Healthcare Sustainability to Address Climate Change: Call for Action to the Infectious Diseases Community

Abstract

The US healthcare system’s contribution to greenhouse gas emissions and climate change is disproportionately high and harms the public. Several medical specialties are now reassessing how they can mitigate healthcare’s harmful environmental impact. Healthcare sustainability is broadly defined as measures to decrease greenhouse gas emissions, waste, and other pollutants generated during the healthcare delivery process. Prior efforts and programs by infectious diseases (ID) professionals, such as antimicrobial stewardship and infection prevention and control can form a framework for ID professionals to help apply this expertise to healthcare environmental sustainability more broadly. This call to action proposes strategies for ID societies and professionals to incorporate climate change education for trainees, increase research and funding opportunities in healthcare sustainability, and calls for action by ID societies to champion system changes to decrease greenhouse gas emissions.

INTRODUCTION

The “One Health” approach aims to optimize the health of humans, animals, and ecosystems by recognizing that they are interdependent [1]. This approach has been applied to the study of zoonoses and resistant bacteria, but less discussed is how the environment affects human health. Climate change is a grave threat to human health and increases the risk of infectious diseases (ID) because of the disruption to planetary ecosystems [2–5]. Rapid decreases in greenhouse gas emissions (GHGe) are urgently needed to protect health [6]. The risk of climate change is especially important to children, who are uniquely vulnerable to the health impacts of a changing climate and will live more years in a changed climate. Estimates are that the current generation of children will experience up to 7 times the risk of lifetime extreme weather exposure than past generations, with a higher risk the more the world warms [7].

This article will provide professionals working in ID medicine, public health, and basic or translational research with an introduction to opportunities to decrease healthcare and/or research associated GHGe. For the purposes of this discussion, healthcare sustainability will be broadly defined as measures to decrease GHGe, waste, and other pollutants generated during the healthcare delivery process.

HEALTHCARE INDUSTRIES CONTRIBUTE TO THE CLIMATE CRISIS

In 2018, healthcare-associated air pollution and GHGe were estimated to cause the loss of 388 000 disability-adjusted life years in the United States alone [8]. The US healthcare system accounts for 8.5% of total United States GHGe, 35% of which is from the hospital setting [9]. In April 2022, the Department of Health and Human Services launched the Health Sector Climate Pledge, a voluntary initiative for healthcare systems to commit to reducing GHGe by 50% by 2030 and achieving net zero emissions by 2050 [10] and in addition to prepare for resiliency from impacts of climate change. A group of 133 health organizations representing 900 hospitals have signed the pledge as of November 16, 2023. The Joint Commission in 2023 announced standards for minimizing hospital-associated GHGe, specifically to measure emissions from energy use, purchased energy, anesthetic gas, pressurized metered dose inhalers (which contain a greenhouse gas propellant), fleet vehicle gasoline consumption, solid waste disposal, and incineration. Initially, these standards were proposed as mandatory requirements, however after feedback from healthcare stakeholders, this was adjusted to a voluntary certification program [11]. Many frontline health professionals voiced approval of such mandatory measurements with efforts to decrease GHGe [12].

OPPORTUNITIES TO DECREASE GHG EMISSIONS IN HEALTHCARE AND PROFESSIONAL ACTIVITIES

Opportunities to measure and minimize GHGe are analogous to the way that antimicrobial stewardship and infection prevention efforts have evolved in the past. These efforts may become more scrutinized in the future and in our opinion, should be considered components of quality medical care. Measurement of GHGe is a critical first step to decreasing the climate impact of healthcare. There are emissions that occur directly from health care facilities, such as those from on-site boilers and anesthetic gasses (referred to as a group or “Scope” 1 emissions), those emitted indirectly through purchased energy (Scope 2), and all other indirect emissions (Scope 3). Scope 3 covers 15 categories, including emissions from purchased goods and services, employee commuting, and waste management. Scope 3 emissions are by far the highest percentage of healthcare-associated emissions and the biggest single category is the aggregate of pharmaceuticals, chemicals, and medical supplies [13]. Therefore, daily healthcare processes are a high-impact target area. The mnemonic “WE ACT” was first coined by the Providence healthcare system [14] and targets healthcare sustainability in 5 key domains, including areas in which ID professionals may have specific influence (Table 1).

