned a third. What we really got to is actually all of these steps, every part, how you decide to test it, who you test it on, who's in the room when you're prototyping, how you perceive demand, whose demand are we actually thinking about, that actually all of these are profoundly socially, culturally, morally-related value decisions, and it matters who's in the room when they happen.
In a way, that links these two articles. The plastic syringe, the single-use syringe, was designed with a set of values that made sense to the manufacturers, and to the hospital purchasers, and people in infection control, especially starting in the 60s in a skyrocketing way with the hepatitis and then the AIDS epidemics of the 1980s. But what it produced was this after-effect that people hadn't thought about, partly because of who they invited in the rooms for those decisions.
There was no conversation with environmentalists at all when these things were being created. The reason the spectacle erupted was because people who were outside the room, when the value of single-use disposable equipment, were now feeling the effects of it in a way that had not taken their adverse effects to heart. In a way, this is what links it.
It's not that engineers and device manufacturers are this bad guy, this bad noir. How do we create principles of design and bring principles of justice into how we think about something like a complex medical device, or what we do with our medical waste, or who bears the burden of it in an analogous way? It takes those interfaces with engineers that people like Amy Moran-Thomas are building, and which I think we can actually build in this space.
Takeaways
If you could ask people, the general audience, who is not a clinician or a historian, to take away one thing from your lecture yesterday, what would it be? What is the key theme you would like to raise public awareness around?
I think what I would like to raise public awareness about is that we have, for more than half a century, valued disposability in medicine, and then encouraged a throwaway. It's not that we've just given it like a blind eye and let it go on. We've actually inverted a value system.
If you think about the words, “reduce, reuse, and recycle,” and ways in which—especially here, this is the week in which the COP29 is going on in Azerbaijan, and later this month will be the Global Plastics Treaty meeting in Busan. These are really sincere efforts to understand the role that carbon emissions and plastics consumption are playing in the earth crisis, and the need to address this as soon as we can. That "reduce, reuse, and recycle" all became bad words in medicine.
It's not just that we gave healthcare a pass. It's that if you talk about this idea of recycling syringes was seen as a problem, and we needed to develop syringes to be something that could not possibly be reused. How do we re-evaluate these value systems?
Especially, how do we re-evaluate seeing clashes between disposability, sustainability, and healthcare? People say sustainability is good, but if one person gets an infection in the name of sustainability, then that's not okay. Sustainability and safety are opposite of each other, or sustainability and efficacy, or sustainability and economic efficiency.
The one thing I really want the audience to get away from this is that the costs of this are not evenly borne out. We've talked a lot about our colleagues in Curtis Bay and South Baltimore Community Land Trust, which is just one location in which the uneven effects of the environmental justice consequences of medical risk come to bear. If we take an environmental justice perspective and try to build a system in which we actually rethink the value of disposability, the benefits and its costs, that in terms of safety, in terms of efficacy, in terms of efficiency, these are not necessary dichotomies.
There are actually ways of making substantial progress in all of these domains and doing so with the goal of achieving more justice and moving towards a just transition for those who are most affected. But in order to do so, we just have to look around ourselves and be willing to see the items in everyday care as practitioners or everyday care as patients and ask, who is this for? Who's benefiting from it?
What alternatives exist? That sense that actually the built environment we inhabit is not necessary and is not necessarily the best of all worlds and can be changed, that's really the sense I want people to walk away with.
*This interview has been edited for length and clarity.
Photo credit: Conner Schultz