Waste Reduction Week!

Shugri Nour, Navisha Weerasinghe

As Registered Nurses working in busy hospitals in the Greater Toronto Area, we see the approach of Waste Reduction Week as an opportunity to reflect on what the COVID-19 pandemic and the associated proliferation of personal protective equipment (PPE) has shown us about health sector waste.

Over the course of the pandemic, PPE has become a part of not just public consciousness, but everyday life. Along with our keys, wallets, and phones, grabbing a mask before we head out the door is quickly becoming second-nature. In addition to its embeddedness in our daily routines, PPE features heavily in almost all social and congregate settings; it is, in a word, ubiquitous.

Even for those of us for whom PPE has long been part of our everyday professional lives, the pandemic ushered in unprecedented PPE use. Hospitals in Canada mandated that all patients, visitors and healthcare workers wear masks upon entry into the hospital and remain masked while indoors, contributing to an immediate and significant increase in mask use.

Heightened precautions to mitigate the spread of the COVID-19 virus warranted increased use of isolation status, which resulted in increased use of PPE. Patients with a diagnosis of, or under investigation for, COVID-19 are placed on droplet and contact precautions; this necessitates that any healthcare professionals entering the room wear the required PPE such as gloves, masks, gowns and face shields, even if they are not providing care. Early on, when the virus was new and not well understood, many individuals who presented with COVID-19 related symptoms required isolation in hospital; a number of whom would go on to be cleared by negative COVID-19 swab results within 24 hours. COVID-19 consists of an array of typical and atypical symptoms that often mirror other conditions. For example, symptoms such as shortness of breath and/or headaches, which did not require isolation precautions prior to the pandemic now call for isolation.  

In addition, depending on the patient’s presentation and oxygen needs, those in critical status may require high flow oxygen and/or intubation with ventilation. These procedures place healthcare workers at additional risk, demanding the use of added PPE such as N95 masks and specialized gowns. Moreover, due to isolation protocols, any excess supplies or equipment brought into a patient’s room must be disposed of once the patient is cleared or discharged, contributing to waste.

The vast majority of PPE and other supplies used in this context are single-use disposable items and were either discarded in the garbage or biohazard bags. Early on in the pandemic, hospitals and care settings were threatened with a potential PPE shortage, due to the sudden uprise in use. In response, many hospitals transitioned into recycling N95 masks as a contingency plan to sterilize masks for reuse come a dire shortage in the pandemic. Another change was the shift from disposable gowns to reusable gowns requiring washing.  While the recycling program was short-lived once N95 supply proved consistent, the reusable gowns sustained, and as a result, this reduced waste production and fostered environmental benefits via waste diversion.

When we reflect on how many disposable gloves, masks, gowns and face shields we have been using individually in our respective work settings since the pandemic began, we cannot help but think about how this adds up globally. Although COVID-19 continues to be a threat and the use of PPE is necessary, the massive amounts of PPE waste generated over the past 18 months has heightened our awareness that the type of PPE we use, and the ways in which we dispose of it, require careful consideration.

Waste Reduction Week, which is part of a year-round program that promotes action and celebrates efforts in building environmentally conscious practices while encouraging sustainable, innovative ideas and changes, is a good time for the healthcare sector to take stock of its supply chain, from procurement to disposal. This year, Waste Reduction Week is taking place between October 18-24, 2021; each day will highlight a different theme, including the Circular Economy, Textiles, E-waste, Plastics, Food Waste, the Sharing Economy, and Swap and Repair.

Image from Waste Reduction Week in Canada, https://wrwcanada.com/en

While this national event is not directly aimed at the health sector, these are all areas of relevance to health system sustainability. Let us use the lessons we have learned from the COVID-19 pandemic and the growing specter of PPE waste as inspiration to demand, create, and implement comprehensive changes that promote sustainability of all hospital resources, which span from supply chains to waste streams. These approaches can then mitigate the health system’s significant environmental impact.

PPE waste sheds light on the various types of waste that hospitals produce, broadening the scope for action. We must hold healthcare systems accountable for their part in generating waste and waste-related carbon emissions and work collaboratively as a global community to develop innovative solutions to decrease PPE waste and  all healthcare-related waste. This is something that should be a priority for all healthcare professionals.

About the authors

Shugri Nour is a Registered Nurse working in Hemodialysis for 5 years. She completed her Master of Nursing (MN) at U of T. Shugri is currently a Research Assistant at the Centre for Sustainable Health Systems where she is involved in developing content on sustainable food in healthcare. 

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Navisha Weerasinghe is a Registered Nurse working in the Emergency Department and Med/Surg units in GTA hospitals. Navisha recently completed her Master of Nursing (MN) - Clinical program at the University of Toronto. Navisha is currently a Research Assistant with the Centre for Sustainable Health Systems. Her interests include greening healthcare systems and finding innovative solutions to reduce ward waste in healthcare settings.

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All CSHS guest posts are published under the CreativeCommons Attribution Non-commercial Share Alike license. Guest Contributors are free to publish their guest posts elsewhere.

If you’ve got an idea for a blog post you’d like to author, please contact us.

COVID-19 and PPE Waste: A catalyst for sustainable healthcare?

Shugri Nour, Vivian Tseng, Navisha Weerasinghe

Image 1: The PPE Lifecycle

Since the onset of the pandemic, demand for personal protective equipment (PPE), both within and beyond the health sector has increased significantly worldwide. PPE has proven to be a valuable resource in safeguarding the public and healthcare workers from the infectious disease and preventing the transmission of the virus whilst providing safe patient care. General existing practices do not allow for the recycling of PPE, which include medical masks, respirators, face shields, gloves, and gowns, due to infection control standards. However, there is opportunity to safely recycle and repurpose these primarily plastic items.

The global demand for PPE has gone unabated since the pandemic began, resulting in a pronounced increase in production, distribution, and waste generation (Patricio Silva et al., 2020). Each month of the pandemic, it is estimated that 129 billion face masks and 65 billion gloves are used worldwide by healthcare workers and the general public. From June 2020-June 2021, an estimated 63,000 tons of COVID-19 related-PPE from Canada’s healthcare system and the general public ended up in our landfills, with a smaller portion being incinerated due to biomedical contamination. A worrisome amount of PPE waste has escaped these waste streams altogether; for instance, striking quantities of PPE have washed up along Canada's coastlines. As the pandemic continues, we are seeing surges in the use of single-use plastic by 250 to 300%. This goes beyond PPE to increased consumption of test kits including swabs and plastic vials.

All of this waste produces a sizable carbon footprint. One study documented that the production, distribution and waste of PPE in the National Health Service (NHS) in England during the first six months of the pandemic was approximately twice the amount of PPE consumed in the whole of 2019, and generated 106,478 tonnes of CO2e - equivalent to 64,586 homes' electricity use for one year, or approximately 244 return flights from London to New York daily. In total, PPE use during this 6 month period added an additional 1% to the NHS’ carbon burden. The vast majority of PPE’s carbon footprint arises from the production of materials (46%) and clinical waste (39%) (Figure 1).

Figure 1. PPE-associated carbon emissions.

Adapted from Rizan C, Reed M, Bhutta MF. Environmental impact of personal protective equipment distributed for use by health and social care services in England in the first six months of the COVID-19 pandemic. Journal of the Royal Society of Medicine. March 2021.

At the outset of the pandemic, as institutions scrambled to carry out measures to protect overwhelmed healthcare systems from collapse, initiatives to reduce PPE waste were not prioritized. Moreover, the pandemic had an impact on waste-reduction efforts more generally; it has stalled efforts around the world to replace some single-use devices with reusable or at least recyclable alternatives, and to implement plastic reduction policies. In Canada, for example, the national ban of single-use plastics was delayed from earlier this year to October 2021.

As time went on, there were growing calls to develop policies, programs, and innovations to safely reduce PPE waste. These calls have been met with an array of initiatives aimed at developing reusable options, implement recycling initiatives, and reducing inappropriate use of PPE through public awareness and implementation of hospital protocols to optimize use of PPE. 

Last fall, the Government of Canada itself committed to funding alternative strategies, notably the creation of compostable disposable masks and respirators in their efforts to take action on plastic waste. A Calgary based company called Roswell Downhole Technologies Incorporated and a Winnipeg based company called Precision ADM both received funding to develop innovative solutions in manufacturing compostable PPE including surgical masks, respirators, and gowns. Recently, both companies have joined up to create a full range of medically certified PPE products made from crop-based biopolymers. However, they are in the process of awaiting approval by Canadian composting facilities for intake of their used PPE products. In the meantime, they have opened their operations for grand scale production of compostable surgical masks, respirators, and other PPE products.

