Causing disease by curing disease?

Johny Van Aerde, MD, PhD

EDITORIAL

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As Canada and other OECD countries spend about 10% of GDP on health care, it is inevitable that the delivery of health care services has consequences for the natural environment.

 

Stewardship is an ethic that embodies the responsible planning and management of resources and begins with the willingness to be accountable for some larger body than ourselves.1 The word stewardship has been used in the context of the physician’s role in the sustainability of the health care system.2,3 It has also been used to describe the responsible use of our natural resources and the sustainability of our planet. The main purpose of this paper is to raise awareness around the sustainability of some of the many systems in which we live and work, as awareness and knowledge are the first elements of any change initiative. Based on new data, mostly unknown to the physician community, some reflective suggestions are offered to start those changes. Top

 

During the CMA’s 2016 annual meeting, its president, Dr. Cindy Forbes, vowed to act on climate change. However, she said that the best way to take action against the growing effects of climate change is still to be found.4 Dr. Orbinski, founding member of Médecins sans Frontières and keynote speaker at the same event, told the audience that, in Canada, air pollution alone is linked with 21 000 preventable deaths annually, 92 000 visits to family physicians, and 620 000 trips to emergency departments. He said that, therefore, physicians have some professional responsibility to take a more active role in addressing such problems. He added that discussions about climate change tend to miss the human element, “We don’t see ourselves in them.”5 While Orbinski addressed the serious impact of climate change on global health, this paper deals with the reverse by looking at the effect of the health care system on the environment, and how we as physicians can see ourselves in that narrative. Top

 

The health care system impacts the ecological system

 

As Canada and other Organisation for Economic Co-operation and Development countries spend about 10% of GDP on health care, it is inevitable that the delivery of health care services has consequences for the natural environment. In the United States the health care industry accounts for 8% of the nation’s greenhouse emissions. In the European Union, it is about 5%, equivalent to that of the international aviation and shipping industries combined.

 

The National Health Service (NHS) has probably led in studying the effect of the health care industry on the environment and possesses a decade worth of data. For example, 25% of all public-sector emissions come from the NHS or about 4% of all emissions in England.6,7 This is more than all passenger aircrafts departing from Heathrow airport. Five per cent of all vehicle emissions in England come from road traffic related to NHS activities (patients, staff, supplies, food, etc.). Surprisingly, the largest contribution to the NHS’s CO2 emissions, two-thirds of the total, comes from procurement, mainly pharmaceuticals, medical equipment, and supplies. This exceeds the amount of CO2 produced by direct energy use (electricity and fuel for buildings) by more than three times (Figure 1).6,8 Top

 

Translating this data into an understandable narrative, Tennison10 estimated that the average admission day produces 380 kg of CO2 per patient, and each subsequent day produces another 80 kg. This means that the amount of CO2 produced for five patients, each admitted to hospital for one week, would be the same amount as emitted by an average car driving 18 000 km.

 

For each patient admitted, the NHS produces 5.5 kg of waste per day, twice as much as in the United States and ten times as much as in Germany.11 Although no overall data on waste production exist for Canada, some hospitals, like Lions Gate Hospital in Vancouver, have monitored the weight of certain supplies that were turned into waste. Per inpatient day, 718 g of paper was used (print, towels, toilet paper, cups/plates), 268 g of diapers (adults and children), and 165 g of gloves (synthetics and paper).12 A mix of 80 hospitals in Ontario used, on average, 1230 L of water per bed,13 which is four times the amount used by the average citizen in Canada. Annual energy consumption per square meter of floor space, or energy intensity, of hospitals and other health facilities is remarkably consistent across geography, ranging roughly from 230 to 330 kWh/m2.14  That means that each 4 m x 4 m surface area consumes about as much energy as the average Canadian does each year.  Top

 

Overall, the ecological footprint of health care institutions is 400–700 times their actual surface area. Thus, for every hectare of land a health institute occupies, 400–700 hectares are needed to sustain its functioning and services.12,15

 

Economic, health, and quality co-benefits of reducing the ecological footprint of our health care system

 

