3

Business Practices to Produce Health

George Isham, senior advisor at HealthPartners, reiterated a theme of the keynote address by Ian Galloway that the relevant outcomes for business are not just financial gain, but social gain as well. The conventional definitions of business need to be enlarged so business is still about the creation of value for both individuals and organizations, said Isham, and also about social values that are important in terms of health outcomes. In this session, panelists discussed how the private sector can leverage its resources and expertise to improve population health. Larry Soler, president and CEO of the Partnership for a Healthier America (PHA), described PHA’s approach to working with private-sector companies on initiatives to make the healthy choice the easy choice. Mark Weick, director of Sustainability Programs at The Dow Chemical Company (Dow), discussed the development and implementation of the company’s collaborative blueprint for sustainability, and how health is a key component of that sustainability. Gary Cohen, president and co-founder of Health Care Without Harm, described the organization’s issue-specific approach to transforming the health sector to be environmentally sustainable, and making hospitals and health systems anchor institutions in communities and leading advocates for environmental health and justice. Box 3-1 includes highlights from this session.

MAKING THE HEALTHY CHOICE THE EASY CHOICE

Soler started his presentation by showing a video from the Designed to Move campaign, produced by Nike in collaboration with PHA and a number of other organizations.¹ The main message of the video is that if current trends continue, children today will be the first generation to live shorter lives than their parents. PHA focuses on ending obesity, and Soler shared several examples of how PHA is working with private-sector

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¹ The video can be viewed as part of the complete video of Soler’s presentation at http://iom.nationalacademies.org/Activities/PublicHealth/PopulationHealthImprovementRT/2015-JUN-04/Videos/Panel%20I/6-Soler-Video.aspx (accessed November 19, 2015).

companies, like Nike, on initiatives designed to make the healthy choice the easy choice for American families.

PHA is not a big organization, so it partners with large organizations whenever possible to scale its work, Soler said. Because PHA negotiates voluntary agreements with industry, the impact can begin immediately (unlike legislation, which can be difficult to pass and challenging to implement). It is important that these agreements are meaningful, said Soler, and are not just the easy way out (i.e., they should not be a replacement for regulation that would be more impactful, if the regulation is realistic). Ensuring accountability in the system is also important, and the PHA process was developed to try to ensure that commitments made are commitments kept, Soler said.

PHA takes its agreements with industry very seriously, and Soler noted that PHA meets with approximately 10 companies for every one that results in a signed commitment. PHA asks for significant business impact and meaningful change. To the extent possible (and he noted that it is not always possible), PHA tries to focus on communities most in need and communities of color. The process requires that clear metrics be agreed to by both parties. Negotiations with companies can sometimes be lengthy, and he said negotiations with one major partner took more than 18 months to come to agreement. After the PHA board approves the agreement, a Memorandum of Understanding is signed, and a public announcement is made. PHA strives for public accountability and transparency, and issues an annual report highlighting what each of PHA’s partners has done (or has not done).² To ensure accuracy, the annual reports go through third-party outside verification.

PHA wants these initiatives to be successful and profitable for the companies, Soler said. If they are not profitable, they are not sustainable. PHA is not seeking charity as much as it is seeking sustainability and success for its partners, he said.

More than 150 private-sector partners are now working with PHA on a broad range of projects. Areas of focus include healthy food access, community engagement, health care (including a focus on health information technology), early childhood education, healthier marketplace (including reformulating foods and beverages), and healthy foods in hospitals, college campuses, affordable housing development, and physical activity. Soler shared examples of early childhood education and healthier marketplace commitments.

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² See http://progressreports.ahealthieramerica.org/2014 (accessed November 19, 2015).

Early Childhood Education Commitments

Nearly 1 million child care settings are expected to be participating when PHA commitments are fulfilled in 2017. Partners include some of the largest providers, such as the YMCA, Bright Horizons^®, KinderCare, the Learning Care Group, and others. As part of their commitment to PHA, child care centers are serving fruits and vegetables and healthier beverages at every meal and snack, having water available, encouraging family-style eating whenever possible, providing at least 1 hour of physical activity per day, and limiting screen time. Soler noted that getting the initiative going was difficult, but once the first private partner signed on, it became a competitive advantage for that company, and others became interested as well.