At the University of Toronto, two members of the Temerty Faculty of Medicine have been developing a sustainable way to ensure front-line workers have secure access to PPE. The initiative, dubbed the ROSE Project, is led by Denyse Richardson, an associate professor in the Department of Medicine, and Reena Kilian, a lecturer in the Department of Family and Community Medicine. In an effort to develop a reusable mask that meets Level 1 safety criteria (the standard for low-barrier fluid exposure), they have joined forces with a textile engineer, an architect, sewing experts, a knowledge translation expert and a medical student. On top of using locally available materials, their goal is to open-source their mask design to ensure both availability and accessibility. The masks are currently in the process of laboratory testing to ensure compliance of international safety standards.

The Children’s Hospital of Eastern Ontario (CHEO) Research Institute discovered the potential of reusable masks for decreasing PPE-related waste based on hospital staffing. Dr. Richard Webster, a clinical researcher at CHEO who has helped spearhead the initiative, described its main impetus as such: “From our hospital’s COVID screening tool we were surprised that at the moment, 60% of staff are on site for non-direct patient care. This was much higher than we expected!” Because staff who are not directly involved with patients do not require the same level of PPE as those who are, the CHEO team worked with a local charitable organization to developed a reusable cloth mask. The reusable mask, which was piloted with high satisfaction amongst staff, underwent testing at the National Research Council and has an initial particle infiltration efficiency of 88 percent, decreasing to between 72 and 77 percent after approximately 50 washes. This exceeds recommendations issued in February 2021 by the American Society for Testing Materials (ASTM) where it is indicated that high-performing or Level 2 consumer masks should meet or exceed 50 percent particle filtration efficiency (PFE) when tested. These standards from ASTM, including ones for surgical and N95 masks, are also adopted by Health Canada. This mask has now been launched as a community mask for purchase and once funding permits, the CHEO team will perform Health Canada medical device testing to approve its use in healthcare settings. The introduction of this reusable mask in healthcare settings offers a unique solution to mitigate PPE waste.

In February 2021, Canada’s first recycling program for PPE was launched in long term care and urgent care facilities across Vancouver. Recycling bins collect single-use face masks and N95 respirators from front-line workers, which are then broken down and re-purposed into construction materials. To respond to the demand for PPE recycling, TerraCycle has also created the Safety Equipment and Protective Gear Zero Waste Box, a recycling service for discarded nitrile and latex gloves, dust masks, garments, hairnets, and safety glasses. The collected waste is mechanically separated into fibers and plastic components, which can be recycled, composted, or turned into new plastic products. More general PPE recovery programs, such as the PPE Recovery Initiative launched by RecycleSmart and Green Circle Ideas earlier this year, have made PPE collection accessible to a broader audience of allied health professionals and Canadian businesses in general.

Images 2 & 3: PPE Recovery Initiative receptacles at a Toronto Massage Therapy office.

COVID-19 remains a major threat to public health, and our response is contributing to the ongoing threat of significant environmental harms associated with the increased usage of PPE. Given proper design standards, material selection, and user guidelines, reusable PPE has been shown to be effective in infection control while providing a suitable environmentally friendly alternative. For example, a UK study identified that over a six-month period the use of reusable gowns and face shields could have saved 20% of the total emissions from disposable PPE. Another factor that may decrease carbon emissions is the local production of PPE supplies. In fact, domestic manufacturing in the United Kingdom would reduce 12% of the emissions from PPE by limiting airfreight use and saving 12,491 tonnes CO2e over the six-month study period. This reduction was seen due to the elimination of greenhouse gases produced from overseas travel. As a result, the UK study demonstrates how other countries can limit their emissions as well by prioritizing cleaner energy used in domestic manufacturing of PPE.

Canada and our healthcare system face many challenges up ahead as we move towards net-zero carbon while continuing to curb the spread of COVID-19. Considering that the usage and demands for PPE are only expected to grow around the world, the need for our healthcare system to scale down this impact and invest in alternative, innovative strategies cannot be understated. In this way, COVID-19 was the primary catalyst for short-term and long-term changes in plastic waste management systems and technologies.

About the authors

Shugri Nour is a Registered Nurse working in Hemodialysis for 5 years. She completed her Master of Nursing (MN) at U of T. Shugri is currently a Research Assistant at the Centre for Sustainable Health Systems where she is involved in developing content on sustainable food in healthcare. 

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Vivian Tseng (BHsc) is a second year Master of Public Health (MPH) student at the Dalla Lana School of Public Health, University of Toronto. She holds a bachelor's degree in Psychology and Health Studies from the University of Toronto. Vivian is interested in health equity, specifically how to shape policies and programs to ensure equitable access to the social determinants of health necessary to improve population health outcomes. 

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Navisha Weerasinghe is a Registered Nurse working in the Emergency Department and Med/Surg units in GTA hospitals. Navisha recently completed her Master of Nursing (MN) - Clinical program at the University of Toronto. Navisha is currently a Research Assistant with the Centre for Sustainable Health Systems. Her interests include greening healthcare systems and finding innovative solutions to reduce ward waste in healthcare settings.

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All CSHS guest posts are published under the CreativeCommons Attribution Non-commercial Share Alike license. Guest Contributors are free to publish their guest posts elsewhere.

If you’ve got an idea for a blog post you’d like to author, please contact us.

Green Gab with Ed Rubenstein

The Green Gab

*Cross-posted on Emerging Leaders for Environmental Sustainability in Healthcare’s (ELESH) website as “The Green Gab: Ed Rubenstein”

Ed Rubinstein is the Energy & Environment Manager at the University Health Network. He’s been leading the hospital’s many environment programs since 1999 and has helped UHN become a leader in greening health care.

Yousef: Alright so could you tell us a little bit about who you are?

Ed: Hello my name is Ed Rubinstein. I’m the Director of Environmental Compliance, Energy, and Sustainability at the University Health Network here in Toronto. My team oversees all things environmental sustainability related to health care. We don’t actually do a lot of the hands-on stuff but in regard to waste for example, we work with purchasing, we work with environmental services, we work with many different kinds of stakeholders and champions to get things through. We do a lot of energy stuff, that’s the one exception where we are a little more hands-on. We have several energy managers who identify projects, implement projects as well support the many other operational and capital things going on here in terms of trying to get as much efficiency and low carbon as possible. And we oversee things like Environmental Compliance – anything environmental kind of comes through us at some point.

Y: That’s great. And when were you initially attracted to the field of sustainability in healthcare?

E: This is how long ago, when I saw the job posting in 1999 in the newspaper. I’ve always been interested in environmental issues. I did my bachelor’s in organic chemistry at UofT. I did my masters in Forestry and Wood Science also at UofT. And it’s through that, going from chemistry through forestry, I decided I was really interested in environmental issues. So I wanted to get in the field, and I worked for a while as an environmental consultant doing mainly soil and groundwater assessments and remediation. And then this opportunity came into play with some background in Environmental Management Systems required. Again, in the newspaper, applied, got the job, and have been busy ever since. 1999, just over 20 years ago.

Y: Wow that’s incredible. So kind of getting a little bit broader here, what are your thoughts on how environmental sustainability impacts healthcare and vice versa?

E: So I think one reason why, I mean I obviously, hopefully, enjoy my job having been at it so long, is that health and healthcare and environmental health or sustainability are so interlinked. They are things that are high value for me. So for example, just looking at healthcare there, by its nature there’s a lot of waste and a lot of things happening and there’s concern about the overall sustainability of our health system. How do we find these things? By reducing some of the waste and streamlining and giving better working environments and you know better patient care we can support that. And then there’s the more traditional way, where we know a lot more now about how poor environmental health impacts human health, which puts a burden on our healthcare and things like that and we’re seeing very very clearly these days. By dealing with environmental sustainability in healthcare, I can kind of help the healthcare system but also help with health overall which also helps the healthcare system. So it’s all very closely interlinked. I like those connections and it calls for some bigger system thinking I think, but it’s also made it quite interesting.

Y: They definitely go hand-in-hand with each other. I’m sure you’ve got lots going on, but is there a sustainability initiative or program that you’re involved in or you would like to see that you could tell us about?

E: We have some big sites. So we’re very focused on energy efficiency as well as waste. Again when I say we’re involved in everything environmental, we really are. We’re doing some pretty exciting things around energy where we’re saving a lot of money for the hospitals. We’re making them more resilient so it kind of plays into being climate ready for future potential impacts of climate change, making sure the hospitals can withstand them better. But also they’re low carbon too, which is important – public institutions like hospitals are going to be around for a long time. We’re already investing a lot of money in them so we’re almost a good fit for some of these, I wouldn’t say leading edge, but some of these newer ideas. But it takes a bit of work to get these things pushed through. Really excited about that. But having said that, we’re applying the same thing towards transportation. You know lots has happened because of COVID around cycling and active transport. We’ve been working on this for years and now many of the things we kind of wanted to do for a while but didn’t have the resources or the bandwidth, we’re pushing forward with it now.

We’re doing work on food. Tying into the food we feed our patients, but also thinking about food security. Many of the things at the root of inequity we’re seeing with COVID and racial inequities in health, the same roots go for environmental justice. And they’re also tied to healthcare as well. By being able to try and deal with these from our perspective and maybe lead by example and implement things, we’re hoping that we can at least be part of the broader change that needs to happen in overall sustainability and equity.