Physicians may ignore these statistics and hide behind their responsibility to serve each patient and the health system in general. However, the health care system, the financial system, and the ecological system are closely intertwined, and their sustainability is inseparable from their interdependence. It seems logical then that, besides climate change and environmental sustainability, there are potential synergies and co-benefits between the core objective of health care and efforts to minimize environmental impacts.6,7

 

First, there are financial co-benefits to developing environmentally sustainable approaches to the delivery of health care. For example, promoting efficiency of resource use reduces direct costs. Using peer-reviewed data from the US’s Environmental Protection Agency, the organization Practice Greenhealth has created an energy impact calculator that allows hospitals to estimate some of their health impacts, such as premature deaths, chronic bronchitis, asthma attacks, and ER visits.16 It also estimates the financial cost to society. For instance, a typical 200-bed hospital in the coal-powered US midwest, using 7 million kWh/year is responsible for over $1 million/year in negative societal public health impacts ($0.14/kWh), and $107 000/year ($0.01532/kWh) in direct health care costs.16 Top

 

Efficiency measures at the Mayo Clinic have reduced its energy consumption by 36% in the decade since they started in 2006.17 Even countries with fewer financial resources than Canada have proved that this co-benefit can be accomplished and is lucrative. In Brazil, one efficiency project reduced the demand for electricity of a group of 101 hospitals by 5769 MWh/year and the cost by 25%.7 These savings can be reinvested for enhanced patient care elsewhere.

 

Second, there are the obvious health co-benefits from reducing the health care industry’s impacts on the environment. However, while we try to cure disease, the delivery of the services also contributes to some of those diseases. For instance, air pollution causes 369 000 premature deaths in Europe each year,7 and the release of toxins related to health care activities, such as sulfur dioxide, nitrogen oxide, and mercury, adds to the disease burden.7,18 Further details of the effect of climate change on disease burden have been well reported by the WHO.19

 

Finally, there are co-benefits when changes to health and social care services simultaneously improve quality of care and reduce environmental impacts. For example, minimizing duplication and redundancy in care paths, delivering the right care in the right place at the right time, and optimizing a smooth, continuous flow of care throughout the entire health care system would meet the objectives of both quality-of-care and ecological agendas. Top

 

Innovation

 

Innovative delivery of health care services can decrease the environmental and financial burden and improve quality of care in three areas: where, what, and how.

Changing WHERE care is delivered

The buildings where care is provided and patients and staff traveling to and from those buildings produce 35% of health care carbon emissions. Making facilities more sustainable and minimizing distance traveled for care can influence this component. For example, mobile breast screening can reduce carbon emissions by two-thirds, compared with women traveling to a central clinic.6 Less obvious initiatives linked indirectly with where care is delivered include low-carbon food menus, software to automatically turn off office computers over weekends, and re-use of redundant office furniture in hospitals or regions.6 On a small scale for each of us, simple measures like managing the use of paper, using reusable supplies and energy efficient lighting, minimizing the use of toxins, recycling, turning off computers at night, and using greener transportation all make a difference when multiplied by more than 100 000 physicians.20,21

 

Changing WHAT care is delivered

Prevention measures can reduce subsequent resource demands and lifetime use of health care services. Investing in self-management can also reduce unplanned hospital admissions among people with long-term conditions.6 The relevance of these findings to sustainability is that reduced demand can be a proxy for avoided environmental damage, provided that reduced resource use in one part of the system does not create increased demand for other forms of care in another part of the system.

 

Evidence-based and personalized care at all levels, ensuring treatment and support that is of maximum value to patients for a given investment of resources also minimizes wastage. More evidence is needed to establish which care pathways have the greatest environmental impact and find clinically appropriate alternatives. Although no large scale studies exist, there are some interesting small examples. Gatenby estimated that carbon emissions from reflux surgery were seven times those from medical treatment, but that annual emissions from ongoing medical treatment made the surgical approach more carbon efficient by the ninth year after surgery.22 Another example demonstrates that the anesthetic desflurane has a greenhouse gas effect that is 10 times that of other anesthetic gases.23 Other examples can be found in the systematic review of the environmental impact of health services by Brown et al.14 Top

 