Table 1.

Framework for Sustainable Healthcare Delivery

Acronym	Category	Representative Examples
W	Waste	Eliminating low-value tests/treatment (diagnostic/medication stewardship) Decreasing pharmaceutical waste Risk/benefit of solid waste from Infection Prevention efforts Decreasing single-use plastics (eg, from pharmaceutical delivery processes, through intravenous to oral conversion, reusable gowns) Decreasing unnecessary microbiology waste Biohazardous material management
E	Energy and water	Renewable energy procurement Energy conservation Water conservation
A	Agricultural/food cycle and anesthetic gas	Local food procurement Redistribution of unused but consumable food Composting while mitigating disease spread Serving less meat, antibiotic-free meat Decreasing desflurane, nitrous oxide use
C	Chemicals and pharmaceuticals	Reduce ethylene oxide public harms Sustainable procurement Optimizing lifecycle use of antimicrobials including pharmaceutical waste
T	Transportation	Telemedicine Employee commuting Virtual or regional options for professional meetings Electrification of vehicles

In aggregate, “WE ACT,” is a call to healthcare providers to call on hospital administrators, local, state, and federal leaders and to supply chain providers to alter processes and supplies to minimize healthcare’s environmental impact.

Physicians and other clinicians are integral to enabling and facilitating healthcare sustainability because they can emphasize the public health benefits of healthcare sustainability to hospital administrators. In addition, they can directly connect healthcare sustainability with the core missions of most health systems, which is to protect health and treat the public. Clinical care is the single largest factor driving healthcare emissions [9], therefore there are multiple opportunities for clinicians to reevaluate clinical choices while balancing patient safety and quality. One center was safely able to reduce the anesthetic gas emissions by 87% through physician-led efforts to reduce unnecessarily high flow rates and changes in the types of inhaled anesthetic gas use [15]. The infection prevention group at 1 hospital in the United Kingdom reduced inappropriate personal protective equipment use which saves 25 974 kgCO₂e annually (equivalent to 66 586 miles driven by a gas-powered vehicle) and increased staff satisfaction [16]. Converting medications from intravenous to oral also improves healthcare sustainability. A study in Brazil estimated that making 275 switches from IV to oral medication resulted in reduction of 170 kg of waste. This included needles, syringes, infusion bags, equipment, reconstituted solution bottles, and medication [17].

Pediatric care has unique opportunities to improve healthcare sustainability. Antibiotic waste has been documented by several pediatric hospitals due to specific weight-based dosing and vial size convention [18, 19]. This could be improved by implementation of timely placement of stop dates and consideration of dose ranges with vial size convention, which would be in line with optimizing dose and duration that are integral to antimicrobial stewardship efforts. In children, use of a rapid magnetic resonance imaging (MRI) has been used to diagnose pediatric acute hematogenous osteomyelitis and reduces length of stay and need for anesthesia, thereby optimizing care and also decreasing GHGe associated with care [20]. Resources to decrease GHGe in healthcare are listed in Table 2.

Table 2.

