COVID-19, Monkeypox, climate change and surgery: A syndemic undermines the right to be operated in a clean, healthy and sustainable environment

Abstract

The compounding effect of infectious outbreaks and climate change has put a strain on surgical care. Adverse weather conditions derail preoperative planning, postoperative recovery, supply chains and equipment. The COVID-19 pandemic has restricted elective surgical care for the past two years. It is expected that novel SARS-CoV-2 strains and the emergence of Monkeypox can also put barriers to surgical care. Consecutively, mounting surgical morbidity and strenuous efforts to adhere to infection control further increase the ecological footprint of surgical care fueling a vicious circle of clinical and environmental challenges. Multilevel action from the side of surgeons and surgical societies is required. This includes creating contingency plans for sustainable surgical practice amidst public health emergencies, informing stakeholders and the public about the cumulative ramifications of the syndemic on surgery and promoting social participation among surgeons.

Summer 2022 marked the declaration of a clean, healthy and sustainable environment as a universal human right by the General Assembly of the United Nations.¹ This development stresses the need to reconsider the right of surgical patients to be operated in clean, healthy and sustainable environmental conditions.

Climate change contributes to surgical burden, and surgical burden in turn increases the ecological footprint of healthcare. Prolonged periods of heat can derail surgical planning due to the exacerbation of chronic health conditions such as heart failure, kidney disease and asthma. Humidity increases the risk for surgical site infection and wound dehiscence.² Evidence from a 17 – year long observation in a surgical department in Germany indicated that for every temperature increase by 1 °Celsius the risk for surgical site infections increased by 1%, while for every additional heat or heavy rainfall day the same risk increased by 2%. While the etiology of this risk remains unclear, it is reasonable to assume that factors related to the healthcare personnel (eg sweating, working in unease) and to the integrity of the surgical equipment and supplies can be held accountable for this. Although this likelihood appears small, the cumulative impact of adverse climatological conditions can result in worse surgical outcomes.³ Subsequently, every additional day of hospitalization due to a wound infection can increase the energy use in the hospital by up to 272 kWh/day depending on the severity of the infection.⁴ Precipitations, floods and extreme weather conditions can result in injuries among the public and healthcare workers, destroy equipment and stored consumables or severe surgical supply chains. Conversely, favorable temperatures and mild weather phenomena do not impede surgical workflow and support patients’ recovery and return to every - day - life activities.⁵ This indicates the major potential of the newly declared human right to a clean and healthy environment to reduce surgical morbidity and mortality and support optimal surgical care. Therefore, upholding the right of patients to be operated in a clean, healthy and sustainable environment appears as a worthy endeavor for surgeons and surgical societies.

Efforts towards operating in a healthy environment are hindered by the ongoing public health crisis. COVID-19 has put a strain on surgical care and training for the past two years. Ever - increasing waiting lists, recurrent postponement of elective surgery, and anxiety and uncertainty shared by both patients and healthcare workers briefly outline the surgical shortcomings of this outbreak.⁶ Limited access to general healthcare has also played an important role in the progression of comorbid non - communicable diseases that make surgical patients more vulnerable to adverse environmental conditions.⁷ Simultaneously, adherence to infection control and epidemiological surveillance protocols has increased the carbon footprint and energy intensity of surgery, fueling a vicious circle of ecological and surgical burden.⁸ It has been estimated that during the first months of the COVID-19 pandemic the energy consumption for the production of test kits, masks, shields, gloves and ethanol – based disinfectants exceeded 360 TJ.⁹

In the past, one could argue that this type of connection between surgery, infectious outbreaks and the environment is vague. Nevertheless, summer 2022, a period of intense heat accompanied by numerous COVID-19 and MPX infections, has already provided a glimpse into surgery in non - clean, un - healthy and non - sustainable conditions. Subsequently, hospitals were forced to postpone or cancel elective surgery and insurance companies started planning for heat - related hospitalisations, including surgical operations.^{10 , 11} Heat - related postponement of elective surgery during summer 2022 can lead to an avalanche of health - menacing discordance, in case COVID-19 and potentially MPX hospitalisations restrict surgical services in autumn 2022.

