Eye on Emissions

Four years ago, ophthalmology resident Dr Liana Dedina was performing intravitreal injection after injection at the eye clinic in Adelaide’s Queen Elizabeth Hospital when she struck an idea. 

Today, Liana’s idea can not only achieve substantial outcomes in waste minimisation strategies for ophthalmologists, but there are also visible lessons for the broader healthcare community. 

At the time, the Australian healthcare sector was reported as producing seven per cent of the country’s overall carbon footprint, with hospitals and pharmaceuticals the major contributors.

Fast forward to the global coronavirus pandemic, and single-use waste in clinical settings drastically increased — one local health service reported a 40 per cent increase in its clinical waste — and multiplied the existing challenges. 

We all know the saying “Rome wasn’t built in a day, but they were laying bricks every hour”, and it rings true to finding waste minimisation solutions to reduce carbon emissions in healthcare — there isn’t a one-size-fits-all immediate solution.

Herein though lies the promise of one then-resident’s humble idea to change what she can control, that has grown to provide salvageable solutions through simple everyday changes — changes that every ophthalmologist should start adopting today. 

 

The visible problem

In 2019, as an ophthalmology resident working at the Queen Elizabeth Hospital, Dr Liana Dedina performed many patient treatments with more than 3,000 estimated intravitreal injections being administered by the clinic each year.

Performing a large percentage of the injections, Liana said it was eye opening to realise how much waste was being generated from each procedure. 

“This prompted me to liaise with the hospital’s waste management and local utility companies to consider various options of addressing the issue,” she said.

“The brown bin for co-mingled, dry, and non-contaminated waste — along with usual paper recycling bin — seemed like a perfect fit for the clinic. 

“It was only after a year of ongoing waste minimisation in the eye clinic, that the idea of sharing our experience in paper was conceived.”

 

Addressing the challenges

In her own words, Liana describes the challenge of healthcare waste management as “grand” and “overwhelming”. 

“For someone like me, dedicated to zero waste in personal life, seeing mindless waste in a hospital setting is heart breaking,” she said.

Liana also notes that ‘carbon emissions’ is a topic of endless complexity and trying to calculate the emissions from salvageable clinical waste is not a straightforward task. 

“A metallic calliper disposed to a landfill will not generate carbon emissions. 

However, utilising further virgin materials to produce new callipers will,” she said.

“Not to mention, hidden emissions in the form of packaging and transportation must also be considered — the challenge of exact calculations quite often lies with the lack of production transparency.” 

There is also the challenge of achieving a transfer of sustainability literacy to the adoption of sustainable practices, with existing messaging to ‘Reduce, Reuse and Recycle’ tired and potential agents for change growing increasingly desensitised.

“It seems that over the years, not only was this message forgotten, but its certain aspects have been completely warped,” Liana reflects.

“Reduce has been replaced by ‘Augment’ and ‘Multiply’ — single-use instruments and lenses, pre-loaded intraocular lenses, and minims drops are just a few of these.

“The waste here is two-fold at a minimum; the piece of equipment itself, and the packaging it comes with — and the latter is often quite excessive. 

“Recycle is becoming ‘Dispose’ in many clinical areas. You may not believe it, but there are entire clinical settings that do not have a single recycling bin, paper or otherwise.

 “Overall, the challenges in ophthalmology are unique on a smaller scale, especially when it comes to the specifics of the instrumentation used.

Largely, however, they are the same for all medical specialties — where excess, complacency and convenience have slowly replaced the pillars of sustainability.” 

 

Action for private practice

There are three key steps in taking an active role to become part of the solution and not the problem, Liana explains.

The first step in the battle against waste is awareness. 

“It is not enough to have recycling bins in a practice, understanding what can be recycled by the local council is equally important,” she said.

“Not all plastics can be recycled everywhere, so pay attention to the numbers on the plastic — for example, in Alice Springs, only high-density polyethylene (or number 2 plastic) is recycled.

 “Another good example of items usually not recycled by councils are lids, including those for milk, soft drink, and soap containers.” 

The second step in this seemingly endless battle is personal responsibility. 

“Actively seeking out ways to further reduce waste one creates is challenging, so I encourage you to look up Zero Waste initiatives in your local area,” Liana said.

“There are various organisations, such as TerraCycle, that provide a variety of Zero Waste boxes and options. 

“As a personal example, we have multiple Zero Waste boxes at home — for mixed waste such as fabrics, plastics of uncertain identity, pens, markers, lids; empty medication blister packs (between our three dogs, each with a unique medical condition, we go through many tablets a year); soft plastics; and notably, face masks! — face masks do not have to go to landfill.” 