Healthcare Sustainability Resources and Funding Opportunities

Healthcare Sustainability Resources
National Academy of Medicine: Carbon Accounting Basics	https://nam.edu/programs/climate-change-and-human-health/action-collaborative-on-decarbonizing-the-u-s-health-sector/carbon-accounting-101/
Environmental Sustainability in the Outpatient Setting	https://mygreendoctor.org/
Agency for Healthcare Quality and Research: Reducing Healthcare Carbon Emissions Primer	https://www.ahrq.gov/sites/default/files/wysiwyg/healthsystemsresearch/decarbonization/decarbonization.pdf
Massachusetts General: Healthcare SOS	https://www.massgeneral.org/environment-and-health/healthcaresos
World Health Organization guidance for climate-resilient and environmentally sustainable healthcare facilities	https://www.who.int/publications/i/item/9789240012226
Practice Greenhealth	https://practicegreenhealth.org/
Health Care Without Harm	https://noharm.org/
UK Centre for Sustainable healthcare	https://www.susqi.org/; https://sustainablehealthcare.org.uk/susqi.
Mazzetti waste calculatora	https://www.mazzetti.com/resources/mtools/wastecare-calculator/.
Healthcare Emissions Calculator	https://practicegreenhealth.org/tools-and-resources/health-care-emissions-impact-calculator.
Environmental Protection Agency emissions calculatorb	https://www.epa.gov/energy/greenhouse-gas-equivalencies-calculator.
Environmental justice index	https://www.atsdr.cdc.gov/placeandhealth/eji/index.html.
Global Road Map for Health Care Decarbonization	https://healthcareclimateaction.org/sites/default/files/2021-09/Road%20Map%20for%20Health%20Care%20Decarbonization%20Executive%20Summary.pdf
Inflation Reduction Act Benefits for Healthcare Systems	https://noharm.medium.com/inflation-reduction-act-deep-dive-new-investment-tax-credit-opportunities-and-elective-pay-options-c8e8ecdc44c3#b17b
Funding Opportunities for Healthcare Sustainability
Agency for Healthcare Research and Quality request for proposals for reduction of Carbon footprint and creating resiliency within healthcare	https://grants.nih.gov/grants/guide/notice-files/NOT-HS-23-006.html.
National Institute of Environmental Health Sciences	https://www.niehs.nih.gov/research/supported/centers/ehd/index.cfm.
National Institutes of Health	https://grants.nih.gov/grants/guide/rfa-files/RFA-ES-23-007.html.
Bill and Melinda Gates Foundation	https://gcgh.grandchallenges.org/challenge/accelerating-catalyzing-solutions-climate-changes-impact-health-agriculture-and-gender.
Burroughs Wellcome Fund	https://www.bwfund.org/funding-opportunities/climate-change-and-human-health/.

^aFree online calculator that provides quantitative estimates on an institution’s waste footprint.

^bTranslates carbon emissions into units of transportation or fossil fuel use, such as gallons of gasoline, miles driven.

Improving healthcare services through quality improvement initiatives is already familiar to antimicrobial stewards, infection preventionists, and other health professionals. The Centre for Sustainable Healthcare in the United Kingdom offers additional dimensions in quality improvement. This approach specifically recognizes that there are finite financial and environmental resources available to deliver healthcare. Healthcare value is holistically viewed with a goal to optimize clinical outcomes while minimizing negative social, environmental, and financial impacts (Figure 1). A sustainable healthcare system aims to prevent need for healthcare, eliminate low-value testing and treatment, and to deliver healthcare with the lowest GHGe-intensive processes and medications [21].

Figure 1.

Sustainable value of healthcare. Healthcare has the most value when it achieves the best clinical outcomes while creating the least social, environmental, and financial negative impacts [21].

Preventing hospitalization and/or decreasing length of stay represents a substantial opportunity to decrease solid waste and GHGe. In a life cycle assessment in a hospital in New York, it was estimated that 5.5 kg of solid waste and 45 kg of CO₂ (equivalent to 115 miles driven by an average gas-powered vehicle) was generated per hospitalization day. In the intensive care unit, 7.1 kg of solid waste was generated and 138 kg CO₂ per hospitalization day (equivalent to 354 miles driven miles driven by an average gas-powered vehicle) [22, 23].

Finally, professional meetings could be made available by virtual options, thereby significantly decreasing the overall GHGe of professional meetings and/or be switched to hubs where regional attendees could gather. Transitioning from a pure “in-person” to virtual meeting can substantially reduce the GHGe by 94% and energy use by 90% [24].

PARALLELS BETWEEN ANTIMICROBIAL STEWARDSHIP AND HEALTHCARE SUSTAINABILITY

Considerable advances have been made in antimicrobial stewardship since the term was first coined in 1996 and can serve as an example of how healthcare sustainability can evolve in the future. ID professionals initially identified the overarching goal of eliminating inappropriate antimicrobial use and the gap that existed between that goal and existing practices. ID physicians and researchers participated in the White House Plan to Combat Antimicrobial Resistance in 2015, and from this emerged the current requirements to have an antimicrobial stewardship program at every hospital [25].

