Spotlight on Health & Climate Change: Decarbonising healthcare

Dr Forbes McGain and Dr Cristina Richie join Lancet editors Chloe Wilson and John Carson to discuss the whys, the hows, and the ethics of decarbonising global healthcare.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Chloe: Hello and welcome to this third in a series of special podcasts on health and climate change, commissioned as part of the Lancet's 200th anniversary year celebrations. I'm Chloe Wilson, a senior editor at the Lancet, and I'm delighted to be joined by my co host John Carthen. 

John: I'm John Carson, a senior editor at The Lancet Planetary 

Chloe: Health, and I'm also delighted to be joined by our guests, Christina Ritchie and Forbes McGain to talk about decarbonising healthcare.

So over to you, Forbes, would you mind introducing yourself? 

Forbes: G'day everyone. My name's Forbes McGain from Melbourne, Australia. I'm an anesthetist and intensive care physician at Western Health and also have a role as the Associate Dean of Sustainable Healthcare at the University of Melbourne. 

Chloe: That's great.

And then over to you, Christina, if you wouldn't mind introducing yourself. 

Cristina: Hi, I'm Dr. Christina Ritchie. I'm a lecturer in the ethics of technology at the Edinburgh's Future Institute, Centre for Technomoral Futures, University of Edinburgh, and my research is dedicated to clean, just and ethical healthcare and technologies through the development of strategies and policies.

Chloe: Lovely. Thanks very much. And so a question to both of you and maybe if we just start with Forbes again why did you get into researching in this topic? How did you get into it? 

Forbes: Yeah, that's a really interesting question. I think that a lot of it stems from, my values and my interests from early days living on a farm in Northern New South Wales and Australia, having a platypus or swing in the creek and eels and fish and.

I think it's a love of nature from a very early age. And I realized I probably was going to probably going to lose my medical profession if I was going to get chained to trees and stopping bulldozers from ripping them down. So instead, I ended up, realizing that I was able to influence, all the waste and unnecessary things we do in medicine, in particular, if I'm within the system.

Working for change and trying to look at our carbon footprint, our waste water, et cetera. So yeah, that's really where it all began and is where I've ended up. And along the way, there's been a PhD out of the University of Melbourne in sustainability. And it's been a lot of fun and it's a great lot of work we did with lots of people.

Chloe: Great. Thank you. And same for you, Christina. How did you get into researching in this topic? 

Cristina: My early career was characterized by an emphasis on sexual and reproductive ethics, because from an early development in my university career as a philosopher and ethicist, I became very concerned about population growth, which quickly became an question of carbonation growth, because it's not just a numeric developing world problem.

It's really the lower rates of birth in the industrialized world that are causing the most carbon emissions. And therefore that can do the most to reduce carbon emissions by not reproducing biologically. That quickly led into more environmental sustainability and biomedical ethics work on reproductive technologies, because obviously that's an additional medical carbon footprint.

In addition to. The resource use and population growth of reproduction. And now my work has pivoted and focused on our approaches and expectations towards health care and technology as an outgrowth of this concern for planetary health and sustainability that affects everyone. 

John: So if we could start off with introducing the topic a bit, I'll start with Forbes again and we can switch it around later on.

When it comes to climate change mitigation, a lot of people are familiar with the need to. decarbonize the energy sector, the transport sector, things like that. But why should we be looking to decarbonize healthcare globally? 

Forbes: Thanks, John. There's been over the last decade a number of studies firstly, beginning with work that Jody Sherman and Matt Hegelman did in the US showing that healthcare is about 10%.

of the US's total carbon emissions, which is in effect all more than all of the UK's entire carbon emissions of the whole nation. We've done some work in Australia as well saying somewhat similar numbers and worldwide is around 5 percent of the total carbon emissions of the world. So it is important.

It's up there, uh, as an important economic sector. That's the first part. I think the second part is that it's more about values and morals and things like that are really important. It's first, doing no harm. I think that we, we all know climate change is here and it's getting worse and to continue to contribute to climate change by all the things we do in healthcare is problematic and we should be trying to reduce that whilst providing excellent patient care.

I think there are, for me, there are two major factors that are playing into why healthcare needs to lead in this area, because we commit, because we omit and commit and because we should be doing no harm and leading the way towards a lower carbon world. 

John: We've seen if you've got any thoughts on the imperative rationale for decarbonizing healthcare.