Thirdly, practices must consider medical or otherwise waste in context of its utility elsewhere.

Liana explains that ‘expired’ medical materials pose another significant challenge. 

“In my other initiative at Flinders Medical Centre, expired and opened-but-unused material are kindly collected by the theatre and clinic nursing staff,” she said.

“These include, syringes, sutures, betadine, gowns, towels, gloves, drapes, needles, normal saline, and blades, among others. 

“I then donate these ‘expired’ medical materials to local animal welfare organisations where syringes are used for animal feeding, drapes and gowns are utilised as linings, and surgical materials can be used by the veterinary hospitals.” 

 

Action for hospital settings

The issue for many hospitals is not the provision of adequate infrastructure to address waste management, it is the underutilisation of this infrastructure.

“Face mask boxes generate an obscene amount of waste in hospital settings, which then makes the journey into landfill, despite readily available and proper avenues of paper disposal,” Liana said.

“I constantly find myself picking up empty mask boxes, cans, and many other inappropriately disposed materials for further sorting.”

The way forward according to Liana is heightened staff education and in hospital initiatives, including designated sustainability committees — something which is increasingly becoming commonplace.

“Education should empower and challenge staff,” Liana said. “Questioning daily actions is also important.

“Do you really need three paper towels to dry your hands, or can you use one thoroughly to achieve the same?

“Do you really need to use a single-use cup for a drink, when a ceramic one is available?

“I believe that before introducing more complex ways of approaching waste in a medical setting, all available and simple avenues must be saturated,” she said.

 

Action for manufacturers 

Broader contributors to the health landscape can also play a role, including manufacturers.

A visibly obvious area of single-use equipment production that can be promptly addressed concerns packaging, with several parameters that could be optimised further.

“Every intravitreal injection, regardless of the manufacturer, is accompanied by an excessive amount of paper packaging,” Liana explains. 

“Do we need a plump information booklet included with every single injection and does the box containing the injection need to be as large as it is?”

Aside from these observations, Liana also queries the option of postproduction initiatives that carry a level of accountability for the generated waste, such as collecting used single-use equipment and distributing it to the appropriate recycling facilities.

 

Input from industry

Global engineering, management and development consultancy, Mott MacDonald, has had a presence in Australia for more than 40 years — with an ever-increasing footprint in the health sector.

Internationally, the firm is known for its expertise in sustainability, recently producing a highly regarded global report into single-use plastics.

Mott MacDonald’s Net Zero Lead for Asia Pacific, New Zealand and Australia, Andrea Gaffney, reflects that the climate crisis is a health crisis with a very strong feedback loop between the two systems. 

“Based on current projections, without climate action, emissions from Australia’s health sector will more than triple by 2050,” Ms Gaffney said. 

“Today, global health care is a major contributor to climate change — if it were a country, it would be the fifth largest emitter on the planet. 

Ms Gaffney notes that during COVID-19, medical waste from single-use equipment in hospitals was estimated to have increased by an alarming 25–130 percent, but several issues are continuing to compound the problem. 

This includes a lack of awareness of the problem, availability of solutions to consume less and minimise waste, access to alternative solutions, and the structure of our health setting. 

The paper produced by Dr Liana and her co-authors may seem small in impact, but Ms Gaffney recognises its potential for positive effect. 

“In Australia, and indeed globally, the world’s population is expected to both increase and age over coming decades, and with that growth will come a greater demand and pressure for health services and medical devices.” she said. 

“At the same time this is expected to occur, the world’s carbon trajectory and the health sector’s carbon footprint must sharply decline. 

“To do this, the health sector must urgently and radically transform its approach to emissions whilst also increasing the focus on sustainability. 

“This will require a whole of industry approach,” Ms Gaffney said. “Reducing the amount of single-use plastic consumed and minimising waste going to landfill is crucial, and whilst it will be difficult to negate single-use plastics entirely, efforts to reduce and adopt alternative solutions need to be prioritised and, where appropriate, scaled. 

Across Australia’s Federal and State political landscapes, Ms Gaffney acknowledges the aligned commitments to reach net zero targets by 2050. 

“By extension, this will require a whole of economy response to decarbonisation and health will have a role to play in achieving these ambitious goals. 

We need to understand the scale of the problem, set ambitious targets, and establish a decarbonisation roadmap. 

“These steps are critical enablers, but to deliver the change required, they need to be accompanied by a genuine commitment from leaders to drive the change and make action a priority.”

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