Healthcare should not cost us the Earth
BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4289 (Published 06 November 2020) Cite this as: BMJ 2020;371:m4289
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Dear Editor
We read with great interest the article ‘Healthcare should not cost us the Earth’ by Bennett & Maraka. We agree that the COVID-19 pandemic has imposed environmental challenges on the NHS, particularly due to increased personal protective equipment (PPE) consumption. Indeed, at the beginning of the pandemic, it did not help to find that over half of all surgical face masks in the national inventory had expired, along with 80% of respirators.[1] One simple way of avoiding such waste in the future is to have resilient demand-driven supply chains with lower reserves.
They mention that if PPE is locally sourced rather than imported from China, we would avoid unnecessary carbon footprint. Firstly, we are unclear about the evidence behind this reasoning. Secondly, even if true, this view is too reductive. The structural change of the UK economy from manufacturing-based to service-based means we simply do not have the same capacity for large-scale production, nor the necessary complex supply chains for materials and industrial equipment needed for manufacturing as China.[2] Moreover, moving to local supply chains would financially harm existing reliable suppliers. Should they collapse, we would be reliant on our own inexperienced ones. This would not bode well for future pandemics.[3] Additionally, we would have to justify the expense and the resulting increase in UK pollution to the taxpayer. Therefore, persevering with the same PPE sources at a time of shortage and national emergency is not simply a ‘financial shortcut’ but a logistical necessity.
We agree that healthcare should not cost us the earth, and a better way to realise this is to centralise PPE stock, well in advance of future pandemics that are undoubtedly becoming more common.[4] Centralisation is already being implemented in other NHS areas with great benefit, for example in pathology services,[5] and with regards to hospital consumables such as PPE, a centralised resource would make it cheaper and easier to transport PPE in an environmentally-friendly way.[6] In 2017, England’s Health and Social Care (HSC) carbon footprint reached 6.3% of our total emissions with supply chain being the largest contributor at nearly two-thirds.[7] Currently, PPE is moved via petrol or diesel vehicles. Delivering PPE by electric vehicles and drones powered by renewable energy for example could significantly cut these figures. One promising example of this is upcoming NHS drone test flights that will fly PPE between a centralised warehouse and hospitals in Mid and South Essex NHS Foundation Trust.[8] Centralising PPE stock would therefore be in line with the NHS’s plan to reach net-zero emissions by 2050.
References
[1] https://www.channel4.com/news/revealed-ppe-stockpile-was-out-of-date-whe...
[2] https://hbr.org/2020/04/bringing-manufacturing-back-to-the-u-s-is-easier...
[3] Feinmann Jane. PPE: what now for the global supply chain? BMJ 2020; 369 :m1910
https://doi.org/10.1136/bmj.m1910
[4] https://www.weforum.org/whitepapers/outbreak-readiness-and-business-impa...
[5] https://improvement.nhs.uk/resources/pathology-networks/
[6] NHS Supply Chain Focus on Sustainability Report 2010
https://wwwmedia.supplychain.nhs.uk/media/2017/10/Sustainability_report_...
[7] https://www.sduhealth.org.uk/policy-strategy/reporting/natural-resource-...
[8] https://www.gov.uk/government/news/space-company-takes-to-the-skies-alon...
Competing interests: No competing interests
Another hidden environmental challenge of healthcare
Dear Editor
The evocative title and viewpoint expressed by Bennett and Maraka has merit – “Healthcare should not cost us the Earth”[1]. They make sobering comments about the (unavoidable) reality of the pandemic contributing to environmental pollution. Salas et al. are also to be congratulated on providing a very thoughtful and thorough analysis and pathway forward to reduction of environmental impact of healthcare [2], a topic all too easily ignored in the noble effort to save lives and improve individual quality of life. However, we wish to qualify the impression given in both articles - and many others - regarding telemedicine, and add perspective regarding e-health overall as another “hidden environmental challenge” [1]. For clarity, telemedicine is a component of telehealth, which is itself a component of e-health, now often referred to as a component of digital health. Here the collective term e-Health is used.
Spurred by the COVID-19 pandemic several factors have contrived to encourage global adoption of e-health solutions, a circumstance expected to continue for the long term [3,4]. First – almost instantaneous global awareness of e-health solutions has been created amongst patients, providers, and politicians by the enforced and rapid application of virtual and technological approaches to health and healthcare [3,5,6]. Second - the World Health Organization (WHO) continues to urge member states to adopt e-health (now digital health), promoting m-health in particular [7,8]. Third – the global digital health market is projected to grow six-fold (at a CAGR of 28.5%) to over 600 billion dollars (USD) by 2026, with m-Health as a leading component [9]. Each of these provide significant stimulus to all users – patients, providers, policy-makers, and partners (vendors) that may - at first blush - suggest e-health interventions are an ideal solution.
However, e-health has been succinctly defined by WHO as “the use of information and communication technologies (ICT) for health” [10], and ICTs have for some time been known to contribute to environmental impact [11,12]. Ergo, e-Health, including telemedicine, has environmental impact. This has been illustrated in the Environmental e-Health Impact Model [13], which shows impacts at all three life-cycle stages – upstream (resource depletion, manufacturing, and global product distribution), midstream (primarily electricity usage and ‘evergreening’ of equipment), and downstream (typically accumulation of ‘waste electronic and electrical equipment’ (WEEE), with zero, poor, or inappropriate attempts at re-use or recycling). The model also highlights the importance of life-cycle analysis to inform the cradle to grave assessment of net environmental impact, acknowledged by Salas et al. as a ‘critical knowledge gap’ [2].
