Q: How significant is healthcare’s contribution to climate change?
Globally, healthcare accounts for 5% of greenhouse gas emissions. In the U.S., about 8.5 % of emissions come from healthcare. In addition, healthcare produces similar fractions of the United States’ toxic air pollution, which is a significant contributor to premature deaths.
The idea that healthcare pollution is causing harm that can be prevented is a new concept. Our research found that the health damages are on the same order of magnitude as from medical errors. We take medical errors very seriously. We’ve gone to great lengths to measure the problem, formalize patient safety work, and do what we can to prevent medical errors. The public health impacts from healthcare pollution ought to be taken just as seriously.
Q: What are the hurdles to integrating sustainability into healthcare?
Healthcare is a unique industry. Our widget, if you will, is a health outcome. We already have a social mission. We’re already doing good in the world. I think that we feel as though that’s enough. So compared to other industries we’re lagging behind in the sustainability movement.
Beyond that, there’s not enough information or communication around our own emissions—that’s number one. And number two, the fact that climate change is a crisis that’s rapidly approaching a tipping point is not appreciated within the healthcare delivery sector. The harm seems distant, both physically and geographically, and so it’s not felt urgently the way patient care delivery is.
Q: Academic research on sustainability in healthcare is something new.
It is. I got interested in sustainability in healthcare while doing my specialty training in anesthesiology. As we take care of patients, we’re using a lot of materials and not always using them efficiently. Every item must come from somewhere. Producing it is causing some harm to the environment and to population health. Disposal is causing some harm. When I looked into it, there was no information on how big that harm was, and therefore no guidance on what to do to mitigate it.
“We started to put some numbers behind what is obvious: that there’s a lot of healthcare pollution. By beginning to understand the magnitude of the problem and the hotspots, we can prioritize our intervention.”
When I finished my training, I took a job here at Yale specifically because it allowed the opportunity to partner with researchers through the Yale School of the Environment, including, notably, Julie Zimmerman. We started to put some numbers behind what is obvious: that there’s a lot of healthcare pollution. By beginning to understand the magnitude of the problem and the hotspots, we can prioritize our intervention.
Q: Could you give an example of how you uncover opportunities for improvement?
I can talk about our research on anesthetic gases. For context, after our research, the National Health Service in England found that 2-3% of their health sector footprint comes from inhaled anesthetic gases. If we look specifically at perioperative services—before, during, and after surgery—inhaled anesthetics account for about half of emissions.
The inhaled drugs that we use in anesthesia are very potent greenhouse gases. Some are also very destructive to the ozone layer. We have indoor controls to protect against occupational exposure, but there are not outdoor mandates, so these drugs are essentially vented off hospital rooftops.
Our life-cycle analysis study looked at inhaled gases used for general anesthetic as well as propofol, an intravenous alternative. For the inhaled gases, the biggest emissions impact is in the waste phase—the venting off the rooftops. That tells us it’s our best opportunity for an intervention. Gas capturing and destruction technologies are potential solutions. Different inhaled gases also have different emissions impacts—desflurane and nitrous oxide are particularly bad. While the intravenous option, propofol, has several orders of magnitude less greenhouse gas emissions in a clinically equivalent quantity.
The takeaways from the study were: We waste a lot of these drugs. We should waste less. We should avoid desflurane and nitrous oxide where possible. They have a much higher emissions impact than alternative gases. And propofol is a much better choice from a life-cycle greenhouse gas perspective.
Clinically, we have to keep in mind that these drugs have different properties and that’s why we choose one over another. But where we have the opportunity, we should choose approaches that are also better for population health.
Q: How do you integrate these findings into clinical practice?
Beyond publishing, speaking and teaching, we are working to build information into existing electronic decision support tools. The University of Michigan’s Multicenter Perioperative Outcomes Group uses electronic healthcare data to build provider-level and institution-level performance reports, to improve quality of care at hospitals around the country. We’ve made some progress on developing metrics for inhaled anesthetics in those databases. We’ve also developed electronic alert tools in the operating room to guide providers to reduce waste of inhaled anesthetics. We’re also working to give providers feedback to influence environmentally preferable decision-making to also reduce emissions.
At Yale New Haven Health, we have electronic decision support tools for communicating the latest, most streamlined treatments of certain conditions to reduce variability in practice. We’re in the process of building environmental emissions into this Care Signature program as well. We especially want to embed environmental emissions information into our procurement system, together with our electronic health records.
Q: How should a large healthcare system set priorities for sustainability programs?
Initiatives focused on renewable energy, building efficiency, electrification of facilities and transportation, food, and laundry are all valuable, and commonly the focus of healthcare sustainability work. The big challenge is the medical supply chain. It accounts for about 70% of healthcare’s footprint.
In healthcare, and elsewhere, the first sustainability initiative people tend to focus on is recycling. We use so many disposable materials, particularly a lot of plastic. It’s very visible; people feel bad. I think we spend too much energy trying to recycle, however, because it takes too much time away from much larger opportunities for reducing emissions.
We need to be focusing upstream, on reducing the excessive consumption of materials to begin with, because that’s where we have a lot of opportunity and that’s where the bigger impact lies. Part of the solution there is choosing more reusable supplies.
Another very big part is policy setting. While trying to achieve zero harm to individual patients, we’ve completely neglected the indirect effects of healthcare pollution on population health. We have to find the right balance between how we safely take care of our patients and our communities. Along with that, developing metrics and data support tools will make it easier to include environmental emissions information in decision making throughout the organization.
Q: Are there healthcare systems that offer a model of sustainability for others to follow?
The global exemplar is England’s National Health Service (NHS). It’s one of the largest health systems in the world. It’s the sixth largest employer, globally.
The NHS has been measuring their emissions since 2008, when England’s Climate Change Act mandated it. In 2020, just before the pandemic, they launched the Greener NHS initiative, which projects that by 2040 they can get to net zero excluding parts of the supply chain. By 2045 they estimate they can be fully net zero.
Q: What about in the U.S.?
Currently, there’s no established system to compare one healthcare organization to another. Only a handful of healthcare institutions report any sustainability performance. Notable ones include Kaiser Permanente, Cleveland Clinic, and Gunderson Healthcare. While there are international frameworks for voluntary corporate social responsibility reporting, there is no healthcare standard that accounts for healthcare’s widget—the clinical outcome. Therefore, there are no established best practices to aspire towards. In particular, voluntary reports frequently neglect Scope 3 emissions, which essentially encompasses the supply chain. For healthcare, this is the biggest problem.
My group has called for strong incentivizes for reporting and draw down of emissions. We’ve proposed that this be adopted through the Centers for Medicare and Medicaid’s Value-Based Payment program, which essentially reimburses good performance, and doesn’t pay or even penalizes for bad performance. The Veterans Affairs insurance program could also do something similar. Virtually every hospital has a significant income coming through the government. If emissions are tied to government payment, health systems would be incentivized to achieve net zero.