Healthier Marketplace: Walmart Commitment

Another example of PHA’s work with large companies is the agreement with the retailer Walmart, which serves 140 million Americans weekly, including many low-income Americans. Aspects of the Walmart commitment include reformulating thousands of packaged everyday food items, making healthier choices more affordable, developing strong criteria for a simple front-of-package seal, providing solutions to address food deserts by building stores, and increasing charitable support for nutrition programs. Soler pointed out that Walmart is not only working to reformulate its own branded foods, but it is also working with its suppliers to change their recipes to lower sugar, fat, and calories in their products as well. This will impact not just Walmart, but other stores selling those products. Walmart is using its volume power to drive the change beyond Walmart, which is significant, he said.

Marketing the Message

Soler asserted that it has never been more difficult in Washington, DC, to get even some common-sense advances accomplished. More and more people are looking to non-legislative strategies to make policy change, he added. Soler referred participants to a recent newspaper article that highlights the work of First Lady Michelle Obama, including her Let’s Move! campaign.³ Having a very popular First Lady take up the cause of childhood obesity garners significant attention. The announcement of Nike’s $50 million contribution in support for physical activity program-

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³ See http://articles.latimes.com/2014/feb/02/nation/la-na-obama-action-20140202 (accessed November 19, 2015).

ming, including $10 million in support of her Let’s Move! Active Schools campaign, included athletes such as Gabby Douglas, Bo Jackson, Colin Kaepernick, and Serena Williams. Using the star power of the First Lady, athletes, and celebrities can help companies gain national attention, and a public relations boost can be an important incentive for companies to participate in these initiatives, Soler said.

Soler shared a video about the value of advertising in spreading the message of health.⁴ Working with a host of diverse partners in health, produce, entertainment, advertising, and marketing, PHA has “branded” Fruits and Vegetables: “FNV.” Following the marketing model of major companies (e.g., Apple, Nike), Soler explained, a multimedia campaign featuring endorsements of FNV by the First Lady and a host of celebrities was created to tell the American public about how fruits and vegetables are great.⁵ At the time of the workshop, the advertising campaign had been launched in two pilot markets, Fresno, California, and Norfolk, Virginia, and Soler said the impact would be evaluated. He added that this type of marketing approach has been tried by the fruit and vegetable industries before, but has been difficult for them to do themselves. Having an organization such as PHA bring groups together has been helpful.

Soler noted that support from consumers has also been essential to bringing healthier foods to the marketplace. He suggested that 5 or 10 years ago, although companies might have been willing to make these types of changes to foods, people were not really interested in eating the changed (i.e., healthier) foods. Now, the millennial generation is driving changes in the market toward healthier foods.

Elements of Success

Soler summarized some of the common elements of success and lessons learned from PHA’s work with the private sector. He reiterated that profitability leads to sustainability, and PHA wants its corporate partners to be profitable and successful with healthier choices. Having clear metrics outlined in the written agreements is absolutely necessary, he said. There should also be a common understanding of the accountability process at the outset, and partners should understand that they will be evaluated and held accountable for what they agree to do. Finally, support from the executive leadership of the company is essential. Signed agreements are important, as it can be difficult to keep momentum when

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⁴ The video can be viewed as part of Soler’s presentation at http://iom.nationalacademies.org/Activities/PublicHealth/PopulationHealthImprovementRT/2015-JUN-04/Videos/Panel%20I/6-Soler-Video.aspx (accessed August 7, 2015).

⁵ See http://www.fnv.com (accessed July 31, 2015).

CEOs, presidents, and other senior leaders move in and out of positions in companies. Soler added that companies often need help from PHA to get through the agreement process. PHA has had to develop a lot of technical expertise to help companies identify and overcome any internal roadblocks to making a commitment and successfully meeting the goals.

