Preventive Healthcare and Environmental Sustainability

Rini Dass, B.ScN., M.ScN., Adult-N.P.[1], Ana Hategan, M.D.[2]

Author information

[1] Assistant Clinical Professor, Adult-Nurse Practitioner, McMaster School of Nursing, McMaster University, St. Peter’s Hospital, Hamilton, ON, Canada.

[2] Clinical Professor, Geriatric Psychiatrist, Division of Geriatric Psychiatry, Department of Psychiatry and Behavioural Neurosciences, Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.

World Health Organization (WHO) defines health as a state of complete physical, mental, and social wellbeing (Government of Canada, 2010). It does not only represent the absence of disease or disability (Government of Canada, 2010). Health promotion and disease prevention and environmental sustainability are interconnected. An environmentally sustainable health system has the responsibility to conserve natural resources and protect global ecosystems to support health and wellbeing of current and future generations (WHO, 2017). Consumption of energy and other resources, production of greenhouse gas (GHG) emissions, use and disposal of toxic chemicals, and production of medical waste and wastewater are among the major impacts that healthcare can have on the environment (WHO, 2017). There appears to be a positive correlation between health and environment. Healthier the population, lesser disease burden, and lesser waste and impact on the environment. Vice versa, healthier the environment, healthier the population (Fuller et al., 2022).

It is well recognized that pollution is a planetary threat, with impacts on health that transcend local and national boundaries, and that it affects us worldwide (Fuller et al., 2022). Global action on all major modern pollutants including GHGs is needed. An all-hands-on-deck approach to transitioning away from fossil fuels to a clean, renewable energy is an effective strategy for mitigating pollution and slowing down climate change, while benefitting planetary health (Fuller et al., 2022). In this vein, active travel, such as walking and cycling, not only results in fewer GHG emissions that are warming the atmosphere but is increasingly recognized as an important source of physical activity (Pucher et al., 2010). Encouraging such health promotion activities has shown to improve management of many diseases such as diabetes mellitus and cardiovascular health, and decrease rates of premature death, among multiple other health benefits, while also contributing to reducing the environmental pollution (Fuller et al., 2022; Patterson et al., 2020; Pucher et al., 2010).

Personalized preventive healthcare delivering individualized care focused on lifestyle behaviour modification and disease prevention has been found to reduce cost of healthcare due to less disease burden, and subsequently reducing medical waste and improving equity in care (Hughes & Meadows, 2020; Musich et al., 2016). Preventive healthcare is essential at any stage of life. Measures should start as early as childhood. It should be integrated in day-to-day activities in environments such as schools and workplaces. Examples of such measures include adopting a healthy diet, encouraging physical activity, and implementing programs to promote good mental health and wellbeing and, eventually, integrating practices that affect both the overall health and the environment.

Support from government and healthcare leaders is needed to fund programs focused on health promotion and disease prevention, especially on preventable chronic diseases, with an eye on environmental sustainability. Support and funding is needed for more “green space activities” (e.g., walking, cycling, running, playing ball games) in communities, homes, schools, and workplaces. In 2021, hospitals (25%), pharmaceuticals (14%), and physicians (13%) were still the three largest shares of health dollars (over 50% of total health spending) (Canadian Institute for Health Information, 2021). Therefore, it is the hope that implementing programs for health promotion and disease prevention will hopefully decrease this healthcare spending while improving the environmental determinants of health (e.g., air pollution, chemical safety, lack of access to healthcare, poor water quality, climate change and natural disasters).

REFERENCES

Canadian Institute for Health Information. (2021). National Health Expenditure Trends, 2021 — Snapshot. https://www.cihi.ca/en/national-health-expenditure-trends-2021-snapshot. Accessed August 29, 2022.

Fuller, R., Landrigan, P. J., Balakrishnan, K., Bathan, G., Bose-O'Reilly, S., Brauer, M., Caravanos, J., Chiles, T., Cohen, A., Corra, L., Cropper, M., Ferraro, G., Hanna, J., Hanrahan, D., Hu, H., Hunter, D., Janata, G., Kupka, R., Lanphear, B., Lichtveld, M., … Yan, C. (2022). Pollution and health: a progress update. Lancet. Planetary health, 6(6), e535–e547. https://doi.org/10.1016/S2542-5196(22)00090-0

Government of Canada (2010). Creating a Healthier Canada: Making Prevention a Priority. https://www.canada.ca/en/public-health/services/health-promotion/healthy-living/creating-a-healthier-canada-making-prevention-a-priority.html. Accessed August 29, 2022.