Cristina: Yeah. I just want to echo Forbes's statement in that healthcare is caught in a missional contradiction. The mission is to make people healthy and well, but through the release of carbon emissions, it contributes to climate change health hazards, which are detrimental to health. Of course, treating those climate change health hazards requires more carbon.

So healthcare is in a, cycle. Moreover, healthcare carbon doesn't just stay within national borders. It gets exported worldwide. So this is a matter of global justice in that healthcare carbon in the industrialized world goes to those who are already medically underserved, making their health issues worse.

And so healthcare has both the specific obligation as part of its missional identity. And the more global imperative to remedy healthcare disparities and really ensure that everyone has a good quality of medical life. 

Chloe: Yeah, absolutely. And progress you think that we've made towards decarbonizing healthcare systems so far?

Are there any very good examples of systems that are doing a good job? I think, we've heard a lot about what the NHS has been doing and to decarbonize healthcare, but are there any other healthcare systems that, that we've perhaps heard a bit less about? 

Cristina: Yes, there's two, at least when I was in the Netherlands at the Delft University of Technology, some of the work that was being done was on the Dutch green health deal.

And so NHS, of course, has a commitment to zero carbon, net zero carbon, and they have legally binding carbon reduction measures as part of the Climate Change Act of 2008. So while they have taken a more institutionalized national approach, the Dutch green healthcare deal is a voluntary. Initiative where organizations, pharmaceutical companies, hospitals and health care organizations can sign on and commit either to decarbonization or sustainability initiatives.

In addition, at the University of Bergen, they're working at Sustainability pathway for the Norway healthcare system. So there are examples on the national level in addition to a variety of more local sustainability initiatives that you'll see throughout the U. S., I'm sure Australia, and in the U. K. 

Forbes: Yeah, I think there's I think that concept of the micro, meso, and macro is pretty useful as well, just keeping it, you're right, the NHS is, I think, leading the way, as from a national perspective having reduced their carbon footprint by more than 20 percent over the last decade, through the leadership of David Pynchon and those nationalists, and now Nick Watts and the breeding healthcare team, fantastic work from them really good.

work at the meso level perhaps groups like Kaiser Permanente in the US and other groups in other parts of the world. And then there's also a lot of small fry, you could say, activity going on amongst doctors and nurses and, other clinicians trying to make a difference, general practitioners with their own work groups like Doctors for the Environment in Australia many other groups around the world doing similar things, Global Green and Healthy Hospitals, for example.

So lots of different levels. of activity occurring at national sort of macro, meso, and then micro level. Maybe just give an example. So within our own hospital, and this shows you, the different levels of levers that you're able to change things at the sort of like meso level, you'd say, and from my hospital, for example, at Western Health of Melbourne, we were able to, with the board of the hospital, plus the CEO and others, very supportive of moving towards the first.

fully electric and fully 100 percent renewable electricity, no gas anymore for heating, a new hospital. We're able to get there, get it over the line, have the state government sign off as the first hospital in Victoria, Australia to have that. So that sort of thing is exciting. That's happening in other parts of the world as well.

And it's to, it's really, I think, amongst my sort of senior nursing and medical colleagues, that's been very exciting to see, yes, you can have a real effect here by working as a team and involving the board and the CEO, et cetera to change it as well as, there are other examples of my personal things as well.

John: Picking up on the idea of. So healthcare systems addressing decarbonisation at different levels, at the system level, at the hospital level, what are the types of mechanisms that can be used to decarbonise healthcare? Christina, if I could ask you first, please. 

Cristina: Sure, so again, reiterating this idea of subsidiarity or working where you're at to affect change.

I believe it's the responsibility of everyone involved in healthcare to, to decarbonize and make things more sustainable. So for individuals, that would mean considering if your healthcare is medically necessary, if you can opt out of it, if there's alternatives, just asking your doctor. Is there something else that I can do?

What's the carbon of this? Because then that will alert the doctor that's your patient preference. And then they will start to think they need to know more about sustainability. Doctors can ask patients about their preferences around sustainability and follow the minimum guidelines. of health, safety, and PPE, for instance, which sometimes they over perform in an effort to make it look like they're being more, sanitary, but it's unnecessary from an institutional perspective.

So looking at that. Administrators can link cost containment and cost effectiveness with carbon. So there's been some great work on how much can a ton of carbon buy by Bhopal and Norheim and the BMJ. And really looking at what is the greatest clinical benefit. Versus the carbon impact of medical procedures, but more than that, we don't want to focus too much on carbon numbers because it's morally reductionistic and because we're already over carbonated as a planet.

