Climate change: What does it mean for the future of surgery?

In the 21st century, many members of the health care community have united to address significant challenges in global health, including increasing occurrence of noncommunicable diseases associated with obesity, poor diet, smoking, and air pollution; a lack of infrastructure and resources to provide necessary health care services, including surgical interventions, in low- and middle-income countries (LMICs); and so on. But recently, a number of health care experts have warned that the issue that will most affect human health globally is one that acts as a barometer for the health of the planet itself—climate change.

In a 2018 report, Watts and colleagues suggested that “climate change is the biggest global health threat of the 21st century.”¹ Other notable health care organizations have echoed this sentiment. The United Nations and World Health Organization both have released reports recently that examine the deleterious health consequences of climate change.^2,3 The New England Journal of Medicine (NEJM) featured an article in early 2019 calling climate action “imperative” to protect human health.⁴ A recent uptick in the lay media’s coverage of this topic is notable as well.⁵ Clearly, the health effects of climate change have become a topic of considerable interest to the international health care community, as well as the public.

Following is a brief summary of some of the key concepts at the intersection of climate change and health, including how it is affecting human well-being today and is projected to do so in the future, as well as how health care fits in to the issue—both as a contributing factor and as a force to combat it. This article is based on the contemporary understanding of anthropogenic (that is, human-driven) climate change as the observed warming of the global climate system, which has accelerated since the mid-20th century largely because of rising carbon emissions from human activities.⁶

How climate change is affecting health

Our environment has been proven to have a significant impact on human health. It is unsurprising, then, that a rapidly warming global climate is stressing human health in a number of ways, especially among vulnerable populations, such as children, the elderly, the immunocompromised, pregnant women, the poor, and individuals who work outdoors or who perform manual labor. Some of these identified health effects follow.

Extreme weather events

Perhaps the health effect that most directly affects surgeons is the increase in extreme weather events. The last few years have brought several weather-related disasters to the U.S., including the 2017 Atlantic hurricane season that devastated parts of Texas, Florida, and the U.S. East Coast and did the most long-lasting damage in Puerto Rico. Importantly, research following the storms indicated that the increased rainfall and subsequent flooding can be attributed to human-caused climate change. Research on Hurricane Maria, which struck Puerto Rico, shows that the storm produced the largest maximum daily rainfall of any hurricane since records have been reliably kept and that storms of such severity are significantly more likely to strike today than in the past.⁷

The storms collectively led to thousands of deaths and more than $300 billion in economic damage, resulting from high winds, flooding, and the lingering effects on the infrastructure of the affected locations. Damaged infrastructure, including physical damage to buildings and downed electrical and telecommunications service, is of particular concern to surgeons because the ability to provide safe, high-quality surgical intervention is dependent upon the availability of resources and a stable practice environment.

Articles published in the Bulletin have recounted how surgeons have adapted to damaged hospitals and operating rooms (ORs); how surgeons and patients struggled to get to hospitals; and how strained communication avenues have made patient care much more difficult.^8,9 These reports not only show the dedication and resilience of surgeons and the value of preparation, but also the increasing human and financial toll extreme weather events place on what is already a strained health care system.

“Extreme weather events are affecting health care delivery and access, which is something we’ve seen in the news with increasing frequency,” said Amy Collins, MD, senior clinical advisor for physician engagement at Health Care Without Harm, a global initiative that seeks to bring attention to the environmental impact of health care and educate practitioners on how to make positive changes. “Recent wildfires, flooding in Nebraska, and the hurricanes are forcing hospitals to evacuate and relocate patients, and some hospitals have been out of operation for weeks or months,” added Dr. Collins, an emergency medicine physician, MetroWest Medical Center, Framingham, MA.