DOW: HEALTH AS A COMPONENT OF CORPORATE SUSTAINABILITY

Weick opened his presentation by quoting Ehrenfeld and Hoffman, who wrote that “sustainability is the possibility that humans and other life will flourish on Earth forever” (2013, p. 17). Dow is taking a positive approach to thinking about how the company will innovate, work together, and develop a blueprint for sustainability that involves technology advances, as well as public policy advances and behavioral changes, that will create a far more positive and flourishing world, Weick said. Dow sells advanced chemicals, specialty chemicals, and plastics in about 180 countries, delivering products and solutions in many sectors, including packaging, water, electronics, coatings, and agriculture. Sustainability drives Dow to make every decision with the future in mind, he said. Dow’s 2025 Sustainability Goals introduce the notion of a collaborative blueprint for sustainability, which Weick said builds on previous 10-year commitments that were focused on the company footprint (1995-2005) and handprint (2006-2015).

2005 Environmental Health and Safety Goals

In the early 1990s, Dow set out to address some of the large problems it was facing as a business and to develop annual targets to solve them. The company soon realized that many of the issues that it was dealing with would not be solved using annual targets. A long-term approach was needed to justify capital investment when, for example, there was a need to build a new process or a new facility, release the product, observe the results, and improve. Each of the 10-year sets of goals has engendered a culture change within the company, Weick said.

The first sets of sustainability goals established in 1994 were called Environment, Health, and Safety Goals. These goals were focused on the corporate footprint, and how company operations impacted people directly through emissions, energy use, and safety, said Weick. The initial goals set achievable targets and saw some very significant results. He explained that solid waste was reduced by 1.6 billion pounds; energy efficiency was increased with a savings of 900 trillion BTUs (British thermal units); water usage was reduced by 183 billion pounds; and the worker

injury and illness rate was reduced by 84 percent. One billion dollars was invested toward the goals during that decade, Weick said, resulting in a $5 billion savings.

2015 Sustainability Goals

Dow continued to deliver economic value through its focus on sustainability with its 2015 Sustainability Goals. There was continued focus on its footprint (including spills, leaks, and injuries), with a new focus on what Greg Norris of Harvard University calls the handprint, that is, how Dow’s products and services help its customers solve their sustainability challenges.⁶

Dow focused on supply chains and reducing the risks to communities and employees by reducing the volume of hazardous chemicals being transported to market. This meant redefining how the supply chains were working, and where plants needed to be placed. During this decade, there were 4.3 billion fewer ton-miles of transporting hazardous materials, and 175 fewer hazardous material transportation spills. There were also 275 fewer process safety incidents, and 6,000 fewer spills. There were 1,100 fewer injuries due to an enhanced focus on safety. According to recent rates from the Occupational Safety and Health Administration, Weick said, it is 20 times safer statistically to work at Dow than to work at the average local supermarket.

During that decade, Dow also focused its innovation energy on breakthroughs to world challenges. Inspired by the United Nations Millennium Development Goals, the company focused on breakthroughs in water, healthy oils, energy efficiency in vehicles, and making soap more affordable.⁷ Dow has replaced 1.5 billion pounds of bad fats in the American diet through its omega-9 oils.⁸ Through Dow’s FILMTEC reverse osmosis elements, water can be cleaned to drinking standards that are 30 percent better, with 40 percent less energy.⁹ Ten billion gallons of fuel can be saved using Dow BETAMATE structural adhesives in lightweight vehicle

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⁶ Handprints are good social and environmental impacts, as opposed to the more familiar concept of footprints, which are negative impacts. See, for example, Norris, G. n.d. Doing more good than harm: Footprints, handprints, and beneficence. http://isites.harvard.edu/fs/docs/icb.topic979867.files/Basic%20Beneficience%20Primer.pdf (accessed August 14, 2015).

⁷ See http://www.dow.com/en-us/science-and-sustainability/sustainability-reporting/breakthroughs-to-world-challenges (accessed July 31, 2015).

⁸ See http://www.omega-9oils.com (accessed July 31, 2015).

⁹ See http://storage.dow.com.edgesuite.net/dow.com/sustainability/goals/Breakthrough-to-World-Challenges-White-Paper-FILMTEC-TM-ECO-RO-Elements.pdf (accessed July 31, 2015).

manufacturing.¹⁰ A Dow collaboration with Unilever has developed a long-lasting, affordable bar of soap that will be sold for 10 cents per bar in developing economies, and because of the incorporation of POLYOX polymers, they last about 1 month.¹¹

2025 Sustainability Goals

With its 2025 Sustainability Goals, Dow is maintaining its focus on both footprint and handprint, while incorporating a collaborative blueprint that will maximize economic, environmental, and societal value. The role of business needs to be redefined in society, Weick said. This means building cross-sector collaborations despite the many barriers that have been built up over the years, and the mistrust that has developed among sectors: academia, nongovernmental organizations (NGOs), civil society, governments, and business in order to create the flourishing society that we all envision.