So it's not the case that we just need to reduce emissions. They should have been reduced a long time ago. We're over the 350 parts per million of safe carbon in the atmosphere. So I think essentially what we need is what the Greeks would call a metanoia, which is a turning around of our. What we really think that health care can do for us, but moreover, where we as a society want to expend our carbon.

It's probably going to be in health care and other important things that we need to ask. What are we willing to give up in order to meet carbon targets, ensure distributed health care justice and minimize climate change health hazards? 

Forbes: Thanks, Christina. I was thinking it's one of the terminology there, is really interesting in addition to the Greek would be about the whole low value and perhaps no value care that we know as clinicians happens often, you consider the unnecessary topology or radiology testing, for example.

There are many examples of those where They're well known, but they still happen. I think they're very good examples of where we need to work with the concept of, choosing wisely, internationally, et cetera to work with societies and colleges medical, nursing, and otherwise to reduce that unnecessary low value care.

So I think it's another arm of, as well as financial, and not been, not of benefit to the patient. patient is to introduce that environmental story. I think that's beginning to happen. I think the other area where the, Decarbonization is important is thinking about the actual, research base of a lot of our our knowledge is not really there yet.

It's not really that mature. It's there for hot spots, about carbon, footprint of anesthetics and, in inhalers, for example. But for some other things like a surgeon, knowing which type of operation or that, or whether the operation should be done at all and all those sorts of things, there's a lot still to be done.

And so that's quite exciting. There's a little bit of a it's not quite a carte blanche, but it's getting a bit beyond that now, but it's still a lot of work to do at the basic science level, which is quite exciting. 

John: Picking up on that, would you say that what's been tackled so far has been maybe some of the low hanging fruit?

within the resource use of healthcare systems and there are more complex and 

Forbes: difficult things to think about going forward. Yeah, I think that's something, having discussions with Nick Watts, the head of the Green Healthcare, and now Chris Cornley as well, UK there are certain things that are relatively easy to approach.

For example, improving the energy efficiency of hospitals. And those sorts of things, reducing the use of certain anesthetic gases or inhalers, for example, they're relatively easy things. to do, it's, it becomes harder as we move into the field of what is low value care, for example. And what amount of care, what amount of treatment is going to be suitable.

And as Christina was alluding to, not just for developed nations, high income nations, but also low and middle income nations as well, where they're all contraction and convergence. 

Cristina: Precisely. Exactly. So far a lot of what has. What's been done to decarbonize has been at the structural level.

So essentially if you were a cafe or a university or a hospital, you would look at things like water pathways, the food served, the types of energy being sourced, but not only is that a reaction to the climate issue, it also doesn't really get at the crux of healthcare and biomedical ethics, which is the patient physician relationship.

So I indicated this in my first monograph on principles of green bioethics. that we need to look at health care delivery. And this is the low value care, the low cost care, high value care that's being discussed here. So that's going to be more difficult because it does get into the personal and people are connected to their health care and wellbeing.

Of course they are. But this is what really needs to happen because it's the health care delivery, the pharmaceuticals, the hospital and clinical care that is, It has the largest carbon footprint within healthcare sector carbon emissions. It's not the buildings themselves. 

Chloe: Do you think these issues are something that, that healthcare workers, that patients are thinking about on a daily basis?

Do you think it's something that is very widely recognized in healthcare globally? Because I suppose there's this argument of, who's, Whose role is it to implement these strategies? Should it, is it everybody's role? 

Forbes: I would argue that it's, yeah, it's everybody's role. But I think there's different levels at which people are able to pull the levers.

And I mentioned those micro, meso and macro approaches. And that's why I think it's exciting, for example, what the UK is doing at the high level of a national approach as opposed to little lighthouses here and there of, having a national approach, I think it really does systematize it better.

However, when you're out, we are able to, the micro and the meso is where you've got to aim for, because that's all you have the ability to pull levers upon. I can't influence federal governments to change necessarily what they're doing, but certainly, I think that at many levels we can all be acting upon it.

And I think there is an improving and increasing amount of interest in this field, not just in oh, the rubbish we create in the intensive care unit, for example, well beyond that, I think now staff are beginning to be. At least in hospitals and members I hear about are aware of it. I think at the patient level, it's an interesting one and I think it's an area that really needs to be explored much further and I'd be very excited by that.

I realized perhaps where I work in intensive care more than anything it's not at front of mind for patients or when you come into operating theater, but I do realize that there are other opportunities that could be available where I think patients could be very much involved. And so that's great to, to consider where that's going to lead.

