Climate Change and Healthcare Pollution: Balancing Patient Safety and Public Health with Jodi Sherman, MD

Transcript

• 00:00Welcome everybody to the final
• 00:02evening ethics seminar at the Yale
• 00:04Program for Biomedical Ethics.
• 00:06The final one for this year.
• 00:07Of course we'll be back in in September,
• 00:11but for tonight,
• 00:12I want to introduce Doctor Sherman.
• 00:13But just before I do that to remind
• 00:15you folks who are here and you focus
• 00:17on zoom to let you know how it
• 00:19works is after a brief introduction,
• 00:20I'll turn it over to Doctor Sherman.
• 00:22She'll speak for 45 minutes plus minus.
• 00:25After that, we're going to have time for
• 00:28some discussion questions you guys have.
• 00:30And the folks on Zoom,
• 00:31you can send questions in through
• 00:33the Q&A portion of Zoom,
• 00:35not through chat, but through Q&A.
• 00:37I'll be reading those questions to to Jody
• 00:40and we will, I'll moderate a session.
• 00:43We'll have here a discussion and we'll
• 00:45finish sometime between 6:00 and 6:30.
• 00:47We'll see, Well, we won't go past 6:30,
• 00:50we'll see how we do.
• 00:51So with that said,
• 00:53let me introduce tonight's speaker,
• 00:55Jody Sherman is Associate Professor
• 00:57of Anesthesiology at the Yale
• 00:58School of Medicine.
• 00:59And associate professor of Epidemiology
• 01:01and Environmental Health Sciences
• 01:03and the founding director of
• 01:05the Yale Program on Healthcare,
• 01:06Environmental Sustainability in
• 01:08the Yale Center on Climate Change,
• 01:10and Health.
• 01:11Doctor Sherman also serves as the
• 01:13Medical Director for Yale New Haven
• 01:16Health Center for Sustainable Healthcare.
• 01:18She's an internationally recognized
• 01:19researcher in the emerging field of
• 01:21sustainability and clinical care.
• 01:23Her research interest is in life
• 01:25cycle assessment of environmental
• 01:27emissions human health impacts.
• 01:28And economic impacts of drugs,
• 01:30Devices, clinical care pathways,
• 01:32and Health systems.
• 01:34Her work seeks to establish
• 01:36sustainability metrics paired with
• 01:37health outcomes and costs to help
• 01:40guide clinical decision making,
• 01:41professional behaviors,
• 01:42and organizational management toward
• 01:44more ecologically sustainable practices.
• 01:46To improve the quality, safety,
• 01:48and value of clinical care,
• 01:50and to protect public health.
• 01:52She collaborates with environmental
• 01:54engineers, epidemiologists,
• 01:55toxicologists, health economists.
• 01:57Health administrators,
• 01:58health professionals and most
• 02:00importantly bioethicist tonight, right.
• 02:03Come on.
• 02:04And when I could go on the the her
• 02:07credentials are quite impressive
• 02:09and I just heard today that you
• 02:11were just made coeditor of the
• 02:14British Journal of Anesthesiology.
• 02:15Is that right?
• 02:18Of a special issue. Got you.
• 02:20Well that's not nothing. Okay.
• 02:22I just got this hot hot off the presses.
• 02:24But a little if I got a little wrong,
• 02:25I apologize.
• 02:28Jody trained at the Stanford University,
• 02:31where she was a resident,
• 02:32did a fellowship at University
• 02:34of California at San Francisco.
• 02:36She did her internship at Columbia
• 02:38and received her MD at SUNY
• 02:40Downstate College of Medicine.
• 02:41So we're really fortunate,
• 02:43and I'm a little bit embarrassed to
• 02:45say that this is such a colossally
• 02:46important topic and not one that
• 02:48we've really addressed yet in the
• 02:50program for biomedical ethics.
• 02:51So I think, and this is on me,
• 02:53I think we're a little late to the party,
• 02:55but I'm glad to be here.
• 02:57And we are so pleased that
• 02:57you've made time for us tonight.
• 02:59Thanks a lot, Jody.
• 03:02Well,
• 03:09thanks so much for that kind introduction.
• 03:12I have disclosures,
• 03:13I do have grant funding from the
• 03:15Canadian Institutes of Health Research,
• 03:17Commonwealth Fund and I do serve
• 03:19as faculty for the Institute
• 03:22for Healthcare Improvement.
• 03:23So for learning objectives for today,
• 03:25I hope you'll be able to identify
• 03:27relationship between healthcare
• 03:28pollution and disease burden,
• 03:30summarize some of the latest
• 03:32healthcare pollution findings.
• 03:34Importantly,
• 03:34discuss some ethical conflicts and hopefully
• 03:37describe opportunities for investigation,
• 03:39practice improvement and regulatory reform.
• 03:42So like many people in this emerging space,
• 03:47my interest started during my
• 03:49residency training where was so much
• 03:51fun to be able to do my specialty of
• 03:53anesthesiology take care of patients.
• 03:56And at the same time,
• 03:56it was blatantly obvious that
• 03:58there's a problem.
• 03:59We're using so much stuff,
• 04:01we're wasting so much stuff used and unused.
• 04:03Throwing it away must be causing
• 04:05some harm to the environment.
• 04:08And so really it's I asked a
• 04:10question what is best practice for
• 04:13both patients and public health,
• 04:15and there was little to no information
• 04:17which started me on my career journey.
• 04:20And so I thought it would help
• 04:22me to review some of the core
• 04:24principles of bioethics.
• 04:25I actually was a philosophy
• 04:26major as an undergrad,
• 04:27but it's been quite some time since.
• 04:29I delve into these core concepts,
• 04:32Of course applying them to medical ethics.
• 04:34But beneficence a duty to help the
• 04:36patient advance their own good and to
• 04:38act in their pay in their best interest,
• 04:41autonomy,
• 04:41they do need to honor the patient's
• 04:43right to make their own decisions
• 04:45and to be selfdetermining.
• 04:47Non malfeasance or the duty
• 04:48to do no harm to the patient,
• 04:50which is really what we most
• 04:51think about when we think about
• 04:53the Hippocratic Oath and justice.
• 04:54A duty to be fair and how the care is
• 04:58provided and how resources are allocated.
• 05:01What about public health ethics?
• 05:03This is something I definitely
• 05:05was not taught in medical school.
• 05:06There are some very variabilities to it.
• 05:09It distinguishes itself by emphasizing
• 05:12communitarian values and social justice.
• 05:15And balancing individual autonomy
• 05:16and the economy.
• 05:17Good remains central,
• 05:18but does not begin with emphasis
• 05:20on individual interests.
• 05:22So beneficence of potential benefits
• 05:25to individuals and society should be
• 05:28maximized and potential harms minimized.
• 05:30Non malfeasance includes harm to
• 05:32both patients and public health
• 05:34and should be avoided.
• 05:35Autonomy, duty to honor,
• 05:37rights of self, determination.
• 05:38But this includes members of the community,
• 05:41not just the patients.
• 05:42And justice,
• 05:43maximizing public utility of all affected,
• 05:46which raises questions of equality versus
• 05:49equity and intergenerational rights.
• 05:52And I start thinking further
• 05:54because I work very intently in
• 05:57healthcare administration.
• 05:58Corporations are entities too.
• 06:00Or so does, say, our 17th Amendment.
• 06:04I actually had a hard time
• 06:07finding these same principles.
• 06:08Applied to corporate ethics,
• 06:10But they're there, just in different forms.
• 06:12But it's defined as application of
• 06:15ethical values to business behavior
• 06:16relative to both conduct of individuals
• 06:19and the organization as a whole.
• 06:22Applies to any and all
• 06:23aspects of business conduct,
• 06:24from boardroom strategies and how companies
• 06:27treat their employees, how they treat
• 06:29their producers and their suppliers.
• 06:31Their sales techniques and accounting
• 06:33practices and so try to stretch them
• 06:35to the same principles of beneficence,
• 06:37so that maximizing benefits to shareholders.
• 06:41But I would ask what timeline
• 06:43because there's a difference.
• 06:44If it's a short timeline,
• 06:45then great is good for your shareholders.
• 06:48If it's a longer timeline,
• 06:49sustainability or business is also the
• 06:52same as sustainability of the planet.
• 06:54And I think there are differences between
• 06:57publicly and privately held corporations.
• 06:59Autonomy.
• 06:59I couldn't really make a stretch here.
• 07:01Maybe the audience has some ideas now.
• 07:03Not non malfeasance, of course.
• 07:05Duty to do no harm to the company,
• 07:07whether it's reputation, finances,
• 07:09harm being sustainability as well.
• 07:12And then justice.
• 07:12I already elucidated some of those on
• 07:15how it's applied, including to fair,
• 07:17fair treatment of employees,
• 07:18whether it's wage promotions,
• 07:20diversity, equity, inclusion,
• 07:21being fair with the customer suppliers.
• 07:25And to the community and I think
• 07:27we might even consider structing
• 07:30that to ecosystems in nature.
• 07:32Of course there's a concept
• 07:34of environmental ethics
• 07:38and how we define that I think
• 07:41is is up for conversation.
• 07:44So, but why sustainability in
• 07:48healthcare pollution is the
• 07:50leading cause of morbidity and
• 07:52mortality responsible for 9,000,000.
• 07:54Premature deaths annually,
• 07:55or 16% of all premature deaths,
• 07:59is due to pollution.
• 08:02Healthcare itself is a leading
• 08:04emitter of environmental pollutants.
• 08:05It's against our mission to do no harm.
• 08:08Reducing healthcare pollution can
• 08:09improve the triple bottom line,
• 08:10the best care for the most
• 08:12patients at the least cost.
• 08:14And why I got involved in this work
• 08:16as a healthcare professional is that
• 08:19engaging each other in this industry.
• 08:24Really can be key for public
• 08:26policy and societal transformation.
• 08:27Healthcare is an enormous part
• 08:29of our economy. We are well
• 08:31respected members of the community.
• 08:32Now we do talk a lot or I you'll hear
• 08:34me talking a lot about climate change,
• 08:36carbon dioxide equivalents greenhouse gases,
• 08:39these this is from Rockstrom
• 08:42and Stefan Whitney.
• 08:45The describes the planetary ecosystem in
• 08:48terms of boundaries and 9 dimensions.
• 08:52Where we are outside the planet's
• 08:56ability to regenerate itself,
• 08:58threatening life on Earth.
• 08:59Climate change is just one of those concerns,
• 09:02of course, and biodiversity loss,
• 09:03which is closely related to land use?
• 09:06We are in the midst of the
• 09:08sixth great mass extinction,
• 09:09probably heard calls for 30 by 30,
• 09:11or protecting 1/3 of untouched
• 09:15natural systems by 2030.
• 09:17And of course,
• 09:18nitrogen and phosphorus loading,
• 09:19for example, through fertilization.
• 09:21So for, excuse me,
• 09:23agricultural fertilization.
• 09:24So we're already well beyond the planet's
• 09:28ability to regenerate itself in these
• 09:30areas and really have to act fast.
• 09:33Gray are areas where we don't
• 09:35have enough scientific data yet.
• 09:37Doesn't mean we're not outside
• 09:39the boundaries.
• 09:40But importantly,
• 09:42we can reduce these problems
• 09:45by providing less care.
• 09:47That's not the goal.
• 09:49Obviously,
• 09:49we want to provide better care
• 09:52and more care for the most people.