Weick described Dow’s goals for the next 10 years, which fall into three broad sustainability pillars: unlocking the potential of people and science (Goals 2, 6, and 7), valuing nature (Goal 4), and courageous collaboration (Goals 1, 3, and 5):

Goal 1: Leading the blueprint. Dow is developing a societal blueprint that integrates public policy, science and technology, and value chain innovation to facilitate the transition to a sustainable planet and society. Dow is issuing this as an invitation to have a dialogue and to collaborate, Weick said. The target goal is to have 100 significant dialogues and 10 impactful collaborations. Over many decades different people have considered how to develop a blueprint for sustainability. Now is the time, he said, to make it possible for businesses that are making a transition to short- and long-term sustainable business models.

Goal 2: Delivering breakthrough innovation. Dow invests more than $1.5 billion per year in research and development, Weick said. While producing breakthrough chemistry innovations that advance the well-being of humanity, Dow is committing to six times net positive impact on sustainable development. In other words, he said, for every unit of energy Dow uses, Dow returns six times that benefit back to society.

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¹⁰ See http://storage.dow.com.edgesuite.net/dow.com/sustainability/goals/BTWC-White-Paper-BETAMATE-TM-Structural-Adhesives-Web.pdf (accessed July 31, 2015).

¹¹ See http://storage.dow.com.edgesuite.net/dow.com/sustainability/goals/Breakthrough-to-World-Challenges-Dow-Unilever-on-Lifebuoy-TM-Soap-feat-POLYOX-TM-Polymers-White%20Paper-141009.pdf (accessed July 31, 2015).

Goal 3: Advancing a circular economy. Dow advances a circular economy by delivering solutions while conserving resources and improving efficiency in key markets. We need to move away from the “take, make, and dispose” linear economy, Weick said. Dow will be seeking partners in markets such as packaging, electronics, and agriculture to develop collaborations and demonstration projects. One example thus far is working with the community of Citrus Heights, California, to take previously non-recycled plastics and turn them back into fuel. The target is to deliver six major circular economy projects over the next decade.

Goal 4: Valuing nature. Dow applies a business decision process that values nature, and which will deliver business value and natural capital value through projects that are good for the company and good for ecosystems. Weick noted that Dow has had a collaboration since 2011 with The Nature Conservancy on analyzing the value of ecosystem services (water, land, air, oceans, plant and animal life),¹² and is beginning to see very positive business results that could be replicated and scaled over the coming decade. The target is to develop business-driven project alternatives that will enhance nature and deliver $1 billion in net present value for the company.

Goal 5: Increasing confidence in the safe use of chemical technology. Dow aims to increase confidence and support for the safe use of chemical technology through transparency, dialogue, unprecedented collaboration, research, and its own actions. The foundation for this will be predictive toxicology, Weick explained, where Dow continues to move from in vivo to in vitro to in silico testing.¹³ The targets are to achieve 100 percent support for the use of chemical technology among key stakeholder groups, and to integrate predictive methods into 100 percent of new product assessments and reduce animal use in testing by 30 percent.

Goal 6: Engaging employees for impact. Dow employees worldwide directly apply their passion and expertise to advance the well-being of people and the planet. Dow will be expanding its outreach programs with the target of positively impacting more than 1 billion people worldwide. Ten percent of the workforce will serve as science, technology, engineering, and mathematics (STEM) ambassadors and give 600,000 hours to support better STEM education, and employee volunteers will complete 700 sustainability projects around the world.

Goal 7: Maintain world-leading operations performance in environmental health and safety, and natural resource efficiency. Target metrics

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¹² See http://www.dow.com/en-us/science-and-sustainability/collaborations/nature-conservancy (accessed October 11, 2015).

¹³ In silico testing is done by computer simulation. See http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3129017 (accessed October 12, 2015).

include zero unplanned safety and process safety events, 100 percent health rating, 10 percent improvement in resource efficiency, and 20 percent reduction in water intake.

