The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate

Assessing the spatiotemporal evolution and socioeconomic determinants of PM2.5-related premature deaths in China from 2000 to 2021

China's swift socioeconomic development has led to extremely severe ambient PM2.5 levels, the associated negative health outcomes of which include premature death. However, a comprehensive explanation of the socioeconomic mechanism contributing to PM2.5-related premature deaths has not yet to be fully elucidated through long-term spatial panel data. Here, we employed a global exposure mortality model (GEMM) and the system generalized method of moments (Sys-GMM) to examine the primary determinants contributing to premature deaths in Chinese provinces from 2000 to 2021. We found that in the research period, premature deaths in China increased by 46 %, reaching 1.87 million, a figure that decreased somewhat after the COVID-19 outbreak. 62 thousand premature deaths were avoided in 2020 and 2021 compared to 2019, primarily due to the decline in PM2.5 concentrations. Premature deaths have increased across all provinces, particularly in North China, and a discernible spatial agglomeration effect was observed, highlighting effects on nearby provinces. The findings also underscored the significance of determinants such as urbanization, import and export trade, and energy consumption in exacerbating premature deaths, while energy intensity exerted a mitigating influence. Importantly, a U-shaped relationship between premature deaths and economic development was unveiled for the first time, implying the need for vigilance regarding potential health impact deterioration and the implementation of countermeasures as the per capita GDP increases in China. Our findings deserve attention from policymakers as they shed fresh insights into atmospheric control and Health China action.

Impact of heat waves on semen quality: A retrospective study in Argentina between 2005 and 2023

Heat waves, defined as periods with daily temperatures surpassing the historical average for a specific region, have become more frequent worldwide in recent years. Previous studies have reported a negative association between temperature and semen quality, but the focus has mainly been on Asian and European populations. The study included 54,926 men (18-60 years) undergoing routine semen analysis between 2005 and 2023 at CEUSA-LAEH andrology unit, in Buenos Aires, Argentina. Hourly temperature readings were provided by the Servicio Meteorológico Nacional. R programming (R Studio v2022.07.2) was used to define heat waves, calculate key characteristics, visualize results, and perform statistical tests at the IBYME laboratory. During the period studied, a total of 124 days had heat waves (defined after at least 3 consecutive days with 32.3 °C and 22 °C). Men exposed to heat waves during spermatogenesis exhibited lower sperm number (concentration and count; P < 0.0001) and decreased normal morphology (percentage of normal sperm and normal motile count; P < 0.05) compared to those not exposed. These differences were most pronounced between semen samples from years with several heat waves (2013, 2023) and none (2005, 2007, 2016), displaying 4-5 times higher fold changes (P < 0.05). Further analysis employing multiple regression revealed a significantly negative association between semen quality and heat wave length, suggesting that a prolonged exposure may be more detrimental than an acute exposure. Subsequent analysis focusing on prolonged exposure (≥6-days heat wave) during spermatogenesis revealed a negative (P < 0.05) association between early exposure (spermatocytogenesis: 64-90 days prior semen collection) and semen quality. This study underscores the negative association between early exposure to heat waves during sperm development and semen quality, raising concerns about its possible association with the worldwide declining male fertility. A comprehensive collaborative approach is crucial, involving global governmental policies, sustainable practices, and coordinated efforts across scientific, healthcare, and policy domains.

Mental health, subjective experiences and environmental change

This article responds to Coope's call for the medical humanities to address the climate crisis as a health issue. Coope proposes three areas for progress towards ecological thinking in healthcare, with a focus on ecological mental health. The article emphasises the need to understand the cultural dimensions of mental health and proposes an interdisciplinary approach that integrates insights from the arts and humanities. It examines the impact of climate change on mental health, drawing on The Rockefeller Foundation - Lancet Commission on Planetary Health and recent studies. The discussion focuses on the intersection of mental health, subjective experience and environmental change. Focusing on emotional experiences as constructed from biological and cultural elements, the article proposes a holistic approach to mental health. It proposes two converging lines of research, in constant interaction: first, a historical and cultural research of those concepts, practices and symbols related to the environment, emphasising a cultural history of nature; and second, a synchronous research, drawing on anthropology, sociology and participatory art-based research, to understand how these aforementioned elements influence our current relations with nature. The article concludes by emphasising the urgency of developing narratives and histories that redirect temporal trajectories towards a better future, while respecting and acknowledging diverse narratives of individual experience. It calls for collaborative efforts from the medical humanities to contribute to a more comprehensive understanding of the complex relationship between mental health, nature and ecological crisis.

Approaches to reduce medical imaging departments' environmental impact: A scoping review

INTRODUCTION

Global warming stands as a paramount public health issue of our time, and it is fundamental to explore approaches to green medical imaging departments/(MID). This study aims to map the existing actions in the literature that promote sustainable development in MID towards the promotion of environmental impact reduction.

METHODS

Following the JBI methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), this literature search was conducted on MEDLINE, Embase and CINAHL to encompass studies published after 2013. Combinations of keywords and relevant terms related to environmental sustainability, recycling, medical waste, and greening radiology were applied for this review. Three independent reviewers screened abstracts, titles, and eligible full-text. Disagreement was solved through consensus.

RESULTS

38 out of 4630 articles met all inclusion criteria, and four additional articles were identified and added through reference search. A third of the studies included were published after 2022, and most were conducted in developed countries (36/41). Articles focused on computed tomography (9/41), magnetic resonance imaging (6/41), interventional radiology (4/41), conventional radiography (4/41), ultrasound (2/41), mixed modalities (10/41), or not applicable to an imaging modality (6/41). Four principal categories were identified to decrease ecological footprint: energy consumption, waste management, justification and environmental pollution.

CONCLUSION

To minimise the environmental impact of MIDs raising awareness and promoting education is fundamental. Examinations must be justified adequately, energy consumption must be reduced, and waste management practices need to be implemented. Further studies are required to prioritise the most effective strategies, supporting decision-making among stakeholders.

IMPLICATIONS FOR PRACTICE

Several strategies are already possible to implement to reduce the environmental impact of MIDs and improve the healthcare outcomes for patients.

Balancing patient needs with environmental impacts for best practices in general anesthesia: Narrative review and clinical perspective

Discussions of the environmental impacts of general anesthetics have focused on greenhouse gas (GHG) emissions from inhaled agents, with those of total intravenous anesthesia (TIVA) recently coming to the forefront. Clinical experts are calling for the expansion of research toward life cycle assessment (LCA) to comprehensively study the impact of general anesthetics. We provide an overview of proposed environmental risks, including direct GHG emissions from inhaled anesthetics and non-GHG impacts and indirect GHG emissions from propofol. A practical description of LCA methodology is also provided, as well as how it applies to the study of general anesthesia. We describe available LCA studies comparing the environmental impacts of a lower carbon footprint inhaled anesthetic, sevoflurane, to TIVA/propofol and discuss their life cycle steps: manufacturing, transport, clinical use, and disposal. Significant hotspots of GHG emission were identified as the manufacturing and disposal of sevoflurane and use (attributed to the manufacture of the required syringes and syringe pumps) for propofol. However, the focus of these studies was solely on GHG emissions, excluding other environmental impacts of wasted propofol, such as water/soil toxicity. Other LCA gaps included a lack of comprehensive GHG emission estimates related to the manufacturing of TIVA plastic components, high-temperature incineration of propofol, and gas capture technologies for inhaled anesthetics. Considering that scarce LCA evidence does not allow for a definite conclusion to be drawn regarding the overall environmental impacts of sevoflurane and TIVA, we conclude that current anesthetic practice involving these agents should focus on patient needs and established best practices as more LCA research is accumulated.

The Financial Implications of a Single-Use Device Reprocessing Program at a Tertiary Referral Center Surgical Department

The operating room has been identified as one of the primary contributors to waste and energy expenditure in the health care system. The primary objective of our study was to evaluate the efficacy of single-use device reprocessing and report the cost savings, waste diversion, and reduction in carbon emissions. Data was collected from January 2021 to April 2023. Medline collected the data for analysis and converted it from an Excel file format to SPSS (Version 27) for analysis. Descriptive frequencies were used for data analysis. We found a mean monthly cost savings of $16,051.68 and a mean 700.68 pounds of waste a month diverted, resulting in an estimated yearly saving of $2354.29 in disposal costs and a reduction of 1112.65 CO2e emissions per month. This program has made significant contributions to cost savings and environmental efforts.

