I'd like to present our next presenter, who's Dr. Rabia De La Tour, who's at NYU Langone Health. She will be presenting, prerecorded, she had a conflict that we ended up having her present, Going Green, Sustainability and Endoscopy, which we will start now. Here are my disclosures. Today, we'll start with some definitions and move on to the scope of the problem, discussing both the impact of climate change on health care and the impact of health care on climate change. And lastly, we will discuss interventions that you can make, not only as a hospital, but specifically within your endoscopy unit to improve your hospital sustainability efforts. Let's start with a few definitions. Weather refers to the atmospheric conditions on the short term, in minutes, hours or days. Climate on the other hand, refers to the regional or even global average of temperature, humidity and rainfall patterns over seasons, years or decades. Climate change is the long-term change in the average weather pattern. Climate change and global warming are not synonymous. Global warming, as it suggests, is climate change in the direction of overall warming. Fossil fuels are natural fuels that are found on earth that were formed millions of years ago from dead plants and animals, hence the term fossil. We now harness their pent-up energy for our uses by burning them and converting them to other forms of energy such as gas, steam, electricity. Examples of fossil fuels, also known as non-renewable energy sources, include coal, propane, diesel, natural gas, oil, and of these, natural gas is by far the cleanest and best option. These are in contrast to renewable energy sources such as solar power, wind energy, geothermals, biofuels, and hydropower. When fossil fuels are burned, they release gas into the atmosphere known as greenhouse gases. Greenhouse gases include carbon dioxide, methane, nitrous oxide, and other fluorinated gases, and by far, CO2 is the most abundant one. Now as a gastroenterologist, I have to share that one of the multiple contentions that climate activists have with the cattle industry is that cows' enteric emissions, aka their farts and burps, are actually methane, which is a greenhouse gas, and these enteric emissions contribute to about 2% of the U.S. carbon emissions, and this is even more globally as there are 1.5 billion cows on earth, so it's not an insignificant contributor to our greenhouse gas issue. So when these fossil fuels are burned for energy, and they release these greenhouse gases into the atmosphere, these gases are particularly adept at absorbing and trapping infrared radiation and energy from the sun that would have otherwise escaped. This is causing the earth to slowly become warmer and warmer since a pre-industrial period primarily driven by human activities and fossil fuel burning for energy, and it is known as a greenhouse effect, which we all learned about in elementary school. So as you can see in these graphs, our CO2 levels are the highest they have ever been in recorded history. Following a similar pattern, this graph from NASA illustrates a change in global surface temperature over the past several decades. As you can see, from 1951 to 1980, average temperatures seemed somewhat stable, but from 1980 to now, we've seen a steady, consistent rise in average temperature. 2020 and 2016 tied for the hottest on record, and 2023 is soon to join them in this highest temperature ever. So as long as we, on earth, are reliant on fossil fuels, we will continue to contribute to global warming. This is an inevitable, and as Al Gore put it, an inconvenient truth, but there are absolutely interventions you can make on a daily basis to improve your own carbon footprint, and that we can do as healthcare providers to try to reduce our hospital system's carbon footprint. A carbon footprint is the amount of carbon dioxide or other carbon compounds emitted due to the consumption of fossil fuels, and this can be by a particular person, a group, a hospital, even a country, and globally. We translate the different types of emissions, greenhouse gas emissions that someone creates, into CO2 equivalents for simplification. Now, as you can imagine, this is a very hard thing to measure, hence the paucity of data on this topic that feels truly exact. There are lots of estimates, but it's very difficult to say what your exact carbon footprint is day to day, let alone over a lifetime. From the gas that you use in your car, the electricity you use in your home, how you cook your food, how you travel, the cost of making the shoes you're wearing, and the tools that you use in your endoscopy unit, they all have a footprint and have a cost. But ultimately, the exact number doesn't necessarily matter. What we know is the end result, that our daily behaviors and reliance on fossil fuels for our daily activities are causing global warming, and we need to make some sort of change and sacrifices to mitigate the effect of our actions. How does healthcare play into all of this? Healthcare industry is a major contributor to greenhouse gases. We are cited to be responsible for 4.4% of our global carbon emissions and 8.5% of the U.S. national emissions, and if healthcare were a country, it would be the fifth largest emitter on the planet, right up there with the U.S., Saudi Arabia, Australia, and China. On average, the U.S. hospital will generate anywhere from 29 to 43 pounds of trash per patient per day, which is one of the many contributors to our greenhouse gas and carbon footprint. Daily, each American is responsible for an average of 80 to 100 pounds of CO2 emissions per person per day, which is the equivalent of driving 113 miles in an average passenger vehicle. The global average, in contrast, is 4 to 5 metric tons per person per year. Similar to healthcare emissions per capita in developed countries, our healthcare emissions by country mirror much of the same patterns. The per capita healthcare sector greenhouse gas emissions are also highest in the most developed countries, with the U.S. being one of the largest culprits. Of all healthcare emissions globally, the U.S. healthcare system is responsible for 27% of global emissions. So why should we