Mitigation & Adaptation Strategies for Health Services
Carbon Footprint in Healthcare
In 2014, the total CO2 emissions from health sectors in OECD countries, excluding Chile, India and China were 1.6Gt. This is equivalent to 4.4% of global net emissions of the same year.51, 52 If the global health sector was an independent country, it would be the 4th largest CO2 emitter in the world based on 2016 rankings, below China, the US, and India.
The Canadian healthcare system is responsible for 4.6% of national CO2 emissions. A median estimate of 23,000 disability-adjusted life years (DALYs) are lost annually from direct exposure to hazardous pollutants and environmental changes caused by pollution.53 The WHO defines DALYs as representing the loss of the equivalent of one year of good health, or more specifically, they are considered to be “the sum of the years of life lost to due to premature mortality (YLLs) and the years lived with a disability (YLDs) due to prevalent cases of a disease or health condition in a population.”54 With increasing climate change-related health care demands, the health services sector must implement eco-friendly strategies in its delivery of care. Failure to do so will, paradoxically, exacerbate the negative health outcomes of climate change as GHG emissions increase resulting in declining health conditions and higher mortality rates.
Montana Blum discusses the impact of medical waste on climate change and important considerations for building environmentally sustainable healthcare systems (3:36)
General Mitigation Strategies in Healthcare
Sustainability Efforts in Healthcare
Evidence has shown that there is a need to increase carbon literacy and numeracy in the healthcare workforce.55 In a study of health professionals’ sustainability efforts, participants described a lack of exposure to climate change-related information, and suggested that professional development is needed for improved sustainability practices of clinicians in their workplace.56 Another factor at play in the health sector is the lack of widely accepted metrics for measuring sustainability, which can manifest as a barrier to targeting and measuring mitigation efforts. This may include levels of particulate matter, GHG emissions by sector and institution, and waste production and treatment.57 Without a tangible method to identify the gaps and areas for improvement, it is difficult to develop and operationalize concrete mitigation and adaptation plans. 56, 58
Mitigation Efforts
To address the issue of unsustainability in the healthcare sector, Health Canada has adopted the RETScreen technology, developed by the Government of Canada “to rapidly identify, assess and optimize the technical and financial viability of potential clean energy projects”, and “easily measure and verify the actual performance of their facilities.” 59,60 This is an example of a government-level effort to effectively and systematically implement mitigation strategies that promote sustainable practices in the national health care system. First made available in 1998, RETScreen technology is now widely implemented to broaden sustainable energy use globally.60
CASCADES, a multi-year capacity building initiative made up of four partners – the University of Toronto Collaborative Centre for Climate, Health & Sustainable Care, the Healthy Populations Institute at Dalhousie University, the Planetary Healthcare Lab at the University of British Columbia, and the Canadian Coalition for Green Health Care. CASCADES also striving to transition Canada to “high-quality, low-carbon, climate resilient care.”
Medical Waste Management
Hospitals generate a significant amount of non-recyclable, disposable waste such as masks, gloves, syringes, and other single use plastics. Operating rooms alone produce approximately 35% of total hospital waste.61 The management of this type of waste is particularly challenging as materials are often biohazardous and require careful disposal. In addition, the COVID-19 outbreak significantly increased daily usage of disposable personal protective equipment, exacerbating the issue of excessive medical waste in healthcare facilities. Medical masks, for instance, are made of plastic fibres such as polypropylene, which, when exposed to the environment in the form of degraded microplastics, can be very harmful to ecosystems. Microplastics can also increase atmospheric carbon by interfering with oceans’ capacity for carbon sequestration.62,63,64 It is in part due to this pattern of consumption, and the resources required for safe waste disposal, that the healthcare sector is responsible for such a significant proportion of total GHG emissions. Thus, it is important that health care providers, and more importantly healthcare product manufacturers, are made aware of and held accountable to environmentally-sustainable packaging, separation of non-recyclable from recyclable waste, and disinfecting techniques for reusable medical instruments. In addition to effective waste management and reuse/recycling within hospitals, it is also the responsibility of hospitals and health authorities, as major purchasers of medical equipment, to require manufacturers to use more sustainable materials and production methods as well as to reduce packaging of medical devices when possible.
