How to stop healthcare worsening a global health emergency

By David Lynch - 25th Nov 2022 | 129 views

climate change

While the COP27 conference in Egypt attracted the world’s attention, David Lynch attended a meeting in Dublin on climate change and health. He speaks to doctors about how to limit the impact healthcare has on the environment

Climate change is already killing us,” the World Health Organisation (WHO) Regional Director for Europe, Dr Hans Henri P Kluge, warned earlier this month. One example he cited was the WHO’s estimate that at least 15,000 people died in Europe, specifically due to the heat, in 2022.

However, Dr Kluge added that “strong action now” on climate change could prevent more deaths.

This month world leaders gathered in Sharm el-Sheikh, Egypt, at the 2022 United Nations Climate Change Conference (COP27). Concerns over the environment are rarely absent from national and international headlines and a growing sense of urgency is reflected in healthcare.

Neutral

The HSE’s Climate Action Plan 2022-2050 launch date “will be confirmed in the coming weeks”, a spokesperson told this newspaper.

It is the first plan of its kind and will commit the HSE to being climate neutral by 2050.

“We will be starting with this immediately,” Dr Philip Crowley, HSE National Director for Strategy and Research, told the Medical Independent (MI). Asked about the significant length of time covered by the plan (28 years), Dr Crowley said “there will be reviews of it [the plan] during it, annually certainly”.

He spoke about the upcoming strategy at the recent Environment, Health, and Wellbeing Conference 2022, which was held on 9 November in Dublin. It was jointly organised by the HSE, Environmental Protection Agency and the Economic and Social Research Institute.

Dr Crowley told attendees that climate change endangers health in a variety of ways. These include extreme heat leading to heat-related illness and death, and poor air quality leading to respiratory and cardiovascular disease. Extreme weather also could lead to droughts, which would have knock-on health effects. Dr Crowley also referred to the mental health impact of climate change. 

This was highlighted recently by the Turn2Me charity, who reported “a huge increase” in the number of people with climate-related anxieties in Ireland.

“I think we have to strike some sort of sweet point between urgency and pessimism,” Dr Crowley told the conference.

“We need urgency, but we need some optimism as well.”

Dr Crowley added that healthcare had a significant environmental impact through the use high energy intensive buildings, waste from clinical procedures, and transportation due to the supply chain for pharmaceuticals and other goods.

Other examples included the use of anaesthetic gases and inhalers for asthma.

Dr Crowley said a procurement system that reflected these environmental will form part of the new strategy (see panel).

The HSE has identified 170 “significant energy users” within the health service that account for 75 per cent of the energy use and carbon emissions. There are currently 111 local energy teams in place across the health service and in hospitals.

These will be reshaped into green teams,  “so broadening their remit”.

Dr Crowley, who has a public health background and practises as a GP, said that different specialties have become increasingly aware of environmental health.  

“Certainly, you could see that specialties like general practice and anaesthesiologists have really become aware of the particular impacts of their practice in their area,” he told MI.

“Overall, I think, we [the HSE] need to continually raise awareness. That’s part of this communications programme that we are going to try and start. It is to get all of our staff… to come together. I really think we could achieve a lot.”

We need urgency, but we need some optimism as well

Mobilise

Dr Crowley said the experience of the health service and the Covid-19 pandemic could act as a blueprint with action taken at a local and national level.

“People pulled together around a common purpose,” he said.

“Climate change is the next thing. Obviously, it has been around a long time. But I think if we can mobilise our staff and all of their good ideas, if we can manage to enable people locally to institute changes around how they get to work, the environment they work in, waste, etc, we could change a lot without having to tell everybody what to do.”

There are concerns internally within the HSE over the possibility of achieving emission targets. In October, MI reported that the risk the HSE may not achieve a 51 per cent reduction in overall greenhouse emissions by 2030 has been included in its corporate risk register. However, the HSE said that where “challenges have been identified in meeting these targets, appropriate mitigation and control measures are in place”.

The Irish Doctors for the Environment (IDE) group has highlighted that the HSE need to first establish the current emission levels from its national building stock and from the cost of transportation and disposal of items used in the health system.