Y: So we spoke to Lisa [Vanlint] last week which was fantastic. She told us a little bit about the cycling program you guys are recently doing. So exciting – it’s really great. Is there any other program you could tell us about?

E: I don’t know if you guys are familiar with the deep lake water cooling system? We’ve just, in the middle of pandemic, hooked up Princess Margaret Hospital to it. So now we have three of our hospitals hooked up to it. We have a research tower in the MaRS complex that we’re trying to get that hooked up to as well. We also have an education building, the Michener Institute, which we’re looking to get hooked up as well. And then I can’t give you a lot of details but at Toronto Western, which is not close enough to hook up to the Enwave system, we’ve got some really exciting things on the go there. It’s to use thermal energy from sewers.

Y: Wow!

E: It’s basic physics, there’s a few bits of secret sauce in terms of technology but nothing crazy. This is not like AI, this is mostly tried-and-true technology but a really good application and a fortuitous, unique setting we have at Toronto Western Hospital, where we think we can make it work.

Y: So I guess the goal here is to reduce the energy used to cool air and save costs as well as reduce your impact on the environment?

E: Yup and also as I mentioned to add to the resiliency and redundancy for our buildings, to make them more climate-ready if you will.

Cristian: So for the HVAC plan that you have going, and trying to get it to the Western Hospital, what are some of the challenges that you faced in trying to get this into different areas or different places?

E: So just generally speaking, again I can’t give away too many details at this point, it’s a big change, it’s very expensive. So we have to look at financing this. We have to do our due diligence. This is going to go to our boards, so they need to be aware of the risks and how those risks are being mitigated. I think the biggest challenge, again this is not leading edge, this is almost off-the-shelf technology, but the biggest challenge is that it’s a fair amount of work and there’s a lot of people who need to get involved in making sure it works.

The best example is like I said in April we brought Princess Margaret Hospital onto deep lake water cooling in the middle of pandemic, and that involved our energy managers, the consulting engineers, the project team, some of our clinical end users that are going to be impacted, our facilities- a lot of people had to come together, and throw in the pandemic again in April – there’s lots of uncertainty. It really is just juggling many balls and bringing lots of people together. It’s setting a vision and getting people to buy into the vision and working towards it, and making sure that you’re as ready as possible when you get asked those key questions. It’s just more bringing it together. That’s the biggest challenge. I know other organizations have looked at it. They haven’t been successful. And the only reason I can see is that they don’t have a dedicated team like we do who can actually take ownership of something and pay attention to details and see it through to the end.

There’s no difference why we should have this and SickKids doesn’t have it. Why don’t they have it? The fundamentals are exactly the same. It’s really just on their side, they just haven’t had the focus to drive it forward.

C: What are some of the factors that led to the success of the energy environment program?

E: Well what we do is, we have a strategic plan and we focus on making sure that we do good stuff, we engage people, we document what we’ve done and then use that to engage people. So we can show results, tangible results, and not just in dollars, cents, or recycling percentages, but also other benefits as well. That engages people even more and opens them up to ideas, and they’re more approachable when we have different things we want to try.

C: That sounds like you have a really good team of people.

E: Yeah! Everyone says they have the best team, but it is a really good team, and they’re all at some level personally engaged in environmental sustainability, which really helps drive things forward. You probably saw that with Lisa.

C: Yes we did. Now, is there anywhere we can learn more about any of your initiatives.

E: On the website [Talkin’ Trash with UHN] you’ll see there’s all kinds of stuff but if you dig a little deeper there’s some information on the projects we’ve done. So some of the deep lake water cooling, some of the energy retrofits, our food gardens that we’ve implemented, so there’s lots of good stuff there. And if there’s anything you want to dig a bit deeper on, for sure we’d always be happy to share some of those details.

C: Yes, that sounds great. What impact has COVID-19 had on these sustainability initiatives?

E: Good question. So, because we’re an essential service, we were still able to do some of our construction projects. Part of it is doing stuff and part of it is planning for the next round, so we always have something on the go.

The biggest thing, and we don’t know the full impact yet, is around waste. So there’s lots of PPE, and we’ve moved to a lot of single-use stuff due to the hesitancy to reuse things, especially in a hospital setting. We’ve also modified the way we run our buildings in terms of fresh-air, due to the uncertainty around the way COVID is transmitted. This is beyond our code, but we’re doing it for safety reasons, so there’s an energy impact.

We’re kind of in an uncertain mode right now, we’re getting back to basic things and making sure we’re safe. It’s like a bit of recovery I think, you know, for COVID, and for the next COVID whenever that is. Basically adjusting to the new normal, and I think, especially around reusable items, we need a lot more research about what can or can not be reused safely – you know, how many millions of masks and gloves are being used. So, how can we make sure people are safe, but reduce some of the environmental impact. No answers, but there are some people thinking about it and working on it right now.

C: That looks like it’s everything. We want to thank you so much for your time, we’re grateful for you taking the time to speak with us.

E: No worries, glad to be able to help out guys. Take care.

Green Gab with Dr. Edward Xie

The Green Gab

*Cross-posted on Emerging Leaders for Environmental Sustainability in Healthcare’s (ELESH) website as “The Green Gab: Dr. Edward Xie”

Dr. Edward Xie is an Assistant Professor and Faculty co-Lead of Climate Change and Health in the Department of Family and Community Medicine at the University of Toronto. He works as an emergency physician through University Health Network and partners with ELESH as a fellow of the Centre for Sustainable Health Systems.

Edward’s academic interests focus on health services and policy related to determinants of health and inter-sectoral problems, such as homelessness, poverty, addictions, and climate change. He completed an MSc at the LSE and LSHTM with a focus on economic analysis and social policy.

Green Gab: So, before we begin – congratulations to you and to Dr. Green for your new appointments as Faculty Leads of Climate Change and Health.

Edward Xie: Thanks a lot, I really appreciate it.

We’re still trying to feel out where we’re going to go, but we’re hoping to work with leaders in different fields within primary care, and more specifically within the Department of Family and Community Medicine within UofT. We’re looking for ways that we can enhance and improve sustainability within education, quality improvement, clinical practice, and operations of healthcare centres as well. And to do that, we’re working very closely with our social accountability leaders because we know that issues of climate change and health and other environmental issues are very closely tied to local communities and people who may be more marginalized.

GG: That’s really exciting. Could you tell us a little bit about who you are?

EX: I work partly as an emergency doctor and I did my training in family medicine and emergency medicine at UofT and then at McGill afterwards. And I practice a little bit of family medicine, mainly through some volunteer clinics – there’s one through UofT. And there was one serving uninsured populations and now I’m practicing a little bit of family medicine related to isolation centres for people who are experiencing homelessness during the pandemic. Most of the other time I’m doing emergency medicine at the University Health Network. And then the rest of my time is spent on research, teaching and advocacy work.

I have an interest in global health as well, however you want to define that. I work with an academic group that does faculty and learner exchanges with Addis Ababa University. I’ve worked with Doctors Without Borders – MSF – before as well. And then I work on the board of Toronto Environmental Alliance and Canadian Association of Physicians for the Environment. And then loosely with a few other advocacy organizations as well, including the Decent Work and Health Network and others.

GG:  That’s wonderful, so you’re really at the heart of it all. So when were you initially attracted to the field of sustainability in healthcare?

EX:  I had an interest in environmental degradation and environmental protection for a long time now. And then I started to think about its effects on health and how healthcare would have an influence on the environment probably more in the last four or five years. That’s been fairly recent for me. I did a master’s in health policy a few years ago and my thesis was around how to communicate the effects of climate change on health.

GG:  Right. Extending from that point, what are your thoughts on how environmental sustainability impacts healthcare and even vice versa?

EX:  That’s a really great and super complex question. The first part being how does environmental sustainability affect healthcare. We unfortunately don’t have a healthcare system if it’s unsustainable. So, the main questions for me are how can we maintain a healthcare system that undermines itself, for example through emitting pollution, either through air pollution or through greenhouse gas pollution. We know that in Canada, air pollution contributes to over 15 000 deaths each year alone, and so, if the healthcare system is not watching how it contributes to air pollution, that really undermines its own goals.

The same is true for greenhouse gases as well. The estimate is that the Canadian healthcare system contributes about five percent of Canada’s total greenhouse gas emissions, and that’s quite similar to and even rivals other major sectors such as air travel. And so when we think about the goal of healthcare to improve health, it’s really undermined if we’re contributing to air pollution and climate change because we know that both of these can damage health.

Climate change is also going to limit our resources and contribute to supply chain disruptions. A few years ago there was a very strong hurricane, called Hurricane Maria, and it was thought to have been made more intense and more likely because of climate change. It wiped out a major facility that was producing intravenous saline, which is used worldwide as a very common medication to replenish fluids to help with dehydration and low blood pressure. Because of that disruption, there was a shortage all across North America of this very common, very important medication. We can expect that through the many different effects of climate change – either through increasing intensity or frequency of storms, through an increase in wildfires, through sea level rise and other effects around the world where we get all of our medical and healthcare supplies from – that this situation will get worse. We need to think about sustainability as a core issue that’s related to environmental degradation.