as healthcare providers care about this? I mean, ultimately, we are tasked with taking care of our patients. Why then should we also carry the heavy burden of climate change, and how does this impact our patients? So in 2021, a wonderful editorial was published by The Lancet and 200 other journals targeting all disciplines, essentially making a call to arms for we as healthcare providers should and must limit our carbon emissions to limit the effects of global warming, highlighting the impacts that it has not only on our health, but our patients' health. And what they said in this article was that temperature rise is the greatest threat to global public health, and a global increase of 1.5 degrees Celsius above the pre-industrial average and the continued loss of biodiversity risks catastrophic harm to health that will be impossible to reverse. How might climate change impact our delivery of care? Climate change will exacerbate current challenges with regard to provision of adequate nutrition and access to clean water, particularly in the developing world. It will force migration between countries and within countries and will drive relocation from rural to urban areas, further straining sanitation and clean water provision. An increase in high rainfall events, flooding, and droughts will be associated with an increase in enteric infections and hepatitis. Changes in habitat may result in altered distribution of GI illnesses such as viperior cholera. And with climate change and the subsequent impacts of it, we can see worsening mental health outcomes, a known contributor to substance and alcohol abuse, which could result in a rise in liver and pancreas disease. The infrastructure required to the delivery of GI care is extremely vulnerable to weather events, and this will become more and more frequent. The GI community needs to join the debate on climate change by organizing, educating, advocating, and supporting our political leaders as they face the enormous challenges posed by global warming. Moving on to greenhouse gas emission sources within health care, we divide them into three scopes. Scope 1 includes onsite energy that's used, your fleet vehicles, the waste of your anesthetic gases and refrigerants. Scope 2 contributors are the purchased electricity used in your hospital system and the purchased steam. And then scope 3 emission sources include type of travel, employee commutes, waste disposal, medical service and equipment, pharmaceuticals, and REIT procurement. Scope 3, for me, as the Chief Sustainability Officer in my hospital, is the best place for a clinician to actually have some action items and try to reduce the carbon footprint of the hospital setting. And as you can see from this graph, the widest is scope 3, meaning scope 3 emissions are the largest in any health care setting, and that's where I think we as clinicians can take the biggest role in reducing our hospital's carbon footprint. So what is the scope of the problem within GI? When you're talking about the greenhouse gas emission from endoscopy, it's really important to talk about what the different contributors are. So the lowest hanging fruit is the waste that we produce, right? We see it in real time, we're producing waste, it's going, a lot of it is going straight into landfill, unless you aren't recycling, because of our resource-heavy decontamination processes, our complex waste streams, the sheer number of cases that we do, which is about 18 million endoscopies per year in the United States, and our heavy reliance on single-use, non-recyclable consumables. So endoscopy is cited as being the third highest generator of waste in health care, and this is obviously just behind the ORs, but we produce a lot of waste. The energy consumption from the waste that we produce is cited to be as much as 39 million tons of coal being burned per year, driving 80 million miles in an average passenger vehicle annually, or consuming 3.995 million gallons of gasoline. So your next natural question should be, okay, so what can I do about the amount of waste that's produced? So studies that have come out from looking at this, one of which was from Swapnagiam in 2020, simply looking at the trash that we've created, and what part of this trash was plastic, and what part of that plastic is recyclable, and potentially recycling it. So here's an itemized list of the different plastic items that were produced during endoscopy, and then these were then separated out to recyclable items, and the hope would be that you could start a recycling pilot at your institution within your endoscopy unit, or OR space, to try to mitigate the effect of the endoscopies on your carbon footprint. A similar study in 2022 by Namburar and colleagues did a five-day audit of two centers, included 270 endoscopies, and found that they averaged 2.4 kilograms of waste per case. 64% of which was going to landfill, 28% to the biohazard or red bags, 9% recycled. And if you multiply this by the 18 million procedures we do in the United States, the waste in volume was equivalent to covering 117 soccer fields with waste one meter deep. And in weight, it was equivalent to almost 25,000 passenger vehicle cars in weight. So we produce a lot of waste, and this is one of the first areas that we can try to target areas for improvement and try to reduce this waste within endoscopy. Now there are going to be some naysayers out there who, again, revert back to the fact that we need to focus primarily on patient care, and within GI, it's going to be very difficult for us to achieve these tasks. But changes are afoot. In fact, just this year, the Joint Commission proposed a potential environmental sustainability critical access hospital program that they kind of fed out to the country and asked and polled people to see if they'd be interested in making this a mandatory requirement in their hospital. Now, the response, as you can imagine, was we need more time, this is not something that we can implement right away. But when stuff like this happens, you can anticipate that this may become a fixture of our Joint Commission evaluation within the coming years. Now, when you're looking at the carbon footprint of an