key: cord-0917518-jqy3drj3
authors: Hess, Jeremy J.; Salas, Renee N.
title: Invited Perspective: Life Cycle Analysis: A Potentially Transformative Tool for Lowering Health Care’s Carbon Footprint
date: 2021-07-12
journal: Environ Health Perspect
DOI: 10.1289/ehp9630
sha: b691b0795f08045dc261618dada6761d71cc1f04
doc_id: 917518
cord_uid: jqy3drj3

nan

The concept that physicians have a duty to avoid iatrogenic harms is as old as the medical profession itself. The history of medicine is punctuated by calls for harm reduction. The Hippocratic Oath included prohibition against "cutting for stone" (Edelstein 1967) . In the 19th century, Semmelweis's campaign to end puerperal fever focused on providers' hand hygiene (Pittet and Boyce 2001) . Two decades ago, the landmark report, To Err is Human, laid bare the death toll associated with medical errors in the United States (Institute of Medicine and Committee on Quality of Health Care in America 2000) and outlined a path forward for the sector.

In recent decades, a new front in this battle opened as the health care sector has slowly awoken to the fact that health care delivery contributes substantially to the harms and inequities associated with global climate change (Chung and Meltzer 2009) . Compelling evidence of the harms associated with current medical practice, in the form of unnecessary greenhouse gas (GHG) emissions, has accumulated steadily over the last decade Sherman 2016, 2018; Watts et al. 2019 Watts et al. , 2021 .

Medicine is energy and resource intensive, and surgical and anesthetic services particularly so. In this issue, Drew et al. (2021) provide new insight into the footprint of one of the most carbon-intensive areas of medical care, providing a useful new summation of evidence that has several implications for how medicine might make rapid progress in its ongoing effort to rein in iatrogenic harms.

First, their review provides strong evidence of the widely varying climatic impacts of specific practices. The authors updated systematic review methods for the life cycle analysis (LCA) literature and incorporated a broad swath of new studies. These works provided new insights into the staggering environmental impacts associated with surgical and anesthetic practices and confirmed key realities. For example, single-use products generally, although not universally, contributed more to GHG emissions than reusable products. Although this is the most comprehensive review of these services to date, the authors stress that our knowledge still covers only a small proportion of health care's total emissions.

Second, the authors highlight LCA's key role in advancing sustainability in health care and identify multiple knowledge and practice gaps that need to be filled for LCA to realize its full potential as an environmental accounting tool. The review notes the lack of consistency in LCA practices and reporting but also highlights the potential for consistently applied LCA methods and reporting standards to feed into quality metrics. This potential is of particular importance for environmental health, with its branches of exposure assessment, risk assessment, industrial hygiene, hierarchy of controls, and risk communication, all of which are essential for realizing LCA's full potential.

Third, the authors rightly acknowledge the ethical importance of this work but then pivot to the technical and operational considerations. The health care sector would do well to follow their example in greening its practices. Beneficence and nonmaleficence are the starting points; operationalizing healthier practices is the goal. The medical field needs to broaden its quality initiatives to include GHG mitigation activities (Ossebaard and Lachman 2021) , and its chief quality officers need to develop or acquire environmental accounting expertise. Drew et al. (2021) provide indicators that could be included in sustainability dashboards (e.g., the volume of desflurane and propofol used in anesthetic practices), and they recognize the importance of clinically relevant metrics that align with providers' perspectives [e.g., using maintenance of minimum alveolar concentrations for 1 h, originally developed by Sherman et al. (2012) ].

Fourth, Drew et al.'s (2021) work highlights the transformative potential of combining standardized LCA methods with a widespread commitment to minimizing the environmental impacts of health care. Noting the demographic and risk transitions, they highlight the importance of early changes in surgical and anesthetic systems of care. Early adoption of GHG emissions reductions as a quality metric has worked well for the National Health Service in the United Kingdom (Pencheon et al. 2009 ) and Kaiser-Permanente in the United States (Shilt-Moody and Tsai 2019; Storz 2018). Treating the need for emissions reductions as an uncontroversial, logical conclusion of their commitment to population health, these institutions have demonstrated that harms associated with emissions can be reduced through standard quality improvement activities. We believe that regulators could speed implementation of these measures by providing incentives to support activities at scale, analogous to the use of Title VI and Medicare to integrate hospitals in the 1960s (Reynolds 1997) .

Medicine has a long commitment to evidence-based practice but sometimes falters, and implementation of new practices often takes decades (Dopson et al. 2003) . Data must be acquired and analyzed, and hegemonic practices tend to resist change. Medical education has often played a key role, not only in updating practice with recent evidence but also in facilitating the requisite culture change needed to realize the commitment to evidence-based practice (Claridge and Fabian 2005) . Passive implementation often fails; intentional, multifaceted interventions are often required (Grol and Grimshaw 1999) . Drew et al. (2012) summarized the evidence, but additional efforts will be required to move the agenda forward.

This evidence arrives at a unique moment for health care and for global action to protect the climate. The COVID-19 pandemic has underscored the fundamental importance of widespread access to functioning health care systems and the potential for international cooperation to reduce future global-scale risks from pandemic disease and climate change. The pandemic has also highlighted the potential for rapid mobilization and practice change in health care if there is sufficient motivation, necessity, and urgency with clear objectives and sufficient resources. The world's attention is turning to the looming threat of climate change and to the need for health care to minimize its contribution to the problem at the same time it is preparing to treat its ill effects. There are enormous health benefits to aggressive GHG emission reductions (Haines 2017) . The health care sector now has a unique opportunity to halt the vicious cycle of health care harming its patients by exacerbating climate change and air pollution and to instead embrace concerted efforts to reduce its emissions. Drew et al.'s paper helps illuminate the way.

An estimate of the carbon footprint of the U.S. healthcare sector

History and development of evidence-based medicine

Evidence-based medicine and the implementation gap

Operating in a climate crisis: a state-of-the-science review of life cycle assessment within surgical and anesthetic care

Environmental impacts of the U.S. health care system and effects on public health

Estimated global disease burden from US health care sector greenhouse gas emissions

The Hippocratic Oath: text, translation and interpretation

Evidence-based implementation of evidence-based medicine

Health co-benefits of climate action

To Err Is Human: Building a Safer Health System

Climate change, environmental sustainability and health care quality

Health sector leadership in mitigating climate change: experience from the UK and NSW

Hand hygiene and patient care: pursuing the Semmelweis legacy

The federal government's use of Title VI and Medicare to racially integrate hospitals in the United States

Life cycle greenhouse gas emissions of anesthetic drugs

Turning the tide: the shift to climate change mitigation

A practical guide for physicians and health care workers to reduce their carbon footprint in daily clinical work

The 2020 report of The Lancet Countdown on health and climate change: responding to converging crises

The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate