How Healthcare Harms the Environment (and ultimately, you)

If healthcare wants to do no harm, it needs to get greener

Healthcare systems are, by definition, concerned with treating and preventing physical and mental health conditions. It therefore seems counterintuitive that they are significant contributors to climate change and pollution, and consequently to ill health globally.

If 2020 has taught us anything, it’s that the world isn’t quite prepared for a global health crisis. The year has been understandably dominated by COVID-19, and this looks set to continue for the next few months at least (let’s hope not years).

The issue is, there is another looming health crisis, which has the potential to be even more disruptive and deadly. Climate change has been recognised as a serious cause of disease since around the 1990s, with the World Health Organisation and Intergovernmental Panel on Climate Change (IPCC) issuing regular reports about the damaging effects climate change has on health.

On average, healthcare systems account for 4.4% of global greenhouse gas (GHG) emissions. The National Health Service (NHS) in the UK accounts for around 5.4% of national GHG emissions. The US alone accounts for 27% of global healthcare carbon emissions, followed by China (17%) and then the EU (12%).

In recent years, there has been a significant surge of interest in environmental issues, with the conversation becoming more established in mainstream media. Healthcare-related environmental damage is well-documented, but is infrequently talked about. This is odd considering GHG emissions from healthcare systems are over double the global emissions from air travel (2%) and not far off the emissions from livestock (5.8%), both of which are the subject of heated debates.

It is crucial to understand how healthcare affects the environment, how this impacts our health, and what we can do to help.

How Healthcare Affects the Environment

Healthcare systems impact the environment in a number of ways. While the carbon footprint is the most widely studied, there is also a significant issue with regards to pollution.

Carbon Footprint

Healthcare is responsible for a significant amount of CO₂ and other GHG production.

There are obvious sources of GHG production — healthcare is a massive industry and therefore uses significant amounts of power, often generated from fossil fuels. It also relies heavily on transport networks for goods, staff and patients.

However, there are some surprising causes of GHG emission that are unique to healthcare — anaesthetic gases and inhalers.

Certain gases used as part of general anaesthesia have dramatic global warming effects. For example, using 1 tonne of desflurane has the same global warming potential as 3714 tonnes of carbon dioxide.

The other culprits are inhalers. Metered dose inhalers (the commonest type) use hydroflurocarbons as propellants, which are potent GHGs. The ‘blue’ inhaler most commonly used in asthma adds 439kg of CO₂ to the carbon footprint of each patient that uses it per year. That’s the equivalent of driving about 1500 miles/2400km in a standard petrol car. Of course, this isn’t to say people should stop using inhalers, but that we need to move to greener solutions.

Pollution

Healthcare has a propensity for producing two types of pollution in particular — air and plastic.

The ruinous effects of plastics (especially single-use) on the environment has had a lot of press recently. Plastics linger for centuries, most notably affecting aquatic ecosystems.

However, they have become ubiquitous in healthcare for many reasons:

• Low cost
• Easy and quick to produce
• Able to make very specific, specialised shapes — this is difficult with metal
• Lightweight (nice for the surgeons that have to hold them for hours)
• Disposable sterile instruments are arguably safer than sterilising & re-using metal products — a very small number of infectious diseases (such as prions) aren’t killed by standard sterilisation techniques

This results in vast quantities of plastic waste, not only from the product itself, but also from the plastic packaging used to keep it sterile. Unfortunately, this is also the case for many things that needn’t be sterile, but come individually wrapped in plastic anyway. A non-exhaustive list:

• Syringes for oral medication (effectively cutlery)
• Gauze (doesn’t always need to be sterile)
• Bags of IV fluid/medication (only the connector needs to be sterile)
• Scissors
• Face masks/oxygen tubing

This is not to say these things don’t need to be clean, but they often don’t need to be sterile.

Most plastics in healthcare (about 85%) are ‘non-hazardous’ and thus go to landfill or recycling schemes. The contaminated plastics should be incinerated for infection control purposes to prevent contamination of landfill sites and water sources.

