Green Doctors

As doctors we have a duty of care to firstly do no harm and secondly to provide leadership in advocating for action to protect health and humanity. Yet for many of us our workplaces significantly contribute to an adverse ecological footprint.

Evidence strongly suggests that human activity is significantly contributing to an alarming rate of climate change, which is predicted to present increasing challenges to the maintenance of human health and the effective delivery of local and global healthcare. Within Australia, it is likely that there will be more extreme heatwaves, fires and floods as well as changes in the distribution of certain vector-borne diseases such as dengue and Ross River viruses. These changes will lead to further demands on our increasingly strained health and emergency services. Globally, the Lancet publishes ‘climate change is the biggest global health threat of the 21st century’1.

We are a profession that prides ourselves on evidence-based practices yet we remain relatively quiet as scientific evidence continues to accumulate on the need to reduce carbon emissions to prevent an impending devastating situation for human health and humanity. All whilst plausible answers and solutions are published daily.

Even if the evidence for anthropogenic involvement is not absolutely 100% we should be reminded of the precautionary principle, written by Bradford Hill in 1965 ‘… all scientific work is incomplete…and is liable to be upset or modified by advancing knowledge. This does not confer upon us a freedom to ignore the knowledge that we already have, or to postpone that action that it appears to demand at a given time’2.

The healthcare sector’s contribution to greenhouse gas emissions, landfill and environmental degradation is not insignificant. Although there is no equivalent Australian data we know the United Kingdom’s National Health System (NHS) is responsible for 3.2% of that country’s total carbon footprint3.

Hospitals are high energy and water consuming, waste producing organisations. Embracing sustainable practices can lead to significant environmental advantages as well as having the potential to deliver financial gains. A recent joint publication by the World Health Organization and Health Care Without Harm ‘Healthy Hospitals, Healthy Planet, Healthy People’ describes numerous cost saving examples associated with environmentally sustainable hospital modifications4.

As practising doctors we can instigate actions within our everyday practice that have the potential to lead to significant reductions in carbon emissions. Audits investigating the sources of CO2 emissions generated by the NHS have shown that addressing the procurement practices of medical equipment and drugs as well as those of goods and services (procurement accounting for a staggering 60% of total NHS CO2 emissions) is just as, if not more important, than decreasing the emissions accrued from powering healthcare buildings (22%) or through staff and patient travel (18%)5.

Within hospitals, operating suites are a significant contributor to energy resource consumption and waste production, generating approximately 20% of hospital waste6. Anaesthetists and surgeons have a constant presence in operating suites and are well placed to improve the environmental effect of their workplaces. By following the waste hierarchy ethos of ‘Reduce, Reuse, Recycle’ in our everyday practice and even taking further steps to ‘Rethink and Research’ our daily environmental impact, we can make a difference and hopefully encourage those around us to as well.
REDUCE
Address adverse environmental impacts, waste and costs by using less of everything (power, equipment, products, medications etc.).

Reduce landfill and clinical waste streams by ensuring correct waste segregation and the implementation of recycling options. Clinical waste generally has a higher fossil fuel carbon content compared with general waste, requires either high temperature incineration or chemical treatment before deposition into landfill, and is usually 10 fold the expense of general waste to dispose of.

Consider the environmental impact of the medical gases (N2O, sevoflurane, isosflurane, desflurane) we may administer and how this can be reduced. Their overall contribution to greenhouse gas emissions can be thought of as low, however when their emission amounts are related to daily activities their effects can be considered significant. For example, each minute of N2O usage at 0.5 litre / minute is equivalent in global warming potential to driving an average car 1 km7. Therefore administering N2O for a day can be contributing as much to the ‘greenhouse effect’ as driving an average car 500-1000 km. Although sevoflurane, isoflurane and desflurane are generally administered in far lower concentrations than N2O, Ryan et al in Anaesthesia and Analgesia have recently published that 1-2 litres FGF (fresh gas flow) at 1 MAC (minimum alveolar concentration) of desflurane, using European Union data, equates to driving a car 375-750 km per hour of anaesthetic use, whereas sevoflurane or isoflurane equate with driving 28 km (2 litres FGF) or 31-62 km (1-2 litres FGF) per hour of use, respectively8.

REUSE
Assess the validity of reusing medical equipment were appropriate. The replacement of reusable medical items with disposable (single-use) items is ubiquitous, often due to perceived lower costs and infection risks. Yet little evidence supports this practice, in fact evidence exists to the contrary. Life cycle analysis studies that have been done on anaesthetic trays and laproscopic surgical equipment have shown environmental and financial advantages of reusable items compared with disposable ones9-11.

RECYCLE
Promote recycling options at work. Co-mingled (collecting paper, cardboard, glass, plastic and metal in the one receptacle) recycling programs exist for local government curb-side collections. It is incongruous that co-mingled recycling does not occur within the controlled setting of all our hospitals. Almost 60% of anaesthetic general waste is potentially recyclable12.

