Section 1: The importance of practicing sustainable healthcare delivery

Background

In 2015, pollution was estimated to be responsible for 9 million premature deaths; which comprised 16% of global deaths (Landrigan et al., 2018). According to the Lancet Commission on Pollution and Health report (2018):

Exposures to contaminated air, water, and soil kill more people than a high-sodium diet, obesity, alcohol, road accidents, or child and maternal malnutrition. They are also responsible for three times as many deaths as AIDS, tuberculosis, and malaria combined, and for nearly 15 times as many deaths as war and all forms of violence. (Landrigan, et al., 2018, p. 1).

Many of the pollutants that harm our health are major greenhouse gasses (GHGs) and are harming the health of our planet’s natural systems (Landrigan, et al., 2018). Human sectors contribute to the emission of these pollutants and GHGs, with healthcare being a top emitter. In fact, it has been suggested that if the global health sector were considered a country and its emissions were compared to that of other countries, it would be the fifth-largest emitter in the world, responsible for approximately 4.4% of global net emissions (Healthcare Without Harm [HCWH] & Arup, 2019). Besides harming our natural systems and being a significant contributor to climate change, these GHGs and pollutants are linked with negative human health outcomes. In Canada, it is estimated that healthcare emissions alone result in 23,000 disability-adjusted life years lost annually (Eckelman et al., 2018).

Interestingly, when ranked against other national healthcare systems, Canada’s health sector is considered the 9th worst GHG emitter. However, if you look at emissions on a per capita basis, one begins to see a different picture; Canada’s health sector is the second highest GHG emitting healthcare system on a per capita basis. In other words, while in total our health system does not emit as much as other health systems do globally, when emissions are examined on a per capita basis (i.e., on the basis of how many emissions are produced on the basis of each individual healthcare user), Canadians are emitting significantly more GHGs (over 1 metric ton of carbon dioxide emitted per person) than citizens of other countries. This indicates that the Canadian health sector still has a great deal of work to do in terms of developing a healthcare system that is sustainable and promotes the health of our natural systems and humanity.

Generally speaking, the health sector’s main purpose around the world is to protect and promote human health, but due to its significant emissions, it can be paradoxically stated that the health sector, directly and indirectly, harms human health. Moreover, the health sector’s organizational systems and structures are extremely vulnerable to the effects of climate change (Smith et al., 2014). Considering healthcare’s climate vulnerability and its moral and ethical mandate to support, protect, and maintain human health, it is clear that now, more than ever, there is a critical need for a healthcare system that is sustainable and driven by a planetary health perspective.

Healthcare professionals (doctors, nurses, midwives, and others) are essential players in the development of sustainable healthcare systems as they are uniquely situated to be leaders in this field. These professionals both act on what science and research demonstrate as best evidence and speak with ethical and moral authority. Healthcare professionals are often the most trusted professionals in the eyes of the public and can help persuade people and nations to reduce their emissions and strive for a healthy planet. “Most importantly, they are powerful advocates for the very thing that people worldwide care about most and are most threatened by climate change: our health and well-being and that of future generations” (Al-Delaimy, Ramanathan, and Sanchez Sorondo, 2020, p. 396).

Healthcare Emissions

Generally speaking, every country’s health system, directly and indirectly, emits GHGs via product procurement, active care delivery, and services and technologies from a carbon-intensive supply chain (HCWH & Arup, 2019). The most significant source of emissions (71%) are derived from healthcare’s supply chain via production, transportation, and disposal of goods and services such as pharmaceuticals, food and agricultural products, medical devices, hospital equipment, and instruments. (HCWH & Arup, 2019). Another 17% of emissions result directly from healthcare facilities and vehicles owned by health organizations. The final 12% are indirect emissions that are derived from purchased energy, such as electricity, steam, cooling, and heating (HCWH & Arup, 2019). “Fossil fuel consumption is at the heart of health care’s emissions. Energy — primarily the combustion of fossil fuels — makes up well over half of health care’s climate footprint when measured across all three scopes” (HCWH & Arup, 2019, p. 4).

Theoretical Models

We can use theory to help guide our thinking regarding the problems and solutions related to the development of sustainable healthcare systems. Theory gives us a unified starting point when examining sustainable healthcare systems. We propose Systems Thinking Theory as one that is useful for our explorations.