endoscopy, the waste is just one aspect of that carbon footprint. In addition to that, you need to consider the energy it takes to light the room, to energize the computer that you're using to document your findings, the nasal cannula plastic that's being used to give the patient oxygen. What are the carbon footprints of all of those items, not only to create them, but to energize them? And so that waste assessment is just one aspect. We are doing a full life cycle assessment of endoscopy at our hospital, and it is near completion. But what we found is that an average EGD is equivalent to driving 21 miles in an average passenger vehicle, including every aspect of the endoscopy, every tool used, and what it took to create those tools, and a colonoscopy is equivalent to driving 25 miles in an average passenger vehicle. So you can only imagine what the carbon footprint is when you multiply that by the 18 million endoscopies that we perform in our country annually. So we've talked about the problem, what is the actual plan? There are large scale plans, including global roadmaps for health care decarbonization, a lot of which has to do with trying to transfer our energy sources to renewable energy, investing in zero emission buildings and infrastructure, trying to transition to zero emissions, sustainable travel and transport, and providing healthy and sustainable food to not only our patients, but our staff within the hospital setting. On a more local level, the GI edition of our plan involves a lot of advocacy, research, education, and this includes all the different societies working together with industry, not against, but with industry is very important to try and decarbonize our health care. There's a lot of different papers out there that can guide you on simple steps that you can take that I'll also talk about today, one of which is an ACG toolbox that I wrote, which talks about simple steps you can take within your endoscopy unit to try to improve your carbon footprint. On the local level within our endoscopy units, there are several things that you can do to improve your carbon footprint. Reduce is the most high impact item, then reuse, and lowest impact will be recycle. So when it comes to reduction, telemedicine was a great thing that came out of the awful pandemic. We saw a rise in telemedicine, which reduces travel not only from patients, but a lot of providers are able to provide care for their homes. But the most important thing for us to transition to in the coming years will be to avoid unnecessary procedures. I think the latest colon cancer screening guidelines for patients with one to two polyps was a great improvement. Changing that interval from five to 10 years to seven to 10 years will avoid unnecessary procedures. But as we saw, procedures are the biggest ticket items that we need to focus on when it comes to reducing our carbon footprint as an industry. We can also switch to plant based menus for our patients and for our staff. Consider double basin washers for washing your scopes. Using environmentally friendly cleaning solutions, an important item is waste allocation education within your endoscopy unit, so avoiding things going into the regulated medical waste or red bins that don't belong there because getting rid of those and incinerating those has a much higher carbon footprint than landfill. Choosing preference cards, this is more pertinent in the ORs, but if you are in a location where there's several clinicians and physicians and they like different items, ensuring that unnecessary things aren't opened and wasted if they're not needed. Switching to LED light bulbs and turning lights off or having motion detectors, especially in ambulatory centers which are not working or functioning at night and then reducing travel. In terms of reusing, reprocessing is a great option because if you reprocess items that are reprocessable through different companies that offer this service, you can actually make money for the hospital. So you can send things back like pulse oxys to be reprocessed and then it's your hospital's choice if they want to buy those used items. It's much like buying a refurbished iPhone. Some people will not do it and some people will, but being able to sell those back and avoid those items from going into landfill is very important. Another thing you can consider is food composting. This is great, especially if you have, you know, physician dorms or med student dorms within your hospital. If you work in an academic center where things can be a little bit more organized in the patient food, also cafeterias for faculty is a great place for food composting. Reusable gowns are great. We often fall under the umbrella of peri-op, but our procedures, as we all know, for the most part are not sterile. So we don't need sterile gowns and sterile gloves. So having reusable gowns is a great option. Reusable scope buttons, reusable washcloths as opposed to the sterile gauze. Considering biodegradable packaging, which is something that we talk to industry a lot about, and donating your expired goods. So a lot of items that are in DASB unit, once they expire, they previously went into landfill, fresh, unopened. But we found companies that we can actually donate these to and they go to developing countries and are put to good use. We can also reuse surgical and medical products. And last but not least, you can try a recycling pilot. I started a recycling pilot in my hospital and now we've expanded to almost all of our ORs and all rigid plastics. It's a great option to prevent this plastic from going and sitting in a landfill for many, many, many years. You can also consider recycling cardboard. A lot of the boxes that our items come in never see patients. They're completely clean and they can easily be recycled. And lastly, disposable scopes, if indicated. If you use a disposable scope, you often have to request the bid for it to be recycled. So it's really important that you go through that process and send it back because much of those items within the actual broken down scope can be reprocessed and reused.

climate change

healthcare

sustainability efforts

greenhouse gas emissions

endoscopy waste