The recent Lancet Countdown report on Climate Change highlighted the impact of the healthcare sector on global emissions. The report indicates that the total emissions footprint of the global health sector is 5.2% or 2.7 GtCO2e of total global emissions, while contributing to 10% of global GDP. As per Health Care Without Harm, the Indian health sector’s contribution to the country’s total emissions is approximately 2%. While this may seem like a small, the fact that it continues to increase at a rate of approximately 5% every year is a cause for concern. Additionally, the extensive use of anesthetic gases, single use plastics, generation of biomedical waste and a poor substitution uptake of renewables makes the issue more germane. Given that India has committed to a net-zero target by 2070, and international health systems like the UK’s NHS and the US’ Department of Health and Human Services department giving clear reduction and net zero targets, the need for concerted action on decarbonization by the Indian healthcare sector has become an imperative.
As we begin this journey of decarbonization, it is important to understand the key contributors to the emissions inventory in a typical hospital. Studies by the UK’s NHS indicate that 24% of emissions are through delivery of care, which includes energy use, procurement of pharmaceuticals and chemicals, use of medical equipment and materials like anesthetic gases and metered dose inhalers. Add to that another 10% of emissions are contributed by patient and visitor travel to hospitals and through staff commutes. Most of the emissions however, come from the supply chain, averaging at 62% of the total carbon footprint. Of this, pharmaceuticals, chemicals, and medical devices make much of the emissions inventory, with non-medical equipment, food and catering and business services like indemnity insurance bringing up the rear.
Indian healthcare offers slight variations but are broadly in line with global peers. As per a 2019 report by Health Care Without Harm and ARUP, on an average 8% of total emissions in Indian healthcare are attributable to direct emissions, i.e., those generated through operational emissions. A further 11% of emissions come from indirect emissions, those from purchased energy sources for a hospital or health center. 81% of emissions are through the supply chain which includes emissions on account of manufacturing, transport and storage of pharmaceuticals, medical devices and chemicals, transport, and business services. As Indian healthcare becomes more mature in the years ahead, it may start to mirror the emissions inventory of the rest of the world, but the skew towards most emissions coming from the supply chain are likely to remain unchanged.
As with any data set, it is easy to postulate and take positions. It can be argued that till the supply chain emissions, largely beyond the scope of healthcare providers, are not reduced, any meaningful progress towards decarbonization will remain futile. Others could argue that the onus remains on the decarbonization efforts by power generators and equipment manufacturers to ensure the health sector meets its carbon neutrality and net zero ambitions. The merits of these arguments aside, the onus remains on the sector to implement measures that impact direct and indirect emissions. Not only does this make economic and ecological sense, but it is also critical in order to reduce the climate related disease burden that one is witnessing over the past decade.
First, the health sector needs to conduct an analysis of their actual carbon footprint. An emissions inventory framework for all hospitals and health institutions needs to find priority amongst policymakers and health administers. Only with real and credible data can the sector make targets and affirm to actions that are measurable and impactful. Multiple solutions based on the UN’s Greenhouse Gas (GHG) Protocol are available for ready use by healthcare institutes. Second, the sector needs to create emission and consumption reduction targets that look at fossil fuel consumption, waste generation, water consumption and effluents generated. This is a critical step towards the sector making consequential progress towards reducing its carbon footprint with eventual attainment of net zero ambitions. Third, the need to move en-masse to renewable sources of energy is the need of the hour. The marketplace mechanism of power purchase in many jurisdictions allows for judicious decisions to be taken on sourcing of energy for the health sector. This move towards cleaner fuels should have adjuncts including increasing self-generation through solar energy and exploring new technologies like renewables-based power back-ups and enhanced battery storage to meet critical operational needs of a hospital. Fourth, the generation of biomedical waste has seen an exponential rise in the Covid years. While unavoidable, the levels of biomedical waste generation need to see a commensurate reduction as we emerge in the post Covid clinical world. This will only be possible with a significant reduction in the use of masks, gloves and single use plastics for clinical procedures that do not require these. Keep in mind, as Indian healthcare becomes more specialized and tertiary care facilities grow across India, the commensurate generation of biomedical waste is expected to rise. The sector, therefore, needs a clear roadmap on defining the appropriate, safe and required use of masks, gloves and single use plastics that ensure harmonization between high quality care, staff safety and the carbon footprint. Attaining net zero to landfill for biomedical waste is a challenge, given the health risks and toxicity of this type of waste, local and state governments need to prioritize increased capacity creation of waste-to-energy units that are aligned towards biomedical waste.
In addition to the above, the healthcare build will need to be aligned with the principles of carbon neutrality and energy efficiencies. Buildings with energy efficiency certifications like LEED go a long way in ensuring lowering of the carbon footprint and should be taken up in a concerted manner within the broader health sector. Also, the introduction of new low-embodied carbon materials and greater use of smart building technologies that lower the footprint need prioritization. While these measures can help the sector make progress on carbon neutrality, it will continue to depend on the broader industrial ecosystem to help attain net zero status. The decarbonization of the supply chain needs partnerships, incentives, and regulatory measures. While the health sector must use its purchasing power, the lack of alternatives or fiscal and regulatory motivations for manufacturers to decarbonize will impede progress. Therefore, industry participation in developing alternatives and embarking on a net-zero journey will need to go hand in hand as the sector decarbonizes.
Governments and regulatory agencies too will need to play their part in this journey. Healthcare accrediting bodies need to have measurable standards on consumption, waste reduction targets and decarbonization in place to provide regulatory nudges. Similarly, access to funding and incentives that aligns with progress on healthcare decarbonization needs broader deliberation. The use of carbon offsets finds discussion within healthcare decarbonization, given that involuntary and unavoidable residual emissions will continue to persist even in the most decarbonized systems. However, just like with any other sector, offsets should be the port of last call, rather than the first off-the-shelve approach. And given the tortuous history of offsets currently, the health sector would be best advised to pursue other strategies more vigorously.
The Covid-19 pandemic reaffirmed the role of the health sector in fore-fronting a national cause and response. It builds on the tremendous work done by the sector previously as India made admirable progress on various health indicators and continues to do so. And therefore, the onus on facing the perpetual pandemic that is climate change, requires the same fervent response from the sector to decarbonize. The route to the planet getting back to the pink of health is in part through greener healthcare.
Dr. Karan Thakur is a healthcare administrator and heads sustainability initiatives at Apollo Hospitals. He tweets @karanthakur
