Intended for healthcare professionals

Rapid response to:

Letters Covid-19 and net zero for health

Healthcare should not cost us the Earth

BMJ 2020; 371 doi: (Published 06 November 2020) Cite this as: BMJ 2020;371:m4289

Rapid Response:

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.

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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.
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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.
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Competing interests: No competing interests

13 January 2021
Richard E Scott
Maurice Mars, Department of Telehealth, College of Health Sciences, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa; College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia.
Department of Telehealth, College of Health Sciences, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
Department of Community Health Sciences, 3330 Hospital Dr NW, Calgary, AB T2N 4N1