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Pollution is a leading cause of morbidity and mortality, and was associated with an estimated 9 million premature deaths globally in 2015 or 16% of all deaths.1 Most environmentally mediated deaths are linked to air pollution,1 with many health experts believing climate change is the leading public health issue of the 21st century. Major disruptions to food production, water supplies, and coastal livability are predicted unless significant action is taken to reduce greenhouse gas (GHG) emissions.2 Ironically, modern health care is a major contributor to pollution that adversely affects human health.3-6 It is estimated that the health sectors of the United States,3 Australia,4 England,5 and Canada6 emit a combined 748 million metric tons of carbon dioxide equivalents annually. If the health sectors of these countries were an independent nation, they would rank seventh in the world for GHG emissions.7
Building quality into health systems includes avoiding harm to patients from care that is intended to help, improving efficiency, and reducing non–value-added care. Minimizing health care pollution requires addressing excessive or inappropriate resource use, and optimizing the environmental footprint of health care could contribute to improved population health. Environmental sustainability is an underappreciated dimension of health care quality.
Despite the magnitude of health care resource use and spending, there has been insufficient research into its environmental sustainability. An established field of multidisciplinary inquiry, sustainability science combines the methodological expertise of environmental science and engineering to solve complex problems that threaten earth systems and the future of human existence. The overarching principles and validated tools of sustainability science could be applied to the health sector to critically examine the ways in which the current provision of health care depletes natural resources and creates toxic emissions that undermine the health of current and future generations.
Some accounting methods exist to measure energy use at the health care facility level (such as the Energy Star program, which calculates target energy values from actual energy data and operating characteristics), and health sector GHG emissions at the national level (such as those developed by the National Health Service Sustainable Development Unit, a government agency that develops tools, policy, and research to embed sustainable development across health and social care systems in the United Kingdom). However, there is no international, standardized approach. In particular, no established environmental metrics reflect specific clinical activities, even though patient care drives health care–related energy and material consumption. For example, heating, ventilation, and air conditioning (HVAC) account for 50% of hospital energy use because air conditioning is thought to play a vital role in infection control in health care facilities, which are subject to higher standards than other sectors. This is most pronounced in operating rooms where HVAC requirements account for 90% to 99% of energy use in an attempt to improve sterile conditions for safe surgery.8 Infection control practices are also driving a concerning shift toward single-use consumables throughout health care facilities, resulting in increased material consumption and energy use from supply chain activities. To reduce health care emissions, a comprehensive framework is needed that places patients at the center of sustainability research, ensuring that environmental assessments consider clinical resource use, pollution, health outcomes, and the costs of health care services to drive practice improvement.
Traditional valuations in health care fail to consider the public health effects of pollution from activities up and down the supply chain, including environmental emissions from natural resource extraction, manufacturing and packaging, transportation, utilization, and disposal management. An accurate accounting of health care costs should include public health sequelae of these activities.3,6 As health care resources become increasingly strained, efforts are underway to move toward value-based care. There is a convergence of resource conservation and improved environmental sustainability with cost reduction and improved population health. However, reducing unnecessary resource consumption is insufficient and environmentally preferable choices are also required. Value-based methods that incorporate environmental performance into decision-making are critical.
The industrial ecology framework seeks solutions to (1) eliminate unnecessary resource consumption and pollution from human systems, (2) keep products and materials in use, and (3) regenerate or renew natural systems. Industrial ecology principles and tools, most notably life cycle assessment, could be systematically applied to assess health care services. Life cycle assessment is an internationally standardized (ISO 14040) scientific method for quantifying those solutions in terms of resource use, emissions, and effects on the environment. Material flow analyses of energy and material resources put toward specific health services may be helpful to identify clinical priority areas for mitigation. For example, inhaled anesthetics are potent GHGs that are responsible for a majority of emissions from North American operating rooms. Compared with alternative clinical techniques such as total intravenous anesthesia, life cycle GHG emissions of inhaled anesthetics are multiple orders of magnitude higher.8
Better methods are needed to account for environmental emissions associated with the production and use of medical devices and products, given the global supply chain and variability in use between geographic regions. Life cycle inventory databases are used to conduct assessments and provide a rigorously derived accounting of the energy and resources needed to manufacture or produce a given material, as well as the environmental emissions typically released in the material’s creation. Currently, life cycle inventories contain limited information about health care–related products, particularly pharmaceuticals. The Environmental Product Declaration framework (ISO 14025) could be used to create product category rules for medical supplies to encourage manufacturers to report emissions and improve their products. Creation of a life cycle inventory database containing whole medical products, including drugs and devices, could aid environmentally preferable purchasing (the procurement of less environmentally harmful supplies). Such a medical supply database could be integrated with the electronic health record to support health care decision-making by enabling clinicians to select the least harmful drugs and supplies when choices exist, much as cost information is used to encourage selection of less expensive medications and supply substitutes. Such data integration could support environmental quality improvement efforts.