Hughes, D. L., & Meadows, P. D. (2020). Reducing Medical Waste to Improve Equity in Care. American journal of public health, 110(12), 1749–1750. https://doi.org/10.2105/AJPH.2020.305962

Musich, S., Wang, S., Hawkins, K., & Klemes, A. (2016). The Impact of Personalized Preventive Care on Health Care Quality, Utilization, and Expenditures. Population Health Management, 19(6), 389–397. https://doi.org/10.1089/pop.2015.0171

Patterson, R., Panter, J., Vamos, E. P., Cummins, S., Millett, C., & Laverty, A. A. (2020). Associations between commute mode and cardiovascular disease, cancer, and all-cause mortality, and cancer incidence, using linked Census data over 25 years in England and Wales: a cohort study. Lancet. Planetary Health, 4(5), e186–e194. https://doi.org/10.1016/S2542-5196(20)30079-6

Pucher, J., Buehler, R., Bassett, D. R., & Dannenberg, A. L. (2010). Walking and cycling to health: a comparative analysis of city, state, and international data. American Journal of Public Health, 100(10), 1986–1992. https://doi.org/10.2105/AJPH.2009.189324

WHO (2017). Environmentally sustainable health systems: a strategic document. https://www.who.int/publications/i/item/WHO-EURO-2017-2241-41996-57723. Accessed August 29, 2022.

Healthcare Professionals Need to Unite For the Sustainability Cause And Share Information

As healthcare professionals, we tend to work in our own little silos, certainly attending to, and acquiring information that specifically impacts our particular profession. This mode of thinking is antiquated, not only in terms of healthcare delivery, but in terms of how we, as responsible healthcare professionals address the environmental impact of our professional activities.

Recently, my girlfriend in Wales, who happens to be a medical doctor, was diagnosed with breast cancer. An entire team of healthcare professionals was created and collaborated on the decision making process to create the best treatment outcome for her particular situation.

In a similar fashion, I believe we healthcare professionals need to collaborate and share our knowledge about best practices with respect to environmental sustainability in the healthcare sector. It is at this point, that I'll make you aware that I am not a medical doctor, but a dentist.

For a few years now, I have been experiencing “climate grief”, “the psychological response to ecological loss related to the changing climate. This grief can be experienced as profound sadness, helplessness, guilt, anxiety, or numbness related to the climate crisis” (https://www.psycom.net>anxiety). As a responsible global citizen, I felt the need to address my guilt and anxiety: guilt, because as a healthcare professional I felt the need to find out how I can implement and encourage positive change in my profession, and anxiety, because I am overwhelmed by the belief that our governments will do too little too late to address this global existential threat.

I have created a small group of like-minded dentists who actively search for companies that embrace environmentally responsible products/protocols. I held a three hour continuing education virtual event for my dental component society where twelve speakers (including Dr. Ali Abbass, anesthesiologist, and Linda Varangu (@greenhealthcare.ca) contributed content. I started a small pilot project to collect PPE from several dental offices which I personally transported to MEA Health.ca, a PPE recycling facility in Kitchener ( I live in Muskoka). This initiative has now grown, with the help of Rotarians/healthcare professionals in several regions of Ontario. Now, several family healthcare teams are also using this recycling initiative to responsibly collect and dispose of their PPE, and different Rotary clubs are helping to collect and recycle the PPE in their areas. The world disposes of 50,000 “blue masks” EVERY SECOND (https://blogs.worldbank.org).....this is unsustainable.

One of the speakers at that event was the VP of Dentec Safety, a company that makes reusable respirators without exhalation valves that are Health Canada approved. Yes, this respirator is perhaps slightly less comfortable than the ubiquitous N95 masks we continue to throw out; I view this as a minor inconvenience. Adopting this reusable respirator for my clinical activities mitigates my contribution to the PPE waste dilemma; it is a solution I am better able to live with.

My network of like-minded healthcare professionals continues to grow; it is why I'm writing this. We must share ideas/initiatives/products that make healthcare as a sector, more sustainable. In connecting with the creators of this website, we have shared information that has grown our armamentarium for environmentally responsible delivery of healthcare (I've provided all of my links for the website).

We must advocate inside and outside of our own professional spheres. This week I connected with executives within the two biggest companies that distribute oral care products; I encouraged them to provide and highlight samples of sustainable products for their booths at the upcoming Annual Spring Meeting of the Ontario Dental Association, and I questioned their overuse of packaging that is not recyclable. I indicated that I understood that marketability was important: “Let us dentists help you promote the sustainable options”. I asked the P and G rep to profile their recycling initiative; very few dentists are even aware of this program. Today I will do my best to connect with a 3M rep and ask why their company, which has greatly benefited from the pandemic, in the form of N95 mask sales, is not addressing the end stage of their products, and partnering with recycling companies. ESGs (Environmental/Social/Governance responsibility) are now on the radar of most forward thinking companies.