Systems Thinking Theory

Traditional healthcare systems and education have been built on mechanistic, cause-and-effect scientific models. While historically helpful, these models are limited in that they “do not fully explain the complexity of humans, our relationships and the interconnectedness of all life” (Al-Delaimy, Ramanathan and Sanchez Sorondo, 2020, p. 213). If we are going to succeed in promoting planetary health and limiting the pressure humanity is placing on our planetary boundaries (Image 1), a more holistic model of health is necessary. Planetary boundaries refer to the limits placed on our planet via anthropogenic forces (i.e., climate change, freshwater usage, land-system changes, etc.); there are safe operating zones, zones of uncertainty, and beyond the zones of uncertainty that identify high risk to planetary health (Steffen et al., 2015). A holistic model of healthcare suggests that we are dynamic, social, and complex beings that are in constant, intimate relationships with all other living things on Earth. “Individual, community and planetary health are inseparable” (Al-Delaimy, Ramanathan, and Sanchez Sorondo, 2020, p. 213). This holistic perspective is at the heart of planetary health and is necessary for the development of sustainable healthcare; we require a health system that promotes both human health as well as the health of our planet and its natural systems.

Image 1: Planetary boundaries (Steffen et al., 2015)

What is Sustainable Healthcare?

To start, the term sustainability should be understood. Knut et al. (2013) state that sustainability is a complex term with consistent themes in the literature, such as the idea that we need to work on things now so that we (and future generations) can enjoy them in the future. This idea brings about a sense of longevity, resilience, cycles, and permanence; “a steady-state approach rather than a frontier mentality” (p. 17). Sustainability is concerned with relationships and the interconnectedness of our planet and its natural system; it is concerned with resource preservation, reducing our consumption, and appropriate disposal of waste products. When we think sustainably, we acknowledge the planetary boundaries and look for ways to thrive while remaining safely within them; we view humanity as guardians of the planet’s natural systems and resources, not as its owners. Finally, there is a distinct leaning towards upholding social justice. In other words, sustainability inherently recognizes that it is unjust for some communities to exploit the earth’s natural resources at the expense of others.

Sustainable healthcare, then, refers to the delivery of healthcare services that does not put detrimental stress on either human or natural systems (Knute et al., 2013). It is a style of healthcare delivery that consciously works at promoting planetary health by reducing its GHG emissions, waste, and overall environmental impact. Health systems can achieve this through various methods, and some examples include retrofitting buildings so that they run on more sustainable sources of energy, offering more plant-based meals for patients and their families as it is known that meat and associated farming practices are extremely carbon intensive, reducing consumption of resources and materials and properly diverting waste, paying attention to transportation GHGs associated with either health system processes (e.x., driving lab samples to a local laboratory for analysis) or with travelling to/from the health building (e.x., patients travelling to the hospital to access medical services or healthcare employees getting to work), and addressing and de-carbonizing the supply chains associated with procuring healthcare equipment and resources. This is not an exhaustive list, and there are many ways to reduce healthcare’s planetary impact when paying attention to these areas and beyond. In fact, several leaders are already starting to do this important work.

Organizational Leaders in Sustainable Healthcare

There are many leaders in this field who are already helping develop sustainable healthcare systems around the world, such as the Canadian Coalition for Green Health Care (CCGH) and Health Care Without Harm (HCWH). The CCGH is a national group that works closely with individuals, agencies/organizations, and others who are actively involved in healthcare delivery by sharing best practices related to sustainable healthcare delivery. HCWH works with healthcare delivery leaders and supports them in several areas: Canadian health sector data collection, green leadership, green purchasing, health and environment, local and sustainable Foods, safer chemical policies/toxics reduction, sustainable buildings, sustainable energy and GHG, sustainable transportation, and finally, waste management and minimization (Canadian Coalition for Green Health Care, n.d.).

