LOW←TECH MAGAZINE English

Communal Luxury: The Public Bathhouse

Tue, 17 Sep 2024 00:00:00 +0000

Image: Bathhouse built on top of a hot pool, Taiwan. Photo from early 20th century, public domain.

No Running Water at Home

For people in industrial societies, few activities demand more privacy than washing and grooming the body. We usually do it alone, in our private bathrooms, with locked doors. Seen in a historical context, that is unusual. Bathing in the presence of others has been the rule rather than the exception. As late as the first half of the twentieth century, many households, even in the most advanced industrial societies, did not have running water at home, let alone a private bathroom. ¹

A bathroom requires a domestic water supply, but also a sewer drain, and an energy source to heat the water. Of course, it’s possible to have a hot bath at home without these infrastructures. Ever since Antiquity, the rich have built private baths in their houses. Most often, they could do that because less well-off people - either servants or slaves - filled and emptied their bathtubs with bucketloads of water and collected firewood to heat them.

However, for most people, it was more practical to take their bodies to the water rather than the other way around. For some, that meant bathing in rivers, lakes, and springs. For others, especially in urban environments, it meant visiting the public bathhouse.

Image: Bathhouse in Aachen Germany, by Jan Luyken, 1682.

Is Bathing Unsustainable?

Modern bathing practices are a textbook example of an unsustainable lifestyle based on fossil fuels. Hot water production is the second largest energy use in many homes (after space heating and/or cooling), and much of it is used for bathing or showering. ² The modern bathroom also uses a lot of water and adds extra energy use through space heating and waste-water treatment. Building and renovating bathrooms requires resources, too.

Sustainability advocates follow two strategies to address these problems. The first strategy concentrates on technological solutions, such as low-flow showerheads, water boilers heated by solar collectors, waste-water heat recovery systems, and greywater recycling. The second strategy counts on behavioral or social changes by questioning modern standards of cleanliness and comfort: bathing or showering shorter and less frequently, taking cold showers, or doing a cat wash at the sink. ²³

These strategies are unlikely to bring much results. Many technological fixes are difficult or impossible to install in existing buildings, especially in cities. For example, as the number of floors increases, an apartment building quickly runs out of roof space to install solar collectors for all residents. On the other hand, promoting discomfort as a sacrifice for sustainability is unlikely to engage broader environmental practices. ³⁴

Communal bathing makes it easier to disconnect bathing practices from fossil fuels.

Communal bathing could be a third approach, but it’s rarely mentioned. That’s remarkable because, in terms of resource efficiency, it’s hard to beat. Building and operating a bathhouse for 1,000 people requires much less energy than building and operating 1,000 individual bathrooms. A public bathhouse is also more efficient concerning materials, money, and space. ⁵

Just as importantly, public bathing makes applying the sustainable technologies mentioned above more feasible. That further reduces energy consumption and makes it possible to disconnect bathing practices from fossil fuels. Finally, a public bathhouse can achieve significantly improved sustainability without promoting discomfort. On the contrary, pooling resources to build something for a community rather than for every household separately allows for a high level of sustainable extravagance. That may be an easier sell than cold showers.

Image: Public bathhouse in Dunkirk, France, opened in 1897.

Bathing in Rivers, Lakes, and Hot Springs

Nature has provided humans with bathing facilities through streams, rivers, pools, lakes, waterfalls, and rain showers. Humanity spent much time in tropical Africa, where bathing did not require artificially heated water for comfort. When we moved into colder climates, Nature presented us with another solution: hot springs. Many tens of thousands of thermal springs exist around the planet — only a few present-day countries lack them entirely. ⁶⁷

Bathing in hot springs was common in ancient civilizations all over the world. However, it’s a practice that goes back even further in time. Archeological evidence abundantly shows that many prehistoric settlements established themselves near hot springs. ⁶⁸ It’s impossible to prove rock solid that people used those waters for bathing, but why wouldn’t they, especially in cold regions? ⁹

Enjoying a hot bath is a practice that predates recorded history.

Today’s bathing culture relies on fossil fuels, but if we consider the historical context, enjoying a hot bath is not unsustainable. In the case of hot springs, the entire infrastructure and operation — water supply, drainage, and heat source — are already in place.

Our ancestors also invented the steam or sweat bath to take advantage of cold water in all seasons and climates. Rather than heating water, it heats people so they can bathe comfortably in cold water. The earliest steam huts, from prehistoric times, were little more than small log cabins or tent-like structures covered with woolen blankets or hides. ¹⁰¹¹¹²¹³

Painting: Bathing Place, oil on canvas, Paul Gauguin, 1886.

The Birth of the Bathhouse

Artificial bathing facilities made from brick or stone appeared around 4,000 years ago. ¹⁴ They could be an open-air pool, a bathhouse, or a private bathroom. Many bathhouses and bathing pools were built on top of natural hot springs, modifying the natural environment to make it more convenient, safe, and attractive.⁶⁸ People also began to divert water into urban bathing facilities using canals, pipes, and aqueducts. They started building baths that used artificially heated water as well.

The Ancient Romans are most famously associated with the public bathhouse, although they took much inspiration from the Ancient Greeks. Greek bathhouses comprised rooms with individual hip baths against the walls. Sitting up straight, the bathers threw hot water over themselves or had this done by a servant. In contrast, Roman bathers shared the water in large bathtubs or pools. Both used steam baths as well. ¹⁵¹⁶¹⁷¹⁸

At the height of the Empire, there were around 1,000 public baths in the city of Rome alone for a population of about 1 million people - one bathhouse per 1,000 people. ⁸¹⁹ The most prominent bathhouses were the “thermae,” which could hold up to a few thousand people bathing at the same time. These facilities, which only appeared in the largest cities, were richly decorated with mosaics, marble floors and pools, granite columns, and statues. However, most Ancient Roman bathhouses were smaller neighborhood baths called “balnea.” ¹⁵

Image: Cross-section of the Baths of Diocletian by French architect Edmond Paulin, 1880. This bath complex was the largest of Ancient Rome, with a capacity of over 3,000 people.

The Preindustrial Bathhouse

The public bathhouse’s history continues after the Roman Empire’s demise. In the East, the Roman bathhouse evolved into the hammam, which ditched the pools and concentrated more on sweating as a cleaning method.²⁰²¹ After a sweat bath, people threw water over themselves. Reminiscent of the small Roman baths known as balnea, hammams spread in large numbers in all cities of the Islamic world as they facilitated bodily cleanliness and the accomplishment of body ablutions before praying. ²²

In Western Europe, many Roman baths fell into disrepair. However, the public bathhouse returned in full swing during the late Middle Ages, when a new period of urbanization set in. ²³²⁴²⁵ In the 13th, 14th, and 15th centuries, a lot of European cities had a public bathhouse per 2,000 to 5,000 citizens.²⁶ Many were steam baths inspired by the hammam. A second type of bathhouse offered wooden bathtubs to seat a small group of people. The medieval bathhouse was known as a “stew,” which refers to the oven that either heated water for the bathtubs or filled the room with steam. ²³²⁵

Image: A former medieval bathhouse, built in 1562, in Münden, Germany. Photo by Axel Hindemith (CC BY-SA 4.0).

Image: The women's bathhouse, by Albrecht Dürer, 1496.

Painting: Rudas Baths, Ludwig Rohbock, 1850. The Rudas Baths in Budapest were built in 1550 and are still in operation.

Northern Europe and Russia - never conquered by Roman or Islamic Empires - stuck to sweat and hot air baths. For example, public “banyas” existed in towns throughout Muscovy during the Middle Ages. ¹² Asia also developed independent bathing cultures. For instance, in late medieval Japan, people shared private hot baths among families, neighbors, and friends for economic reasons. For these “cooperative baths” of mostly four to ten individuals, every bather brought a portion of firewood to heat the water. That practice evolved into larger public baths - “sento” - which experienced rapid growth from the fifteenth century onwards.²⁷²⁸

Image: Women taking a vapour bath. Wood engraving by Olaf Sörling.

Image: Men in a Japanese bathhouse, early twentieth century. Image in the public domain.

Bathing for Pleasure

Nowadays, sustainability advocates who promote shorter or less frequent showers implicitly regard bathing as a strictly utilitarian practice. However, for most of history, bathing was never just about hygiene. Apart from getting clean, people also visited public baths to relax, have fun, and socialize. Rather than a quick affair, the bathing process — no matter its form — often went on for hours. ¹⁵²⁸

The Ancient Greeks sat together in individual bathtubs, having conversations, for which the space’s acoustics were optimally suited. ²⁹ In Ancient Rome, public baths were places where people went almost daily to be seen, mingle, relax, gossip, dine, or play sports and study. Bathers accessed beauty treatments such as massages, shaving, hairdressing, and depilating. They celebrated parties and anniversaries and honored foreign guests. ¹⁵¹⁷¹⁹²⁵³⁰

Rather than a quick affair, the bathing process — no matter its form — often went on for hours.

The medieval European bathhouse continued these traditions with less splendor but not necessarily with less revelry. In particular, medieval stews with wooden bathtubs were often a place of amusement that also furnished food, drink, music, and various types of bodily care. ²³ In Japan, during the 16th century, public baths became places to gather and socialize, with large groups of people eating, drinking, and singing. ²⁷²⁸ River bathing, which continued around cities and in rural areas until the 20th century, was a kind of play in which swimming was a potential element. ³¹

At the same time, bathing was considered essential to prevent and cure diseases, following the Hippocratic ideas that people could maintain or restore the balance of bodily fluids by exposing the body to cold, hot, moist, or dry circumstances. The layout of preindustrial baths reflected these ideas, featuring pools and spaces of different temperatures. ¹⁵²¹

Image: Miniature drawing in "De Sphaera Mundi", written by Johannes de Sacrobosco, circa 1230.

Playing chess at the Széchenyi Baths in Budapest, Hungary, 1970s. Photo by Kereki Sándor. Found at [Fortepan](https://fortepan.hu/hu/).

Communal Luxury

While these elements of pleasure, social interaction, and health continue today in mineral spas, there is a crucial difference with earlier bathing practices. The present-day spa is far too expensive to substitute for a private bathroom. In contrast, the historical public bathhouse was an egalitarian institution.

Roman public baths had no or low entrance fees and were open to everyone. There were no areas reserved for higher-ranking patrons. Combined with the splendid architecture and opulent decoration of the baths, this ensured that even the most humble servant would have a taste of luxury. ¹⁵¹⁷¹⁹ These customs continued into the European Middle Ages and were shared by bathing cultures across the world. ²³ For example, in Japan, the bathhouse aided in “slowly deconstructing the existing social hierarchy and created a new cultural flow between the elite and the commoners.” ²⁸³²

The only separation happened between men and women, and it was far from universal across space and time. They would either go to different bathhouses, occupy different sections, or share the same spaces at different times of the day or the week. ¹²¹⁵¹⁷¹⁹²³

Image: A sento in Japan. Photo by [Stuart Gibson](https://stuartgibson.aminus3.com/portfolio/).

