Wildfires, air quality, flooding, and extreme temperatures are all effects of climate change that are negatively affecting the health of patients around the world. Whether it is a sickle cell crisis or a nephrotoxicity during cancer treatment, hematologists are learning to recognize and address the health impacts of climate change every day. However, sometimes overlooked is the negative impact the health care sector itself has on the environment.
The health care industry is a significant producer of greenhouse gas emissions and air pollution in the U.S. and globally. The global health care sector accounts for about 5.2% of all global carbon dioxide emissions, with the U.S. logging the highest contribution at around 553 million metric tons of carbon dioxide equivalent.1,2 In the U.S., the health care sector alone accounts for approximately 8.5% of domestic greenhouse gas emissions, and those emissions are on the rise, increasing 6% from 2010 to 2018.2
“We’re a huge part of the national economy, so it stands to reason that we also contribute a very large fraction of our pollution, but of course that is against the mission of health care,” said Jodi Sherman, MD, an anesthesiologist and founding director of the Yale Program on Healthcare Environmental Sustainability in New Haven, Connecticut, who has published extensively on the health care sector’s carbon footprint.
Part of Dr. Sherman’s research has been calculating the impact of health care-generated emissions on patient health. In a 2020 analysis published in Health Affairs, Dr. Sherman and her colleagues calculated that U.S. health care pollution created health burdens resulting in a loss of about 388,000 disability-adjusted life-years in 2018.2 Dr. Sherman said that figure puts damages from health care pollution on the same level as harm from preventable medical errors, as first reported in the landmark Institute of Medicine report “To Err is Human” in 1999.3
“Health care pollution prevention is the new patient safety movement and cannot be ignored. We haven’t been measuring it before, and now we need to measure it. We need to take it just as seriously as preventing medical errors,” Dr. Sherman said.
ASH Clinical News spoke with researchers who are measuring the impact of health care-related emissions, as well as advocates for sustainability in medicine, to better understand how U.S. health care institutions are contributing to climate change and what clinicians can do to help reverse the damage.
Health Care as Pollution
“The health care sector is very energy, resource, and waste intensive,” explained Amy Collins, MD, who is the medical director of physician engagement and education at Practice Greenhealth, a U.S. membership and networking organization for health systems and hospitals interested in environmental sustainability. Practice Greenhealth is part of Health Care Without Harm, which advocates for environmentally responsible health care internationally.
Health care is a unique industry because it has 24-hour operations with high energy requirements for diagnostic and therapeutic equipment, as well as heating, cooling, and ventilation. Hospitals and health systems also produce tens of thousands of tons of solid waste daily, including regulated medical waste, plastic, and food waste. Hospital fleet transportation, supply chain operations, and even employee commutes all add to the overall environmental footprint. “Basically, every health care activity from the boardroom to the operating room to the kitchen to the radiology department generates waste and emissions,” Dr. Collins said.
Greenhouse gas emissions are typically divided into categories based on their origin. In health care, Scope 1 emissions include direct energy use by health care facilities, combustion from owned or leased vehicles, and anesthetic gases. Scope 2 emissions include combustion from purchased electricity sources. Scope 3 encompasses the entire health care supply chain, including pharmaceuticals, medical products and devices, equipment, and the solid waste generated in facility operations.
The supply chain accounts for the majority of health care emissions at 82%, with pharmaceuticals, chemicals, and medical devices as the most emissions-intensive elements, according to the 2020 analysis from Dr. Sherman and colleagues.2
“What is consistent with many industries is that the vast majority of emissions come from the supply chain of goods and services,” Dr. Sherman said. “If you delve down to the level of the health care organization,
there’s going to be some variation. For example, a nursing home is not going to have the same breakdown as a
hospital, but by and large, as with many service industries, the supply chain is the biggest culprit. Within health care, the worst offenders are pharmaceuticals and chemicals, medical devices and supplies, and food.”
