The anaesthetist and the environment
In June 2009, and again in March this year, the Association of Anaesthetists of Great Britain and Ireland (AAGBI) ran a 1-day seminar on ‘The anaesthetist and the environment’. In addition, the AAGBI’s Winter Scientific Meeting included a special session on the environment. These brought together, for the first time, informed anaesthetists (with knowledge, for instance, of carbon footprint, environmental impacts and waste management) and, crucially, external experts in the field. The conclusions were clear and unanimously voiced. The Earth is in the midst of an environmental crisis, driven largely by human activity. In our work and personal lives, we all bear responsibility for this, and for the harm it causes to others.
We are all, to some degree, aware of this, but are often ignorant of the details. How many of us, for instance, understand the health impacts of the plasticisers used in some drip/infusion bags on the risk of cancer in our patients?
The AAGBI initiative was also timely given the accelerating international concern about climate change. Data published in major reputable journals show that we are far exceeding even the ‘worst case’ emission trajectories envisaged by the Intergovernmental Panel on Climate Change [1–4]. The impacts of these emissions have also been underestimated – with polar ice melt rates far exceeding those predicted. The latest modelling suggests that future impacts are likely to be far more serious than was thought likely even a year ago – with polar temperature increases of 16 °C predicted within our lifetimes . Worse still, such modelling excludes the range of positive feedback loops known to exist, making such projections underestimates. Thus, warmed oceans hold less carbon dioxide, methane released when tundra methane hydrates melt is 23 times as potent a greenhouse gas as carbon dioxide, and shrinking icecaps reflect back less incoming radiation [6–9]. No wonder, then, that the University College London/Lancet Commission in 2009 described climate change as ‘the biggest global health threat of the 21st century’ , nor that the presidents of seventeen international medical colleges (the Royal College of Physicians included) recently raised the same alarm . Now would seem to be the time for us all to take responsibility – as individuals, and as a profession.
As well as warming our environment we are also contaminating it. Anaesthetists are prolific users of disposable devices and particularly plastics, which clutter landfill, generate dioxin when incinerated and contain plasticisers with emerging health effect. Bisphenol-A is ubiquitous in plastics and has recently been associated with ischaemic heart disease and diabetes . Another plasticiser, Di(2-ethylhexyl) phthalate (DEHP) is commonly used in PVC imparting strength and flexibility to plastic devices in a wide variety of applications. However, DEHP migrates from PVC into the environment and may contaminate intravenous infusions . In addition, DEHP is an endocrine disruptor  although its effects on human adults are currently unclear. Whilst the fabrication and life cycles of devices used in the treatment of patients are beyond the control of individual clinicians, we can nevertheless be informed and critical consumers who ask for information about what things are made from, their environmental costs, their possible harmful effects and the existence of alternatives.
Impact of the National Health Service
The National Health Service (NHS) has a carbon footprint of 18 million tonnes of carbon dioxide per year . This is composed of energy (22%), travel (18%) and procurement (60%). Despite an increase in efficiency, the NHS has increased its carbon footprint by 40% since 1990. This means that meeting the Climate Change Act  targets of 26% reduction by 2020 and 80% reduction by 2050 will be a huge challenge.
What is the NHS doing?
As a major employer with a substantial estate, the NHS has a proportionately large responsibility towards the environment. This duty was recognised with the establishment in April 2008 of the NHS Sustainable Development Unit for England (SDU; http://www.sdu.nhs.uk).
The SDU aims to be a source of leadership, expertise and guidance concerning sustainable development to all NHS organisations in England and to achieve this by raising awareness across the NHS about the important responsibilities of, and actions for, the NHS regarding sustainable development and climate change. This includes promoting a culture of measurement and management that will eventually lead to a process of carbon governance. The SDU also helps to shape NHS policy locally, nationally and internationally such that promoting sustainable development and adapting to and mitigating climate change is both necessary and possible for every NHS organisation.
A key role for the SDU is to ensure that the very best practice and innovations on sustainability in the NHS and elsewhere are evaluated and costed, and the mechanisms for implementation are made fully available to all NHS organisations. A plan for environmental action by the NHS can be found in Saving Carbon, Improving Health: the NHS Carbon Reduction Strategy for England  This strategy establishes that the NHS should have a target of reducing its 2007 carbon footprint by 10% by 2015. This will require not only that the current level of growth of emissions be curbed, but that the trend be reversed and absolute emissions reduced. Ten key areas for action are identified (Table 1), together with a blueprint for implementation.
Table 1. Priority areas for delivery of the NHS Carbon Reduction Strategy for England .
|1. Energy and carbon management|
|2. Procurement and food|
|3. Low carbon travel, transport and access|
|6. Designing the built environment|
|7. Organisational and workforce development|
|8. Role of partnership and networks|
What about the AAGBI?