Probably the most recent example that’s top of mind is COVID-19, where we’ve seen links between human industry pushing further into the environment, increasing exposure of human societies to new viruses. And there is a link between increased demands on the environment, increased push for resource utilization and this increased exposure to new health conditions that we’ve never had before and creating, unfortunately, new diseases that we’re not prepared for. It’s concerning.

GG:  During your time in this field, is there a sustainability initiative or program that you were involved in or you headed that you could share with us?

EX:  I haven’t done a lot yet. I’m still fairly new to it. If anything, I’m actually taking a lot of inspiration from ELESH that held a really cool event late last year which showcased some really interesting ideas from students from UofT of ways to improve health and reduce the impact on the environment. We also are looking to partners from around the world for inspiration. This includes the UK where they actually have a government mandate and a health system mandate to reduce greenhouse gas emissions. They have a lot of programs and a dedicated health unit that oversees reductions in emissions and sets standards for how healthcare facilities can actually reduce their environmental impact. We’re hoping to implement something like that here as well, where we can offer people a range of different options that they can introduce to reduce their environmental impact.

One of the things that we’re very excited about, and we’re kind of watching other groups being involved in, is this idea of social prescribing, or more broadly shifting healthcare behaviours and shifting models of care towards prevention. Alliance for Healthier Communities here and the National Health System in the UK have been working on this. Instead of focusing on prescribing medications or prescribing healthcare interventions, social prescribing means prescribing things that improve social isolation for people or improve the social and cultural environment for people that helps their health conditions, including mental health. To use social isolation as an example, that contributes to depression, worsening health, and health care utilization.

GG:  What would be some challenges to implementing those initiatives you described from the UK?

EX: The UK actually has a legal mandate to achieve the goals they’ve set out. We don’t have that type of top down leadership to have a long-term vision of drastically reducing our emissions. There is less extrinsic motivation to achieve specific goals. And I think in the UK it’s really a major motivating force where it gets everybody on side with a particular objective. That lack of a mandate is probably the main barrier.  

GG: What are some successes that you have encountered in the healthcare system with regards to sustainability?

For Toronto Environmental Alliance, part of those efforts include changes that on the face of it don’t seem like they relate to health but they actually have a major impact. One of the major initiatives is called Climate Hubs. It works with community groups in community centres or even community health centres to promote awareness of climate change and look for local resources that organically spring from the communities. That has included, for example, neighbourhood gardens, which have several benefits. They serve as a way to have better access to food in parts of the city that are not well served by mass market grocery stores and where past urban planning hasn’t been able to supply access to nutritious and affordable food. They are a way of improving neighbourhood cohesion and social inclusion within the community. They are also a way of increasing green space. So efforts like that are really cool, and it’s really great to see that within that organization. It’s a way of improving health, civic engagement, and neighbourhood cohesion.

GG:  What impact has COVID-19 had on sustainability initiatives?

EX:  It’s been good and bad. Obviously COVID-19 has been tragic in terms of its human toll, and its impact is just devastating to lower resource areas, especially outside of Canada, but also within Canada for remote and rural communities. It can be a lot more difficult to get healthcare, even within cities, when access to healthcare has been reduced. It’s also made it harder to reduce the amount of waste that healthcare is putting out because we find that we are using a lot more single-use masks and PPE. There are different options that healthcare organizations have looked into to improve that. There are certain ways of reusing PPE, of decontaminating it, cleaning it and repurposing it. We’re really hoping to see more of that happening. In some ways it’s been an opportunity to promote innovation along those lines, because with the pandemic there have been disruptions within supply chains. It’s important for us, especially the engineering folks, to look at how we can reduce our use of resources and deliver healthcare more efficiently, so that if there are more supply chain disruptions in the future, we’re not so reliant on having to bring in more resources from outside Canada.

Canada’s been quite slow at developing systems for virtual care and tele-medicine and we’ve seen COVID-19 drive a major push to establish those possibilities where they’re suited to the care that’s needed. So hopefully access to fast internet for communities in Canada improves, and that also improves the access to healthcare through virtual care and tele-medicine. I’m also hoping that it changes the way that we think about work, and in some ways whether it’s possible to do work virtually instead of having to be at work for people who would benefit from or would prefer to work from home. Flexible work hours may help getting around issues related to childcare or having to care for other family members at home. We can also ask if there are opportunities from the pandemic because of the unemployment level that we’re seeing, to have more employment in roles that are extremely beneficial for society but also reduce impact on the environment. Those would be a lot of the caring roles that are important, so not just childcare but also elder care and other social care roles.

GG:  We’re really grateful for you taking the time to speak with us and explain your experience in healthcare and sustainability in healthcare.

EX:  Thanks so much for doing this. What ELESH is doing is fantastic. I really love the energy that’s in your group, so I thank you for actually taking this initiative, it’s awesome. Sorry for my long rambling answers, I’m sure transcribing them will be challenging.

GG:  No worries, we love it.

EX:  Alright thanks guys, take care.

The Green Gab is an initiative led by the Emerging Leaders for Environmental Sustainability in Healthcare (ELESH) that engages health system leaders in conversations about the climate crisis, environmental sustainability, and their vision for the future of sustainable healthcare.

The initiative takes the form of a series of interviews that will be published on the ELESH website. Interview guests include clinicians, non-clinicians, academics, advocates and activists. ELESH hopes to generate public dialogue around the role of healthcare in responding to climate and environmental crisis, and shine a spotlight on leaders who are working to bring healthcare into a sustainable future.

The Green Gab is Paula Samaha, Yousef Safar, Alia Almneni, Cristian Santos, Nargol Salimi, Danielle Toccalino, and Colin Sue-Chue-Lam

All CSHS guest posts are published under the CreativeCommons Attribution Non-commercial Share Alike license. Guest Contributors are free to publish their guest posts elsewhere.

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People, Prosperity and Planet: The role of G7 Countries in Buying the Future We Want. Leveraging Public Procurement to #BuildBackBetter

Sandra Hamilton, PhD researcher at the Manchester Institute of Innovation Research

*This article first appeared on the Manchester Institute of Innovation Research’s (@MIOIR) blog, and has been cross-posted here with permission.

In 2021, amidst a global pandemic, a post-Brexit, globally ambitious United Kingdom assumes the G7 Presidency. Hosting this year’s G7 summit presents the UK with the opportunity to unite the world’s most advanced economies around a more inclusive and sustainable #BuildBackBetter agenda. The Group of Seven consists of the USA, under newly elected President Biden; three EU member states – Germany, France, and Italy; the UK, Canada, and Japan. Operating as a newly independent trading nation, the UK has now secured trade agreements covering all but one, the USA, of the G7 countries, which combined make up a third of an increasingly inequitable global economy.

Economics has become uncoupled from society (Chataway et al., 2014), with increased productivity no longer equating to social progress (Alvaredo et al., 2018; Bivens, 2014; Saez and Zucman, 2016). Under pressure to shape an economy that works in service to society, G7 countries have a global responsibility to unite and design public policies that will proactively influence and shape the directionality of future economic growth (Mazzucato, 2018).  In their role as regulators, G7 governments collectively influence the baseline standards for global trade. While regulation typically seeks to mitigate race-to-the-bottom market activity, public procurement offers an underutilised, potentially powerful, policy mechanism to stimulate and reward the most responsible, rise-to-the-top market actors.

“As large institutional customers, G7 countries must now become exemplary role models in the advancement of strategic Sustainable Public Procurement (SDG12.7)”

As large institutional customers, G7 countries must now become exemplary role models in the advancement of strategic Sustainable Public Procurement (SDG12.7). On January 1st, 2021, the UK became the first nation in the world to mandate that taxpayer-funded contracts must be fully leveraged to maximise social value. The UK’s policy progression from the voluntary guidelines in the 2013 Social Value Act, to the mandatory inclusion of social and environmental criteria in public procurement contracts (UK GOV, 2020) emulates the best practice leadership established at the sub-national level by Wales, Scotland and across the Greater Manchester Region.

In the pursuit of #SDG 12.7 Sustainable Public Procurement, the gap between the G7 leaders and laggards is growing.  In Canada, the integration of sustainability criteria in public procurement has been described as superficial (Da Ponte et al., 2020). Today, a Canadian company bidding on a UK central government contract will, in addition to price and quality, also be evaluated based upon their level of commitment to addressing a societal problem. The fact that Canada has no equivalent policy or legislation requiring companies bidding on taxpayer funded contracts to do the same is a disservice to Canadians and reflects how very different national, and sub-national, approaches to public procurement can be; despite operating under the same trade agreement.

