Where do we stand, where do we want to go?

The healthcare sector is particularly resource-intensive; a visit to a modern intensive care unit is enough to illustrate this. However, when considering the totality of practices, hospitals, treatments and associated traffic, it is estimated that approximately 5% of the world’s_{CO2 equivalents} are attributable to healthcare. Consequently, sustainable thinking and action, and concomitantly reduced resource consumption, should be urgent goals for the healthcare sector to take responsibility in the fight against global warming.

Start CME test

Fossil fuels such as lignite and hard coal, crude oil and natural gas have been used for energy production on a large scale since the industrial revolution and are still used today. This produces carbon dioxide (_CO2), which, as a greenhouse gas, is one of the main triggers of climate change, considered to be the greatest current (this century) threat to human health. Excessive consumption of resources (raw materials, water, land area) in general leads to a dysbalance of natural systems. To illustrate this, the planetary stress limits model is used [1]. Unfortunately, individual countries and humanity as a whole regularly exceed calculated biophysical limits before the end of a calendar year and this point in time is called Earth Overload Day. In Switzerland this day fell this year on 13.05.2023, in Qatar on 10.02.2023. This means that all the resources available within the country each year were already used up in the first half or quarter. Obviously, this cannot work in the long term and is therefore not sustainable. In order to change this state of affairs, a joint show of strength is required, which entails changes for daily life. This is a difficult task for society and politics, which is known to lead to numerous controversies.

The healthcare sector is particularly resource-intensive; a visit to a modern intensive care unit is enough to illustrate this (note, for example, organ replacement procedures such as dialysis). However, when considering the totality of practices, clinics/hospitals, treatments/applications, and associated traffic, it is estimated that approximately 5% of global_{CO2 equivalents} are attributable to healthcare [2]. This may seem secondary compared to certain industries, but there is no denying that they share responsibility for climate change, which itself poses a major threat to the health of the population. Consequently, sustainable thinking and action, and concomitantly reduced resource consumption, should be urgent goals for the healthcare sector to take responsibility in the fight against global warming. This article brings together some practical aspects related to sustainability in clinical care; however, the details of solutions may vary greatly depending on the particular institution [3]. Other societal challenges, such as demographic change, must also be part of the equation if the healthcare system and individual facilities are to be fit for the future. Ultimately, processes and structures will need to be completely rethought in some cases in order to arrive at creative and innovative solutions that will make healthcare resilient to climate change and other pressures.

Sustainable health care

The World Health Organization (WHO) published the concept “Healthy Hospitals, Healthy Planet, Healthy People!” back in 2009 and defined 2020 frameworks that can be applied to medical facilities worldwide depending on country-specific circumstances [4]. This publication is intended to serve as a blueprint for decision-makers worldwide who are planning the implementation of sustainable measures (e.g., health policy makers, boards of hospital associations, etc.). Starting points for sustainable interventions are modern technology, water supply and disposal, energy supply, infrastructure, human resources, hygiene and waste management. Depending on the level of development and economic strength, the healthcare systems of individual countries naturally differ considerably. From the local perspective, therefore, an orientation in a Central European comparison is decisive. Weisz et al. [5] calculated the total emissions of the Austrian health care system and also_{CO2 equivalents} for different medical care sectors. While in the outpatient sector, consumables and medicines accounted for the largest share of_{CO2 equivalents}, in the inpatient sector 36% of_{CO2 equivalents} were attributable to the purchase of medical goods and services, 31% to direct energy consumption and 19% to medication consumption. It can be assumed that these figures can also be roughly applied to Switzerland and Germany. In turn, six areas of action are identified by the authors for potential mitigation of climate change in the health care system:

Reduction of direct energy consumption
Use of more sustainable product alternatives
Avoiding inefficiencies in the healthcare system
Adjustment of medical treatments
Changes in national health care planning.
Transforming the health system to promote human and planetary health.

This clearly shows that structuring and prioritization of measures is necessary. In the following, we would like to highlight a few selected aspects; in addition, we refer to an excellent article on a variety of interventions for more sustainability, which can also be initiated by the employees in hospitals themselves [6].

