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Health care providers have duty to reduce impact of their work on environment
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Climate change is predicted to be one of the largest health threats of the 21st century. Human activities are increasing the release of greenhouse gases, leading to global warming and eminent catastrophe. It is important for every individual to know about carbon/greenhouse gas emissions, and each one of us must endeavor to limit the same so as to leave the earth in a better position than it is now.
Health care itself is a large contributor to carbon emissions. The health care sector is responsible for one-seventh of the U.S. economy. The energy used in health care facilities is highly extensive and almost double that per square foot of traditional office space. The carbon footprint of the National Health Service in England is estimated to be 20 million tons of greenhouse gases and accounts for 25% of all public sector emissions in the United Kingdom. Reducing greenhouse gas emissions from health care facilities is of prime importance. Instilling the concept of “going green” in medical and health care education is important to raise awareness and initiate efforts to improve not just the patients’ health but also that of the surrounding environment.
Cataract surgery is the most common ophthalmic surgery and one of the most common elective day care surgeries performed worldwide. It is important to understand the impact of cataract surgery on the environment. Scientifically understanding the extent of the problem will help us devise strategies to limit the potential damage. The average carbon footprint of a single eye cataract surgery in the Cardiff study was 181.8 kg CO2 eq, and the approximate value for all cataract surgeries conducted in Cardiff in 2011 was 405.1 tons. To put this in perspective, the average carbon footprint of a U.K. resident is about 10 tons per year; a flight between New York and London is 1 ton to 2 tons per passenger.
The various types of energy loss in cataract surgery can be classified as building energy, travel energy, procurement and waste energy. Building energy includes the energy used per square foot, along with water and food consumption and disposal. Construction of new clinics and operation theater complexes should include the concept of green buildings, utilizing sustainable and efficient designs, green building materials, energy efficient lighting, air cooling or heating systems, natural ventilation and rainwater harvesting. Use of clean energy such as solar or wind power can help reduce dependence on other sources of electricity. In the Cardiff study on the carbon footprint of cataract surgery, building energy contributed to 36.1% of emissions. Using simple efficient systems to limit the waste of water and electricity in an existing setup can also help, but in the long run, building a new environmentally friendly facility would be a welcome measure.
Travel energy contributed to 7% of energy used in the Cardiff study, and a significant amount was due to the multiple visits that a patient made to the hospital. Reducing the number of visits through measures such as same-day cataract surgery might help curb wasteful energy expenditure. Another interesting concept is simultaneous bilateral cataract surgery, which is practiced in a few centers. Immediate sequential bilateral cataract surgery, which is practiced frequently in pediatric patients, also has the benefits of faster visual recovery, improved outcomes and cost-efficiency in adults. This might, in addition, be helpful in reducing our carbon footprint. Holding postoperative checkups in hospitals closer to the patient’s home might be a choice in places such as the United Kingdom, where most cases are covered by the NHS. Camp surgeries, as practiced in India where people are brought from an outlying area in a single vehicle to undergo surgery and return the next day, might also reduce the energy used for a large group of people to travel.
Procurement of medical equipment and drugs was responsible for 53.8% of all energy emissions, and medical instrument procurement alone was responsible for 32.6%. Although this is the most energy-consuming sector in the entire chain, measures to reduce the energy used are limited due to constraints with existing laws. However, ophthalmological societies should coordinate with the ophthalmic industry and regulators to reduce unnecessary waste. For example, IOL packaging can be reduced without compromising sterility. Bulk orders can reduce the number of trips required to replenish stocks, and dealing with a local buyer closer to the hospital can reduce the procurement energy losses. The Cardiff study, with a waste loss of 1.88%, reported a minimal benefit of recycling components generated in the cataract pathway. A study from Aravind Eye Hospital in India reported the estimated carbon footprint of a single cataract surgery to be 15 kg CO2 eq as compared with 181.8 kg CO2 eq in the Cardiff study. The smaller carbon footprint in the Aravind study was essentially due to increased reuse of products such as operation theater gowns, drapes and instruments after re-sterilization. The use of two adjacent surgery tables reduces the time between surgeries and speeds up the process.
The amount of waste generated per case is 0.25 kg, of which two-thirds are recycled, one-fifth is the disposable face mask and one-fourth is the IOL packaging. Somner and colleagues noted that compared with phacoemulsification, manual small-incision surgery generates a smaller carbon footprint, but by recycling some of the disposable materials, we can reduce the carbon footprint of phacoemulsification, as shown in the Aravind study. One suggestion was to send so-called disposable instruments back to the manufacturer for re-sterilization instead of preparing fresh instruments. This might also help in reducing the cost of surgeries. However, this might introduce third-party issues with sterilization or the allocation of space in the hospital to autoclave these products, along with the energy spent to send them for sterilization. Use of topical anesthesia instead of peribulbar anesthetic can reduce the use of disposable needles and syringes. Nitrous oxide released into the atmosphere during general anesthesia can be recirculated and reused using a special circuit. The materials used intraoperatively, such as drops, could be passed on to the patient to be used during the postoperative period. Studies have also shown the benefits of shifting from a paper-based system to electronic records.
To conclude, as health care providers, it is our duty to reduce the impact of our work on the environment as much as possible. Even small efforts can go a long way in creating a healthy and sustainable environment.
References:
Lansingh VC, et al. Clin Experiment Ophthalmol. 2015;doi:10.1111/ceo.12527.
Morris DS, et al. Eye (Lond). 2013;doi:10.1038/eye.2013.9.
Pyott A. Eye (Lond). 2011;doi:10.1038/eye.2010.199.
Somner J, et al. J Cataract Refract Surg. 2009;doi:10.1016/j.jcrs.2008.09.026.
Turley M, et al. Health Aff (Millwood). 2011;doi:10.1377/hlthaff.2010.1215.
Venkatesh R, et al. Curr Opin Ophthalmol. 2016;doi:10.1097/ICU.0000000000000228.
For more information:
Dennis S.C. Lam, MD, FRCOphth, can be reached at State Key Laboratory in Ophthalmology, Sun Yat-Yen University, 54 South Xianlie Road, Guangzhou 510060, People’s Republic of China; email: dennislam.gm@gmail.com.
Disclosure: The authors report no relevant financial disclosures.