Mitigation Efforts
Numerous opportunities for more sustainable healthcare practices have been identified as a way to reduce medical waste. Single-use packaging for sterile equipment, for example, generates significant amounts of plastic waste. Practice Greenhealth, an American organization focused on providing sustainable healthcare solutions, suggests implementing reusable metal sterilization containers, as opposed to disposable sterile wrap, for operating room equipment. This introduction would not only generate significantly less waste but also offer more substantial protection of equipment from contamination and cut hospital costs.65 The recognition of the challenges of balancing environmental concerns and safety requirements when it comes to the provision of health services is important. Autoclaving, for example, the most commonly employed method of sterilizing hospital equipment, requires significant energy to run. However, the negative environmental impacts of employing this process are outweighed by the reduction in waste that would otherwise be generated from disposable tools that cannot be sufficiently decontaminated.65
E-Waste Management in Healthcare
In addition to the common forms of healthcare waste such as syringes, gloves, and expired drugs and medications – large amounts of medical electronic waste, or e-waste, are generated. Examples of medical e-waste include microscopes, electrocardiograms, sphygmomanometers, and diagnostic laboratory equipment. Along with the risk posed from these devices coming into contact with dangerous chemicals and biological agents while in use, when e-waste is improperly disposed of it can release toxic chemicals, such as polybrominated diphenyl ethers (PBDE), into the air. These chemicals not only accumulate leading to respiratory issues in humans, but can also react with O2 to produce CO2, increasing GHG emissions.66 In order to ensure its proper disposal, medical e-waste must be treated, including going through a thorough disinfection process available at specialized facilities.67
Mitigation Efforts
Historically, the focus of e-waste management has been on its environmental impacts, however, more recently, there has been a shift to include the detrimental human health impacts of its improper management, including its disposal. Various guidelines have been created on both an international and regional level to increase awareness and encourage policy development for more responsible disposal. This has resulted in a growing number of international organizations and initiatives beginning to focus on encouraging adequate monitoring and regulation of e-waste.67 Canada has signed onto the 1992 Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and their Disposal, a UN Treaty intended to protect the environment and human health.68 Nationally, Environment Canada’s Waste Reduction and Management Division is responsible for e-waste oversight and accountability, however, despite measures in place to control how e-waste is disposed of, millions of tonnes are illegally smuggled out of the country and dumped in countries like Nigeria, India, and Ghana.68
One of the ways the health care sector can address the issue of e-waste is through ‘green IT’. Green IT aims to reduce carbon emissions and energy consumption by improving information communication technology design, reducing the use of dangerous chemicals, promoting use of renewable energy, and encouraging refurbishment rather than disposal.69 Energy-efficient systems such as virtual servers and data storage can increase technological efficiency and decrease the need for frequent replacement of technology.69
Healthcare Infrastructure
Canada’s healthcare system relies heavily on non-renewable energy sources in order to operate healthcare facilities as well as transportation to and from hospitals. Hospitals operate 24/7 in order to serve their communities and thus, require significant energy for their daily operation and maintenance. Hospital energy consumption is typically used for activities like space heating and cooling, ventilation, lighting, medical equipment usage, hot water, and cooking.70 According to Major Energy Retrofit Guidelines by Natural Resources Canada, a typical hospital in BC will source 63% of its energy from natural gas, a non-renewable energy source.71
In terms of transportation, ambulances servicing Canadian hospitals typically run on gasoline or diesel while helicopters require aviation fuel. The Canadian Energy Centre reports that while distances traveled and fuel use are not consistently monitored or reported, these transportation methods are highly dependent on and require large amounts of nonrenewable energy sources.70
Mitigation Efforts
In order to reduce healthcare facility dependence on non-renewable energy sources and to reduce GHG emissions, more sustainable alternatives must be implemented. The WHO recommends that hospital architecture and building orientation consider natural landscapes and sun exposure to allow for passive cooling and heating as well as natural sources of lighting. Renewable energy sources, such as solar, hydroelectric, and wind should be promoted where possible in hospitals, particularly when considering plans for new construction. A combination of natural ventilation, through doors and windows, and mechanical ventilation, which is more efficient but requires significant sources of energy, will not only reduce the overall energy required, but allow for better air circulation that can effectively reduce the risk of airborne disease transmission.72
In addition, as operating rooms are estimated to be unoccupied up to 40% of the time, controlling room maintenance during periods of low-use can lead to significant energy savings.45 Further, in comparison to standard halogen lighting, LEDs with variable colour temperatures are better able to mimic our natural circadian rhythm and therefore can improve alertness.73 LEDs can also offer up to 50% more energy savings.74 Cost reduction from optimized energy use can subsequently be allocated towards improving patient care.
Finally, alongside building maintenance, transportation is a significant emitter of GHG. This includes but is not limited to ambulance and helicopter patient mobilization. Currently, very few electric vehicles are being used in the healthcare sector. The reluctance to switch to more environmentally friendly patient transport is largely due to the high initial costs, additional infrastructure required such as charging stations, time required to fully charge vehicles, and the limited travel distance on a single charge.75 As electric vehicle technology improves and costs decrease, there is great possibility for their increased use in healthcare contexts.
