All right, everybody, we're going to get our next session started on the GI carbon footprint. And it's my great honor to introduce our ASG president, Dr. Brett Peterson from Mayo Clinic. Thank you very much. I'm delighted to have the opportunity to introduce our next speaker. This is the Gene and Lynn Overholt Endowed Lecture. This is the inaugural Endowed Lecture in their name. This was established and is presented by the ASGE Foundation with generous financial support from friends and colleagues of Dr. Gene Overholt and Mrs. Lynn Overholt. He was a past president of the ASGE and recipient of our Rudolph V. Schindler Award. His many accomplishments are familiar to you all when you think backwards in that they include the development of the flexible sigmoidoscope in the early 1960s, an innovation that paved the way for almost everything we do today with flexible colonoscopy and other instruments. Dr. Overholt was also instrumental in moving endoscopy from the hospital environment to the ambulatory surgery center environment, thereby creating an entirely new paradigm for the provision of cost-efficient GI care and cancer screening purposes. His groundbreaking research into photodynamic therapy and laser-induced fluorescence lay the foundation for today's endoscopic therapies for Barrett's esophagus and esophageal cancer. Our speaker today, Dr. Rabia De La Tour, is Director of Endoscopy at Bellevue Hospital Center in New York, Associate Program Director of the NYU Gastroenterology Fellowship, and Assistant Professor of Medicine at NYU Grossman School of Medicine. She will present the inaugural Overholt Lecture entitled, What Changes Are Afoot Relative to Sustainable Endoscopy? Thank you. Thank you so much for that lovely introduction and for having me here today. One title I'm going to selfishly add is that I'm the first ever Chief Sustainability Officer for Bellevue Hospital, which is the oldest public hospital in the country. So it's been one of my unique honors and pleasures to be able to serve in that role and improve our hospital's carbon footprint. So today we're going to talk about a few definitions, what's the scope of the problem within gastroenterology, what changes are afoot, and a few interventions that you as endoscopists can take part in in order to improve your hospital's carbon footprint. All right. So a few definitions to start us off. So weather is the atmospheric conditions on a short-term. For example, today it's sunny outside. That's the weather. Climate, on the other hand, refers to long-term weather patterns. It is cold in this area of the world and warm in this area of the world. So climate, again, is a long-term change. Climate change is a long-term change in weather patterns, and global warming is when the weather patterns turn towards warming. Fossil fuels are natural fuels found on Earth that were actually formed millions of years ago from dead plants and animals, and 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. And again, this is very simply put, but that's the term fossil comes from. It's actually from old plants and animals. Examples of fossil fuels are basically all non-renewable energy sources because you can't refossilize those dead plants and animals, and they include coal, propane, diesel, gas, oil, and natural gas is actually the best option in terms of the cleanest burning solution. This is in contrast to renewable energy sources such as solar power, wind energy, geothermals, biofuels, and hydropower, which you've all heard of. So when fossil fuels are burned, they release gas into the atmosphere called greenhouse gases. CO2 is the most abundant of these gases, but there's other gases as well, which are actually more potent than CO2 in terms of the greenhouse effect, which we'll talk about. All right. So the carbon footprint is the amount of carbon dioxide and other carbon compounds emitted due to the consumption of fossil fuels by a particular person, a group, a hospital. You have your own carbon footprint. Your hospital has its carbon footprint, and your home has a carbon footprint. These are basically created by the type of electricity you use in your hospital or your home, heating and cooling, how you get to work, do you ride a bike, do you drive a car, do you take the bus, and your long distance travel, as well as the food you eat and the consumer goods. So everything has a carbon footprint, and it's not just the amount of gas you burn in your car. It's how much energy you took to create the shoes on your feet and the type of hair gel you use in your hair. I was talking to someone about that today. So all of these things have a carbon footprint. So the consumption of products and goods and buying more goods also has its own carbon footprint, which is often overlooked. And another thing to keep in mind is that you give off different types of gases for your carbon footprint, and they have CO2 equivalents. So carbon dioxide is just one type of greenhouse gas, but the other ones to simplify it are basically converted into CO2 equivalents so that we can have a lingo or a way to explain these things and simplify it. So when these fossil fuels are burned for energy, which we are, again, very heavily relying on, unfortunately, they release these greenhouse gases into the atmosphere, which basically trap the sun's rays, heat energy, and warm our earth. And this is called the greenhouse effect, as we all learned in elementary school. So as you can see in this graph, our carbon dioxide levels over the last 800,000 years are the