Pledges, Not Mandates
Awareness of health care as a contributor to climate change is growing, as are calls to action. In 2021, the Biden administration created the Office of Climate Change and Health Equity within the Department of Health and Human Services (HHS). The priorities of the office include “supporting regulatory efforts to reduce greenhouse gas emissions and criteria air pollution through the health care sector, including participating suppliers and providers.”4
Additionally, on Earth Day in 2022, the White House and HHS launched the Health Sector Climate Pledge, which encourages health care organizations to commit to a goal of reducing greenhouse gas emissions by 50% by 2030 and achieving net zero emissions by 2050. The pledge is voluntary and does not tie federal funding to meeting or missing any of the targets. However, the pledge calls on participants to publicly announce progress on emissions reductions annually, designate an executive-level lead for emission reduction efforts by 2023, conduct an inventory of Scope 3 supply chain emissions by the end of 2024, and develop and release a climate resilience plan by the end of 2023 that allows for continuous operations in the event of a climate emergency. As of April 2023, 116 organizations representing 872 hospitals, as well as health centers, suppliers, insurers, pharmaceutical companies, and group purchasing organizations, have signed on to the pledge.5
Another large national effort on climate change and health care is being led by the National Academy of Medicine (NAM). In 2021, NAM launched the Action Collaborative on Decarbonizing the U.S. Health Sector, a public-private partnership that brings together leaders from health systems, federal health agencies, insurance companies, pharmaceutical and device manufacturers, and accrediting bodies. Much like the HHS efforts, this collaborative is focused on reducing emissions while building resilience in the face of climate events. To date, the group has focused on creating resources for the industry to use in making decarbonization plans. For instance, the NAM Action Collaborative released a short list of key actions for hospitals and health systems that includes establishing an executive-level sustainability team, performing a greenhouse gas emissions inventory, setting specific decarbonization goals, and developing an implementation plan.6
The NAM Action Collaborative suggests focusing on reductions in building emissions by increasing the amount of electricity from renewable sources, reducing emissions from anesthetic gases and pressurized metered dose inhalers, reducing physical waste and single-use plastics, reducing food waste and disposable food packaging, and reducing transportation emissions by holding virtual meetings and using electric vehicles.6
Some regulatory efforts have been aimed at facilitating these efforts. In March 2023, the U.S. Centers for Medicare & Medicaid Services issued a categorical waiver allowing most health care facilities to use a health care microgrid system (HCMS) as a source of emergency power. Previously, facilities were restricted to using generator or battery-powered sources. An HCMS can be powered by clean energy sources such as fuel cells, solar panels, or wind turbines.7,8
Although the increasing awareness is a positive signal, the lack of mandatory reporting is a concern, according to advocates and researchers.
“We’re seeing high levels of engagement from health professionals, health systems, the federal government,
NAM, and The Joint Commission (TJC), which is very encouraging,” Dr. Collins said."However, achieving the necessary progress requires mandated reporting, tracking, and reductions because we know that voluntary efforts are not likely to get us where we need to be when we need to be there."
Dr. Sherman agreed that voluntary efforts are important but won’t allow for the type of rapid progress needed, especially when health care organizations have competing priorities and face continued staffing and financial pressures as the world emerges from the COVID-19 pandemic.
“It’s the old adage: You can’t manage what you don’t measure. We need to measure how we use resources
in greater detail, and we need to measure their associated emissions to identify hot spots and to develop data-driven strategic plans. Every organization should be doing this, and it needs to be in a standardized, transparent
fashion,” Dr. Sherman said. “If we don’t agree on how we’re counting things, then we don’t know that we’re speaking the same language, and we can fall victim to greenwashing.”
In March 2023, TJC requested public comment on draft sustainability standards that would have required
hospital leaders to designate someone to oversee activities to reduce greenhouse gas emissions. It also asked hospitals to measure at least three of the following: energy use, purchased energy (electricity and steam), anesthetic gas use, pressurized metered dose inhaler use, fleet vehicle gas consumption, and solid waste disposal to landfills or through incineration. The standard would also have required hospitals to use that information to develop a plan to reduce emissions. However, TJC reversed course before the comment period closed in April and announced that the standard would be voluntary, not mandatory.9
“I’ve been surprised that [the standards have] not been met with a terribly warm reception. We don’t think that they’re a terribly high bar,” Jonathan Perlin, MD, PhD, president and CEO of TJC, said during a meeting of the NAM Action Collaborative in April where he outlined TJC’s thinking on the standards. “These were really meant to be introductory standards. They were meant to assist organizations in beginning to quantify much of the information that they already have.”