In closing, Weick said this is an invitation to have a dialogue about how businesses can continue to help in developing a more sustainable future for our society.

The Evolution of the Blueprint

In response to a question about how Dow decided to develop the 2025 goals around the blueprint for sustainability, Weick said it was a progression. The company has a sustainability external advisory council that has been in place since 1992, which includes about 10 academic, government, and NGO leaders who advise Dow senior management in a series of semiannual meetings. In fall 2009 they tried to envision what a sustainable society would look like, as well as what Dow’s place in that sustainable society would be, on Dow’s 200th birthday, which is in the year 2097. Of course, it is impossible to predict all the technological and societal changes, Weick said, but it provides a framework for thinking beyond Dow and its current assets. Dow looked at the next generation approach to sustainability, starting in 2009 with a long-range visioning process, and looked at what was going to happen after the 2015 sustainability goals were finished. In 2013, the senior executives decided that they needed further engagement and input from employees and customers. Extensive interviews were conducted with employees across the company, particularly the Millennial population, to find out what kind of company they wanted to inherit and lead. What they learned really drove the thinking about taking care of the company’s footprint and handprint, but also forging the blueprint for human sustainability. Weick noted that this strategy entails simultaneous changes in the market as a whole, and some of Dow’s competitors are thinking along the same lines. The transformation needs to be not only of industry, but of society in general, and the role of business in society needs to be redefined, he said.

HEALTH CARE WITHOUT HARM

The health care sector is the one sector in the economy that operates within an ethical framework to “do no harm,” Cohen said. Health care in the United States accounts for 18 percent of the economy and uses an enormous amount of energy (mostly fossil fuels) and creates an enormous amount of waste (see Box 3-2). Health Care Without Harm¹⁴ was estab-

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¹⁴ See https://noharm-uscanada.org (accessed July 31, 2015).

lished in 1996 to transform the health care sector to be environmentally sustainable, and to serve as a leading advocate for environmental health and justice.

A Focus on Addressing Key Problems

Cohen shared several examples of the accomplishments of the coalition. In 1996, there were about 4,500 medical waste incinerators, which are a leading source of dioxin emissions. Over the course of a decade, the health sector has almost completely moved away from incineration, and now recycles a significant portion of its waste, he said. Reprocessing medical devices, for example, reduces waste and saves money in the process. This has had an enormous positive environmental impact.

Another major concern was mercury emissions. In the mid-1990s, the Centers for Disease Control and Prevention (CDC) said there was enough mercury pollution in the environment that it could impact brain development in utero. Just as Mercury was the messenger god, Cohen said, mercury use in health care was a clarion call for the need to address the environmental and health impacts of the hundreds of problematic chemicals that are in the system (in supply chains, buildings, medical devices, etc.). Health Care Without Harm started with one hospital in Boston, working to convince them to eliminate mercury thermometers and use safer alter-

natives. The change spread to all of the hospitals in Boston, then to other cities, and now 5,000 hospitals have committed to eliminate mercury, not just in thermometers, but also in blood pressure devices, fixatives, and other uses. All of the pharmacy chains in the United States have agreed to stop selling mercury thermometers. Mercury is being completely phased out of health care in the United States, and the European Union is taking similar action. In 2013, the Minamata Treaty was signed, focused on phasing out mercury-based measuring devices in health care by 2020. This is an example of how the health care sector can lead by example, Cohen said, by detoxifying its own supply chain and creating the momentum and the inspiration for other sectors to follow suit.

Health Care Without Harm staff members are also working with hospitals to remove toxic chemicals from buildings to make them healthier for patients and employees. One area of focus is achieving flame retardancy without using toxic flame retardants in furnishings. Kaiser Permanente, for example, is no longer purchasing furniture with toxic flame retardants, formaldehyde, or other toxic chemicals. Four other large hospital systems have followed the Kaiser example, and there is now a $50 million per year market demand for products that are safer for hospitals. Manufacturers are changing their practices to produce these safer products for hospitals, which Cohen noted helps to create a broad, industrywide momentum to transform the practices of a whole sector (e.g., drive the production of nontoxic flame retardants in school, home, and office furnishings). This also extends to flooring, lighting, and energy systems. Again, the health care sector can lead by example in the transformation toward a broader sustainable economy.

