Some 8.5% of total greenhouse gas emissions in the United States are generated by healthcare systems, with gastroenterology making an outsized contribution to the healthcare sector’s impact on the environment. Some GI experts are beginning to sound the alarm about this problem and encouraging their peers to do something about it.

Heiko Pohl, MD, a professor at the Geisel School of Medicine at Dartmouth, in Lebanon, N.H., has come to a painful understanding about the impact of his work on the environment. He has watched the waste bin in his endoscopy suite fill up with debris from case after case, knowing the discarded materials would ultimately end up in a landfill or be incinerated. Day after day.

It turns out that the medical waste that’s generated during an endoscopy has been estimated to be the third largest in hospitals (Gut 2023;72[3]:493-500).

“Our world is in a very bad situation, and there is some urgency to act,” Dr. Pohl said. “Otherwise, we might have a situation where thresholds are overstepped that can’t be turned back.”

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He isn’t alone in this view. Madhav Desai, MD, MPH, an assistant professor at the University of Minnesota, in Minneapolis, has come to a similar conclusion about the amount of waste generated by endoscopic procedures.

Understanding the Impact

To tackle the problem, “the first thing is to start tracking the numbers,” Dr. Desai said. “If we don’t examine it, we don’t know.”

Spurred by their growing concern, both gastroenterologists have been researching this problem and potential ways to address it.

In a recent study presented at Digestive Disease Week 2023, Dr. Desai and his co-investigators collected information on waste generation and energy consumption during 450 standard GI procedures over the two-month period from May to June 2022 (presentation 52). They found that every 100 routine endoscopies generates roughly 220 kg of landfill waste and 1,400 gallons of water waste. In addition, these 100 endoscopies lead to 1,980 kWh of energy consumption—the equivalent of about 1,200 miles traveled by an average fuel-efficient car, roughly the distance from Seattle to San Diego. The team also found that 72% of total waste goes to a landfill, while 24% is biohazard waste. The carbon footprint of 100 GI endoscopies is roughly 1,500 kg of carbon dioxide equivalents, an amount that requires 1.8 acres of U.S. forests to offset.

In a study published last year, Dr. Pohl and a team of seven others aimed to measure the amount of waste generated during their endoscopic procedures to better understand the effect of changing from reusable to single-use endoscopes (Gut 2022;71[7]:1326-1331).

Looking at two U.S. academic medical centers with low and high endoscopy volumes, the team found an average of 2.1 kg of disposable waste generated during one endoscopic procedure. Extrapolating that number across the United States, the total waste generated was calculated to weigh 38,000 metric tons, or the equivalent of 25,000 passenger cars, covering 117 soccer fields at a depth of 1 meter.

Another study published last year showed the carbon dioxide equivalent of single-use endoscopes to be 24 to 47 times greater than that of reusable endoscopes (Gastrointest Endosc 2022;96[6]:1002-1008).

That said, reusable endoscopes still carry rates of infection higher than their single-use alternatives, Dr. Pohl said, so that is another factor that needs to be considered in the decision making.

“It’s a moving goal and everyone is working toward it,” Dr. Desai added. “Single-use scopes may not be a viable option unless we have a recyclable material or bio-friendly material in the scope themselves.”

Separately, an estimated 70% to 80% of the health system’s carbon footprint comes from the supply chain, as well as fossil fuels involved with the transport, use and disposal of supplies, material and equipment (Health Aff 2020;39[12]:2071-2079), Dr. Pohl told Gastroenterology & Endoscopy News. A simple instrument like a snare, for example, typically is shipped in a package, used once, and then carried away to a landfill or classified as highly biohazardous material.

Making Workplace Changes

Although gastroenterologists may have little impact on the carbon footprint produced or generated by the supply chain, it’s still possible for those in the endoscopy unit to bring about change.

Dr. Pohl said reducing use and increasing reusable efforts are key to aligning with sustainable economy principles and bringing the United States a step closer to its peers.