The Fuel Use of Roman Bathhouses

How sustainable was that communal luxury? Most research about the energy use of bathhouses concerns Ancient Roman baths. Historians have sometimes faulted the large bathhouses from the Empire for their wastefulness, arguing that their widespread use caused deforestation. ³³³⁴³⁵ However, in recent years, archeological research, thermal analysis, and heat transfer studies have made it increasingly clear that Ancient Roman bathhouses, in spite of their opulence, were remarkably energy-efficient buildings. ³⁶³³

The first reason was the hypocaust system. It consisted of one or more underground furnaces that distributed hot air under the floor and into the hollow walls (some baths had heated ceilings, too). Because of the large radiant surfaces, the spaces in the building could be heated at a lower temperature, saving energy. Although the water for the pools was reheated periodically in an insulated boiler close to the furnace, the heat in the floors and the walls helped to keep it warm for an extended period. ³⁶³³

A study of the Stabian Baths, one of the oldest surviving thermae, shows a fuel consumption of between 5 and 8 kg of firewood per hour, depending on the season. ³⁶³⁷ That corresponds to a wood supply of slightly more than 60 ash trees per year, which was unlikely to cause deforestation. ³⁶ Firewood consumption was probably even lower because Roman baths routinely supplemented wood with other locally available fuels, often waste products: reeds, harvest by-products (olive pits, orchard trimmings, chaff), and animal wastes (dung and bones). ³³

Many Roman baths were heated almost exclusively by solar energy on sunny days.

Following the same methodology, a study of a later bathing complex - the Forum Baths in Ostia - shows that the Romans continued improving their bathhouses’ energy efficiency. ³⁸³⁹ The Forum Baths were three times larger than the Stabian Baths - 923m2 versus 310m2 of heated spaces - but their calculated annual wood consumption is not even twice as high: roughly 100 trees per year. ³⁸³⁶ The newer bathhouse had thicker walls (two meters instead of one meter), as well as much larger glazed windows, which increased the share of solar radiation. ⁴⁰ Earlier research has shown that the Forum baths were heated almost exclusively by solar energy on sunny days. ⁴¹

The studies above assume that the Romans heated their baths for 24 hours daily and only shut them down for maintenance. Roman bathhouses likely continued to be heated through the night, as it was more practical and energy-efficient. Many baths were open daily, and it could take a whole day to heat them from a cold state. In later centuries, medieval stews and hammams often used the heat or the ashes of the furnace to bake bread and other foods at night. ⁴² Hammams and medieval stews were less energy-efficient than Roman baths. Hammams had heated floors but no heated walls and few windows, while medieval stews often had none of these.

Image: The large windows of the Forum Baths. Image: [Jan Theo Bakker](https://www.ostia-antica.org/regio1/12/12-6.htm).

Image: The hypocaust of the Great Baths complex, Ancient Dion. Imgae by Carole Raddato (CC BY-SA 2.0).

Image: Historical Reconstruction of the Roman Baths in Weißenburg, Germany, using data from laser scan technology. Credit: [CyArk](https://en.m.wikipedia.org/wiki/File:Cyark_Weissenburg_Reconstruction.jpg#filelinks). CC BY-SA 3.0

Roman Bathhouse Versus Private Shower

How does the energy use of the Roman bathhouse compare to that of the modern shower? Academic research does not provide an answer, but a quick calculation shows that the Roman bathing experience, which lasted for hours, was more energy-efficient than the present-day private shower, which lasts, on average, 9 minutes. The daily energy use of the Forum baths corresponds to the daily energy use of 557 showers. ⁴³ While we don’t know how many people visited the Forum Baths daily, they likely surpassed that number: the baths could host up to 500 bathers simultaneously. ⁴⁴

The Roman bathing experience, which lasted for hours, was more energy-efficient than the present-day private shower, which lasts, on average, 9 minutes.

Furthermore, in the calculation above, the energy use for the shower only concerns water heating, while the fuel use for the public baths also - and mainly - includes space heating. ³⁶ For example, assuming that the water in the pools of the Stabian baths was changed only once per day, heating the water accounted for less than 10% of the total energy use, corresponding to the energy use of only 52 showers. The low energy use for water heating is partly explained by the excellent thermal insulation of the heated floors and walls, meaning that space and water heating cannot be separated. However, it is also because the Romans shared the water in pools, while every shower requires freshly heated water.

The Roman bathhouse also compares favorably to the typical backyard sauna, for which the fuel consumption hovers between 5 and 15kg of firewood per session. ⁴⁵ Only sixteen such sauna sessions require as much fuel as the Stabian baths used daily. The sauna has no heated floor and walls. Furthermore, historically, it was often built partly underground to save fuel, but nowadays, it’s usually a badly insulated building standing in a cold climate.

Image: Bathing sandals for women, Saudi Arabia. Heated floors of hammams were too hot to walk on barefoot. Source: [Wereldmuseum](https://collectie.wereldmuseum.nl/) (CC BY-SA 4.0).

The Public Baths of the Industrial Revolution

Bathing practices have changed quite a lot since Roman and late medieval times, particularly in most of the Western world. Few of us will have the time or even the need to linger in a bathhouse for several hours daily, and some of us may feel uncomfortable bathing in public. ³⁰ However, a bathhouse can also take a form more in line with modern bathing habits. The public bathhouse of the Industrial Revolution demonstrates this.

In the nineteenth and early twentieth centuries, cities received large numbers of immigrants who came to work in factories. Most of these people were housed in overcrowded tenement buildings without running water, leading to unsanitary conditions. ⁴⁶ Recurring epidemics and new medical insights led to a “gospel of cleanliness” that resulted in a new wave of public bathhouses across the Western world. Many of these baths only disappeared between the 1950s and 1980s.

The public hygiene movement began in England and peaked there in the 1840s. By 1896, more than 200 municipalities in Britain were maintaining public baths. The English bathhouse emulated the splendor of Roman baths in its architecture and decoration: it was “large, handsome, and costly.” ⁴⁶ However, it did not copy the Ancient bathing customs. It now reserved different sections of the bathhouse for different social classes. Furthermore, while the pools still provided social interaction, the bathtubs were now placed in individual compartments. Finally, the modern bathhouse instituted maximum time limits for using the pool and the bathtubs. ⁴⁶⁴⁷⁴⁸

Image: Nechelles public baths in Birmingham, England, 1910. Image by Oosoom (CC BY-SA 3.0).

Image: The restored interior of the Amalienbad in Vienna, Austria, built in 1926. It was one of the largest bathhouses in Europe at the time, holding up to 1,300 bathers simultaneously. The original roof could slide open in good weather. Image by Schwimmschule Steiner (CC BY-SA 4.0).

The Shower Bathhouse

Germany, the first to follow the British on the continent, also built monumental bathhouses. ⁴⁹ However, in the 1880s, Berlin physician Oscar Lasser argued that the large baths were too costly to build in the necessary numbers. He proposed the introduction of smaller bathhouses with nothing but showers in individual compartments. Until then, the shower was only attached to a bathtub or used in barracks and prisons, where soldiers and inmates were showered with cold water. ⁴⁸⁴⁶²⁵

The shower bathhouse became the dominant public bath type in most of Western Europe and also in North America, where the sanitary reform movement took off in the 1890s. ⁵⁰⁵¹ It cleared away the last vestiges of the Ancient bathing culture by ditching the pools and switching to a more practical architecture. For better or worse, the public bathhouse from the Industrial Revolution was the “antithesis of the preindustrial bathhouse.” ⁴⁷ Although bathers still made use of communal infrastructure, there was no more space for pleasure, social interaction, public nakedness, and social mixing.

For better or worse, the public bathhouse from the Industrial Revolution was the antithesis of the preindustrial bathhouse.

As the higher social classes gradually gained access to their private water supply and bathrooms, the public bath became increasingly associated with poverty. Although shower bathhouses did not have separate sections for different social classes, they were mainly built in low-income neighborhoods, aimed at the poor only. Bathers were led to their shower cubicle by an attendant, who opened the tap, decided on the water temperature, and started a timer. People had at most 20 minutes to undress, shower, and dress again.⁴⁶⁴⁷ “The poor had to be clean but not enjoy it too much.” ⁴⁶

Image: The last bath attendant of a bathhouse in Haarlem, the Netherlands, in 1984. Image in the public domain.

Bath and shower rooms equipped with timers in Amsterdam bathhouses, 1985. Source: [Stadsarchief Amsterdam](https://archief.amsterdam/beeldbank/detail/ca27031b-8e92-023a-eb42-461dc0cf6fd2/media/728f468c-3dca-91e3-0eb9-6dca39ea8130?mode=detail&view=horizontal&q=badhuis&rows=1&page=24).

Image: Shower cubicles in a municipal bathhouse in Amsterdam, the Netherlands. Stadsarchief Amsterdam.

Image: Boiler room of a municipal bathhouse in Amsterdam, the Netherlands, 1985. Stadsarchief Amsterdam.

Bring Back the Public Bathhouse?

In Europe and North America, the public bathhouse disappeared once everyone got their private bathroom - although we still bathe together in sports centers and continue using communal bathrooms in hostels or campings. The public bathhouse survives elsewhere but is in decline almost everywhere. For example, Cairo had only eight hammams in 2000, compared to more than seventy at the beginning of the 19th century.⁵²⁵³ In 1968, greater Tokyo boasted 2,687 public bathhouses. In 2022, only 462 were left. ⁵⁴⁵⁵

Historically, the bathhouse was born out of the need for efficiency: bathing was too resource-intensive to organize individually. That is no longer the case thanks to the advance of central infrastructures - fossil fuels, electricity, water supply, sewers. However, in the context of the present environmental crisis, the resource efficiency of the public bathhouse has become relevant once again. It’s a solution that could reduce energy use relatively quickly without the need for new technologies or sacrificing comfort. Resilience is another argument for the bathhouse. ⁵⁶

Image: Municipal bathhouse at Javaplein in Amsterdam, the Netherlands. Image: Stadsarchief Amsterdam.

Image: A former bathhouse in Flensburg, Germany. Image: VollwertBIT (CC BY-SA 2.5).

What Type of Public Bathhouse Do We Want?

The metamorphosis of the public bath in the 19th and 20th centuries, which also affected public baths outside the Western world, presents a challenge to anyone wanting to revive public bathing for sustainability. What type of bathhouse do we want? Of course, the Roman bath and the shower bathhouse are both extremes, and many intermediate forms are imaginable. Nevertheless, any designer of a future bathhouse will have to make decisions that are likely to be controversial.

For example, one could argue that the shower bathhouse not only fits modern bathing practices but also maximizes resource efficiency. That is especially true when the government, rather than the bather, controls shower duration and water temperature. In that way, the public bathhouse could become a technology to enforce frugality upon the whole population. However, to put it mildly, such an approach is unlikely to generate enthusiasm for reviving public bathhouses. Neither does it do much to improve social interaction. ⁵⁷

Any designer of a future bathhouse will have to make decisions that are likely to be controversial.

Advocating for the return of the preindustrial public bathhouse, which centers around social interaction and communal luxury, may be more successful in luring people away from their private bathrooms, but it also runs into obstacles. The public bathhouse has faced resistance for 2,000 years, mostly because of conflicting views about health and morals. ⁵⁸ For example, concerns about debauchery and prostitution - real and imagined - run throughout the history of the bathhouse in all cultures. ⁵⁹ Separating males and females does not fully address those worries.

Image: Scene of a bathhouse, c. 1470, painted by the Master of Anthony of Burgundy (Berlin Staatsbibliothek, Ms. Dep. Breslau 2, vol. 2, fol. 244).

Any plea for reviving public baths will also have to deal with the fear of contagious disease. For example, a “lockdown” of society, as many governments applied during the coronavirus pandemic in 2020 and 2021, is incompatible with public bathhouses. Such a measure only works when everybody has a private bathroom. ⁶⁰ The link between communal bathing and health is complex. Science has confirmed many of the health benefits of cold, hot, and steam baths and has also shown the importance of social interaction. However, bringing people together will always raise health risks, too.

How to Build a Low-tech Bathhouse?

There’s another distinction between bathhouses built before and after the Industrial Revolution: preindustrial baths worked with renewable fuels, while industrial baths ran on fossil fuels. Many modern bathhouses had an on-site coal power plant, which heated the space and the water and provided electricity for lighting. Fossil fuel-powered bathhouses are more energy efficient than fossil fuel-powered private bathrooms, but we can do better than that.

A large bathhouse heated by a hypocaust system and large windows is still hard to beat as a carbon neutral technology, at least based on sustainable wood production. ⁶¹⁶² However, biomass combustion creates air pollution, while we could also power a bathhouse with renewable energy sources that don’t have that problem. The most apparent solution for space and water heating is flat plate solar collectors in which the sun heats water. Heat-generating windmills are a low-tech alternative to solar thermal collectors in less sunny climates. ⁶³ Other potential heat sources are geothermal energy and factory waste heat.

Fossil fuel-powered bathhouses are more energy efficient than fossil fuel-powered private bathrooms, but we can do better than that.

A solar or wind-powered bathhouse’s biggest drawback is its dependency on favorable weather conditions. To compensate for that, solar or wind power can be combined with thermal energy storage, such as insulated water tanks. Storing heat in a thermal mass for longer periods is much cheaper and more sustainable than storing electricity in chemical batteries. However, it requires space that only communal bathing can offer. Steam baths and saunas are more difficult to disconnect from biomass combustion, but some innovative examples exist. ⁶⁴

Clustering bathing facilities in a shared infrastructure also creates sufficient space for a bathhouse to have extensive heat insulation (a decisive factor in energy consumption) and provide for its water supply (for example, by catching and storing rainwater) as well as wastewater treatment (for example through phytoremediation using plants).

Architects have applied some of these ideas in countries where public baths are still used. For example, in a mountain village in China, a community bathhouse for 5,000 people is largely off-the-grid, pumping up its water from a well, heating it with solar collectors, and filtering the run-off wastewater from the showers and the toilets in basins filled with bamboo plants. ⁶⁵

Image: This bathhouse in China has 24 showers and serves a community of 5,000 residents. It recycles the waste-water with bamboo plants. Source: BAO Architects.

However, a public bathhouse also fits the more high-tech vision of a centralized energy infrastructure based on solar PV panels and wind turbines that provide electricity. In such a configuration, public bathhouses could absorb excess electricity during abundantly sunny or windy days. Rather than curtailing the electricity from surplus solar and wind power, we could use it to power electric heat pumps and store the heat in the thermal mass of public baths. ⁶⁶ While this approach is less resource-efficient than off-grid bathhouses operating without electricity, it still beats a scenario in which a centralized renewable power grid supplies energy to many private bathrooms.

Kris De Decker

Many thanks to Jonas Görgen and Elizabeth Shove for their feedback on an earlier version of this article.

Marie Verdeil and Roel Roscam Abbing contributed to the selection of images.