Climate change is another challenge for public health, Cohen said, and there is a lot of movement in health care to embed energy efficiency into operations, and to lead the transformation toward a renewable energy economy (Guenther and Cohen, 2014). Kiowa Hospital in Greensburg, Kansas, for example, was completely destroyed by a tornado and was rebuilt to run on wind power. Kaiser Permanente has recently announced one of the largest solar purchases of any company in history, and plans to have 50 percent of its facilities run on solar power within the next several years. That kind of transformation not only addresses price fluctuations in the energy market, he said, but is also good for the larger ecology of communities they serve.

Another area with a major transformation is food purchasing. Farmers’ markets now operate in hundreds of hospitals around the country. Hospitals are using their purchasing powers to support more local and sustainable food production in the communities they serve. Better food purchasing strategies impact climate, environmental health, patient safety, and worker health. Cohen suggested that health care workers suffer from

the same rates of obesity, diabetes, and other issues related to food as the general community. Hospitals are starting to link up with the school systems in their communities to be anchors for transforming the entire food supply for the region (discussed further below).¹⁵

The Healthier Hospitals Initiative

The Healthier Hospitals Initiative is a collaboration of Health Care Without Harm, Practice Greenhealth, and 12 large health systems to create a series of clear, actionable steps to move the whole sector forward on environmental health and sustainability.¹⁶ Initiatives were created around cleaner energy, safer chemicals, healthier food, less waste, and smarter purchasing, with clear metrics, guidance, and case studies for each. About 1,000 hospitals in 46 states are participating in the initiatives and contributing data. The program is voluntary, Cohen said, but requires commitment at the highest level, including a signed agreement from the CEO.

Examples of outcomes include 146 hospitals spent 18 percent of their food-purchasing budget on local and sustainable foods; 457 hospitals were able to achieve an aggregate 24 percent recycling rate, resulting in 445,000 tons of materials that did not have to go to the landfill; and reprocessing of single-use medical devices has dramatically increased.

Hospitals as Anchor Institutions for Improving Community Food Environments

The health care sector is second only to the military in terms of its enormous clout and presence in American society. In 200 different cities, the health care institution is the largest employer and the economic engine of those communities. Given its enormous presence in American society, the health care sector can have a huge catalytic impact on the rest of the economy, Cohen said. Health Care Without Harm is working with hospitals around the country to see themselves as economic anchor institutions for improving community food environments by modeling nutrition and improving environmental health inside and outside their facilities. Health Care Without Harm is also collaborating with community-based programs to support a healthy regional food system and increased access to healthy food. Initiatives are under way around the country, with hospitals, school systems, and universities working together to transform the

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¹⁵ Participating hospitals, health systems, and other organizations are listed at http://www.healthierhospitals.org (accessed October 12, 2015).

¹⁶ See http://healthierhospitals.org/sites/default/files/IMCE/fnl_hhi_milestone_report_rev.pdf (accessed July 31, 2015).

supply chains in their communities, and to create jobs and an economy that supports health.¹⁷ Health Care Without Harm is also working with health care professionals to be effective public policy advocates for environmental health and sustainable food systems.

Lessons Learned

In closing, Cohen highlighted some of the lessons learned from working with hospitals and health systems to transform the health sector. Educating the health profession about environmental health is critical, he said. To be able to address population health issues, providers need to understand how the environment (e.g., food, climate change, toxic chemicals) impacts people’s health. Cohen and colleagues learned to appeal to the mission of the institutions, their mandate under the Patient Protection and Affordable Care Act (ACA), and also the money that sustainability measures can save. Cohen and colleagues also learned to provide practical solutions to hospitals to address their environmental performance and to create healthy collaboration as well as competition among sector players. They have also learned that because of the health care sector ’s economic power, aggregating hospital demand and purchasing power drives markets for safer products. Celebrating success is also very important, he said, showing by example how improvements can be made.

Cohen said it is important to create both inside and outside strategies, meaning exerting pressure from inside and outside institutions to have healthier practices. Engage both the policy and market realms, he said. Policy is important, but in many cases the market can move much faster. Build networks of collaborators instead of monolithic organizations, develop partnerships, create joint ownership of agendas and strategies, and build trust over time. It has also become clear that the movement needs to be international, he said, as most of the environmental issues we face now are global issues.

