Medical industry contributions to the climate crisis: Behind the green drapes

Abstract

The climate crisis is rapidly unfolding with immediate, disastrous consequences including rising surface temperatures, melting of icecaps and glaciers, rising of sea levels and destructive wildfires spanning the globe. The impact of these climate changes on human health is broad, ranging from immediate heat-related deaths to acute and chronic respiratory and cardiovascular illness. Ironically, the healthcare industry itself contributes to climate change in many ways including waste generation, energy consumption, pharmaceutical production, equipment manufacturing, transportation and infrastructure. In addition to these obvious ways, the use of hydrofluoroalkane-propelled metered dose inhalers contributes significantly to the climate footprint of healthcare and is easily addressed immediately by changing to dry powder inhalers and soft mist inhalers where feasible and appropriate based on patient needs, safety, and availability of inhalers. Implementing carbon offset programs, investing in research and development and raising awareness among healthcare professionals are crucial components to reform. The healthcare industry must lead by example and commit to long term sustainable practices that not only mitigate the environmental footprint of the healthcare industry but also improve patient outcomes.

Keywords:

• Particulate matter
• air pollution
• combustion
• ozone
• dust storm
• global warming
• epithelium
• inflammation

The climate crisis is unfolding before our eyes at an unprecedented rate with July 2023 being the hottest month ever recorded on earth! The consequences of climate change are dire as we have witnessed with the destructive wildfires spanning the globe. The desertification of large swaths of northern Africa has generated plumes of particulate matter (PM: “desert dust)” that have blanketed the Middle East and Europe and have even been carried by prevailing winds as far as North America. The warming climate is responsible for melting of the polar ice caps and rising sea levels, extreme weather events including droughts, heavy rains and floods, wildfires, and for the dispersion of the Gulf Stream current that moderates the climate of large parts of northwestern Europe. If this trend is not reversed, large parts of the world may soon become uninhabitable. There is little doubt that these climate changes are largely due to human-generated greenhouse gas emissions including carbon dioxide (CO₂) and methane.^1–5

Climate change with global warming has a myriad of direct and indirect effects on human health. Increased ambient surface temperatures can lead to dehydration, hyperthermia and, in extreme circumstances, to circulatory collapse (shock) and death, particularly in vulnerable populations such as children and the elderly, who have impaired thermoregulation.⁶ Warming global temperatures are responsible for longer seasons and higher levels of aeroallergens such as ragweed, leading to an increased incidence and severity of upper (rhinitis, sinusitis) and lower (asthma, bronchitis) allergic respiratory tract diseases.⁷ Combustion reactions from burning of fossil fuels not only generate CO₂ and H₂O (the prototypical greenhouse gases that are the primary cause of global warming) but incomplete combustion of fossil fuels generates a variety of toxic substances including carbon monoxide, sulfur and nitrogen oxides, ozone and particulate matter (PM). Increased levels of airborne PM and ozone have been directly linked to respiratory and cardiovascular morbidity and mortality.^1,8,9 High levels of PM interfere with lung development in utero and during infancy and childhood, detrimental effects that prevent affected individuals from attaining normal pulmonary function^10,11 and predisposing to chronic obstructive lung disease (COPD) in adulthood.^12,13 High levels of PM and ozone lead to exacerbations of asthma and COPD^14–16 and are associated with an increased incidence of the acute respiratory distress syndrome (ARDS)¹⁷ and increased incidence and adverse outcomes in patients with pulmonary fibrosis.^18,19 The common mechanism underlying these respiratory effects of PM exposure is hypothesized to be recurring and chronic injury to lung epithelial cells.

In the ongoing struggle against the climate crisis, attention has been focused primarily on industries like oil and gas, coal, transportation and agriculture as the primary culprits. In a bitter irony, the medical industry itself is a significant contributor to the global carbon footprint, thus harming the very patients that we endeavor to serve (www.noharm.org/ClimateFootprintReport). As we work toward creating a more sustainable future, it is critical to evaluate the ways in which the healthcare industry exerts a significant toll on the earth’s environment and contributes to climate change with deleterious effects on respiratory health.

The healthcare industry generates massive amounts of waste, ranging from single-use medical equipment to the use of non-recyclable packaging materials. Recent estimates indicate that the health care sector is responsible for 4.4-4.6% of global worldwide greenhouse gas emissions.^20,21 In the United States, the healthcare sector accounts for about 5% of greenhouse gas emissions.²² In Canada, recent estimates suggest that healthcare accounts for 4.6% of greenhouse gas emissions²³ and in the United Kingdom, healthcare accounts for 4-5% of the country’s greenhouse gas emissions.²⁴ The climate-burden of healthcare includes production of hazardous materials, pharmaceutical waste and plastics that end up in landfills or oceans. The manufacturing, transportation, and disposal of these materials contribute significantly to greenhouse gas emissions, thus escalating the climate crisis.

Healthcare facilities, particularly hospitals, consume massive amounts of energy. The need for around the clock lighting, heating, cooling, sanitation and sterilization processes and operation of medical equipment requires high energy consumption. This energy often comes from fossil fuels, releasing carbon dioxide and other pollutants into the atmosphere.

