Environmentally sustainable surgical health systems: an analysis of policies, tools, and guidelines

Climate change and insufficient access to surgical care are two intersecting global health challenges that disproportionately affect populations in areas, such as low-income and middle-income countries (LMICs), rural and remote communities, and island states. Five billion people worldwide have no access to safe surgical care and anesthesia, resulting in over 17 million preventable deaths per year.¹ In 2015, The Lancet Commission on Global Surgery recommended scaling up surgical, anesthesia, and obstetrics care through National Surgical, Obstetric, and Anesthesia Plans (NSOAPs), as a strategic effort embedded within countries’ national health plans.¹ Climate change poses a threat to human health, with far-reaching consequences for surgical care.² Climate change increases surgical care burden by contributing to natural disasters, extreme weather, and health conditions, such as cardiovascular, respiratory, oncological, and infectious diseases. Furthermore, medical care contributes to climate change through emissions of hydrofluorocarbons and chlorofluorocarbons in anaesthesia and carbon embedded in disposables and consumables used during delivery of surgical care.¹, ³, ⁴

Sustainable health practices and policies must be designed to mitigate the effects of climate change and optimize resource preservation. NSOAPs can provide a blueprint for building surgical systems by contextually adapting to local health-care systems and policies.⁵ However, operating rooms are resource-intensive. The carbon footprint of surgery ranges from 6·00—8·14 kg of CO₂ equivalents (CO₂ e) per operation.⁶ Meeting the projected need for an additional 143 million surgeries in LMICs ¹ would mean that total emissions could reach 858·0 million to 116·4 billion kg of CO₂ e.²

Considering the enormous projected surgical carbon footprint, we assessed the inclusion of environmental sustainability in NSOAPs, global surgery guidelines, manuals, surgical capacity assessments, and planning tools. We identified resources through the websites of the Harvard Program in Global Surgery and Social Change, the Global Surgery Foundation, and other global surgery centres and organisations. Environmental sustainability was defined as reducing waste, improving energy efficiency, and minimising the environmental effect of health-care practices.⁶ Additionally, we sought expert opinions and used snowball sampling to ensure our list of resources was sufficiently comprehensive.

Eight NSOAPs have been launched, of which five were publicly accessible. Only two (40%) of five plans reported some consideration for environmental sustainability, limited to waste management and alternative energy sources (table). A review of the 18 global surgical documents related to surgical capacity assessment and planning revealed that only one (5·6%) document addressed environmental sustainability (appendix pp 1—2). To our knowledge, no guidelines regarding indicators for assessing or improving environmentally sustainable surgical capacity building exist.

Our analysis reveals major gaps in consideration of environmental sustainability in surgical planning and a missed opportunity to integrate sustainability into health policy. However, in the Western Pacific region, the regional NSOAP leadership recognised a unique opportunity to develop climate resilient surgical systems, which could potentially serve as models for other regions with similar challenges.⁷ By prioritising sustainability in surgical care, health systems initiate proactive steps toward mitigating the effects of climate change and promoting equitable access to quality surgical care for future generations.

Absence of recognition within the publicly available documents does not imply that environmental sustainability is not informally discussed. Nonetheless, an explicit commitment to holding all actors accountable for sustainable practices is necessary to ensure focus on this issue. These findings highlight the gap in integrating environmental sustainability considerations into surgical planning, policies, and capacity-building. Existing NSOAPs and surgical capacity assessment tools should be updated to reflect current and potential practices to address climate change sustainability.⁸ A dedicated tool could even be developed to assess the ecological sustainability of surgical practices optimised for available resources. Additionally, strategies such as matching supply and demand, value-based health care, and engaging clinicians in sustainability advocacy and action should be implemented to promote sustainable practices tailored to the local context.⁹ Lastly, locally driven solutions and decolonisation efforts in global surgery are imperative to ensure sustainable, contextual, and appropriate surgical systems adapted to local health-care systems and natural environments.⁴

Strategies to integrate environmental sustainability into surgical planning include: consistently incorporating waste management principles (reduce, reuse, recycle, rethink, and research) through each NSOAP domain;¹⁰ optimizing energy use by investing in key infrastructure, including renewable energy sources, which will ultimately reduce costs; improving service delivery using reusable and renewable resources; and favouring local over general anaesthesia whenever feasible. Telemedicine can also facilitate sustainability and reprocessing and remanufacturing can reduce waste. Educating the workforce promotes responsible resource use and reduces waste. Lastly, research and needs assessments should be prioritised to understand the unique local contexts and resources available. By implementing these actions, global surgery can move towards increasingly environmentally sustainable and responsible surgical practices.

DV is supported by the Canadian Institutes of Health Research Vanier Canada Graduate Scholarship. All other authors declare no other competing interests.

Notes:

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9. ↩ Luo OD, Razvi Y, Kaur G, et al.—A qualitative study of what motivates and enables climate-engaged physicians in Canada to engage in health-care sustainability, advocacy, and action. Lancet Planet Health. 2023; 7: e164-e171
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