An assessment of sustainable transport infrastructure in a national healthcare system

INTRODUCTION

Healthcare contributes significantly to carbon dioxide emissions, which can be reduced by promoting sustainable mobility amongst staff commuting. This study aims to investigate the national sustainable transport infrastructure for staff of healthcare facilities and utilise this data to develop a novel scoring and ranking system.

METHODS

This was an empirical retrospective observational study. Data was collected on all 47 hospitals sustainable transport infrastructure. A working group calculated the weighted scores for each sustainable transport data point. These scores were used to calculate the Total and Active Sustainability Scores for each hospital, allowing a ranking to be formed.

RESULTS

7 of 47 (15 %) hospitals had EV charging on campus. 17 of 47 (36 %) hospitals had secure bike parking. 2 of 47 (4 %) hospitals had a "bike hub". 18 of 47 (38 %) hospitals had a bike lane. 13 of 22 (59 %) city hospitals had bike sharing facilities. 42 of 47 (89 %) hospitals had one public transport route. City hospitals ranked higher in both Total & Active Sustainability Scores.

DISCUSSION

This study explored a new concept of measuring sustainable transport infrastructure. Frameworks examining sustainability are available, however, none allowed for ranking of hospitals. This study highlights the lack of both research in this field and sustainable transport infrastructure in hospitals.

Low-value health care, de-implementation, and implications for nursing research: A discussion paper

Globally, the nursing profession constitutes the largest proportion of the health workforce; however, it is challenged by widespread workforce shortages relative to need. Strategies to promote recruitment of the nursing workforce are well-established, with a lesser focus on strategies to alleviate the burden on the existing workforce. This burden may be exacerbated by the impact of low-value health care, characterised as health care that provides little or no benefit for patients, or has the potential to cause harm. Low-value health care is a global problem, a major contributor to the waste of healthcare resources, and a key focus of health system reform. Evidence of variation in low-value health care has been identified across countries and system levels. Research on low-value health care has largely focused on the medical profession, with a paucity of research examining either low-value health care or the de-implementation of low-value health care from a nursing perspective. The objective of this paper is to provide a scholarly discussion of the literature around low-value health care and de-implementation, with the purpose of identifying implications for nursing research. With increasing pressures on the global nursing workforce, research identifying low-value health care and developing approaches to de-implement this care, is crucial.

Guiding principles for the next generation of health-care sustainability metrics

Metrics for health-care sustainability are crucial for tracking progress and understanding the advantages of different operations or systems as the health-care sector addresses the climate crisis and other environmental challenges. Measurement of the key metrics of absolute energy use and greenhouse gas emissions now has substantial momentum, but our overall measurement framework generally has serious deficiencies. Because existing metrics are often borrowed from other sectors, many are unconnected to the specifics of health-care provision or existing health system performance indicators, the potential negative effects of health care on public health are largely absent, a consistent and standardised set of health-care sustainability measurement concepts does not yet exist, and current dynamics in health systems such as privatisation are largely ignored. The next generation of health-care sustainability metrics must address these deficiencies by expanding the scope of observation and the entry points for interventions. Specifically, metrics should be standardised, reliable, meaningful, integrated with data management systems, fair, and aligned with the core mission of health care. Incentives with the potential to contradict sustainability goals must be addressed in future planning and implementation if the next generation of metrics is to be effective and incentivise positive systemic change.

Climate change and children's respiratory health

Climate change has significant consequences for children's respiratory health. Rising temperatures and extreme weather events increase children's exposure to allergens, mould, and air pollutants. Children are particularly vulnerable to these airborne particles due to their higher ventilation per unit of body weight, more frequent mouth breathing, and outdoor activities. Children with asthma and cystic fibrosis are at particularly high risk, with increased risks of exacerbation, but the effects of climate change could also be observed in the general population, with a risk of impaired lung development and growth. Mitigation measures, including reducing greenhouse gas emissions by healthcare professionals and healthcare systems, and adaptation measures, such as limiting outdoor activities during pollution peaks, are essential to preserve children's respiratory health. The mobilisation of society as a whole, including paediatricians, is crucial to limit the impact of climate change on children's respiratory health.

Meteorological gaps in audits of pedestrian environments: a scoping review

BACKGROUND

Weather and season are determinants of physical activity. Therefore, it is important to ensure built environments are designed to mitigate negative impacts of weather and season on pedestrians to prevent these losses. This scoping review aims to identify built environment audits of pedestrian environments developed for use during a specific weather condition or season. Secondly, this review aims to investigate gaps in the inclusion of relevant weather mitigating built environment features in pedestrian environment audit tools.

METHODS

Following a standard protocol, a systematic search was executed in CINAHL, Medline and Web of Science to identify built environment audit tools of pedestrian spaces. These databases were chosen since they are well-known to comprehensively cover health as well as multi-disciplinary research publications relevant to health. Studies were screened, and data were extracted from selected documents by two independent reviewers (e.g., psychometric properties and audit items included). Audit items were screened for the inclusion of weather mitigating built environment features, and the tool's capacity to measure temperature, precipitation, seasonal and sustainability impacts on pedestrians was calculated.

RESULTS

The search returned 2823 documents. After screening and full text review, 27 articles were included. No tool was found that was developed specifically for use during a specific weather condition or season. Additionally, gaps in the inclusion of weather mitigating items were found for all review dimensions (thermal comfort, precipitation, seasonal, and sustainability items). Poorly covered items were: (1) thermal comfort related (arctic entry presence, materials, textures, and colours of buildings, roads, sidewalk and furniture, and green design features); (2) precipitation related (drain presence, ditch presence, hazards, and snow removal features); (3) seasonal features (amenities, pedestrian scale lighting, and winter destinations and aesthetics); and (4) sustainability features (electric vehicle charging stations, renewable energy, car share, and bike share facilities).

CONCLUSIONS

Current built environment audit tools do not adequately include weather / season mitigating items. This is a limitation as it is important to investigate if the inclusion of these items in pedestrian spaces can promote physical activity during adverse weather conditions. Because climate change is causing increased extreme weather events, a need exists for the development of a new built environment audit tool that includes relevant weather mitigating features.

The effect of ambient temperature on lipid metabolism in children: From a prospective cohort study

BACKGROUND

Dyslipidemia is increasingly recognized as an essential risk factor for cardiovascular diseases. However, few studies illustrated the effects of ambient temperature exposure (TE) on lipid levels in children. The study aimed to examine the association between ambient TE and lipid levels in children.

METHODS

Based on a prospective cohort, a total of 2423 children (with 4466 lipids measure person-time) were collected from 2014 to 2019. The meteorological observation data and adjusted variables were collected. Mixed-effect models and generalized additive mixed model (GAMM) were applied to investigate the association between ambient TE and lipid levels.

RESULTS

A significant negative association was observed between TE and low-density lipoprotein cholesterol (LDL-C) or total cholesterol (TC) levels both in all children [LDL-C, β(95%CI) = -0.350(-0.434,-0.265), P < 0.001; TC, β(95%CI) = -0.274(-0.389,-0.160), P < 0.001] and by different sex group. However, no significant association was found in low-density lipoprotein cholesterol (HDL-C) or triglycerides (TG) levels. The estimated optimal ambient TEs for LDL-C were 18.273 °C and 18.024 °C for girls and boys, respectively. For TC, the optimal ambient TEs were 17.949 °C and 18.024 °C, respectively. With ambient TE decreased, the risk of dyslipidemia increased for both boys [OR = 0.032(0.006,0.179), P < 0.001] and girls [OR = 0.582(0.576,0.587), P < 0.001].

CONCLUSION

This study provided a comprehensive illustration about the associations between ambient TE and lipid levels in different sex and ages from a prospective cohort study. The findings will provide evidence for the government to prevent dyslipidemia in vulnerable children through regulating TE.