Incineration obviously does come with its own issues, releasing harmful byproducts into the atmosphere, such as dioxins, sulphur oxides, particulate matter and heavy metals.

While much of this is now heavily regulated (mainly to reduce the release of exceptionally dangerous dioxins), there are still significant amounts of particulate matter and sulphur oxides released in the process.

Air pollutants are also released by fossil fuel power stations and manufacturing plants that serve healthcare facilities, as well as the multiple petrol and diesel vehicles used directly (e.g. ambulances) or indirectly (e.g. HGVs for goods, cars for staff & patients) by the health service.

How the Environment Affects Health

Climate change affects human health in a multitude of ways. The IPCC breaks them down into three categories:

• Direct impacts — such as results from extreme weather (droughts, floods etc.)
• Effects mediated through natural systems — e.g. disease vectors, waterborne disease and air pollution
• Effects mediated through human systems — e.g. occupational impacts, undernutrition, mental stress

Heat

High temperatures cause a number of medical problems:

• Dehydration — this can lead to an increased risk of falls, nausea, headaches, and low blood pressure (leading to fainting). Can also cause kidney damage
• Heat oedema (swelling of arms/legs)
• Heat cramps
• Heat exhaustion and heat stroke (over 50% mortality rate)

The last five years have been the five hottest since records began in 1880. The heatwave that affected much of Europe in 2003 is estimated to have caused at least 70,000 deaths due to the extreme heat and crop shortages, and the number of heat related deaths will only continue to rise with increasing global temperatures.

Flooding

Floods impact health in a number of ways. People die in the initial event due to drowning, hypothermia and traumatic injury. Following this, there is an increase in infectious diseases such as cholera, leptospirosis and diarrhoeal diseases. There is also a significant toll on people’s mental health and financial wellbeing — many people will lose their entire house and most of their possessions, which can cause significant mental distress and financial hardships even if no physical injuries are suffered.

There is likely to be an increase in large storms and heavy rainfall over the remainder of the century, and coupled with melting ice caps (and therefore rising sea levels), floods will become more abundant.

Much of London, as well as Liverpool, Hull and many other coastal cities in the UK could be underwater by 2050 if no action is taken to prevent it.

Infectious Diseases

Many infectious diseases are ‘vector borne’, that is they are carried by another organism before they infect humans. Most commonly, these vectors are insects and arachnids, such as mosquitoes and ticks.

The most well-known of these is malaria. The majority of malaria transmission happens in Africa (over 90%) at present; with temperate regions getting warmer and having increased rainfall, the area mosquitoes are able to live in could expand, and therefore even more people may be affected by malaria. There is still debate as to whether this will occur however, as there are many other factors that impact malaria transmission, such as sanitation, housing standards and access to healthcare.

The larger concern comes from dengue fever, a disease transmitted by a different species of mosquitoes. Most commonly it will cause few or no symptoms, but in a small number of cases, this can progress to severe dengue, which can lead to death. There is no specific treatment or vaccine, and the number of cases have been increasing dramatically across the globe — approximately 390 million people are now affected each year. This is a 30-fold increase from 50 years ago. More cases are now being acquired in temperate regions (such as parts of Europe) and this is likely to keep increasing.

Additionally, there was recently the first case of UK acquired babesiosis, a tick borne disease similar to malaria.

An increase in typically tropical diseases in temperate areas is likely to be accompanied by an increase in food and water-borne diseases worldwide. It is known that increasing ambient temperatures lead to an increase in the rates of food poisoning (such as Salmonella and Campylobacter). It is unclear why, but thought to be due to interactions with certain algae in water sources.

Air Quality

Air quality encompasses a vast number of components, but the most important for health are generally particulate matter (very small bits of solid or liquid suspended in the air), ozone, sulphur dioxide and nitrous oxides.