Webinar Global Policy Innovation: To #BuildBackBetter, public procurement is increasingly being transformed into a social policy mechanism. Some G7 countries have significantly strengthened policy and enacted legislation to stimulate more transparent, socially responsible supply chains in taxpayer-funded contracts. On February 10th, 2021, in this webinar hosted by the Centre for Sustainable Health Systems at the University of Toronto’s Institute of Health Policy, Management, and Evaluation, in partnership with the Centre for Global Health at the Dalla Lana School of Public Health, University of Manchester, MIOIR PhD candidate Sandra G. Hamilton will discuss global trends and the level of policy ambition across G7 countries to advance SDG 12.7 – UN Sustainable Development Goal, Sustainable Public Procurement.

Date:  Wednesday, February 10th, 2021

Time:   12pm EST, 5pm GMT

Topic:  Building Back Better: Sustainable Health Systems after COVID-19

Register HERE

Bibliography

Alvaredo, F., Chancel, L., Piketty, T., Saez, E., Zucman, G., 2018. The Elephant Curve of Global Inequality and Growth. AEA Papers and Proceedings 108, 103–108. https://doi.org/10.1257/pandp.20181073

Bivens, J., 2014. Raising America’s pay. Why It’s Our Central Economic Policy Challenge. Economic Policy Institute. URL https://www.epi.org/publication/raising-americas-pay/ (accessed 1.12.21).

Chataway, J., Hanlin, R., Kaplinsky, R., 2014. Inclusive innovation: an architecture for policy development. Innovation and Development 4, 33–54. https://doi.org/10.1080/2157930X.2013.876800

Da Ponte, M., Foley, M., Cho, C.H., 2020. Assessing the Degree of Sustainability Integration in Canadian Public Sector Procurement. Sustainability 12, 5550. https://doi.org/10.3390/su12145550

Mazzucato, M., 2018. The Value of Everything. Making and Taking in The Global Economy. Penguin, Random House, UK.

Saez, E., Zucman, G., 2016. Wealth Inequality in the United States since 1913: Evidence from Capitalized Income Tax Data *. The Quarterly Journal of Economics 131, 519–578. https://doi.org/10.1093/qje/qjw004

UK GOV, 2020. Procurement Policy Note 06/20 – taking account of social value in the award of central government contracts [WWW Document]. GOV.UK. URL https://www.gov.uk/government/publications/procurement-policy-note-0620-taking-account-of-social-value-in-the-award-of-central-government-contracts (accessed 10.13.20).

ABOUT THE AUTHOR

Sandra G. Hamilton is a UK/Canadian PhD researcher at the Manchester Institute of Innovation Research (@MIOIR). Her research investigates public sector innovation and the role of public procurement in shaping more responsible business conduct and sustainable markets. Sandra is Canada’s first Social MBA, designer of Canada’s first municipal Social Procurement Frameworks and, as a recognised industry expert, in 2017, she was invited to present her work on ‘The Importance of People, in a People, Planet, Profit approach to Sustainability” at the WTO Symposium on Sustainable Government Procurement in Geneva.

If you’ve got an idea for a blog post you’d like to author, please contact us.

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Canada's plans to reach net-zero carbon by 2050 must include the health sector

Vivian Tseng, CSHS Intern

As more Canadians experience the devastating effects of pollution, wildfires, heat waves and the spread of infectious diseases brought about by climate change, the calls to action become more urgent. This month, the Government of Canada has taken a major step in answering these calls by releasing the Canadian Net-Zero Emissions Accountability Act. Under this new legislation, the government is required to incrementally establish five-year targets to reduce greenhouse gas emissions beginning in 2030. Though the plan currently lacks specifics on implementation and enforcement, its ultimate goal is to achieve net-zero emissions by 2050 in accordance with the international targets outlined in the Paris Agreement, to which Canada has committed.

However, if Canada’s lackluster track record in meeting similar targets over the past three decades is any indication, the country’s ability to meet this newest goal is far from certain. Canada failed to achieve the 2012 target made under the Kyoto Protocol and is currently on track to miss both its 2020 and 2030 targets to reduce greenhouse gas emissions by 17% and 30%, respectively, below 2005 levels. The Government of Canada acknowledges it will need “support and engagement from all parts of society, including provinces, territories, Indigenous Peoples, youth, and businesses” if it is to have any chance at achieving net-zero emissions by 2050.

Though not explicitly identified, Canada’s healthcare sector, which had the third highest greenhouse gas emissions per capita globally in 2019, has a key role to play in helping the country meet this target. Healthcare-related carbon emissions arise largely from supply chains and service models; they are collectively responsible for 5% of Canada’s total greenhouse gas emissions, and result in 23,000 disability-adjusted life years lost annually. The 2019 policy briefing for Canada in the Lancet Countdown Report on Health and Climate Change articulated an urgent need for the development of a sustainable, national initiative to achieve net-zero emission healthcare by 2050. In establishing a framework to reduce emissions which will work alongside the new legislation, Canada’s healthcare sector can take inspiration from the United Kingdom.

Source: Government of Canada

In response to England’s own broad target of reaching net-zero carbon emissions by 2050, the National Health Service (NHS), which has long been actively working to reduce its carbon footprint, ramped up its efforts with a commitment (first announced earlier this year) to eventually eliminate all net carbon emissions under its direct control.  The NHS fleshed out the logistics of this commitment and revealed its intention to reach net-zero carbon by 2040 in a report published last month, making it the first healthcare system to execute a national plan to reduce emissions.

The news could not have come at a more opportune time, as more research coming out of the COVID-19 pandemic points to climate change as a driver of adverse health effects and health inequalities. In fact, air pollution is the leading cause of environmentally related morbidity and mortality worldwide, responsible for one in eight deaths globally. Health systems will need to respond to the increasing number of (disproportionately inflicted) climate-change related health impacts, but they can also play a more proactive role by seeking to mitigate their own, not insignificant, contributions to climate change. Accordingly, the direct action taken now by the NHS to address the carbon emissions associated with the activities identified in Figure 1 below will benefit public health and health equity in the long-run.

Figure 1: Sources of carbon emissions by proportion of NHS Carbon Footprint Plus

Source: National Health Service

The NHS plans to eliminate all emissions generated in the NHS Carbon Footprint Plus. This includes the emissions from travel by patients and visitors, and the 3 scopes presented in Figure 2 (below):

• Scope 1: Direct emissions from owned or directly controlled sources, on site

• Scope 2: Indirect emissions from the generation of purchased energy, mostly electricity

• Scope 3: All other indirect emissions that occur in producing and transporting goods and services, including the full supply chain

Figure 2: Greenhouse gas protocols scopes in the context of the NHS

 Source: National Health Service

The NHS’ sustainability interventions for each scope include:

• Estate and facilities: Using on-site renewable energy and heat generation, optimizing building usage, upgrading buildings, and improving building insulation, lighting and heating

• Travel and transport: Electrification of NHS transportation, increased virtual care and preventative care, and using active transit

• Supply chain: More efficient use of supplies, using low-carbon substitutions and product innovation, and by ensuring suppliers are decarbonising their own processes

• Anaesthetics & Medicines (25% of emissions within the NHS): Optimizing prescribing, substituting high carbon inhalers and anaesthetic gases for low-carbon alternatives, and improvements in production and waste processes

“The climate emergency is a health emergency.
NHS, 2020”

 Along with these interventions, the NHS envisions a new service model - one that is:

1. focused on preventative care to reduce demand for healthcare services and benefit patients throughout their life course;

2. digitally-enabled to support patients through virtual care and monitoring. Not only will this reduce the emissions caused by travel to and from healthcare facilities, but patients may benefit (albeit to varying degrees given the digital divide) from greater access to care and the increased efficiency that results from fewer unnecessary hospital visits and admissions;

3. equity-based to focus efforts on reducing air pollution and improving access to green spaces in racialized and poorer neighbourhoods, which are disproportionately affected by air pollution and already at greater risk of poor health outcomes.

The NHS recognizes that “The climate emergency is a health emergency.” The healthcare sector has a responsibility to address climate change due to the significant effects it has on population health and in worsening health inequalities. Going net-zero comes with a variety of benefits, including promoting health, reducing air and water pollution, and saving costs. Even more significant is the projected amount of lives (5,770) which will be saved per year by 2040 in the United Kingdom due to reductions in air pollution. Although it is difficult to quantify the outcomes of this plan, these early projections show promising potential benefits for health.

The healthcare community has a tremendous opportunity to take a lead role in mitigating the threat to human health brought about by climate change. The NHS has set a strong example by laying the groundwork for a realistic and effective plan to reach net-zero carbon emissions by 2040.  Canada’s healthcare sector must follow suit if the country is to achieve net-zero carbon emissions by 2050 - an ambition that must be met to protect the health of Canadians and the planet.

About the author:

Vivian Tseng (BHsc) is a first year Master of Public Health (MPH) student at the Dalla Lana School of Public Health, University of Toronto. She holds a bachelor's degree in Psychology and Health Studies from the University of Toronto. Vivian is interested in health equity, specifically how to shape policies and programs to ensure equitable access to the social determinants of health necessary to improve population health outcomes. 