The surgical outpatient clinic and the environment

Rising global temperatures will have a radical impact on the environment where global warming is associated with weather extremes such as thunderstorms and droughts which can affect the regional ecosystems. The healthcare sector is a major emitter of greenhouse gasses. Within healthcare, the outpatient clinic is responsible for a considerable sum of emissions. These can be organized under scopes 1, 2 and 3 as described in the Greenhouse Gas Protocol where scope 1 accounts for direct emissions from healthcare facilities, scope 2 is emissions from purchased electricity and scope 3 is indirect emissions including procurement and waste. Emissions and mitigation strategies from the surgical outpatient clinic are outlined under each scope of the Greenhouse Gas Protocol. These include using insulation materials, renovating or building new facilities, incorporating renewable energy sources and utilizing more efficient appliances. Telehealth and virtual clinics have been shown to be an effective method of delivering care while avoiding the combustion of fossil fuels to facilitate patient transport. In addition, virtual set-ups are cost effective and have not been proven to compromise patient safety when implemented correctly.

A Realist Review Protocol into the Contexts and Mechanisms That Enable the Inclusion of Environmental Sustainability Outcomes in the Design of Lean Healthcare Improvement Interventions

Healthcare makes a significant contribution to the social, economic and environmental benefits of communities. It is correspondingly a significant employer and consumer of both energy and consumables, often at high costs. Lean, a quality improvement methodology focuses on the elimination of non-value add (NVA) activities (steps that do not add value from the perspective of the customer) to improve the flow of people, information or goods. Increasingly, Lean thinking is evolving from its initial focus on eliminating NVA to a more holistic approach that encompasses sustainability. However, little work has been undertaken intentionally, including environmental sustainability outcomes in Lean healthcare interventions. Realist review methodology facilitates an understanding of the extent to which an intervention works, for whom, in what context, why and how, and has proven useful in research relating to Lean interventions in healthcare settings. This protocol provides details for a realist review that will enable an understanding of the specific contexts in which certain mechanisms are activated that enable the inclusion of environmental sustainability outcomes in the design of Lean healthcare improvement interventions.

Random Forest and Feature Importance Measures for Discriminating the Most Influential Environmental Factors in Predicting Cardiovascular and Respiratory Diseases

BACKGROUND

Several studies suggest that environmental and climatic factors are linked to the risk of mortality due to cardiovascular and respiratory diseases; however, it is still unclear which are the most influential ones. This study sheds light on the potentiality of a data-driven statistical approach by providing a case study analysis.

METHODS

Daily admissions to the emergency room for cardiovascular and respiratory diseases are jointly analyzed with daily environmental and climatic parameter values (temperature, atmospheric pressure, relative humidity, carbon monoxide, ozone, particulate matter, and nitrogen dioxide). The Random Forest (RF) model and feature importance measure (FMI) techniques (permutation feature importance (PFI), Shapley Additive exPlanations (SHAP) feature importance, and the derivative-based importance measure (κALE)) are applied for discriminating the role of each environmental and climatic parameter. Data are pre-processed to remove trend and seasonal behavior using the Seasonal Trend Decomposition (STL) method and preliminary analyzed to avoid redundancy of information.

RESULTS

The RF performance is encouraging, being able to predict cardiovascular and respiratory disease admissions with a mean absolute relative error of 0.04 and 0.05 cases per day, respectively. Feature importance measures discriminate parameter behaviors providing importance rankings. Indeed, only three parameters (temperature, atmospheric pressure, and carbon monoxide) were responsible for most of the total prediction accuracy.

CONCLUSIONS

Data-driven and statistical tools, like the feature importance measure, are promising for discriminating the role of environmental and climatic factors in predicting the risk related to cardiovascular and respiratory diseases. Our results reveal the potential of employing these tools in public health policy applications for the development of early warning systems that address health risks associated with climate change, and improving disease prevention strategies.

A Life Cycle Assessment of Reusable and Disposable Surgical Caps

INTRODUCTION

Surgical cap attire plays an important role in creating a safe and sterile environment in procedural suites, thus the choice of reusable versus disposable caps has become an issue of much debate. Given the lack of evidence for differences in surgical site infection (SSI) risk between the two, selecting the cap option with a lower carbon footprint may reduce the environmental impact of surgical procedures. However, many institutions continue to recommend the use of disposable bouffant caps.

METHODS

ISO-14044 guidelines were used to complete a process-based life cycle assessment to compare the environmental impact of disposable bouffant caps and reusable cotton caps, specifically focusing on CO2 equivalent (CO2e) emissions, water use and health impacts.

RESULTS

Reusable cotton caps reduced CO2e emissions by 79% when compared to disposable bouffant caps (10 kg versus 49 kg CO2e) under the base model scenario with a similar reduction seen in disability-adjusted life years. However, cotton caps were found to be more water intensive than bouffant caps (67.56 L versus 12.66 L) with the majority of water use secondary to production or manufacturing.

CONCLUSIONS

Reusable cotton caps have lower total lifetime CO2e emissions compared to disposable bouffant caps across multiple use scenarios. Given the lack of evidence suggesting a superior choice for surgical site infection prevention, guidelines should recommend reusable cotton caps to reduce the environmental impact of surgical procedures.

Global, regional, and national burden of stroke attributable to extreme low temperatures, 1990-2019: A global analysis

BACKGROUND

Extreme ambient temperatures have been linked to increased risks of stroke morbidity and mortality. However, global estimates of the burden of stroke due to extreme low temperatures are not well-defined.

AIMS

This study aimed to determine the global burden of stroke due to extreme low temperatures and its spatiotemporal trend from 1990 to 2019.

METHODS

Based on the Global Burden of Disease Study 2019, we obtained global, regional, and national data on deaths, disability-adjusted life years (DALYs), age-standardized mortality rate (ASMR), and age-standardized rate of DALYs (ASDR) of stroke attributed to extreme low temperatures, further stratified by age, sex, and sociodemographic index (SDI).

RESULTS

Globally, in 2019, an estimated 474,000 stroke deaths with the corresponding ASMR (6.2 (95% uncertainty interval (UI): 4.6-7.9)) and ASDR (103.9 (95% UI: 77.0-134.5)) per 100,000 population, were attributable to extreme low temperatures. The most significant burden was observed in Central Asia, followed by Eastern Europe and East Asia. From 1990 to 2019, the global burden of stroke and its subtypes (ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) attributable to extreme low temperatures exhibited a decrease in both ASMR and ASDR. Significant decreases in stroke burden occurred in the high-SDI regions, high-income Asia Pacific, and subarachnoid hemorrhage cases. Moreover, the ASMR and ASDR increased with age and were higher in males than females.

CONCLUSION

The global stroke burden due to extreme low temperatures remains high despite a decreasing trend over the past three decades. The stroke burden due to extreme low temperatures was more notable for Central Asia, older people, and the male sex.

Teaching global interdependence to health professions students during the Anthropocene epoch: Findings from documentary analysis of an interprofessional education course

AIM(S)

To examine the effects of new course material that incorporated the Anthropocene and The Centers for Disease Control's (CDC) 'Climate Effects on Health' framework into an IPE course to enhance students' understanding global interdependence.

BACKGROUND

Teaching global interdependence with a suitable framework and relevant content in an introductory Interprofessional Education course in undergraduate programs is challenging when these early learners who do not have significant clinical experience. Therefore, it is necessary to adapt these courses to provide a framework that all students can relate to regardless of previous experience.

DESIGN

The design for this study was qualitative document analysis.

METHOD

The required introductory IPE course was for students on the programs offered by the College of Health Sciences and the School of Nursing. Students (n = 142) from seven health professions programs, including athletic training (n=9), nursing (n=70), nutrition and dietetics (n=8), occupational therapy (n=15), physical therapy (n=31), radiation therapy (n=2) and magnetic resonance imaging and pre-professional students from other majors (n=5) were enrolled in this IPE course. The study used data derived from the final reflections submitted by the students. The CQI analysis focused on students enrolled in a dedicated interprofessional course related to health professions.

RESULTS

Ways interprofessional teams can address global challenges like the Anthropocene, climate-related illnesses and severe weather events were revealed in student responses. Three themes that emerged from the student responses included: public health collaborations, holistic health promotion and policy advocacy.

CONCLUSION

Incorporating the concept of Anthropocene and the 'Climate Effects on Health' framework into an IPE course can be a promising approach to shaping students' perception and enhancing their knowledge about global interdependence. By doing so, students can gain a deeper understanding of how human activities have an impact on the climate and ecology of the planet and how severe weather can lead to various health problems.