The spread of water supply and sewer networks took a lot of time, especially in older European cities. Before 1900, only the most expensive Paris flats had a bathroom. ²⁶ Plumbed-in private baths appeared in the wealthiest British households in the 1860s. Still, it was not until the 1950s that working-class homes were routinely supplied with hot and cold running water. ³ In the newer cities of the USA, installing a water supply and sewer infrastructure was easier. From the 1870s, American plumbing outstripped that of every other country. More than half of all American houses had a complete bathroom in 1940. For comparison, in the whole of France, only one house or apartment in ten had a shower or bath in 1954. ²⁰ ↩︎
Mist Showers: Sustainable Decadence?, Kris De Decker, Low-tech Magazine, 2019. https://qelnixcor.cloud/2019/10/mist-showers-sustainable-decadence/ ↩︎ ↩︎ ↩︎ ↩︎
Pickerill, Jenny. “Cold comfort? Reconceiving the practices of bathing in British self-build eco-homes.” Annals of the Association of American Geographers 105.5 (2015): 1061-1077. https://www.tandfonline.com/doi/full/10.1080/00045608.2015.1060880 ↩︎ ↩︎ ↩︎
The trend is towards more and longer showers ² and more, larger and more luxurious private bathrooms. For example, more than one-third of new single-family homes in the US had three or more bathrooms in 2021, compared to “only” a quarter in 2005. Source: Number of Bathrooms in New Homes in 2021, Jesse Wade, National Association Of Home Builders, November 2022. https://eyeonhousing.org/2022/11/number-of-bathrooms-in-new-homes-in-2021/ ↩︎
How much water public bathing can save depends on how exactly people bathe together. Shared pools and bathtubs bring water savings, but individual showers and bathtubs do not, even if placed in a communal space. ↩︎
Erfurt, Patricia. “Hot springs throughout history. The Geoheritage of hot springs.” Cham: Springer International Publishing, 2021. 119-182. ↩︎ ↩︎ ↩︎
Tamburello, Giancarlo, et al. “Global thermal spring distribution and relationship to endogenous and exogenous factors.” Nature Communications 13.1 (2022): 6378. ↩︎
Cataldi, Raffaele, Susan F. Hodgson, and John W. Lund. Stories from a heated earth: our geothermal heritage. No. 19. Nicholson, 1999. ↩︎ ↩︎ ↩︎
Even some animals - like snow monkeys and capybaras - are known to enjoy bathing in hot springs. See, for example: Matsuzawa, Tetsuro. “Hot-spring bathing of wild monkeys in Shiga-Heights: origin and propagation of a cultural behavior.” Primates 59.3 (2018): 209-213. https://link.springer.com/content/pdf/10.1007/s10329-018-0661-z.pdf. ↩︎
Sonntag, C. F. “The History of Baths and Bathing in Britain before the Norman Conquest.” Proceedings of the Royal Society of Medicine 13.sect_hist_med (1920): 25-46. ↩︎ ↩︎
Aaland, Mikkel. “Sweat: The illustrated history and description of the Finnish sauna, Russian bania, Islamic hammam, Japanese mushi-buro, Mexican temescal and American Indian & Eskimo sweat lodge.” (1978). ↩︎
Pollock, Ethan. Without the banya we would perish: a history of the Russian bathhouse. Oxford University Press, USA, 2019. ↩︎ ↩︎ ↩︎
The first written reference to the steam bath dates back to the fifth century BC, when Greek historian Herodotus compared the Scythian sweat bath north of the Black sea to the Greek steam bath of his time. However, it’s very likely that its origins go back to prehistoric times. Not surprisingly, the steam bath and the hot air bath initially spread in regions with cold and long winters: northwestern Europe, Russia, Alaska, and Canada. It was also used by Native Americans, and spread to Central and South America as well. ¹⁰ ↩︎
One of the earliest archeological records of human-made bathing facilities dates back to around 2300 BC in what is now Pakistan. The inhabitants of Mohenjo-daro, the probable capital of the Indus civilization, built wells and drainage systems allowing for private bathrooms in most residential buildings, as well as a large, communal bathing pool. The private bathrooms had a 1m2 shallow platform, where people threw buckets of water over themselves. The “Great Bath” was a brick basin with steps on either side and a capacity for 160 m3 of water. As the city was located in a hot desert climate, there was no need for heating the water. Sources: Graeber, David, and David Wengrow. The dawn of everything: A new history of humanity. Penguin UK, 2021 + Jansen, Michael. “Mohenjo-Daro, Indus Valley civilization: water supply and water use in one of the largest Bronze Age cities of the third millennium BC.” Geo: A new world of knowledge (2011). https://openarchive.icomos.org/id/eprint/1541/1/110601geo_06_2011_indian_edition_email.pdf ↩︎
Maréchal, Sadi. Public baths and bathing habits in Late Antiquity: a study of the archaeological and historical evidence from Roman Italy, North Africa and Palestine between AD 285 and AD 700. Diss. Ghent University, 2016. https://biblio.ugent.be/publication/7235534/file/7235545.pdf ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎
Fagan, Garrett G. “The genesis of the Roman public bath: recent approaches and future directions.” American Journal of Archaeology 105.3 (2001): 403-426. ↩︎
Kosso, Cynthia, and Anne Scott, eds. The nature and function of water, baths, bathing, and hygiene from antiquity through the Renaissance. Vol. 11. Brill, 2009. ↩︎ ↩︎ ↩︎ ↩︎
Both the Greeks and the Romans also used cold baths in combination with sports facilities. Here, the act of washing was secondary. ¹⁵¹⁹ ↩︎
Hoagland, Alison K. The bathroom: a social history of cleanliness and the body. Bloomsbury Publishing USA, 2018. ↩︎ ↩︎ ↩︎ ↩︎ ↩︎
Ashenburg, Katherine. The dirt on clean: An unsanitized history. Vintage Canada, 2010. ↩︎ ↩︎ ↩︎
Fournier, Caroline. Les bains d’al-Andalus: VIIIe-XVe siècle. Presses universitaires de Rennes, 2018. https://books.openedition.org/pur/44617#anchor-resume ↩︎ ↩︎ ↩︎
Sibley, Magda, Camilla Pezzica, and Chris Tweed. “Eco-hammam: the complexity of accelerating the ecological transition of a key social heritage sector in Morocco.” Sustainability 13.17 (2021): 9935 ↩︎
Coomans, Janna. “Janna Coomans - The Medieval Bathhouse (MA Thesis - 2013).” The Medieval Bathhouse: Bathing Culture in the Late Medieval Low Countries (2013): n. pag. Print. ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎
Wurtzel, Ellen. “Passionate Encounters, Public Healing: Medieval Urban Bathhouses in Northern France.” French Historical Studies 46.3 (2023): 331-360. https://read.dukeupress.edu/french-historical-studies/article/46/3/331/381254/Passionate-Encounters-Public-HealingMedieval-Urban ↩︎ ↩︎
Büchner, Robert. Im städtischen Bad vor 500 Jahren: Badhaus, bader und Badegäste im alten Tirol. Böhlau, 2014. ↩︎ ↩︎ ↩︎ ↩︎ ↩︎
Thirteenth century Paris, with 200,000 inhabitants, counted around 30 public bathhouses ²³²⁴, while 14th century London, with a population of 80,000, had at least 18 public baths. ²⁰ In the late 14th century Low Countries, Bruges (30,000 inhabitants) and Ghent (40,000 inhabitants) each had around twenty public baths, while smaller cities like Maastricht and Leuven (15,000 inhabitants) had around five. Vienna (Austria) counted 29 bathhouses in the fifteenth century. ²³ Medieval bathhouses, like hammams, were smaller than Roman baths. Medieval stews found in Germany and the Low Countries had a ground surface of between 100 and 200 square meters. ²³ The typical roman city bath had a surface of about 500 m2. ¹⁵ ↩︎ ↩︎
Butler, Lee. “Washing Off the Dust”: Baths and Bathing in Late Medieval Japan." Monumenta Nipponica 60.1 (2005): 1-41. https://web.archive.org/web/20190818120651id_/http://muse.jhu.edu:80/article/182356/pdf ↩︎ ↩︎
Merry, Adam M., “More Than a Bath: An Examination of Japanese Bathing Culture” (2013). CMC Senior Theses. Paper 665. http://scholarship.claremont.edu/cmc_theses/665 ↩︎ ↩︎ ↩︎ ↩︎ ↩︎
Gill, A. A. ““Chattering” in the Baths: The Urban Greek Bathing Establishment and Social Discourse in Classical Antiquity.” (2011). https://tobias-lib.ub.uni-tuebingen.de/xmlui/bitstream/handle/10900/61481/CD27_Gill_CAA2008.pdf?sequence=2&isAllowed=y ↩︎
Górnicka, Barbara. Nakedness, shame, and embarrassment: A long-term sociological perspective. Vol. 12. Springer, 2016. ↩︎ ↩︎
A Cultural History of Parson’s Pleasure, George Townsend, PhD, Birkbeck, University of London, 2022, unpublished. See also: Dive in! A history of river swimming in Oxford. Museum of Oxford, expo 2023. https://moxdigiexhibits.omeka.net/exhibits/show/dive-in#:~:text=Dive%20In!-,A%20history%20of%20river%20swimming%20in%20Oxford,places%20for%20bathing%20and%20swimming. ↩︎
The egalitarian nature of the public bath was reinforced by the fact that people were partly or completely naked. “One stripped not only of their clothes but also of their social rank and material wealth, which become largely invisible”, concludes a historian of the Japanese public bath. ²⁸ “The true collective is a naked collective”, observes another, referring to the Russian banya. Source: Gearsimova, A. “My Banya, Your Banya: From Reality to Myth.” (2016). ↩︎
Mietz, Michael. “The fuel economy of public bathhouses in the Roman Empire.” Master’s thesis, Ghent University, Faculty of Arts and Philosophy, Campus Boekentoren, Blandijnberg 2 (2016): 9000. https://libstore.ugent.be/fulltxt/RUG01/002/303/996/RUG01-002303996_2016_0001_AC.pdf ↩︎ ↩︎ ↩︎ ↩︎
Wilson, A (2012) Raw materials and energy, in “The cambridge companion to the roman economy, scheidel 2012. ↩︎
Ancient deforestation revisited, Journal of the history of biology, 44 (1), 43-57. https://www.researchgate.net/profile/J-Donald-Hughes/publication/45407393_Ancient_Deforestation_Revisited/links/08ce17d911d2244431641d70/Ancient-Deforestation-Revisited.pdf ↩︎
Miliaresis, Ismini. “Heating the Stabian Baths at Pompeii.” Curious (2021): 83. https://library.oapen.org/bitstream/handle/20.500.12657/58973/1/external_content.pdf#page=91 ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎
The study assumes that the baths were heated for 24 hours per day and only shut down for maintenance. The fuel used for heating up the bath initially (calculated at 35 kg in the case of the Stabian Baths) is added only once to the total yearly energy use. The results are also based on the assumption that the water of the baths was changed once per day (and thus had to be heated from a cold state once per day). ↩︎
Veal, Robyn, and Victoria Leitch. Fuel and Fire in the Ancient Roman World: Towards an integrated economic understanding. McDonald Institute for Archaeological Research, 2019. https://www.repository.cam.ac.uk/bitstreams/c349fc20-11d0-4ad4-a2e9-55dccca9f2df/download ↩︎ ↩︎
Miliaresis, Ismini Alexandra. Heating and Fuel Consumption in the Terme del Foro at Ostia. Diss. University of Virginia, 2013. https://libraetd.lib.virginia.edu/public_view/5d86p0445 ↩︎
Whether or not the (small) windows in the Stabian baths had glass or shutters is not entirely clear. The study concludes that energy use is pretty similar with both glazed and unglazed windows. However, the Forum baths, with windows several meters high, would have required almost 1.5 times more wood to heat rooms with unglazed windows during the month of May, and more than twice as much in the coldest month. ↩︎
Ring, James W. “Windows, baths, and solar energy in the Roman empire.” American Journal of Archaeology 100.4 (1996): 717-724. ↩︎
This may have been true for Roman bathhouses as well, but I could not find any reference to it. For hammamns, see, for example: Sibley, Magda, and Martin Sibley. “Hybrid transitions: combining biomass and solar energy for water heating in public bathhouses.” Energy Procedia 83 (2015): 525-532. ↩︎ ↩︎
A fuel use of 7.5 to 12 kg/hr averages at 9.75 kg/hr, which corresponds to 234 kg firewood per day. One kg of wood contains roughly 5 kWh of thermal energy, which brings the daily fuel use of the Forum baths to 1,170 kWh. A shower of 8.9 minutes (the average in the netherlands) takes 2.1 kWh of thermal energy. ² Conclusion: the daily energy use of the Forum Baths equals that of 557 showers. The daily fuel use of the smaller and less energy efficient Stabian baths corresponds to the energy use of 378 showers. ↩︎
Brünenberg–Jens-Arne, Monika Trümper–Clemens, et al. “Stabian Baths in Pompeii. New Research on the Development of Ancient Bathing Culture.” (2019). https://www.academia.edu/download/67567783/Truemper_et_al._Stabian_Baths_RM_2019.pdf ↩︎
The energy use of a sauna is more variable than the energy use of a shower, and I could not find any reliable academic research. The data I use are a rough estimation based on numbers that I found on internet forums and websites. Also note that climate explains part of the difference in energy efficiency: the sauna is often located in a cold climate, while most Roman baths stood around the Mediterranean. ↩︎
Williams, Marilyn T. Washing” the great unwashed": public baths in urban America, 1840-1920. Ohio State University Press, 1991. https://kb.osu.edu/bitstream/handle/1811/6282/1/Washing_the_Great_Unwashed.pdf ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎ ↩︎
Dillon, Jennifer Reed. Modernity, sanitation and the public bath: Berlin, 1896–1933, as archetype. Duke University, 2007. https://dukespace.lib.duke.edu/bitstreams/33e2fe84-16ec-4044-91d6-75d5c87d37e3/download ↩︎ ↩︎ ↩︎
Ladd, Brian K. “Public baths and civic improvement in nineteenth-century German cities.” Journal of urban history 14.3 (1988): 372-393. ↩︎ ↩︎
The Stuttgart Bathhouse, for example, had two large pools, 300 dressing rooms, 102 bath tubs, two Russian-Roman baths, two cold water baths, a sun bath, and a bath for dogs. By the end of the century, almost every German city had erected at least one monumental bathhouse, which often included a restaurant and barber shop as well. ²⁵⁴⁶ ↩︎
New York City built 25 monumental bathhouses, and Boston included swimming pools and gymnasiums. However, other American cities exclusively built shower bathhouses for the poor classes. For example, by 1920, Chicago had erected more than twenty shower bathhouses throughout the poor and working class districts. ⁴⁶ ↩︎
Germany and Austria built shower bathhouses in poor neighbourhoods but also continued to build elaborate and expensive facilities for the higher social classes, many of them having a water supply but still lacking bathrooms. ⁴⁶ ↩︎
Talmisānī, Mayy, and Eve Gandossi. The last hammams of Cairo: a disappearing bathhouse culture. American Univ in Cairo Press, 2009. ↩︎
Damascus went down from 40 hammams in the 1940s to 13 in 2004. Source: Sibley, Magda. “The Historic hammāms of Damascus and Fez: lessons of sustainability and future developments.” The 23rd conference on passive and low energy architecture (PLEA). 2006. https://www.academia.edu/download/52232181/The_Historic_Hammms_of_Damascus_and_Fez_20170321-32624-5s2lbk.pdf Morocco is an exception. Various sources present different numbers for operating hammams which vary between 6,000 and 10,000 hammams that still operate using the traditional heating system. ⁴² ↩︎
“Tokyo starts effort to revive public bathhouses”, Julian Ryall Tokyo, October 1, 2022. https://www.dw.com/en/japan-launches-campaign-to-revive-fading-public-bathhouses/a-63282747#:~:text=In%20an%20effort%20to%20protect,pop%20into%20their%20local%20bathhouse. ↩︎
“Public baths fade from Tokyo, with nearly half gone over 15 years”, Natsumi Nakai, October 10, 2023. https://www.asahi.com/ajw/articles/15025294#:~:text=Public%20bathhouses%20are%20swiftly%20disappearing,to%20the%20Tokyo%20metropolitan%20government. ↩︎
“Fuel Crisis Forces Syrians to Use Public Baths”, Sputnik International, 2023. https://sputnikglobe.com/20230131/fuel-crisis-forces-syrians-to-use-public-baths-1106687250.html See also: “Aleppo bathhouse boom as Syria crisis turns showers cold”, Africanews, 2021. https://www.africanews.com/2021/12/30/aleppo-bathhouse-boom-as-syria-crisis-turns-showers-cold/ ↩︎
“Why we need to bring back the art of communal bathing”. Jamie Mackay, Aeon Magazine, 2016. https://aeon.co/ideas/why-we-need-to-bring-back-the-art-of-communal-bathing ↩︎
This is especially true in Western Europe, where opposition grew so strong that the bathhouse eventually disappeared in some regions between the sixteenth and the nineteenth century. ²³ The reasons for the temporal demise of bathing in Western Europe - a unique event in world history - are controversial among historians. Some point to the pressure of the Catholic and Protestant church, who increasingly perceived the medieval stews as places of immorality and sin. ⁵⁹ Others see the cause in epidemics, or point to changing medical views - doctors no longer considered hot water and steam healthy. ²³ Opposition started even before organized religion appeared. Ancient Roman philosopher Seneca was critical of the larger Roman baths and wrote several rants against them. He complained about the noise in the thermae, and accused them of extravagance and hedonism. See, for example: Moral letters to Lucilius by Seneca. Letter 86. On Scipio’s villa. https://en.wikisource.org/wiki/Moral_letters_to_Lucilius/Letter_86 ↩︎
In Ancient Rome, some bathhouses allowed mixed bathing, while others separated male and female bathers. Prostitution was legal, but the fact that a man’s wife had bathed with other men was a legitimate reason for divorce. ¹⁵ In Muslim Spain, substantial fines were assessed to men who either slipped into the bathhouse on days assigned to women, or who were caught spying through the windows of the structure. Women risked their legal rights if they did the same. Abusing a woman in a bathhouse, even verbally, carried the death penalty. See: Powers, James F. “Frontier municipal baths and social interaction in thirteenth-century Spain.” The American Historical Review 84.3 (1979): 649.667. In the Low Countries during the middle ages, authorities distinguished “honest” from “dishonest” stews. To maintain the quality of the “honest” bathhouses, they abolished, mixed bathing, set rules for bathmaids, and made prostitution in the bathhouse illegal. ²³ ↩︎ ↩︎
There’s no doubt that public bathhouses were a vector in historical epidemics. Medical tracts even advised against visiting the bathhouse. However, almost all baths remained open, very likely because they were seen as a service too essential to withdraw. At least, that was the case in the medieval Low Countries and in the Roman Empire, see: ²³²¹ ↩︎
How to make biomass energy sustainable again? Kris De Decker, Low-tech Magazine, September 2020. https://qelnixcor.cloud/2020/09/how-to-make-biomass-energy-sustainable-again/ ↩︎
Moreover, the hypocaust was further improved in the middle ages, meaning that it could be made even more energy efficient than in Roman times. See: Heat storage hypocausts: air heating in the middle ages, Kris De Decker, Low-tech Magazine, March 2017. https://qelnixcor.cloud/2017/03/heat-storage-hypocausts-air-heating-in-the-middle-ages/ ↩︎
Heat your house with a mechanical windmill, Kris De Decker, Low-tech Magazine, February 2019. https://qelnixcor.cloud/2019/02/heat-your-house-with-a-mechanical-windmill/ ↩︎
For example, researchers at the University of Stuttgart have devised a hybrid storage system consisting of a pressurized water and steam tank that serves as a storage for solar energy. The steam can be released in a sauna anytime, while the water serves to heat the space. See: Schaefer, M., et al. “Development of a zero-energy-sauna: Simulation study of thermal energy storage.” Energy and Buildings 256 (2022): 111659. https://www.sciencedirect.com/science/article/abs/pii/S0378778821009439. A very low-tech example is “Solauna”, which works with solar heat alone, basically by building a very large and well-insulated solar box cooker. See: https://www.biopiscinas.pt/en/solar-sauna/. “Lytefire” creates heat and steam by sunlight from mirrors concentrated on a metal plate or a bag of stones. See: https://lytefiresauna.com/en. ↩︎
See: https://www.designboom.com/architecture/bao-split-bathhouse/. Another example is a bathhouse in Eastern Iran, built in 2004, which runs on two solar collector fields (195 m2 total) and two thermally insulated storage tanks (3m3 each). The facility supplies hot water for twelve showers and four baths, serving the hot water demands of 150 people per day. Source: Azad, E. “Design, installation and operation of a solar thermal public bath in eastern iran.” Energy for Sustainable Development 16.1 (2012): 68-73. Researchers are also investigating the combined use of biomass furnaces and solar thermal collectors for hammams in Morocco. See: Krarouch, M., et al. “Simulation of floor heating in a combined solar-biomass system integrated in a public bathhouse located in Marrakech.” IOP Conference Series: Materials Science and Engineering. Vol. 353. No. 1. IOP Publishing, 2018. See also: Mohamed, Krarouch, and Haller Michel. “Design optimisation of a combined pellets and solar heating systems for water heating in a public bathhouse.” Energy Reports 6 (2020): 1628-1635. See also: Sibley, Magda, Camilla Pezzica, and Chris Tweed. “Eco-hammam: the complexity of accelerating the ecological transition of a key social heritage sector in Morocco.” Sustainability 13.17 (2021): 9935. See also: Zbaidi, Mourad, et al. “Improving the Energy Efficiency of a Traditional Hammam by Using Two Types of Heat Exchanger.” International Journal on Engineering Applications 11.6 (2023). ↩︎
How (Not) to Run a Modern Society on Solar and Wind Power Alone, Kris De Decker, Low-tech Magazine, September 2017. https://qelnixcor.cloud/2017/09/how-not-to-run-a-modern-society-on-solar-and-wind-power-alone/ See also: Battery Killers: Grid-Interactive Water Heaters, Kris De Decker, No Tech Magazine, May 2015. https://www.notechmagazine.com/2015/05/battery-killers-grid-interactive-water-heaters.html ↩︎