HCWH’s main mission is to transform healthcare worldwide so that the sector can be a world leader in the global movement for health and justice (Health Care Without Harm, n.d.). More concretely, they have actively made international healthcare systems more sustainable through various initiatives, including (but not limited to): a) helping close more than 4,400 incinerators that burned carcinogenic medical waste (which helped hospitals save money, reuse and reprocess resources, and utilize alternative waste treatment strategies); b) they launched the Health Care Climate Challenge – an initiative that has over 300 participating institutions (representing over 22,000 hospitals) across 40 countries committing to climate action; c) created the Greenhealth Approved program which helps healthcare providers quickly identify safe, sustainable products and thereby supporting them in making the often challenging decisions of whether a product is more/less harmful for the environment; and d) supported hundreds of hospitals in adopting the “green operating room” strategy, which helps save money and valuable resources while also reducing pollution and waste (Health Care Without Harm, n.d.).

Role of Healthcare Professionals

There are many different ways for healthcare professionals to assist with developing sustainable health systems. First, they must educate the public, developers, and decision makers about the health consequences of ignoring planetary health. Second, health professionals should conduct research that explores and expands the intersection between planetary health, climate change, climate action, and healthcare. This research must be translated into easy-to-read/understand material for the public so they can also incorporate this information into their daily lives (Kalogirou et al., 2021; Landrigan et al., 2018). Finally, and perhaps most importantly, health professionals must advocate for planetary health.

Research suggests that advocacy requires both a top-down and a bottom-up approach (Kalogirou et al., 2021). In other words, while significant change is required to come from decision-makers and leaders in the health sector (top-down), health professionals and even healthcare users need to advocate for the prioritization of planetary health and push leadership in this direction (bottom-up). Without this bottom-up advocacy and a clear demonstration from health professionals that planetary health is important to strive for, it is unlikely that decision-makers will make the necessary changes in a short enough time frame. One clear way for healthcare professionals to advocate for the integration and prioritization of planetary health is to “reclaim [their roles] at the heart of environment and development policies, taking a more proactive approach.” (Al-Delaimy, Ramanathan and Sanchez Sorondo, 2020, p. 97). For example, nurses in one study objected to the practice of disposing of narcotics down the drain; they recognized that the narcotics were getting into water systems and harming surrounding natural systems (King and McCue. 2017). The nurses advocated for a change in policy and a change in what it meant to properly dispose of narcotics in their workplace. Another example includes doctors who objected to the use of certain anaesthetic gasses in the operating room on the premise of them being harmful GHGs. These doctors also advocated for changes in policy and practice to support the health of the planet as well as humans (Özelsel, Sondekoppam & Buro, 2019.

Outcomes of Sustainable Healthcare

The outcomes of sustainable healthcare are perhaps best explored through the lens of co-benefits. According to Knute et al. (2017), co-benefits have a triple bottom-line: healthy planet, healthy people, and economic profit. In other words, co-benefits are actions that are good for the planet and for either human health or the economy. “Substantial health gains can be achieved from taking action to prevent climate change… [and pursuing] efforts to limit temperature increase to 1·5°C could make economic sense in some scenarios and countries if health co-benefits are taken into account” (Markandya, Sampedro, Smith, Van Dingenen, et al., 2018). An example of a co-benefit is related to Canada’s plans to phase out coal-fired power by 2030; this will avoid more than 1,000 premature deaths associated with corresponding air pollution and yield an additional $5 billion in health benefits by 2035 (Environment and Climate Change Canada, 2021).

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We need another paragraph here I think that explicitly talks about the connection between sustainable health systems and the benefits that brings to populations… but I will need more time to finish this. So this is a placeholder for that paragraph. I will generally discuss co-benefits related to health – less GHGs emitted = better air quality = better lung and heart health. Encouraging health users and employees to use low-emissions forms of travel (car-pooling, biking/walking/active transportation, light rail train) = less GHGs emitted and more exercise (biking/walking) = better health. Including more plant-based meals within health facilities for patients, families, and staff = lower GHG emissions related to food = better health through diet. Green roofs, retrofitting building, composting, presence of gardens (that can be used to help support meal services) = lower emissions and carbon reduction = better health and better mental health (more green spaces = better mental health). 

Table X: Practical Actions for Healthcare Practitioners and Green Teams (Kalogirou et al., 2020; Kurth, 2017; Sayre et al., 2010)
Prolem
Healthcare Professional Actions
Outcome
Levels of GHGs associated with food production are immense. Animal farming is extremely resource-intensive and food waste is a significant source of emissions. Moreover, “[the] global economic, environmental, and social cost of food wastage is estimated at US$2.6 trillion” (Project Drawdown, n.d.).
Working with food services to offer more plant-based food options that are locally sourced.

