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Journal of Rural Medicine : JRM logoLink to Journal of Rural Medicine : JRM
. 2021 Jul 1;16(3):132–138. doi: 10.2185/jrm.2020-049

Assessment of environmental sustainability in renal healthcare

Kei Nagai 1, Hiroaki Suzuki 2, Atsushi Ueda 1,3, John W M Agar 4, Norihiro Itsubo 2
PMCID: PMC8249367  PMID: 34239623

Abstract

The health effects of climate change are becoming increasingly important; there are direct effects from heatwaves and floods, and indirect effects from the altered distribution of infectious diseases and changes in crop yield. Ironically, the healthcare system itself carries an environmental burden, contributing to environmental health impacts. Life cycle assessment is a widely accepted and well-established method that quantitatively evaluates environmental impact. Given that monetary evaluations have the potential to motivate private companies and societies to reduce greenhouse gas emissions using market mechanisms, instead of assessing the carbon footprint alone, we previously developed a life cycle impact assessment method based on an endpoint that integrates comprehensive environmental burdens into a single index—the monetary cost. Previous investigations estimated that therapy for chronic kidney disease had a significant carbon footprint in the healthcare sector. We have been aiming to investigate on the environmental impact of chronic kidney disease based on field surveys from the renal department in a hospital and several health clinics in Japan. To live sustainably, it is necessary to establish cultures, practices, and research that aims to conserve resources to provide environmentally friendly healthcare in Japan.

Keywords: healthcare, carbon footprint, life cycle assessment, life cycle impact assessment, chronic dialysis

Introduction

Recently, human-induced climate change has been identified as the greatest global health threat1). The temperature of the Earth is determined by the balance between energy input from the sun, and energy lost back into space. Atmospheric gases such as water vapor, carbon dioxide (CO2), ozone, methane, and nitrous oxides are known as greenhouse gases (GHGs); these GHGs are required for photosynthesis and to warm the Earth. Industrial activities and changes to the natural landscape, such as deforestation, produce GHG emissions; these emissions have raised the average global temperature by 0.85% between 1880 and 20122). Experts have examined several warming scenarios, and have forecasted that the global mean surface temperature may rise between 0.3 and 4.8 °C by 21003). Alarmingly, global CO2 emissions are rising faster than the predicted worst-case emission scenarios4). In 2018, the Intergovernmental Panel on Climate Change (IPCC) stated that annual global emissions must be halved by 2030, and net-zero emissions must be achieved by 2050 to limit warming to 1.5°C5).

Alongside the higher incidence and severity of extreme weather events due to global climate change, heat stress presents a real risk of death in vulnerable populations6). Ironically, the healthcare system itself carries an environmental burden that contributes to global climate change. Healthcare activities contribute significantly to the total national CO2 emissions, although these contributions vary widely depending on the country. For example, this contribution was estimated to be 10% in the United States for 2003–20137), 7% in Australia for 2014–20158), and a modest 4% in England in 20129). Subsequent international studies have carried out a global assessment of the wide-ranging environmental footprint of the healthcare sector10). Studies suggest that the enhanced activity of the healthcare sector initiates an adverse feedback cycle by increasing the environmental impact of healthcare (Figure 1).

Figure 1.

Figure 1

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Cycle of climate change, disease and healthcare.

We propose the concept of a feedback cycle between climate change, an excessive disease burden, an increased need for healthcare services, and accelerated greenhouse gas emissions that increase global temperatures. Compared to the impact of environmental change on health, the impact of healthcare on the environment has received less attention.

Reducing GHG emissions protects human health from the direct and indirect impacts of climate change11). It also benefits human health through mechanisms independent of those related to modifying climate risk; these are the health co-benefits of mitigation12, 13). Human populations will grow, age, and likely become more vulnerable to climate risk. As such, there is an immediate need for action to avoid worst-case future scenarios11). This review aims to summarize the evidence linking health and environmental sustainability to help establish best practices that consider humans and the planet.

Effect of Climate Change on Human Health

The principal pathways linking climate change with health may be categorized into direct and indirect mechanisms11, 14, 15). Direct risks are due to changes in the characteristics of extreme weather events and the resulting storms, floods, droughts or heatwaves. Indirect risks are mediated by the effects of climate change on ecosystems and social structure11). The estimated impact of climate change on human health is likely to change depending on the predicted future climate and socioeconomic scenarios16, 17). A previous study has estimated the climate-related relative risks of health effects, and the ratio of deteriorating health alongside climate change relative to that without climate change18). These risks are shaped by social and geographic dimensions, unevenly distributed across the world, and are influenced by socioeconomic development, technology, and health service provision1).