All CSHS guest posts are published under the CreativeCommons Attribution Non-commercial Share Alike license. Guest Contributors are free to publish their guest posts elsewhere.

If you’ve got an idea for a blog post you’d like to author, please contact us.

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Green Gab with Lisa Vanlint

The Green Gab

*Cross-posted on Emerging Leaders for Environmental Sustainability in Healthcare’s (ELESH) website as “The Green Gab: Lisa Vanlint”

Lisa Vanlint is the Energy Steward at University Health Network and has worked there since 2011. Lisa focuses on employee engagement, behavior change and environmental compliance in varied areas of sustainability including energy, waste, procurement, toxics and transportation. She also captains a dragon boat team (extremely sustainable transportation!).

Green Gab: So first off, could you tell us a little bit about who you are?

Lisa Vanlint: So, I’m Lisa Vanlint. I work at University Health Network (UHN) and I’m an Energy Steward there working in the energy and environment department. I’ve been there since 2011, and I must say it’s a very exciting place to work and a particularly exciting department to work in because I get to bring sustainability and healthcare together. These are two things that I absolutely love, and there is so much crossover, though not everybody sees it. The more people make this connection, the more we can build healthy societies, not to get too grand, but why not?

There’s a lot going on at UHN, from the hands-on patient care to the research element, to the training of all staff. There’s an element for sustainability in everything that happens. And that’s one of the wonderful things about my department is that we try to work with all different elements of UHN to ensure that happens. 

My role focuses on training and engagement. There’s a lot of project work as well, but the training and engagement part is definitely the fun side. So, one of the things that I do like to do is try and make sure that if somebody is doing something good already, that we can amplify whatever that is so that people can say, “Oh wait, that’s a good idea. I hadn’t thought of that. Why don’t we do that? We can do that”. It’s amazing how easy it becomes once one person has done that leading to being able to bring more people into the fold.

GG: Wow, that’s fantastic. I was doing some background and the list of stuff you’re involved in when it comes to the Energy Steward role is incredible.

LV: Thank you. One of the other things is that it gets to be a part of healthcare but it’s also a lot of other things. So, there’s the energy element, so energy conservation, waste reduction, toxics dispositions, so we want to make sure that people throw things out properly when they do have to throw things out. And it can even do some of the more fun things like sustainable transportation, how people are getting to and from- and actually that’s been one of the things that has been taking a lot of my time lately, in a great way. As well as even sustainable food and gardens and things like that. But sustainable transportation is the project I’m currently working on, to help increase our bike parking infrastructure, which really helps.

GG: When were you initially attracted to the field of sustainability in healthcare?

LV: I was always attracted to the idea of sustainability ever since I was a teenager and went to the Environmental Youth Alliance conference where I met David Suzuki and saw him speak for the first time. Now this was a long time ago, when he was new. I’m dating myself a little bit there, but that’s okay. And that was absolutely eye opening. 

Fast forward a few years and actually I’m in nothing related to sustainability but I’m in healthcare. But I knew it was important to understand how systems work in healthcare, and then there was an opportunity to become the Greening Coordinator at St. Michael’s Hospital where I worked at the time. And I saw that job description and was so excited by it because again it went back to the idea of sustainability and it was a very exciting role to take. So, I went from there and then went to University Health Network. It’s been a nice journey. 

GG: So kind of getting a little bit broader here, but what are your thoughts on how environmental sustainability impacts healthcare, even vice versa?

LV: So, one of the things we try to talk about a lot is climate change. I know right now everybody is thinking of the other C-word, COVID-19, but climate change hasn’t gone anywhere in this time and in fact I think there’s a lot more awareness of how the climate affects our health. 

With places like India shutting down and then all of a sudden having air that they can breathe and see through, there’s actually a lot of avoided deaths that we’re having because of lowered amounts of air pollution, for example. 

There’s such a correlation between the climate and health that I hope that everybody else gets it as much as I think that this group does. Because if we ignore it as well, if we live in a way that doesn’t acknowledge the importance of our climate and the importance of sustainability, then we will create so many more health problems. So, there is such a link between us and our environment. Now the good thing is, if we fix many of the things in our environment, we also fix so many things in health. So, really, it’s a public health issue.

GG: Is there a sustainability initiative or program that you were involved in or that you headed within the healthcare system?

LV:  A lot of people normally would travel to work via TTC. Because of COVID-19, people are a little nervous to do so because of fears of transmission. You know, trying to avoid public spaces. It would be devastating if everybody all of a sudden went from taking transit to driving a car to work – think about what the gridlock would be like, and as we know climate change is coming from us burning fossil fuels, not to mention the fact it’s really expensive to build parking lots. We don’t have the space to do that and it would be a terrible waste of funds to do so. 

On the other hand, we can actually fit a lot more people in bike parking infrastructure, and we’re glad to see the City of Toronto has put in 40km more protected bike space. If you build it, they will come. They’re coming. We’re getting more inquiries about cycling and UHN in the 4 months than we had in the last 4 years. So, we’re about to increase our cycling infrastructure by about double. 

And it doesn’t sound like much, but that simpler thing allows people to make a much healthier choice, and it’s healthy for the environment as well.

GG: What are some challenges that you’ve faced trying to implement this?

LV: Funding.

The reason the best things don’t happen all at once and easily is because someone has to pay for it. So, it’s trying to make sure that, I guess, everybody has the right intention and also the right funding source in order to make sure this happens. And that you can prove that whatever you’re doing is an effective use of funds as well. Not every sustainability project saves money, but many of them do, especially when they’re related to energy. Often you can show that, “Hey, if we do this, then every year we save X amount of dollars”. At this point in time, we’ve got a fantastic graph, you can see it in our annual report, and I forget what the recent amount is, but it’s in the many, many millions of dollars that we’re saving cumulatively through our energy projects.

GG: What are some of the factors you think have led to your success in this position?

LV: I’ll give a lot of credit to my boss, Ed Rubinstein, he’s fantastic. One of the things that he’s always insisted on is metrics. For everything that we do, we try to measure the impact. We try to make sure that we have ongoing project tracking so that we know exactly what we’ve done and where we want to go and how to get there. I try to tell my son this – does not work well. One day.

GG: That’s very good to hear. What’s the next step for your plan at the moment?

LV: There are so many plans that are going on right now, I’ve only talked about a couple of things. I haven’t even fully appreciated things like so many staff that are part of sustainability like our Green Team. You basically are a Green Team, but this is all UHN staff. They’re welcomed to join the Green Team and this is just people who kind of want to act almost like a fire marshal but for the environment for their area. Though we’ve got a great team in Energy and Environment, we’re small and UHN is huge. There are over 16,000 employees, that’s a lot of ground to cover. I can’t have this one-on-one conversation with everybody, I would love to, that would be great. So the Green Team by training them, it’s following the “train the trainer” methodology, where they’re able to sort of go into their areas and use that lens of sustainability to look around and say, “Oh, you know, this we can improve. Why are we doing that? Maybe we need to do this”. And there’ve been so many projects where there was waste reduction or going to reusables when something was single use. There’s always a challenge though because, and I’m finding this from COVID, speaking about single use, that everybody has gotten so comfortable with the idea of disposable everything. Eventually we’re going to have to unlearn a lot of the things that we learned in that respect. At the same time as protecting ourselves and our communities. I don’t think that in order to protect everyone that we have to necessarily go to everything disposable. We’ll get there. 

GG: Yeah we’ll get there, exactly. Now, in terms of the project for biking, is there anywhere where people can read more about the initiative?

LV: For the bike initiative, we haven’t put it out there yet, as to how big a lot of these bike parking plans are going to be. Mostly because we don’t want to announce it until it’s ready to go so people can use it. So, no. We’ve hinted it to our bicycle user group, which is about 600 or so staff that are interested in cycling and we just send them information about a little bit that’s going on at UHN for cycling, so they are shortly going to be really excited. We consulted with them as well, so I think they know some things going on because I did say, “Blue skies, if you could have everything you wished for, what would you like?” to make sure that, because, you know, we’ve had our plan, but I might be missing something if I’m not at a specific place and don’t know what their concerns are. I was happy to see that what we wanted to do turned out to be what we should be doing, but we had even more good feedback to make sure we were on the right path. But when it comes to most things, we put everything on our blog, Talkin’ Trash with UHN. 

GG: Alright, well, we’re really grateful to have you here, thank you so much for everything, for your time.

LV: Thank you, any time.

The Green Gab is an initiative led by the Emerging Leaders for Environmental Sustainability in Healthcare (ELESH) that engages health system leaders in conversations about the climate crisis, environmental sustainability, and their vision for the future of sustainable healthcare.

The initiative takes the form of a series of interviews that will be published on the ELESH website. Interview guests include clinicians, non-clinicians, academics, advocates and activists. ELESH hopes to generate public dialogue around the role of healthcare in responding to climate and environmental crisis, and shine a spotlight on leaders who are working to bring healthcare into a sustainable future.