With more than 300 public comments received, much of the feedback was negative, Dr. Perlin said. Specifically, health care leaders cited workforce shortages, financial challenges, and challenges of patient care in a changed environment as reasons why the standards should not be required. On the other hand, Dr. Perlin said many younger clinicians requested that TJC enact requirements around sustainability.
The Medical Society Consortium on Climate and Health’s state clinician groups organized a health professional sign-on letter asking TJC to reconsider its decision to make the standards voluntary. The letter had an overwhelming response, with 800 signatures in a few days, said Lisa Patel, MD, MESc, a clinical associate professor of pediatrics at Stanford University in Palo Alto, California, and executive director of the consortium. “We don’t have hard numbers about how many health professionals want to engage in this work, but based on how many people stand up when they’re given the opportunity, it’s scores across the country now,” she said.
The pushback on curbing health care emissions is coming from senior administrators, Dr. Patel said. “I work in a hospital, so I get it. Doctors and nurses are leaving in droves, and our health care system is recovering from a pandemic,” she said. “What I think these health care administrators who are putting up roadblocks are missing is that part of our morale problem is that we’ve lost our compass somewhat. Working around sustainability … really empowers people and gives them a sense of mission and purpose.”
Searching for Solutions
The realization that health care services are a contributor to climate change and downstream health harm can be demoralizing, but some clinicians are finding a sense of mission in working to make changes within their health care systems.
Smitha Warrier, MD, an anesthesiologist at the University of Utah health system in Salt Lake City, was in her third year of residency when she learned about the environmental implications of anesthetic gases. “I was trying to do all these things in my home life, and I had never connected what I did at work to the environment,” said Dr. Warrier, who is chief surgical operations officer and medical director of environmental and social sustainability. “I am helping this one person at the expense of our community.”
Within the specialty of anesthesia, extensive research shows that the inhaled anesthetic desflurane has significantly greater emissions than clinically equivalent alternative anesthetics.10 The first step for Dr. Warrier and her colleagues in anesthesia when they learned about the emissions differences was to cut back on desflurane.
As she continued to investigate opportunities to improve sustainability within the operating room, she often found that sporadic initiatives championed by one passionate advocate ended when that person moved to another position or facility. As she gained a leadership role with her hospital, she built up buy-in across the organization’s leadership for tackling sustainability issues at the clinical level. In 2019, the University of Utah health system created a health care sustainability initiative with a full-time director and Dr. Warrier working as the initiative’s medical director.
The initial focus has been on raising awareness among clinicians and asking them to identify potential changes in their own areas of practice. So far, they have had initiatives to reduce surgical supplies during orthopedic surgeries that decreased the carbon footprint, changes to the cafeteria menu that decreased associated emissions, and HVAC changes that reduced energy usage.
“When people hear about it, they are immediately asking, ‘What can we do?’ We really need champions clinically in each space who know their space for this to be successful,” Dr. Warrier said.
Research Directions
Andrew Hantel, MD, a hematologist-oncologist and health services researcher at Dana-Farber Cancer Institute in Boston, sits on his institution’s sustainability committee. The approach they are taking is to work through health care processes systematically to parse out efficiencies and reduce emissions through life cycle assessments.
For example, Dr. Hantel and his research colleagues are examining the basic medical oncology clinic appointment to look for which elements contribute to carbon emissions or to waste. They also consider how the emissions and waste produced translate into human harm. His current research asks how some care delivery aspects of oncology, like telehealth, can reduce emissions while maintaining patient centeredness.
For telehealth, it’s important to note that it’s not a one-to-one replacement for the in-person visit. Certain oncology activities, like laboratory services, imaging, and chemotherapy, require a trip to the clinic. However, it may be possible to move those services closer to a patient’s home. This makes them more convenient while also reducing travel, which is one of the largest contributors to emissions. “Our analyses look at what can we modify to reduce climate harms while maintaining, or even improving, patients’ care,” Dr. Hantel explained.
From a research standpoint, one of the challenges is the limited information about the climate impacts of many oncologic medications because so much information is proprietary, Dr. Hantel said.
“We can evaluate much of the care delivery process for a medication, but its manufacturing largely remains a black box,” he said. “While many companies have initiatives to reduce their climate impact, few have been willing to share these data. That remains a major barrier to figuring out how to make things better.”