Direct effects

Direct effects on human health and wellbeing result from rising temperatures and subsequent changes in the frequency and intensity of storms19), floods20), droughts21), and heatwaves22). Although societies are adapted to local climates across the world, heatwaves represent a real risk to vulnerable populations; there is a potential for significant increases in risk from extreme heat under each of the predicted climate change scenarios6). On an individual basis, tolerance to any change is diminished in individuals whose capacity for temperature homeostasis is limited by the extremes of age or dehydration11). Collectively, there is strong evidence for a relationship between extreme high temperature and human morbidity and mortality, and heat-related mortality is rising as a result of climate change across a range of localities23).

Indirect effects

Climate conditions affect the risks associated with the transmission and distribution of diseases through vectors such as mosquitoes carrying dengue or malaria24). Changing weather patterns are also likely to affect the incidence of diseases transmitted through infected water sources25), such as hurricanes that result in the mixing of wastewater and drinking water. This creates insufficient access to clean water, potentially causing cholera26) and typhoid fever27). Changes in temperature, precipitation frequency, and air stagnation affect the severity of air pollution, posing significant health risks. Fine particle air pollution is estimated to be responsible for 4.2 million additional deaths globally every year, mainly due to respiratory and cardiovascular diseases28). Climate change has important implications for livelihood, food security, and poverty as crops and livestock have physiological limits in terms of health, productivity, and survival, including those imposed by temperature. Heat also poses significant risks to occupational health and labor productivity in areas where people work outdoors (e.g., farmers), for long hours in hot regions29). Moreover, the higher frequency of droughts, floods, and other extreme weather events impact crops and livestock yields; this means the number of habitable areas on the planet are declining1, 5, 6).

Climate change-induced migration can occur through a variety of social and political pathways. This ranges from sea level rise and coastal erosion, to changes in extreme weather, average precipitation and temperature, which reduces land availability and exacerbates food and water security issues. Although predicting the actual number of people to be affected by climate change continues to be a challenge, a large number of people will be forced to migrate by 205030). Climate change is considered an important factor in exacerbating the likelihood of conflict30). Migration driven by climate change may incur potentially severe impacts on mental and physical health through wide-ranging and complicated mechanisms31, 32).

Consequences of climate change-related health effects

Collectively, climate change poses a clear risk to mental illness33, 34), malnutrition35), allergies36), cardiovascular diseases37), infectious diseases24, 26, 27, 38), injuries39), respiratory diseases28), poisoning40, 41) and renal diseases42, 43) via complicated mechanisms; the evidence supporting this relationship has been progressively collected over time.

Carbon Footprint of Healthcare

Compared to the health impacts of environmental changes, the impact of healthcare on the environment has received less attention10). The environmental footprint of the healthcare sector, including air, water, and soil pollution, has unintended and negative impacts on human health7). By 2009, a global movement on planetary health had been initiated, and in 2015 the Lancet Commission on Health and Climate Change provided several recommendations1, 11), calling for: “Support for accurate quantification of the avoided burden of disease, reduced healthcare costs, and enhanced economic productivity associated with climate change mitigation”. Their recommendations also noted that “these will be most effective when combined with adequate local capacity and political support to develop low-carbon healthy energy choices”.

In light of these recommendations, there is an urgent need to clarify the current carbon footprint of the general and specific healthcare sectors. With increasing investment in healthcare around the world, there is considerable potential to exacerbate the harm to human health from the pollution and environmental damage from this sector10).

General healthcare sector

The most aggressive attempt to quantify health-related GHG emissions was undertaken by the United Kingdom National Health Service (NHS). They used an estimate derived from NHS expenditure data and supplemented this with detailed data on building energy consumption and travel; the complete life cycle carbon footprint of the NHS for the 2004 calendar year was 21.3 million metric tons of CO2 equivalent (CO2e), which is approximately 3% of all emissions in England44). Subsequently, studies at the national-scale for the United Kingdom45), United States7, 46), Canada47), Japan48), and Australia8) reported that healthcare sector emissions contributed between 4% and 10% of total GHG emissions in these countries; these were largely based on NHS expenditure data. Recently, international collaborative studies have found that healthcare causes global environmental impacts10, 49). Researchers used a global supply-chain database containing detailed information on healthcare sectors and quantified the direct and indirect environmental damage driven by the demand for healthcare10). The study revealed that the global environmental burden from healthcare was between 1% and 5% of the total global burden, and accounts for more than 5% of the national burden in some countries10). In most countries, the healthcare sector had the largest carbon footprint of the service sectors, and was comparable in size to the food sector49).

