UBC EnviroMed

Since the healthcare system tends to fixate on curing people and fixing problems that have already been created, it is often difficult to examine the upstream factors leading to disease. This is unsustainable.

Climate change is without a doubt contributing to an increased prevalence of certain diseases, such as respiratory and cardiac conditions and infections. However, when examining even further upstream, it becomes clear that healthcare itself is contributing to climate change. The current standards of practice are wasteful and don’t tend to take into account that resources are limited and environments are being polluted. Even a brief search through the literature makes it apparent how little the detrimental effects of healthcare on the environment are being considered.

Currently, there is hardly any research on sustainable healthcare. When it comes to climate change and health, there needs to be a paradigm shift from a focus on fixing what is broken to preventing what could be.

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1: Our Obligation

Canada is the third largest emitter of healthcare life cycle greenhouse gas emissions per capita in the world, after Australia and the United States. Globally, healthcare emissions account for 4.6% of total greenhouse gas emissions. [1] Although this may not seem like a large percentage, this equates to 33 million tonnes of greenhouse gas emissions in Canada per year. And that’s not all. Healthcare activities generate over 200,000 tonnes of other pollutants as well. [3] The largest sectors contributing to health damages include public hospitals (22%), prescribed drugs (21%), and physician and clinical services (13%). [3,15]

Despite the alarming numbers, research specific to the environmental footprint for Canada and BC is lacking.

The environmental footprint of healthcare

• Hospital building design
  • Sustainable building design aims to have a minimal impact on the environment during construction and operation. Using strategies that cater to the natural environment can help improve energy efficiency and can also promote wellbeing. [14]
• Energy use
  • Hospitals require a lot of energy, from lighting, to heating and cooling, to numerous medical equipment. Therefore, monitoring and managing energy use is an important method of mitigation. [4]
• Water use
  • Healthcare facilities tend to be the most water-intensive users in a community. Infection control and prevention policies often limit the conservation practices that can be implemented. Given that many communities are already experiencing water shortages, water monitoring and conservation methods are possible and should be enforced. [2]
• Procurement
  • The production and distribution of medications and equipment accounts for a large portion of healthcare related emissions and also increases exposures to harmful pollutants. Sustainable procurement of medical goods would not only decrease the environmental impact, but also reduce the direct harms healthcare is imposing on health. [12]
• Waste production
  • Healthcare is a notoriously wasteful practice. While maintaining infection control is important, there are various ways that waste could be reduced, from moving away from single-use plastics to re-evaluating how much equipment should be used in the first place. [16]
• Transportation
  • Healthcare isn’t delivered equitably across the province, and therefore some patients have to travel far distances to necessary appointments. Telehealth appointments are an instrumental tool in reducing emissions from travel as well as decreasing time and costs for patients to attend these appointments. [7,8]
• Land use
  • Our land is limited, and what we decide to do with our land has a critical impact on our overall environmental footprint. Although hospitals are necessary for our health, transforming more forests into urban cities releases greenhouse gases stored by trees. Plus asphalt holds in heat, increases the risk of heat waves and related illnesses. [5]
• Food consumption
  • Although hospitals aren’t usually considered a dining centre, food is an important aspect of health. Since food distribution and consumption has a huge environmental impact for each individual, the distances food travels, and the emissions of the types of foods being offered in hospitals should be considered. [5]

Why should we care?

An estimated 23,000 life years are lost due to disability each year from direct exposures to pollutants from Canada’s healthcare system and indirect damages due to the consequences of malnutrition, infectious disease, and temperature extremes. [3]

These health impacts are expected to occur at every stage of life, from young children to older adults. However, despite the various ways that climate change will progressively impact health, this issue is vastly understated in the medical community. [15]

Healthcare workers are in a unique position to speak up about important policies and, therefore, have a responsibility to recognize and respond to that duty. Given the impacts of climate change on health, advocacy for climate action is an obligation that physicians should accept.

Why should we speak up?

Expertise

• Healthcare workers in general have the medical knowledge and training to understand the health trends seen, and to attribute the growing prevalence of diseases, such as respiratory conditions, to the changing environment.

Effectiveness

• Given their medical expertise, physicians are more likely to be effective at communicating the issues with climate change (and the fact that it exists) to both the general population and policymakers. They have the social influence to effect change.

Public trust

• In following the Hippocratic Oath, physicians have a responsibility to ‘do no harm.’ They have a duty to uphold the trust of their patients, which includes advocating for their health and the safety of the environment.

Low risk/cost

• Given the position of power that physicians hold, advocating for climate change action is unlikely to come at any risk or cost to the individual. Other individuals within the climate movement do not have the same opportunities to speak up, and may not have the same freedom to express their opinions. Physicians should be conscientious of the power and the privilege they are given, and should use that power to affect positive change in the world.

As a global community, failing to act will undoubtedly result in severe outcomes. As voices of power and expertise, physicians should respond to this crisis and they should do it now.