highest they've ever been in recorded history. Following a very similar pattern, our temperatures, as this graph from NASA illustrates, showing the global surface temperature over the last several decades, from 1951 to 1980, the average temperature seemed somewhat stable, but from 1980 to now, they've been rising. And 2016 and 2020 actually tied for the hottest on record. So this is a real problem. And as long as we are reliant on these fossil fuels and burning them for our energy sources, we're going to continuously contribute to global warming. And it's just as an inevitable, and as Al Gore put it, an inconvenient truth that we must acknowledge and do what we can to try to reverse the impacts of this. But there are several interventions that you can make on a daily basis, not only in your home, but also in the hospital system that you work in to try to improve this. And I'm going to talk about healthcare's contribution to this and what we can do to try to improve it. So I read my children a book called Horton, Here's a Who by Dr. Seuss. And there's a lot of naysayers out there that say, what you do in your home on a daily basis is not going to make a difference. But as we all start to whisper together, that whisper eventually reaches a fever pitch, and you can eventually hear a scream, which is very loud and will actually have impactful change to improve or try to reverse the impacts of industrialization and global warming. So the healthcare industry, as we all know, is a major contributor to greenhouse gases. We are cited as contributing 4.4% of the global carbon emissions as a healthcare sector, and 8.5% of the U.S. national emissions come from the healthcare sector. So if healthcare were a country, as global healthcare were one country, we'd be the fifth largest emitter of greenhouse gases on the planet, right up there with the U.S., Saudi Arabia, and other industrialized nations. And it's cited that the average U.S. hospital generates 29 to 43 pounds of trash per patient. And these are things that have caught national attention. A lot of different people are tweeting and writing about it. And so it's something that people are looking to us to improve. So the spotlight is on us to make change, because ultimately, we are the boots on the ground in the hospital every day. So even if you don't have a formal training in sustainability, or you're not an engineer, you can still make some positive change within your healthcare setting that is going to make a difference. So daily, each American is responsible for about 80 to 100 pounds of carbon dioxide per person per day, which is the equivalent of driving 113 miles in an average passenger car. The global average is four to five. So we as Americans are four to five times worse than other citizens of the world. And yet they're often left holding the bag when it comes to catastrophic climate change induced weather changes like flooding and, you know, droughts. And so it's really important that we make changes within our country and can serve as an example to other industrialized nations. Similarly, our healthcare system is also far, far, far worse compared to other healthcare industries in other countries in terms of our emissions, we're actually the worst in terms of our emissions as a healthcare industry. And a lot of this is driven by pressure on us in terms of infection control. And we're going to talk about that and how we can improve. So temperature rise is the greatest threat to global public health, according to this Lancet article from 2021. And in many ways, it's become the new patient safety movement to try and improve what you can within a daily basis. So I highly recommend reading this article. More than 200 journals on every continent publish this editorial from opto to veterinary medicine. It's an excellent short read. And what they say is that a global increase of 1.5 degrees Celsius above the pre-industrial average and the continued loss of biodiversity can risk catastrophic harm to health that will be impossible to reverse. This is very important for us to improve in any way we can. So what are the actual impacts of climate change on GI health? How does it impact our delivery of care? So climate change will exacerbate current challenges with regards to provision of adequate nutrition and access to clean water, particularly in developing countries. It's going to force migration between countries as we've already seen within countries and drive relocation from rural to urban areas, further straining sanitation and clean water provision. An increase in high rainfall events, flooding, and droughts will also be associated with increased enteric infections and hepatitis, and changes in habitat may result in altered distribution of GI illnesses like Vibrio cholera. The infrastructure required to deliver GI care is vulnerable to extreme weather events, and this is going to become more and more frequent. We saw a lot of these supply chain issues during the pandemic. And with large scale changes with climate change as well, we're going to see similar issues with supply chain over and over again. We also have seen increased incidence of issues with mental health, which can drive increased substance abuse, particularly alcohol, and how that impacts us is, forgive me, these slides just jumped back, is increased alcoholic hepatitis and pancreatitis. I'm having a little spasm with the slides. All right, so as a GI community, we need to join the debate of climate change by organizing, participating, and supporting our