Surgical sector and intensive care

Among healthcare services, the contribution of surgical procedures and intensive care on the carbon footprint have been considered. A determination of the carbon footprint of three academic quaternary-care hospitals in Canada, the United Kingdom and United States revealed that surgical operating suites emitted 3.2 to 5.1 million kg of CO2e over 1 y50). Interestingly, the use of anesthetic gases and energy consumption substantially contributed to the overall carbon footprint of the healthcare sector. Another report from a university hospital revealed that the carbon footprint for one cataract operation was 181.8 kg of CO2e51). Building and energy use was estimated to account for 36.1% of overall emissions, while travel and procurement (including medical equipment) was estimated to be 10.1%, and 53.8%, respectively51). Comparing the surgical treatment of gastric reflux with medical management, the initial carbon footprint from surgery was 1,081 kg of CO2e per patient52). This is nearly seven times greater than the footprint of medical management; however, subsequent emissions from continuing treatment were much lower for surgical patients (30 versus 100 kg of CO2e). A review of 150 procedures using laparotomy, conventional laparoscopy or robotically associated laparoscopy, revealed that the total carbon footprint per patient was 22.7, 29.2, and 40.3 kg of CO2e, respectively53). In intensive care units, the daily carbon footprint was 178 kg of CO2e per patient with septic shock in the United States54). Such estimates from a bottom-up inventory of items associated with intense GHG emissions are important to promote environmentally friendly healthcare for specific medical conditions.

Renal treatment sector

Maintenance hemodialysis (HD) is a major therapy used to save the lives of patients with end-stage renal disease. HD programs have a particularly large carbon footprint, with recurrent, per capita resource consumption and waste generation profiles that are disproportionately high compared with most other medical therapies55,56,57). Patients undergoing conventional in-center HD, with a 4 h thrice-weekly regimen, were estimated to use approximately 500 L of water per treatment, based on a previous survey58). Moreover, this therapy was responsible for a considerable amount of waste generation and travel distance of patients and staff55, 58). As a result, annual emissions were estimated at 3.8 and 10.2 tons of CO2e per patient in the United Kingdom and Australia, respectively56); this is more than two-thirds of the estimated national mean annual per capita CO2 emissions of 15.4 tons. The largest share of carbon emissions originated from pharmaceuticals (37.5%) and medical equipment (23.5%)56), which was consistent with findings in other sectors51). Unfortunately, despite their apparent large collective carbon footprint, there is very little data available on the life cycle impacts of individual pharmaceutical compounds or devices59). Beyond carbon emissions, more comprehensive life cycle analysis is also required to identify the broader environmental impacts of pharmaceuticals and devices (e.g., pollution and resource depletion during production)55).

Life Cycle Assessment to Determine Precise Local Environmental Impacts and Damage

Life cycle assessment (LCA) is a widely accepted and well-established method to quantitatively evaluate environmental processes and products60,61,62). During the manufacturing stage, environmental impacts are assessed from raw material extraction and processing (cradle), the manufacture, distribution, and use, to the recycling or final disposal stages (grave). For example, in terms of hemodialysis treatments, the distribution of the dialysate powder concentrate from a factory to a dialysis unit appears to have a lower environmental load than liquid concentrate. However, it is possible that the manufacturing of highly concentrated powders requires a large amount of energy; as such, it is still unclear whether the powder or liquid concentrate is suitable for environment-friendly HD. Although there is little scientific evidence available on LCA in dialysis technology beyond the carbon footprint study, several LCA methods have recently been developed, and may be applied to the renal treatment sector.

National-scale studies for the United Kingdom45), the United States7, 46), Canada47), Japan48), and Australia8) have used environmentally extended input-output (EEIO) modeling to show that healthcare sector emissions contribute to the total national emissions in these countries. EEIO models have been widely used since the 1970s63), and underpin consumption-based accounting of emissions64). An important advantage of using EEIO modeling is that healthcare sector emissions are estimated on a life cycle basis. This means that estimates account for electricity, transportation and pharmaceuticals65). Each country records emission inventories, monetary input-output tables, and health expenditure data. As such, differences in the assessment of emissions need to be corrected and used in a global scope with a multi-region input-output (MRIO) that covers more than one country49). Recent worldwide research has utilized powerful models that include 14,847 country-sectors from 189 countries10).