• 09:54And so there's this concept of the
• 09:57social foundation that we want
• 09:58to be above the the foundation,
• 10:00so no one's left behind but below.
• 10:04The ecological system is so-called
• 10:07donut economics.
• 10:08So even those talk will be
• 10:10mostly about climate change.
• 10:11I would be neglectful if we didn't
• 10:13talk somewhat about plastics.
• 10:15Most plastic is actually
• 10:16derived from fossil fuels,
• 10:18so their sources and their business
• 10:21interests are very similar.
• 10:22If we consider if we
• 10:24continue business as usual,
• 10:26there will be more plastic volume
• 10:28than fish in the ocean by 2050.
• 10:30And it's not just what's
• 10:31floating on the surface.
• 10:32If you've heard of the great
• 10:34gyres or the garbage patches or,
• 10:36you know,
• 10:37there was a.
• 10:39Very well known 18 year old who developed a
• 10:41device that safely skims a surface ocean.
• 10:43That's not going to solve this issue.
• 10:46There's plastic at the bottom of the
• 10:49ocean and in fact there's no place
• 10:52that's untouched by plastic pollution.
• 10:54And of course the fossil fuel drive plastic,
• 10:57which is about 95% or more of all
• 11:00our plastic doesn't go anywhere.
• 11:01It just breaks down into smaller
• 11:03and smaller pieces.
• 11:03And so we've got micro
• 11:06nanoplastic pollution problem.
• 11:07I literally can't keep up
• 11:08with the evidence on this.
• 11:09Every time I do a slide a talk,
• 11:13I end up adding more and more
• 11:15on to this list.
• 11:17Plastic is ubiquitous in our tap
• 11:19water and table salt around the world.
• 11:22Found in human stool,
• 11:23Found in wild animal stools and
• 11:26remote places on the planet.
• 11:28Found in human blood, Found in placentas.
• 11:30Found in breast milk,
• 11:31found in sperm, Found in lungs.
• 11:34And now the nanoplastics are
• 11:36found in the brain have breached
• 11:39the blood brain barrier.
• 11:41This is being called the plasticine error.
• 11:45And it's not just obstructive concerns.
• 11:49These plastics are laden with chemicals,
• 11:53and so there's a cocktail
• 11:57chemical contaminants,
• 11:59many of which are known neurotoxins.
• 12:02Endocrine disruptors, carcinogens.
• 12:04And so we are constantly
• 12:08being exposed to all this.
• 12:11And so industrial chemicals
• 12:15are not regulated the same as
• 12:17pharmaceuticals and pharmaceuticals.
• 12:19You you have to demonstrate safety before
• 12:22releasing something to the marketplace.
• 12:24The opposite true is of chemicals.
• 12:26There's more than 100,000
• 12:28industrial chemicals in existence.
• 12:30There is no requirement to prove safety
• 12:32before releasing them into the marketplace.
• 12:35The the trouble is that with 100,
• 12:39you know, 100,000 chemicals out there,
• 12:41how do you prove harm?
• 12:43It's a it's the same exact
• 12:45story as a tobacco story,
• 12:47and there's been a movement toward
• 12:49the precautionary principle,
• 12:49which is prove proving safety first
• 12:52before releasing to the marketplace.
• 12:55And then the healthcare sector,
• 12:57I never thought about this in my training,
• 12:58but the healthcare sector is a
• 13:01leading purchaser of chemicals.
• 13:03On the right is an image from the
• 13:05famous Body Burden study from
• 13:06the environmental working Group.
• 13:08This started the whole biomonitoring field.
• 13:12There was A at the time.
• 13:14This is now, gosh, at least 15 years ago,
• 13:17if not actually more than 20 years ago.
• 13:18I'm dating myself a very small study
• 13:21looking at new board newborn cord.
• 13:24Samples across the United States
• 13:28for 267 chemicals of concern.
• 13:30Out of those 100,000,
• 13:32virtually every single chemical
• 13:33is found in every single one
• 13:35of those blood cord samples.
• 13:37So in other words,
• 13:38babies are being born polluted.
• 13:40There's a massive experiment being
• 13:42conducted on all of us without consent.
• 13:46So I am going to shift to climate change.
• 13:48It will be the bulk of this talk.
• 13:50Climate change is called a health emergency.
• 13:56An urgent action.
• 13:57There's still a window where we can act.
• 13:59Urgent action is required to secure a fair,
• 14:03equitable and livable future for all.
• 14:05It's not that we're going to go away,
• 14:07but civilization will look very
• 14:08differently if we don't change things.
• 14:11We're already seeing harm from 1.2 degrees
• 14:15average centigrade surface temperature
• 14:18change compared to preindustrial baseline.
• 14:22So if we'll get historic emissions.
• 14:25Business as usual.
• 14:26We're seeing a four to five
• 14:29degree centigrade average change,
• 14:31which is not compatible with human life.
• 14:34Our current policies to mitigate
• 14:35bring us between 3:00 and 4:00.
• 14:38Pledges get us somewhere between 2.6 and 3.2,
• 14:41the Paris agreement,
• 14:42so even though there was global
• 14:45consensus on signing this.
• 14:47Not all national policies actually
• 14:49get us to that.
• 14:50And really,
• 14:51the scientific community says we need
• 14:53to limit warming to 1 1/2 degrees
• 14:55centigrade in order to avert the worst
• 14:58predicted harms to civilization this century.
• 15:01And in fact, this is possible than
• 15:02the laws and chemistry and physics.
• 15:04It requires unprecedented
• 15:06scale and timeline of action.
• 15:09And in fact,
• 15:10there's there's some really
• 15:11great lessons from the COVID.
• 15:1219 pandemic,
• 15:13where the global community came together,
• 15:15shared scientific information,
• 15:17shared resources.
• 15:19We actually can do this.
• 15:20This is a matter of political will.
• 15:23And so nobody's death certificate is
• 15:24going to say climate change on it.
• 15:26So direct effects of climate change,
• 15:28including more storms and floods,
• 15:30droughts, heat waves,
• 15:32wildflowers, these are wildfires.
• 15:34These are direct effects of climate change.
• 15:37Indirect effects are things
• 15:39like poor water quality,
• 15:41air pollution and physical harm
• 15:47through from storms and then physical
• 15:51displacement of populations,
• 15:53causing political instability,
• 15:55which we're actually already seeing.
• 15:58And not everyone is affected equally,
• 16:00so those most vulnerable are often.
• 16:05Harmed the worst and the
• 16:07least capable of adapting,
• 16:09and so some of the known health
• 16:11impacts from all of these include,
• 16:14of course, mental illness,
• 16:17problems with food and and water nutrition,
• 16:21worsening allergy seasons,
• 16:24worsening cardiovascular
• 16:26serovascular disease,
• 16:27of course infectious diseases,
• 16:28and so forth.
• 16:31Climate change also impacts health systems.
• 16:34In addition to seeing altered healthcare
• 16:36patterns of increased disease burdens,
• 16:38there's structural risks to our our
• 16:41buildings or utilities or physical
• 16:44infrastructure supply chain interruptions.
• 16:47There's a lot of similarities
• 16:49with with the COVID-19 pandemic,
• 16:52and a lot of lessons to be taken as well.
• 16:56And in fact, we're already saying this.
• 16:58There's increased numbers of billion dollar
• 17:02storms in the United States every year,
• 17:05both from wildfires and from hurricanes,
• 17:08flooding. These are already dated.
• 17:10Hard to even keep up with it all on the left,
• 17:12of course. Hurricane Sandy,
• 17:14which we felt certainly here in New Haven.
• 17:17I live just off the Grand St.
• 17:19at the time,
• 17:20right on the Quinnipiac River.
• 17:22My whole street was flooded and was
• 17:24evacuated by the National Guard.
• 17:26And of course you're seeing some
• 17:28famous images here of NYU Langone
• 17:30being evacuated on the right,
• 17:31of course the campfires which leveled
• 17:34the the the Paradise Fire also
• 17:38leveled the Adventist Health Center.
• 17:41You're seeing it being evacuated
• 17:42literally an hour before it caught fire.
• 17:45So we're already seeing these disruptions.
• 17:47And then, of course,
• 17:48supply chain disruptions.
• 17:49Hurricane Maria, most famously,
• 17:51people across the United States
• 17:53were aware of saline shortages,
• 17:55but also there were drug shortages.
• 17:57This led to patient safety concerns from
• 18:01substituting less desirable medications,
• 18:04changing protocols,
• 18:05cancellation of elective cases
• 18:07due to these shortages.
• 18:09And then of course,
• 18:10my specialty of anesthesiology was also.
• 18:13Specifically affected the
• 18:14small vials if you pivocain,
• 18:16which are used for spinal anesthesia
• 18:18for commonly used for emergency
• 18:21C sections were completely out.
• 18:24Ironically,
• 18:24we had to substitute 30ML vials which
• 18:28we cannot easily safely split split
• 18:31between patients without creating new
• 18:33systems and so we had this paradox of
• 18:36throwing away 99% of this drug when
• 18:40we had shortages of the smaller one.
• 18:43And so Healthcare is a major
• 18:45contributor to this problem.
• 18:47Our organizations run 24/7,
• 18:49they have hightech therapeutic
• 18:51and diagnostic equipment.
• 18:53Our industry is very unique
• 18:55requirements for infection prevention.
• 18:58We have a regulatory complexity
• 19:00and business models that Dr.
• 19:02wasteful unnecessary utilization of
• 19:04resources and we have a culture of excess
• 19:08and where disposability is normalized.
• 19:11And of course,
• 19:12we have a social mission
• 19:12to our individual patients.
• 19:14So we feel that we're doing good
• 19:15in the world and we are doing
• 19:16good at the world in the world.
• 19:18But what about public health?
• 19:19What about the harm we're causing at the
• 19:22same time that we're helping patients?
• 19:24And so this is our work with The Lancet
• 19:26Countdown in health and Climate change.
• 19:28Globally,
• 19:28the healthcare sector emits 5.2% of
• 19:32total global greenhouse gas emissions.
• 19:35Healthcare is an enormous part
• 19:36of our economy, 10% globally,
• 19:3820% of United States.
• 19:411/4 of these global emissions
• 19:42come just from the United States,
• 19:45even though we're only we only
• 19:47have 4% of the population,
• 19:50so we have the highest per capita
• 19:52healthcare greenhouse gases in the world.
• 19:54Now if we had the best
• 19:55healthcare system in the
• 19:56world, that might somehow justify
• 19:58those emissions, but we don't.
• 20:001/4 of services globally in 1/3
• 20:02in the United States are deemed
• 20:05inappropriate or low value wasteful.
• 20:07Half the world Box likes lacks
• 20:09access to essential health services.
• 20:11In the United States.
• 20:13Half of Americans are on or under insured,
• 20:1711% totally uninsured.
• 20:18And we can see if we plot per
• 20:21capita healthcare greenhouse gas
• 20:23emissions against some measure
• 20:25of healthcare system quality.
• 20:28We've used many measures now
• 20:29and the story is the same.
• 20:31Here you're seeing the I HME's
• 20:33Healthcare Access and Quality Index.
• 20:36You can see the United States is
• 20:38by no means the best performing
• 20:40health system in the world,
• 20:41despite having the highest
• 20:43greenhouse gas emissions.
• 20:45But there's a good news in this
• 20:47story here and that there is
• 20:49room to improve and reduce our
• 20:52emissions while maintaining or
• 20:53even improving healthcare quality.
• 20:55To break even point is around
• 20:58400 kilograms per capita,
• 20:59and so right now we're about four times that.