Cristina: It really depends. Some people are thinking about it a lot and some are not, but I know from teaching medical students and pharmacy students back in the United States, that they were incredibly concerned about particularly what was visible, which was the waste that they were producing and the amount of trash that they saw and maybe unnecessary.

Disposal of tools that could have been repurposed or that weren't used. And so the medical students across the U. S. and in the U. K., even with the General Medical Council's recommendation that physicians need to be aware of climate change, they want to know what they can do. There's also, pockets of patients that are concerned that ask about healthcare impact.

And of course there's physicians that, they, after medical school, they get trained and they see this. I think a lot of. Then they'll feel that there's nothing that they can do about it and it's frustrating and they experience distress over the amount of waste. So really institutional supports are required and a sense of solidarity working towards more sustainable health care on all levels I think will facilitate not only the goodwill that's needed to do something so morally imperative, but also the practical actions that will make it possible.

Chloe: Do you think there are any particular strategies that we can employ to help patients take a more active role if they wanted to, and same with with medical students or clinicians, if people are interested in this and want to get more involved, what are some of the strategies that are, that could be put in place potentially?

Forbes: I'll maybe talk about staff, perhaps first, medical students and nurses and etc, I think education is incredibly important, but it's, education is just the beginning of the story because There has to be an ability to change things after that education alone doesn't change the universe. So I think that, that part and practical outcomes are really exciting.

And just a little example is some of the nursing staff came to me recently in Melbourne and we're talking about, reusable gowns instead of disposable ones, and we were going through more than a million disposable gowns a year. In PPE gowns during COVID 19, we switched over to reusable gowns and we could talk about, that.

positives and negatives of that, but essentially the main positives are it actually reduces the amount of carbon, even if you're washing it. It actually financially was saving as well. The, that story is really powerful because everyone, that was just initially the intensive care, but then everyone wanted it.

So the whole hospital went. And that's really exciting to see it's word of mouth, like they were talking about it, not really involving me at all all the intensive care so much, but other people then wanting to get on board and change as well. And medical students hearing about it, nurses and then other hospitals doing it.

It just ballooned and it's really exciting to see that sort of change happening. So this sort of, this tipping points, whether it be social tipping points or environmental tipping points they, things don't change for a long time, then suddenly they do change and it's not a linear relationship at all, sadly, a bit like climate change itself.

But so I think that's the sort of thing I'm really excited about, is that suddenly things can change when you don't expect it. And I think that at the level of the working with patients. I think that we're just beginning that story. I think that's one that needs to be picked up upon.

I, I hope to encourage others to, to do that as we go along. 

Cristina: And with the change, absolutely no change can happen unless there's options for more sustainable healthcare. So if a patient comes in and says, is this medically necessary? That's one issue, but is there a more sustainable alternative? We don't have information on that.

So there's not so much that patients can do other than opt out of medically unnecessary care, which they absolutely can do. Make sure their advanced directives are up to date so they're not receiving futile end of life care. And just start asking the physicians about it if it is a concern. On the institutional side, there's some simple things, just divesting from fossil fuels would be incredibly helpful, but also again, looking at Are we marketing health care as a service or is it something that is to support basic human life?

And a lot of times the elective, the unnecessary, the redundant, the lifestyle treatments are what's contributing to carbon. So this means that there needs to be, I think, more tenacity on the part of physicians to just say, it's not medically indicated. There's no clinical reason for this procedure and stick within biomedical ethics.

So I think it's really important to frame it as we're not doing this because the carbon cost is too high. It's not a green death panel, not going to refuse you cancer care because the carbon treatment rather, it's not within the scope of professionalism to provide low impact service that might not have any clinical benefit.

And it would be unjust. to give you a treatment that would be minimally beneficial and might harm you because anytime you go into the clinic or the hospital, there's risk of infection and further medical sequela, injury and death. So this needs to be considered too. 

Forbes: Christina, that's a very good point and one that I work in intensive care that I deal with almost on a daily basis and you see very strong differences amongst different countries.

And how that occurs is quite extraordinary, the level of 

John: that. But the individual healthcare workers clinicians, nurses, other practitioners, does that often do you feel prison practical, ethical difficulties, stress, if they feel like they have to enact some kind of just general target? To reduce consumption of resources or does the change have to come from, a higher up level about procurement, about changing practices and suggested best practice on a systems level.