Separately, the Department of Health told this newspaper that its climate change oversight group, which was formed in September 2021, met in plenary twice over the following 12 months. The meetings were held in September 2021 and February this year. The group, which is chaired at principal officer level, aims to “meet two to three times a year” depending on issues of relevance to its whole membership, a Department spokesperson told MI.

“The main value of the climate change oversight group is as a forum for regular bilateral engagement and sharing of climate related information and developments. Representation on the group covers a wide range of stakeholders from across the Department of Health and the HSE.” 

COP

Speaking to MI when the COP27 conference was still ongoing, Dr Rachel MacCann, Infectious Diseases SpR and Operations Officer for the IDE, said that her main hope for the event in Egypt would be to bring some of the “focus towards healthcare”.

“Particularly focus on green healthcare procurement and also preventative strategies,” she said.

“If you have prevention as a sort of driver of healthcare you reduce the burden on the hospital system and you are making people more resilient to the challenges of climate change.”

Dr MacCann said that if the international healthcare sector was a country, it would be the fifth largest emitter in the world. Within this country, Irish healthcare accounts for 4.4 per cent of national carbon emissions.

She said procurement was also an “opportunity and it should be [used] to promote green businesses”.

Dr MacCann added the HSE and others “could have a dual impact [by procurement] both from a health point of view and even a national economic point of view”.

In January, MI reported on the growing trend of climate change activism and advocacy among doctors. After almost three years of a pandemic, are there signs of flagging energy?

Dr MacCann warned “burnout is important to recognise because the workforce is just so fraught with a lot of stress from Covid, but also [due to the general] restrictions that we sometimes face in the working environment and not being able to do our jobs properly in terms of resources and time”.

She told MI that doctors often “feel those same frustrations about climate change”.

“I have met so many staff who are so exasperated with how healthcare waste is carried out in hospitals. You know, people try to make a big effort [in their hospitals], which is to be applauded. But really, you need a whole system change, the whole hospital needs to be on board.

“If that sort of change is not brought about soon, staff will start getting fatigued and they will stop caring about, say, using the right bins in hospitals. So I think the appetite among healthcare workers is certainly there. But they also need buy-in from their employers to actually do the things they want to see done.”

Public health

In August, the HSE’s public health medicine environment and health group (PHMEHG) published its annual report. The group noted that its work was conducted over the last 12 months in the context of the “public health reform process in line with the Crowe Horwath Report”.

According to the report, PHMEHG “has advocated for [environment and health]
to be included as a key component of health protection reform and as such, resourced adequately”.

The group also called for a national environment and health surveillance system and to “prioritise protecting health from serious environmental issues”.

“There are a number of clinical priorities for public health medicine related to the environment including the health impacts of air pollution, issues with water quality and quantity, climate change and the need for strong advocacy on preventing environmental issues that impact on health,” according to the PHMEHG report.

Public health doctors’ “important” role in environmental health could be developed and expanded as part of the current reform programme, Dr Ina Kelly, Consultant in Public Health Medicine and member of PHMEHG, told MI.

The reform programme includes the appointment of 84 public health consultants by December 2023.

Dr Kelly said that public health consultants and specialist in public health medicine currently operate under statutory functions “and part of that is all influences on health… including the environmental aspect”. 

“Definitely we will have a role in it, in terms of what’s happening and influencing peoples’ health and then also on doing something about it… and [the current legislation] tells us to advise local and the relevant authorities.”

Dr Kelly, who spoke on health risks and hazards from health waves and air quality at the recent Environment, Health, and Wellbeing Conference, believes changes may be coming as to how public health doctors engage with climate change.

“How will this be impacted by the reform programme? I think that as we build up our multidisciplinary teams … public health specialists or consultants in public health will have a farther reach and be able to do more,” the former IMO President told MI.

“We have had so few resources up until now, that really we have been only touching the edges of what we can do. We need obviously to be working a lot more with all our colleagues, with all the different agencies that all have a different role in this, and we all need to be working together.”

She noted that the staff on the multidisciplinary teams “haven’t been working on the environmental side before”.

“It’s more on the infectious disease side,” Dr Kelly added. “So we are going to have to train them up in all of that. But I think, yes, we potentially will have a much better opportunity in the future to start impacting and providing our experience into the [environmental]  health of the public.”

Dr Kelly said the reform programme will mean “environmental health is going to have a higher profile that it did before” with a more national focus.