Although there is an urgent need to assess the deteriorating health, impacts, and environmental burden of the healthcare sector, most existing methods do not provide detailed information on the extent of impact on humans and the environment66). This prompted the development of a methodology using the results of damage assessment called life cycle impact assessment (LCIA), which has rapidly attracted attention. The Life Cycle Impact Assessment Method based on Endpoint Modeling (LIME), was developed in Japan and published in 200567); in 2015, it was updated to version 3 (LIME-3). This LCIA uses impact categories such as midpoints (e.g., air and water pollution) and endpoints (e.g., human health and biodiversity), and integrates these outcomes simply, through the use of a single index. Remarkably, LIME can evaluate the monetary index with the potential to put pressure on companies and societies to reduce GHGs using market mechanisms68) (Figure 2).

Figure 2.

Figure 2

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Concise diagram of life cycle assessment and life cycle impact assessment.

Most life cycle assessment studies have quantified CO2 emissions relating to various human activities, including healthcare. Beyond midpoint investigations such as carbon footprint counting, life cycle impact assessment depicts the actual impacts on humans and natural ecosystems based on human activity and industry. Quantification of detrimental health effects, social asset loss, destruction of biodiversity, and reduction in productivity such as photosynthesis are integrated into a single index to clearly show the environmental burden of human activity. Monetary evaluations (e. g., yen and dollar) have the potential to motivate private companies and societies to reduce greenhouse gas emissions using market mechanisms. Abbreviations: LCA, life cycle assessment; LCIA, life cycle impact assessment; LIME, life cycle impact assessment method based on endpoint modeling; DALYs, disability-adjusted life years.

Future Direction: An On-going Field Survey of the Renal Sector

An important topic for future research is the connection between the healthcare carbon footprint, healthcare performance, and health outcomes49, 69). As previously discussed and well-summarized in reviews57, 58), chronic dialysis therapy for end-stage renal disease is resource-heavy. This is particularly the case in remote areas because of the transportation of patients and medical staff, and the large amounts of pharmaceuticals and devices required. The delivery of dialysis therapy also differs between countries70). From the environmental conservation perspective, home dialysis therapy is more popular because of geographic and water supply issues; this has been investigated more in Australia and the United Kingdom than in Japan57, 58, 71). This provided the basis to examine the current reality of dialysis therapy in Japan, focusing on environmental problems in order to develop future planet-friendly therapeutics for renal disease.

There is also a need for broader surveying of environmental attitude, knowledge, and practice patterns around the world; this has been undertaken in the United Kingdom and Australia15, 72). Following this initiative, we established a patient-based cohort with end-stage renal disease and regional surveillance for patients and medical staff in a hospital and several health clinics in Japan (unpublished). To the best of our knowledge, this is the first attempt at an environmentally-themed research in the renal sector in Japan. There has also been an investigation into the health consciousness and pro-environmental behavior of non-specific health professionals in a large hospital in Japan73). We aim to establish more relevant basic units of medical procedures and procurement for LCIA, and ultimately develop an optimal solution for mitigating climate change and maintaining human health and society. Additionally, popularizing a resource conservation culture, practice, and research is necessary to achieve environmentally friendly healthcare in Japan, given its high healthcare and environmental burden.

Conclusion

The medical community is positioned at the forefront of responding to the health impacts of climate change. The health profession has the ability and the responsibility to act as public health advocates by communicating the threats and opportunities to the public and policy makers, and ensuring that climate change is understood as being central to human wellbeing14, 33). Beyond quantifying the carbon footprint, the recently developed LCIA should be put into practice and used to evaluate the environmental burden of healthcare. On-site field surveys are also beneficial towards establishing bottom-up inventory data regarding healthcare. This data should focus on the appropriate sector and evaluate the carbon footprint, and impacts to human health and natural ecosystems.

Acknowledgements

This article was supported in part by the Japan Society of the Promotion of Science (JSPS) grant no. 18KK0431 and the Japanese Association of Dialysis Physicians grant no. 2019-1. We thank Dr. Kentaro Nakajima for his contribution to data collection.

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