Health Economics in a World of Uneconomic Growth

Multiple, accelerating and interacting ecological crises are increasingly understood as constituting a major threat to human health and well-being. Unconstrained economic growth is strongly implicated in these growing crises, and it has been argued that this growth has now become "uneconomic growth", which is a situation where the size of the economy is still expanding, but this expansion is causing more harm than benefit. This article summarises the multiple pathways by which uneconomic growth can be expected to harm human health. It describes how health care systems-especially through overuse, low value and poor quality care-can themselves drive uneconomic growth. Health economists need to understand not only the consequences of environmental impacts on health care, but also the significance of uneconomic growth, and pay closer attention to the growing body of work by heterodox economists, especially in the fields of ecological and feminist economics. This will involve paying closer heed to the existence and consequences of diminishing marginal returns to health care consumption at high levels; the central importance of inequalities and injustice in health; and the need to remedy health economists' currently limited ability to deal effectively with low value care, overdiagnosis and overtreatment.

Impacts of heat and wildfire on preterm birth

BACKGROUND

Climate change continues to increase the frequency, intensity, and duration of heat events and wildfires, both of which are associated with adverse pregnancy outcomes. Few studies simultaneously evaluated exposures to these increasingly common exposures.

OBJECTIVES

We investigated the relationship between exposure to heat and wildfire smoke and preterm birth (PTB).

METHODS

In this time-stratified case-crossover study, participants consisted of 85,806 California singleton PTBs (20-36 gestational weeks) from May through October of 2015-2019. Birthing parent ZIP codes were linked to high-resolution daily weather, PM2.5 from wildfire smoke, and ambient air pollution data. Heat day was defined as a day with apparent temperature >98th percentile within each ZIP code and heat wave was defined as ≥2 consecutive heat days. Wildfire-smoke day was defined as a day with any exposure to wildfire-smoke PM2.5. Conditional logistic regression was used to calculate the odds ratio (OR) and 95% confidence intervals (CI) comparing exposures during a hazard period (lags 0-6) compared to control periods. Analyses were adjusted for relative humidity, fine particles, and ozone.

RESULTS

Wildfire-smoke days were associated with 3.0% increased odds of PTB (ORlag0: 1.03, CI: 1.00-1.05). Compared with white participants, associations appeared stronger among Black, Hispanic, Asian, and American Indians/Alaskan Native participants. Heatwave days (ORlag2: 1.07, CI: 1.02-1.13) were positively associated with PTB, with stronger associations among those simultaneously exposed to wildfire smoke days (ORlag2: 1.19, CI: 1.11-1.27). Similar findings were observed for heat days and when other temperature metrics (e.g., maximum, minimum) were used.

DISCUSSION

Heat and wildfire increased PTB risk with evidence of synergism. As the occurrence and co-occurrence of these events increase, exposure reduction among pregnant people is critical, especially among racial/ethnic minorities.

A Hexagonal Aim as a Driver of Change for Health Care and Health Insurance Systems

Policy Points Improving health systems requires simultaneous pursuit of a patient centered approach aligned with the health professional: improving the experience of care, improving the health of populations, reducing per capita costs of care - Triple Aim - and improving the work life of the care providers - Quadruple Aim -. Reinforcing the recently defined Fifth Aim as equity through "health democracy" to represent the wants, needs and responsibility of the population in taking care of their health and their healthcare. Adding a Sixth Aim to take into account the increased health risks due to climate change.

CONTEXT

Improving health systems, such as the U.S. or French, requires simultaneous pursuit of a patient centered approach aligned with the health professional: improving the experience of care, improving the health of populations, reducing per capita costs of care - Triple Aim - and improving the work life of the care providers, including clinicians and staff - Quadruple Aim -. While these aims are already ambitious, they may be insufficient when considering the economic, social and environmental challenges to the health of our communities in the near and long term.

METHODS

A conceptual framework to provide additional ethical guardrails for health systems.

RESULTS

Recently, authors have articulated a Fifth Aim and we propose to add a Sixth Aim to the Quadruple Aim model. These additional aims are meant to account for our growing knowledge around the determinants of health and the challenging processes and structures of governance across a wide range of sectors in society including healthcare. We are strengthening the Fifth Aim defined as equity through "health democracy" to represent the wants, needs and responsibility of the population in taking care of their health and their healthcare. The Sixth Aim is to account for the increase in risk to population health due to climate change as well as the impact our health systems have on the environment.

CONCLUSIONS

As social tension and environmental changes seem to continue to impact the structure of our society this "Hexagonal Aim" taken together might provide additional ethical guiderails as we set our healthcare goals.

Promoting sustainability activities in clinical radiography practice and education in resource-limited countries: A discussion paper

OBJECTIVE

Urgent global action is required to combat climate change, with radiographers poised to play a significant role in reducing healthcare's environmental impact. This paper explores radiography-related activities and factors in resource-limited departments contributing to the carbon footprint and proposes strategies for mitigation. The rationale is to discuss the literature regarding these contributing factors and to raise awareness about how to promote sustainability activities in clinical radiography practice and education in resource-limited countries.

KEY FINDINGS

The radiography-related activities and factors contributing to the carbon footprint in resource-limited countries include the use of old equipment and energy inefficiency, insufficient clean energy to power equipment, long-distance commuting for radiological examinations, high film usage and waste, inadequate training and research on sustainable practices, as well as limited policies to drive support for sustainability. Addressing these issues requires a multifaceted approach. Firstly, financial assistance and partnerships are needed to adopt eco-friendly technologies and clean energy sources to power equipment, thus tackling issues related to old equipment and energy inefficiency. Transitioning to digital radiography can mitigate the environmental impact of high film usage and waste, while collaboration between governments, healthcare organisations, and international stakeholders can improve access to radiological services, reducing long-distance commuting. Additionally, promoting education programmes and research efforts in sustainability will empower radiographers with the knowledge to practice sustainably, complemented by clear policies such as green imaging practices to guide and incentivise the adoption of sustainable practices. These integrated solutions can significantly reduce the carbon footprint of radiography activities in resource-limited settings while enhancing healthcare delivery.

CONCLUSION

Radiography-related activities and factors in resource-limited departments contributing to the carbon footprint are multifaceted but can be addressed through concerted efforts.

IMPLICATIONS FOR PRACTICE

Addressing the challenges posed by old equipment, energy inefficiency, high film usage, and inadequate training through collaborative efforts and robust policy implementation is essential for promoting sustainable radiography practices in resource-limited countries. Radiographers in these countries need to be aware of these factors contributing to the carbon footprint and begin to work with the relevant stakeholders to mitigate them. Furthermore, there is a need for them to engage in education programmes and research efforts in sustainability to empower them with the right knowledge and understanding to practice sustainably.

Health burden and costs attributable to the carbon footprint of the health sector in the European Union

BACKGROUND

The healthcare sector has an environmental impact of around 4.6% of global CO2 emissions, contributing to aggravating the climate crisis. However, the impact of the health sector's emissions on human health is not regularly assessed. We aim to estimate the health burden and associated costs of the health sector's carbon footprint within the European Union (EU).

METHODS

We calculated disability-adjusted life years (DALYs) and associated costs based on human health damage factors (DALYs/kg-CO2e) by considering four scenarios. Three scenarios for shared socioeconomic pathways (S1 - high growth, S2 - baseline, and S3 - low growth) represented variations of global society, demographics, and economics until 2100. A fourth scenario (S4) considered the current EU's 55% reduction goal of greenhouse gas emissions. The healthcare sector's emissions per capita (in CO2-equivalent) in 2019 were extracted from the Lancet Countdown, and population data were retrieved from Eurostat for the same year.

RESULTS

In the EU, 365,047 DALYs (95%CI: 194,692-535,403) are expected to be caused by the health sector's emissions at baseline (S2). In an S1 scenario, the burden would slightly decrease to 316,374 DALYs (95%CI: 170,355-462,393), whereas a S3 scenario would increase 486,730 DALYs (95%CI: 243,365-681,422). If EU's carbon goals are met, the burden could be substantially reduced to 164,271 DALYs (95%CI: 87,611-240,931). Costs can amount to 25.6 billion euros, when considering DALYs monetisation.

CONCLUSION

CO2 emissions from the health sector are expected to significantly impact human health. Therefore, it is important to ensure that EU climate policies for public buildings are in line with the Paris Agreement, increase funding for climate mitigation programs within the healthcare sector, and review clinical practices at the local level.