The AAGBI and its charitable partner, the AAGBI Foundation, occupy handsome premises in central London. These are heated and lit, populated by staff who travel to and from their homes, and are often filled with members from all over the UK. We publish this journal (printed in Singapore and air freighted to UK for distribution) and project our President and Honorary Secretary to the USA, Australia and Continental Europe for occasional meetings of the ‘Common Interest Group’ and the European Society of Anaesthesiologists respectfully. In short, the AAGBI and those associated with it have – with the best will in the world – a substantial environmental impact. What can we do about it?
The answer (as always) is multifaceted and complicated. Indeed, there isn’t ‘an answer’ but, rather, lots of little answers, part answers and opportunities, and we need to move forward with all of them. The most obvious aspect of the AAGBI’s carbon footprint is travel by delegates to its seminars at Portland Place, its Winter Scientific Meeting in London each January, and its Annual Congress each September, held in different locations around the UK. Easy (but facile) alternatives spring to mind in a moment. Why not stop travelling to meetings altogether ? At its worst (at this point one can see a gleam in the eye of many NHS managers and budget holders), we can conjure up a piteous minimalist vision whereby each of us sits at home, undertaking continuing medical education/professional development by staring at our iPhones and pressing the occasional button. This miserable projection misses one of the key realities of postgraduate education, namely networking. People come to seminars and meetings as much for peer interaction as they do for content delivered from the podium. We are supposed to be reflective practitioners (and we are supposed to be training our medical students to become them…). Part of the reflective reality of complex professional careers is the opportunity to discuss the challenging issues that emerge from our practice. This simply isn’t going to happen without bringing people together and the AAGBI properly recognises this and provides excellent opportunities to do so. Nonetheless, we might try to provide improved opportunities for distance learning, offer more ‘local’ meetings (bring a few speakers to the audience, not a large audience to the speakers), consider whether overseas speakers can appear by satellite/videoconference, minimise the production of waste, and make rail travel (not travel by air or car) the norm. The AAGBI’s building – like many such venues – pays heed to aesthetics, not emissions. Perhaps the time has come to leave corridors darker and rooms cooler, and to remove completely the bottled water and meat options in our hospitality? As a start, the AAGBI has commissioned an independent review of its energy consumption and is now working to implement its recommendations.
It doesn’t stop there. In addition to its direct impact, the AAGBI as an organisation is nothing without its members who in turn are citizens with personal and family environmental footprints that they must determine themselves. The AAGBI has no business hectoring members about their private lives and one hopes it will avoid the temptation to do so. Nevertheless, as working clinicians within the NHS the AAGBI’s members – in fact all anaesthetists – are major users of single-use items, generators of waste, and decision makers throughout their daily practice. Further, we influence purchasing and a proportion of us are leaders at departmental, institutional, regional and national levels. In short, we are a powerful group with plenty of opportunity to influence environmental issues in relation to procurement and provision of health care.
Finally, our public voice can be heard – and it is important that this happens. As one exemplar, between 7th and 18th December 2009, Copenhagen hosted world leaders to lay a plan to reduce climate change. Before the meeting the President of the Royal College of Physicians of London – and 16 other such international College leaders – warned: ‘There is a real danger that politicians (at Copenhagen) will be indecisive, especially in such turbulent economic times as these. Should their response be weak, the results for international health could be catastrophic’ . This caution was well founded as the talks stalled and the meeting ended with a US led ‘accord’, announced while many delegates claimed to have not had sight of it and the meeting only agreed to ‘note’ the document. A far cry then from the hoped for legally binding agreement. We might each add our voice to theirs, and act, recognising that even halving our carbon dioxide emissions in the next 11 years (the Scottish Parliament has a target of a 42% reduction by then ) falls short of scientific mandates and may still be may be insufficient .
In late 2009 the AAGBI released a statement (see http://www.aagbi.org) that notes that climate change and environmental degradation represent a major threat to human health and survival in coming decades, and that if climate change is to be contained in any meaningful way, urgent and drastic action by every organisation and individual is required. The AAGBI Council therefore committed to examine and make public its own actions to produce meaningful and sustained reductions in greenhouse emissions from its buildings and activities, and called upon other professional organisations to do the same. The AAGBI called upon its members to exert influence within their own organisations to mitigate against climate change and environmental degradation, and to lead by example. Finally, the AAGBI called upon Government to lead the transition to a carbon-neutral economy as soon as possible. The AAGBI’s statement is an attempt by the organisation to set out its stall and focus our thoughts. None of these are new ideas and good business practice typically coincides with good environmental practice, so we are doing some of it already. Cutting back on travel saves train fares, air fares and time, as well as carbon, and members expect us to do that, whatever the motivation.
Time is pressing, the failure of Copenhagen lies immediately behind us and we face the abyss.