The irony of healthcare

As health professionals, we have an expected overriding duty of care to do no harm and advocate for action to protect health and humanity. Yet few of us consider the health consequences associated with the significant ecological footprint, including greenhouse gas emissions, of our workplaces.

As highlighted in a series of The Lancet in 2009, and supported by many peak medical organisations, “climate change is potentially the greatest health threat of the twenty-first century.” Moreover, climate change is not only an existential threat to health, but it could undo many of the advances of modern medicine. As former World Health Organization Director-General Margaret Chan said, “the real bottom line of climate change is its risk to human health and quality of life.”

Healthcare’s environmental footprint is significant, using vast quantities of resources and producing considerable waste. Our workplaces and practices may be disproportionally contributing to greenhouse gas emissions and pollution.

In January 2018, published modelling in The Lancet Planetary Health estimated that Australia’s healthcare sector is responsible for 7% of Australia’s total greenhouse gas emissions. To put that into context, that means our sector contributes more to Australia’s national emissions profile than the state of South Australia.

Hospitals are responsible for almost half of the sector’s emissions – contributing 44% of the total footprint.

Unless this issue is addressed, healthcare’s environmental impact is unlikely to be either sustainable or acceptable in the long term. Particularly as efforts to reduce carbon emissions and combat climate change intensify and it becomes increasingly apparent that our hospitals that aim to heal the sick are in fact contributing to the adverse health effects of present and future generations.

In 2013, Eckelman and Sherman published modelling on the Environmental Impacts of the US Health Care System and Effects on Public Health, which estimated that the US health care system is responsible for 10% of the US’ greenhouse gas emissions; 12% of acid rain; 10% of smog formation; and 9% of respiratory disease from particulate matter; contributing to approximately 405,000 Disability-Adjusted Life Years (DALYs) annually.

Fortunately, many of the changes needed to improve environmental sustainability within healthcare can concurrently deliver financial sustainability and quality improvements. For example, processes that promote resource and waste efficiency, prevent avoidable activity, focus on value and cost-effectiveness and place greater emphasis on primary care, prevention and self-management will often lead to better environmental, financial and healthcare quality outcomes.

There are several state-based, hospital- and practitioner-led initiatives aimed at improving environmentally sustainable practices in the sector. However, Australia does not have an overarching coordinated strategy to address and improve our healthcare’s environmental footprint and greenhouse gas emission profile – potentially also forgoing the associated financial and quality benefits that such coordination could foster.

France, Austria and the United Kingdom have national health sustainability units. In England, the Sustainability Development Unit (SDU) has facilitated an 11% reduction in greenhouse gas emissions from their National Health Service (NHS) between 2007 and 2015. In that time the level of healthcare increased by 18%. Achievements associated with this SDU also include: £90 million of annual savings from the healthcare budget (mainly in energy, waste, and water costs); quality improvement programs saving £68 million and 25,000 tonnes of carbon dioxide emissions, and the identification of further large savings through three interventions – a modest reduction in drug wastage, using combined heat and power systems in certain health facilities, and replacing 5% of business travel with teleconferencing, reducing the need to travel.

An Australian Healthcare Sustainability Unit (HSU) could facilitate a similar system using the English SDU example, and aim to achieve some of the environmental and financial gains demonstrated by the UK’s NHS through developing sustainable strategies for the sector incorporating preventative healthcare, primary healthcare/community care and hospital care.

As a society, we need greater emphasis on keeping people well and out of hospitals to truly achieve improvements in healthcare environmental sustainability. We can do this by developing strategies and policies that minimise the need for escalation of care and the associated increases in required resources and costs. Greenhouse gas emissions from the primary and preventative care sectors are low, yet less than 2% of Australia’s healthcare budget is allocated to preventative healthcare.

As identified by the authors of the 2012 report, “Sustainable health and social care. Connecting environmental and financial performance,” in The King’s Fund, “Ultimately, the most sustainable system is one that minimizes unnecessary or ineffective use of resources by delivering the right care, in the right place, at the right time – and by preventing care needs from arising at all.”

So, what can a doctor do? Successfully advocating for a national Healthcare Sustainability Unit (HSU) with state-based HSUs is likely to be the most effective measure we could take to improve our health sector’s environmental sustainability.

Doctors for the Environment Australia (DEA) has an Australian Healthcare Sustainability Unit (HSU) – DEA Proposal that can be found on www.dea.org.au and on a more local level DEA has also developed “Improving a hospital’s environment impact: what can a doctor do? A practical guide to achieving change.”