Environmentally Not So Friendly: Global Warming, Air Pollution, and Wildfires: JACC Focus Seminar, Part 1

Environmental stresses are increasingly recognized as significant risk factors for adverse health outcomes. In particular, various forms of pollution and climate change are playing a growing role in promoting noncommunicable diseases, especially cardiovascular disease. Given recent trends, global warming and air pollution are now associated with substantial cardiovascular morbidity and mortality. As a vicious cycle, global warming increases the occurrence, size, and severity of wildfires, which are significant sources of airborne particulate matter. Exposure to wildfire smoke is associated with cardiovascular disease, and these effects are underpinned by mechanisms that include oxidative stress, inflammation, impaired cardiac function, and proatherosclerotic effects in the circulation. In the first part of a 2-part series on pollution and cardiovascular disease, this review provides an overview of the impact of global warming and air pollution, and because of recent events and emerging trends specific attention is paid to air pollution caused by wildfires.

Pediatric Resident and Program Director Views on Climate Change and Health Curricula: A Multi-Institution Study

PURPOSE

The American Academy of Pediatrics emphasized in a 2007 policy statement the importance of educating trainees on the impacts of climate change on children's health, yet few studies have evaluated trainee knowledge and attitudes about climate change-related health effects in children. This multi-institution study assessed pediatric resident and program director (1) knowledge/attitudes on climate change and health, (2) perspectives on the importance of incorporating climate and health content into pediatric graduate medical education, and (3) preferred topics/activities to include in climate and health curricula.

METHOD

This mixed-methods study employed an anonymous cross-sectional survey of pediatric residents and residency program directors from Association of Pediatric Program Directors (APPD) Longitudinal Educational Assessment Research Network (LEARN)-affiliated programs. Multivariable regression models and factor analyses were used to examine associations among resident demographics and resident knowledge, attitudes, and interest in a climate change curriculum. A conventional content analysis was conducted for the open-ended responses.

RESULTS

Eighteen programs participated in the study with all program directors (100% response rate) and 663 residents (average response rate per program, 53%; overall response rate, 42%) completing respective surveys. Of the program directors, only 3 (17%) felt very or moderately knowledgeable about the association between climate change and health impacts. The majority of residents (n=423, 64%) agreed/strongly agreed that physicians should discuss global warming/climate change and its health effects with patients/families, while only 138 residents (21%) agreed/strongly agreed that they were comfortable talking with patients and families about these issues. Most residents (n=498, 76%) and program directors (n=15, 83%) agreed/strongly agreed that a climate change curriculum should be incorporated into their pediatrics training program.

CONCLUSIONS

Pediatric residents and program directors support curricula that prepare future pediatricians to address the impact of climate change on children's health; however, few programs currently offer specific training, despite identified needs.

A systematic review of ambient heat and sleep in a warming climate

Climate change is elevating nighttime and daytime temperatures worldwide, affecting a broad continuum of behavioral and health outcomes. Disturbed sleep is a plausible pathway linking rising ambient temperatures with several observed adverse human responses shown to increase during hot weather. This systematic review aims to provide a comprehensive overview of the literature investigating the relationship between ambient temperature and valid sleep outcomes measured in real-world settings, globally. We show that higher outdoor or indoor temperatures are generally associated with degraded sleep quality and quantity worldwide. The negative effect of heat persists across sleep measures, and is stronger during the hottest months and days, in vulnerable populations, and the warmest regions. Although we identify opportunities to strengthen the state of the science, limited evidence of fast sleep adaptation to heat suggests rising temperatures induced by climate change and urbanization pose a planetary threat to human sleep, and therefore health, performance, and wellbeing.

Addressing Health Equity in the Context of Carbon Capture, Utilization, and Sequestration Technologies

PURPOSE OF REVIEW

To describe the role of health equity in the context of carbon capture, utilization, and sequestration (CCUS) technologies.

RECENT FINDINGS

CCUS technologies have the potential to both improve and worsen health equity. They could help reduce greenhouse gas emissions, a major contributor to climate change, but they could also have negative health impacts like air and noise pollution. More research is needed to fully understand the health equity implications of CCUS technologies. CCUS technologies have both health equity risks and benefits. Implementing misguided CCUS projects in vulnerable communities could exacerbate environmental injustice and health disparities and have the potential to increase carbon emissions. However, well-conceived projects could benefit communities through economic development. Governments, industry, and society should prioritize and expedite the reduction of CO2 emissions before considering carbon reductions via CCUS. Furthermore, CCUS projects must be thoroughly evaluated and should only proceed if they have demonstrated a net reduction in CO2 emissions and provide more benefits than risks to local communities. This underscores the importance of prioritizing health equity in the planning of CCUS projects.

The Climate Change Burden on Immune Health: Are Persons Living with HIV More at Risk?

Climate change poses one of the most significant modern threats to overall human health,especially for vulnerable populations including persons living with HIV (PLWH). In this perspective, we specifically explore the concept of immune resilience in human health and how climate change phenomena - including extreme weather events, food insecurity, pollution, and emerging diseases - may exacerbate immune dysfunction and comorbidities faced by PLWH and hinder access to HIV treatment and prevention services. Multidisciplinary, collaborative efforts are urgently needed to quantify these impacts, develop mitigation strategies, and strengthen policies and funding to bolster immune resilience for PLWH in the face of accelerating climate change.

Heatwave exacerbates air pollution in China through intertwined climate-energy-environment interactions

Climate change is increasing the frequency and intensity of heatwaves, raising concerns about their detrimental effects on air quality. However, a role for heatwave-human-environment interactions in air pollution exacerbation has not been established. In the summer of 2022, record-breaking heatwaves struck China and Europe. In this study, we use integrated observational data and machine learning to elucidate the formation mechanism underlying one of the most severe ozone pollution seasons on record in central eastern China, an area that encompasses approximately half of China's total population and sown land. Our findings reveal that the worsened ozone and nitrogen dioxide pollution resulted from a mismatch between energy demand and supply, which was driven by both heatwaves and energy policy-related factors. The observed adverse heatwave-energy-environment feedback loop highlights the need for the diversification of clean energy sources, more resilient energy structures and power policies, and further emission control to confront the escalating climate challenge in the future.

Assessment of subjective well-being of healthcare workers in response to heat and personal protective equipment under controlled conditions using a standardized protocol

BACKGROUND

Due to climate change, the increasing frequency of hot summer days and heat waves can result in occupational heat strain, especially in non-air-conditioned workplaces. Healthcare workers (HCW) engaged in patient care are particularly affected, as they are additionally exposed to physical stress. The use of personal protective equipment (PPE) can aggravate heat strain in HCW. This study aimed to examine the subjective well-being of HCW when exposed to heat and PPE under controlled conditions.

METHODS

This study was designed as a randomized crossover trial. Participants performed standardized healthcare tasks in a climatic chamber for approximately 3.5 h at different indoor temperatures (22 °C and 27 °C) and varied working conditions (with or without PPE). The effects on participants' subjective well-being, encompassing thermal, physiological and psychological stress were assessed using a customized questionnaire.

RESULTS

Heat had a greater effect than PPE on thermal, physical and psychological stress. Conversely, PPE had a greater effect on physical demand and effort. For the majority of outcomes, combined exposure to heat and PPE resulted in the highest perceived discomfort. Furthermore, the participants reported increased sweating and other discomforts when working at elevated temperatures or with PPE.

CONCLUSIONS

In this study, heat and PPE, but particularly the combination of both factors, were identified as unfavorable working environments. Although the trials were conducted in a controlled environment, the outcomes provide valuable information about the effect of heat and PPE on HCW in a real-life setting. Furthermore, the design used in this study can be beneficial in evaluating the effect of mitigation strategies.

Carbon footprint and cost reduction by endoscopic grading of gastric intestinal metaplasia using narrow-band imaging

BACKGROUND AND AIM

Gastric intestinal metaplasia (GIM) is a high-risk factor for the development of gastric cancer. Narrow-band imaging (NBI) enables endoscopic grading of GIM (EGGIM). In the era of climate change, gastrointestinal endoscopists are expected to reduce greenhouse gas emissions and medical waste. Based on the diagnostic performance of NBI endoscopy, this study measured the environmental impact and reduced cost of implementing EGGIM during gastroscopy.