DISCUSSION

Participants discussed making the business case for engagement in healthier practices and taking a triple bottom-line approach (environmental, social, and financial outcomes). Participants discussed some of the internal organizational challenges, and the role of mandated engagement (i.e., regulation). There was also discussion of the role of anchor institutions in driving progress and helping to define shared goals among local partners.

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¹⁷ See http://www.healthierhospitals.org (accessed October 12, 2015).

Making the Business Case for Engagement

Panelists discussed some of the challenges of trying to promote a new strategic vision within the private sector. Soler said one of the earlier challenges was that PHA had not yet built trust among the community members with whom they were going to work. Advocates wondered if PHA would just be providing quick and easy wins for industry (i.e., not having substantive agreements). Companies, especially those in the food space, were wary of working with a nonprofit that they did not know and may have had concerns about motives.

PHA worked hard in the beginning to be very clear about what it would and would not do. In particular, PHA made it clear that it would not engage in governmental or regulatory policy advocacy. Soler noted that other organizations excel in that area, and PHA did not believe it could provide additional value. Furthermore, taking policy positions would not help PHA to develop trust with different private-sector and advocacy partners. PHA focused on voluntary commitments that were significant and meaningful, but had accountability. Once that trust was established, interactions were much smoother.

A challenge for Health Care Without Harm was making the business case to bring investor-owned hospital systems to the table. Cohen said the early adopters around sustainability issues in the health care sector were the not-for-profit organizations, including Kaiser, and the Catholic faith-based institutions with a core mission to be an overall healing ministry. The private sector was not motivated until Health Care Without Harm was able to make a strong business case that many of these sustainability measures also saved money. He added that the ACA has also played a role by changing the incentive system for the entire enterprise of health care in America. For industry, and for Dow in particular, Weick said, there are people who think in a short-term way. Those people are brought along by seeing the business case, and the triple bottom line of social, environmental, and economic benefits.¹⁸

Catherine Baase of Dow noted that the business community cannot thrive if the community around it is failing. Soler agreed that the business case goes beyond profit. Profit is an easier argument to make. He added that some companies aggressively market the work they have done with PHA, or with the First Lady’s initiatives, with their employee base to show them what the company has done. Having an employee base that is proud to be part of the company is very important. Another component of the business case is having employees who are fit for the job. If nothing

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¹⁸ For more information on the triple bottom line, see, for example, http://www.ibrc.indiana.edu/ibr/2011/spring/article2.html (accessed September 10, 2015).

changes, one out of two Americans will be obese by the year 2030. This will have an impact on the ability of certain jobs to be filled, Soler said.

Weick said that within Dow and other companies, net present value is a key metric for business. One problem is that this can unwittingly project a path that no longer exists into the future. For example, 10 years from now, the price of water in areas that are water stressed will not be zero or minimal. The price of water used by company facilities in those areas (e.g., for production) needs to be incorporated into the net present value calculation. Explaining these types of future scenarios to corporate finance staff is necessary for building the business case for sustainability.

Cohen said that Health Care Without Harm engages many of the hospitals about their use of fossil fuels, and in particular coal. Together with the U.S. Environmental Protection Agency and U.S. Department of Energy, Health Care Without Harm developed a tool to show the direct health impacts related to the use of coal for every kilowatt hour used. The broader societal impact of coal use includes the costs of asthma cases and respiratory diseases. The business case changes when the social and health impacts of a particular business practice are incorporated, he said. Isham of HealthPartners concurred and emphasized the importance of incorporating the social and environmental bottom lines into the cost of doing business.

A participant pointed out the need to comply with international requirements with regard to environmental and health impact. Weick said that Dow has been doing environmental impact assessments on its projects for a very long time. The health impact assessment is a new tool that is now being used in many projects going forward.

