Orthopaedics Online
10 Nov 2023

Climate crisis and the damage to healthcare

By Jessica Lamba, Gareth Chanb and James Gibbsc

aMedical Student, Brighton and Sussex Medical School
bST7 in Trauma & Orthopaedics, East Sussex Healthcare NHS Trust
cConsultant Orthopaedic Surgeon, University Hospitals Sussex NHS Foundation Trust

COVID-19 has implemented a severe encumbrance on the National Health Service (NHS) and the resources within it. Adjacent to the economic and social complications lies the climate change issue, our current environmental crisis. Climate change was declared this century’s greatest threat to public health and is essential that it is tackled imminently1.  The reduction of carbon emissions was lower than envisaged by the UN Environment program 2019 and remains largely unabated2 . Collectively, it further enforces this paradoxical relationship between climate change and public health, whereby health care services are a glaring contribution to environmental pollution3.

Nationally the NHS is responsible for 4-5%, around 25 megatonnes, of the carbon emissions, which is the equivalent to Croatia’s total annual emissions4,5 and 25% of public sector emissions6. The World Health Organisation (WHO), predicted there were 250,000 deaths per anum due to climate change and eight million fatalities because of air pollution6,7. Alongside the risk to the health of current and future populations, health systems are afflicted by the risk of supply-chain disruption, resource scarcity and infrastructure damage, which feeds into this adverse feedback loop, whereby the health sector is both perpetrator and victim of climate change3,8. While the ultimate objective is patient care and safety, planet health is equally important and plays a colossal part in the deterioration of public health. 

Why are we looking at orthopaedic surgery? 

Surgical specialties are a resource-intensive subsector of the healthcare system. Surgical specialties collectively attribute to a large proportion of the carbon emissions and 20-33% of total hospital waste within the NHS9,10-13. Within this, trauma and orthopedics make up 33% of the surgical workforce and contribute to 25% of all surgical interventions14. With an aging population and an increase in orthopedic referrals from primary care, demand for these services is expected to increase by 7-8% per anum14. There is minimal evidence surrounding the principles of sustainability and the benefits associated with orthopaedic surgery15. It was calculated that the climate impact from one operation ranged from 146-232kg CO2 per operation3. This probes the discussion whether detrimental elements can be reduced and/or or avoided and if the issue lies within the system, the individual surgeons, or the practice of surgery itself.  

What is a life cycle analysis? 

A life cycle analysis (LCA) is a calculation used to facilitate the quantification of material and energy inputs and outputs in one cycle within a defined system3. LCA is split into four phases, the first phase outlining study objectives and scope. This study aimed to quantify the sustainable impact of two materials used in wound closure.  

A functional unit is needed in an LCA study as a basis of comparison which is necessary to assess different products that carry out the same function3,17. The functional unit of this project was one Caprosyn packet versus one Vistat orthopaedic clip device, which contains 35 clips.  

The scope of a LCA is set by defining system boundaries, data categories and explicitly listing the processes, inputs and outputs included in the calculation3,17. The scope in this project was to determine which choice of wound closure is more sustainable by focusing the boundaries on a cradle-to-grave method. This looks at raw material extraction, production, transportation, use and disposal. The outputs associated with this focuses on carbon dioxide emissions associated with the relevant processes. There is also the option to conduct a cradle-to-cradle method which refers to products that are reused. The total amount of carbon emissions across the product’s 'life' is calculated and divided by the number of times it is utilised17.

The second phase, life cycle inventory analysis (LCIA), compiles and quantifies the inputs and outputs of each process in production. It is complex and usually relies on the employment of established LCA data sets which contain granular and region-specific data. The quantitative and qualitative results focus on the impacts that the products can specifically have on the environment, such as air pollution and fossil fuels. This helps to measure how the product specifically impacts the environment3,17.

Conclusion 

The main results of the study confirmed the initial hypothesis made and showed that Caprosyn is less harmful to the environment by a significant amount. Both the production and end-of-life phase contribute to this result, as Vistat is substantially heavier and hence requires more raw materials and a greater mass is incinerated. Equally, there is a smaller proportion of plastic in Caprosyn. Plastic was found to be more damaging to the environment in terms of production and incineration and hence contributed significantly to the LCA of Vistat.  

The lack of specificity was one of the key limitations associated with this study.  This is partially due to medical products involving proprietary materials, such as polyglytone in Caprosyn. The lack of transparency amongst producers makes this hindrance more difficult to overcome. Additionally, there is a lack of data on the databases available specific to medical technology. 

The results from this study have added a new element in the sutures versus staples debate17,18. It is a small change that every surgeon can make without compromising the quality of care, a decision that could potentially have great impact.  

References
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