The Green Gab is Paula Samaha, Yousef Safar, Alia Almneni, Cristian Santos, Nargol Salimi, Danielle Toccalino, and Colin Sue-Chue-Lam

All CSHS guest posts are published under the CreativeCommons Attribution Non-commercial Share Alike license. Guest Contributors are free to publish their guest posts elsewhere.

If you’ve got an idea for a blog post you’d like to author, please contact us.

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Virtual Care as Environmentally Sustainable Health Care

Bobby Gheorghiu, Waldo Beauséjour, and Nicole Simms

*Cross-posted on Canada Health Infoway’s website as “Environmentally Sustainable Health Care”

What happens when a pandemic meets a heat wave? It’s a question that many jurisdictions are asking themselves this summer, weighing the need for emergency cooling centres against the continued need for physical distancing. This intersection between COVID-19 and climate change shows in microcosm the interconnections between health systems and natural systems.

We know that climate change affects a wide range of human activities, but we don’t always think of its impacts on health care. Yet climate change is a risk factor for worse health outcomes, whether through direct impacts such as heat-related illness, or indirectly through factors like poor air quality.

In turn, the health care system has significant effects on the environment. If the global health system were a nation, it would be the fifth largest emitter of CO2. While the bulk of these emissions arise from the procurement of medications and equipment, the energy needs of infrastructure and health-related travel comprise a substantial portion as well.

In our recent webinar, researcher Nicole Simms noted that as the health system’s purpose is to improve health outcomes, it must also take steps to mitigate the environmental effects that compromise them.

To that end, the increasing use of virtual care holds promise for reducing carbon emissions. According to Infoway’s 2019 Access Digital Health Survey, Canadians in rural areas traveled an average of 23.6 km to their regular place of care, while their urban counterparts traveled an average of 13.1 km, both significantly larger distances than the approximately 4-7 km travel break-even point (depending on vehicle fuel efficiency) needed to offset the relatively minor carbon emissions of virtual care.[1]

The virtual delivery of care has particular implications for carbon savings in Canada. While Canadians’ cars are among the world’s least fuel efficient[2], our energy grid is comprised largely of non-carbon-emitting sources.[3] The virtual delivery of care thus allows us to replace fuel-inefficient cars with technology run on relatively clean energy. If half of in-person visits were replaced by virtual visits, carbon emissions would be reduced by 325,000 metric tons. These savings are equivalent to taking more than 70,000 passenger vehicles off the road for a year.

A 50 per cent adoption rate might sound high, but we’re already there. Since the beginning of the COVID-19 pandemic, approximately 60 per cent of visits have been conducted virtually, either by video, telephone or text/email.

There are potential environmental savings on a systemic level, as well. From past studies, we know that patients with access to their personal health information are more confident in managing their care, particularly with respect to chronic conditions. Virtual care can provide a means to improve continuity of care and help manage conditions before they worsen. Better health outcomes mean patients are likely to require fewer hospital admissions and/or emergency department visits, thus reducing care-associated emissions further.  

Reducing emissions also decreases the health risks associated with climate change. And as we’ve seen, better health outcomes reduce health system usage—  and therefore, emissions. Simms describes this as a “positive feedback loop,” with increasingly significant benefits to patients and the environment.

The COVID-19 crisis has opened space in which to reassess how we deliver care. By incorporating environmental sustainability into our health system post-COVID, we can protect the health of patients and the planet. Working together, we can avoid making our next health crisis an environmental one.

Interested in continuing the conversation? Watch our webinar “How the Rise of Virtual Care is Contributing to Sustainable Healthcare,” and tune into the Digital Health InfoCast on August 4 to hear Nicole Simms in conversation with Bobby Gheorghiu and Waldo Beauséjour.

[1] Holmner A, Ebi KL, Lazuardi L, & Nilsson M. (2014). Carbon footprint of telemedicine solutions-unexplored opportunity for reducing carbon emissions in the health sector. PLoS One. 2014;9(9):e105040.

[2] International Energy Agency (IEA), 2019, (Fuel Economy in Major Car Markets: Technology and Policy Drivers 2005-2017). https://webstore.iea.org/fuel-economy-in-major-car-markets

[3] Natural Resources Canada. Energy Fact Book: 2019-2020.  https://www.nrcan.gc.ca/sites/www.nrcan.gc.ca/files/energy/energy-factbook_EN-feb14-2020.pdf

ABOUT THE AUTHORS

Bobby Gheorghiu
Senior Manager, Performance Analytics
Canada Health Infoway

Bobby works with stakeholders in academia, private and public sectors to develop and monitor performance targets for initiatives such as PrescribeIT®, Canada’s national e-prescribing service, to ensure widespread adoption of technology and to demonstrate tangible benefits of investments in digital health. He holds an MHSc in Health Policy, Management, and Evaluation from the University of Toronto.

Waldo Beauséjour
Analyst, Performance Analytics
Canada Health Infoway

Waldo holds a Master’s degree in Applied Economics. He currently serves as Analyst, Performance Analytics at Canada Health Infoway. He has experience in applied social research and quantitative research methods for over 10 years. He has led and contributed to several quantitative surveys, research and impact evaluations aiming at investigating the impact of government-led or funded interventions on health outcomes.

Nicole Simms, PhD
Managing Director
Centre for Sustainable Health Systems, University of Toronto

Nicole is the Managing Director of the Centre for Sustainable Health Systems, which works in collaboration with health partners to shift healthcare practice and policy toward comprehensive (environmental, social, and financial) sustainability, from the ground up and the top down. She holds a PhD from the Department of Geography, Environment & Society at the University of Minnesota, and an MA in Geography/Environmental Studies from the University of Toronto.

All CSHS guest posts are published under the CreativeCommons Attribution Non-commercial Share Alike license. Guest Contributors are free to publish their guest posts elsewhere.

If you’ve got an idea for a blog post you’d like to author, please contact us.

IF COVID-19 IS THE SPRINT TO SAVE HUMANITY, THEN CLIMATE CHANGE IS THE MARATHON

Sharon Au, Guest Contributor

As the head of the World Health Organization Climate Change Unit, Diarmid Campbell-Lendrum recently stated, “if COVID-19 is a sprint to save lives, then acting on climate change is the marathon”. The coronavirus disease 2019 (COVID-19) has brought unprecedented challenges globally to society and the economy, highlighting the vast impacts that human activities have on the environment.

In efforts to control the spread of COVID-19, China implemented strict self-quarantine measures, traffic restrictions, and closure of businesses and other industrial facilities. The economic slowdown at least partly contributed to the significant reductions in nitrogen dioxide (NO2), as shown from NASA and European Space Agency (ESA) pollution monitoring satellites.

Source: NASA Earth Observatory

““… the silver lining is that it has highlighted the substantial human health benefits of aggressive air pollution control measures…” ”

Similar reductions have been observed globally. NASA satellite data show that March 2020 NO2 levels just across the border in North Eastern U.S. were about 30% lower than the March average between 2015 to 2019.

Source: NASA

Meanwhile in Canada, the Southern Ontario Centre for Atmospheric Aerosol Research (SOCAAR) has released preliminary data which indicate that nitrogen dioxide and ultrafine particulate matter in downtown Toronto have dropped by almost half their concentrations prior to the economic slowdown.

Source: Southern Ontario Centre for Atmospheric Aerosol Research

A recent study has estimated that the improved air quality during the quarantine period prevented a total of 8,911 NO2-related deaths, of which 65% were from cardiovascular diseases, such as hypertensive disease, coronary heart disease, and stroke, as well as chronic obstructive pulmonary disease (COPD). On top of that, another 3,214 deaths related to fine particulate matter (PM2.5) were avoided, 73% of which were from cardiovascular diseases and COPD. These estimates are of China alone – so imagine the impact of air pollution reduction on a global scale. While COVID-19 has caused a significant number of deaths, the silver lining is that it has highlighted the substantial human health benefits of aggressive air pollution control measures, including significantly reduced pollution-related mortalities.

A study of air pollution and severe acute respiratory syndrome (SARS) – a viral respiratory infection also caused by a coronavirus – showed that SARS patients with short-term exposure to moderate air pollution indices (APIs) had an 84% increased risk of death from SARS compared to those with short-term exposure to low APIs. SARS patients from regions with high APIs had double the risk of death from SARS compared to those from regions with low APIs. Similarly, a national study from the Harvard T.H. Chan School of Public Health concluded that an increase of only 1 µg/m3 in long-term exposure to PM2.5 leads to an 8% increase in COVID-19 mortality.