• 21:02But there there is a positive story here.
• 21:06But if we look at the disease
• 21:08burden from healthcare,
• 21:09to help trying to contextualize
• 21:11the scope here,
• 21:13we've estimated that healthcare pollution,
• 21:14both greenhouse gas and non
• 21:16greenhouse gas pollution,
• 21:17together cause an estimated 388,000
• 21:20disability just of life here's lost annually,
• 21:23especially from particulate matter.
• 21:25And the biggest source of particulate
• 21:28matter and greenhouse gas emissions
• 21:30emissions is fossil fuel combustions.
• 21:32Clean up our energy and we'll do a lot here.
• 21:36This harm is similar.
• 21:37Magnitude is death due to medical
• 21:39errors as first reported by the
• 21:41Institute of Medicine in 1999 in
• 21:42the famous to Errors Human report,
• 21:44which found 44 to
• 21:4944 to 98,000.
• 21:51I believe it was premature deaths
• 21:54due to medical errors or ACT.
• 21:56The actuaries say it's about
• 21:5810 years of life lost.
• 22:00For each of those deaths,
• 22:01and if you multiply that by ten,
• 22:03we're in the same order of magnitude
• 22:05as harm from healthcare pollution.
• 22:07And if there's no other take away,
• 22:09it's this that pollution prevention
• 22:11is the new patient safety movement.
• 22:14Everything we do in Healthcare is
• 22:16through the lens of patient safety.
• 22:17Since this report came out,
• 22:19we thought we were doing good beforehand
• 22:21and we learned not Harm is just as big
• 22:24from healthcare pollution and it cannot
• 22:27be ignored and in order to impact.
• 22:29You have to know where there's emissions
• 22:31coming from and several studies including
• 22:34our own paint a similar picture.
• 22:36About 2/3 of healthcare
• 22:38come from the supply chain.
• 22:40The goods and services that we use to
• 22:43deliver care about 5% for anesthetic gases
• 22:46and pressurized metered dose inhalers.
• 22:49Building energy and transportation are are
• 22:51other big areas but the biggest one here.
• 22:54Is the supply chain,
• 22:56especially pharmaceuticals and chemicals,
• 22:58medical devices and supplies and food,
• 23:02and the two ways to impact
• 23:04or mitigate these emissions.
• 23:05One is to address waster and
• 23:07efficiency in the system.
• 23:08Clinicians, administrators, regulators.
• 23:10We control consumption of resource.
• 23:13The other big way to reduce emissions
• 23:15is to use stuff and services with
• 23:18less embodied emissions in them.
• 23:21Manufacturers,
• 23:21regulators they control will
• 23:22go to marketplace,
• 23:24although we have some agency and
• 23:26some of the things that we select.
• 23:28So I'm going to shift gears and
• 23:29talk about the problem with
• 23:31healthcare acquired infections.
• 23:32This is one of the harms that
• 23:34it is our duty to prevent.
• 23:37There are about 700,000 healthcare
• 23:39acquired infections annually in acute
• 23:41care hospitals in the United States and
• 23:43it's the number one adverse event globally.
• 23:45About 75,000 premature deaths annually,
• 23:48the United States causing costing between
• 23:506 and $7 billion from excessive care.
• 23:55And this data is already old,
• 23:57so I would imagine it's even
• 23:59larger than that.
• 24:00It is our duty, obviously,
• 24:02to prevent harm from healthcare
• 24:05required infections.
• 24:06Unfortunately,
• 24:06this is driving a trend toward
• 24:09excessive use of single use
• 24:11disposal devices and drug waste.
• 24:14And anyone who's in the clinical care spaces
• 24:17knows exactly what I'm talking about here.
• 24:20So I'm going to give you an example
• 24:22from the perioperative space,
• 24:24although this is just one type of infection,
• 24:26surgical site infection,
• 24:27we go back a couple 100 years.
• 24:30If you had a major surgery,
• 24:31you had about 95.
• 24:32Percent chance of getting an infection.
• 24:34About a 40% chance of survival.
• 24:37Along comes my hero is somewhat wise
• 24:39and then of course pastor and listor.
• 24:41So germ theory.
• 24:44Of course Lou and Hook in the
• 24:47microscope and and the ability to see
• 24:50those terms and to do pasteurization
• 24:52have aseptic antiseptic techniques
• 24:55and most important things that have
• 24:58happened in the history of medicine.
• 25:00To decrease infections and
• 25:03increase survivability,
• 25:05the next blip you see here
• 25:06in the curves is
• 25:07from the introduction of antibiotics
• 25:09between World War One and World War Two,
• 25:11the next greatest invention
• 25:14in the history of medicine.
• 25:17And so now you're seeing as we refine
• 25:20our antibiotics and treatments over
• 25:22time or asymptotically approaching 0,
• 25:26and now you have less than a 5%
• 25:28chance of getting infected and
• 25:30greater than 95% chance of survival.
• 25:31But we have a problem here if
• 25:34you blow up that portion of the
• 25:35curb as we're trying to get to 0,
• 25:37we're throwing more and more and
• 25:39more stuff trying to get to 0 and
• 25:43we're ignoring the increasing harm,
• 25:44the increasing indirect.
• 25:46Burden of disease from all
• 25:48the stuff we're using,
• 25:50all the stuff we're throwing away.
• 25:52And we really have to ask this question,
• 25:54is IF0 healthcare acquired infections?
• 25:57Are they realistic and we cannot
• 26:00ignore the indirect damages.
• 26:02Now of course causes of
• 26:04infection are multifactorial.
• 26:05The two most important things
• 26:07to prevent infection are staff
• 26:09discipline and a something,
• 26:11an antiseptic technique,
• 26:13especially washing our hands,
• 26:15which we know we don't do enough of.
• 26:17And then of course,
• 26:18the patient health status,
• 26:18are they immunocompromised?
• 26:19You have diabetes,
• 26:21they have immune disorders,
• 26:22Do they have cancer?
• 26:24Of course, exposure site types
• 26:26and quantities of inoculation,
• 26:27those two matter as well.
• 26:29But we know we've got a problem.
• 26:30We don't wash our hands enough and
• 26:33we're not going to cure hand washing
• 26:36or diabetes by throwing more and
• 26:38more disposables at the problem.
• 26:40And we also have another problem and that
• 26:43is what we've learned through the pandemic.
• 26:45And that our supply chains are
• 26:48very vulnerable to interruption.
• 26:50We require so much stock to be
• 26:52coming in and out because of our
• 26:55reliance on single use disposal.
• 26:57The supply chains are very fragile.
• 27:00On the left are this is the United States on.
• 27:02On the left you're seeing
• 27:04some nurses in Brooklyn,
• 27:05NY, on the right in England,
• 27:07in the UK These are hard images
• 27:10to look at and of course.
• 27:13Our global supply chain,
• 27:15and it benefits us in many ways
• 27:17because it can reduce production
• 27:19costs and storage costs,
• 27:21reduces local pollution in some countries,
• 27:23but it actually increases
• 27:24pollution in other countries.
• 27:26And we know that there are unfair
• 27:27wages in other countries and unfair
• 27:29labor practices in other countries.
• 27:31So there's a real question about it.
• 27:33Is it just?
• 27:34And there's also a lack of
• 27:36transparency of suppliers.
• 27:38And so we do know who our
• 27:39direct suppliers are,
• 27:40but it is well known that it
• 27:44is very rare that second tier,
• 27:47third tier suppliers are transparent.
• 27:50And any vital hub in this web
• 27:54can take the whole system down,
• 27:57which is what happened partially
• 27:59would happen with the pandemic.
• 28:00And whether it's climate change or pandemics,
• 28:02the risks are the same.
• 28:04Now part of the problem we have
• 28:07in the Healthcare is over cleaning
• 28:09over sterilization critical items.
• 28:12Things that normally contact
• 28:13sterile tissue need to be sterile.
• 28:16Some uncritical items are those
• 28:18that contact mucous membranes are
• 28:20not intact skin.
• 28:21They do not need to be sterile.
• 28:22Things that you put in your
• 28:24mouth do not need to be sterile.
• 28:26Obstetrics procedures.
• 28:29Colorectal procedures and two procedures.
• 28:32Many of those are not sterile techniques and
• 28:35many of them do not require sterile devices.
• 28:39And then non critical items.
• 28:40Things that touch intact skin are
• 28:42blood pressure cuffs or pulse oximeter.
• 28:44Probes are bed linens.
• 28:46These are things that are pillows.
• 28:48These are things that are
• 28:50disposable or patient.
• 28:51Gowns are are are clinician gowns.
• 28:54These are things that are disposable.
• 28:55It's it's really rather insane.
• 28:58I'm going to give him one example
• 28:59from my own practice now.
• 29:01We use thousands of medical
• 29:03devices every day in a hospital.
• 29:05I call this a bit of a Canary.
• 29:06This is laryngoscope.
• 29:07Of course we used to put in a breathing tube,
• 29:09has two parts,
• 29:11the tongue blade and the handle.
• 29:14There has been some,
• 29:15so the tongue blade goes in the mouth.
• 29:17So that's a semi critical device that
• 29:19must be at least high level disinfected.
• 29:22So that goes down to the central
• 29:25sterilization department for processing.
• 29:27The handle, something we hold on
• 29:29to is considered low risk,
• 29:31and so low risk items are
• 29:33cleaned at the point of use.
• 29:35But there has been a loophole in
• 29:38CDC designation of this handle.
• 29:41There's been conflicting designations
• 29:43by professional societies,
• 29:45and so the CDDC leaves it to
• 29:49industry to decide, well,
• 29:52industry by their own declarations.
• 29:55Are not infection prevention specialists.
• 29:57They can say how to clean something.
• 30:00They can't say what level of risk it is.
• 30:03And so,
• 30:04but industries jumped all over
• 30:06this and so now there is saying
• 30:09that these are intermediate risk
• 30:11devices and must go down to
• 30:14central sterilization and supply.
• 30:15Or alternatively you can buy their
• 30:18single use disposable device.
• 30:20And so there's this wave.
• 30:22Of moving to single use of
• 30:25social devices across the country
• 30:28because of this regulatory risk.
• 30:29And so there's this concept of greenwashing.
• 30:32There are many different aspects to it,
• 30:34but in general it's a practice of
• 30:36making unwarranted or exaggerated
• 30:37claims of sustainability or
• 30:39environmental preference and an
• 30:41attempt to gain market share.
• 30:43This particular device was presented to
• 30:47our Peri Operative Manager as a green device.
• 30:51Because it could be recycled.
• 30:53Well, that is questionable,
• 30:55but nonetheless, I didn't.
• 30:57And also cheaper,
• 30:58but I didn't take anyone's word for it.
• 31:00So we got together with their
• 31:02engineering students and it was
• 31:03called the Life Cycle Assessment.
• 31:05LCA is a modeling tool for quantifying
• 31:07the total resource inputs and
• 31:09environmental burdens over the
• 31:10life cycle of a product or process.
• 31:13We tend to think about stuff
• 31:15as we're using it.
• 31:16We think less about what goes into
• 31:19manufacturing it and even less about
• 31:21the natural resource extraction that
• 31:23even preceded the manufacturing.
• 31:25And we might think about something,
• 31:28what happens to something when
• 31:29we throw it away.
• 31:30But unless you consider all
• 31:31of these things together,
• 31:32you can't make very fair you
• 31:35can't make any assessment
• 31:36of environmental performance.
• 31:38And so LCA considers the entire system the
• 31:42the hotspots are not always intuitive.