Changing HOW care is delivered

Delivering well-coordinated and integrated care and improving communication and information sharing reduces waste of financial and environmental resources. Appropriate, accountable, and professional use of telehealth and telecare intervention can reduce emissions.24,25 Each telemedicine consultation saves an estimated 39 kg of CO2. This can add up, as North Yorkshire County in the UK found when it saved $1.5 million a year by using a telecare support package.6

 

The use of wearable technology for monitoring health parameters might further change the way health is monitored and, perhaps, how care is provided. Pharmaceuticals account for about 22% of the NHS carbon footprint and 13% of its cost.6 Reducing the large volumes of wasted medicines can be accomplished by optimizing stock management and reducing inappropriate prescribing or over-medication. Combined purchasing power can also be used to influence, not only cost, but also the manufacturing processes. Some suppliers are attempting to “green” the production of pharmaceuticals by investing in hydroelectric and wind-powered factories and by creating enzyme technology that allows chemical reactions needed for production to take place at lower temperatures. Novo Nordisk was able to lower its energy use well below European energy targets with such initiatives.17

 

What should physicians and physician leaders do?

 

As medical experts, we zoom in on the immediate details and problems of today’s patients in front of us. As a result, we rarely back off far enough to see the large and long-term systemic effects of our day-to-day activities. As the development of an organizational culture of learning is the essence of successful changes, how can we support a sustainability agenda for our institutions and be engaged in sustainability initiatives, together with other frontline workers, executives, patients, and citizens? How can we ensure that our health system adopts sustainable procurement and commissioning practices? As part of an overarching governance structure, how can we, as physician leaders, use our influence to ensure that environmental issues are incorporated into supportive policy frameworks? As in the NHS, environmental sustainability and savings must find a place on the agenda at board meetings, just as we review patient-related quality topics regularly.

 

Economics, quality improvement, and environmental sustainability are all affected by the services we deliver, simply because they are interconnected with the ultimate system we call planet Earth. The NHS is probably the most advanced health care system on this topic; for the last decade, it has been monitoring its performance against 29 measures every year.8

 

Limited, voluntary initiatives also exist in Canada: for example, the Greening Health Care Sector of the Ontario Hospital Association13 and Green Healthcare Canada.26 At the national level, HealthCareCan recently released a report on the economic and environmental impact, resilience, and sustainability of Canada’s hospitals and recommended, “Scale and spread best practices nationally that will help to reduce the significant … demands on the environment in accordance with the ‘Comprehensive environmental health agenda for hospital and health systems around the world’.”15,27 How can this recommendation also find a place in the new Canadian health accord(s)? Top

 

References

1.Block P. Stewardship: choosing service over self (2nd ed.). San Francisco: Berrett-Koehler; 2013.

2.Nohr CW. Stewardship in an integrated health care system: what it means for physicians and patients. Alberta Doctors’ Digest 2016; Sept./Oct.:6-9.

3.Picard A. How stewardship might heal our healthcare woes. Globe and Mail 2016; 27 Sept.

4.Picard A. CMA head vows to act on climate change. Globe and Mail 2016; 23 Aug.

5.Bronca T. Rewriting narrative on climate change. Medical Post 2016; 6 Sept.

6.Naylor C, Appleby J. Sustainable health and social care: connecting environmental and financial performance. London: King’s Fund; 2012. Available: https://tinyurl.com/z62ludt (accessed 5 Jan. 2017).

7.Healthy hospitals, healthy planet, healthy people: addressing climate change in health care settings. Geneva: World Health Organization. 2009. Available: https://tinyurl.com/zc9q8gu (accessed 3 Jan. 2016).

8.Sustainable Development Unit. Carbon footprint update for NHS in England 2015. London: NHS; 2016. Available: https://tinyurl.com/jsg5clz (accessed 22 Dec. 2016).

9.Sustainable Development Unit. NHS England carbon footprint. London: NHS; 2012.

10.Tennison I. Indicative carbon emissions per unit of healthcare activity (briefing 23). London: NHS Sustainable Development Unit; 2010. Available: https://tinyurl.com/jz5w2ml (accessed 11 Jan. 2017).

11.Greenhouse gas emissions from a typical passenger vehicle. Ann Arbor, Mich.: Environmental Protection Agency; 2014. Available: https://tinyurl.com/juhhhpu (accessed 29 Dec. 2016).