Extreme heat events

Climate change is increasing the amount and severity of extreme heat events around the world, with the number of people who experienced extreme heat increasing by more than an estimated 125 million from 2000 to 2016.² Thousands of people die annually from the effects of extreme heat, such as heat stroke, dehydration, and cardiovascular issues. Extreme heat already is recognized as one of the greatest dangers facing inhabitants of cities¹⁰—the most densely populated areas of any country—and the problem is expected to worsen as the climate continues to warm domestically and globally. As of June 2019, record heat waves in Europe have led to several deaths, with more projected.¹¹

Air pollution

A primary driver of climate change is the increased global burning of fossil fuels and coal, which emits a high amount of carbon dioxide. A dangerous side effect is the addition of a large amount of pollutants to the air in the form of fine particulate matter that is suspended in the atmosphere.¹ Air pollution concentrations have worsened in cities across much of the world—particularly in rapidly developing countries in Asia such as China and India—which has led to an increase in incidence of associated health conditions, including heart disease and lung cancer, and approximately 4.2 million deaths.¹²

Climate-sensitive diseases

The rising global temperature has changed the capacity for the transmission of some insect- and water-borne illnesses, such as dengue fever, Lyme disease, and malaria. The increased temperature across regions means that insects and water-based pathogens can live in a wider geographic area for an extended amount of time, increasing their chance to spread to human populations.¹

In addition, a 2017 study in Infection Control & Hospital Epidemiology showed that the risk of surgical site infections (SSIs) is “highly seasonal,” with the highest incidence in warmer months and lowest in colder months.¹³ Although ongoing research needs to be done to determine how the climate may affect these rates, it suggests that a warming climate is more conducive to increased instances of SSIs.

Undernutrition and lack of potable water

Extreme weather events, such as prolonged, severe drought in LMICs, have been shown to decrease the quantity and quality of crop yields, which leads to undernutrition and its associated health effects, including delayed wound healing.¹

Drought and extreme rain both affect access to drinkable water in different ways—drought leads to reduced availability of fresh water, and excessive rainfall leads to runoff from agriculture and industry, inadvertently contaminating water sources.¹

Mental health and well-being

Not to be lost among the more noticeable somatic effects of climate change is the associated damage to mental health. Victims of powerful storms and wildfires—which can displace populations, undermine financial and familial stability, and lead to disease and death—are often found to suffer from anxiety, depression, post-traumatic stress disorder, and suicidal ideation.¹⁴ Beyond lowering quality of life, the stress of mental illness leads to poorer immune response and overall health.

The effects on surgery

The intersection of climate change and health is still an inchoate field of study, and how climate change and surgery intersect is even less explored. But the noted health effects reveal a through line into the modern, holistic picture of human health—and into the field of surgery.

Preoperative patient health

The American College of Surgeons (ACS) recently became the home of the Strong for Surgery program, which is intended to identify, evaluate, and modify patient health factors preceding an operation that are indicative or contraindicative of a better recovery and fewer complications.¹⁵ Strong for Surgery checklists cover areas such as nutrition, glycemic control, medication management, and smoking cessation, among others. These factors reflect the overall health of a patient, and if they are at a substandard level before an operation, a patient is at a higher risk for suboptimal recovery. A rapidly changing, deteriorating climate can affect these risk factors in different ways.

For example, with respect to nutrition and glycemic control, climate change threatens food security and food production, as previously noted, and is likely to lead to under- and malnutrition, which can negatively affect wound healing and recovery.¹ Climate change also can affect medication management. Many pharmaceuticals are produced in Puerto Rico, and Hurricane Maria heavily damaged the production of such basic medical supplies as intravenous saline bags—a vital component of hospital health care. Hospitals experienced shortages of these resources for more than a year after the storm.¹⁶ Increasingly unpredictable and devastating weather events have the potential to make properly medicating patients more difficult as the production facilities are exposed to worsening weather events.

And the effects of smoking, which have been proven to decrease wound healing and lung function after surgery, among other known detriments, will become difficult to avoid on a population level if air pollution continues to increase. The mechanisms of damage to the body between smoking and breathing in polluted air are similar and include increased incidence of respiratory and cardiovascular disease—and air pollution is now believed to cause more deaths.¹⁷ The patient factors that initiatives such as Strong for Surgery seek to address to ensure optimal surgical outcomes may become more difficult to control on a patient level because of a degraded environment.