• 31:45And importantly, even though we I talk and
• 31:46we talk a lot about greenhouse gas emissions,
• 31:49carbon emissions, it's not the only
• 31:51environmental pollutant of concern.
• 31:53There are multiple environmental
• 31:54impacts and we have to be careful.
• 31:55We're not shifting one problem to another.
• 31:58So this is a method of quantifying
• 32:00emissions for design and decision support.
• 32:03And so very briefly we did an LC of the.
• 32:07Reasonable disposable laryngoscope.
• 32:08So for the single use disposables,
• 32:11the SUD's we consider raw
• 32:12material extraction all the way,
• 32:14manufacturing,
• 32:15packaging and then eventually throwing
• 32:17away and compare that to reusable.
• 32:20Now importantly,
• 32:21especially if you're reading the literature,
• 32:23you don't have to know how to interpret it.
• 32:25The handle was rated for 4000 uses,
• 32:28so one disposables compared to 1/4
• 32:32thousandth of a reusables manufacturing.
• 32:36And packaging and transportation to
• 32:40one use in cleaning and repackaging
• 32:43and one four thousandth of the device
• 32:46being thrown away in one package.
• 32:48So you have to do a fair comparison.
• 32:50We also looked at cost.
• 32:51We considered refurbishment.
• 32:53We consider labor costs and disposal fees.
• 32:56Now there's a lot of information here.
• 32:58I just want you to squint at it.
• 33:00There are some clear things to
• 33:02take away here.
• 33:02The Gray is a disposable and
• 33:05the green are the reusable.
• 33:07So even though the vendor told us
• 33:09that it was more costeffective and
• 33:11more environmentally friendly to you
• 33:13because we could recycle that device,
• 33:16that is not what we found.
• 33:17The disposable device several times,
• 33:21the emissions of all different scenarios
• 33:24and how to clean the reusable and.
• 33:27It also increased our cost by about $700,000,
• 33:32just our one department.
• 33:33The other take away here is the waste phase.
• 33:37Now the manufacturer said it's green,
• 33:40you can recycle it.
• 33:41Actually all those components are
• 33:43not recyclable and you have to go
• 33:45to a vendor willing to take it,
• 33:47which would be about 1000 miles away.
• 33:50But for the sake of argument,
• 33:52so the red here is the average US waste mix,
• 33:55so a fraction is.
• 33:57Recycle The fraction is incinerated
• 33:59in a fraction of landfill.
• 34:01For the sake of argument,
• 34:02we said what if we could 100%
• 34:04recycle this device, which we can't.
• 34:06But what if we could?
• 34:07That's what this bar is representing.
• 34:09And what this means is that we
• 34:13cannot overcome the higher emissions
• 34:16of these devices by recycling.
• 34:17We cannot recycle our way out of this issue.
• 34:21And in fact,
• 34:22we need to ask ourselves what a
• 34:24singleuse disposal device is.
• 34:25There is an industry called reprocessing,
• 34:27which third party takes some of
• 34:29our disposal devices, cleans them,
• 34:31test them, send them back,
• 34:32sells them back at a fraction of the cost.
• 34:35And it's important to know that
• 34:37singleuse disposal is an industry
• 34:39designation, is not a regulatory designation.
• 34:41It does not mean that a device
• 34:44can't be reused.
• 34:45What it does mean is that
• 34:47whoever cleans it assumes
• 34:49that it's going to function
• 34:51as originally intended.
• 34:52And so there's this concept of
• 34:54the circular economy that should
• 34:55become carbon common parlance.
• 34:57What we have is a linear economy,
• 34:59a take, make waste,
• 35:00where we extract resources, we make stuff,
• 35:02we use it very briefly and we throw it away.
• 35:05The circular economy comes
• 35:06from nature and nature.
• 35:07There is no such thing as waste.
• 35:10The waste product of 1 system
• 35:11is a feedstock for another.
• 35:13And that is the the the foundation of this.
• 35:16Approach.
• 35:17So we want to retain and reuse
• 35:19things as much as possible,
• 35:21repair and refurbish them as needed,
• 35:23repurpose them when they can't be
• 35:25used for their original intention.
• 35:26The last thing you want to do is recycle.
• 35:28It's better than nothing.
• 35:30But even that might even
• 35:32be called into question.
• 35:33And of course we need to redesign things.
• 35:36We need to redesign products and
• 35:38services where fewer embodied
• 35:39materials and chemicals and energy.
• 35:41We need to design things for reuse.
• 35:43They have a modular design so
• 35:45they're easy to disassemble,
• 35:46clean and reassemble.
• 35:47And we need systems for recovering
• 35:49and repurposing materials.
• 35:51We need to address policy drivers
• 35:53of manufactured obsolescence.
• 35:54I'm going to shift gears and talk
• 35:56about a couple of medication examples.
• 35:59I mentioned that 5% of health sector
• 36:03emissions are coming from inhaled
• 36:05anesthetics and meter dose inhalers.
• 36:08Meter dose inhalers used for
• 36:10reactive airway disease.
• 36:10You see people puffing.
• 36:13Those inhalers have a propellant
• 36:16that actively pushes the medication
• 36:19into the patient's lungs.
• 36:21One Albuterol inhaler.
• 36:23Because of those,
• 36:25the gases in the delivery device is
• 36:28equivalent of driving 200 miles.
• 36:30There are 55 million devices sold
• 36:32annually in the equivalent of more
• 36:34than a half million cars on the
• 36:36road just in the United States.
• 36:38There are multiple device
• 36:40alternatives with 110th,
• 36:41120th the emissions,
• 36:43most notably dry powered inhalers,
• 36:44softness inhalers.
• 36:45Of course not every patient can use these,
• 36:49we can't get to 0 metered dose inhalers,
• 36:52but we do know that Sweden is now
• 36:54about 12% metered dose inhalers,
• 36:57the USUK around
• 37:0070%. So we have room to move on this.
• 37:05So choosing, we talked about making choices.
• 37:08Lower embodied carbon as one of
• 37:12our approaches to mitigation.
• 37:14So inhale anesthetics is another area.
• 37:17These are not.
• 37:18These medications are not metabolized.
• 37:19They're exhaled by the patient.
• 37:21They're essentially blown off the
• 37:23hospital rooftop where they are potent
• 37:25greenhouse gases and some of them are
• 37:27destructive to the ozone layer and
• 37:30their emissions are uncontrolled.
• 37:31This is another study we did.
• 37:32Again, I just want you to squint at it.
• 37:34These top three drugs you see here,
• 37:37Destroine, Isoflorine and Cevoflorine.
• 37:39Deaths Rain is at least 20 times
• 37:41the emissions of isoflorine and
• 37:43cevoflorine on a life cycle basis.
• 37:46The pink hair.
• 37:47So you see the the other thing is if you
• 37:49use in combination with nitrous oxide,
• 37:51which is common,
• 37:53nitrous oxide emissions are.
• 37:55Close to those of deserine and clinical
• 37:58clinical equipment quantities.
• 37:59And so if you add them to
• 38:01Isopylane and Cebo chlorine,
• 38:03they make those combinations worse.
• 38:06And then this one that you
• 38:07can hardly see here,
• 38:08propofol,
• 38:08it's not a typo,
• 38:10it's an intravenous medication and the
• 38:13life cycle greenhouse gas emissions
• 38:15are several orders of magnitude
• 38:18fewer than the inhale metaesthetic.
• 38:21So here's an opportunity where choices exist.
• 38:24Choose a lower carbon approach.
• 38:27And so of course there are other
• 38:29things we use in anesthesia,
• 38:30general inhale with the patient being asleep,
• 38:33we could do regional or peripheral
• 38:34nerve block whether we numb up an arm,
• 38:36for example for a limb surgery
• 38:40or here you're seeing a patient
• 38:41getting an injection to have either
• 38:43a spinal or epidural.
• 38:44Those are types of regional
• 38:46anesthesia or total intravenous,
• 38:48meaning you could have general
• 38:50anesthesia but performed.
• 38:51Surely through intravenous drugs.
• 38:52And again, if you just squint at this,
• 38:54we hypothesize any anesthetic approach,
• 38:57you know,
• 38:58because it's not just those drugs
• 38:59we use lots of drugs and supplies,
• 39:00medications,
• 39:01any anesthetic approach that use
• 39:03inhale anesthetics would be a worse
• 39:06approach from an environmental perspective.
• 39:08And that's what we found.
• 39:11Similarly,
• 39:11different approaches to surgery.
• 39:14This study looked at different
• 39:17approaches to hysterectomy,
• 39:18looking at open procedures and
• 39:21abdominal procedure versus a vaginally
• 39:24assisted abdominal procedure.
• 39:26Compared with minimally invasive
• 39:28laparoscopic robotic procedures
• 39:29and some of the takeaways here,
• 39:32the purple or the inhaled anesthetics.
• 39:33Inhaled anesthetics is responsible
• 39:35on average for about 50% of
• 39:38perioperative emissions.
• 39:40The other big offenders here are the
• 39:44single use consumable instruments
• 39:47and linens and the minimally invasive
• 39:50procedures are using a lot more of these.
• 39:55Obviously environmental performance
• 39:56is not how we're going to select our
• 39:59approach to a surgical procedure.
• 40:01That said.
• 40:02There are no better clinical outcomes
• 40:05from robotic versus laparoscopic procedures.
• 40:08So that's something to pay attention to.
• 40:10These large bars here represent the
• 40:13emissions of the anesthetics or
• 40:16or impacted by anesthetics because
• 40:18some of the patients in these
• 40:20studies had intravenous anesthesia
• 40:21versus the inhaled gases and and I
• 40:24already told you that there's four
• 40:26orders of magnitude difference.
• 40:27That's why you're seeing those error bars.
• 40:30Here's another interesting study
• 40:31comparing the same procedure
• 40:32performed in different countries.
• 40:34So variation in practice,
• 40:36particularly this is cataract surgery.
• 40:38So if you look at the emissions
• 40:40from the same surgery performed
• 40:42in the UK versus II has,
• 40:48you know, two fold fewer emissions
• 40:51for the same procedure on the right,
• 40:54you're seeing all the trash from one
• 40:56cataract surgery in the United States.
• 40:58And on the bottom bottom,
• 41:00similar amount of trash from 93
• 41:02cataract surgeries performed in the UK.
• 41:05Now of course we also have to
• 41:06ask about clinical outcomes.
• 41:08While this study didn't look at that,
• 41:09other studies have shown that the
• 41:12clinical outcomes are are very similar.
• 41:15Now, it's a low risk procedure,
• 41:16but it really begs the question
• 41:18of what we're doing differently,
• 41:21why we're doing it differently.
• 41:22And also, it's not just about the global
• 41:25S learning from us how to do better care.
• 41:27It's about us learning from
• 41:29them how to do better care.
• 41:31And so we also have a problem with even
• 41:34when we're delivering the right care,
• 41:36using too much stuff,
• 41:38using, doing too many tasks,
• 41:40too many medications.
• 41:41We really have to match the patient
• 41:43complexity to the preparedness
• 41:45and the stuff that we use.
• 41:46Simple cases, simple stuff,
• 41:48complex cases, complex stuff.
• 41:50If we over prepare we create waste and
• 41:53if we under prepare we create risk.
• 41:56So it really is about finding
• 41:58that balance And another topic,
• 42:00we're almost done here that I
• 42:03really want to dresses this idea
• 42:05of inappropriate care.