Reducing food waste via appropriate portion sizes and composting food scraps.
If 50–75% of people adopt a healthy diet of about 2,300 calories per day and reduce meat consumption overall, around 54.19–78.48 gigatons of GHGs could be avoided at minimum (Hawken, 2017).

Reducing food waste can result in the reduction of 88.50–102.20 gigatons of GHGs (Hawken, 2017).

Production of new materials is a significant contributor to GHG emissions. As our consumption of resources continues to increase, so does the environmental footprint of extraction of raw materials (Hawken, 2017).
Analyzing waste management practices, assessing what waste can be reduced, reused, recycled, and what alternatives exist to incineration.
About 50% of recycled materials come from households, while the rest from industry. If the average worldwide recycling rate of metals, plastic, glass, and other materials, such as rubber, textiles, and e-waste increased to 62–82% of total recyclable municipal solid waste, recycling could avoid 10.36–11.29 gigatons of carbon dioxide equivalent emissions by 2050 (Hawken, 2017).
In 2018, humanity walked an average of 200 kilometers per person per year. This equates to less than seven minutes of walking per day. We drive seven times as much as we walk. The International Energy Agency estimated that the transportation sector produced 9.5 gigatons of carbon dioxide equivalent emissions in 2018 (International Energy Agency, 2018).
Assessing transportation associated with: a) the organization. Finding local suppliers whenever possible and streamlining transportation routes; b) staff and patients. Organizing and incentivising alternative low-carbon options such as ride-shares, walking groups, or biking competitions.
If public transit is used for 29-34% of all urban passenger trips, this could save 9.42–15.42 gigatons of GHG emissions from cars.

Carpooling has no implementation costs. It can reduce emissions by 9.6-11.07 gigatons of carbon dioxide while saving approximately US$7.40–9.18 trillion.

It is assumed that an increase in bicycle infrastructure will drive bicycling from under 3% to almost 5–6% of urban trips globally by 2050. This would avoid 2.73–4.63 gigatons of carbon dioxide equivalent emissions.

Health Professionals and the Built Environment

The environment is more than an area’s trees, cars, people, and wildlife. It represents the totality of life and various interactions among and between people and any area of the planet. There will be profound impacts on the environment of future generations that are derived from decisions made in the past and today. The built environment consists of many features that have been constructed and modified by humanity. For example, how rooms are laid out, the construction of homes and various land uses in a neighborhood. The built environment even extends to the structure of neighborhoods in metropolitan areas, to the way regional and national geography and infrastructure interact to protect from natural disasters.

The built environment provides a blueprint for how our daily lives are conducted, it influences health across life spans (both human and animal), and represents important pathways through which individuals come into contact with many health risks. There is growing evidence that some environments promote health, while others increase morbidity and mortality. However, the associations between the built environment and health have only been examined closer over the past two decades, and efforts to implement interventions to address health concerns pertaining to the built environment are only in their infancy (Elf, Anåker, Marcheschi, Sigurjónsson, & Ulrich, 2020; Lopez, 2012).

Features of the built environment reflect the interplay of economic, political, and other similar factors. Some of these factors directly influence the built environment; others are more indirect. These include, but are not limited to:

•       Laws: development takes place within a legal and constitutional framework
•       Geology: soils, coastlines, tectonic factors
•       Economics: economic trends, incomes, local economic factors
•       Personal and societal values: neighborhood preferences, social factors
•       Health assumptions: beliefs regarding causes of morbidity and mortality
•       Ideology and political theory: theories of poverty, personal liberty, private property
•       Technology: automobiles, Internet, pollution prevention
•       Science: research, theories

Collaboration between interdisciplinary professionals (i.e., healthcare providers, welfare, social work) are becoming key elements to support the built environment through efficient and productive efforts at promoting health. Interprofessional teams have been found to increase provider and patient satisfaction, reduce the number of medical errors and other patient safety issues, promote workforce retention and reduce system inefficiencies resulting in higher costs. (Al-Delaimy, Ramanathan and Sanchez Sorondo, 2020; Lopez, 2012). The table below summarizes different professional groups that contribute to the built environment, and their roles.

TABLE 1. Healthcare Without Harm

(Lopez, 2012)