We are approaching a key moment as a civilisation as we try to address the existential threat of climate change. In response, the world is moving to a sustainable future and countries are rapidly signing up to a commitment to meet net-zero emissions by 2050 – but there is considerable work ahead. Much focus centres on energy generation and transport as these sectors will require massive transformations to reduce emissions, however other sectors such as healthcare must contribute as well. By living more sustainably health outcomes can be improved. Paradoxically though, the healthcare sector is a major contributor to emissions, which in turn harms our health.
The impact of climate change on health
Health is a key part of the rationale to address climate change and create a more sustainable society. Climate change can have direct impacts on health, due to increased intensity and frequency of weather events, and indirect impacts, through worsening air quality and modifying the spread of infectious diseases. A recent article described the health consequences of extreme urban heat, which include cardiorespiratory mortality, renal disease, mental illness, reduced labour productivity and health system impacts². The article also described simple solutions such as increasing reflectivity of buildings, which reduces ambient temperature and the subsequent risk of heat-related death. Overall it has been estimated that approximately one-quarter of health burdens are connected to environmental pollution².
Healthcare and sustainability
Healthcare saves lives and improves the quality of life. However, healthcare also adds to pollution, which can harm public health. Previously it has been estimated that global healthcare, if considered as a country, would be the fifth-largest carbon emitter globally³. The recent pandemic has shown that public health responses, when implemented correctly, can save thousands of lives. However, to achieve this, consumables such as single-use personal protective equipment, disposable face masks and hand sanitiser products were needed, which has dramatically increased waste in the healthcare sector. One story highlighted this problem by documenting the use of over 50 single-use gowns during a 24-hour period to treat a patient with COVID-19 in intensive care⁴.
A study from 2018 estimated the carbon footprint of Australian Healthcare to be over 35,000 kilotonnes of CO2 emissions annually, representing approximately 7% of the total CO2 emissions in Australia⁵. The authors noted that the emissions for healthcare was approximately half the emissions for construction (estimated to be 14% total emissions) and were equivalent to the total emissions for 7% of the Australian population, approximately equivalent to the population of South Australia⁵.
Life cycle assessments
The major contributors to emissions in healthcare in Australia include hospitals (public hospitals: 34%; private hospitals: 10%) and pharmaceuticals (19%)⁵. In order to assess sustainability and the environmental impacts of new products and processes, life cycle assessments (LCAs) are used often. LCAs assess the environmental aspects and potential impacts of products or processes over their entire life cycle, from raw material extraction to production, use, and end of life in a structured way. Typically, LCAs include four steps:
Goal and scope definition
– Goals of the study are provided and scope defined
– The objective of the study, application, audience, system boundaries, and functional unit (FU) for analysis are clarified
Life cycle inventory (LCI)
– Data regarding all inputs (e.g., energy or raw material) and all outputs (e.g., products, co-products, waste, emissions) over the life cycle of the system under study are collected and compiled within an LCI analysis
Life cycle impact assessment (LCIA)
– The LCIA evaluates the magnitude and significance of the collected environmental impacts
– The impacts can be assigned to several midpoints and endpoints via several LCIA methodologies. Impact categories are differentiated into depletion categories (e.g., land use or water use) and pollution categories (e.g., global warming, ozone depletion, eutrophication, ecotoxicology, human toxicology, acidification, or effects of wastes). Endpoint categories can be value-weighted and related to areas of protection: human health effects, natural environmental quality, natural resources, and synthetic environment
Interpretation
– The results of the inventory and the impact assessment are discussed in order to draw conclusions, which can then be used to provide recommendations and support decision-makers.
(Adapted from Seifort et al. 2021⁶)
A recent systematic review documented LCAs undertaken in hospitals and their contribution to management decision-making⁶. The review identified 43 articles, including 13 articles with a LCA on products such as medical devices, 8 articles with a LCA on processes such as surgical procedures, and 22 articles with footprint assessments such as medical treatments or auxiliary processes⁶. The review showed that LCAs can support evidence-based decision making in multiple settings, however the authors noted further work is required to integrate environmental information with other factors such as patient safety or infection risk⁶.
Triple bottom line and SROI
A framework that brings together environmental impacts with social and financial impacts is known as the triple bottom line. Economist John Elkington first introduced the idea of a triple bottom line framework in 1994, arguing that for organisations to become more sustainable, they must go beyond the traditional first “bottom line” of profit and loss and integrate the environmental and social costs of doing business into their corporate accounting structures⁷. This approach has been proposed for clinical specialities such as surgery to address issues such as reusing and redesigning surgical kits, considering alternatives to certain anaesthetic gases and reprocessing single-use devices⁸.
Social Return on Investment (SROI) is a type of impact assessment that incorporates the triple bottom line to tell a rich story of how change is created. The method converts changes in the social, environmental, and healthcare domains into monetary units which can be compared to the cost of implementation. A unique feature of SROI is the input of numerous stakeholders who are impacted by the change, which is collated, analysed and used to determine the impact.
ESG frameworks
Another term frequently used in combination with, or in place of, sustainability is ESG (standing for Environment, Social and Governance). While sustainability and ESG are similar concepts, ESG provides a specific and measurable framework to improve sustainability in companies. The environmental dimension focuses on improving the environmental performance of a company, such as reducing carbon emissions, improving resource efficiency and reducing waste. The social dimension focuses on a business’ impact on its employees, customers, and the community, including aspects like workplace safety, diversity and inclusion and customer satisfaction. Finally, the governance dimension focuses on a business’ leadership and structure, such as how much executives get paid, who is on the board and whether shareholders get to vote on important issues.
Public demand for governments and companies to act on sustainability is rapidly growing through protests, petitions and campaign donations⁹. In addition, consumers are starting to modify their behaviour, with searches for sustainable goods increasing globally by 71% since 2016⁹. Corporations are starting to respond to this trend with approximately 70% of the ASX 200 companies having a sustainability strategy, however only 18% explicitly identify ESG opportunities¹⁰ . When examining health and pharmaceutical companies within the ASX 200, only 60% have a sustainability strategy with 0% identifying ESG opportunities¹⁰ . Currently sustainability reporting is not a compulsory requirement in Australia, however ESG performance has become a key area of focus for investors interested in impact investing.
Conclusion
A rapid reduction in CO2 emissions is essential to keep the Earth’s temperature within limits for the survival of humans and other species, a discussion that dominated talks at the recent COP26 conference. Although it is clear that strategies need to be implemented for reducing the harmful effects of CO2 emissions and restoring the Earth’s energy balance, it is also important to ensure that these strategies do not unintentionally cause harm. Health is a sustainability paradox: Improving sustainability can improve health, but conversely, improving health through interventions and services can harm sustainability (which negatively impacts health). The COVID-19 pandemic has seen a proliferation of unsustainable practices which require reconsideration in light of the environmental challenges we face. New healthcare interventions and services cannot continue to be evaluated using only traditional metrics such as efficacy, safety, and cost-effectiveness. Frameworks such as SROI, which integrate health outcomes with environmental and social impacts can be used to provide a holistic assessment of value.
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