METHODS

Using NBI endoscopy in 242 patients, EGGIM classification and operative link on GIM (OLGIM) staging were prospectively performed in five different areas (lesser and greater curvatures of the corpus and antrum, and the incisura angularis). We estimated the environmental impact and cost reduction of the biopsy procedures and pathological processing if EGGIM were used instead of OLGIM.

RESULTS

The diagnostic accuracy of NBI endoscopy for GIM was 93.0-97.1% depending on the gastric area. When a high EGGIM score ≥ 5 was the cut-off value for predicting OLGIM stages III-IV, the area under the curve was 0.862, sensitivity was 81.9%, and specificity was 90.4%. The reduction in the carbon footprint by EGGIM was -0.4059 kg carbon dioxide equivalents per patient, equivalent to 1 mile driven by a gasoline-powered car. The cost savings were calculated to be $47.36 per patient.

CONCLUSIONS

EGGIM is a reliable method for identifying high-risk gastric cancer patients, thereby reducing the carbon footprint and medical costs in endoscopy practice.

Reducing the carbon footprint of cataract surgery: co-creating solutions with a departmental Delphi process

BACKGROUND

Climate change is arguably the greatest threat to global health of the 21st century. Although cataract surgery is a major contributor to global greenhouse gas emissions, recent literature review identified a paucity of evidence-based strategies for improving the environmental impact of cataract services. Our study aimed to assess the effectiveness of a departmental Delphi process for improving cataract services' environmental sustainability.

METHODS

All members of ophthalmology theatre teams in a UK teaching hospital were invited to participate in a three-stage Delphi process. Team members were surveyed for suggestions for reducing the department's environmental impact. Suggested interventions were refined during a plenary face-to-face discussion and ranked. The highest ranked interventions were combined into a mutually agreed action plan. Data on the economic and environmental cost of cataract services was collected prior to and six months after the Delphi process using the Eyefficiency mobile application.

RESULTS

Twenty-three interventions were suggested by a range of staff cadres. Interventions were ranked by 24 team members. The 2nd, 4th, 5th, 8th and 11th ranked interventions were combined into an "Eco-packs" project in collaboration with suppliers (Bausch + Lomb), saving 675 kg of waste and 350 kg of CO2 equivalent annually.

CONCLUSIONS

The Delphi process is an effective method for provoking departmental engagement with the sustainability agenda that we would encourage all ophthalmology departments to consider utilising. The baseline per case CO2 equivalent measured in our department was reproducible and could serve as a maximum benchmark to be improved upon.

Utilization of Health Care Services and Accessibility Challenges among Adults Aged 50+ before and after Austerity Measures across 27 European Countries: Secular Trends in the SHARE Study from 2004/05 to 2019/20

This study aimed to assess and compare the utilization of preventive and other health services and the cost or availability in different regions of Europe, before and during the economic crisis. The data used in the study were obtained from Wave 8 of the Survey of Health, Ageing and Retirement in Europe (2019/2020) and Wave 1 data (2004/5), with a sample size of 46,106 individuals aged ≥50 across 27 countries, adjusted to represent a population of N = 180,886,962. Composite scores were derived for preventive health services utilization (PHSU), health care services utilization (HCSU), and lack of accessibility/availability in health care services (LAAHCS). Southern countries had lower utilization of preventive services and higher utilization of other health services compared to northern countries, with a significant lack of convergence. Moreover, the utilization of preventive health services decreased, whereas the utilization of secondary care services increased during the austerity period. Southern European countries had a significantly higher prevalence of lack of accessibility. An increase in the frequency of lack of accessibility/availability in health care services was observed from 2004/5 to 2019/20. In conclusion, our findings suggest that health inequalities increase during crisis periods. Therefore, policy interventions could prioritize accessibility and expand health coverage and prevention services.

Environmental Impacts on Cardiovascular Health and Biology: An Overview

Environmental stressors associated with human activities (eg, air and noise pollution, light disturbance at night) and climate change (eg, heat, wildfires, extreme weather events) are increasingly recognized as contributing to cardiovascular morbidity and mortality. These harmful exposures have been shown to elicit changes in stress responses, circadian rhythms, immune cell activation, and oxidative stress, as well as traditional cardiovascular risk factors (eg, hypertension, diabetes, obesity) that promote cardiovascular diseases. In this overview, we summarize evidence from human and animal studies of the impacts of environmental exposures and climate change on cardiovascular health. In addition, we discuss strategies to reduce the impact of environmental risk factors on current and future cardiovascular disease burden, including urban planning, personal monitoring, and mitigation measures.

How social background and interest in science are linked to junior high school students' perceptions of the ecological transition

Junior high school students are tomorrow's key protagonists in the ecological transition. They need enlightened education to face the uncertainty and challenges of climate change. The development of climate change education programs requires a clear understanding of how young people perceive the issue. This study deals with social representations. Its aim was to understand how social background and interest in science are linked to the way young people perceive the concept of the ecological transition. Four hundred twenty-nine junior high school students took part in this study. Data were collected and subjected to prototypical analysis and factorial correspondence analysis. Three main findings emerged from the analysis: (1) the participants had significant knowledge of the ecological transition, (2) their awareness of the social aspects of climate change was limited, and (3) their representations of the ecological transition were linked to their interest in science and their parents' social background. To conclude, these results underline the importance of educating all social classes about effective solutions for the ecological transition. Our findings also highlight the need to consider existing representations and prior knowledge when designing educational programs on climate change issues.

How an Audit-and-Feedback-Based Educational Program Contributed to a Reduction in Environmentally Harmful Waste Anesthetic Gases Among Anesthesiology Residents

Background Waste anesthetic gases (WAGs) contribute to greenhouse gas emissions. US anesthesiology resident education on how to reduce WAG-associated emissions is lacking, so we developed an electronic audit-and-feedback-based program to teach residents to reduce fresh gas flow (FGF) and WAG-associated emissions. Objective To assess the program's effectiveness, we measured individual and combined mean FGF of residents during their first, second, and last weeks of the 4-week rotation; then, we calculated the extrapolated annual emissions based on the combined resident mean FGFs. Resident attitudes toward the program were surveyed. Methods During 4-week rotations at a teaching hospital, anesthesia records were scanned to extract resident-assigned cases, FGF, and volatile anesthetic choice during the 2020-2021 academic year. Forty residents across 3 training years received weekly FGF data and extrapolated WAG-associated emissions data via email. Their own FGF data was compared to the low-flow standard FGF of ≤1 liter per minute (LPM) and to the FGF data of their peer residents on rotation with them. An online survey was sent to residents at the end of the project period. Results Between their first and last weeks on rotation, residents decreased their mean FGF by 22% (1.83 vs 1.42 LPM; STD 0.58 vs 0.44; 95% CI 1.67-2.02 vs 1.29-1.56; P<.0001). Ten of 18 (56%) residents who responded to the survey reported their individual case-based results were most motivating toward practice change. Conclusions An audit-and-feedback-based model for anesthesiology resident education, designed to promote climate-conscious practices with administration of volatile anesthetics, was effective.

Environmentally sustainable gastroenterology practice: Review of current state and future goals

OBJECTIVES

The health-care sector contributes 4.6% of global greenhouse gas emissions, with gastroenterology playing a significant role due to the widespread use of gastrointestinal (GI) endoscopy. In this review, we aim to understand the carbon footprint in gastroenterology practice associated with GI endoscopy, conferences and recruitment, identify barriers to change, and recommend mitigating strategies.

METHODS

A comprehensive search of PubMed, Embase, and the Cochrane Library was conducted to explore the carbon footprint in gastroenterology practice, focusing on endoscopy, inpatient and outpatient settings, and recruitment practices. Recommendations for mitigating the carbon footprint were derived.

RESULTS

This narrative review analyzed 34 articles on the carbon footprint in gastroenterology practice. Carbon footprint of endoscopy in the United States is approximately 85,768 metric tons of CO2 emission annually, equivalent to 9 million gallons of gasoline consumed, or 94 million pounds of coal burned. Each endoscopy generates 2.1 kg of disposable waste (46 L volume), of which 64% of waste goes to the landfill, 28% represents biohazard waste, and 9% is recycled. The per-case manufacturing carbon footprint for single-use devices and reusable devices is 1.37 kg CO2 and 0.0017 kg CO2, respectively. Inpatient and outpatient services contributed through unnecessary procedures, prolonged hospital stays, and excessive use of single-use items. Fellowship recruitment and gastrointestinal conferences added to the footprint, mainly due to air travel and hotel stays.