• 42:06We know we do too many tests to we
• 42:09prescribed too many medications,
• 42:11we do too many procedures.
• 42:13We prolong death at end of life
• 42:15most of our spending and is at end
• 42:18of life and much of it not wanted.
• 42:21And so how we act as clinicians,
• 42:24the micro level meaning in our
• 42:25personal practice we need to adhere
• 42:28to evidence based practice that means
• 42:30de adopting old ways of doing things
• 42:32being on top of new ways of doing things.
• 42:34Here at Yale New Haven Hospital,
• 42:36we have the Care Signature program,
• 42:38which really makes it easy for us to do
• 42:41the most streamlined current best practices.
• 42:45So we need to avoid technology
• 42:47and indication creep as well,
• 42:48something new and shiny for
• 42:51one specific indication.
• 42:53Once it becomes available,
• 42:54then people start using things liberally.
• 42:56That creates a lot of waste.
• 42:59We need to focus more on
• 43:00shared decision making,
• 43:01providing care that is wanted by the patient.
• 43:04And also that also means educating
• 43:06our patients and not providing
• 43:08unnecessary care because they want it.
• 43:11The famous example, of course,
• 43:12being antibiotics for childhood
• 43:15ear infections,
• 43:16most of which are viral in nature.
• 43:20Of course parents feel bad.
• 43:21They want a solution, they want a pill,
• 43:23but the pill is not the answer.
• 43:24And so education is really important.
• 43:27And so shared decision making is not
• 43:29only just providing care that is wanted,
• 43:32it means not providing.
• 43:33Unnecessary care just because it is wanted.
• 43:37So at the meso level that means
• 43:39acting within our organizations,
• 43:40better care, coordinate in coordination,
• 43:42avoiding duplication of care,
• 43:44working to create institutional
• 43:46structures to promote best
• 43:48practices within our departments,
• 43:50within our institutions.
• 43:51And again this idea we can develop
• 43:54protocols for D adopting low value
• 43:57care and on the macro level.
• 43:59Of course universal healthcare
• 44:01access will will be one of the
• 44:04things to advocate for here,
• 44:05but also addressing clinical care guidelines,
• 44:08standards of care education,
• 44:10addressing payment models to
• 44:12discourage low value care.
• 44:13So there's ways of us getting
• 44:15involved on the national level
• 44:17and even international level.
• 44:19And so of course as an acute care provider,
• 44:23this is not my area,
• 44:24but I would be remiss if I
• 44:25didn't talk about prevention
• 44:27and crime disease management.
• 44:28Things like green spaces,
• 44:30encouraging active transportation,
• 44:31more physical activity,
• 44:32more Whole Foods,
• 44:33plant based diet,
• 44:34addressing the social determinants of
• 44:37health and affordable primary care
• 44:39moving upstream to prevent people
• 44:41from needing care to begin with is
• 44:44essential for mitigating healthcare harm.
• 44:46That said, if we.
• 44:48Expand and do the same things to more
• 44:51patients in the name of of prevention.
• 44:53We will not be solving the problem,
• 44:56We'll be worsening the problem.
• 44:57So it really is about care transformation.
• 45:00Some good news,
• 45:01some good things that are happening globally.
• 45:03Nationally,
• 45:03the scientific community is called
• 45:05for having emissions by 20-30,
• 45:08getting to net 0 by 2050.
• 45:10On the left,
• 45:11you're seeing the National Health
• 45:12Service was the first in the world to
• 45:16regulate. Carbon reduction on of their
• 45:20national of their nation with that
• 45:23involve involved all their national
• 45:25systems including the health system.
• 45:27So they've been measuring their emissions
• 45:30since 28 and they have a whole greener
• 45:33NHS program is what it's called to
• 45:35strategically mitigate my team as part
• 45:37of the part of the analytics here.
• 45:39So if you figure what are all the
• 45:42things we can do to mitigate emissions.
• 45:45And and phase them in strategically,
• 45:48how long will it take to get to net zero?
• 45:51And that's really what this plan is
• 45:53all about. So the NHS has led this.
• 45:55They got together with COP 26 and with
• 45:59the UNF Triple C and The Who created a
• 46:03global movement of committing to low carbon,
• 46:06resilient health systems.
• 46:07The White House has a similar
• 46:09mandate under executive order
• 46:11affecting all federal health systems.
• 46:14The Joint Commission has developed
• 46:16an environmental standard to help to
• 46:19help move hospitals in this direction
• 46:21of accounting and mitigation.
• 46:22The National Academy of Medicine
• 46:24has a action collaborative and
• 46:26decarbonizing the US health sector.
• 46:28The
• 46:30SEC has proposed rules that would require
• 46:33accounting by all accounting and mitigation
• 46:36by all publicly traded organizations.
• 46:38Of a certain size.
• 46:40This all requires decarbonization
• 46:42targets and timelines.
• 46:44We can't just have them, you know,
• 46:45I'd like to say a merry band of
• 46:48volunteers who start a recycling program.
• 46:50We have to have clear targets and timelines.
• 46:53We have to be very strategic about this,
• 46:55which means we have to have robust
• 46:58benchmarking methods and tools,
• 47:00and we have to consider interventions that
• 47:03are both feasible and impactful together.
• 47:06Addressing waste and inefficiency
• 47:07and reducing embodied emissions
• 47:09and our goods and services.
• 47:11And we have to be careful
• 47:13to avoid greenwashing,
• 47:13both intentionally and unintentionally.
• 47:15And so my colleague and I on Doctor Anna
• 47:19McNeill is a surgeon at the University
• 47:22of British Columbia have developed
• 47:24a planetary healthcare framework.
• 47:26You've heard these principles in my talk,
• 47:28but I'll just present them.
• 47:31The key principles include reducing emissions
• 47:33and body within healthcare services.
• 47:35Conclusive electrification
• 47:36combined with clean energy,
• 47:39switching to a circular economy
• 47:41and being better resource stewards,
• 47:43matching supply with demand,
• 47:44meaning we have to address
• 47:46inappropriate care,
• 47:46which is a huge problem in
• 47:48our country and globally,
• 47:50but we certainly recognize here in
• 47:51the United States and moving upstream
• 47:53to reduce demand for healthcare to
• 47:55begin with through health promotion,
• 47:56disease prevention and addressing
• 47:58the social determinants of health.
• 48:00And when we think about value in the
• 48:02triple bottom line of the best care for
• 48:04the most patients at the least cost,
• 48:05least cost isn't just financial,
• 48:07it also means least environmental
• 48:09and social harms.
• 48:10And that's what we mean by high value care.
• 48:14And so there's now a concept of
• 48:16planetary health and there is a
• 48:19an update to the Hippocratic Oath
• 48:21or which has already been updated.
• 48:29Sorry, I'm. I'm blanking.
• 48:31On 1948, the Hippocratic Oath was updated
• 48:34by the World Medical Association,
• 48:37but it has just undergone a new proposed
• 48:40update to account for planetary health.
• 48:43I encourage everyone to read this,
• 48:45and in fact, I think medical
• 48:47students should recite it during
• 48:48their White Coat Summers ceremonies.
• 48:50And with that,
• 48:52I will pause and take questions.
• 49:00Thank you doctor. Sherman let me
• 49:02see how we can figure out what the
• 49:04how are we going to do this week.
• 49:06Karen how do you want to
• 49:08set up for questions Karen.
• 49:13OK all right. So we we so that the
• 49:17folks on on there we have nothing
• 49:19on zoom you just have the folks
• 49:20here I'm going to do a little walk
• 49:22in here with this you've got that.
• 49:24OK. So I'm going to take the.
• 49:27Take the first question if I can Jody,
• 49:32we, you know the the specter,
• 49:35the importance of public health,
• 49:37it was raised in in conversations I
• 49:39think that we had prior to this and
• 49:41what's the importance of your work.
• 49:42I guess what I'm trying to,
• 49:44what I'm trying to get around to is
• 49:45it seems to me that to fix this it's
• 49:47got to be a public health solution
• 49:49which is to say that I'm pretty much,
• 49:50I'm pretty much I know that I need the
• 49:54disposable kit for me and everybody
• 49:56else should use the other one.
• 49:58And I think that probably a lot
• 50:00of people feel that way.
• 50:01Do you know what I mean?
• 50:02That that there has to be,
• 50:04I don't want to sound authoritarian
• 50:07about this,
• 50:07but one gets a sense there has to be
• 50:09kind of a higher authority that says, no,
• 50:10this is what we're going to do, right?
• 50:12Because particularly, you know,
• 50:13in a society that's so values
• 50:15individualism so much that to say,
• 50:17well, we're going to do this for
• 50:19the benefit of the planet,
• 50:20that's a hard sell.
• 50:20We're going to do this for
• 50:22the benefit of the group.
• 50:22That's a hard song unless someone's kind
• 50:24of overseeing the benefit of the group.
• 50:25But I think everybody's pretty clear
• 50:27that everybody else ought to cut back
• 50:29on their emissions except for me.
• 50:31So.
• 50:31So is there a strong initiative
• 50:34on a national level in terms of
• 50:36public health to make these things
• 50:37happen in the hospital?
• 50:39Right. Well, I think there's a few
• 50:42issues that you've highlighted and want.
• 50:45We cannot sacrifice individual
• 50:47patient safety for public health.
• 50:50That is also. A moral issue, right.
• 50:55So we cannot do harm to our patients.
• 50:58So right now it's about using
• 51:01environmental information to be
• 51:03part of the decision making.
• 51:05Not the first thing or the only thing,
• 51:06but part of what goes
• 51:08into our decision making.
• 51:09And two things.
• 51:10Firstly, that requires evidence.
• 51:12We need to know what's more or less harmful.
• 51:14That requires disclosure by industry.
• 51:18That requires.
• 51:20Funding for research and that requires
• 51:24disclosure standards and we also
• 51:26need guidance of what to do in the
• 51:29absence of information in the terms
• 51:32in in terms of infection control.
• 51:34There are things that we know are
• 51:36safe to do and then there's a lot of
• 51:38stuff that we have no information on.
• 51:39But the default is let's just
• 51:42throw everything away and just
• 51:44like it's our responsibility to
• 51:46not prescribe antibiotics for a
• 51:48probable viral ear infection.
• 51:50And we also have to be mindful of
• 51:53inappropriate use of disposable goods.
• 51:55And I also hear you suggesting
• 51:59the need for regulation.
• 52:02And I would say that's true because in fact,
• 52:05nationally,
• 52:06you asked what's happening nationally,
• 52:07the White House has a a
• 52:10pledge to decarbonize healthcare.
• 52:14They've had about over 100.
• 52:17Corporations and health organizations have
• 52:19since signed on to this White House pledge,
• 52:23which is to have emissions by
• 52:2520-30 get to net 0 by 2050,
• 52:27which is the international
• 52:29scientific mandate and is
• 52:32possible and requires commitment.
• 52:35But unfortunately,
• 52:36voluntary pledges are not enough.
• 52:38So I have published on and I've
• 52:40in fact testified in front of
• 52:42Congress that we need mandatory
• 52:44reporting and mitigation.
• 52:47Thank you. You know,
• 52:48your analogy to antibiotics with
• 52:49viruses is of course a very good one.
• 52:51Antibiotics for viruses,
• 52:52we should we cut that out?
• 52:54That'll cut out some waste.