Development of robust, standardized metrics to define environmental performance and gauge progress is required. This approach could occur on multiple levels, including for individual supplies and products, and alternative care pathways (ways in which those resources are used differently to achieve the same clinical outcome). This approach also could be used to assess performance of individual clinicians, hospitals, and health care systems. Environmental performance metrics could be integrated into existing clinical quality reporting structures, such as the Qualified Clinical Data Registries and the Centers for Medicare & Medicaid Services. The Joint Commission and other health system accreditors could establish standards for clinical sustainability that would be monitored through existing audit mechanisms.
Reducing the environmental footprint of health care activities requires engagement of clinicians and hospital administrators, professional societies, regulatory bodies, policy makers, and industry. Evidence-based best practices should be included in clinical practice guidelines and other professional standards. The Choosing Wisely initiative in the United States and the Getting It Right the First Time program in the United Kingdom develop evidence-based recommendations regarding the appropriate use of health care resources and elimination of harm due to overinvestigation and overtreatment. By encouraging evidence-based resource use, the mandates of these programs are tightly aligned with an environmental sustainability agenda because eliminating unnecessary care reduces unnecessary resource use and emissions. Such partnerships could be encouraged to bring environmental stewardship into the health care quality discourse.
There is a critical need for funding mechanisms that support health care sustainability science. In the United States, health care sustainability overlaps with the missions of government funding bodies within science and engineering (National Science Foundation), health care delivery (Agency for Healthcare Research and Quality), and environmental health sciences (National Institute of Environmental Health Sciences). However, no single agency has taken ownership of this field, resulting in limited funding opportunities. Inter-agency collaborations or explicit ownership and the creation of funding mechanisms will be needed to close this gap.
Optimizing resource and waste management practices are key components of environmental performance improvement in clinical care, but insufficient for a sustainable future. Minimizing negative environmental influence of health care activities requires innovation beyond simple determination of the least-bad existing options. Policy-relevant research is required to drive business investment and government oversight toward improved outcomes for patients and public health alike. Through innovative design, it is possible to improve performance and mitigate toxicity, hazards, and reduce resource consumption. Higher-level decision-makers could set ambitious targets for health care delivery, design funding models that align incentives with wellness outcomes, and implement organizational redesign to create a sustainable health care system within the short time horizon mandated by global environmental change.
A global commission for the advancement of environmental sustainability in health care could be created to stimulate and accelerate scientific research, and provide implementation guidance and policy efforts. Such a commission would require strategic institutional partnerships and dedicated financial and human resources. This focused multidisciplinary collaboration could illuminate the inextricable linkages between patient and planetary health, and seek to embed Health in All Policies as a core value in the health care industry.
Corresponding Author: Jodi D. Sherman, MD, Yale University Schools of Medicine and Public Health, 333 Cedar St, New Haven, CT 06520 (firstname.lastname@example.org).
Published Online: August 2, 2019. doi:10.1001/jama.2019.10823
Conflict of Interest Disclosures: None reported.
Funding/Support: This material is based on work supported by grant 1818038 from the National Science Foundation, the Yale University School of Medicine, New York University Green Grants Fund, Yale University School of Public Health, Yale University School of Nursing, and the Yale University Office of Sustainability.
Role of the Funder/Sponsor: The funders/sponsors had no role in preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The opinions, findings, conclusions, and recommendations expressed in this article are those of the authors and do not necessarily reflect the views of the funders.
Additional Contributions: We thank the steering committee of the Workshop on Environmental Sustainability in Clinical Care for their guidance and leadership: Joseph Bialowitz, MS, Melissa M. Bilec, PhD, Anthony Costello, FMedSci, Robert Dubrow, MD, PhD, Matthew J. Eckelman, PhD, Harriet W. Hopf, MD, Robert Lagasse, MD, Forbes McGain, MBBS, PhD, Rachel Stancliffe, MSc, and all the workshop participants (https://publichealth.yale.edu/climate/research/conferences/copy_of_index.aspx).
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Sherman JD, MacNeill A, Thiel C. Reducing Pollution From the Health Care Industry. JAMA. Published online August 02, 2019. doi:10.1001/jama.2019.10823
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