CONCLUSION

Gastrointestinal endoscopy and practice contribute to the carbon footprint through the use of disposables such as single-use endoscopes and waste generation. To achieve environmental sustainability, measures such as promoting reusable endoscopy equipment over single-use endoscopes, calculating institutional carbon footprints, establishing benchmarking standards, and embracing virtual platforms such as telemedicine and research meetings should be implemented.

Environmental sustainability in obstetrics and gynaecology: A systematic review

BACKGROUND

The healthcare sector is responsible for 4%-10% of global greenhouse gas emissions. Considering the broad range of care that obstetricians and gynaecologists provide, mitigation strategies within this specialty could result in significant reductions of the environmental footprint across the whole healthcare industry.

OBJECTIVES

The aim of this review was to identify for what services, procedures and products within obstetric and gynaecological care the environmental impact has been studied, to assess the magnitude of such impact and to identify mitigation strategies to diminish it.

SEARCH STRATEGY

The search strategy combined terms related to environmental impact, sustainability, climate change or carbon footprint, with the field of obstetrics and gynaecology.

SELECTION CRITERIA

Articles reporting on the environmental impact of any service, procedure or product within the field of obstetrics and gynaecology were included. Included outcomes covered midpoint impact categories, CO2 emissions, waste generation and energy consumption.

DATA COLLECTION AND ANALYSIS

A systematic literature search was conducted in the databases of MEDLINE (Ovid), Embase (Ovid) and Scopus, and a grey literature search was performed on Google Scholar and two websites of gynaecological associations.

MAIN RESULTS

The scope of the investigated studies encompassed vaginal births, obstetric and gynaecological surgical procedures, menstrual products, vaginal specula and transportation to gynaecological oncologic consultations. Among the highest yielding mitigation strategies were displacing disposable with reusable materials and minimising content of surgical custom packs. The lowest yielding mitigation strategy was waste optimisation, including recycling.

CONCLUSIONS

This systematic review highlights opportunities for obstetricians and gynaecologists to decrease their environmental footprint in many ways. More high-quality studies are needed to investigate the environmental impact of other aspects of women's and reproductive health care.

"Dirty Dry Eye"- A waste volume analysis from topical therapy in keratoconjunctivitis sicca

PURPOSE

The healthcare system is responsible for around 5% of CO2 emissions globally and in Germany. So far, there are no data on the amount of waste from dry eye disease (DED) therapy in ophthalmology. The aim of this project was to evaluate the amount and type of waste from single- and multi-dose units (SDU/MDU) generated by eyedrops used to treat DED in Germany.

METHODS

The net waste weight (outer/inner packaging, instruction leaflet, empty container) from factory-sealed products was determined using a precision scale. Based on prescription data from PharMaAnalyst, a database of medical prescriptions from over 70 million patients in Germany, the total annual waste volume for 2016-2021 and the net weight of a 30-day treatment were calculated.

RESULTS

The total annual waste volume increased significantly (p < 0.0001) from 7.13 tons in 2016 to 20.64 tons in 2021. A 30-day treatment with MDUs (without/with filter) results in a significantly lower mean waste volume (paper: SDU 24.3 ± 18.7 g; MDU 4.8 ± 1.7 g/8.8 g ± 1.7 g; SDU/MDU p = 0.0003, with filter p = 0.0034; plastic: SDU 35.0 ± 4.0, MDU 6.6 ± 0.7 g/ 15.1 g ± 5.8 g, SDU/MDU p < 0.0001, with filter p < 0.0001).

CONCLUSION

Prescription-based treatment of DED in Germany causes an increasing and substantial waste volume. The use of SDUs is considerably more resource-intensive than MDUs. Due to the large and rising number of patients suffering from DED improvements in packaging could considerably reduce the CO2 footprint of DED treatment.

Environmental sustainability: the attitudes and experiences of UK students in the oral health care profession

Objective This study aims to provide insight into the attitudes and perspectives of undergraduate dental students from UK dental schools regarding environmental sustainability in dentistry (ESD) and the manner and extent in which ESD is included in the current undergraduate oral health care curricula.Methods This study is a multi-centre, nationally representive study involving a cross-sectional online survey of undergraduate Bachelor of Dental Surgery and dental hygiene and therapy students in UK-based dental schools. Data analysis was conducted through descriptive statistics and thematic analysis.Results In total, 263 students from 13 UK schools completed the survey, resulting in a national school response rate of 68.4%. Key findings are: 97.3% of students believe that the dental profession should be more actively engaged in environmental sustainability but students currently have very little exposure to ESD at an undergraduate level; and 76.8% of students expressed that they are concerned about the impact that oral health care provision has on the environment, but only 23% of students have independently researched ESD.Conclusions Students identify that oral health care professionals should become more engaged in efforts to mitigate the negative impacts from our activities on the environment, principally via education at all levels. The data from this study provide insight into the current level of awareness and concerns for the environmental impacts of oral health care provision, and are a powerful driver for the inclusion of ESD into the undergraduate curriculum in UK based dental schools.

Climate Change Adaptation Methods for Public Health Prevention in Australia: an Integrative Review

PURPOSE OF REVIEW

Climate change poses a serious threat to human health and well-being. Australia is not immune to the public health impacts and continues to be underprepared, putting the population health at risk. However, there is a dearth in knowledge about how the Australian public health system will address the impacts of climate change.

RECENT FINDINGS

This integrative review synthesises tools, frameworks, and guidance material suitable for climate change adaptation from a preventive public health perspective. The literature search was conducted in electronic databases MEDLINE, PubMed, CINAHL, and Web of Science. Of 4507 articles identified, 19 articles met the inclusion criteria that focused on operational methods in public health and excluded the clinical context and reactive disaster response approaches. This review revealed that Australia is ill-prepared to manage climate change adverse health impacts due to ineffective adaptation strategies. The review highlights that Australia urgently requires effective adaptation strategies such as undertaking a National Adaptation Plan process and an improved understanding in managing complex health risks. Taking this action will strengthen the public health system and build health resilience especially for vulnerable populations. These findings will help understand and develop of the necessary adaptive strategies in Australia.

Climate Change and Children's Health: Building a Healthy Future for Every Child

Observed changes in temperature, precipitation patterns, sea level, and extreme weather are destabilizing major determinants of human health. Children are at higher risk of climate-related health burdens than adults because of their unique behavior patterns; developing organ systems and physiology; greater exposure to air, food, and water contaminants per unit of body weight; and dependence on caregivers. Climate change harms children through numerous pathways, including air pollution, heat exposure, floods and hurricanes, food insecurity and nutrition, changing epidemiology of infections, and mental health harms. As the planet continues to warm, climate change's impacts will worsen, threatening to define the health and welfare of children at every stage of their lives. Children who already bear higher burden of disease because of living in low-wealth households and communities, lack of access to high quality education, and experiencing racism and other forms of unjust discrimination bear greater risk of suffering from climate change hazards. Climate change solutions, advanced through collaborative work of pediatricians, health systems, communities, corporations, and governments lead to immediate gains in child health and equity and build a foundation for generations of children to thrive. This technical report reviews the nature of climate change and its associated child health effects and supports the recommendations in the accompanying policy statement on climate change and children's health.

Position paper on sustainability in cardiac pacing and electrophysiology from the Working Group of Cardiac Pacing and Electrophysiology of the French Society of Cardiology

Sustainability in healthcare, particularly within the domain of cardiac electrophysiology, assumes paramount importance for the near future. The escalating environmental constraints encountered necessitate a proactive approach. This position paper aims to raise awareness among physicians, spark critical inquiry and identify potential solutions to enhance the sustainability of our practice. Reprocessing of single-use medical devices has emerged as a potential solution to mitigate the environmental impact of electrophysiology procedures, while also offering economic advantages. However, reprocessing remains unauthorized in certain countries. In regions where it is possible, stringent regulatory standards must be adhered to, to ensure patient safety. It is essential that healthcare professionals, policymakers and manufacturers collaborate to drive innovation, explore sustainable practices and ensure that patient care remains uncompromised in the face of environmental challenges. Ambitious national/international programmes of disease prevention should be the cornerstone of the strategy. It is equally vital to implement immediate actions, as delineated in this position paper, to bring about tangible change quickly.

