Greening Nova Scotia’s healthcare system in a COVID-19 world

The pandemic taught us we can make sweeping changes to healthcare when crisis arrives. The climate crisis has arrived.

Sean Christie would like the healthcare system to save the environment while it saves lives. - ALEXA CUDE
Alexa Cude
Sean Christie would like the healthcare system to save the environment while it saves lives.

The grim state of the climate had been in the back of neurosurgeon Sean Christie's mind for a while, "but as my kids get a bit older and start to ask questions and are much more environmentally conscious than I was at their age, it just kind of hit me: Listen, we have to do something." 

Christie had started taking steps to address climate change at home, and got to thinking about the other place where he spends much of his life: the Halifax Infirmary. Something needed to be done to address climate change and waste there, too, even if "it probably needed to be done 30 years ago," he says. 

That led to conversation with colleagues about the state of the planet, which led to two nurses in Christie's team, Jennifer Hoyt and Donna MacQueen, kickstarting a recycling program to divert waste from the operating room. That initiative was pivotal for starting the process of change within the neurosurgery operating room. And that led Christie's team to start an environmental impact data-collection research partnership with the Healthy Populations Institute. 

Initiating a recycling program might seem like a simple thing to do, says Christie, but things are difficult to change in the healthcare sector. This meant there was a large task ahead, both for himself and for the others striving to achieve a more sustainable healthcare system in Nova Scotia. Christie's team had merely taken its first step.  

In a normal year, Christie does up to 225 spine surgeries, give or take. For each of those surgeries, an average of three or four garbage bags of waste are produced, plus at least half a bag of paper and one bag of plastic—all of which has gone to landfills for decades. The new recycling program has cut that landfill-destined waste in half. 

Christie estimates that, with around three to four spine surgeries a day at the Halifax Infirmary, there are anywhere from 1,350 to 4,000 bags of waste created each year at this hospital alone. And that's not even taking into account the fact that every spinal patient has to drive to Halifax multiple times: before the surgery, for the surgery itself and after the surgery. If you add to that all the material used for the operation, much of which is single-use and disposable and comes from far away, very quickly you begin to suspect that the environmental impact of the healthcare system may well be staggering.

The Canadian association of physicians for the environment reports that carbon pollution from the health sector increased at double the rate of the national average between 2009 and 2015, accounting for 4.6 percent of total carbon emissions in Canada in 2015. By comparison, methane emitted by Canadian livestock accounts for about 3.5 percent of all our emissions. In addition, the Canadian healthcare system also generated over 210,000 metric tonnes of other pollution that ended up in our air, our water and our soil in 2015. As the most product-intensive areas of the healthcare system, operating rooms produce the largest amount of waste.

It wasn't always this bad. The prevalence of single-use items in hospitals has only risen since Christie began his training in 1996. "Between then and now, it's been an exponential rise in disposables," he says. 

click to enlarge All of this ends up in the garbage after every surgery Christe performs. - SUBMITTED
Submitted
All of this ends up in the garbage after every surgery Christe performs.

Sitting at his desk, Christie pulls out a plastic tray full of medical tools. "For example, I open something like this up for a case," he says, showing off slender sticks with a sharp point on one end and a handle on the other, scope-like devices and another set of tubes all in plastic packaging, "and it all goes in the garbage. And that's just one small example." 

When COVID-19 hit, it didn't exactly improve matters on that front, either. "There certainly is a ramp-up on disposables with all of this," says Christie. "I'm of mixed views, you know, there's obviously the safety of patients and caregivers that needs to be paramount, but it would be nice if there was a little bit more thought or research into what really needs to be done in order to attain the level of safety that you need." 

Even in pre-pandemic times, balancing patient safety and environmental protection was already tricky, and sometimes incompatible, says Christie. Compromising patient safety for the sake of the environment is not an option. "I recognize that with a pandemic like this, the scales have to change a little bit to maintain that safety. However, I don't think that we should disregard the environmental side of things."

After the conversation with his kids, which led to the conversation with his colleagues, which led to the recycling program, which led to reimagining how the whole neurosurgery department deals with waste, Christie's concern about the environmental impact of the healthcare system led him to team up with Gillian Ritcey, managing director of the Healthy Populations Institute at Dalhousie University. In fact, Christie has recently been appointed co-lead, along with senior research scientist Daniel Rainham, of the Healthy Populations Institute's flagship project, "Creating Sustainable Health Systems in a Climate Crisis". 

The goal is to coordinate a province-wide effort to green Nova Scotia's healthcare system, says Ritcey. It's a priority, she says, "because the health consequences of climate change are frightening and disastrous and the healthcare system should not be contributing to them."

Ritcey says that there are lessons we can learn from the current pandemic and apply to the climate crisis. "A key message from the Healthy Populations Institute is that we've seen an urgent and collective response to COVID-19. We've proven to ourselves, and to each other, that the world can come together and make quick and impactful changes to protect humanity." she says. 

This means applying an equity lens to climate solutions for the healthcare system. "You've got racial and economic inequality that has been an epidemic in our country and in the world for a very long time. This is a lens that absolutely needs to be considered in any solution," she says, highlighting the fact that marginalized communities have been harder hit by the pandemic, are already subject to more environmental health problems due to exposure to pollution, and will bear the brunt of climate change impacts. (In early December, Bill C-240, which aims to study and redress environmental racism in Canada, will begin its second reading in the House of Commons). 