The distinction between the terms “stewardship” and “sustainability” should be recognized. “Stewardship” involves careful management of resources, but “sustainability” expands upon stewardship to explicitly include the concept of meeting current needs without sacrificing the ability of future generations to meet their own needs. Healthcare sustainability is an expansion of the types of efforts of antimicrobial stewardship programs and involves examining the entire healthcare system in a more systematic and holistic way.

For both antimicrobial stewardship and healthcare sustainability, an emphasis on long-term goals of preserving resources is a major driving factor. Antimicrobial stewardship programs have proven to lead to cost savings [26] and improved health outcomes, such as decreased length of stay [27]. Expanding these efforts to healthcare sustainability has even more potential for cost savings and can ensure a resilient supply chain network.

INFECTION PREVENTION AND CONTROL AND HEALTHCARE SUSTAINABILITY

The field of infection prevention and control (IP&C) was established in the 1950s in response to an epidemic of hospital-acquired Staphylococcus aureus. Infection surveillance in healthcare facilities decreases the need for healthcare utilization through prevention [28]. However, due to the ubiquity of single-use disposable supplies in IP&C, infection prevention strategies are perceived as opposing those of sustainability due to the generation of vast amounts of solid waste [29]. Healthcare solid waste is integrally tied with GHGe, both because landfill waste generates methane, but also because pharmaceutical and regulated medical waste require energy-intensive disposal with either incineration or autoclaving. In the first 18 months of the COVID-19 pandemic, more than 8 million tons of pandemic-associated plastic waste were generated globally, with more than 25 000 tons entering the global ocean [30]. With supply chain shortages, there was difficulty in procuring equipment, and conservation of equipment became urgently needed.

Despite what appear to be fundamentally opposing priorities, IP&C has the potential to be a powerful partner for healthcare sustainability. First is in research efforts to quantify environmental impacts vs potential for infection prevention outcomes. Many IP&C activities, such as contact precautions for select multidrug-resistant organisms, lack robust supporting evidence, and further efforts to quantify the benefits of these recommendations are needed. When personal protective equipment is required, healthcare systems have an opportunity to source recycled products, such as from retired athletic uniforms into reusable isolation gowns [31]. In addition, the life cycle assessment of reuse vs disposing of hospital equipment can be integrated into supply chain sourcing decisions [32], but needs to include consideration of potential infection prevention implications. Infection preventionists and healthcare epidemiologists are integral to teaching healthcare staff, are in contact with hospital administrators, routinely coordinate processes and procedures to minimize infection risk, and could incorporate these concepts into daily activities.

Experiences from other countries demonstrate that patient-centered and environmentally sustainable healthcare is possible. The Aravind Eye Care System in India generates 10 times less solid waste per eye surgery compared to the same surgeries performed in the United States [33, 34]. A significant portion of this waste reduction relies upon IP&C practices that are prohibited in US surgical centers, such as increased use of reprocessed items and decreased personal protective equipment. Aravind modified their IP&C practices given that cataract is a relatively safe procedure with minimal microbial contamination and most of the IP&C rules originated in other surgical specialties. Despite these modified IP&C practices, Aravind’s patient outcomes, including infectious outcomes, are similar to the United States [31, 35]. This suggests that regulatory practices could be individualized for every specialty and infection preventionists could be an essential partner in this process.

DIAGNOSTIC STEWARDSHIP IS CRITICAL TO HEALTHCARE SUSTAINABILITY AND COST CONTAINMENT

The United States spent 17.8% of gross domestic product (GDP) on health care in 2021, the top among 38 high-income countries [36]. Despite one of the highest per capita spending on healthcare, the United States does not have the best health outcomes, as evidenced by having one of the least favorable rates of maternal and infant mortality. One contributor to high costs among inpatients is excess testing [37].

The concept of diagnostic stewardship aims to eliminate nonessential testing and has proved to be critical in eliminating unnecessary antimicrobial treatment. Infectious disease providers are already focusing on low-value bacterial cultures and molecular testing in clinical settings [38, 39]. Diagnostic stewardship for testing suggested by ID clinicians is often overlooked. Broad microbial differential diagnoses are often rightfully considered in patients typically seen by our subspecialty. However, in addition, feedback to trainees regarding the utility for performing each test being considered should be provided. Each test should be evaluated considering the pretest probability of a diagnosis, the available turnaround time, and the impact on clinical management. As ID providers, stewardship of antimicrobials is often a high priority, but less consideration is given to stewardship of radiologic procedures. The utilization of testing, such as computed tomography (CT) and MRI is higher in the United States compared with other high-income countries [40]. The need to utilize these radiologic procedures should be reevaluated, with greater consideration given for less energy-intensive imaging [41] such as ultrasound, where appropriate.