Cristina: I'd say it's both and it's bi directional and I'm not a medical doctor, but I do often get asked to be the resident ethicist on hospital teams that are looking at becoming more green. For instance, in Lothian Healthcare in the UK, Or, in some places in the U. S. Also, University of Amsterdam, and what those people have done is there's been physicians or clinicians that say, we want to make things more green, so we're going to track the emissions, track the waste, and bring this data to the administrators and say, look, we didn't reduce the patient benefit at all, but we did reduce our waste.

And this is something that can be implemented as a template elsewhere. At the same time, the institutional support needs to be there so that the clinicians are supported when they make good medical decisions that are more sustainable. And so it's seen all as fitting together between professionalism, cost, sustainability, and justice for the patients and their medical needs.

Forbes: The other point I'd stress again is the whole concept of low value care and no value or negative care. They're really important. By definition, those. That medical treatment is ineffective and avoiding that is a good thing. And it's not really from the point of view of an environmental benefit, it's actually for the benefit of the patient first and foremost, but also the benefit of society financially and then environmentally, et cetera.

So I think that I think that's, a, that, that is not a difficult ethical problem, that's not a very ethical problem at all. It's an ethical problem exactly when we think about all the waste that we're creating, and waste financially and resource wise to do unnecessary things. So really in many cases, in fact, virtually all cases, sustainability will lead to, is ethically appropriate.

So I don't think. I don't see that as being a major problem. I see other problems or reasons why sustainability is not occurring and part of that is apathy or perhaps also an upfront cost of having a more sustainable hospital. For example, as I mentioned, a 100 percent electric hospital, no gas, et cetera.

So those factors often come into play are more problematic. 

John: So in that sense, do you see perhaps addressing this, the determinants of health issues? Social economic determinants as health that is part of reducing the resource intensity of healthcare overall. No, absolutely. 

Forbes: Yeah, there's no, no arguments there.

Yeah, I think that all of those factors of, turning health, the whole concept of what health is is of incredible importance. I I think that primary health care, if you want to call it preventive health care, I know there's debates about turn preventive now but that sort of concept of keeping people healthy rather than treating the unwell.

And every in, in a way of thinking about it is that every time a person comes in hospital, that's a failure of the system. Because it means that person, for whatever reason, has become ill, potentially for a preventable disease. 

Cristina: We absolutely need to address the social determinants of health.

And global healthcare disparities. We also need to recognize that there will be an environmental trade off with that. So obviously if someone is not using the medical industry, it could be for a few reasons. It's because they're living and flourishing in a healthy, good life. Which is great. So there's no medical carbon footprint, but it could also be because they're excluded from the medical industry because of structural heterosexism, racism, ableism, etc.

And so they can't access it. So we want to be careful that as we reduce carbon that the disproportionately disadvantaged are not suffering most and that policies are not going to continue to exclude people. So let's assume those are in place and we have the good healthy people we've addressed better health, better planetary health for people, and there's lower medical carbon because that person is not in the healthcare industry.

The environmental trade off is that person is still on a globe that's over carbonated where we're over our, number of earths that we use per year. And so actually by them being alive, they are using more resources for housing, for food. They're still going to need end of life medical care, and they're still going to need any maintenance care.

This contradiction leads to obviously a dilemma of what's good for people to live longer, healthier lives may not be good for the planet, thus pointing to the fact that again, if we want these values. Good long healthy lives, which we absolutely do then we need to say We need global carbon reduction in areas that have less human value, less ethical value, for instance, perhaps fast fashion or fast food agricultural practices so that we can keep these things that are important and not get into the horrible trade offs between more healthy people or less people because they don't have medical care because we're an environmental liability.

Chloe: Thank you, Christina. And something that I wanted to ask about was the way that we weigh up the environmental costs of a treatment. So we discussed about it a little bit. Already, but in terms of the way that healthcare systems work, obviously cost is a very is an aspect that has to be considered near the UK has the National Institute of Clinical Excellence and other countries have their systems that the recommended treatment you know, and cost is a large aspect of that.

Do we think that that we should be weighing up environmental costs as aspects of treatment as well? 

Forbes: Yes, I think there's a lot of debate occurring right now in that area and we've seen articles. Coming out about, the quality improvement or the assurance, for example, having markers of sustainability, whether it's a, and look, carbon dioxide is a very blunt instrument that, having a carbon emissions profile of an operation, for example, or treatment, I think those sorts of things are coming.

And that's quite exciting to to start to build into the story of not just an issue about financial cost but also environmental. So I think that's beginning. I think there's still a bit of way to go before that gets nutted out as to exactly what is used for that. But I do think it's got a real role in sending a signal to all of us.