• 52:55But I was, I thought you were going
• 52:56to go in a different direction,
• 52:57which is that even though for my patient,
• 52:59I think you know what a third generation
• 53:02Cephalosporin will really do the job here,
• 53:05that nevertheless I feel a responsibility
• 53:07because of the overall concern
• 53:08of antibiotic resistance not to
• 53:10go directly perhaps to that third
• 53:12generation Cephalosporin to the latest.
• 53:14And greatest antibiotics,
• 53:15but to use something that's simple
• 53:17because we worry so much about
• 53:19creating resistance strengths to
• 53:20the more developed antibiotics.
• 53:22So it's the same sort of thing.
• 53:23So I think within the medical
• 53:24culture we've had some upbringing
• 53:27in the idea that well,
• 53:28it may be fine for this patient,
• 53:30but in fact in the long run
• 53:32it's going to do harm.
• 53:33Well,
• 53:33and that's also the virtue
• 53:35of decision support tools,
• 53:36including nudges in our
• 53:38electronic health record that
• 53:40point us to better first choices.
• 53:43Point us, don't restrict us, but point us.
• 53:46And that's also why we need
• 53:48decision support tools,
• 53:49why the work of care signature is really,
• 53:51I think a shining star of our organization.
• 53:54Thank you, I I've always had the
• 53:56sense it's a psychological thing
• 53:58and and I may be off based on this.
• 54:01I wonder what you're thinking.
• 54:02But sometimes when I do things
• 54:04or when I see things I have,
• 54:06I fall back and it was somebody must
• 54:08have the right this the first time.
• 54:10I used the whole freaking kit
• 54:11for one quick procedure and
• 54:13then threw the whole thing away.
• 54:14Except the sharps I threw away
• 54:15over here and everything else.
• 54:17I thought, well, someone,
• 54:18somebody who knows more than
• 54:19me and authority has figured
• 54:20out that this is the best way.
• 54:22For us to do this,
• 54:22which is to throw away all this
• 54:24stuff every time we do a procedure
• 54:25and and or when you use you know
• 54:27a complicated device to administer
• 54:29medication and throw the whole designs away,
• 54:31the disposable, the Ringoscopes.
• 54:32I I couldn't believe it when I saw it.
• 54:33I said well really this is the
• 54:35best thing overall,
• 54:35all right.
• 54:36There's the sense that somebody
• 54:38in authority overseeing this as a
• 54:39side of this is really what's best.
• 54:41And my fear is and I don't mean
• 54:43to be cynical,
• 54:44actually don't my fear is that they
• 54:46figured out this is what's best in
• 54:47the short run for the bottom line.
• 54:49And perhaps also for infection prevention.
• 54:51I think a lot of this is that
• 54:52in the short run,
• 54:53this is what's best for the bottom line.
• 54:54And that's we're all about the
• 54:56short run and we're all about the
• 54:58bottom line because some of the
• 54:59stuff that we throw away in the
• 55:02practice of medicine is just amazing.
• 55:04It amazes me.
• 55:05So I always thought that somebody's
• 55:06figured out that this is the best way,
• 55:07but not so well.
• 55:09I don't believe somebody's
• 55:10figured out it's the best way.
• 55:11I think much of it is manufactured
• 55:15obsolescence by industry.
• 55:18Regulatory loopholes,
• 55:19lobbying to obfuscate and preventing,
• 55:26not putting forth accurate information,
• 55:29misleading information.
• 55:30And then of course there
• 55:32you're absolutely right.
• 55:34It's a lot of it is about convenience.
• 55:36But if you actually do the analytics now,
• 55:39when when we first made this switch to
• 55:42disposable lingoscopes in our department.
• 55:44I went to our para operative manager
• 55:45and he started touting about how
• 55:47much money it was going to save and
• 55:48how was better for the environment.
• 55:50And I said show me the data.
• 55:51And I actually I didn't believe it.
• 55:53So that's why we did our own study.
• 55:55He was presenting data presented by industry.
• 55:58Now of course we do have our own
• 56:02internal value analytics teams,
• 56:04but I will say this that.
• 56:07If it doesn't pass the sniff test,
• 56:10I I I personally investigate
• 56:12and I would say it's not always
• 56:15true that reusables are cheaper.
• 56:17It's not always true that
• 56:19reusables are safer.
• 56:20It's not always true that reusables
• 56:22are better for the environment.
• 56:24But by and large,
• 56:26all the research that has been
• 56:28done has shown that to be true
• 56:30and we really cannot sit back and
• 56:33just let this trend go unfettered.
• 56:35It really has to be looked at
• 56:38critically and in fact there is so much
• 56:40money and opportunity to be saved,
• 56:42but we have to look for it
• 56:44and instead the easy way out,
• 56:45just like it's easy to to take our
• 56:47buyer to go coffee and throw the cup
• 56:50away versus carrying our cup with us.
• 56:52It's just more convenient.
• 56:54It takes less time,
• 56:55takes less human resource.
• 56:57That doesn't mean it's better
• 56:58for our bottom line.
• 56:59In fact,
• 57:00creating more jobs in our local community
• 57:02supports the social determinants
• 57:04of health and and prevents harm
• 57:06and need for healthcare services.
• 57:08So really have to look broader
• 57:10than what's most immediate.
• 57:12Thank you. We have,
• 57:13there's a question back,
• 57:14we got a few questions in the house.
• 57:15So I'm going to run with the
• 57:17microphone so that the folks
• 57:18on Zoom can hear you as well.
• 57:22I think this is critically important
• 57:24and I'll trump your cynicism with mine.
• 57:27You mentioned the bottom line.
• 57:29My question is better for the bottom line.
• 57:30The question is whose bottom line?
• 57:33And my frustration is that it's politics
• 57:36and profit that really rule today,
• 57:38and I don't know how science that
• 57:41we in science can overcome that.
• 57:44Well, I I will tell you that
• 57:46there are some shining stars,
• 57:48some healthcare organizations shining stars.
• 57:51And we're actually different
• 57:52than other industries.
• 57:53Other industries are really motivated in
• 57:55this space and many are already do carbon,
• 57:57carbon accounting and mitigation,
• 57:59looking for greener solutions for
• 58:01real because they have reputational
• 58:04risks because there are many
• 58:07studies now that show that.
• 58:09Potential employees want this and
• 58:12they will absolutely choose between
• 58:15job opportunities based on the
• 58:17corporate responsibility profile
• 58:19of a of a particular industry,
• 58:23a particular organization.
• 58:26So, but there are some shining stars
• 58:29and organizations and I will tell
• 58:31you that those that are shining
• 58:33stars either have a religious
• 58:35mission where they understand that.
• 58:37Protecting planetary health
• 58:38is a matter is a moral issue,
• 58:40a matter of ethics,
• 58:41and we're part of the environment.
• 58:43It shouldn't have to be a moral stretch.
• 58:45We cannot survive unless that
• 58:47the environment is thriving.
• 58:49But those who recognize it as a
• 58:52moral issue tend to be those that
• 58:55are religious based organizations.
• 58:58The other shining stars are
• 59:01those that have tied.
• 59:03Executive pay to environmental performance
• 59:13can you you
• 59:14you presented some wonderful data
• 59:17and I'm interested in what the the
• 59:20status is of you the you of your
• 59:24ability to use this data to persuade
• 59:26health institutions, hospitals,
• 59:28health systems to make the changes that.
• 59:32Seem to be pretty obvious and available.
• 59:37Do Do the institutions respond #1, #2?
• 59:42Are there enough of you that are making
• 59:45the case to the institutions that they need
• 59:48to be changing and that there are ways
• 59:51to change that are readily accomplishable?
• 59:53Where where do things stand just in
• 59:57terms of moving health institutions?
• 01:00:00In the directions that you'd like to see,
• 01:00:03Yeah, thanks for that question.
• 01:00:05There are not enough professionals
• 01:00:07in that being paid in the space.
• 01:00:10I will say that most of the work is
• 01:00:13being done on a voluntary basis,
• 01:00:15which isn't going to go far enough,
• 01:00:18as I like to say, a merry band of volunteers.
• 01:00:20You can't, can't get it done
• 01:00:22with a merry band of volunteers.
• 01:00:24So the Agency for Healthcare Research
• 01:00:26and Quality has put forth a primer
• 01:00:29on how to measure and get started.
• 01:00:31I was one of the authors on that.
• 01:00:34This goes along with a brand new Office
• 01:00:37of Climate Change and HealthEquity,
• 01:00:40which is also collaborated with the
• 01:00:41White House and the White House pledge.
• 01:00:44And I will say that.
• 01:00:47Organization.
• 01:00:47So I I told you 2 main ways to
• 01:00:49reduce emissions is number one is
• 01:00:50to reduce waste and efficiency.
• 01:00:52Whichever 1 can get behind,
• 01:00:53you're going to save money doing that.
• 01:00:55And then there's sort of a question,
• 01:00:56why haven't when we've been able
• 01:00:58to get it done.
• 01:00:59I think that it's a very complex issue.
• 01:01:02A part of it is what motivates us as
• 01:01:05individuals providing the care, right.
• 01:01:07So if so, I, for instance,
• 01:01:10have a fixed salary,
• 01:01:12the organization makes or loses money
• 01:01:14based on my behaviors doesn't really affect.
• 01:01:17Me in a way that is is felt so.
• 01:01:20I mean I care about it,
• 01:01:21but I would say most providers don't care
• 01:01:23about care about that as a motivation.
• 01:01:26However,
• 01:01:26if you start presenting their pollution
• 01:01:28data to them and start educating them
• 01:01:30on the fact that they are causing harm,
• 01:01:33I guarantee you they will
• 01:01:34be motivated to waste less.
• 01:01:35So one is simply getting enough
• 01:01:39awareness and and education around
• 01:01:42why it's important to prevent waste.
• 01:01:45The other on environmentally
• 01:01:48preferable drugs and devices,
• 01:01:49part of it is that there is are limited
• 01:01:53things that are known to us as clinicians.
• 01:01:56There's a lot of information being
• 01:01:59put forth by suppliers now and it's
• 01:02:01really hard to sort through all that.
• 01:02:04But importantly is to start by doing
• 01:02:08organizational missions, measurement.
• 01:02:10This is pretty straightforward.
• 01:02:13And with that information,
• 01:02:14any organization can make a strategic
• 01:02:17plan based on where their hot
• 01:02:19spots are and based on what's most
• 01:02:21feasible for that organization.
• 01:02:23And it's kind of,
• 01:02:24there are some similarities,
• 01:02:25Inhale, anesthetics, meter,
• 01:02:27dose inhalers, those are hot spots.
• 01:02:29But every organization has to start
• 01:02:31with benchmarking its emissions.
• 01:02:33And I guarantee you once they
• 01:02:35start saying it's not hard to do,
• 01:02:36they'll identify hotspots,
• 01:02:37which by the way are hotspots that
• 01:02:40they're probably already thinking about
• 01:02:42anyway and there are opportunities for
• 01:02:44them to save money and those things.
• 01:02:46So I have a couple of online questions,
• 01:02:48then we're going to get to yours also.
• 01:02:51One is something I was actually
• 01:02:52thinking about Jennifer Miller's work,
• 01:02:53but I say she's already chanted.
• 01:02:54We'll get to her in a couple minutes.
• 01:02:56One is a question is who are the
• 01:02:58best stakeholders to be asking?
• 01:03:00Show me the data to encourage the suppliers.
• 01:03:02To design for improve
• 01:03:04environmental performance,
• 01:03:05who should be asking for these
• 01:03:06data that the physicians,
• 01:03:07for example, is it the consumers?