How Sustainable is High-tech Health Care?

Thu, 18 Feb 2021 00:00:00 +0000

The surgeon, a painting by David Teniers, 1670s.

The environmental footprint of the health care sector

Health care is one of the most important economic sectors in high income countries, but its environmental footprint is underreported and not often considered. Most research into sustainable health care is less than five years old. A 2019 research paper calculated that the sector accounts for 2-10% of national carbon footprints across all OECD countries, China, and India, with an average share of 5.5% overall. ¹ ²

The data refer to the year 2014, when the health care sectors of all these 36 countries combined were responsible for 1.6 Gt of greenhouse gas emissions. This corresponds to 4.4% of the global total emissions that year (35.7 Gt) – almost double the share of aviation. The US has the most carbon-intensive health care system, accounting for up to 10% of national carbon emissions. ³ It also produces 9% of national air pollution, 12% of acid rain, and 10% of smog formation nationally.

The environmental footprint of health care keeps increasing. For example, in the US, the health care sector’s greenhouse gas emissions grew by 30% between 2003 and 2013. ³ The rise in emissions couples an increase in spending – in fact, the emissions are often calculated based on spending. US national health expenditures as a percentage of Gross Domestic Product (GDP) increased from 3% in 1930, to 5% in 1960, to 10% in 1983, to 15% in 2002, and to 17.7% in 2019. ⁴ ⁵ In the EU, health care spending per capita more than doubled between 2000 and 2018, and total spending is now at 9.9% of GDP. ⁶

If the whole world would copy today’s US health care system, the global carbon footprint of the health care sector would amount to almost half of total emissions worldwide in 2014.

The 36 countries whose health care systems together cause 4.4% of global emissions only have 54% of the worldwide population. The remaining 46% of the population produces little or no health care related emissions because they don’t have access to health care. If we were to extend the OECD-China-India health care system globally, emissions would double to about 8% of the worldwide total. Furthermore, there are very large differences between these 36 countries. If the whole world were to copy the US health care system, the global carbon footprint of the health care sector would amount to around 16 Gt – almost half of total emissions worldwide in 2014.

Intense spotlights, high power medical equipment

What makes modern health care so resource-intensive? ⁷ To start with, modern hospitals are high energy users, primarily because of large plug loads from medical devices, lighting, ventilation and air-conditioning. ³ ⁸ ⁹ ¹⁰ ¹¹ ¹² In operating rooms, the high power use is mainly due to the use of intense spotlights and ultra clean ventilation canopies. In intensive care units and diagnostic imaging departments, medical equipment dominates the power load. ⁹

Technologically Advanced Operating Room. iStock.

An MRI-scanner in Taipei, Taiwan (2006). Image: Kasuga Huang (CC BY-SA 3.0).

Like so many other sectors in modern society, health care has come to rely on all types of machines and devices. ¹³ Some of this medical equipment has very high power use. For example, an MRI-scanner, one of the most powerful diagnostic imaging technologies, can use as much electricity as more than 70 average European households. A 2020 study calculated that high-tech medical diagnostic technology (both MRI- and CT-scanners) was responsible for a whopping 0.77% of global carbon emissions in 2016. ¹⁴

The power use of smaller medical equipment is poorly researched, but an inventory of two US hospitals showed that they had 14,648 and 7,372 energy using devices, of which the infusion pumps alone consumed more electricity on aggregate than an MRI-scanner. ¹³ The high density of medical equipment also increases the electricity use of air-conditioning in hospitals. ⁹

Resource use along the supply chain

Even more energy – around 60% of the total – is used indirectly along the supply chain. ¹ ³ ¹⁰ ¹⁵. This concerns the procurement of medical equipment, pharmaceuticals, and other medical products.

To start with, the growing number of medical devices used in hospitals also needs to be manufactured and brought to market. This requires activities such as the mining of resources and the construction and operation of research laboratories, factories and transport vehicles. This “embodied energy” of the medical equipment supply chain is very poorly researched. A study calculated that the production of an MRI-scanner requires more than half the fossil fuels used in the production of a passenger jet, and that the embodied energy is one third of the total energy use of the machine. ¹⁶

Modern health care is also highly dependent on pharmaceuticals, which account for between 10 and 25% of total health care emissions, depending on the country. ¹⁵ ¹⁷ A 2019 study revealed that the global pharmaceutical industry produces more greenhouse gases than the global automotive industry: 52 MtCO2 versus 46 MtCO2. ¹⁸ However, there is almost no data about the environmental footprint of specific pharmaceuticals, because corporate secrecy prevents scientists from making life cycle analyses.

Pharmaceutical Manufacturing Laboratory. Source: iStock.

Rubber gloves production line. Source: iStock.

Face mask production line. Source: iStock.

Single-use disposable products are another source of health care energy use and pollution. ¹⁹ ²⁰ ²¹ ²² ²³ ²⁴ These products are worn by medical personnel and patients (face masks, gloves, overshoes, hats, drapes, gowns). Towels, basins, sterile plastic packaging, and utensils such as syringes, laryngoscopic handles and blades, anaesthetic breathing circuits, and even surgical instruments are also provided for single use. These disposable products are supplied to hospitals in so-called custom packs, which are sets of prepackaged sterile products for any specific medical procedure you can imagine. In principle, once a pack is opened, all items are discarded, even if they were not used.