Energy and buildings

Energy consumption in both the inpatient and outpatient sectors is a significant contributor to_{CO2 emissions}. An analysis of ten internal medicine practices in Switzerland showed that energy consumption (especially heating) and transportation of patients and staff contribute most to the overall CO2 _footprint[3]. Another Swiss study evaluated the environmental impact of 33 hospitals. Heat supply was responsible for 26% of GHG emissions, followed by food service (17%) and building infrastructure (15%). Pharmaceuticals came in fourth, followed by electricity consumption and the production of operational consumables. Less significant then in comparison are waste/wastewater, electronic equipment, laundry, textiles, and large medical equipment manufacturing (Fig. 1) [7].

The same working group also showed that half of the Swiss hospitals could reduce their emissions by about 50% without reducing services. It makes a significant difference whether renewable or fossil energies are used. Hospitals that supply energy with district heating, for example, perform significantly better in the life cycle assessment. Admittedly, this technology is not available everywhere.

Structural measures are usually required to improve the energy balance of buildings, for example, modern heating and cooling systems, the use of energy-efficient natural insulating materials (for facades, windows, roofs) or the greening of roofs and facades contribute to this. Implementing such construction projects is difficult in existing medical facilities due to the need for continuous operations. On the other hand, energy consumption can be reduced relatively easily by using energy-efficient lighting systems (light-emitting diodes=LEDs), controlling air conditioning in a targeted manner, and regularly servicing electrical equipment. New purchases often pay for themselves after just a few years due to reduced energy consumption.

Another aspect of sustainable resource use is the responsible use of water. Clinics and dermatologists in private practice can reduce water use by using water-efficient fixtures, collecting rainwater for watering plants, and training staff on water conservation. Cost savings can also be achieved here [3].

Digitization

Hygiene measures to combat the Covid 19 pandemic have led to increased use of digital applications and teledermatology. Although telemedicine is not new, it is often not yet sufficiently established in everyday medical care. However, dermatology in particular, due to its visual orientation, offers good conditions for using and further developing the possibilities of digital cross-sector structures.

Teledermatology can potentially be beneficial for the climate, as travel distances can be saved on the patient side. Overall, conducting online consultations or providing remote treatment (store-and-forward) could reduce unnecessary travel and associated_{CO2 emissions}. In addition, telemedicine allows for more efficient use of resources by potentially requiring fewer physical exams and waiting times (less need for space). Digitization of practice processes can also reduce the use of paper by introducing digital appointment scheduling, reporting of findings and electronic patient records. Simple changes, such as double-sided printing, can mean an immediate reduction in paper consumption. However, it must be remembered that power consumption and the purchase of necessary end devices must be taken into account in the life cycle assessment, and digitization does not automatically lead to greater sustainability. Overall, however, it is reasonable to assume that dermatologists who integrate telemedicine into their practices can not only achieve environmental benefits, but also increase facility efficiency and flexibility. This can contribute to patient satisfaction; young patients in particular expect digital offerings.

Dermatohistology is an essential part of dermatology in German-speaking countries. Here, too, digitization plays a major role. In some cases, the classic microscope is already supplemented by a “whole slide scanner” and a computer screen. This offers the possibility of a “home office” for diagnosticians and can thus save travel distances and accelerate consultative co-assessments by experts. Artificial intelligence (AI) and deep learning will be used in a complementary way in terms of pattern recognition in tumor diseases or even inflammatory diseases. Initial studies show that AI already reliably detects and distinguishes seborrheic keratoses, dermal nevi, nodular basal cell carcinomas and malignant melanomas, for example. Forchhammer et al. [8] assume that AI will become a kind of “digital co-driver”, which will not replace dermatohistologists, but will act as an independent decision support. At this point, it is worth mentioning the enormous power consumption by AI applications at this point in time, which is caused by the necessary computing steps. Therefore, when implementing appropriate innovations and in the energy-intensive laboratory sector in general, a power supply from renewable sources should also be considered.

Consumables and externals

Dermatologists can consciously manage the consumption of medications and supplies. This can be achieved through close inventory control, avoiding over-ordering, and using reusable or recyclable materials. Avoiding waste and over-consumption of materials not only has environmental benefits, but also leads to savings in material costs.