Request that your personal dentist takes part in the Terracycle initiative that allows dentists to collect (free of charge to them) used oral health products (toothpaste tubes, toothbrushes, dental floss and mouthwash containers) for recycling. We must approach the environmental issue in every way we can.....and that means sharing information and acting on it. I have discussions with my fellow local medical professionals about their choice with respect to inhalers and delivery systems for medications. (There is a low-waste pharmacy in Antigonish, Nova Scotia that has adopted reusable glass vials for prescriptions (https://www.cbc.ca>nova -scotia). These sorts of conversations need to multiply. Let's all be part of the environmental solution, and not just the problem. We cannot turn a blind eye and do nothing.

Dr. Laurie Houston

TELEHEALTH AND VIRTUAL CARE

The availability of virtual clinics in Canada and worldwide has increased in recent years, the COVID-19 pandemic particularly contributing to the increased demand and provision of virtual care (i.e., medical care delivered at a distance by means of technology). The rise of virtual care during this pandemic has been viewed by many as a silver lining. It is this jump in advancement and adoption of technology that may help drive decarbonization pathways and sustainability in healthcare. PEACH Health Ontario promotes putting a “green spin” on the use of virtual health and health information technology, with a focus on pathways that can be implemented today and scaled to even greater mitigation ambition in the longer term.

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Did you know? Research has shown that the proportion of physicians in Ontario who provided virtual care increased from 7% in 2019 (the prepandemic period) to 85.9% in 2020 (during the pandemic) [1]. The rates of virtual care use increased across all age groups. Patients with psychiatric disorders had the highest rate of virtual visits, followed by those with heart failure, chronic obstructive pulmonary disease, angina, diabetes mellitus, hypertension, and asthma [1].

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Virtual Care - What Lessons Have Been Learned?

Healthcare providers have long advocated for the advantages of telehealth use in reducing travel and costs associated with it, particularly regarding the decrease in carbon intensity [2]. In a 2010 article by Yellowlees et al. [3], the authors argued that the healthcare sector in North America was generally lacking environmentally sustainable practices. Fast forward a decade later, there is still a great deal of work for the healthcare sector to make a greener stance. By implementing green practices, the healthcare sector could benefit financially as well as reduce its negative impact on the health of people and the planet. Virtual care and health information technology can save energy, fuel, and raw materials (e.g., paper, plastic) and thus reduce the carbon footprint of the healthcare sector [3].

In recent years, the American Telemedicine Association launched a task force to study how the use of telehealth and telemedicine may be affecting climate change and global warming [4]. In 2017, this task force addressed that matter; researchers at a U.S. university found that telehealth and telemedicine programs saved patients and clinicians 5 million miles of travel over 18 years, equal to about nine years in travel time and $3 million in costs, and helped their academic location to reduce nearly 2,000 metric tons of carbon dioxide (CO2), 50 metric tons of carbon monoxide, 3.7 metric tons of nitrogen oxides, and 5.5 metric tons of volatile organic compounds [4].A recent U.S. study looking at the reduction in greenhouse gas emissions from transportation to outpatient clinic visits showed that emissions rose from 18.5 to 19.6 (in 2019) before declining to 10.5 kilotons CO2-equivalent in 2020 [2]. In this same study, ambulatory visit carbon intensity declined from 8 to 4 kg CO2-equivalent per visit over the same time period [2]. If clinicians were to maintain those gains or expand upon in the post-pandemic world, further impacts on practice design could potentially contribute to even greater reductions in greenhouse gas emissions. Thus, providing telehealth virtual visits can be one tool to fight climate change.

However, sustainability measures are evidently needed. There is a need to develop robust, standardized metrics to define environmental performance and evaluate progress if the healthcare sector is to meaningfully embark on reducing its environmental impacts. Patients, clinicians, and medical leaders need adequate information in order to maximize the environmental benefits of online and virtual care. A 2019 Canadian Medical Association report [5], The Future of Connected Health Care, outlined that Canadians were already ready for the healthcare sector to modernize and match the online experience they were getting from other sectors. In this vein, Ontario announced in 2019 its Digital First for Health strategy to support an inclusion of virtual care [6]. In 2020, a Virtual Care Task Force (VCTF) was created by the Royal College of Physicians and Surgeons of Canada, the College of Family Physicians of Canada, and the Canadian Medical Association to set the stage for broader discussion and more detailed efforts [7]. This VCTF took a pan-Canadian approach to the issue of virtual care and strongly believed that national leadership was needed on this issue. The VCTF report outlined the actions required to promote excellence in virtual care in Canada.