Both the the patient, as well as the broader society, government, and doctors and nurses, for example in allowing us to go, okay how can we do it differently? Is it possible to do this differently? Maybe it isn't but also then starts to bring in the story of further education and what we could do to change the way this operation was being done.

Why was it done in the first place? How many days of intensive care they had? What does a general practitioner think of this treatment with, I don't know, steroids versus another medication, for example? I think it's really exciting what could come out of this. But there's a fair amount, a fair body of work to be done there.

Cristina: We absolutely need to look at carbon in addition to cost. And I don't think that saying something is too carbon intensive is any, More morally distasteful than saying it's too expensive either way patients are not going to want to hear that but there's so many issues with the carbon calculations and that it Depends on the country you're in and that it would take a really long time to do all of this carbon emission Calculations, so that's why I rely more on a principle approach or a common sense approach to health care carbon reduction or just health care Sustainability and saying we need to Be Discerning between what's medically necessary and what's not what's a simple treatment and what's a higher level treatment if there's global access to these kinds of things and really think about what is the impact of high tech healthcare?

What is the impact of elective treatments that are maybe our standard of living, such as a shoulder joint replacement, so you can play golf, not because you're in severe pain. These things that. Okay. The industrialized world, we already have many of us a very high quality of medical life while others don't and it's a zero sum game with carbon soon to think about reallocating healthcare, carbon and resources without necessarily attaching the carbon metric to it because people are suffering right like regardless of the environmental.

Issue, people are suffering right now with less access to health care worldwide. And that needs to be remedied without ballooning the medical industry resource use. So that means reallocation needs to occur. 

Forbes: Thank goodness. I'm not a golfer. Christina. So you really good point, a really good point about that, that's, that touches on a lot of issues about ethics and values and oh, I want this sorry, you can't have it and all those sorts of things.

I think it's fascinating what we, what you just introduced there. I will say that I think that there are and I think thinking that just what you're just saying it, when we reduce reuse, And then recycle, that's not so important really. I think the avoid and reducing is fairly self evident.

I think where it becomes a bit trickier is things like what we still need to work out is, for example, telehealth. Intuitively it just seems to make sense that everyone, telehealth, great, driving as much, etc. But then you've got to think okay, if we miss only just a couple of people who've got diabetes and they, Come to harm as a result of that.

How are we working through that? We're just going to be really careful in how we do this really well with telehealth as an example, or introducing some new electronic medical record. I think there's a lot of nuance and that's okay because we're introducing something new. We just need to be studying it carefully.

So a lot of exciting things ahead. 

Cristina: And actually reduce, reuse, recycle is so important because A lot of what gets done outside of healthcare or even in healthcare is the recycling, but that was meant to be the very last step. The very first priority was meant to be reduced. So reduce the amount, reduce the kind, reduce the number, and again, you can do that in ethical or unethical ways.

It's unethical to exclude people or to deny medically indicated care, but it is ethical to say at this time of environmental crisis, we need to maybe back away from treatments that are medically redundant or only suit a lifestyle project like gestational surrogacy because you don't need to be pregnant or make pregnant too.

have a medical quality of life. And in fact, pregnancy can make you cause maternal mortality and morbidity. So these are decisions that people want to hold onto their healthcare here, even if it's not really healthcare, even if it's just medical technologies. So balancing this while also saying, for instance, in telehealth, there may be exceptions where people would be encouraged to come in or would be encouraged to use telehealth that needs to be considered, as well as emphasizing.

The effects of choosing any medical care, which will always include increased risk of climate change health hazards. So part of what I've written about on greed informed consent will say if someone does, if they can't prevent a healthcare issue and they do need medically indicated care, one of the things that doctors could do is ask just Are you aware that after this treatment, you might be more at risk for climate change, health hazards, because we know that this will release carbon.

And in this way, the physician patient relationship expands, not just to the immediate clinical need in front of them, but also what happens to their patient outside of the clinic. And you don't want to endanger patients in any way. So they need to be aware of this, too, that there is this trade off anytime we use anything, and really, again, valuing what's important to us now, and highlighting those preferences within a just and ethical system that includes everyone in the planet.

John: I think you've both touched upon here, this idea of over medicalization within high income countries. Do you think that some of the trends in healthcare research, things like individualized medicine, big data, the inclusion of AI possibly to, produce ever smarter, ever more personalized treatments, potentially runs counter to the ambition of making healthcare more sustainable.

Because when I hear some of those ideas, I tend to think actually, storing a lot of data and running an AI is actually very energy and resource intensive. 

