With large-scale demand and a mission to protect public health, hospitals are emerging as the next frontier of the sustainable food movement. Health care institutions spend $12 billion in the food and beverage sector each year,1 and a single hospital can have an annual food budget of $1–7 million or more.2 Even small shifts in foodservice budgets can create new markets for alternative foods.

To date, the darlings of the food movement have been farmers’ markets, Community Supported Agriculture (CSA) programs, and urban farms that connect eaters directly with the source of their food. These models appear to have boosted the number of small farmers in the U.S. after decades of freefall,3 but research shows that we now have an increasingly bifurcated system that favors small-scale direct markets and large-scale commodity markets. What’s more, experts believe that direct market models are reaching a saturation point even though they’ve barely begun to scratch the surface of the agricultural status quo. Local food sales account for less than two percent of total farm gross, and the goods exchanging hands at some 7,800 farmers’ markets nationwide represent less than one percent of total U.S. agricultural production.4

Meanwhile, mid-sized family farmers are being squeezed out by the march of consolidation within the food system, as are independent middlemen that aggregate, process, and distribute food regionally.5 This agriculture of the middle, meaning mid-sized family farmers and mid-level food system intermediaries, represents the most threatened set of entities in the agricultural sector. Direct market models hold little sway in solving this problem, they are too small to support mid-sized farmers, and they purposefully cut out middlemen.

Leading-edge food system advocates are looking to institutional buyers like hospitals, schools, and universities to help rebuild this missing middle ground because they buy in large volumes and they rely on the wholesalers, processors, and distributors that make up the functional infrastructure of the U.S. food system. But the leap in scale from an individual buying three onions at a farmers’ market to a hospital buying three hundred cases is not simply one of numbers, it presents an entirely different set of challenges, opportunities, and relationships. When you’re making soup for six hundred, changing your grocery list quickly gets complicated.

A team of San Francisco Bay Area hospitals have been at the vanguard of this institutional food revolution since 2005. Leaders including Kaiser Permanente, University of California at San Francisco Medical Center, John Muir Health, and the San Francisco VA Medical Center, gathered at the FoodMed Conference in Oakland, California that year. A non-profit organization called Health Care Without Harm convened leaders from the sustainable agriculture, environmental health, public health, and health care sectors to discuss their overlapping concerns and goals. Together, they articulated a systemic environmental nutrition approach to healthy food, going beyond counting calories and balancing food groups to address the many ways the food system impacts public health.

Since then, over 550 hospitals nationwide, they have signed a Healthy Food in Health Care Pledge generated by the nonprofit coalition Health Care Without Harm (HCWH) which states that “for the consumers who eat it, the workers who produce it and the ecosystems that sustain us, healthy food must be defined not only by nutritional quality, but equally by a food system that is economically viable, environmentally sustainable, and supportive of human dignity and justice.”

Hospitals are putting this vision into practice by serving local produce when it’s in season, switching to rBGH-free dairy products, and sourcing seafood from community-based fisheries. They are buying fair trade coffee, cage-free eggs, and organic salad greens. Some are reducing meat servings to lower their greenhouse gas footprint and are using the cost savings to buy grass-fed beef and free-range chicken raised without antibiotics or added hormones.

“Local, organic chicken was a real challenge” says one leading Bay Area Hospital Food and Nutrition Services Director.   Under the current system, he can place an order on his food distributor’s website, and the next day hundreds of uniform 4-ounce chicken breasts show up on his loading dock, shrink-wrapped and stacked by the case. Procuring local, organic chicken first required weeks of working through bureaucratic purchasing and legal systems to set up a new vendor relationship. When the hospital finally received its first delivery, it was an ice-packed box of whole chickens with the heads and feet still on.   “My cooks almost died,” he reports. Having to chop off chicken heads is a far cry from lining up a row of boneless, skinless meat parts in the griller. Most institutional kitchens no longer have the equipment or staff with the knowledge necessary to deal with whole foods.

The pallets of uniform poultry parts that come through national distributors like Sysco and US Foods also help hospitals to meet strict federal dietary guidelines, as each cut arrives within a fraction of the weight ordered. In contrast, locally-sourced chicken breasts, even if they arrive pre-processed, might come in a four to eight ounce range, forcing staff to slice and individually weigh servings. With tight budgets, paying staff to mete out perfect portions may not be time that a hospital foodservice department can afford.

Efficiency has been a dirty word in some food movement circles, but a little efficiency goes a long way when you’re serving hundreds to thousands of meals every day. Equally blasphemous has been middlemen. But buying food at the institutional scale means relying on certain industrial-style standards and relationships. Hospitals are a microcosm of the challenges that face the alternative food movement as it seeks to scale up — they need to balance their sustainable food goals with their need for efficiency and affordability.

Initiatives like the Farm Fresh Healthcare Project offer insight into how leading hospitals are working with distributors to retrofit existing supply chains to become shorter, more flexible, and more transparent. Since 2011, a team of hospitals in the San Francisco Bay Area have partnered with Health Care Without Harm and Community Alliance with Family Farmers to source more local and organic produce from family farmers.

Beyond purchasing power, hospitals can leverage another form of currency in support of organic agriculture – moral authority. Polls consistently show that health professionals rank as some of the most trusted experts in the United States. [1] They can “tell stories about great farmers,” as Luis Vargas, Procurement Manager for Nutrition and Food Services at University of San Francisco Medical Center says, “People look to us for this leadership, and we should be showing the way.” Like the first hospitals to ban smoking on their grounds, which led to greater public awareness and smoking restrictions in other locations,6 those that are leading the environmental nutrition movement are enacting changes that will have ripple effects throughout society.

—Kendra Klein

DOI: 10.14433/2016.0004


  1. Harvie. in Designing the 21st Century Hospital Vol. September   (Hackensack, NJ, 2006).
  2. FSD. 2011 Hospital Census, <https://www.foodservicedirector.com/sites/default/files/FSD%20Hospital%20Census%202011.pdf> (2011).
  3. Kirschenmann, F., Stevenson, S., Buttel, F., Lyson, T. & Duffy, M. Why worry about agriculture of the middle? , (MIT Press, 2008). DOI: 10.7551/mitpress/9780262122993.001.0001
  4. Barham, J. et al.   (ed USDA) (Agricultural Marketing Service, 2012).
  5. Lyson, T. A., Stevenson, G. W. & Welsh, R. Food and the mid-level farm: Renewing an agriculture of the middle. (The MIT Press, 2008).
  6. Cohen, L. & Mikkelson, L.     (Prevention Institute, Oakland, CA, 2004).

[1] Gallup 2014. Honesty/Ethics in Professions 2013. Available online: https://www.gallup.com/poll/1654/honesty-ethics-professions.aspx.