“We have to be more conscientious and take the environmental aspect into account when we approach procedures and interventions,” he said. “We cannot just wait for leadership but work together from the base, as physicians, nurses and health employees,” Dr. Pohl said.

But, Dr. Desai said he believes hospital leadership is required for successful efforts to reduce environmental waste generation and energy consumption. “If leadership sets an example, other departments will follow,” he said.

Institutions should start tracking how much waste they’re generating and gain a better understanding of items that are potentially recyclable, Dr. Desai said. “They should come up with benchmarking numbers about how much waste generation is more than the limit and then implement programs institutionally,” he said.

A Look at Global Factors and Their Effects on Endoscopy

Could the war in Ukraine and the supply chain crisis affect access to single-use endoscopes and gastrointestinal endoscopy at large? That question has been posed by a group of researchers in Italy.

Luca Elli, MD, PhD, the chief of the Center for Prevention and Diagnosis of Celiac Disease at the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, in Milan, and his colleagues wrote a postscript in Gut (2023;72[2]:407-408), praising the paper by Heiko Pohl, MD, et al, on the environmental impact of GI endoscopy (see main story) and positing the question of what it means for endoscopy to be sustainable in the modern world.

Sustainability is a fluid concept affected by time and various inputs, such as the environment and the economy, Dr. Elli and his co-authors wrote. “For example, availability and the price of resources and, as a consequence, the social, environmental and financial impacts of a health product or intervention, are not static,” they noted. “Consequently, the sustainability of gastrointestinal endoscopy, as well as of all health products and interventions, may frequently change and the sustainable practices of today could become the unsustainable practices of tomorrow.”

In an interview with Gastroenterology & Endoscopy News, Dr. Elli also noted a geographic element to endoscopy’s sustainability. “There’s the question of whether what’s sustainable in France could have a different impact in China, the U.S. or Italy,” he said. The interconnected, global aspects of supply chains—with North America and Europe depending on equipment, resources and even waste disposal in other countries—is not something that likely will change anytime soon, according to Dr. Elli.

In light of global affairs—particularly climate change and war and strife in countries that may be part of the global supply chain—the authors wrote that GI endoscopy professionals should consider reducing the impact of interventions, including reexamination of the sustainability of single-use endoscopes.

Dr. Elli and his co-authors pose some questions to help the field fill in some information gaps: “Could we do more to improve the efficiency of the reprocessing of reusable endoscopes? What is the rate of clinically relevant contamination of reusable devices? Should we follow the recent [FDA] recommendation to transition to disposable duodenoscopes and caps or can we just select patients who can benefit most from the use of disposable devices?”

The question of sustainability in endoscopies is still novel, with much still to be determined, Dr. Elli told Gastroenterology & Endoscopy News. At this point, “we are at time zero.”

—N.S.

Dr. Elli reported no relevant financial disclosures.

According to Dr. Desai’s calculations, recyclable bins on-site can possibly reduce waste by 20%, while implementation of energy-saving equipment—such as light sensors in the late afternoon and evenings—can go a long way toward helping, too.

In 2022, the United Kingdom’s health system became the first to embed net zero into legislation through the Health and Care Act of 2022, aiming to reach net-zero emissions for its carbon footprint by 2040.

Dr. Pohl said he believes it is feasible for the United States to do the same in its federal healthcare system by 2050. To address this issue, in March 2023, the Department of Health and Human Services published the Health Sector Climate Pledge, an invitation for hospitals to commit and pledge toward a net-zero path by implementing changes in their healthcare systems.

Drs. Desai and Pohl consider efforts to make endoscopy more environmentally friendly just the beginning. They’ve set their sights more broadly—to surgeries, pulmonary medicine and beyond.

“We have to go back to a regenerative approach of using resources,” Dr. Pohl said. “We can’t just take resources out of the Earth and think they are infinite.”

—Natalie Schachar

Dr. Desai reported no relevant financial disclosures. Dr. Pohl reported financial relationships with Cosmo, InterVenn and Steris.

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This article is from the September 2023 print issue.