Externals such as ointments, creams and lotions are used extensively in dermatology and play a major role in basic therapy, e.g. for “refatting”, and light protection is always a highly topical issue. Increasingly, cosmeceuticals are also gaining in popularity. The bases of topicals are usually based on non-renewable or fossil raw materials such as mineral oils. However, formulations cannot be changed without further ado, as galenic problems may occur. An alternative to mineral oils and silicones are vegetable oils and waxes. However, these must be protected from rancidity by antioxidants such as tocopherol or polyphenols. Thus, they are usually used only in lower concentrations. Vegetable oils with saturated fats are less sensitive to oxidation. They are called neutral oil and consist of medium-chain fatty acids with caprylic acid and capric acid. They are readily soluble in water and biodegradable. For example, squalane, a saturated viscous oil, which is a natural component of the stratum corneum of our skin, can be obtained as a raw material from vegetable lipids (e.g., olive oil) [9]. Patients and cosmetic clients are showing an increasing awareness of ecological issues brought to the attention of dermatologists.

Modern sunscreens combine physically and chemically active ingredients. Chemical filters act primarily by absorbing UV radiation. The most commonly used filters are Octocrylene and Benzophenone (which mainly absorb UVB) and Avobenzone and Benzophenone 8 (which mainly absorbs UVA). Certain aromatic compounds, such as oxybenzone, have been shown to accumulate in marine animals and cause genetic changes [10], so the recommended extensive use of UV protectants may well be ecologically problematic. This has led some island nations to ban certain UV filters. The dermatological community should take it upon itself to work on the development of environmentally friendly externals incl. UV filters and to educate the public accordingly. In addition to ingredients, sustainable external therapy also includes preference for suitable packaging for creams and lotions. The use of biodegradable packaging reduces the contribution of dermatological practice to waste production and promotes the circular economy. Classic packaging materials include plastics, glass and aluminum. In terms of their environmental impact, packaging made of plastics, such as polyethylene terephthalate (PET) and aluminum, actually proved to be more sustainable than glass at this point in time, due to the high energy consumption in glass production with a low recycling rate. PET is the plastic most commonly used for packaging topicals. It is lightweight, unbreakable, highly resilient and can be recycled and returned to the material cycle relatively easily. In addition, the low weight leads to lower transport energy requirements and consequently to a better life cycle assessment [9]. However, the degradation of certain plastics in the environment (PET, for example) produces greenhouse gases such as methane. Furthermore, there is a direct link between plastic production and climate change due to the predominantly petroleum-based production (Fig. 2).

Furthermore, a justifiable life cycle assessment for the use of plastics only exists in the case of adequate recycling. In recent decades, however, only a fraction of the plastic produced has been adequately recycled, and an urgent global turnaround is needed to stop the increasing pollution of the environment with plastic (Fig. 3).

At this time, participation by the dermatology community in reducing the generation of plastic waste should be called for.

Dermatosurgery

With the increasing incidence of skin tumors in an aging population, dermatosurgery will continue to have an increasing importance in dermatology. As in intensive care units, material consumption in the operating room is enormous due to the high hygiene requirements. In recent years, there has been an increasing trend towards the use of disposable materials without subsequent reprocessing for reuse. This field has been considered for years as an ideal intervention point for a more sustainable work. In 2023, German physicians published a narrative review on this topic, summarizing various options for sustainable work in the OR under the 5Rs “Reduce – Reuse – Recycle – Rethink – Research” (Fig. 4) .

Approaches include the use of appropriate sieves and consistent documentation of unused cutlery to reduce the burden on reprocessing. The use of sterile supplies should be based on current hygiene recommendations and the size of the procedure; in some circumstances, for example, head covers or sterile gowns may not be necessary. Where appropriate, the use of reusable gowns is possible [12]. If larger operational departments are consistently converted, there is enormous potential for savings. For example, in an American hospital with over 17,000 annual inpatient surgeries, a reduction of over 1000 kg of medical waste per year was achieved. Furthermore, electricity consumption was reduced, resulting in cumulative savings of over $100,000 [3].