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Reflect

Watch this short video produced by Healthcare without Harm on the obligation of healthcare workers to advocate for environmental justice. [6]

References

[1] Watts, N., Amann, M., Arnell, N., Ayeb-Karlsson, S., Belesova, K., Boykoff, M., Byass, P., Cai, W., Campbell-Lendrum, D., Capstick, S., Chambers, J., Dalin, C., Daly, M., Dasandi, N., Davies, M., Drummond, P., Dubrow, R., Ebi, K. L., Eckelman, M., … Montgomery, H. (2019). The 2019 report of The lancet countdown on health and climate change: Ensuring that the health of a child born today is not defined by a changing climate. The Lancet, 394(10211), 1836–1878. https://doi.org/10.1016/s0140-6736(19)32596-6 

[2] Canadian Coalition for Green Healthcare, Society, C. H. E., & Environnement, S. S. (n.d.). GHG+H2O Green Facility Toolkit. Retrieved May 4, 2021, from https://greenhealthcare.ca/ghgwater/ 

[3] Eckelman, M. J., Sherman, J. D., & MacNeill, A. J. (2018). Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis. PLoS Medicine, 15(7). https://doi.org/10.1371/journal.pmed.1002623

[4] Government of Canada. (2020, February 20). Benchmarks and Best Practices for Acute and Extended Health Care Facilities: A Guide for Energy Managers and Finance Officers. https://www.nrcan.gc.ca/energy/publications/efficiency/buildings/5985 

[5] Healthy Food Team. (2020, September 8). The dirt on climate change: Regenerative agriculture and health care | Health Care Without Harm. Healthcare Without Harm. https://noharm-uscanada.org/regenerativeagriculture 

[6] Healthcare without Harm, Freethink, & Skoll. (2020, October 1). Doctors Fighting Deadly Climate Change [Video]. Youtube. https://www.youtube.com/watch?v=sU8ipo8CUOo&ab_channel=Freethink 

[7] Holmner, Å., Ebi, K. L., Lazuardi, L., & Nilsson, M. (2014). Carbon Footprint of Telemedicine Solutions – Unexplored Opportunity for Reducing Carbon Emissions in the Health Sector. PLoS ONE, 9(9), e105040. https://doi.org/10.1371/journal.pone.0105040 

[8] Holmner, Å., Rocklöv, J., Ng, N., & Nilsson, M. (2012). Climate change and eHealth: a promising strategy for health sector mitigation and adaptation. Global Health Action, 5(1), 18428. https://doi.org/10.3402/gha.v5i0.18428 

[9] Macpherson, C. C., & Hill, J. (2017). Are Physicians Obliged to Lead Environmental Sustainability Efforts in Health Care Organizations? AMA Journal of Ethics, 19(12), 1164–1173. https://doi.org/10.1001/journalofethics.2017.19.12.ecas2-1712 

[10] Macpherson, C. C., & Wynia, M. (2017). Should Health Professionals Speak Up to Reduce the Health Risks of Climate Change? AMA Journal of Ethics, 19(12), 1202–1210. https://doi.org/10.1001/journalofethics.2017.19.12.msoc1-1712 

[11] Maibach, E., Miller, J., Armstrong, F., El Omrani, O., Zhang, Y., Philpott, N., Atkinson, S., Rudoph, L., Karliner, J., Wang, J., Pétrin-Desrosiers, C., Stauffer, A., & Jensen, G. K. (2021). Health professionals, the Paris agreement, and the fierce urgency of now. The Journal of Climate Change and Health, 1, 100002. https://doi.org/10.1016/j.joclim.2020.100002 

[12] McGain, F., & Naylor, C. (2014). Environmental sustainability in hospitals – a systematic review and research agenda. Journal of Health Services Research & Policy, 19(4), 245–252. https://doi.org/10.1177/1355819614534836 

[13] Naylor, C., & Appleby, J. (2012). Sustainable health and social care: Connecting environmental and financial performance. The King’s Fund, 28. https://www.kingsfund.org.uk/publications/sustainable-health-and-social-care

[14] Waddington, K., & Varangu, L. (2016). Canadian Coalition for Green Health Care Leading the Evolution of Green. Healthcare Quarterly (Toronto, Ont.), 19(3), 23–29. https://doi.org/10.12927/hcq.2016.24869 

[15] Watts, N., Amann, M., Arnell, N., Ayeb-Karlsson, S., Belesova, K., Boykoff, M., Byass, P., Cai, W., Campbell-Lendrum, D., Capstick, S., Chambers, J., Dalin, C., Daly, M., Dasandi, N., Davies, M., Drummond, P., Dubrow, R., Ebi, K. L., Eckelman, M., … Montgomery, H. (2019). The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate. The Lancet, 394(10211), 1836–1878. https://doi.org/10.1016/S0140-6736(19)32596-6 

[16] Yu, A., & Baharmand, I. (2021). Environmental Sustainability in Canadian Critical Care: A Nationwide Survey Study on Medical Waste Management. Healthcare Quarterly, 23(4), 39–45. https://doi.org/10.12927/hcq.2020.26394 

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2: Climate Solutions

Challenge yourself to think of different ways that climate solutions and mitigation strategies could be used to target the different domains of healthcare. The possibilities are truly infinite! 