12.Tudor T, Marsh C, Butler S, Van Horn J and Jenkin L.  Realising resource efficiency in the management of healthcare waste from the Cornwall NHS in the UK. Waste Manage 2008;28(7):1209-18.

13.Germain S. The ecological footprint of Lions Gate Hospital. Hosp Q 2001/2002;5(2):61-6.

14.Greening health care sector report: utility conservation and management. Toronto: Ontario Hospital Association; 2015.

15.Brown L, Buettner P, Canyon D. The energy burden and environmental impact of health services. Am J Public Health 2012;102(12):e76-82.

16.Greenhealth cost of ownership calculator. Reston, Va.: Practice Greenhealth; 2017. Available: https://tinyurl.com/zdnsws9 (accessed 11 Jan. 2017).

17.Britnell M. Climate change and sustainability In: In search of the perfect health system. London: MacMillan-Palgrave; 2015: 194-201.

18.Green is green. Ottawa: HealthCareCan; 2016. Available: https://tinyurl.com/he947hj (accessed 3 Dec. 2016).

19.Climate change and human health — risks and responses. Summary. Geneva: World Health Organization; Available: https://tinyurl.com/zn5wtcw (accessed 13 Jan. 2017).

20.Foxman S. Greening your practice. Ont Med Rev 2010;April:36-7. Available: https://tinyurl.com/hfuv92f (accessed 23 Dec. 2016).

21.Green office solutions for physicians. Toronto: Canadian Association of Physicians for the Environment; n.d. Available: https://tinyurl.com/jlly25z (accessed 23 Dec. 2016).

22.Patenby P. Modelling the carbon footprint of reflux control. Int J Surg 2011;9(1):72-4.

23.Ryan S, Nielsen C. Global warming potential of inhaled anaesthetics: application to clinical use. Anesth Analg 2010;111(1):92-8.

24.Masino C, Rubinstein E, Lem L, Purdy B, Rossos P. The impact of telemedicine on greenhouse gas emissions at an academic health science center in Canada. Telemed J E Health 2010; 16(9): 973-976.

25.Wootton R, Tait A. Environmental aspects of health care in the Grampian NHS region and the place of telehealth. J Telemed Telecare 2010;16(4):215-20.

26.Green hospital scorecard. Branchton, Ont.: Canadian Coalition for Green Health Care; 2016. Available: http://greenhealthcare.ca/ghs/ (accessed 12 Jan. 2017).

27.A comprehensive environmental health agenda for hospitals and health systems around the world. Reston, Va.: Health Care Without Harm; n.d. Available: https://tinyurl.com/hwkbmmr (accessed 12 Jan. 2017).

 

Author

Johny Van Aerde, MD, MA, PhD, FRCPC, is editor-in-chief of the Canadian Journal of Physician Leadership and past president of the Canadian Society of Physician Leaders.

 

Correspondence to: johny.vanaerde@gmail.com

 

This article has been reviewed by a panel of physician leaders.

Top

 

Finally, there are co-benefits when changes to health and social care services simultaneously improve quality of care and reduce environmental impacts. For example, minimizing duplication and redundancy in care paths, delivering the right care in the right place at the right time, and optimizing a smooth, continuous flow of care throughout the entire health care system would meet the objectives of both quality-of-care and ecological agendas. Top

During the CMA’s 2016 annual meeting, its president, Dr. Cindy Forbes, vowed to act on climate change. However, she said that the best way to take action against the growing effects of climate change is still to be found.4 Dr. Orbinski, founding member of Médecins sans Frontières and keynote speaker at the same event, told the audience that, in Canada, air pollution alone is linked with 21 000 preventable deaths annually, 92 000 visits to family physicians, and 620 000 trips to emergency departments. He said that, therefore, physicians have some professional responsibility to take a more active role in addressing such problems. He added that discussions about climate change tend to miss the human element, “We don’t see ourselves in them.”5 While Orbinski addressed the serious impact of climate change on global health, this paper deals with the reverse by looking at the effect of the health care system on the environment, and how we as physicians can see ourselves in that narrative. Top