• 01:03:10Yeah, well, it's actually,
• 01:03:11it starts with the SEC, that's for sure.
• 01:03:14So there are proposed rules by the
• 01:03:16SEC to mandate on this reporting.
• 01:03:18It's already happening in Europe.
• 01:03:20So we're behind the times and a
• 01:03:22lot of the corporations we work.
• 01:03:24With our global entities,
• 01:03:26so even if the SEC doesn't
• 01:03:28come on board quickly,
• 01:03:30the the global corporations are
• 01:03:31being pressured in this direction
• 01:03:33and that is that they need to measure
• 01:03:35and mitigate their own emissions.
• 01:03:37That's part of it.
• 01:03:38Because if they decarbonize or
• 01:03:40is 1 expression what's embodied
• 01:03:42in the stuff that they provide,
• 01:03:44that's going to help everyone and
• 01:03:46also create a knowledge base that
• 01:03:48that other organizations like
• 01:03:50healthcare organizations can use.
• 01:03:52The other part of that is that there
• 01:03:54has to be mandated reporting on the
• 01:03:56level of products and standards around that.
• 01:03:58Just like we have food and nutrition labels,
• 01:04:01there needs to be similar labels at
• 01:04:02the level of the product and then
• 01:04:05also has to come from regulators.
• 01:04:07Thank you. Ask your question next, please.
• 01:04:10Thanks for the presentation.
• 01:04:12Doctor Jody and Doctor Sherman,
• 01:04:14I guess I'm thinking about in the
• 01:04:16context of a lifecycle analysis
• 01:04:19when you have, you know 2.
• 01:04:23Two procedures that have clinical equipoise,
• 01:04:25but you have clinicians that are
• 01:04:27trained or who have been fed this
• 01:04:29idea that you know we need to be
• 01:04:31able to reduce hospital acquired
• 01:04:33infections And you know there's a very
• 01:04:36compelling argument that a singleuse
• 01:04:39device leads to like lower risks.
• 01:04:42I'm wondering to what extent
• 01:04:44there needs to be like research
• 01:04:48paired with this LC Air like.
• 01:04:50How how can you convince A clinician
• 01:04:53beyond showing them the lowered
• 01:04:56ecological impact of a reasonable
• 01:04:59outcome to believe like I don't know
• 01:05:02that clinically it would be like equal
• 01:05:04and when they have so much almost
• 01:05:06marketing that goes against that narrative,
• 01:05:08Sure, that's a great question.
• 01:05:11Part of the challenge with
• 01:05:13healthcare acquired infections
• 01:05:14is that they are multifactorial.
• 01:05:17You would literally need.
• 01:05:19I forget it has been estimated,
• 01:05:21but you know something like millions of
• 01:05:24cases to prove one infection related
• 01:05:27to a particular device outside of,
• 01:05:30you know, obvious things like
• 01:05:33central line infections for example.
• 01:05:36So it it makes it very difficult
• 01:05:39if not impossible.
• 01:05:40And so we are actually calling
• 01:05:42for creating standards on on how
• 01:05:44we define and how a report risks.
• 01:05:47Related to we can't.
• 01:05:49We can't report the infection,
• 01:05:50but we can report realist risks.
• 01:05:52I mean, we can report infections,
• 01:05:54but in terms of causality,
• 01:05:56we we can't always identify what it is.
• 01:05:58So we're now calling for experts
• 01:06:00to come together and develop
• 01:06:02a system of reporting risks to
• 01:06:05better identify those cases.
• 01:06:07But there's also a rational approach.
• 01:06:09If you're not doing a sterile procedure,
• 01:06:12you do not need sterile devices.
• 01:06:15That's a pretty simple thing.
• 01:06:17There are situations where we know,
• 01:06:19for example,
• 01:06:20longer drapes prevent central line
• 01:06:23infections versus shorter drapes.
• 01:06:25There are some things that we know about,
• 01:06:26but we also have to use our judgment
• 01:06:29and we have to be better stewards,
• 01:06:32stewards of our resources.
• 01:06:34And there's this concept of de adoption
• 01:06:37de adopting old ways of doing things
• 01:06:39that are not supported by evidence.
• 01:06:41That requires education,
• 01:06:43both at the undergraduate,
• 01:06:44graduate, postgraduate level.
• 01:06:46That requires culture change.
• 01:06:48That requires everyone recognizing
• 01:06:51that excessive use of things
• 01:06:55has its own risk involved.
• 01:07:01So another question from the Zoom world.
• 01:07:03But before I get to that question,
• 01:07:07which is from Jen Miller, who works
• 01:07:09at has developed a pharma scorecard.
• 01:07:12And she's one of our faculty here,
• 01:07:13essentially has to do with ethical
• 01:07:15principles and bioethical practices.
• 01:07:16Or essentially a company
• 01:07:18receives a a a scorecard,
• 01:07:20an ethical scorecard, if you will.
• 01:07:23And then they have their incentivized
• 01:07:25then to improve the ethical practices
• 01:07:27of that pharmaceutical company.
• 01:07:29And I wonder if there's an analogy
• 01:07:30to be drawn, which is to say,
• 01:07:32could we have a scorecard?
• 01:07:33You mentioned this about having like
• 01:07:35we have warnings on here's how many
• 01:07:38calories this particular drink has in it.
• 01:07:40If we have similar things on the
• 01:07:43label about exactly how much impact
• 01:07:45this has had on the environment,
• 01:07:47about the whether it's the
• 01:07:48greenhouse gas emissions, etcetera,
• 01:07:49etcetera,
• 01:07:50it said to have us an analogous
• 01:07:52scorecard for the pharma companies
• 01:07:54or for other companies.
• 01:07:55But then I want to get to
• 01:07:57Jen's question also after,
• 01:07:58yeah, well, there is such a thing.
• 01:08:00It's called ESG,
• 01:08:01environmental social governance.
• 01:08:02This is what the SEC is working on and would
• 01:08:05apply to large pharmaceutical corporations.
• 01:08:08In that there is a standardized method
• 01:08:12of measuring and required transparency
• 01:08:16on environmental performance,
• 01:08:17meaning, you know, in part,
• 01:08:19greenhouse gas emissions,
• 01:08:20social performance,
• 01:08:21meaning what harm we're doing in.
• 01:08:26Harm we're doing in the world and also
• 01:08:28our responsibility to diversity, equity,
• 01:08:30inclusion and fair pay and also governance,
• 01:08:33meaning what governance structures
• 01:08:35do we have to moderate and systems
• 01:08:37in place to oversee that and to
• 01:08:40oversee performance improvement.
• 01:08:42There is a standardized,
• 01:08:43standardized method of measuring
• 01:08:45that and transparent reporting
• 01:08:47and that is what the SEC is doing.
• 01:08:50That's what ESG reporting is all about.
• 01:08:54The next question please from Zoom,
• 01:08:55which is great talk is the first comment.
• 01:08:57If the 25 largest pharma companies
• 01:08:59by market cap asked you to identify
• 01:09:02your top three to five recommendations
• 01:09:04for how they could reduce their
• 01:09:07negative environmental impact,
• 01:09:09what would you say? And within that,
• 01:09:10so that your three to five recommendations
• 01:09:12for the big pharma companies,
• 01:09:14but also is there a shining star or a
• 01:09:16shining practice in the pharmaceutical sect?
• 01:09:22Well, there is a new group called SMI,
• 01:09:26the Sustainable Medications Initiative,
• 01:09:28which is a collaboration amongst
• 01:09:32pharmaceutical companies to develop a methods
• 01:09:35of measuring and reporting emissions.
• 01:09:38So I'd say that that is a a positive thing.
• 01:09:42I do continue to worry about greenwashing.
• 01:09:46So in terms of top, top practices,
• 01:09:48there's a challenge because of course.
• 01:09:51These are forprofit corporations who
• 01:09:54are incentivized to sell more stuff.
• 01:09:57Everybody benefits,
• 01:09:58even pharmaceutical companies from lean
• 01:10:00practices reducing waste and inefficiencies.
• 01:10:03So that that is something that that benefits.
• 01:10:06We need to move toward greener design.
• 01:10:09That means green chemistry as well.
• 01:10:11So there's a whole movement happening in
• 01:10:13that regard and that's great to move away
• 01:10:16from forever chemicals to design things to.
• 01:10:18To have a function but to also break
• 01:10:20down as part of what green chemistry
• 01:10:22and green pharmacy is all about.
• 01:10:24But I would say one thing that
• 01:10:26really has to well, two things.
• 01:10:27I would say the list could go on,
• 01:10:30but one of the things that we struggle
• 01:10:33with is that package sizes are much
• 01:10:35bigger than we need and as a result
• 01:10:39we cannot split packages between
• 01:10:41patients in the hospital environment.
• 01:10:44There are either infection concerns.
• 01:10:47Or regular regulatory concerns.
• 01:10:49If, for example,
• 01:10:50one patient's insurance has paid
• 01:10:51for something and they've only
• 01:10:53used a fraction for it,
• 01:10:54we are forced to throw it away,
• 01:10:55which is obscene.
• 01:10:58So pharmaceutical companies really need
• 01:11:01to make things and packages that are
• 01:11:05the right size and need to be priced.
• 01:11:10Appropriately,
• 01:11:11sometimes they they they price things.
• 01:11:13Even larger packages can be
• 01:11:15cheaper than smaller ones.
• 01:11:16There's a lot of gaming in the system there.
• 01:11:18They really need to package things
• 01:11:20appropriate in appropriate size.
• 01:11:22The other is that we need to address
• 01:11:25Best Buy dates or expiration dates.
• 01:11:28They're somewhat arbitrary in the
• 01:11:32sense that they there's out to a.
• 01:11:35Particular period of time where
• 01:11:37medications are proven to be stable
• 01:11:41and lack any bacterial growth
• 01:11:43or or viral or or fungal growth,
• 01:11:47but they don't necessarily take
• 01:11:49it out to the the end point and
• 01:11:52so addressing Best Buy dates is
• 01:11:57another important strategy.
• 01:11:58I will say that I don't think any
• 01:12:00of these are going to come from
• 01:12:02the Pharmaceutical industry.
• 01:12:02I think it has to be regulated.
• 01:12:05Thank you. Other questions from inside
• 01:12:08the Do you have a question, Karen?
• 01:12:10No, Yes, this gentleman here
• 01:12:18thanks Doctor Sherman,
• 01:12:19not to spark a polemic discussion,
• 01:12:22but how has Yale New Haven,
• 01:12:25our own institution responded to a
• 01:12:28lot of research topics or anything and
• 01:12:30have they implemented any policies?
• 01:12:34Regarding, I mean any sustainable practice,
• 01:12:38what we do, the Yale New Haven Health System
• 01:12:41has a Center for sustainable healthcare.
• 01:12:43We do have a systemwide executive
• 01:12:46committee and each delivery network has
• 01:12:48a green team that meets regularly to
• 01:12:51discuss how to implement these changes.
• 01:12:55We were the first healthcare organization in
• 01:12:58the world to get rid of deaths rain, which
• 01:13:01is the worst offending inhale anesthetics.
• 01:13:04We did that back in 2013,
• 01:13:06saved our organization $1.2 million
• 01:13:08that year, just this hospital alone.
• 01:13:11Yale, New Haven at York Street campus,
• 01:13:13save the equivalent of 360 cars
• 01:13:15off the road annually.
• 01:13:16By getting rid of that drug.
• 01:13:18We actually started a global movement.