political leaders as they face enormous challenges posed by global warming. Okay, so in terms of our emissions, there's scope one, scope two, and scope three. This is how people who are experts in sustainability look at different emissions within a hospital setting. Now, I don't have a formal training. I'm not in sustainability. I'm not an engineer, but I am a clinician like most of you are, and so I don't necessarily deal with scope one and scope two emissions, but as this graph shows you, scope three are the largest source of carbon dioxide emissions from a hospital setting, and those include your employee commutes, waste disposal, medical devices and equipment, your pharmaceuticals, and your meat procurement, so what you actually feed your patients, and since those are the biggest contributors and those are the things that we deal with on a daily basis or have the largest hand in potentially changing, those are the things that are action items for us to potentially change within our hospital setting. All right, so there's been a few studies on what the actual scope of the problem is within GI. This is a great study by one of my colleagues who I work with on the multi-society task force on fighting climate change that was done in 2020, and they simply looked at the trash generated from an endoscopy and weighed the plastic waste specifically and looked at what could have potentially been recycled and multiplied that times the 18 million endoscopies we perform annually in this country, and what they found was that the energy consumption of our endoscopies is equivalent to 39 million tons of coal being burnt per year. Now, you can only imagine what type of impact that has on the environment, and so this kind of places a little bit of pressure on us to think twice about next time we schedule a maybe weakly indicated procedure and the impact it's going to have on the environment. A similar study was done in 2022 where, again, they simply weighed the trash. They did a five-day audit of two centers, 278 endoscopies, and found that each case was generating 2.1 kilograms of waste, 64% was going to landfill, 28% biohazard in those red bins that are often incinerated, and 9% recycled, and again, the amount of waste that was generated was equivalent to covering 117 soccer fields with waste, one meter depth, and equivalent to 24,900 passenger cars in terms of weight. That's a lot of waste, and this doesn't really take into consideration the actual carbon footprint that a lot of the production and supply chain creates. Every time you use a sphincter tome or every time you use a snare, producing those items also has a carbon footprint, the bite block that's put in a patient's mouth, the gauze that you use, and so that's an area of potential study, and so we did just that. A study out of Europe actually looked at the endoscopy waste that was generated in terms of actual CO2 emissions, and they calculated it was 4.2 kilograms of emissions per procedure for waste disposal and energy use. One of my medical students and I did a similar study on a full life cycle assessment, looking at how much energy did it take for the pulse ox on the finger, the bite block, every single item in an endoscopy, and what was the actual carbon footprint of a full life cycle assessment from start to finish, including the lights and the ceiling, the energy it took to run the computer on which our probation is running on every single item in an endoscopy, and what we found was that an EGD, one EGD, is equivalent to driving 21 miles in an average passenger vehicle, and a colonoscopy is about 25, and if you multiply that times 18 million endoscopies per year, that's quite significant. Okay, so now to the heart of the issue, so what changes our foot? Some of you may know about this, but the Joint Commission recently put out this statement saying that they were essentially going to create a critical access hospital program related to environmental sustainability. What they did was propose this and ask for feedback, which actually just closed a few days ago, the feedback period, and say, if we made this mandatory, what do people feel about it? Now, as you can imagine, there was a resounding negative feedback saying you can't make this mandatory, we're not ready, and so the conclusion was that the Joint Commission is actually going to make this optional for hospitals to have a point person who's in charge of basically saying, is your hospital up to standards with sustainability practices or not? And so for now, it's going to be optional, but as you can imagine, with most things with the Joint Commission, optional only means that it's going to become mandatory in a decade or so, maybe even less, hopefully. And so at my hospital, as a chief sustainability officer, I was really excited about this, but you know, obviously other hospital systems still need more time to accept the fact that this is a real problem, and then try to make some sort of program, put some programs in place to actually create that change. So what is the actual plan? What are we going to do about this massive problem? So there's large scale options for what we can do, and then there's smaller scale options, which I'll talk about. So in terms of a global roadmap for healthcare decarbonization, there's several things that the hospital system on a larger scale with engineers and the sustainability folks can do, including running your hospital with 100% clean, renewable energy, and those are the solar energies, the wind energies, the geothermals we