Forbes: Yeah. Great question. I suppose my answer is, I don't know. I don't know anyone does yet but potentially this could be just another, yeah, very large, not just in terms of data stories and things like that, but also blood tests and everything else that everyone's going to have and ongoing visitations and therapies and MRIs or goodness knows what it will lead on to after that.

So it's that concept of is there going to be a lot more low value clear or low value screening, for example, that comes out of this? It's a tricky one that I think we should at least be cognizant of as we roll along here. 

Cristina: The data, like John said, is absolutely there. That AI and technology is incredibly carbon intensive, training new algorithms, the amount of.

trace minerals, the energy for storage, we're running these processes are huge. And that's really a concern in the ethics of technology, which is also where I'm working. But there have also been advances medically because of AI algorithms. And so we don't want to stymie progress. And it human innovation and ingenuity and the ability to cure diseases and make these technologies is one of the most incredible things that we have as humans, but they're not morally neutral.

There's trade offs and there's winners and there's losers and the concern. Not only is that the healthcare disparities will continue to grow as technology happens so quickly, but that all of the other issues in technology, the biases, the environmental impact will be replicated in healthcare, making healthcare systems worse for the already marginalized.

So it just needs to be very carefully considered. While also, again, focusing on what is really the good, basic, high quality care that's medically necessary, that's available to all people. 

Forbes: It's an interesting point, Christina, that, in a way, we're going through a bottleneck right now, where it'd be like, humanity coming through the out of Africa bottleneck and, we might get through this, or we may not, as civilization we've got some big trouble here.

And so really what we're doing right now at the moment is allowing maybe some time for human ingenuity, but also how the way we behave as a civilization, how the way we interact with each other as people we're buying at a time, perhaps until, there could be a huge flourishing. I don't know.

Imagine a machine that, picks up whether you've got any disease and no, you're not going to have anything for the next 10 years. Great. That would be wonderful. And then you don't need any more tests or anything like that. But then, that's all pie in the sky at the moment. But in a way, what we're doing right now, what I think my role is just being part of a system trying to buy this time to allow us to get to that next stage of flourishing.

Because I really do care about us as a species and us as a civilization, but if we don't care enough, it ain't gonna happen. 

Cristina: I'm wary of appealing to the future because we're not actually flourishing in a degraded society that is incurring loss of biodiversity with global droughts and heat waves and systemic justice.

So I don't think that hoping that technology will fix anything, and I don't think that's what you're suggesting, but as is Society does need to have a drastic change for everyone and the people that are most affected Usually don't have the power the people in the developing world So this has to be pressure on the countries that are the biggest polluters the u.

s and china Who also have the biggest health care carbon footprints and we need to Like maybe you and I are not affected, but other people are. And so this needs to be done like today. It should have been done years ago because really we can't flourish just with a good body and a good mind. We only flourish when we're in a healthy ecosystem where the plants give us.

Good nutrients and the atmosphere is not toxic. And so we need to think more, I think, systems and our interconnection, not just that we are dominating nature, but we are part of nature and thinking about the interplay on us and how we then impact nature through our healthcare, our technology, our consumeristic practices.

Forbes: Couldn't 

John: agree more, Christina. I think you both picked up on this idea that. Making more sustainable healthcare systems is about, to a large part, health justice. Do you think that greening healthcare systems is a way to get towards universal healthcare or can be part of that process? 

Cristina: It could be in two ways.

First, by just reducing the carbon emissions of the healthcare industry and therefore tackling climate change health hazards. That would be one way where it could be close to universal healthcare. But unless there's some international agreements and reallocation of healthcare carbon, healthcare resources, skills, personnel, and intellectual developments on a global level, there won't be much more we can do about that.

I would like to see more collaboration and solidarity between countries without being colonialist. Really looking at things like Doctors Without Borders or locally in the U. S. Planned Parenthood, these things that provide basic medical care that prevent disease and death and tend to be lower carbon as well.

Forbes: Yeah, look I think that they're big societal issues. I think they're really important. I can see a lot of vested interests who would not be happy at all with those sort of conditions. And I can see enormous variation in different healthcare systems that, are there for whatever historical and vested reasons.

That, that are going to be quite intransigent and difficult to change, but yes, part of the system of changing. And look, John, I think that moving forward. As I've said, to a more of a system where just keeping, importantly keeping people healthy, keeping out of people, out of hospitals and keeping the broader society as well as broader nature is incredibly important.