Access to surgery and growing disparities

These patient-level factors, significant as they are, are made even more difficult to address when patients lack access to surgery. The Lancet Commission on Global Surgery, since 2014, has been promoting the message that surgery is “an indivisible, indispensable part of health care,” as nearly one-third of global burden of disease is attributable to surgically treatable conditions—but more than half of the planet’s population lacks access to surgery and anesthesia.¹⁸ The primary driver of this lack of access is economic in nature, with most underserved populations living in LMICs, with access decreasing parallel to lower economic status. But access issues exist within the U.S. as well, especially among rural populations and the urban poor.¹⁹

These issues are among those that the surgical community—including the ACS through Operation Giving Back, in its volunteers’ efforts to train local surgeons and increase surgical representation in LMICs²⁰—has sought to address. These concerns are particularly noteworthy in the context of climate change because the effects of the warming global environment, in terms of health, disproportionately affect the poor and other vulnerable populations.²¹ Climate change is likely to exacerbate these extant problems by increasing the risk of health effects; further decreasing the economic power, and subsequent access to health care, of LMIC populations;²² and physically displacing populations as a consequence of their geographic homes becoming less hospitable because of rising sea levels, extreme weather events, and increasing potable water scarcity and drought.²³ The net effect is that health care, and especially location- and resource-dependent surgery, will become further out of reach for a vast number of people around the world—an outcome diametrically opposed to the contemporary global mission of access to care for all.

Taking action

The response to the challenges of climate change in the U.S. must be comprehensive and target the largest sources of carbon emissions, including government, business, and what may be a surprising contributor—the U.S. health care system itself. If its $3.3 trillion gross domestic product were counted as a distinct entity, U.S. health care would be the fifth-largest economy in the world and the seventh-largest producer of carbon dioxide.²⁴

These figures uniquely position the health care system as both a significant contributor to climate change and its associated health effects, but also as the field responsible for safeguarding patient care. As the authors of a January 2019 NEJM article state, “Tackling this challenge may feel overwhelming, but physicians are well placed and, we believe, morally bound to take a lead role in confronting climate change with the urgency that it demands.”²⁵

Greening the OR

Physicians can affect the change necessary to lessen health care’s role in the climate change. The logical place to start for surgeons is in recognizing the significant impact that ORs have on a hospital’s carbon footprint. Surgery is, by necessity, a resource- and energy-intensive field, but a study in The Lancet Planetary Health on the carbon footprint of three ORs suggests the extent of energy use and patient-safe ways to reduce it. These solutions involve such changes as the selective use of desflurane, an anesthetic agent with high carbon emission side effects, and occupancy-based OR ventilation to reduce energy requirements in rooms that are not in use.²⁶

Furthermore, paying attention to physical resources used in the OR can significantly decrease the effect on the energy required for disposal of used instruments and tools used in a single operation—and also lower hospitals costs. A 2015 Bulletin article detailed some of the ways that hospitals accomplish these energy and cost savings, which include monitoring and changing the use of single-use devices and disposable instrumentation; environmentally preferred purchasing; and limiting items thrown away in biohazardous waste bags, which cost considerably more to dispose of than other waste and release more carbon dioxide and other harmful elements when incinerated.²⁷

The Cleveland Clinic, OH, has integrated environmental sustainability into its core mission. Sofya Asfaw, MD, FACS, a general surgeon at Cleveland Clinic, noted that because ORs account for a significant portion of a hospital’s resource and energy use and waste, it is vital that surgeons and their accompanying support staff address the issue. “We have taken the challenge of reducing our hospital’s carbon footprint and met it head on,” Dr. Asfaw said.

In addition to using some of the previously mentioned methods of promoting a green, sustainable OR, Cleveland Clinic now recycles preincision plastics instead of throwing them away, which has diverted “more than 1 million pounds of plastic from landfills;” has converted all OR lights to LED (light-emitting diode); and promotes the use of a scrubless solution to sterilize hands before surgery (after the first scrub of the day) instead of water, saving hundreds of thousands of gallons of water, according to Dr. Asfaw.