talked about, investing in zero emission buildings and infrastructure, especially if a new building is going to be built, not having the same old types of buildings built, making sure that they're up to standards for being LEED certified. Transitioning to zero emissions, sustainable transport and travel, providing healthy, sustainable food. We've seen a lot of hospitals transition to meatless Mondays and other items that have a lower carbon footprint. You can also incentivize and produce low carbon pharmaceuticals, implement circular healthcare and sustainable healthcare management, and establish greater healthcare system effectiveness. In terms of the GI edition of what the plan is, there's a lot of work that we can do primarily in education, spreading awareness, which we're already doing. We have a multi-society task force, as I mentioned, who just wrote a white paper on this topic. I also wrote a paper for the ACG on some practical solutions you can use in your endosc unit to improve the carbon footprint, and 51 nations have signed up to decarbonize their healthcare industries. What's the plan in terms of the actual endosc unit? There's multiple things you can do, and this is an order of impact. You can reduce, reuse, and recycle. Reduction includes things like telemedicine. We saw that the model of telemedicine really worked during the pandemic, and a lot of hospitals have held onto that practice. It reduces a lot of the carbon footprint by patients don't have to travel to the office necessarily. They can do visits from home, and so that's really improved the carbon footprint. You can also avoid unnecessary procedures, and this is probably going to be the single-handedly most impactful thing that we can do as endoscopists. We need to find a way to reduce that 18 million procedures per year, because a lot of those aren't truly indicated, weak indications. We've done a lot of other things to improve that, such as a new colon polyp surveillance guidelines changing the lowest surveillance interval from five to 10 years to seven to 10 years. There's also things like the cytosponge, which can reduce the amount of upper endoscopies people have, and a lot of non-invasive measures that we're utilizing. You can introduce plant-based menus to your hospital, double basin washers are better than single basin washers for washing your scopes, environmentally friendly cleaning solutions. You can educate people on not putting things into those regulated medical bins that don't belong there, because those are then incinerated, and they have a markedly worse carbon footprint and are more expensive to dispose of. Surgical preference cards are good for the OR, so unnecessary things aren't open. You can change all your light bulbs to LED light bulbs, and you can reduce travel. In terms of reusing things, there's multiple items in your hospital that often get thrown out that the hospital can sell back to companies to reprocess, make money, and help the environment. These include pulse oxes, STD boots, EKG leads, and a whole other series of endomechanics. And if you're just throwing those out, you're actually losing an opportunity to not only make money, which administrators love, but also help the environment. We should be composting our food. You can also consider reusable gowns, because when GI was actually put under the umbrella of peri-op, we have a lot of sterile procedures in place that aren't necessary. We can reuse our scope buttons, we can reuse our washcloths and send them for washing as opposed to sterile gauze, biodegradable packaging for all the items we use, and we can donate expired goods, which is something that we do at my hospital, I'm happy to talk to anybody about afterwards. You can also reuse surgical and medical products, like I mentioned. And lastly, you can recycle. You can recycle the plastic, especially those plastic saline bottles, metal, cardboard, and disposable scopes, as indicated. Just a few pictures left, and then I swear I'm done. You can reprocess devices for reuse. Stryker is a company that offers this service, and again, you'd be making money for your hospital while helping the environment. It just is a win-win-win, no-brainer, in my opinion. These are some of the items that you can recycle in your hospital. I started a recycling pilot a few years ago, and we've now expanded to all rigid plastics within 30 ORs at NYU and at Bellevue as well. We're starting our recycling pilot next week by strategically placing bins in every single OR, having local champions in every single room or unit to say, do not use this bin for trash. This is for recycling only. And the easiest thing to do is start with just one item and make sure that it's a clean stream of recycling so that you don't have trash thrown into those bins. These are just some of the items that we recycled. Again, this is a lot of mom-and-pop shop stuff like I had to do myself, but it's possible. So there's companies that will accept your expired devices and actually send them to developing countries. It's really rewarding to know that it's not just going to go to landfill when it's in its intact packaging. You can also introduce plant-based foods to your hospital system, not only for patients but for staff. And here's just a photo of some of the wonderful accolades we've gotten for the work that we've done. And that's pretty much it. Thank you so much for your time.

sustainable endoscopy

carbon footprint

healthcare industry

emissions reduction

renewable energy sources

greenhouse gas emissions