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Should ecological optimization and carbon reduction strategies be listed among priorities when surgical pathways are designed?
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An established model of environment-friendly surgery
Our experience at the Aravind hospitals shows that a sensible approach to surgery that takes the environment and carbon reduction into account is feasible and safe for the patient. All eye surgery, and particularly cataract, is high-volume surgery. If we do not do responsible waste segregation, the impact on the environment is huge. Waste segregation, which allows recycling and reusing waste, is critical in every sector of health care, but even more in eye care, in which we use many tiny items that come with a huge amount of packaging. IOLs, anesthetics and other drops we use in eye surgery are individually packaged and then delivered in boxes, surgical knives are individually protected by plastic caps, and everything is accompanied with several paper booklets. At Aravind, we do systematic and rigorous waste segregation for recycling.
In the developed world, everything is single-use and disposed of for each case, although there are parts such as the phaco tip that can be autoclaved and reused, thus reducing the cost as well as the carbon footprint of surgery. We flash sterilize the surgical instruments and phaco tips in between surgeries, while the phaco tubing and cassettes are disposed of at the end of the day. Flash autoclaving is fast and effective. In the U.S., it is not allowed and they do full-cycle sterilization, which takes more than 1 hour, while we obtain the same results in just a few minutes. There are no reasons other than habit for not doing so, as shown by our studies. Our infection rate is comparable to the international rate and even lower than the rate obtained in some developed countries. We generate one-tenth of the waste of U.S. operating rooms, and we have similar results in our surgery, a similar number of complications and infections, and comparable visual outcomes.
Rengaraj Venkatesh, MD, is from Aravind Eye Hospital, Pondicherry, India. Disclosure: Venkatesh reports no relevant financial disclosures.
Our generation has already lost much time
Fifty years ago, credible scientific evidence about progressive global warming from carbon dioxide accumulation in the atmosphere raised enough concern that a warning was presented to then President Lyndon Johnson, asking him to rein in carbon pollutants. Today, most Americans believe, and overwhelming scientific evidence proves, that mankind’s role in contributing to global warming is real and significant. We look back on President Johnson’s inaction and wonder why. If we look forward, though, will our behavior be even less defensible than President Johnson’s?
A recent study in the U.K. shows that the average 5- to 10-minute cataract surgery generates as much waste as a single human does in an entire week of ordinary living. In the U.S., we perform about 4 million surgeries per year now, which brings the total waste up to the equivalent of one human’s waste for almost 100,000 years. And that is just one type of procedure among the many medical interventions that generate waste. Can we ignore this when we have a swirl of plastic garbage the size of Texas floating in our ocean?
The medical system has never been oriented to reducing its carbon footprint. Putting patient safety first, we generate packaging solely for the purpose of keeping the contents sterile and reducing cost. We use mountains and mountains of inexpensive Styrofoam and other non-recyclable plastics. It is not in the FDA’s or industry’s mandate to reduce waste, so why spend the engineering effort and cost to use more reasonable packaging? Moreover, why take any risk of infection when we can simply throw away the cataract surgery tubing, cassette and all the drape materials that unnecessarily cover the patient from head to toe? To be sure, the carbon cost of re-sterilizing certain materials outweighs that of discarding them, but would it not be reasonable at least to try to reduce our carbon waste in medical procedures? Could the FDA not include this in recommendations, if not regulations, for manufacturers?
Our generation has already lost much time and been a significant contributor to the problem of carbon pollution. While we can be proud of the legacy of technology advancements we will be giving the next generation, should we be like President Johnson and squander an opportunity to make the future world a better place?
John A. Hovanesian, MD, FACS, is OSN Cataract Surgery Section Editor. Disclosure: Hovanesian reports no relevant financial disclosures.