It is reasonable to assume that insurance plans are not sufficient to address the cumulative impact of infectious outbreaks and adverse environmental conditions on access to surgery. So far, the surgical community has already faced similar challenges in low - resources countries and regions where endemic infections and adverse climate put barriers to surgical care. Humanitarian surgery initiatives have attempted to respond to such situations by deploying international healthcare workforce and medical supplies. However, the global nature of both climate change and epidemiological emergencies urges for wider and more comprehensive solutions. In the western world, most European countries issue and oversee their own guidelines about conditions such as temperature and humidity in the operating theater. In principle, this allows hospitals to maintain temperatures between 18 °C and 24 °C (and in some occasions up to 27 °C for pediatric surgery) in operating rooms.¹² European institutions or agencies, such as the European Center for Disease Prevention and Control, could issue homogeneous guidelines for the adaptation of these standards to the climate crisis. On the other hand, in the United States (US), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) regulates intraoperative humidity and temperature. While constructing a homogeneous response might be easier in the US, special provisions for the different environmental conditions in states such as Alaska and Texas are necessary.¹³ Left unaddressed, the strain that epidemiological emergencies and environmental disruption put on surgical care can increase the global burden of disease and trigger social challenges (Fig. 1 ).

Fig. 1.

The multilevel effects of the ramifications of climate and epidemiological crisis on surgical care.

Surgeons need to act at multiple levels - as individual practitioners, as members of scientific societies and professional bodies and as citizens:

Contingency plans and surgical safety and efficacy checklists need to be devised in order to standardize the management of surgical cases affected by infections and/or environmental conditions. Recently, an adaptation to the surgical safety checklist of the World Health Organization (WHO) has been proposed, in order to mitigate the risk of MPX transmission in surgical settings.¹⁴ This plan emphasized hygienic measures and ample use of PPEs. The challenge lies in coupling infection control with environmental sustainability. In this frame, recent studies have shown that economizing water in the operating theater does not significantly increase the risk for infections. Assessing the same strategy in MPX and COVID-19 can lead to a cost – effective tradeoff for sustainable disinfection.¹⁵

A new model of surgical practice combining environmental sustainability and infection control should be designed and gradually implemented. Although the specifics of such an endeavor fall upon academic surgical institutions and surgical health bodies, some key points of consideration include reducing the use of pollution - generating anesthetic gasses such as isoflurane and using consumables based on recyclable bioplastics.¹⁶

Academic surgical institutions and surgical societies need to inform stakeholders and the public about the compounding impact of infectious outbreaks and climate change on surgical services and training. Risk communication should be plain, to ensure that both citizens and regulators understand the repercussions of the situation on access to surgical care, official and out-of-pocket healthcare expenditure, disability and death.

Surgeons and allied healthcare professionals should prompt positive change towards hygiene and environmental sustainability in their communities and social circles. Their engagement, from informal conversations to volunteering and activism, can provide relevant advocacy with genuine insights.

Both the interpretation of the crisis and the proposed solutions can become quite lengthier. Nevertheless, to consolidate the understanding of the syndemic a pragmatic example would suffice. In March 2020, a middle-aged adult with a history of heart failure and low back pain is scheduled for spinal fusion. Due to consecutive COVID-19 outbreaks in their area, the operation is eventually scheduled for late June 2020. Few days before the operation, heart failure was exacerbated due to high temperatures and the operation was again postponed for September 2020. With the latter being subject to the epidemiological situation at that time, one should understand that this person and their caregivers saw their quality of life and earning potential declining for approximately half year. The average waiting time for elective surgery during 2020 was approximately three months, hence the above estimation is realistic – to the extent that the patient did not contract a complicated COVID-19 infection in the meantime.¹⁷ The equation becomes more complex in case the patient was the family's bread - winner and their family had running debt that could not be financed during the year. The concomitant effect of infectious outbreaks and climate change on surgery undermined the patient's right to be operated in a safe environment and brought havoc upon them and their dependents. Multiplying the case and its implications by the number of postponed elective surgeries, the multifaceted and global nature of the matter becomes evident.

One can still consider the right to be operated in a clean, healthy and sustainable environment as a vague construct with limited overlap to the day-to-day surgical routine. Nonetheless, in a world where “no health issue stands alone”, this approach is at least shortsighted.

Funding

The authors have not received any funding with regard to this paper

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.