Addressing climate change and inequality within the context of a global pandemic is a mammoth task, but having a "physician champion" like Christie helps, says Ritcey. His team started small, diverting a few bags of paper and plastic from the waste stream, asking questions and starting conversations. He noticed a problem and decided to address it, says Ritcey. "There's a lot of waste, and change could be made in his operating room." 

Almost unbelievable, but not uncountable, amounts of waste are produced after each surgery performed in hospital - SUBMITTED
submitted
Almost unbelievable, but not uncountable, amounts of waste are produced after each surgery performed in hospital

From there, Ritcey says the Healthy Populations Institute is going to use Christie as a starting point—and a bit of leverage—"to show that operating rooms are hotspots for carbon emissions, and to hopefully test some low-carbon alternatives." All while bringing it to the attention of policy and program decision makers in Nova Scotia. 

The Nova Scotia Health Authority is already working on some sustainability initiatives, mainly focused on making hospital buildings more energy-efficient, but Christie says they have shown a keen interest in becoming involved in the sustainable healthcare systems project. There have been discussions on implementing a province-wide recycling program for hospitals, to start.

In an email correspondence in mid-August, Brendan Elliott, Senior Advisor in Media Relations, wrote: "Nova Scotia Health recognizes our responsibility to be environmental stewards and has a number of energy and environmental stewardship projects underway, which in 2019 alone resulted in $930,000 in energy savings and represented more than 5,100 tons of carbon dioxide that will not go into our atmosphere." 

Elliott admitted that beyond energy consumption, there is no other data currently available on environmental impacts of Nova Scotia's healthcare system. This is one of the reasons why the data collected by the Healthy Populations Institute will be so important. It will provide some of the baseline information needed to get the attention of policymakers. 

The data collection will involve looking at the life cycles of devices and disposable items used in Christie's operating room. Like the scenes in Grey's Anatomy where after an operation every piece of gauze and instrument is counted, it's to see if each item's environmental footprint can be shrunk—not making sure nothing was accidentally left inside the person on the operating table.  

"If we're looking at an operating room, let's say the sutures used for a surgery, that would include working your way back to where those sutures were produced, how they were mined, the minerals and materials that were mined to produce those sutures, how they were packaged, how long they travelled from wherever they were produced to the end destination of being in the operating room at the Halifax Infirmary," says Ritcey. 

Carbon emissions are assigned to the product at every stage of its life cycle, and then added up to get a big-picture image of the environmental impact of the operating room. From there, Ritcey and Christie hope they will be able to start exploring alternatives that will result in lower carbon emissions. 

However, they both strongly agree that finding more environmentally-friendly alternatives must never compromise patient care. Rather, it's about looking at things like the supply chain, at the energy grid, at the way people get to and from the hospital, as well as any changes in practices that have the same patient health outcomes. 

No one is saying doctors should operate without disposable gloves, says Christie, and some things will undoubtedly have to remain disposable. He says some degree of environmental damage may be inevitable, "but then we mitigate them through and another alternative strategy," such as carbon offsets.   

"I think that humans can be pretty smart and that we should be able to come up with some of these things. I don't think it will be quick, I don't know if it will happen during my career, but by getting the ball rolling then we get smart people thinking about how to do this," he adds. 

And while changes big enough to reverse the ongoing climate crisis might not happen during Christie's career, Emma McDermott, a second-year Dalhousie medical school student, says change is coming. "The interest is definitely growing for environmental health in medical school," she says.

This is why McDermott worked with Ritcey this September to deliver an online inter-professional education course on planetary health and sustainable health systems through the Healthy Populations Institute. The online course was a success, attended by twenty-five students from three different campuses and three different health professions, say Ritcey and McDermott. 

Ritcey says this shows the appetite to include the topic of planetary health and sustainable health systems in training programs for medical students. McDermott agrees. She and her classmates want to see a healthcare system that contributes to climate solutions rather than being part of the problem, and thankfully, the idea that the health of the planet is directly related to the health of the animals and humans that live on it is gaining traction. 

Over the next year, McDermott and four other medical students at Dalhousie University will be working on a project to advocate for the creation of green teams who work on sustainability initiatives within local hospitals, through a grant they received from the Canadian Federation of Medical Students. 

As McDermott and her classmates continue to advocate for sustainable healthcare systems and prepare to enter the profession, Christie, Ritcey and their colleagues continue to bring awareness to the environmental impact of the healthcare system and possible solutions. 

Christie hopes that within a year or two he'll be able to give a fairly accurate assessment of what it costs to have surgery done in Nova Scotia "from the viewpoint of the earth, if you will," he says. "We'd like to start with the spine program, then roll out to interested people in the department of surgery in general, and then roll out to the health authority," says Christie. 

As he contemplates the sheer number of items that end up in the landfill every day, Christie reflects, "for people that aren't familiar with what goes on in the hospital, a lot of people would be pretty surprised. We take stuff for granted. The syringes—how many thousands of syringes are thrown away every day? They're all plastic and they're just thrown away. Is there a better alternative? I'm not saying I know what it is, but I want to be able to say, OK this is what we're doing in 2020 and this is the impact."  

For Christie and the others working on greening the healthcare system, the question in coming years will continue to be "what can we change?"


Correction: This article initially spelled Donna MacQueen's name incorrectly. It's been updated to reflect the correct spelling. The Coast regrets the error

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