“Our crowning achievement has been educating the next generation of clinicians and residents and making health care sustainability something that is ingrained in their mentality, in how they approach their patients in the operating room,” Dr. Asfaw said. In addition to including tenets of environmental sustainability in the standard residency curriculum “from day one,” six years ago the Cleveland Clinic created the Ken Lee Memorial Fellowship, which focuses on greening the OR and promoting climate-positive practices. Each year, the fellow, a general surgery resident, creates a project on sustainability that focuses on the OR and helps improve efficiency, decrease energy use, and reduces the OR’s carbon footprint. Dr. Asfaw, the Ken Lee Memorial Fellowship director, said that “these projects have had lasting effects on how we operate and on how our ORs function.”

Ultimately, Dr. Asfaw notes, efforts to green the OR are multidisciplinary and include supply chain management, facilities staff, environmental services, nursing leadership, and more. Having support from the entire team is important in implementing sustainability programs in other hospitals. Because surgeons are natural leaders in and out of the OR, “it is critical to have surgeon champions communicating with and educating key stakeholders to express the importance of these initiatives,” she said.

The work to address how health care and ORs contribute to climate change takes time and effort, but Dr. Asfaw noted, “As clinicians, we need to think of the work in this sector not as ‘extra,’ but as a necessary part of our practice to maintain public health.”

Carbon neutrality and energy independence

At the institutional level, hospitals and health care organizations can commit to at least becoming carbon emission-neutral, meaning that their carbon emissions are balanced out by carbon savings elsewhere. Kaiser Permanente, Oakland, CA, and the Boston Medical Center, MA, for example, have both made considerable strides in reducing their carbon footprints;^28,29 and Dr. Asfaw said that Cleveland Clinic aims to be carbon neutral by 2027. Gundersen Health System, La Cross, WI, has even become energy independent and now produces more energy than it consumes.³⁰ Additionally, financially divesting from the fossil fuel industry is one way that health systems can both directly reduce their reliance on health-negative consumption, as well as send a message that public health takes precedence over monetary gain.

Adaptability

Even if the U.S. health care system takes collective action on climate change, some environmental disruptions now appear inevitable. Hence, hospitals and health care facilities must be prepared to adapt.

As previously noted, extreme weather events are likely to further increase in frequency, scope, and intensity, so hospitals in vulnerable areas are taking steps to mitigate future disasters. In response to damaging 2001 storms, the Texas Medical Center rebuilt its facilities to house power systems at a higher elevation and to provide power through a plant independent from the Houston, TX, power grid; these preparations left the medical center largely operational during Hurricane Harvey.³¹ Similarly, hospitals in New York, NY, and Boston have changed their energy generation placement and positioned critical patient care functionality above the first floor of the building both in response to Hurricane Sandy and in preparation for coming storms. It is vital that health care facilities remain open during weather and climate disasters, and these adaptations and preparations are likely to become mandatory in the future.

A collective voice

It will take a system-wide effort to bring health care to a level that will markedly reduce its carbon footprint. To that end, several health care organizations are making coordinated efforts to educate colleagues and the public on the health effects of climate change and the necessity of action, as well as providing resources and pathways to get involved. Two such groups include Health Care Without Harm, mentioned previously, and the Medical Society Consortium on Climate and Health.

Health Care Without Harm

Health Care Without Harm “seeks to transform health care worldwide so that it reduces its environmental footprint and becomes a community anchor for sustainability and a leader in the global movement for environmental health and justice.”³² Dr. Collins’ organization works to “support physicians interested in promoting climate-smart health care, which is our term for environmentally responsible health care, and in taking climate action,” she said. Presenting data and statistics on costs and environmental impact to hospital leaders can sway opinion on local changes, and it’s important to know the business case for greening of the OR, for example.