The pharmaceutical sector, specifically its production and distribution systems, have substantial environmental consequences. The synthesis of pharmaceutical compounds often involves energy-intensive processes, and the disposal of unused medications can contaminate water and soil. Moreover, pharmaceuticals often end up in wastewater systems, impacting aquatic ecosystems and potentially entering the food chain.

Volatile anesthetic gases, a crucial component of modern surgical practice, are used to induce and maintain anesthesia during surgical procedures. Importantly, these gases can also contribute to climate change due to their potential as greenhouse gases. The primary volatile anesthetic gases of concern include desflurane, isoflurane and sevoflurane.

Attending national and international medical conferences involves air and/or ground travel, the use of hotels by attendees and staff, and the operation of the conference facilities all of which use large amounts of energy and contribute to climate change. I raise this issue with some trepidation given that I am the immediate past president of the American Thoracic Society, an organization that holds annual scientific and medical conferences with over 12,000 attendees from around the globe.

The current article by Gupta et al.²⁵ focuses on the contribution of medical inhalers, particularly hydrofluorocarbon (HFC) gas-propelled metered dose inhalers (MDIs) that function as greenhouse gases, to climate change, a topic that is both timely and prescient. In their insightful and carefully analytical review, Gupta et al. carefully delineate the magnitude of the climate burden of the manufacture and use of pressurized MDIs for the treatment of obstructive lung disease including asthma and COPD. The propellants in these MDIs, historically chlorofluorocarbons (CFCs) and hydrochlorofluorocarbons (HCFCs), were potent contributors to ozone depletion and global warming. While newer inhaler designs and replacement of CFCs with hydrofluoroalkanes (HFAs) mitigate some of these effects, the overall impact of use of these pressurized MDI inhalers on climate change remains a concern.

While the contributions to the climate crisis are becoming clearer, solutions to the crisis remain complex and, in some cases, on the distant horizon. How do we address the climate burden of healthcare? Some relatively simple strategies that are likely to be effective include changing (where possible and safe and appropriate for patients) from MDIs to dry powder inhalers (DPIs) and soft mist inhalers for individuals with asthma and COPD. Any change from MDIs to DPIs or soft mist inhalers would need to be done thoughtfully balancing patient safety and preference, cost, and availability of DPIs or soft mist inhalers. Adhering to asthma guidelines and proper use of inhalers and appropriate use of inhaled corticosteroids (ICS) as controllers will also decrease the need for short acting beta agonists, many of which are in the form of MDIs. Other promising strategies and initiatives that can drive positive change include:

1. Sustainable Design and Operations. These include reduction of energy consumption, water usage, and waste generation. Incorporating renewable energy sources, energy-efficient technologies, and green building practices.

2. Reforming Waste Management. The healthcare industry needs to prioritize waste reduction through strategies such as reusing medical equipment and implementing recycling programs for plastics and metals. Proper disposal of hazardous waste and pharmaceuticals is essential to prevent environmental contamination.

3. Pharmaceutical Stewardship. Implementing take-back programs for unused medications and promoting responsible pharmaceutical disposal can prevent contamination of water bodies and minimize the environmental impact of pharmaceuticals. Decreasing use of volatile anesthetics and use of scrubbing or reclamation techniques for these gases in the operating rooms.

4. Telehealth and Digital Solutions: Healthcare needs to expand the use of telehealth and digital healthcare solutions that will reduce the need for physical visits, thereby decreasing energy consumption related to commuting and facility operations.

5. Sustainable Procurement: Healthcare institutions can prioritize the procurement of eco-friendly products and equipment including choosing suppliers with sustainable practices.

6. Public Awareness and Education. Raising awareness among healthcare professionals, patients and the public about the environmental impact of the medical industry can inspire collective action and behavioral changes.

7. Research and Innovation. Governments and private companies need to invest in research to develop environmentally friendly medical technologies, materials and treatment methods that can pave the way for a more sustainable healthcare future.

In conclusion, while the primary goal of healthcare is to safeguard and improve human health, its contribution to climate change remains substantial. The environmental impact of healthcare is broad, encompassing waste generation, energy consumption, pharmaceutical production, equipment manufacturing, transportation and infrastructure. As detailed in the article by Gupta et al.,²⁵ the use of HFA-propelled MDIs contributes to the climate footprint of healthcare and can be addressed by changing to DPIs and soft mist inhalers where appropriate balancing availability and patient preferences and safety. Implementing carbon offset programs, investing in research and development and raising awareness among healthcare professionals are crucial components to reform. We must lead by example and commit to sustainable practices that not only mitigate the environmental footprint of the healthcare industry but also improve patient outcomes. By addressing these challenges head-on and adopting a comprehensive approach to sustainability, the healthcare industry can transition toward a future where healthcare and planetary health coexist in harmony.

Author contributions

G.P. Downey researched the topic and wrote the article.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the National Institutes of Health under Grant [R01HL157424] and National Center for Advancing Translational Science (NCATS) under Grant [4UH3TR002445].