The healthcare industry in some ways is hazardous to our health. Charged with protecting patients, the healthcare sector is itself a source of deadly pollution from greenhouse gases and other air pollutants.
That reality prompted the National Medical Association (NMA) in July 2021 to adopt a resolution on Sustainability Education and Research in Anesthesia to take action against this threat from within.
The resolution was the brainchild of Stephen Houser, MD, an anesthesiologist from Greensboro, NC. He’d never been taught about sustainability or climate change during his medical training, but he began to notice the real-life consequences of a warming climate in the operating room. When temperatures rose, he found he was being called in to do many more epidurals for women in early labor. On hot days, he might see a few more outdoor workers with fractures after falls related to “dehydration.”
As Houser learned more about the health impacts of climate change, he looked for solutions in his own life and work. That’s when he learned that the healthcare sector is responsible for around 8.5% of total US greenhouse gas emissions (GHG). More specifically, anesthesia plays a big part, contributing to about 51% of hospital operating room GHG emissions. Many commonly used anesthetic gases, such as nitrous oxide, are also greenhouse gases that are usually vented directly into the air without pollution controls.
“We’ve got to be educated about this within the anesthesia community,” Houser says.
With NMA’s passage of his resolution, the largest and oldest national organization representing African American physicians in the United States, Houser is planning to do just that.
An education at intersection of climate change, health, and equity
Houser says the United Nations Intergovernmental Panel on Climate Change, IPCC, reports spurred him to action. He feels even more urgency with the IPCC’s most recent 2021 update projecting dire health consequences, particularly for communities of color, without sweeping interventions to limit GHG emissions.
In the waning days of August, the Biden administration’s Department of Health and Human Services (HHS) announced the creation of the Office of Climate Change and Health Equity (OCCHE): Its goal, in part, is to tackle the healthcare sector’s role in fueling climate change. An additional aim of the new office involves addressing health inequities worsened by climate change.
NMA has already been working at the intersection of climate change, health, and equity for close to a decade.
Founded in 1895 as a professional home for African American physicians not welcome to join the American Medical Association (AMA), NMA physicians consider the elimination of health disparities a core part of their mission. That focus on environmental health and climate change grew organically from this mission, as many of NMA’s 50,000 physician members practice in communities most adversely affected by the warming climate.
Mark Mitchell, MD, a preventive care physician and co-chair of the NMA’s Commission on Environmental Health, has been a key leader in that effort, spearheading health professional education on climate risks for close to seven years. He also worked on a collaboration with the Medical Society Consortium on Climate and Health to launch the Climate and Health Equity Fellowship earlier this year. (Houser is one of the six Climate and Health Equity Fellows in the inaugural class.)
“The fellowship program is to develop leaders of color in the climate and climate and health space, and to talk about how communities of color are disproportionately affected,” Mitchell says. Ultimately, he says he hopes the fellows will be viewed as trusted voices to advocate for climate action, both in and beyond the healthcare system.
For Houser the fellowship provided an in-depth opportunity to learn the science behind climate change and its impact on health and use that knowledge to promote and advocate for equitable, health-focused ways to mitigate the worsening impacts of climate change.
He says he has been able to immediately focus on his own specialty as a target in efforts to limit GHG emissions from the healthcare industry. He notes the outsized role that anesthesiology, a specialty wherein providers usually work behind the scenes, plays in GHG emissions.
“It’s kind of interesting because people don’t really know [their] anesthesiologist … But there’s actually a lot we can do to protect the public from climate change.”
Inhaled anesthetic gases commonly used for general anesthesia can be quite potent heat-trapping gases, Houser says. Gases inhaled during general anesthesia don’t break down in the human body, so patients breathe them out, pretty much unaltered. These gases are then vented out directly into the atmosphere.
One of the most expensive inhaled anesthetics, desflurane, can remain in the atmosphere for 14 years. The standard use of desflurane per hour during surgery is the equivalent of driving 235 to 470 miles. Compare that to a readily available and less costly alternative, sevoflurane, which has about a one-year atmospheric “lifetime.” One hour of use warms the atmosphere about as much as driving a car 71 miles.
Another gas that can cause more harm, nitrous oxide, is relatively cheap and is used commonly across the globe. It can hang out in the atmosphere for more than 100 years and can also damage the ozone layer, making it particularly problematic.
The GHG emission problem arises because human bodies don’t really break down the gases when we breathe them in during general anesthesia, so we breathe them out, pretty much unaltered. These gases are then vented out directly into the atmosphere.
The NMA resolution seeks to increase education about the differences in GHG emissions to encourage use of alternative agents as much as possible. The goal is to also encourage research into better ways of recycling anesthesia gases and potentially using scavenger systems to collect these anesthetics rather than allowing them to be vented into the air.
There are other benefits to being a climate-conscious anesthesiologist according to Houser. “If you’re mindful, you can use a regional nerve block when it’s appropriate,” potentially limiting side effects from general anesthesia.
Houser hopes that with this resolution now official NMA policy, more providers will become climate conscious.
Global solutions to address a global problem
Houser’s work fits in well with the broader work of many anesthesiologists nationally and internationally. Practice Greenhealth, a nonprofit that works with healthcare member organizations, assists facilities in “Greening the OR,” and anesthetic gas reduction is an important focus area.
The work of Brian Cheseboro, MD, an anesthesiologist in Portland, Oregon, has been highlighted by Practice Greenhealth. He serves as medical director for environmental stewardship for the Oregon Region of Providence Health & Services, a seven-state 55-hospital health care system. Since 2016, he has been working with anesthesia providers in his network of hospitals to move away from desflurane and toward anesthetic gases that contribute less to GHG pollution.
“That program was successful, we drove our anesthesia emissions down by 95%,” Cheseboro says. Along with lowered emissions came lower costs, all through education and voluntary practice changes.
His data shows no changes in clinical quality outcomes for any type of surgery. He also found no significant difference in the amount of time it took patients to recover when comparing similar types of surgery and alternative inhaled anesthetic gases.
Armed with his data, Cheseboro was able to encourage most providers in his own institution and in surrounding areas to shift their practices. Internationally, according to Cheseboro, anesthesia governance bodies are working together to approach how to share best practices for safe, high-quality care delivery that also takes into account environmental and climate change impacts.
Houser says he too is working within the NMA and broader anesthesia community to help spread the message.
With no time to spare, he worries about the climate change-related heat impacts on his daughters during the upcoming soccer season in South Carolina. He laments that he can’t stop wondering what the world is going to be like for them.
“With the most recent IPCC report” Houser says, “it really feels like we need all hands on deck. This is the part I can play.”