Even better, sustainability initiatives are also an opportunity for us to re-evaluate the status quo, and simultaneously implement quality improvement methods to help us provide better care to patients. [3]

When integrating sustainability initiatives with healthcare, the following benefits are realized: [2,3]

• Reduced recurrent/long-term costs
• Planetary health promotion
• Human health promotion

“Ultimately, the most sustainable system is one that minimises unnecessary or ineffective use of resources (financial or natural) by delivering the right care, in the right place, at the right time – and by preventing care needs from arising at all, where possible.”

— C. Naylor & J. Appleby, 2012

References

[1] Bajgoric, S., Appiah, J., Wass, V., & Shelton, C. (2014). Sustainability in clinical skills teaching. The Clinical Teacher, 11(4), 243–246. https://doi.org/10.1111/tct.12141 

[2] Desmond, S. (2016). Implementing climate change mitigation in health services: the importance of context. Journal of Health Services Research & Policy, 21(4), 257–262. https://doi.org/10.1177/1355819616645373

[3] Jamieson, M., Wicks, A., & Boulding, T. (2015). Becoming environmentally sustainable in healthcare: an overview. Australian Health Review, 39(4), 417. https://doi.org/10.1071/AH14086

[4] Naylor, C., & Appleby, J. (2012). Sustainable health and social care: Connecting environmental and financial performance. The King’s Fund, 28. https://www.kingsfund.org.uk/publications/sustainable-health-and-social-care

[5] Workman, A., Blashki, G., Bowen, K., Karoly, D., & Wiseman, J. (2018). The Political Economy of Health Co-Benefits: Embedding Health in the Climate Change Agenda. International Journal of Environmental Research and Public Health, 15(4), 674. https://doi.org/10.3390/ijerph15040674 

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3: Advocating for Solutions

Advocating for an initiative may seem like a daunting task. However, there are some useful steps that will help organize a plan of attack and increase successful implementation. In order for an initiative to be carried out favourably, it is important to establish a partnership with as many stakeholders as possible. This can be initiated by obtaining input from affected parties, such as hospital staff and community members. Garnering appropriate support from all levels will guarantee not only implementation, but also continued program success. [3]

1. Conduct the research.

• Study similar initiatives at other hospitals/clinics.
• Consider the context. [1] 
  • Consult community members as well as colleagues and organizational leaders, including nurses, care aids and department managers.

2. Design the initiative.

• Ensure that it addresses community needs.
• Include your organization’s mission for increased chances of success.
• Implement audit/reporting measures to track progress.

3. Familiarize yourself with the pros & cons.

• Know specific costs and benefits
  • It may be useful to compare implementation vs. non-implementation to communicate the benefits effectively.
• Anticipate objections
  • It is better to be too prepared than not prepared enough! Brainstorm what hesitations might come up and prepare arguments to counter these objections.

Legislative advocacy

Although policymaking is not typically discussed in medical school, physicians have the influence and leadership to be involved in health on a systemic level. When policies affect health, such as those surrounding climate action, those with knowledge and experience on the impacts should participate. [2,3,5]

References

[1] Desmond, S. (2016). Implementing climate change mitigation in health services: the importance of context. Journal of Health Services Research & Policy, 21(4), 257–262. https://doi.org/10.1177/1355819616645373 

[2] Jamieson, M., Wicks, A., & Boulding, T. (2015). Becoming environmentally sustainable in healthcare: an overview. Australian Health Review, 39(4), 417. https://doi.org/10.1071/AH14086

[3] Macpherson, C. C., & Hill, J. (2017). Are Physicians Obliged to Lead Environmental Sustainability Efforts in Health Care Organizations? AMA Journal of Ethics, 19(12), 1164–1173. https://doi.org/10.1001/journalofethics.2017.19.12.ecas2-1712 

[4] Maibach, E., Miller, J., Armstrong, F., El Omrani, O., Zhang, Y., Philpott, N., Atkinson, S., Rudoph, L., Karliner, J., Wang, J., Pétrin-Desrosiers, C., Stauffer, A., & Jensen, G. K. (2021). Health professionals, the Paris agreement, and the fierce urgency of now. The Journal of Climate Change and Health, 1, 100002. https://doi.org/10.1016/j.joclim.2020.100002 

[5] Solomon, C. G., & LaRocque, R. C. (2019). Climate Change — A Health Emergency. New England Journal of Medicine, 380(3), 209–211. https://doi.org/10.1056/NEJMp1817067  

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