THE INTERSECTION OF CLIMATE CHANGE, HEALTH, AND THE HEALTH CARE SECTOR

Climate change threatens the health of all people. Increasing temperatures alter the distribution of arthropod-borne, food-borne, and water-borne infectious diseases. Extreme weather events and heatwaves exacerbate food, water, and economic insecurity, and rising sea levels, along with riverbank erosion, leads to migration and displacement of people.

Climate change is caused by anthropogenic greenhouse gas (GHG) emissions. The health care sector is responsible for ~4% to 5% of these global GHG emissions.1 The US health care sector is the highest emitter, contributing about 27% of global health care GHG emissions, followed by China at 17%.1 Multiple international authorities call on the health care sector to commit to climate change mitigation efforts, which begin with defining the source of the problem.

According to the National Health Service in England, sources of GHGs in the health care sector include 62% from the supply chain (such as pharmaceuticals, chemicals, equipment, food), 24% from delivery of care (such as building energy, water, waste, anesthetic gases), and 10% from travel by staff and patients.2 In addition, hospitals in the United States generate 4 billion pounds of waste each year, of which most is improperly disposed via polluting high-energy processing.3

SURGERY IS PART OF THE ENVIRONMENTAL SETBACK

Operating rooms (OR) are one of the largest contributors to a hospital’s carbon footprint, due to 3 main factors. The first is energy consumption: ORs use 3 to 6 times more energy per square foot than any other department in the hospital. Energy is used for electronics, heating, air conditioning, and excess ventilation/air change rates per hour. Second, anesthetic gases are GHGs that are much more potent than carbon dioxide. Finally, ORs produce 20% to 33% of total hospital waste.3 This includes packing materials used to maintain the sterility of supplies, surgical linens, fluids, medications, and regulated medical waste. There is room for environmental stewardship in ORs without compromising patient safety, yet the sanctity and sterility of surgery may have limited research and innovation in this space.

REMEMBER THE R’S

The colloquial dogma of the 3 R’s—Reduce, Reuse, and Recycle—has long been proposed as a framework for reducing waste and GHG emissions.3 Its application is practical and has been demonstrated in select hospitals and organizations nationally, such as the Cleveland Clinic and Practice Greenhealth, a nonprofit environmental consultant.

Alternative energy sources like solar energy and demand reduction strategies, such as HVAC occupancy sensors and motion-detection lighting, limit carbon emissions, and save money. Shutting down HVAC systems during idle hours may save an estimated $6105 per OR without compromising air quality or patient safety.4 Implementation of telemedicine services also has the potential to reduce patient travel GHG emissions.

Choosing reusable medical supplies cuts waste. Surplus medical supplies may be diverted from waste through partnerships with organizations like MedWish International to low-resource global health systems. Other examples of reuse in health care include industry-led reprocessing programs of single-use medical devices. In addition, a majority of supplies used in the OR are potentially recyclable, such as towels, oxygen masks and tubing, plastic bottles, packaging materials, and polypropylene sterilization (blue) wrap through clinical recycling programs like those advocated for by the Healthcare Plastics Recycling Council.

THESE “R” NOT ENOUGH—FUTURE DIRECTIONS WITH EVIDENCE-BASED DECISION-MAKING

There is a missing component to the traditional Rs: Research. In the age of globalization, product life cycles—raw material acquisition, processing/manufacturing, transport, consumption, and waste—have profound environmental impacts. Life cycle assessment (LCA) is an established and rigorous methodology that aims to track these impacts and assess them from a systems perspective using science-based quantification. At each life cycle stage, material, energy, and pollutant emission balances are aggregated based on indicators such as GHG emissions, ozone depletion, water, and land use, eutrophication, and toxicity to humans. The application of LCA is emerging as a tool for research and education in health care sustainability.

The utility of LCA is broad: it can be utilized in a comparative context (is product A more sustainable than product B?) or to identify strategies for process improvement, such as low-carbon product design and supply-chain management.5 For example, an LCA comparing disposable and reusable surgical gowns demonstrated that reusable gowns reduced natural resource energy consumption by 64%, GHG emissions by 66%, water consumption by 83%, and solid waste generation by 84% when the reusable gown was used 60 times.6 Reusable products are typically presumed to be more environmentally sustainable than disposable options. However, the true environmental impact depends on the entirety of the product life cycle, which is captured only in an LCA. LCA research should guide production and purchasing decisions as new single-use medical and surgical technology products gain popularity, such as single-use bronchoscopes, laparoscopic ports, surgical energy, and staple devices.

Because the OR is the most environmentally and resource-costly area of the hospital, understanding the environmental impact of surgery is essential. Application of LCA to a process, such as a surgical procedure, is complex but achievable. A landmark study applying LCA to surgery evaluated 4 common approaches to hysterectomy: vaginal, open abdominal, laparoscopic, and robotic. Although minimally invasive approaches such as laparoscopic and robotic surgery required less energy during the procedure itself, these approaches cost more and utilized more resources. They also produced 30% more regulated medical waste, such as disposable electronic devices, which resulted in significantly higher emissions related to ozone depletion, GHGs, and acidification.7

The LCA is the first step toward data-driven, evidence-based surgical sustainability initiatives and decision-making, which can be used internally by institutions for quality improvement or published externally to contribute to this growing body of science. Future considerations remain, such as expanding the scope of the LCA beyond the OR to the aggregate care of the surgical patient. For example, when comparing the cumulative environmental impact of surgical care, could the robotic hysterectomy (or any other surgical procedure) be more environmentally effective if the patient were to be discharged one or 2 days earlier than an open procedure?

As we continue to push innovative surgical technologies and processes, including minimally invasive approaches, an understanding of the cost, not only in dollars, but to the environment may be part of our future as regulation on GHG emissions from the health care industry may be established, similar to how the current administration has mandated carbon emissions from the automobile industry. Currently, the National Academy of Medicine Action Collaborative on Decarbonizing the US Health Sector is bringing together industry experts, regulators, and government bodies to push the issue forward, with additional momentum from advocacy through the Medical Society Consortium on Climate and Health.

THE BOTTOM LINE

The health care sector has a fundamental role to play in mitigating climate change while delivering high-quality patient care, promoting environmental sustainability, and fostering financial stewardship in alignment with our/their commitment to the health of current and future patients. Surgeons have a responsibility to our patients and the planet to understand how our technological innovations impact our health and the environment. Positive change has already begun, and by utilizing research tools such as LCA, potential solutions can be accurately and scientifically evaluated to optimize the transition of the health care sector to a more sustainable future. This framework can start in the microcosm of the OR.

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