She said up until now public health had been providing “quiet leadership” at a more regional and local level. 

GPs

In general practice, the ICGP’s sustainability working group is finalising a tool-kit to roll-out next year to provide detail on where the carbon footprint is created in general practice.

It will offer “GPs, trainees, practice nurses, and practice staff practical steps they can take to work towards a more sustainable future,” Dr Sean Owens, who is a member of the working group, told MI. He added it is aimed to show “busy and time poor” GPs where the carbon footprint “is within our daily working lives”.

“We believe primary care can be leaders in planetary health by lowering our own carbon, plastic, water, antibiotic, and waste footprint and also by lessening the pressure on tertiary care, where much of healthcare emissions are to be found,” Dr Owens told this newspaper.

“Furthermore, with healthcare’s trusted role, we hope healthcare can affect change at political level by showing how the climate crisis is simultaneously a health crisis.”

Taking action on… inhalers, anaesthetic
gases, and procurement

Tackling the use of asthma inhalers, anaesthetic gases and procurement choices by the HSE are among

the most high-profile actions that health campaigners in Ireland are currently highlighting.

On procurement, Dr Rachel MacCann, Operations Officer, Irish Doctors for the Environment (IDE), told the Medical Independent (MI) she would like to see a “particular focus” on green healthcare procurement.

Procurement

Speaking at the recent Environment, Health, and Wellbeing Conference, she said that individual actions at hospitals and at local level “were great achievements”.

“But when you look at the breakdown of emissions, about 78 per cent of healthcare emission can be attributed to procurement. So making one big change in one central area, I think, can have a more overarching and longer impact than a lot of the individual efforts.”

Speaking at the same conference, Dr Philip Crowley, HSE National Director for Strategy and Research, described “sustainable procurement” as a “complex” area.

“On the one level you would say the HSE has massive leverage,” he said.

“It is a very big buyer of pharmaceuticals and of all types of materials, etc, but actually you would be surprised in a way, particularly with global products like pharmaceuticals, how we have to use our leverage carefully because we are a small market.”

“At the same time, we have leverage and we will use it to ensure we have a green procurement approach.”

Inhalers

On the issue of asthma inhalers, Dr Crowley noted a recent ICGP audit of inhaler use. He said the HSE had been working with the College to “explore” asthma care that protects the environment.

The ICGP sustainability working group would like the Executive to make moves in this area.

“One policy action the HSE could take…would be to suspend PCRS reimbursement for Ventolin [asthma inhalers],” Dr Sean Owens, who is a working group member, told MI.

“With the urgency of the climate crisis, we really need to decarbonise the carbon hot spots first and foremost. In healthcare, these are undoubtedly anaesthetic gases and multi-dose inhalers (MDIs). For example, the seemingly innocuous blue reliever MDI is responsible for a significant proportion of the carbon footprint of the entire health service.”

Dr Owens said switching to “dual preventer and reliever inhalers for asthma has already been shown to be clinically effective, as per evidence base…”.

He noted that moving away from MDIs, in general, “will take time and need buy-in from all stakeholders including patients.”  More importantly, he added, “such a move would send a strong signal externally that the HSE means to decarbonise.”

Anaesthetic gases

The IDE has an anaesthetic gases working group. Its primary aim is to make “anaesthesia more sustainable” and to reduce greenhouse gas emissions among anaesthesiologists through safe use of low-flow anaesthesia, “and sparing use of N2O and desflurane.”

“Anaesthetic gases are a huge area of emission in Ireland and our working group only recently published an incredible audit,” said Dr MacCann.

Speaking at the environmental conference, Dr Crowley noted one of the “arms of our [HSE] climate strategy are clinical impacts on climate, anaesthetic gases is a significant one”.

He highlighted the use of desflurane, in particular.

The College of Anaesthesiologists of Ireland have, thankfully, been great partners in our initial work on creating a climate strategy along with the Irish Doctors for the Environment,” said Dr Crowley.

“They have been doing quite a significant amount of work on anaesthetic gases and we are going to build on that. But they are looking to reduce the use of inhalation anaesthetic agents, particularly those with a high environmental impact and they are going to promote environmentally friendly techniques.”

He said that recent work had meant that, at a national level, 20 per cent of anaesthetic departments have ceased using desflurane.

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