When these practices are questioned, it is often for the hospital waste they create – the average patient in a hospital produces at least 10 kg of waste per day. ²⁵ However, the environmental footprint increases significantly if the embodied energy and waste in the supply chain for making these disposable products is considered too. A study of cataract surgery in the UK – cataracts are the main cause of blindness worldwide – shows that the manufacturing of disposable materials accounts for more than half of the total carbon footprint of the procedure. ²⁶

Anesthetics & Vaccines

Finally, some specialist medical drugs produce emissions too. Inhalation anesthetics, which suppress the central nervous system and are a cornerstone of surgery, are potent greenhouse gases, which evaporate into the atmosphere after they have been inhaled by the patient (vented to the outside through the high energy ventilation systems of modern operating rooms). ²⁷ Maintaining a 70 kg adult anesthetized for an hour produces from 25 kg (using isoflurane) to 60 kg (desflurane) CO2-equivalents, which corresponds to the emissions of driving an average European car (121gCO2/km) for 200-500 km (or driving it for around 4 hours). ¹⁵

Pressurized dose inhalers, which are used to treat asthma and chronic obstructive pulmonary disease, also release potent greenhouse gases. Globally, around 800 million pressurized dose inhalers are manufactured annually, with a total carbon footprint that corresponds to the yearly emissions of more than 12 million passenger cars. ¹⁷ ²⁷ Vaccines are another key element of modern health care. They release carbon emissions not only through their development and production, but also by their resource-intensive distribution, which involves a dedicated cold chain. I could not find any reference to its environmental footprint.

Carbon footprint of medical procedures

Health care services often involve all of the above mentioned sources of emissions: medical devices, pharmaceuticals, and disposable materials. When the emissions in hospitals and along the supply chain are combined, it becomes possible to calculate the environmental footprint of medical procedures.

Operating room in cardiac surgery, 2020. Source: iStock.

For example, studies of cataract surgery and reflux control surgery in the UK estimated the carbon footprint to be 182 kg and 1 ton of emissions, respectively, which corresponds to between 1,517 km and 8,333 km of driving. ²⁸ ²⁹ Renal dialysis, a treatment to replace kidney function, produces 1.8 to 7.2 tonnes of emissions per patient per year, equal to the emissions of 15,000 to 60,000 km of driving. ²⁸ ³⁰

The limitations of carbon and energy efficiency

Although data on its environmental footprint is still incomplete, it seems quite clear that modern health care is not compatible with a transition to a low carbon society. The big question is whether or not this can be fixed without lowering the levels of care, pain relief, and longevity that people in high income societies have grown accustomed to.

Many efforts and studies into health care sustainability aim to reduce energy use and emissions without affecting the quality of medical treatments, often explicitly so. For example, the authors of a 2020 study into the Austrian health care system write that it’s “crucial to understand how the health care sector can reduce its emissions without undermining its service quality”. ¹⁷ Elsewhere, researchers write that “any solution that would reduce environmental impacts while reducing performance at the same time cannot be deployed”. ³¹

As a consequence, many researchers tend to focus on improving carbon and energy efficiency. These strategies aim to deliver the same “performance” or “service quality” but with less energy (thanks to more energy efficient equipment), or with less emissions (owing to more renewable energy sources). ³²

The quality of medical treatments continues to improve, resulting in extra energy use that erases the carbon or energy savings that result from efficiency.

The problem is that the quality of medical treatments continues to improve, resulting in extra energy use that erases the savings that result from carbon and energy efficiency. For example, in 2012 researchers calculated that MRI-scanners could be made 10-20% more energy efficient with relatively simple changes in design and operation. ³¹ Some of their proposed changes are now in use, but the energy use of MRI-scanners has not decreased, on the contrary.

Medical Scientist working on brain tumor cure in a Research Center. Source: iStock.

A first reason is that MRI-scanners now come with higher field strengths (which offer diagnostic images of higher accuracy) and with larger boreholes (which improve patient comfort and allow obese or very muscular patients to be scanned). These innovations have improved the quality of care, but they have done so at the expense of extra energy use. In the 2012 study, the average power consumption per scan before the energy efficiency improvements was 15 kWh. A 2020 study measured an energy use of 17 kWh and 23.6 kWh per scan for an MRI-scanner with a field strength of 1.5 and 3 Tesla, respectively. ³³

Second, MRI-scanners with better diagnostic capabilities also increase energy use in unexpected ways, because medical equipment, pharmaceuticals, and treatments shape and change each other. ³⁴ For example, doctors used to diagnose a patient through physical examination and communication, and only used diagnostic services to confirm the diagnosis, if necessary. Now, diagnostic tests happen upfront and drive the decision process, resulting in more tests and higher energy use. The introduction of new pharmaceuticals can foster increasingly energy-intensive diagnostic practices, too. For example, certain cancer treatment drugs are now being designed to treat a very specific tumor subtype, which requires more and more accurate medical imaging to identify the tumor subtype. ³⁴

Adding more renewable energy sources could potentially lower the emissions of health care both on-site and throughout the supply chain, but as the energy use of medical treatments continues to increase, this outcome is unlikely. Besides, a quick calculation shows that, even without further growth in energy use, a carbon neutral US health care system would gobble up the entire US renewable energy production – sun, wind, hydroelectric, wood, geothermal, biofuels, and waste. ³⁵ The challenge is only slightly smaller in other high-income countries. Finally, renewable energy would not solve all of the health care sector’s environmental damage, and would not even eliminate all of its carbon emissions.

Sufficient health care?

To reduce the environmental footprint of modern health care, we need to question the trend towards ever greater reliance on energy-intensive technologies and services. The same holds true in other domains of life. ³²

However, while some people see the charm and real advantages of frugal and past ways of living when it comes to comfort or convenience, few would be tempted to apply the same principles to health and longevity. After all, the health care equivalent of travelling more slowly or wearing an extra sweater at home may be living a shorter life, suffering more pain, or being less mobile in old age. For example, if we would stop using MRI-scanners, or only use those with a field strength up to 1.5 Tesla, the lower diagnostic accuracy will lead to some cancers not being detected, resulting in lower cancer survival rates, and a lower average life expectancy. Or at least, so it seems.

Barber-surgeon extracting a tooth, a painting by Adriaen van Ostade, 1630.

If health care is viewed in a historical context, it seems clear that there is a powerful connection between the use of energy-intensive medical technologies on the one hand, and the health and longevity of a population on the other hand. Even looking back less than a century shows much lower health outcomes and survival rates for all kinds of diseases, and today’s global average life expectancy (72.6 years) is higher than in any high-income country back in 1950.

Hospitals date back to antiquity, but they merely welcomed those gone mad or awaiting death. In the middle ages, surgery happened at the barbershop, where “barber-surgeons” offered blood-letting, tooth extractions, and amputations alongside the more usual haircuts and shaves. They brew their own anesthetics based on herbs and alcohol, which could be just as deadly as the treatment itself. ³⁶ A look at the “developing” world today also seems to suggest a clear connection between health care emissions, which are very modest, and life expectancy, which can be 20 to 30 years below that in high income countries. ³⁷ ³⁸ ³⁹ ⁴⁰ ⁴¹

However, if one digs deeper, the connection between energy use and longevity is not as strong as it seems. This is proven by the USA, which has the most expensive and unsustainable health care system in the world, but ranks behind most European countries on the Health Care Access and Quality Index (which measures death rates from 32 causes of death that could be avoided by effective medical care). US citizens also have a lower life expectancy than European citizens. Clearly, there are other factors at play, too.

Resistance to disease

To start with, the quality of a health care system is not the only determinant of health and longevity. Here’s where history does have an important lesson to teach us. Medical knowledge dating back to antiquity viewed health in a more holistic way and placed great emphasis on building up the body’s inherent resistance to disease. For example, Hippocrates, often referred to as the father of Western medicine, prescribed diet, gymnastics, exercise, massage, hydrotherapy, and swimming in the sea. ⁴²

One could argue that our forebears had no other choice than to focus on preventing disease, because they had few treatments available. However, the wisdom of their approach is more obvious than ever. Nowadays in high income societies, many patients need medical treatment because of so-called lifestyle diseases – those caused by poor or excessive nutrition, lack of physical activity, stress, or substance abuse. Typical health risks are cardiovascular disease, diabetes type 2, depression, obesity, some types of cancers, and higher susceptibility to infectious diseases. Industrial society has given us effective medical treatments, but it’s also making us sick.

This means that health and longevity can be promoted in other ways than through an increasingly resource-intensive health care system. By addressing the broader determinants of health and longevity, we could make a switch from curative to preventive medicine. ¹⁵ ⁴³ Preventive medicine is not about the government telling us not to smoke (and then cashing in tax money on the sales of cigarettes). Rather, it concerns systemic changes that go beyond behavioural change.

Rush hour in São Paulo, Brazil, 2005. Public domain.

For example, significantly reducing the use of cars in our societies would bring a surprisingly large number of health benefits that would lower the need for energy-intensive medical treatments. It would decrease the health damage done through traffic accidents and through air and noise pollution. It would make people more physically active (preventing many lifestyle diseases), and it would free a lot of public space for people to come together, for kids to play, and for trees to grow (all important factors for the mental health of a population). Finally, reducing the use of cars may easily save more greenhouse gas emissions than the health care system produces.

Switching to a healthier food production system, addressing the environmental damage done by the plastic industry, reducing poverty and social inequality, introducing shorter work hours, and more meaningful jobs are other examples of preventive medicine. We have not achieved the higher life expectancy of today only because of better health care systems. We also got it because of better education, sanitation, safety and traffic regulations, welfare systems, crime control, and a more reliable food supply. The low average life expectancy in poor countries is also partly due to these factors.

Preventive medicine would also reduce the health damage done by the medical treatments themselves. This concerns health damage resulting from medical errors or side effects of pharmaceuticals and more indirectly from the pollution that the health care sector generates. For example, air pollution from health care services contributes to the prevalence of asthma, which in turn increases the demand for health care. Climate change and other environmental damage threaten younger and future generations with even larger health impacts, for example through crop failures, spread of diseases, extreme weather events, and natural disasters. ⁴⁴

The law of diminishing returns

Second, within a health care system, medical practices with higher energy use do not necessarily lead to increased health outcomes in a proportional way. Like so many other sectors in industrial society, curative health care is vulnerable to the law of diminishing returns: it takes ever more energy to gain ever smaller increases in health outcomes. ⁵ Conversely, this means that a relatively small decline in the quality or specifications of medical treatments could yield comparably large reductions in resource use and emissions.