THE BUSINESS CASE FOR HEALTHCARE SUSTAINABILITY

For hospital administrators, it should be emphasized that healthcare sustainability is the right thing to do for patients but can also save substantial amounts of money for systems and is an important component to healthcare resiliency. It is estimated that “greening the OR” initiatives can save approximately $25 000 per operating room (OR) per year. At Memorial Sloan Kettering, this intervention saved almost $1.1 million, diverted nearly 200 tons of waste, decreased energy use by 1.8M kWh, and reduced GHGe from ORs by 1800 mtCO₂e in a single year [42]. Gundersen Health System has been producing more energy than is consumed from fossil fuels since 2015. This was accomplished through energy efficiency upgrades and renewable energy generation, such as with a solar canopy that offsets 10% of the hospital’s electrical usage, resulting in an annual savings of more than $100 000 [43]. At the Cleveland Clinic, by installing a system that adjusts the air exchanges based on whether ORs are in use, they reduced energy costs by $2 million a year [44]. The Inflation Reduction Act, passed in 2022, provides incentives that can be used directly to reduce GHGe through investments in renewable energy, electrification of vehicle fleets, and through other energy efficiency improvements. Nonprofit health systems are eligible for these incentives and can utilize a “direct pay” option, which allows for benefits of tax credits as an upfront payment [45]. Finally, administrators should be aware of avoidable operational costs that nurses and clinicians recognize, such as the costs to purchase and discard unused pharmaceutical waste. ID physicians, stewards, and infection preventionists can mobilize existing relationships with hospital administrators to emphasize the potential cost and health savings from healthcare sustainability efforts.

SYNERGIZING HEALTHCARE SUSTAINABILITY WITH ID MEDICINE CREATES RECRUITMENT, EMPLOYMENT, AND RESEARCH OPPORTUNITIES

By integrating healthcare sustainability with the ID profession, we could present potential trainees with an opportunity to mitigate climate change, thereby increasing desirability of the field [46, 47]. Younger generations are concerned about climate change; in a survey of 10 000 youth ages 16–25, 75% reported being worried about climate change [48]. Per the Infectious Diseases Society of America workforce development strategy, 1 approach for recruitment is to increase recognition of ID as an indispensable resource to healthcare systems [49]. Just as after the 2015 National Action Plan to Combat Antimicrobial Resistance mandated antimicrobial stewardship programs at acute care hospitals and created jobs in antimicrobial stewardship, so too, can healthcare sustainability requirements create opportunities. In future years, if regulations for healthcare systems are implemented, these job opportunities may greatly increase, creating additional funding opportunities for ID providers who have healthcare sustainability expertise. As of January 2024, Health Care Without Harm is aware of more than 20 physicians and/or nurses including 1 ID physician and 1 infection control nurse who serve as medical or clinical directors of sustainability or an equivalent title for their hospital or health system. The current US physicians have between 0.075 and 0.6 FTEs (Full-time equivalent positions) protected for healthcare sustainability work (Amy Collins A.C., M.D, personal communication, Healthcare Without Harm). ID providers would be well suited to lead healthcare sustainability efforts because of their training in antimicrobial stewardship, infection prevention, quality improvement, and the experience of systems-based management. For researchers, there are also funding opportunities in the area of GHGe mitigation and/or resiliency, which can be found in Table 2.

ADVOCACY

ID professionals have a history of advocating for decreasing use of antibiotics in meat and poultry production, for antibiotic stewardship and infection prevention resource support in hospitals, and for development of new antimicrobials. To further healthcare sustainability, ID providers, scientists, and public health professionals can now actively engage with advocacy groups to government, regulatory bodies, and hospital leadership about the importance of healthcare sustainability and decreasing of GHGe (Table 3). One notable example of the effect of clinician-led advocacy was at the University of Pittsburgh Medical Center, where clinicians organized and petitioned hospital leadership to create a healthcare sustainability council, sign the Health and Human Services Climate Pledge, and to designate a chief sustainability officer [50]. This resulted in several clinician-led initiatives, including OR recycling, waste reduction in research laboratories, phasing out desflurane usage, advocating for the use of reusable pulse oximetry probes over disposable ones, and prioritizing staff education on healthcare sustainability initiatives [51].