To instigate broad changes at your workplace / hospital, the first priority is to ensure there is an Environmental Sustainability Officer with executive support and a willingness to engage staff (including hospital engineers). At the Sydney Children’s Hospital Network (SCHN), medical professionals were integral in influencing the employment of an Environmental Sustainability Officer, and across the country many have influenced their workplaces to sign up to the US-based Global Green and Healthy Hospitals Agenda which promotes 10 sustainability goals.

Actions led by both doctors and hospital sustainability officers exist across Australia. Over the last decade, the Mater Misericordiae, Brisbane, with the employment of an Environmental Sustainability Officer, has implemented or explored more than 190 initiatives, involving thousands of staff and saving more than $2.3m. Environmental and financial Life Cycle Analysis research conducted at Footscray Hospital, Victoria, has led to a change from single use to reusable operating room breathing circuits, face masks, plastic trays and other anaesthetic equipment saving more than $6,000 per annum per operating room. In addition, the shutdown of selected steam sterilisers at times of low activity has made savings of $15,000 per annum.

It should be noted that reusing equipment requiring sterilisation does not always result in less greenhouse gas emissions if the energy source is from an emissions intensive source such as brown coal. Western Health anaesthetists (including Foostcray Hospital, Victoria) moved from using the expensive anaesthetic gas desflurane with a high global warming potential (GWP) to sevoflurane, a less expensive anaesthetic gas with a lower GWP, saving the hospital about $30,000 and 140 tonnes of greenhouse gas emissions annually.

Within our daily practices, consider and practice the “Reduce, Reuse, Recycle” mantra. Being conscious of the fact that recycling is a small part of the big picture of environment sustainability, it can often be a great “hook” (the first tangible project) to subsequently enlist staff in further sustainability initiatives. However, when it comes to waste, ensure correct segregation is occuring first.

Segregating infectious and general waste correctly can lead to significant financial and environmental savings. Infectious (clinical) waste is far more expensive to dispose of (commonly 10 times the cost of general waste) and requires extensive processing. Surprisingly, few clinical areas within hospitals do this well, yet correct segregation is potentially the easiest practice to instigate, as no new systems/waste streams need to be altered or introduced.

Using less initially has greater benefits and this includes avoiding unnecessary patient procedures/investigations/activities as well as considering ways to decrease energy and water consumption. Non-clinical areas (even on wards) should not be forgotten. Consider exploring whether computers and air-conditioners can be automatically set to stand by out-of-hours and printers defaulted to double-sided in non-clinical areas.

General practices can also benefit from addressing their ecological footprint. Following recommendations derived from an energy audit in 2016, the Benalla Church St Surgery (north-east Victoria) reaped immediate financial savings of over $4000 per annum (the audit cost less than $1500) with additional sustainability measures (addressing clinical waste, recycling, general waste, paper use) leading to a further $3,130 saving each year.

Australia’s professional medical colleges are beginning to address environmental sustainability practices. The RACP released its Position Statement “Environmentally Sustainable Healthcare in 2016” and ANZCA released a draft “Statement on Environmental Sustainability in Anaesthesia and Pain Medicine Practice” earlier this year.

The AMA first released its Position Statement “Climate Change and Human Health” in 2004, and later revised it in 2008, and again in 2015.

Meanwhile, the Council of Presidents of Medical Colleges (CPMC) recently held a Climate Change and Health Roundtable coinciding with the UK’s SDU founding director Dr David Pencheon’s visit to Australia. The CPMC subsequently released a communique on “Managing and Responding to Climate Risk in Healthcare”, which has been endorsed by 11 medical colleges and can be found on the CPMC’s website.

The Australian health sector faces many significant future challenges, including a rapidly expanding burden of chronic disease, an ageing population, continual costly advances in medical technology, as well as the need to build resilience to climate change-related health threats, and the predicted amplification of extreme weather events (eg. heat waves, bushfires, droughts) associated with climate change.

In this context, the future of high quality healthcare relies on it being delivered in ways that are both environmentally and financially sustainable.

Article contributed by Dr Eugenie Kayak FANZCA, MBBS, MSc. National Deputy Chair Doctors for the Environment Australia (DEA). Article content has drawn extensively from DEA’s related documents. For a full list of refences please contact the editor, andrea.cornish@amansw.com.au