In 2019 it is estimated that air pollution contributed to approximately 7 million deaths. This is more than died from diseases related to smoking (6.3 million) or excess alcohol consumption (5 million). To be clear — these deaths were not those caused by global warming or environmental damage as a whole. These deaths are directly linked to the damaging effects of certain particles and gases in the air.

Particulate matter is the most damaging form of air pollution. It consists of tiny particles from human sources (soot, smoke, dust etc.) as well as from other biological sources (bacteria, viruses, mould spores). They are able to penetrate deep into the lungs where they cause direct damage and inflammation. From here, they can find their way into the blood stream causing diseases such as cancers and heart disease.

Ozone, in very simple terms is a good thing in the higher levels of the atmosphere as it shields us against UV radiation, but is bad for health when it is at earth level. Ground level ozone causes irritation of the lungs and respiratory tract, causing aggravation of lung conditions such as asthma and COPD as well as increasing the risk of having heart attacks and strokes.

Nitrous and sulphur oxides have similar inflammatory effects on airways.

What are we Already Doing?

On 1st October 2020 the NHS announced its very ambitious plan to be ‘net zero’ in carbon emissions by 2040. It is the first public health service in the world to make such a statement, and there is a detailed report explaining the plans to achieve this.

It is a bold plan that will upgrade all the current infrastructure (e.g. LED lightbulbs in all hospitals and GP surgeries to save CO₂ and £3b in the next three decades). The UK health system has already reduced its carbon footprint by 37% from 1990, but there is still a way to go.

Anaesthetic gases are being either phased out or less potent GHG alternatives are being used and there is a very gradual move towards dry-powder inhalers, which don’t have GHGs in.

The NHS has also recently pledged to cut single use plastic in non-clinical settings (that is the canteen, cafes etc.) and thus phasing out plastic cups, straws and cutlery.

What More can we do?

The NHS announcing its plans is an international milestone. It is the first national health system to set such an ambitious target. Everyone will have to play a role, from individual patients, to entire multinational corporations.

Things patients/visitors can do:

• The usual — reduce, reuse, recycle. Bring reusable water bottles/cups to appointments rather than takeout cups, return finished inhalers to pharmacies for recycling, use recycling bins where possible
• Try to reduce your likelihood of needing medical attention at all — stop smoking, exercise regularly, eat plenty of fruit and veg
• Walk or cycle to medical appointments if possible
• Consider phone/video consultations (especially for regular follow up appointments if you don’t have much new to report)

Things healthcare workers can do:

• Be aware of what is recyclable — many things get put in clinical waste that could be recycled
• Be conscious of what sterile equipment you are using (does the medication need to be IV, or could it be given orally?)
• Keep an open mind about telemedicine — especially after COVID-19, it is likely here to stay, so try embracing rather than ignoring it
• Walk or cycle to work, or if you can’t then take public transport/carpool

Things the government/companies/healthcare providers can do:

• Remove/replace plastic packaging where possible
• Provide more recycling facilities in hospital
• Invest in renewable energy — lots of non-critical power supply could be changed to onsite solar power
• Invest in developing electric vehicles — especially ambulances and HGVs
• Plant trees and greenery on hospital/primary care sites (good for decarbonisation and mental wellbeing of staff)

It is one of the basic tenets of medicine — do no harm. Harm from climate change and pollution is already a recognised and significant problem that will continue to worsen. It is unethical for healthcare facilities to not try and reduce their environmental impact, knowing the detrimental effects it has on human health.

Our experiences as healthcare professionals during the COVID-19 pandemic have been unprecedented, and we have seen a huge amount of rapid change in the healthcare industry.

There has been a massive increase in telephone and video consultations, online learning and digital conferences. We have managed to form multi-national scientific research teams and dramatically re-organise how the hospital and healthcare infrastructure functions. It seems that now would be a perfect time to implement other structural and organisational changes that could have a dramatic impact on reducing damage to our planet and to our personal health.