The nexus among CO2 emission, health expenditure and economic development in the OECD countries: New insights from a cross-sectional ARDL model

To find a way to realize sustainable development, this paper applied a cross-sectional ARDL (CS-ARDL) method to explore the interaction between carbon emissions, economic development, and health care expenditure for OECD countries. Firstly, we conduct a cross-sectional test to check whether the data is confronted with this issue. Secondly, we conduct a panel unit root test and cointegration test to confirm whether the ARDL-based method is suitable for our data. Thirdly, we analyze the results and provide possible explanations. Lastly, we conduct a short-term causality test to detect the connection between different variables. The main conclusion of our study includes: 1) Health care is a necessity in OECD countries. 2) Environmental deterioration places a heavy burden on health care expenditure in OECD countries. 3) Health care expenditure of last year negatively affects health care expenditure. 4) There is a short-run causality relationship from CO2, economic development, and dependency rate of youth to health care expenditure in OECD countries. Related policy proposals are provided according to our analysis of the results.

Global supply chains amplify economic costs of future extreme heat risk

Evidence shows a continuing increase in the frequency and severity of global heatwaves1,2, raising concerns about the future impacts of climate change and the associated socioeconomic costs3,4. Here we develop a disaster footprint analytical framework by integrating climate, epidemiological and hybrid input-output and computable general equilibrium global trade models to estimate the midcentury socioeconomic impacts of heat stress. We consider health costs related to heat exposure, the value of heat-induced labour productivity loss and indirect losses due to economic disruptions cascading through supply chains. Here we show that the global annual incremental gross domestic product loss increases exponentially from 0.03 ± 0.01 (SSP 245)-0.05 ± 0.03 (SSP 585) percentage points during 2030-2040 to 0.05 ± 0.01-0.15 ± 0.04 percentage points during 2050-2060. By 2060, the expected global economic losses reach a total of 0.6-4.6% with losses attributed to health loss (37-45%), labour productivity loss (18-37%) and indirect loss (12-43%) under different shared socioeconomic pathways. Small- and medium-sized developing countries suffer disproportionately from higher health loss in South-Central Africa (2.1 to 4.0 times above global average) and labour productivity loss in West Africa and Southeast Asia (2.0-3.3 times above global average). The supply-chain disruption effects are much more widespread with strong hit to those manufacturing-heavy countries such as China and the USA, leading to soaring economic losses of 2.7 ± 0.7% and 1.8 ± 0.5%, respectively.

The environmental impact of energy consumption and carbon emissions in radiology departments: a systematic review

OBJECTIVES

Energy consumption and carbon emissions from medical equipment like CT/MRI scanners and workstations contribute to the environmental impact of healthcare facilities. The aim of this systematic review was to identify all strategies to reduce energy use and carbon emissions in radiology.

METHODS

In June 2023, a systematic review (Medline/Embase/Web of Science) was performed to search original articles on environmental sustainability in radiology. The extracted data include environmental sustainability topics (e.g., energy consumption, carbon footprint) and radiological devices involved. Sustainable actions and environmental impact in radiology settings were analyzed. Study quality was assessed using the QualSyst tool.

RESULTS

From 918 retrieved articles, 16 met the inclusion criteria. Among them, main topics were energy consumption (10/16, 62.5%), life-cycle assessment (4/16, 25.0%), and carbon footprint (2/16, 12.5%). Eleven studies reported that 40-91% of the energy consumed by radiological devices can be defined as "nonproductive" (devices "on" but not working). Turning-off devices during idle periods 9/16 (56.2%) and implementing workflow informatic tools (2/16, 12.5%) were the sustainable actions identified. Energy-saving strategies were reported in 8/16 articles (50%), estimating annual savings of thousand kilowatt-hours (14,180-171,000 kWh). Cost-savings were identified in 7/16 (43.7%) articles, ranging from US $9,225 to 14,328 per device. Study quality was over or equal the 80% of high-quality level in 14/16 (87.5%) articles.

CONCLUSION

Energy consumption and environmental sustainability in radiology received attention in literature. Sustainable actions include turning-off radiological devices during idle periods, favoring the most energy-efficient imaging devices, and educating radiological staff on energy-saving practices, without compromising service quality.

RELEVANCE STATEMENT

A non-negligible number of articles - mainly coming from North America and Europe - highlighted the need for energy-saving strategies, attention to equipment life-cycle assessment, and carbon footprint reduction in radiology, with a potential for cost-saving outcome.

KEY POINTS

• Energy consumption and environmental sustainability in radiology received attention in the literature (16 articles published from 2010 to 2023). • A substantial portion (40-91%) of the energy consumed by radiological devices was classified as "non-productive" (devices "on" but not working). • Sustainable action such as shutting down devices during idle periods was identified, with potential annual energy savings ranging from 14,180 to 171,000 kWh.

How far has the globe gone in achieving One Health? Current evidence and policy implications based on global One Health index

Background

In the 21st century, as globalization accelerates and global public health crises occur, the One Health approach, guided by the holistic thinking of human-animal-environment and emphasizing interdisciplinary collaboration to address global health issues, has been strongly advocated by the international community. An immediate requirement exists for the creation of an assessment tool to foster One Health initiatives on both global and national scales.

Methods

Built upon extensive expert consultations and dialogues, this follow-up study enhances the 2022 global One Health index (GOHI) indicator system. The GOHI framework is enriched by covering three indices, e.g. external drivers index (EDI), intrinsic drivers index (IDI), and core drivers index (CDI). The comprehensive indicator system incorporates 13 key indicators, 50 indicators, and 170 sub I-indicators, utilizing a fuzzy analytic hierarchy process to ascertain the weight for each indicator. Weighted and summed, the EDI, IDI, and CDI scores contribute to the computation of the overall GOHI 2022 score. By comparing the ranking and the overall scores among the seven regions and across 160 countries/territories, we have not only derived an overall profile of the GOHI 2022 scores, but also assessed the GOHI framework. We also compared rankings of indicators and sub I-indicators to provide greater clarity on the strengths and weaknesses of each region within the One Health domains.

Results

The GOHI 2022 performance reveals significant disparities between countries/territories ranged from 39.03 to 70.61. The global average score of the GOHI 2022 is 54.82. The average score for EDI, IDI, and CDI are 46.57, 58.01, and 57.25, respectively. In terms of global rankings, countries from North America, Europe and Central Asia, East Asia and Pacific present higher scores. In terms of One Health domains of CDI, the lowest scores are observed in antimicrobial resistance (median: 43.09), followed by food security (median: 53.78), governance (median: 54.77), climate change (median: 64.12) and zoonotic diseases (median: 69.23). Globally, the scores of GOHI vary spatially, with the highest score in North America while lowest in sub-Saharan Africa. In addition, evidence shows associations between the socio-demographic profile of countries/territories and their GOHI performance in certain One Health scenarios.

Conclusion

The objective of GOHI is to guide impactful strategies for enhancing capacity building in One Health. With advanced technology and an annually updated database, intensifying efforts to refine GOHI's data-mining methodologies become imperative. The goal is to offer profound insights into disparities and progressions in practical One Health implementation, particularly in anticipation of future pandemics.

Climate change, ambient air pollution, and students' mental health

The impact of global climate change and air pollution on mental health has become a crucial public health issue. Increased public awareness of health, advancements in medical diagnosis and treatment, the way media outlets report environmental changes and the variation in social resources affect psychological responses and adaptation methods to climate change and air pollution. In the context of climate change, extreme weather events seriously disrupt people's living environments, and unstable educational environments lead to an increase in mental health issues for students. Air pollution affects students' mental health by increasing the incidence of diseases while decreasing contact with nature, leading to problems such as anxiety, depression, and decreased cognitive function. We call for joint efforts to reduce pollutant emissions at the source, improve energy structures, strengthen environmental monitoring and gover-nance, increase attention to the mental health issues of students, and help student groups build resilience; by establishing public policies, enhancing social support and adjusting lifestyles and habits, we can help students cope with the constantly changing environment and maintain a good level of mental health. Through these comprehensive measures, we can more effectively address the challenges of global climate change and air pollution and promote the achievement of the United Nations Sustainable Development Goals.