It's quite, there's this huge, we've now got more than 8 billion people on the planet and 95 percent of the mass of everything more than a rat is us plus our domestic animals. It's quite daunting to think of the efforts that we've gotta do to keep nature safe and flourishing along with our civilization.

Yeah, there's there's a lot of work ahead 

Cristina: and as I've brought up the population slash resource issue a number of times, I just wanna point to some ethical ways to reduce the amount of people on the earth. That have double dividends that have been promoted by others for instance in the lancet Just making sure that birth control is universal.

It's widely available And that people can access it the un sustainable development goals do indicate that educating women mitigates sexism, but also reduces the amount of children that a woman will bear. So it's good to have women that are educated, who can participate in democracy, economic structures, and have more say in the household.

Making sure that abortion is safe, legal, and rare. When it has to happen, and also just making sure that sexism is reduced wherever possible, that there's options for paternity leave, that women are given the contraception of their choice, whether they're child free and they want contraceptive sterilization, because that's a legal safe.

and good choice for many people. And so there's a lot of ways that we can reduce population growth, therefore work on the carbon emissions and the number of people on the planet in ways that have been widely identified as just an ethical without getting into forced policies that would violate women's or men's autonomy.

John: Would you also say that overconsumption is perhaps the larger part of our problem rather than overpopulation? 

Cristina: It's overcarbonation. So again, it's one child in the developed world can be as carbon impactful as 20 children in China, for instance. This is evidence that came out of 2009. So the next time you're out and you see a family of two.

In europe or america think instead they have a family of 40 because that's the carbon impact not fair to pin it on people in the developing world who have Much lower quality of life who are not over consuming the over consumption. It's not as Flamboyant as flying by a jet. It's just the way we live every day in high income countries That's so carbon intensive So that's really, I don't think so much about overpopulation, although that matters.

I think of overcarbonation, which is the fault of people in the industrialized world. 

Chloe: Thank you so much both. We've had some really great discussions. So coming up for our last question and perhaps a difficult one to fit into a summary, but in, in your opinion, what do you think Needs to happen now.

What are the most important next steps for towards decarbonizing healthcare? 

Cristina: Individuals need to opt out of optional care. They should get angry about the status of climate change and just refuse, an option of refusal. That's always a way to ensure autonomy and to take control over your medical life.

Doctors can ask about patient preferences and if they are concerned about sustainability. We don't want to proselytize necessarily or impose values of our own on others. So just a question, are you concerned about the environmental impact of this procedure? Would you like to see something different?

Governments need to divest through fossil fuels,

And collaboration needs to happen on a global level so that we don't just see our own needs, but we see how we're interconnected to others and how my neighbor's quality of life impacts mine, because we're all on one shared planet going through this together. 

Forbes: Yeah, I think it's everything by everyone all at once.

So I think that once again at the level of the micro level, I think that hope springs eternal. I think that is really important that we need to get this right. It sounds like a story of doom and gloom but we really need, you need practical examples and I think that can happen at the micro level, you as a individual clinician changing what you're doing at work and at home.

And I think that at the level of groups, whether it's societies, colleges hospital level, there are all sorts of things you can be doing at that level, as well as, as I mentioned before, several societies who are trying to make a good change. And then at the much higher level, Department of Health and the greater government leading, and I think the NHS UK is a good example of that of trying to systematize things.

I think also that education and further knowledge is still going to be really important here, as well as behavior change and other change, I think attitudes. I think that, further knowledge about what really is going on with a carbon footprint, for example, of healthcare is still just being sorted through gradually.

For example, we don't know, pharmaceuticals. We have no jolly idea of what's going on with, one drug versus a different drug and how it gets approached and whether it's used. Health technology assessment a good example of that would be why on earth, great stories.

Imagine all the different health technology assessments. In different nations saying why is this not reusable equipment? Rather than why, because it actually is harder to launch something as a reusable device rather than as a single use device. I know that seems nitty gritty but that, that change would seem a very strong signal across the world to all the big pharma and big tech companies.

Health technology assessment, health technology. So I think there's lots of at all different levels where we can be acting to make a real change. Because we do need hope. 

Chloe: Absolutely. Thank you both so much. We've had some great discussions. 

Cristina: Thank you for having me. Thanks for your time.

Gavin: Thanks so much for joining us for this episode of The Lancet Voice. This podcast will be marking the Lancet's 200th anniversary throughout 2023 by focusing on the spotlights with lots of different guest hosts from across the Lancet group. Remember to subscribe if you haven't already and we'll see you back here soon.

Thanks so much for listening.