In order to ensure a more sustainable development, we believe that it is important for educational programs, such as MD programs, other graduate level professional training programs, and graduate medical education programs, to actively integrate mastery of technological advances into training programs. In order to keep up the pace with increasing awareness and adoption of new emerging technologies into clinical practice, some have proposed the conception and implementation of an academic technology division within medical departments. Such division can be tasked with educating both physicians-in-training and practicing physicians about integration of technology acceptance models, as well as integration of emerging digital technologies [8]. Encouraging medical departments to partner with departments of computer science and other technical fields can only foster collaborative opportunities for greater and greener sustainability of medicine.

The healthcare sector must seize the opportunity to modernize and promote the health of the people as well as the planet, because these two issues are ultimately interconnected. Physicians and other clinicians need to raise awareness and educate patients and communities about climate-sensitive health risks, which will go a long way. If there is a considerably growing public demand for virtual care that has a positive influence on both human and planetary health, then we are hopefully going to make good decisions for a successful path to sustainable medicine. The PEACH Health Ontario team aims to make the environmental health benefits of virtual care more widely known so that health systems and societies can adjust and thrive in the “new normal” of the post-pandemic world.

In practice

The PEACH Health Ontario team aims to:

• Scientifically review the current literature on telehealth and virtual care and work to identify effective strategies developed locally and worldwide to help with decarbonization as a realistic way forward on climate change mitigation.

• Make recommendations on a set of strategies and tools that can be disseminated for generalized use across institutions to provide meaningful information on the carbon footprint implications of innovative virtual care modalities.

• Disseminate information on national standards for privacy and security considerations for virtual health care visits.

• Suggest that the CanMEDS Consortium continues to update virtual learning competencies for the undergraduate, postgraduate, and fellowship programs, as well as to promote the continuing professional development (CPD) endeavours through integration of emerging technology-based virtual health strategies.

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REFERENCES

1. Bhatia RS, Chu C, Pang A, Tadrous M, Stamenova V, Cram P. Virtual care use before and during the COVID-19 pandemic: A repeated cross-sectional study. CMAJ Open. 2021;9(1):E107-E114. doi: 10.9778/cmajo.20200311. PMID: 33597307; PMCID: PMC8034297.

2. Dacones I, Cave C, Furie GL, Ogden CA, Slutzman JE. Patient transport greenhouse gas emissions from outpatient care at an integrated health care system in the Northwestern United States, 2015-2020. The Journal of Climate Change and Health. 2021;3:100024. https://doi.org/10.1016/j.joclim.2021.100024.

3. Yellowlees PM, Chorba K, Burke Parish M, Wynn-Jones H, Nafiz N. Telemedicine and e-Health. 2010;16(2).229-232. http://doi.org/10.1089/tmj.2009.0105.

4. Wicklund E. American Telemedicine Association. ATA Task Force to Study Environmental Effects of Telemedicine. June 21, 2017. https://mhealthintelligence.com/news/ata-task-force-to-study-environmental-effects-of-telemedicine. Accessed January 15, 2022.

5. Canadian Medical Association (CMA). The Future of Connected Health Care. Reporting Canadians’ Perspectives on the Health Care System. August 2019. https://www.cma.ca/sites/default/files/pdf/Media-Releases/The-Future-of-Connected-Healthcare-e.pdf. Accessed January 15, 2022.

6. Government of Canada. Ontario's virtual care streamlined action plan. Last modified: June 18, 2021.

https://www.canada.ca/en/health-canada/corporate/transparency/health-agreements/bilateral-agreement-pan-canadian-virtual-care-priorities-covid-19/action-plan-ontario.html. Accessed January 15, 2022.

7. Royal College of Physicians and Surgeons of Canada (RCPSC). Virtual care. https://www.royalcollege.ca/rcsite/health-policy/advocacy/virtual-care-task-force-e. Accessed January 15, 2022.

8. Hategan A, Giroux C, Bourgeois JA. Digital technology adoption in psychiatric care: An overview of the contemporary shift from technology to opportunity. Journal of Technology in Behavioral Science. 2019;4(3):171-177. https://doi.org/10.1007/s41347-019-00086-x.

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PEACH Health Team: Find us at www.peachhealthontario.com.

If you would like to share some suggestions or resources, please send us an email at peachforhealth@gmail.com, send a tweet @PEACH_HealthON, or join us on Facebook www.facebook.com/PEACHHealthON.

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This page will be updated regularly with up-to-date information about this important initiative.