Infection control is a good example. The development of general anesthesia in the 1840s made surgery possible, but at the time over 90% of surgical wounds became infected, often leading to death. ⁴⁵ The first major decrease in infection rates followed antiseptic practices (1880-1900), and the second followed the introduction of antibiotics (1945-1970). By 1985, the overall infection rate had decreased to about 5%. Since then, a lot of resources have been invested to achieve incremental gains towards 100% sterility, mainly by replacing reusable supplies by single-use, disposable products. ²⁶

Operating room nurse preparing instruments for surgery at the 3rd Station Hospital, Korea. 1951. Source: US National Library of Medicine.

If properly decontaminated, reusable supplies carry no increased infection risks, but cross-contamination between patients sometimes happens by mistake. Nevertheless, some scientists have advocated for a return to reusable products, which have a much lower environmental footprint in most cases. For example, the use of reusable laryngoscope handles produces 16-25 times less greenhouse gases than single-use, disposable ones. ⁴⁵. The researchers admit that their approach may increase deaths from surgical infections. Still, they argue that the health damage caused by the production of single-use disposable supplies is even more considerable.

Comparisons of cataract surgery in the UK and in India have shown that the same treatment produces only 5% of the emissions and 6% of the solid waste in the UK.

When it comes to maximizing returns, less affluent societies can teach us some lessons. Comparisons of cataract surgery in the UK and in India have shown that the same treatment (phacoemulsification) in India’s Aravind Eye Clinics is much cheaper and produces only 5% of the emissions and 6% of the solid waste in the UK. This is mainly because the Indian surgeons reuse as many supplies, devices, and drugs on as many patients as possible. ²⁶ ⁴⁶ ⁴⁷ ⁴⁸ ⁴⁹ In addition, they use locally manufactured supplies, implants, and drugs, and they apply a dual-bed system in which one patient is operated while another one is being positioned and prepared in the bed next to it.

Although these practices flout regulations for infection control in high income countries, cataract surgery in India achieves similar or better outcomes and does not cause any more infections than it does in the UK or the US. Consequently, it may well be that the law of diminishing returns has reached its ultimate limit, in the sense that an expensive and unsustainable medical practice does not seem to bring any health benefits at all. The Indian eye clinics demonstrate that an effective model of care is possible without expensive and unsustainable supplies and resources. Medical innovation can happen without new technology.

Driven by profit

The law of diminishing returns and the focus on curative medicine are both rooted in the fact that medical innovation is primarily driven by profit. ⁵⁰ ⁵¹ Private companies who develop and sell medical equipment, pharmaceuticals, and other health care products have nothing to win or earn if the demand for new curative health care technologies and products declines, or if medical technologies were to be judged in relation to their resource use. The medical industry – logically – wants to increase the sales of its products, and has enormous marketing budgets and lobbying power at its disposal to achieve that goal. ⁵²

King George Military Hospital, electrical treatment and x-ray room. 1915. Source: US National Library of Medicine.

The WHO estimates that 20-40% of health care spending is wasted, and argues that “the cost-effectiveness, real need, and likely usefulness of many innovative technologies are questionable”. ⁴⁴ ³⁷ An increasing body of academic literature shows the extent to which patients in high income countries are “overdosed, overtreated, and overdiagnosed”. ⁴⁴ ¹⁴

None of this is inevitable. A modern health care system could also work in another economic context. For example, some have suggested the open source development of medical equipment and pharmaceuticals, in which health care technology would become a commons. Shifting the tax burden from labour to resources could be another part of the solution. In high income countries, medical equipment, pharmaceuticals, and disposable products partly serve to reduce the expensive human labour force in health care.

Age and Sustainability

Based on the fragmented data available, it seems likely that the resource use of modern health care systems could be reduced significantly, without bringing us back to the barber-surgeons of the middle ages. A health care system that is more focused on preventive medicine, and which operates outside the logic of the market, could reduce emissions without negatively impacting health, maybe even improving it.

As medical treatments become increasingly resource-intensive, the chances grow that the public health damage of a treatment outweighs the individual gain of a patient, especially at old age.

Otherwise, the law of diminishing returns highlights opportunities to lower the environmental footprint of health care services. For example, if the environmental footprint of health care was halved, it’s very unlikely that life expectancy would decrease proportionally. Nearly half of lifetime health care expenditures – and thus energy use and emissions – is incurred during the senior years (+65 years old). For those up to age 85, more than one-third of their lifetime expenditures will accrue in the remaining years. ⁵³

Advocating for a shorter average life expectancy, even if it may concern a very modest decrease, sounds problematic. However, avoiding the topic is just as problematic. Because of modern health care’s enormous (and still growing) environmental footprint, today’s health and longevity comes at least partly at the expense of the health and longevity of younger and future generations, who have no voice in this debate. ⁴⁴

If we cure one person today, at the expense of making other people sick tomorrow, health care becomes counter-productive. Health is not only a private good but also a public one, and as medical treatments become increasingly resource-intensive, the chances grow that the public health damage of a treatment outweighs the individual gain of a patient, especially at old age.