Taking Action
While a number of areas related to climate change and health care require additional research, clinicians and hospital leaders can make changes today that potentially cut costs and uphold high standards of care, Dr. Sherman said.
“The good news is that there’s an opportunity to dramatically reduce health care emissions without reducing health care access or quality. It’s not about withholding care, and it’s not about death panels or whatever other criticisms might be laid,” she said. “There are exemplars out there doing better in terms of their health system’s performance and their environmental performance.”
References
- Romanello M, Di Napoli C, Drummond P, et al. The 2022 report of the Lancet Countdown on health and climate change: health at the mercy of fossil-fuels. Lancet. 2022;400(10363):1619-1654.
- Eckelman MJ, Huang K, Lagasse R, et al. Health care pollution and public health damage in the United States: an update. Health Aff (Millwood). 2020;39(12):2071-2079.
- Institute of Medicine (US) Committee on Quality of Health Care in America. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. National Academies Press (US); 2000.
- Department of Health and Human Services. About the Office of Climate Change and Health Equity (OCCHE). July 25, 2022. Accessed June 14, 2023. https://www.hhs.gov/ash/ocche/about/index.html.
- Department of Health and Human Services. Health sector commitments to emissions reduction and resilience. April 28, 2023. Accessed June 14, 2023. https://www.hhs.gov/climate-change-health-equity-environmental-justice/climate-change-health-equity/actions/health-sector-pledge/index.html.
- National Academy of Medicine. Key actions to reduce greenhouse gas emissions by U.S. hospitals and health systems. Accessed June 14, 2023. https://nam.edu/programs/climate-change-and-human-health/action-collaborative-on-decarbonizing-the-u-s-health-sector/key-actions-to-reduce-greenhouse-gas-emissions-by-u-s-hospitals-and-health-systems/.
- Centers for Medicare & Medicaid Services. Center for Clinical Standards and Quality. Categorical Waiver – Health Care Microgrid Systems (HCMS). March 31, 2023. Accessed June 14, 2023. https://www.cms.gov/files/document/qso-23-11-lsc.pdf.
- California Hospital Association. CMS will permit health care microgrid systems for emergency power sources. April 4, 2023. Accessed June 14, 2023. https://calhospital.org/cms-will-permit-health-care-microgrid-systems-for-emergency-power-source/.
- National Academy of Medicine. Action Collaborative on Decarbonizing the U.S. Health Care Sector virtual meeting. April 27, 2023. Accessed June 14, 2023. https://nam.edu/event/action-collaborative-on-decarbonizing-the-us-health-sector-virtual-meeting-2023/.
- Sulbaek Andersen MP, Sander SP, Nielsen OJ, et al. Inhalation anaesthetics and climate change. Br J Anaesth. 2010;105(6):760-766.
Teaching for Change
Another area where clinicians are pushing for change is in medical school and residency curricula, where information about the connection between climate change and health has historically been missing.
Thomas Kuczmarski, MD, a hematology-oncology fellow at Fred Hutch Cancer Center in Seattle, began working on integrating information about health impacts of climate change into residency curriculum when he was an intern at Brigham and Women’s Hospital in Boston. He and colleagues began by setting up a few hour-long education sessions spread throughout the year and then expanded that by asking lecturers to incorporate some climate change information into existing lectures.
“Climate change is one of those issues that is very cross-cutting. It affects every area of medicine,” Dr. Kuczmarski said. “We would contact whoever was giving a lecture on chronic kidney disease, for instance, and ask them to incorporate a couple of slides into the presentation to discuss the climate change impacts on kidney disease and why it’s important for residents to learn about heat-related causes of kidney disease. Every single time, the lecturer was super willing to do that, which allowed us to incorporate the topic into a wide array of material.”
They soon realized that other institutions were going through similar processes and creating materials from scratch. They decided to join forces with other hospitals and a larger organization called the Global Consortium on Climate and Health Education to create an open repository that can be used by medical students, residents, and faculty. The program, called Climate Resources for Health Education, includes slide decks and learning objectives across specialties, including hematology-oncology.
“Everyone wants to incorporate this material into their curriculum, but not everyone’s an expert on it and not everyone has the time to do the research on it. So now, if we make this publicly available, the hope is that a lot more people will be able to incorporate it,” Dr. Kuczmarski said.