““… let’s take COVID-19 as a wake-up call and take a step back to reassess our path moving forward.” ”

Epidemics like COVID-19 will occur increasingly frequently, as the world becomes increasingly interconnected from globalization and urbanization, and the impacts of climate change become more extreme and frequent. Air pollution and respiratory health is just one of the many causal links between environmental and human health. With the strong interconnection between environmental and human health, the solution to addressing both of these complex issues lies in an integrated systems-based approach. Let’s take COVID-19 as a wake-up call and take a step back to reassess our path moving forward. As we begin to recover from this pandemic, many environmental efforts are being abandoned, such as the surge in single-use plastics (particularly for personal protection and healthcare), and suspension of environmental regulations in Alberta and Ontario to support industries. On the bright side, many environmental efforts have emerged that we should continue to support, like more virtual meetings, conferences, and appointments, more time spent outdoors, and the City of Toronto’s road closures for pedestrians and cyclists, which encourage active transportation while practicing safe social distancing.

““We must take the lessons learned from this crisis, and act on environmental and human health simultaneously going forward – ultimately, it will better prepare us for the next pandemic.””

We must take the lessons learned from this crisis, and act on environmental and human health simultaneously going forward – ultimately, it will better prepare us for the next pandemic. Thankfully, the Government of Canada has recognized that air pollution increases susceptibility to viral respiratory infections, and have taken steps to improve air quality by working to reduce emissions, protect against wildfire smoke, conduct research on air pollution, and form international agreements and partnerships. The economic stimulus funding from COVID-19 can be our golden ticket to create a paradigm shift towards prioritizing both environmental and human health – more specifically, to develop a more preventative, resilient, and ultimately sustainable health system.

Healthcare professionals have a commitment to the Hippocratic Oath of “first, do no harm” –that is, to always first consider the potential harm any intervention poses. This has led healthcare in the direction of a reactionary approach with a focus on the avoidance of harm, rather than a preventative approach with an emphasis on the creation of health. What can we do to move towards the latter?

First, exposure to nature has a multitude of associated health benefits, as well as the potential for reducing social and economic costs of poor health. One study demonstrated positive relationships between doses of nearby nature and mental and social health, increased physical activity, and nature orientation. So healthcare practitioners in North America and Europe are now prescribing nature or “nature pills” to those under their care. This effective, simple, preventative, and low-cost treatment for health and well-being should become common practice amongst healthcare practitioners.

With the rising urgency for action on sustainability, it is more important than ever for enhanced cooperation through partnerships across sectors, governments, and the world. Implementing Goal 17 of the United Nations Sustainable Development Goals (UN SDGs) – Partnership for the Goals – is vital to ensure sufficient means to achieve the UN SDGs. Here are some examples of initiatives the healthcare industry can work collaboratively with others to accomplish:

• Fund and conduct research and monitoring on the relationship between environmental and human health.

• Advocate and provide expertise in health for stricter environmental laws, regulations, and policies.

• Raise awareness and promote action through the integration of environmental and human health into formal and informal education programs and awareness campaigns.

• Protect, increase, and improve green spaces, such as designing more urban parks, developing more hygiene stations in outdoor settings, and implementing more road closures for active transportation.

• Address social determinants of health through initiatives such as: increasing long-term and community support; improving access to healthcare (e.g. evening and weekend access, telemedicine, services in multiple languages or with interpreters, and transportation); and advocate for social change.

• Support the transition to a low carbon economy through operational changes within healthcare facilities, and political advocacy.

““The urgent, collective, international response to COVID-19 proves that the world can come together to make quick and impactful changes to protect humanity.””

The urgent, collective, international response to COVID-19 proves that the world can come together to make quick and impactful changes to protect humanity. So let’s take the momentum we’ve gained from the sprint to save humanity from COVID-19, and channel it towards the marathon; that is, to save humanity from climate change!

This moment can be a turning point in our long journey to sustainable development. With current health expenditures making up approximately 10% of gross domestic product (GDP), the healthcare industry has an immense opportunity to influence change. The Centre for Sustainable Health Systems (CSHS) is focused on working together to transform the health system into one that truly supports health. Stay tuned for more resources on actions you can take towards creating a more sustainable health system.

About the author:

Sharon Au is a respiratory therapist turned sustainability professional with 12 years working in frontline healthcare, a Certificate of Environmental Sciences, a Master of Environment and Business, and experience in various sustainability roles. From healthcare to sustainability, she has carried her passion to care for others and make a difference.

Follow Sharon on LinkedIn

All CSHS guest posts are published under the CreativeCommons Attribution Non-commercial Share Alike license. Guest Contributors are free to publish their guest posts elsewhere.

If you’ve got an idea for a blog post you’d like to author, please contact us.

ELESH leading interdisciplinary environmental initiatives among health faculties students at UofT

Nicole Simms, CSHS Staff

As current and future health professionals, engaging health faculty students in health system sustainability is of crucial importance in achieving the necessary shift toward environmentally sustainable health systems. Since its inception less than a year ago, we here at CSHS have been awed and inspired by the work of the student-led Emerging Leaders for Environmentally Sustainable Healthcare (ELESH) to this effect. From hosting a successful case competition to winning multiple grants and awards, ELESH has worked tirelessly to develop creative approaches to its primary objective of encouraging “interdisciplinary learning and action to address issues of environmental sustainability across the many disciplines and professions that deliver healthcare.”

To read more about ELESH’s great work over the past year, click here.

Sustainable Dentistry Gaining Attention in Canada

Nicole Simms, CSHS Staff

In an encouraging development on the sustainable dentistry front, the issue of dental waste has recently been taken up at the University of Manitoba, where dental hygiene students in the newly formed Student Environmental Group are seeking ways to reduce the amount of pre-clinic, clinic, and general waste produced at the Dr. Gerald Niznick College of Dentistry in the Rady Faculty of Health Sciences.  These students note the challenges of reducing dentistry’s environmental impact while still having “to follow provincial and national guidelines on things like infection prevention and control” – a sentiment echoed by UofT’s Carlos Quinonez in his recent editorial for the Ontario Dental Association’s Ontario Dentist Journal. In “IPAC Versus the Planet?” Dr. Quinonez discusses the tension between the profession’s new Infection Prevention and Control (IPAC) guidelines and the need to address “the amount and environmental impacts of the plastic and other solid waste produced by dental practices every day and every year” – especially in light of the severity of the impending climate crisis.

In calling on a variety of actors to address this apparent impasse, including policymakers, regulators, associations, and manufacturers, Dr. Quinonez draws attention to the systemic changes needed to support the emergence of a more sustainable health system in Canada – this isn’t something individual practitioners can accomplish on their own, though immediate, permissible changes to practice that enhance sustainability remain an important part of the solution. The role these – and other – actors can play in the requisite multifaceted approach to sustainable dentistry is explored in a newly published paper in the Journal of Dental Research co-authored by our own Dr. Fiona Miller. The work also emphasizes the need to embed environmental sustainability into the dental curriculum and to prioritize research that facilitates evidence-based sustainable practices.

The need for a multifaceted approach to sustainable healthcare has actually been acknowledged by the Canadian Dental Association (CDA) since at least 2009, when it was one of twelve national organizations that signed a joint statement titled “Toward an Environmentally Responsible Canadian Health Sector” alongside the David Suzuki Foundation. The statement included the following calls to action:

• That government at all levels understand and address links between health and the environment and incorporate these links into policy decisions through legislative and budgetary actions.

• That health care organizations pledge to minimize the negative impact of their activity on the environment and to seek solutions to existing barriers.

• That individuals working in the health care sector both model and advocate for environmentally responsible approaches to delivering health care without compromising patient safety and care.

Don Friedlander, then-president of the CDA, offered support for what he termed “the protection of the environment in the context of health care,” noting that the CDA “encourage[s] change in consumption patterns and best practices of ecologic stewardship. After all, this stewardship is in the best interest of everyone’s health.”

While the CDA’s recognition that dentistry has a role to play in mitigating the environmental impacts of the health sector demonstrated foresight, Canada currently lags behind several other countries when it comes to promoting and establishing sustainable dentistry practices. In the UK, for example, where significant resources are devoted to facilitating a shift toward sustainable healthcare, resources on sustainable dentistry abound: the British Dental Journal has published series of papers on the topic, and the Centre for Sustainable Healthcare’s 2018 Sustainable Dentistry: A How To Guide for Dental Practices offers practical information on how the profession can best approach travel, equipment and supplies, energy, waste, biodiversity and greenspace, and measuring and embedding sustainability.

The joint statement that the CDA signed back in 2009 acknowledged the difficulty of efforts like these; this is why it included a pledge to “seek solutions to existing barriers.” That these solutions would involve education, research, and collaborations with policy-makers, vendors, and others was also clearly articulated. As more Canadian dental students and practitioners contribute to the growing body of academic and policy work calling for and crystallizing the logistics of this type of multifaceted approach to sustainable healthcare, we hope to see it increasingly operationalized in this country. A shift toward sustainable dentistry is a necessary component in the realization of that 2009 vision to which the CDA was a signatory: a green Canadian health sector in which “minimizing negative impact on the environment [is] a priority for all organizations and individuals in their day-to-day practices and at all levels of decision-making.”