From theory to practice

Despite knowledge of the causes and drivers of climate change, the concrete implementation of sustainable measures in many areas of society is difficult and has not yet begun to be adequately implemented. Particularly in the medical sector, difficulties arise in implementing sustainable measures, e.g. due to high hygiene requirements and economic pressure [13]. Ultimately, however, it is a misconception that sustainable measures are expensive, as acquisition costs can quickly pay for themselves in view of high energy costs. Furthermore, the avoidance of wasted resources and the conscious use of medical services and applications directly saves costs and is therefore economical. In order to move from the theoretical to the practical part of the implementation, it is recommended according to Mezger et al. The creation of an action plan that can then be brought to life [12]. The following steps are suitable for this purpose:

Evaluation of the status quo of a practice
Setting of (feasible) sustainability targets
Switch to (sustainable) green electricity and green gas
Switch to digital documentation, sustainable consumables, energy-saving IT and switch to a sustainable bank
Implementation of sustainability measures in the operating room
Avoidance of commuter trips in private vehicles (motorized individual transport).
Structural changes
(Honest) communication about one’s own sustainability efforts.

Because sustainability and the fight against climate change is a topic close to the hearts of many physicians, especially the next generation of physicians, there are numerous online resources to draw upon. At this point, we refer to the Sustainability in Dermatology Working Group of the German Dermatological Society, which provides many materials (including patient brochures and quality management templates) on the homepage www.agderma.de. An advanced training module for healthcare professionals on sustainable practice management is under development and will be available soon. Beyond dermatology, the German Climate Change and Health Alliance(www.klimawandel-gesundheit.de) is another source of a wealth of information on the topic.

Take-Home Messages

The healthcare sector is resource intensive and a major contributor to climate change.
Starting points for greater sustainability in the healthcare system include reducing energy and water consumption, using sustainable consumables, and avoiding inefficiency and overprescribing.
Digital applications and teledermatology could help with smarter
Integration into the clinical routine leads to resource savings.
External therapy should be optimized on the part of dermatology in terms of environmental compatibility of ingredients and packaging.
The 5R concept (Reduce – Reuse – Recycle – Rethink – Research) summarizes approaches to greater sustainability that can be applied to areas such as the OR.

Literature:

Rockström J, et al: Planetary Boundaries: Exploring the Safe Operating Space for Humanity. Ecol Soc 2009: 14(2): 32.
Lenzen M, et al: The environmental footprint of health care: a global assessment. Lancet Planet Health 2020; 4(7): e271-e279.
Niebel D, et al.: Sustainability of dermatological offices and clinics: challenges and potential solutions. J Dtsch Dermatol Ges 2023; 21(1): 44-58.
World Health Organization: WHO guidance for climate resilient and environmentally sustainable health care facilities. Geneva 2020. Available from: www.who.int/publications/i/item/9789240012226.
Weisz U, et al: Carbon emission trends and sustainability options in Austrian health care. J Res Con Rec 2020; 160: 104862.
Löffler C: Climate protection in hospitals: what you can do yourself 2022. Available from: www.aerzteblatt.de/archiv/224478/Klimaschutz-im-Krankenhaus-Was-man-selbst-tun-kann.
Keller RL, et al: From bandages to buildings: identifying the environmental hotspots of hospitals. J Clean Prod 2021; 319: 128479.
Forchhammer S, Hartmann T: Digital dermatopathology. Der Deutsche Dermatologe 2021; 69(10): 810-813.
Schempp CM, et al: Aspects of sustainability in topical therapy. Dermatology (Heidelb) 2023; 74(1): 21-26.
Schneider SL, Lim HW: Review of environmental effects of oxybenzone and other sunscreen active ingredients. J Am Acad Dermatol 2019; 80(1): 266-271.
Fuhr L, et al: Plastic Atlas: Facts and figures about a world full of plastic. 2nd ed. Berlin: Heinrich Böll Foundation 2019.
Mezger NCS, et al: Sustainability in the surgical establishment-a narrative review. Surgery (Heidelb) 2023; 94(3): 199-209.
Mezger NCS, et al: Climate change mitigation in practice – status quo, readiness and challenges in ambulatory care. Z Evid Fortbild Qual Gesundhwes 2021; 166: 44-54.