Thanks to Elizabeth Shove

Pichler, Peter-Paul, et al. “International comparison of health care carbon footprints.” Environmental Research Letters 14.6 (2019): 064004. https://iopscience.iop.org/article/10.1088/1748-9326/ab19e1/pdf ↩︎ ↩︎
National estimates of health care sector greenhouse gas emissions have been performed for the UK (2009), the USA (2009 & 2016), Sweden (2017), Australia (2018), Canada (2018), China (2019), Japan (2020) and Austria (2020). For an overview, see [15]. However, because each study has its own methodology, the results are not perfectly comparable. That’s why I quote this source, as it gives comparable estimates. ↩︎
Eckelman, Matthew J., and Jodi Sherman. “Environmental impacts of the US health care system and effects on public health.” PloS one 11.6 (2016): e0157014. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0157014 ↩︎ ↩︎ ↩︎ ↩︎
US National Health Expenditure Data. Centers for Medicare & Medicaid Services. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical ↩︎
Tainter, Joseph. The collapse of complex societies. Cambridge university press, 1988. Page 102 & 103. ↩︎ ↩︎
Current healthcare expenditure, 2012-2017, Eurostat. Current health expenditure per capita (current US$) - European Union, World Bank. Current health expenditure per capita, PPP (current international $) - European Union, World Bank. Health spending, OECD. ↩︎
In what follows, I ignore the resource use and emissions caused by transportation to and from health care facilities, as well as the resource use and emissions caused by the building of the health care facilities themselves. ↩︎
Research in different countries has shown an electricity use of 130 to 280 kilowatt-hour per square metre per year, representing around 50% of total on-site building energy consumption. [11-12] For comparison, residential electricity use in European households is on average 70 kWh/m2/year, and total energy demand is dominated by heating, not electricity. According to a 2016 study, for which scientists collected power data over a period of 18 months in a German hospital, operating rooms have the highest electricity use (438 kWh/m2/year), followed by intensive care units (135 kWh/m2/yr). [9] ↩︎
Christiansen, Nils, Martin Kaltschmitt, and Frank Dzukowski. “Electrical energy consumption and utilization time analysis of hospital departments and large scale medical equipment.” Energy and Buildings 131 (2016): 172-183. ↩︎ ↩︎ ↩︎
Wu, Rui. “The carbon footprint of the Chinese health-care system: an environmentally extended input–output and structural path analysis study.” The Lancet Planetary Health 3.10 (2019): e413-e419. https://www.sciencedirect.com/science/article/pii/S2542519619301925 ↩︎ ↩︎
Bawaneh, Khaled, et al. “Energy consumption analysis and characterization of healthcare facilities in the United States.” Energies 12.19 (2019): 3775. https://www.mdpi.com/1996-1073/12/19/3775/pdf ↩︎
Rohde, Tarald, and Robert Martinez. “Equipment and energy usage in a large teaching hospital in Norway.” Journal of healthcare engineering 6 (2015). http://downloads.hindawi.com/journals/jhe/2015/231507.pdf ↩︎
Black, Douglas R., et al. “Evaluation of miscellaneous and electronic device energy use in hospitals.” World Review of Science, Technology and Sustainable Development 10.1-2-3 (2013): 113-128. https://www.osti.gov/servlets/purl/1172701 ↩︎ ↩︎
Picano, Eugenio. “Environmental sustainability of medical imaging.” Acta Cardiologica (2020): 1-5. https://www.tandfonline.com/doi/abs/10.1080/00015385.2020.1815985 ↩︎ ↩︎
Sherman, Jodi D., et al. “The Green Print: Advancement of Environmental Sustainability in Healthcare.” Resources, Conservation and Recycling 161 (2020): 104882. https://www.researchgate.net/profile/Brett_Duane/publication/343137350_The_Green_Print_Advancement_of_Environmental_Sustainability_in_Healthcare/links/5f216962299bf134048f8960/The-Green-Print-Advancement-of-Environmental-Sustainability-in-Healthcare.pdf ↩︎ ↩︎ ↩︎ ↩︎
Martin, Marisa, et al. “Environmental impacts of abdominal imaging: a pilot investigation.” Journal of the American College of Radiology 15.10 (2018): 1385-1393. https://www.sciencedirect.com/science/article/abs/pii/S1546144018308639. The researchers write that “when production and use phases are combined, the total energy consumption of MRI (>309 MJ/examination, abdominal scan, 1.5 Tesla) is comparable with cooling a three-bedroom house with central air-conditioning for a day”. ↩︎
Weisz, Ulli, et al. “Carbon emission trends and sustainability options in Austrian health care.” Resources, Conservation and Recycling 160 (2020): 104862. ↩︎ ↩︎ ↩︎
Belkhir, Lotfi, and Ahmed Elmeligi. “Carbon footprint of the global pharmaceutical industry and relative impact of its major players.” Journal of Cleaner Production 214 (2019): 185-194. https://www.sciencedirect.com/science/article/abs/pii/S0959652618336084 ↩︎
Laufman, Harold, Luther Riley, and Barry Badner. “Use of disposable products in surgical practice.” Archives of Surgery 111.1 (1976): 20-26. https://jamanetwork.com/journals/jamasurgery/article-abstract/581229 ↩︎
Gilden, Daniel J., K. N. Scissors, and J. B. Reuler. “Disposable products in the hospital waste stream.” Western journal of medicine 156.3 (1992): 269. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1003232/pdf/westjmed00091-0045.pdf ↩︎
Sherman, Jodi D., and Harriet W. Hopf. “Balancing infection control and environmental protection as a matter of patient safety: the case of laryngoscope handles.” Anesthesia & Analgesia 127.2 (2018): 576-579. https://www.researchgate.net/profile/Jodi_Sherman/publication/322407715_Balancing_Infection_Control_and_Environmental_Protection_as_a_Matter_of_Patient_Safety_The_Case_of_Laryngoscope_Handles/links/5a82ba12a6fdcc6f3eadcfab/Balancing-Infection-Control-and-Environmental-Protection-as-a-Matter-of-Patient-Safety-The-Case-of-Laryngoscope-Handles.pdf ↩︎
Thiel, Cassandra Lee, et al. “Life cycle assessment of medical procedures: Vaginal and cesarean section births.” 2012 IEEE International Symposium on Sustainable Systems and Technology (ISSST). IEEE, 2012. ↩︎
Campion, Nicole, et al. “Sustainable healthcare and environmental life-cycle impacts of disposable supplies: a focus on disposable custom packs.” Journal of Cleaner Production 94 (2015): 46-55. ↩︎
“Reusables, Disposables each play a role in preventing cross-contamination”, Elizabeth Srejic, Infection Control Today, April 2016 ↩︎
Sustainability roadmap for hospitals, American Association of Hospitals. http://www.sustainabilityroadmap.org/topics/waste.shtml#.YCsEOXyYXWc. ↩︎
Thiel, Cassandra L., et al. “Cataract surgery and environmental sustainability: waste and lifecycle assessment of phacoemulsification at a private healthcare facility.” Journal of Cataract & Refractive Surgery 43.11 (2017): 1391-1398. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5728421/ ↩︎ ↩︎ ↩︎
Vollmer, Martin K., et al. “Modern inhalation anesthetics: potent greenhouse gases in the global atmosphere.” Geophysical Research Letters 42.5 (2015): 1606-1611. https://agupubs.onlinelibrary.wiley.com/doi/full/10.1002/2014GL062785 ↩︎ ↩︎
Salas, Renee N., et al. “A pathway to net zero emissions for healthcare.” bmj 371 (2020). ↩︎ ↩︎
Brown, Lawrence H., et al. “Estimating the life cycle greenhouse gas emissions of Australian ambulance services.” Journal of Cleaner Production 37 (2012): 135-141. ↩︎
Connor, A., R. Lillywhite, and M. W. Cooke. “The carbon footprint of a renal service in the United Kingdom.” QJM: An International Journal of Medicine 103.12 (2010): 965-975. https://academic.oup.com/qjmed/article/103/12/965/1584174 ↩︎
Herrmann, C., and A. Rock. “Magnetic resonance equipment (MRI)–Study on the potential for environmental improvement by the aspect of energy efficiency.” PE INTERNATIONAL AG, Report (2012). ↩︎ ↩︎
Shove, Elizabeth. “What is wrong with energy efficiency?.” Building Research & Information 46.7 (2018): 779-789. https://www.tandfonline.com/doi/pdf/10.1080/09613218.2017.1361746 ↩︎ ↩︎
Heye, Tobias, et al. “The energy consumption of radiology: energy-and cost-saving opportunities for CT and MRI operation.” Radiology 295.3 (2020): 593-605. https://pubmed.ncbi.nlm.nih.gov/32208096/ ↩︎
Blue, Stanley. “Reducing demand for energy in hospitals: opportunities for and limits to temporal coordination.” Demanding Energy. Palgrave Macmillan, Cham, 2018. 313-337. ↩︎ ↩︎
https://www.eia.gov/tools/faqs/faq.php?id=92&t=4 ↩︎
Duffin, Jacalyn. History of medicine: a scandalously short introduction. University of Toronto Press, 2010. ↩︎
WHO compendium of innovative health technologies for low-resource settings, WHO; 2016-17. WHO, 2018. https://www.who.int/medical_devices/publications/compendium_2016_2017/en/ ↩︎ ↩︎
Medical devices: managing the mismatch: an outcome of the priority medical devices project: methodology briefing paper, WHO, 2010. https://apps.who.int/iris/handle/10665/70491 ↩︎
Global Atlas of Medical Devices, WHO, 2017. https://www.who.int/medical_devices/publications/global_atlas_meddev2017/en/ ↩︎
Page, Brandi R., et al. “Cobalt, linac, or other: what is the best solution for radiation therapy in developing countries?.” International Journal of Radiation Oncology* Biology* Physics89.3 (2014): 476-480. ↩︎
In a survey of surgeons across 30 African nations, 48% reported at least weekly power failures, 29% had operated using only mobile phone lights, and 19% had experienced poor surgical outcomes as a result of it. [28] ↩︎
Parker, Steve. Medicine: The Definitive Illustrated History. DK Publishing, 2016. ↩︎
Hall, Peter A., and Michèle Lamont, eds. Successful societies: How institutions and culture affect health. Cambridge University Press, 2009. ↩︎
Borowy, Iris, and Jean-Louis Aillon. “Sustainable health and degrowth: Health, health care and society beyond the growth paradigm.” Social Theory & Health 15.3 (2017): 346-368. ↩︎ ↩︎ ↩︎ ↩︎
Sherman, Jodi D., and Harriet W. Hopf. “Balancing infection control and environmental protection as a matter of patient safety: the case of laryngoscope handles.” Anesthesia & Analgesia 127.2 (2018): 576-579. ↩︎ ↩︎
Steyn, A., et al. “Frugal innovation for global surgery: leveraging lessons from low-and middle-income countries to optimise resource use and promote value-based care.” The Bulletin of the Royal College of Surgeons of England 102.5 (2020): 198-200. https://publishing.rcseng.ac.uk/doi/pdf/10.1308/rcsbull.2020.150 ↩︎
Haripriya, Aravind, David F. Chang, and Ravilla D. Ravindran. “Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: Results from 2 million consecutive cataract surgeries.” Journal of Cataract & Refractive Surgery 45.9 (2019): 1226-1233. https://www.aurolab.com/images/JCRS%202%20million.pdf ↩︎
Venkatesh, Rengaraj, et al. “Carbon footprint and cost–effectiveness of cataract surgery.” Current opinion in ophthalmology 27.1 (2016): 82-88. ↩︎
Thiel, Cassandra L., et al. “Utilizing off-the-shelf LCA methods to develop a ‘triple bottom line’auditing tool for global cataract surgical services.” Resources, Conservation and Recycling 158 (2020): 104805. ↩︎
Relman, Arnold S. “The new medical-industrial complex.” New England Journal of Medicine 303.17 (1980): 963-970. https://www.nejm.org/doi/full/10.1056/NEJM198010233031703 ↩︎
Smith, Richard. “Limits to medicine. Medical nemesis: the expropriation of health.” Journal of Epidemiology & Community Health 57.12 (2003): 928-928. https://jech.bmj.com/content/57/12/928 ↩︎
In health care, there is a thin line between marketing and corruption, especially when the target audience is medical personnel that may gain benefits from using or prescribing a medical device or drug, or when regulators are influenced to facilitate practices that increase profits. Transparancy International ranks the procurement of drugs and medical equipment fourth on a list of seven processes that carry high risk of corruption, and calls the problem “widespread in all countries”. [37] ↩︎
Alemayehu, Berhanu, and Kenneth E. Warner. “The lifetime distribution of health care costs.” Health services research 39.3 (2004): 627-642. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361028/ ↩︎

Non-Electric Hearing Aids Outperform Modern Devices

Thu, 24 Aug 2017 00:00:00 +0000

Example of an ear trumpet. Source: [Bernard Becker Medical Library Image Gallery (archived)](https://web.archive.org/web/20121206034532/http://beckerimages.wustl.edu/cdm/search/collection/p15793coll3/searchterm/VC703!CID/field/all!all/mode/all!all/conn/or!and/order/identi)

Digital Hearing Aids

Roughly 40% of people between the ages of 55 to 74 suffer hearing loss. Eighty percent of them do not wear a hearing aid, even though their disability often has a negative impact on their quality of life as well as others around them. According to a 2013 research paper, the main reason is the limited performance of the devices.

Interestingly, these results are in line with those of studies performed at the end of the twentieth century, meaning that the introduction of digital hearing aids has had no positive effect on the popularity of the technology. Electric hearing aids consist of a battery, a microphone, an amplifier and a speaker. The more compact electronic hearing aids also contain a microchip.

An additional obstacle in low income countries is the cost of the technology, which concerns the device as well as the batteries, which need to be replaced regularly. Worldwide, roughly 1 billion people suffer from hearing loss. According to the World Health Organisation, only one fifth of them wears a hearing aid.

Ear Trumpets & Speaking Tubes

From the seventeenth century onwards, several types of non-electric hearing aids were developed, based on different acoustical principles. The most important devices were ear trumpets and speaking tubes.

In the ear trumpet, sound from a funnel-shaped metal tube was conducted to a small opening that was inserted in the listener’s ear. Ear trumpets were often slighty curved at one end so that they could be aimed at the sound source more easily. Some models were collapsible for easy carrying.

The speaking tube consisted of a flexible tube with a funnel-shaped opening on one end through which the speaker could talk, while the other end of the tube was put in the ear of the listener.

Stationary Hearing Aids

Speaking tubes and ear trumpets were also combined, especially in stationary hearing aids such as the acoustical chair. This seating had a pair of large trumpets on each side, which amplified the sound and led it through flexible tubes to the listener’s ears.

Similar technology could also be hidden in objects like vases. This was meant for several speakers and listeners gathering around a table. In the days before the telephone, speaking tubes were also used by people with normal hearing to communicate between floors of a building or a ship.

Sound Amplification

Measurements from the late twentieth century show that these devices perform better than today’s high-tech hearing aids. Ear trumpets and speaking tubes not only yielded a sound amplification of 10 to 25 decibels, they also suppressed sounds that came from other directions, further improving their workings. The speaking tube also reduced the noise between speaker and listener.

A speaking tube

Another important advantage was that both devices were very visible and thus encouraged the speaker to talk slower and more clearly. However, this visibility was also considered to be a problem: well-functioning, non-electric hearing aids are laughable.

From the nineteenth century onwards, the development of hearing aids took another direction: much smaller ear trumpets and speaking tubes were now hidden in clothing and accessories.

Vanity

The most popular models were worn as a kind of headband, with small trumpets hidden behind the ears, in hats, wigs, beards or scarfs. An extra advantage was that these devices could be operated hands free. Unfortunately, these hearing aids had poor performance compared to earlier models, and sometimes even impaired hearing.

However, a new trend was set. Since the nineteenth century, the main criterium for a hearing aid is no longer its effectivity but its discretion and compactness. Nevertheless, those who can overcome their vanity can revert to technology that has proven to work.

A large collection of images showing non-electric hearing aids can be found at the Bernard Becker Medical Library Image Gallery (archived).

Sources

“Non-electric aids to hearing: a short history”, S.D.G. Stephens & J.C. Goodwin, in Audiology 23: 215-240, 1984. A full version of the paper can be found online, but for some reason it’s impossible to link to it directly.
“Conceiled hearing aids of the 19th century”, Deafness in Disguise, Washington University School of Medicine.
“Why do people with hearing aids do not wear them?” Abby McCormack & Heather Fortnum, International Journal of Audiology, Volume 52, issue 5, 2013