Voluntary Versus Mandated Business Engagement

Isham asked panelists how much is done on a voluntary basis versus being driven by regulation or law. Weick said industry welcomes smart regulation. Government, academia, NGOs, civil society, and industry need to work in a coordinated way to solve the great sustainability challenges that are ahead of us, said Weick, and regulation is going to be a key part of that. Industry wants to be at the table for these discussions. He acknowledged that having industry at the table creates some distrust among some people who perceive industry as wanting to delay the process, or to maximize its own profits. Industry needs to earn back trust in some sectors, and inspire confidence in society. One example of success is the Montreal Protocol on Substances that Deplete the Ozone Layer. The problem was discerned by academia, and industry was involved in developing the framework that is solving that problem. In a sense, we need the Montreal Protocol for population health, Weick said.

Cohen added that regulation comes after the market has already moved. Twenty-five states passed regulations restricting mercury products after the health care sector had already created momentum and moved the market away from mercury-containing products. Conversely, a very strategic kind of regulation can have a significant impact. Health Care Without Harm worked with the Catholic Health Association and the Internal Revenue Service to change regulations so that nonprofit hospitals could use community benefits to support more upstream interventions around food systems, housing, and other elements that impact population health.

Redefining the Role of Business in Society

Isham observed that there is a perception that business is only “in it for money” and does not really care about sustainable population health. That is why it is important to redefine the role of business in society, Weick said. The classic economic model, that business is there to make money and philanthropy will take care of all the social issues, said Weick, is not a functional model for society. Corporations do have a fiduciary duty to their shareholders to be profitable, Soler said. One approach is to try to help them be profitable (and sustainable) by driving consumer demand for healthier products. Cohen agreed that a demand-driven approach can be successful. If enough demand can be created, the supply chain will respond. If people are demanding safer food, cleaner energy, and safer products, then the supply chain in health care will respond, and the broader supply chain will follow. As long as health care is rewarded for doing more procedures, more tests, and more interventions, Cohen said, there are no incentives for prevention and population health goals. Changes have begun around the incentive structure and financing in health care, but there is much more to be done to incentivize prevention. Health care should not occupy 18 percent of the entire economy, he said.

The Role of Anchor Institutions in Driving Progress and Defining Success

Victor Rubin of PolicyLink commented on urban hospitals, major medical centers, and the universities they are attached to serving as anchor institutions in the community (Schildt and Rubin, 2015). They are involved not only in driving procurement, but in supporting business development (including minority-owned, women-owned, and locally owned businesses), local hiring and job training, and local economic development. He observed that there is a movement toward more progressive anchor institution strategies, as evidenced in the work of the

Democracy Collaborative, where the institutions, local government, nonprofits, and community agree on a common set of goals and metrics for what would constitute progress (Kelly and Duncan, 2014; Zuckerman, 2013). He asked about lessons for local partnerships.

Cohen described Gunderson Health System in La Crosse, Wisconsin, as an example of an anchor institution engaging in community partnership. They have become the first system in the country to become energy independent, producing more renewable energy than they consume in fossil fuels. This was accomplished through community partnerships, for example, with Organic Valley on a wind project; with a local brewery to take its waste heat and run turbines; and with the local landfill to create methane gas. Partnering on these community energy projects powered their own facilities, and helps the community of La Crosse and other communities move toward renewable energy. Health Care Without Harm is also working with the Democracy Collaborative to get large employers, health care systems, and universities in Oakland and Richmond, California, to redirect their supply chains to create green, healthy jobs.

Weick said that Dow’s sustainability goals include contributing to community success. In 14 of Dow’s major locations, communities were asked what community success meant to them. What was learned guided Dow’s development of education and health programs in the community.

Baase stressed that advancing population health will require the engagement of all sectors of society. She pointed out that many different partners were involved in the Gunderson Health System example described by Cohen. Cohen highlighted the value of having an independent and trusted third party in multistakeholder collaborations. In the anchor institution strategy being used in Oakland and Richmond, for example, the nonprofit organizations are the conveners, along with The California Endowment, which serves as the backbone organization and helps to bring collaborators to the table. Soler agreed and added that although many PHA activities are one-on-one with a partner, they are increasingly becoming involved in multistakeholder collaborations, which are often more complicated to manage. Everyone is coming in with a similar overall goal, but with slightly different outcomes that they hope to achieve. It is a balancing act to make sure that the initiative can achieve those outcomes for the partners who are supporting it. Weick noted that it is important to reach a mutual understanding of what each collaborator is going to get out of the collaboration. He added that a common language is needed because terms can have different meanings to different people and in different sectors.