On a larger scale, when speaking to physicians, Dr. Collins emphasizes the importance of advocacy. “I feel very strongly that physicians are advocates. Part of our job is to advocate for our patients, but we can also use our influence and health expertise to advocate for improved public health,” she said. She says to consider a broadened view of the Hippocratic Oath when thinking about the health effects of climate change. “We all take the oath to do no harm,” Dr. Collins said. “Of course, we don’t want to directly harm our patients through our actions, but we also have the opportunity to ensure our policies and health care operations are not harming our communities and the planet.”

The Health Care Without Harm website houses a variety of resources on climate change and health. It also offers the opportunity to join their Physician Network, which “supports emerging and established physician leaders in leveraging their influence and expertise to advance the growing health care sustainability movement and to create climate-smart health care. The Physician Network brings physicians together to share best practices and to inspire one another in advocating for a sustainable and healthy future.”

Medical Society Consortium on Climate and Health

A physician’s voice can be effective on its own, whether in a hospital setting or when weighing in on the health effects of state and federal legislation. But the collective voice of the nation’s health care professionals is even more powerful; thus, professional medical organizations working in concert can have a significant impact on climate action. To that end, the Medical Society Consortium on Climate and Health, a consortium of 23 medical societies that includes the American College of Physicians, American Medical Association, and American Academy of Pediatrics, and represents more than 600,000 U.S. physicians, seeks to harness their influence to help leaders understand the dangers of climate change and how transformations to address the climate will simultaneously promote health.³³

According to Mona Sarfaty, MD, MPH, FAAFP, executive director of the consortium, even before the collaborative formed, it was evident that many physicians were already aware of the human role in climate change and its effects on patient care. Dr. Sarfaty and her colleagues surveyed members of three medical societies to gauge physician understanding of climate change. Most respondents agreed that climate change was occurring, that human agency was the primary driver, and that “it was directly relevant to patient care,” Dr. Sarfaty said. Approximately 70 percent of respondents indicated that climate change was already affecting their patients through poorer air quality from pollutants, increased incidence and symptoms of allergies, or injuries related to extreme weather events, among other examples. “[They] said that physicians had a responsibility to inform the public and to inform their patients about the risks of climate change,” Dr. Sarfaty said. Many of the surveyed physicians wanted to make their own practices environmentally sound, “the majority wanted their own societies to have a policy on the issue,” and they felt they could be better informed.

Those responses revealed an actionable agenda. “We needed to get some educational material and opportunities out there for physicians, we needed to be in touch with their societies to see about policy positions, and we needed to bring groups together so we could help each other to get their societies more engaged in the issues,” Dr. Sarfaty said. A briefing from a representative of the U.S. Global Change Research Group to the initial small group of interested societies led to a consensus statement and the conception of what became the Medical Society Consortium on Climate and Health, which publicly launched in 2017.

“Our mission is informing the public and policymakers about the health impacts of climate change, and the health benefits of solutions,” she said. “We organize, empower, and amplify the voices of physicians.” The group has developed a significant presence in this area, having held annual meetings and released annual reports, as well as having been referenced in more than 170 news stories as of April 2019. The Medical Society Consortium on Climate & Health website serves as both a clearinghouse for information on the health effects of climate change and provides resources and ways for physicians and their groups to take climate action, including suggestions on how to persuade legislators to address the climate at the highest levels.

A great but necessary burden

In late June, more than 70 U.S. medical and public health organizations, including Health Care Without Harm and the member organizations of the Medical Society Consortium on Climate and Health, came together to declare climate change a health emergency and called on policymakers to take steps to address it.³⁴ It is the most recent, most expansive clarion call from the medical community to our nation’s leaders to heed the words of the experts: climate change is here, and it is negatively affecting human health. Thought leaders and physicians tell us that if no action is taken, its effects will continue to worsen and will touch every branch of medicine.

Patients require and deserve total attention to ensuring optimal surgical outcomes, and already surgeons are expected to split their efforts among many activities outside the OR. But the evidence suggests that the health effects of climate change will only increase if no action is taken. In a time of great change and in which future generations depend upon actions taken today, it is vital that the health care community unite to address, in climate change, what some experts suggest may be the greatest threat to human health in the next century.

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