• 01:13:21Dust, dust,
• 01:13:21rain is now banned in Scotland this year,
• 01:13:24as of next year and England
• 01:13:25it will be banned.
• 01:13:27By 2026 it will be banned in Europe.
• 01:13:30So that's one shining accomplishment.
• 01:13:33We have are doing a lot of green
• 01:13:37energy planning for our new
• 01:13:40construction and retrofitting.
• 01:13:41So those are a couple of the
• 01:13:43examples of what we've done.
• 01:13:47Yeah. So somewhat related questions.
• 01:13:49So if a department like emergency medicine,
• 01:13:52you know, I I don't see that
• 01:13:53we're doing anything right now.
• 01:13:54So if a department wanted to start
• 01:13:58doing something other than getting our
• 01:14:00married group together or something,
• 01:14:02what would be the best way of
• 01:14:05starting to make some changes in a in,
• 01:14:08in a way that could be actionable,
• 01:14:10measurable things like that?
• 01:14:13Well, I will say that we don't have
• 01:14:17resource to give project managers to all
• 01:14:20departments to implement these things.
• 01:14:22So really I'd say every department needs
• 01:14:24to start its own green team and not in
• 01:14:26the sense of merry band of volunteers,
• 01:14:28but to identify those projects that
• 01:14:32are obvious to you as professionals.
• 01:14:35That are opportunity for reducing
• 01:14:37waste and if there is information on
• 01:14:40how to reduce embodied emissions,
• 01:14:42that's great too.
• 01:14:43But you know kind of like the
• 01:14:45Choosing Wisely campaign is really
• 01:14:47dependent on specialties to OfferUp
• 01:14:50what the solutions are.
• 01:14:52I think that's true in our own
• 01:14:54organization we don't have
• 01:14:55project managers to give to each
• 01:14:57department has to come from from.
• 01:14:58From you all and then you have to
• 01:15:01propose what needs to be done and I
• 01:15:05would encourage emailing the Center
• 01:15:09for Sustainable Healthcare to put
• 01:15:11forth ideas and and what what it
• 01:15:13would take to implement them or at
• 01:15:14least to start the conversation.
• 01:15:19Thank you so much for that wonderful
• 01:15:22presentation. I wanted to ask you
• 01:15:23if perhaps you could speak a
• 01:15:24little bit more on a topic
• 01:15:26that's near and dear to my heart,
• 01:15:27which is whole food plant based nutrition.
• 01:15:31You know Full disclosure as a
• 01:15:33cardiologist you know that the
• 01:15:35evidence continues to mount that
• 01:15:36you know in terms of cardiovascular
• 01:15:38health and also cancer prevention.
• 01:15:39You know we we know that a plant
• 01:15:41forward at least a predominantly
• 01:15:43whole food plant based diet has a
• 01:15:44lot of different health benefits.
• 01:15:46And we also know that you know that
• 01:15:49like even though The Who has said that
• 01:15:51processed meat is a carcinogen and
• 01:15:53red meat is a probable carcinogen and
• 01:15:55we know that that just beef alone,
• 01:15:57taking aside all the other dietary
• 01:15:59elements is responsible for way more
• 01:16:01carbon emissions than other foods.
• 01:16:03So it's sort of is baffling that
• 01:16:05something that that foods that are
• 01:16:08carcinogens are probable carcinogens
• 01:16:09and major carbon major carbon emitters.
• 01:16:14Are still featured very prominently
• 01:16:15in in the
• 01:16:16food that we serve.
• 01:16:17So perhaps you can talk about more
• 01:16:19about what their impact is and
• 01:16:22how how what you think is the
• 01:16:24path forward to having not only
• 01:16:26healthier offerings that support
• 01:16:28our mission of beneficence and non
• 01:16:30maleficence on an individual level
• 01:16:32but also on a on a planetary level.
• 01:16:35Yeah, thanks for that.
• 01:16:37So actually beef alone accounts for 1%
• 01:16:40of our National Health sector emissions.
• 01:16:42And it's not just what we feed our patients,
• 01:16:43it's what we feed our staff.
• 01:16:45And so there is a lot that can happen.
• 01:16:47There's actually a lot
• 01:16:48that has already happened.
• 01:16:49I don't know how long you've
• 01:16:50been with the organization,
• 01:16:51but there's a lot that has
• 01:16:53already happened to reduce the
• 01:16:54amount of meat that is offered
• 01:16:57both the patients and the staff.
• 01:16:59I'm also particularly concerned of
• 01:17:01all the single use disposables.
• 01:17:03That's another issue.
• 01:17:05How to improve it I think is is
• 01:17:07to get involved and and become
• 01:17:08a leader in that space.
• 01:17:10I will say that we did have another
• 01:17:13passionate person on this topic
• 01:17:14several years ago who decided
• 01:17:16to really clean up our patient
• 01:17:19menus and it failed pretty quickly
• 01:17:21because patients didn't enjoy it.
• 01:17:24Particularly give you an example of that
• 01:17:26kids when they're not feeling well,
• 01:17:27they want their their fish to another
• 01:17:29fish to they want their chicken fingers,
• 01:17:32they want their French fries.
• 01:17:34Whatever can't can bring them comfort
• 01:17:36and get some some calories and then
• 01:17:38really matters So and I think that you know,
• 01:17:41there's some truth to that in adults as well.
• 01:17:43Obviously we don't want to be causing harm,
• 01:17:46but there is something about
• 01:17:48patient comfort that matters.
• 01:17:50And so there are health systems that
• 01:17:54have been very successful by having
• 01:17:58really outstanding chefs preparing meals.
• 01:18:02There's a problem if we're outsourcing
• 01:18:03a lot of that to company that
• 01:18:05provides it for us,
• 01:18:06but then also is a cost mitigation strategy.
• 01:18:09So it's it's an area that needs improvement,
• 01:18:13but also not a simple one.
• 01:18:15It's not a simple saying let's
• 01:18:17just get rid of all the red meat,
• 01:18:19right.
• 01:18:20Thank you, Dr. Sherman.
• 01:18:22Next question away from the Zoom,
• 01:18:24you mentioned CDSS, please say more
• 01:18:26about developments and decision support.
• 01:18:29Is there enough data to make recommendations?
• 01:18:32What work is going on to create such systems?
• 01:18:35How do you envision there being?
• 01:18:36There's a lot of questions in
• 01:18:37wrapping this one question scene.
• 01:18:39So how do you We'll go,
• 01:18:40I'll go through them all and then
• 01:18:41we can take a little bit of it.
• 01:18:42How do you envision they're being
• 01:18:44implemented and used, for example,
• 01:18:46as part of the health record,
• 01:18:48as part of treatment recommendations,
• 01:18:50etcetera?
• 01:18:51Are there CDSS for selecting devices
• 01:18:54or are such systems being developed?
• 01:18:58These questions don't need
• 01:18:59to each be addressed,
• 01:19:00but I'm hoping for more comments
• 01:19:02about what's going on and
• 01:19:03what's needed in this area,
• 01:19:05specifically the CD Hasso you
• 01:19:06explain to us what that is.
• 01:19:08So a clinical decision support
• 01:19:10system is I think what they meant.
• 01:19:14So I said, you know there are actually
• 01:19:16a few things that we know are more or
• 01:19:19less polluting and in terms of drugs,
• 01:19:21you know it's one thing if you have you
• 01:19:24know there you have clinical equity poised.
• 01:19:27But you still need those options.
• 01:19:29And so for example,
• 01:19:30in the case of metered dose inhalers,
• 01:19:32we're working on a clinical decision
• 01:19:35support tool that nudges providers
• 01:19:37to select other types of inhalers
• 01:19:39before prescribing that one.
• 01:19:41So that's an example.
• 01:19:44In the case of inhaled anesthetics,
• 01:19:48not exactly it's it is a point of care tool.
• 01:19:52We have fresh gas alerts that tell us
• 01:19:54when we're using excessive flows of
• 01:19:56gas more than the patients require.
• 01:19:58That's another example.
• 01:19:59In terms of choosing between medical devices,
• 01:20:02there would not be a decision
• 01:20:04supports tool in that regard that
• 01:20:06really is not for clinicians,
• 01:20:08it's the kind of thing that.
• 01:20:10Procurement officers require that data
• 01:20:12to help them choose who to contract with,
• 01:20:15who not to contract with,
• 01:20:17and it's just one factor of many
• 01:20:19that goes into that decision making.
• 01:20:21So I don't know so much that it is a
• 01:20:24a tool so much as it is an algorithm.
• 01:20:27But one thing I do think that really
• 01:20:29needs to happen is that we need a
• 01:20:32better means of accounting of all the
• 01:20:34stuff that we're prescribing and using.
• 01:20:36Some of that is is captured in the
• 01:20:38patient record, some of it is not.
• 01:20:40But of the things that are captured
• 01:20:42in the patient record,
• 01:20:43we can use electronic health systems
• 01:20:46to allow us to assess variation
• 01:20:49between practitioners,
• 01:20:51accounting for differences in
• 01:20:53patients and differences in clinical
• 01:20:55outcomes to identify outlying.
• 01:20:57Providers that have more excessive OR,
• 01:21:01or, or not doing best practices.
• 01:21:04An example has to do with number of
• 01:21:08surgical trays that are used for.
• 01:21:10I'm going to give an example of
• 01:21:12a total knee replacement,
• 01:21:13which is something we've discussed
• 01:21:14with the orthopedic surgery team.
• 01:21:16So that's a way that electronic health
• 01:21:20records can be used to track information,
• 01:21:22identify best practices,
• 01:21:24identify outliers.
• 01:21:26Who can then be shown data to reflect
• 01:21:30as one means of behavior modification?
• 01:21:34Thank you. There's one last question
• 01:21:35which I'll answer, which is,
• 01:21:36are the recording and slides available to us?
• 01:21:39The recording will be,
• 01:21:40there'll be a recording of the of the
• 01:21:42presentation which will be available
• 01:21:44on our website in a few days.
• 01:21:45And I think in the chat you saw
• 01:21:47the CME information was presumably
• 01:21:49everyone could see this.
• 01:21:50You want me to go ahead and say it?
• 01:21:52That's what all that pointing the stuff is.
• 01:21:54Go ahead and say it.
• 01:21:55All right, here we go.
• 01:21:55So for today,
• 01:21:57the number you would you would text is 2 O
• 01:22:0334429435. That's the same
• 01:22:04for all the Yale CME2 O
• 01:22:0834429435. And then the code
• 01:22:10for today's section is
• 01:22:1336153. Joey's going to see if she
• 01:22:15can get to some CME credit for this
• 01:22:17excellent talk she just attended.
• 01:22:18Let me just grab this real quick.
• 01:22:20Thank you very much.
• 01:22:22Doctor Sherman, this was a really,
• 01:22:26really depressing a presentation.
• 01:22:28It was also a really,
• 01:22:29really necessary presentation and and
• 01:22:31beautifully I beautifully got a line for so.
• 01:22:34So thank you very much.
• 01:22:35A lot of work to be done.
• 01:22:36A small token of our appreciation.
• 01:22:38Please join me on connecting.
• 01:22:44OK, so we're all set.
• 01:22:45We're all set for this academic
• 01:22:46year in fact. We'll be back.
• 01:22:47First week in September,
• 01:22:49so you'll be getting emails about that.
• 01:22:50And keep an eye on our website.
• 01:22:52Thank you all very much.
• 01:22:53And with that we can go ahead
• 01:22:54and end the webinar and
• 01:22:55end tonight's session here.
• 01:22:56Thanks everybody.