Manufacturing recycled plastics uses approximately 25% of the energy compared to equivalent plastic products produced from raw products. Hospitals are beginning to recycle non-contaminated plastic products. Not all plastics within hospitals can be recycled together with up to 30% of medical plastics comprising PVC (polyvinyl chlorine). PVC requires separation from other plastics and undergoes a different recycling process. However preliminary PVC recycling programs converting hospital waste into PVC pipes have been set up.

Minimising the volume of batteries, electronic items and medical equipment that ends up in landfill is also important. Food waste has been diverted from landfill to compost deposits or warm farms in several hospitals. Deposition into landfill comes at both an environment and financial cost. Recycling can lead to significant advantages in both these areas.

Water is increasingly scarce in many parts of Australia. Reverse-osmosis renal dialysis units ‘reject’ or discard water (30-50% of the original mains water used) that is formed by pre-dialysis water filtration before exposure to blood products. This ‘reject’ water falls within potable limits in most parts of Australia and has been used in hospital gardens and toilets13.

RETHINK
Analyse the latest evidence and clinical recommendations to ensure appropriate use, prescription and administration habits are preventing unnecessary consumption, waste and cost. Production of most medical drugs can have significant adverse environmental impacts with 99% of the raw materials used in their manufacturing ending up as landfill3. Each patient in French and German hospitals accounts for 1.9 kg and 0.4 kg of waste per day respectively, whereas a patient in a UK hospital accounts for 5.5 kg, with Australian estimates reflecting UK amounts14.

Attention to the procurement policies and processes by which medical drugs, equipment and paper (accounting for 22%, 9% and 5% respectively of total NHS CO2 emissions)5 are sourced could result in significant environmental, financial and ethical benefits.

RESEARCH
Further research surrounding the entire life cycle analyses of the equipment, products and medications used in our health care system is needed. Enabling practitioners to make truly informed decisions about environmental and financial impacts.

GREEN PRACTICES / CONSULTING ROOMS
Medical professionals who own or manage clinics can make further changes. The Australian Conservation Fund in collaboration with Doctors for the Environment Australia have developed ‘The GreenClinic Guide’15. The guide outlines ten points to assist doctors and practice managers to make simple changes to help save energy and water, reduce waste and promote sustainable practices. The suggestions range from purchasing renewable energy for clinics to procuring products with reduce environmental impacts. Several Australian medical professionals have also developed the GreenPractice16 initiative, which aims to inspire both doctors and patients to live and work in a sustainable manner.

Health care professionals as community leaders, educators, providers and contributors to environmental degradation and greenhouse gas emissions need to look towards embracing environmentally sustainable practices within their homes, their workplaces, and the wider community.

REFERENCES

1   Costello A, Abbas M, Allen A et al. Managing the health effects of climate change. Lancet 2009; 373: 1693-1733.

2   Hill AB. The environment and disease: association or causation? Proc R Soc Med 1965; 58: 295-300.

3   Cole A. Saving the Planet as Well As Lives. BMJ. 2009;338:742-744.

4   Healthy Hospitals, Healthy Planet, Healthy People. World Health Organization and health Care Without Harm. www.noharm.org/lib/downloads/energy/Healthy_Hosp_Planet_Peop.pdf (accessed August 2010).

5   Saving Carbon, Impoving Health: NHS Carbon Reduction Strategy for England. www.sdu.nhs.uk/page.php?page_id=94 (accessed August 2010).

6   Lee BK, Ellenbecker MJ, Moure-Eraso R. Analyses of the recycling potential of medical plastic wastes. Waste Management 2002; 22: 461-470.

7   McGain F. Why anaesthetists should no longer use nitrous oxide. Anaesth Intens Care 2007; 35:808-9.

8   Ryan S, Nielsen C. Global Warming potential of Inhaled Anaesthetics: Application to Clinical Use. Anaes and Analg 2010; 111:92-98.

9   McGain F, McAlister S, McGavin A, Story D. The financial and environmental costs of reusable and single-use plastic anaesthetic drug trays. Anaes Intens Care 2010; 38:538-544.

10  Adler S, Scherrer M, Ruckauer KD, Daschner FD. Comparison of economic and environmental impacts between disposable and reusable instruments used for laparoscopic cholecystectomy. Surg Endosc 2005; 19: 268-272.

11   Schaer GN, Ossi RK, Haller U. Single-use versus reusable laparoscopic surgical instruments: A comparative cost analysis. Am J Obs Gyn 1995; 173 (6): 1812-1815.

12   McGain F, Hendel S, Story D. An audit of recyclable waste from anaesthetic practice. Anaes Intens Care 2009; 820-823.

13   Agar JWM. Reusing renal Diálisis Wastewater: The Elephant in the Room. Am J Kidney Dis 2008; 52 (1):10-12.

14   Tudor TL, Marsh CK, Butler S et al. Realising resource efficiency in the management of healthcare waste from the Cornwall National Health Service (NHS) in the UK. Waste Manag 2008; 28: 1209-1218

15   www.acfonline.org.au/greenclinic (accessed August 2010)

16   www.greenpractice.org.au (accessed August 2010)