Climate change and healthcare organizations: a call to arms

The 26th UN Climate Change Conference of the Parties (COP26), which concluded on 13 November 2021, was the latest in more than two decades of a United Nations-facilitated effort to help stave off climate change. The outcome known as the Glasgow Climate Pact, called on 197 countries to report their progress towards more climate ambition next year at COP27, set to take place in Egypt.¹ While there were no breakthroughs, with all commitments being non-binding and despite the world being dangerously off track from a net-zero future in 2050, there were many positive developments.¹ One of the less publicized outputs of COP26 was a Health Program to develop climate-resilient and low-carbon health systems. This was the first explicit intention from health organizations to build climate-resilient and low-carbon footprint health systems. As part of this programme, 54 institutions from 21 countries, representing over 14 000 hospitals and health centres, committed to achieving net-zero emissions.¹ As healthcare professionals, there is a compelling argument to be made for those in the medical profession to lead the charge in bringing to light the health impact of fossil fuel emissions, climate change, and the tightly woven relationship between the two. As expounded in a joint editorial in over 200 health journals, ‘health professionals must hold global leaders to account and join in the work to achieve environmentally sustainable health systems before 2040, recognizing that this will mean changing clinical practice’.²

Healthcare organizations (HCOs) do not typically come to mind as major perpetrators of greenhouse gas (GHG) emissions. The environmental non-profit, Health Care Without Harm, estimates that healthcare industries around the world contribute 4.4% of the world’s CO₂ emissions (2 gigatons of CO₂ equivalent).³ The top three emitters, USA, China, and the European Union, contribute to 56% of the total global healthcare climate footprint. The USA leads in both absolute and per capita emissions, producing 57 times more CO₂ per person compared with India (one of the lowest per capita CO₂ emissions among 47 countries surveyed), with healthcare in the USA contributing to 7.6% of total CO₂ emissions (Figure 1).³ In 2013, total mortality from US healthcare pollution based on pollutant emissions (primarily particulate matter <2.5 μm) was on the same order of magnitude, as deaths from preventable medical errors.⁴ Emissions emanating directly from healthcare operational emissions, or Scope 1, make up 17% of the healthcare sector’s worldwide footprint, while Scope 2 emissions originating from purchased electricity, gas, heating, and cooling contribute to 12%. The vast majority, roughly 71%, is from Scope 3 emissions (Figure 2).³ The latter estimate is likely an underestimate, given the fact that most emissions attributable to HCOs are from their supply chain. Emissions from the supply chain are approximations at best, given the complexities of the calculus and the inherent assumptions. The supply chain described as Scope 3 comprise a vast network of interconnected entities that are large consumers of fossil fuel emissions, such as the pharmaceutical industry, hospital equipment manufacturing, waste, and food.

Figure 1.

Country-specific CO₂ healthcare emissions. Data derived from Karliner et al.³

Figure 2.

Healthcare and greenhouse gas emissions. Data derived from Karliner et al.³

Direct emissions from HCO, or Scope 1, can result from power consumption and medical activities. In the latter category, it is not well appreciated that surgical theatres may represent insidious contributors to GHGs from high energy consumption and the use of volatile anaesthetics for surgical procedures. Operating rooms (ORs) are major consumers of energy compared with the rest of the hospital.⁵ All volatile anaesthetics are halogenated chlorofluorocarbons (halothane, enflurane, isoflurane) or fluorinated hydrocarbons (sevoflurane and desflurane) which have a magnified impact on global warming. A study covering CO₂ emissions in three different hospitals across three different countries found the carbon footprint of surgeries is 9.7 million tons per year, equivalent to the emission from 2 million passenger vehicles.⁵ To put this in perspective, the process of manufacturing electronics in 2019 produced 5.8 million tons of CO₂. Scope 2 emissions from HCOs have remained steady in the USA over the last decade, and while much smaller than Scope 3, also presents an opportunity for radical reform by switching to clean energy sources.

Fossil fuel emissions are at the heart of healthcare’s current emission profile. It is vital that solutions address both energy use and sources. Thus, not only is the the energy intensity of a country’s economy but also the emission intensity of its energy system are critical determinants of overall HCO emissions footprint. Given the direct impact of anthropogenic emissions on health, and the moral high ground of HCOs, they could lead the way in emissions control. Healthcare organizations could start by asking suppliers to report emissions data directly to them, or by using third-party reporting programmes such as the Carbon Disclosure Project’s (CDP’s) Supply Chain Program, a not-for-profit organization that collects GHG emissions information from corporations on behalf of interested partners or communities. Healthcare organizations could also collaborate with a growing number of industry peers to develop a shared infrastructure for their suppliers to report GHG emissions more efficiently. Healthcare organizations could also influence supply chain industries by preferentially using suppliers that are either at net carbon neutral or have already made, or are making, commitments to reduce their emissions.

It should be highlighted that there are plenty of avenues to reduce Scope 1 emissions such as avoidance of desflurane and occupancy-based energy consumption in the OR. Scope 2 emissions can be improved through better energy efficiency in buildings, installation of on-site solar power, and purchasing power from clean energy sources through long-term contracts. Investment in carbon offsets to counter the currently unavoidable emissions from the natural gas power that heats and cools many hospitals may also drive health benefits. The conventional argument against these approaches is the initial capital outlay. However, the public health impact has been shown to more than offset these investments. Health Care without Harm outlines seven high impact actions that HCOs could take to accomplish zero emissions (Table 1).⁶ By implementing these actions, HCOs can help lead the way in the race to net zero. Humanity may simply depend on it.

Table 1.

Seven high-impact actions which highlight actions healthcare organizations can take in the global race to reach net-zero carbon emissions

The seven high-impact actions
1. Power healthcare with 100% clean, renewable electricity: Ensure that healthcare is powered by zero emissions electricity across the three pathways
2. Invest in zero emissions buildings and infrastructure: Ensure every healthcare building and health product manufacturing facility and their infrastructure promote energy efficiency, zero emissions, and climate resilience
3. Transition to zero emissions, sustainable travel and transport: Transition to 100% low or zero emission fleet vehicles and infrastructure, while encouraging active travel and public transport for patients and staff wherever feasible
4. Provide healthy, sustainably grown food: Provide healthy, locally, and sustainably produced fresh and seasonable food with zero food waste
5. Incentivize and produce low-carbon pharmaceuticals: Reduce unnecessary pharmaceutical use, substitute high emissions products with more climate-friendly alternatives, and incentivize the production of affordable green, climate-smart medicine
6. Implement circular healthcare and sustainable healthcare waste management: Implement circular economy principles to procure supplies, deploy clean technologies, reduce the volume and toxicity of healthcare waste, and manage waste sustainably
7. Establish greater health system effectiveness: Reduce emissions by improving system effectiveness, including eliminating inefficient and unnecessary practices, linking carbo reduction and quality of care, and bolstering resilience

From Health Care Without Harm.⁶

Conflict of interest: none declared.