The authors certainly applaud Salas et al. for reminding readers of the moral leadership role inherently held by those working within healthcare, something the authors have strived to do both formally and informally for over a decade [14, 15]. In contrast, the authors have concern about such statements by Bennett and Maraka as “… the pandemic has given us opportunities to reduce our carbon footprint, such as the rise of telemedicine, …” [1] and comments by Salas et al. that recommend telemedicine as a tool to reduce travel for patients and providers [2]. These impressions and suggestions are most likely predicated on publications that suggest reduced greenhouse gas emissions as a result of telemedicine [16-18]. However, in such papers there is no consideration of other issues of importance to a holistic lifecycle analysis. Although some impacts occur at all three life cycle stages, of particular note are water use (an increasingly scarce ‘commodity’) [19], environmental contamination during resource extraction [20], and the accumulation and toxic impact of WEEE at the end-of-life [21].
To this point the authors have found no published holistic life-cycle analysis of any formal e-Health implementation. As a consequence there is simply no evidence-base for assuming telemedicine, or any other aspect of e-health, will “… give[n] us opportunities to reduce our carbon footprint, …” [1]. Even though e-health proponents, the authors would encourage those with the required knowledge and skills to thoroughly and impartially research the net impact of e-health solutions over their entire life-cycle before we so easily embrace and promote telemedicine, or e-health, more broadly - let alone globally.
Given the above, a different closing perspective can be given in regard to telemedicine / e-health being perceived as environmentally appropriate. This is a time of growing pressure by patients, professionals, policy-makers, and partners alike on our single global environment and on our multiple healthcare systems worldwide. In consideration of adoption of e-health solutions, the healthcare profession must acknowledge and assume its leadership role, and re-embrace the seemingly forgotten principle of ‘sustainable development’ [22]. In the absence of evidence - pro or con - we must also reflect on the principle of primum non nocere and ensure the benefits of e-health outweigh the risks to the environment and patients globally [23].
Richard E. Scott 1,2 and Maurice Mars 1,3
1 Department of Telehealth, College of Health Sciences, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa; 2 Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; 3 College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia.
Authors’ contributions: RES and MM jointly contributed to the conception, writing, and revision of the response, and approved the final version submitted for publication.
References:
1. Bennett R, Maraka J. Healthcare should not cost us the Earth. bmj 2020;371:m4289.
2. Salas RN, Maibach E, Pencheon D, Watts N, Frumkin H. A pathway to net zero emissions for healthcare. bmj 2020;371:m3785.
3. Stokel-Walker C. Why telemedicine is here to stay. bmj 2020;371:m3603.
4. Bakken S. Telehealth: Simply a pandemic response or here to stay? JAMIA 2020:27(7):989–990.
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6. Latifi R, Doarn CR. Perspective on COVID-19: Finally, telemedicine at center stage. Telemed J E Health 2020;26(9):1106-1109.
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10. World Health Organization. eHealth at WHO. 2020. https://www.who.int/ehealth/about/en/ (accessed 17 Dec 2020).
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14. Scott RE, Saunders C, Hebert M. Environmental eHealth: A social responsibility for ehealth proponents. Glob Telemed eHealth Updates 2009;2:94-98.
15. Mauco KL, Scott R, Mars M. e-Waste management as an indicator of e-health readiness - an overview of the Botswana landscape. 2016. http://dx.doi.org/10.2316/P.2016.837-004 (accessed 28 Dec 2020).
16. Whetten J, Montoya J, Yonas H. ACCESS to better health and clear skies: Telemedicine and greenhouse gas reduction. Telemed J E Health 2019;25(10):960-5.
17. Paquette S, Lin JC. Outpatient telemedicine program in vascular surgery reduces patient travel time, cost, and environmental pollutant emissions. Ann Vasc Surg 2019;59:167-72.
18. Vidal-Alaball J, Franch-Parella J, Lopez Seguí F, et al. Impact of a telemedicine program on the reduction in the emission of atmospheric pollutants and journeys by road. Int J Environ Res Public Health 2019;16(22):4366.
19. Woods L. Mining threatens Mongolia’s fragile environmental balance. 2016. https://chinadialogue.net/en/pollution/8849-mining-threatens-mongolia-s-... (accessed 22 Dec 2020).
20. Spitz K, Trudinger J. Mining and the Environment - From Ore to Metal, 2nd Ed. CRC Press. 2019.
21. Forti V, Baldé CP, Kuehr R, et al. The Global e-Waste Monitor 2020: Quantities, flows and the circular economy potential. United Nations University (UNU)/United Nations Institute for Training and Research (UNITAR) – co-hosted SCYCLE Programme, International Telecommunication Union (ITU) & International Solid Waste Association (ISWA), Bonn/Geneva/Rotterdam. 2020.
22. World Commission on Environment and Development. Our Common Future. Oxford: Oxford University Press. 1987.
23. LeCroy K. The lie of Primum Non Nocere. Am Fam Physician 2001 Dec 15;64(12):1942..
Competing interests: No competing interests