Table 3.

Healthcare and Scientific Professionals Advocacy Groups

“Sustainabil-ID”	[email protected] Collaborative formed by authors of this article for infectious diseases physicians, pharmacists, public health professionals, and trainees to discuss integrating environmental sustainability into infectious diseases
Union of Concerned Scientists	https://www.ucsusa.org
Medical Society Consortium on Climate and Health	https://medsocietiesforclimatehealth.org
Healthcare Without Harm Physician Network	https://noharm-uscanada.org/content/us-canada/join-our-physician-network

Medical professional organizations including the American Academy of Ophthalmology [52], American College of Radiology [53], and the American Society of Anesthesiologists [54] have developed resources and infrastructure supporting healthcare sustainability for their respective specialties. To date, neither the Infectious Diseases Society of America nor the Society for Healthcare Epidemiology of America have devoted similar resources to addressing healthcare sustainability within infectious disease practice, healthcare epidemiology, or antimicrobial stewardship. More structured, formal committees by national and international ID organizations could amplify these advocacy efforts.

To rapidly expand prevention of ID and for healthcare sustainability within the ID field, we suggest these next steps for the ID leadership and community (Table 4).

Table 4.

Proposed Healthcare Sustainability Strategies for Infectious Diseases Societies and Practitioners

1.Education	Expand ID training to include climate change and infectious diseases, and healthcare sustainability. ID societies could facilitate creation of educational modules that are implemented through a national web-based curriculum
2.Funding opportunities	Create funding and publication opportunities within ID societies and journals
3.Encourage sustainability in research	Include environmental sustainability as primary or secondary research objectives (eg, calculation of GHGe savings from diagnostic stewardship efforts)
4.Formalized committees	Formal committee creation within Infectious Diseases Society of America, Pediatric Infectious Diseases Society and Society for Healthcare Epidemiology, Society for Healthcare Epidemiology in America to advocate for sustainability in ID and to government leaders about climate change, antimicrobial resistance, and healthcare sustainability
5.Job creation	Advocate for hospital systems to include funding for ID physicians capable leading healthcare sustainability councils
6.Expand diagnostic stewardship	Include environmental impact assessment of non-microbiological assays and radiologic imaging in the management of infectious diseases

ID, infectious diseases.

CONCLUSION

ID providers, pharmacists, preventionists, scientists, and public health professionals can be the leaders in reducing healthcare’s climate impact to improve and prevent illness from the climate crisis. We call upon the ID community to “think globally and act locally” and heed this call to mitigate GHGe in the systems you work in daily to address the greatest threat to global public health.

Glossary

 
• Greenhouse gas emissions (GHGe)

  These include carbon dioxide (CO₂) emissions, such as from transportation, methane emissions, such as from landfills, and anesthetic gasses, such as nitrous oxide, which are direct greenhouse gasses. Carbon dioxide equivalent or “CO₂e” means the number of metric tons of CO₂ emissions with the same global warming potential as 1 metric ton of another greenhouse gas.

 
• GHGe

  Scope (group) 1 (direct emissions from health care facilities), Scope 2 (indirect emissions from purchased energy), and Scope 3 (all indirect emissions, not included in Scope 2, that occur in the value chain, including both upstream and downstream emissions).

 
• ID

  Infectious Diseases.

 
• IP&C

  Infection Prevention and Control.

 
• One health

  An integrated, unifying approach to balance and optimize the health of people, animals, and the environment.

 
• Pollutant

  Compounds introduced in the natural environment from human activity that adversely affecting health.

 
• Stewardship

  Responsible management of resources.

 
• Sustainability

  Preserving resources for future generations.

 
• Sustainable Quality Improvement

  Method started in the United Kingdom that aims for best clinical outcomes with environmental, social, and financial impacts.