On December 22, 2021, on the first anniversary of the establishment of the Peking University Institute for Global Health and Development (PKU-iGHD), the “2021 Peking University Global Health and Development Forum: Human Health and Medical Innovation in the Era of Low Carbon Economy”was successfully held.  Prof.Jodi Sherman from Yale University delivered a keynote speech at Health Development in the Post-Pandemic Era Session.

Thank you very much for the kind introduction at Peking University Institute for Global Health and Development conference organizers for this great honor to speak to you today. Healthcare is among the most important sectors in managing the effects of climate change, and simultaneously has an important role in mitigating its own carbon emissions, the focus of the session. Connections between COVID and climate change vulnerability and resilience will be reiterated really building on what Dr. Dzauand also Dr. McClellan were speaking to. So of course we know hospitals are very resource intensive operations, hospitals run 24/7 with high tech diagnostic and therapeutic equipment, and buildings are highly energy intensive to operate. Healthcare has unique requirements for infection prevention and control that distinguishes us from other industries. We have a very complex regulatory and business model system driving low value consumption of resources. And particularly in high income nations, we have a culture of excess and where disposability is normalized.

And importantly, in healthcare, we have a social mission to our individual patients but what about public health? The environmental impact of our practices has been ignored until very recently, and we cannot ignore it anymore. So globally healthcare is 10% of our global economy. So it stands to reason that it's a major polluter. And healthcare intersects with virtually all other sectors of the economy. And thus decarbonizing healthcare will have ripples throughout the global economy. The healthcare sector should be leading in decarbonization and pollution prevention. We know both direct and indirect emissions throughout this economic sector can be estimated using environmentally extended, multi-regional input output models. Combined with annual WHO data on national health expenditures. This is our work from the Lancet “Countdown on Health and Climate Change” . And as was said previously, the most up-to-date which are from 2018 inputs that globally healthcare emits 5% of total global greenhouse gas emissions. That's against our mission to first do no harm.

And similar fractions of toxic air emissions, both of which stem from fossil fuel consumption. And so we can do so much good in preventing greenhouse gas emissions and air pollution by decarbonizing our energy system. 25% of these global missions are coming from the US alone, despite our having only 4% of the global population. So we are an outlier in a very bad way. We know we spend more in the US per capita in healthcare than any other  nation in the world. And our per capita greenhouse gas emissions are the highest in the world. And we see, in our next slide now, importantly also is that the rate rise of emissions over time are about 5% overall, but the fastest growth is both in the US and in China. And that's about 6%. And if the curve is even rising more steeply in China, understandably as the nation is improving its healthcare performance. Now China has a much smaller healthcare carbon footprint per capita than developed countries such as the US. However, it's carbon footprint per unit of healthcare expenditure is comparatively large, in part due to different expenditure structure and especially due to the carbon intensity of China's entire economy. Including its heavy reliance on brown coal, which is very similar to Australia.

So now of course we can pollute less by providing less healthcare, that of course is not the goal. To understand health systems performance, the Lancet “Countdown on Health and Climate Change”  useed these economic input output modeling, not only to understand the carbon emissions per capita and for each nation, but also we needed to associate it with the performance of healthcare systems. And so we went to the Institute for Healthcare Measures to associate the healthcare access and quality index. And the results you're seeing here are from 2020. And the results in 2021 are very similar instead of using the hack index, we use the human development index and the results were virtual the same. After about 450 kilograms of CO2 emissions per capita, there's no real improvement over healthcare access and quality. What this means is that for countries like the US, which by the way is not the best performing as a health system in terms of health outcomes, that there is great opportunity to reduce emissions without sacrificing healthcare access and quality. In fact, offering more resource for more access to more patients and so we can actually improve quality and access without diminishing what we already provide and reducing emissions.

And as Dr McClellan mentioned, globally about a quarter of healthcare service are deemed inappropriate or low value, and that may mean too much care, too low care and these problems are similar, whether it's high income or even low income nations. This is a global problem. And not only within a nation but also even within taking care of the same patient. And so there's a lot of opportunity to improve quality. Now, this is an outstanding paper by Professor Wu from NanjingNormal University. Again, using these environmentally extended economic input out models for spending in different sectors of the economy are associated with embedded emissions. We see that the Chinese healthcare sector emitted 315 million metric tons or 2.7% of total national greenhouse gases in China in 2012. Most of these emissions stem from public hospitals, but also from non-hospital pharmaceuticals in construction. And that's important to know because that way we know we are to target our policy efforts and our improvements.

And so delving further into this paper, as Dr. McClellan said, and as is being consistently found in national and international studies. About four-fifths of these emissions stem from the supply chain of goods and services. So this inner ring here is representing emissions from total healthcare operations. The vast majority are coming from procurement or the supply of goods and services. If we move to the middle ring, we see that within procurement pharmaceuticals is an outlier. Now it's very hard to compare with other nation studies because the methods are different. But here in China, we see the vast majority of admissions are coming from pharmaceuticals compared to the US, for example, where about 20% are coming from pharmaceuticals. But again, as we delve deeper, it helps us to understand where to target our efforts. And if we delve even further into pharmaceuticals, we see where within pharmaceuticals the emissions are stemming from.

And so, again, reflecting back on what Dr. McClellan was saying, one of the greatest sources of emissions is within the supply chain, do stem from medical devices. And as we've learned from the COVID pandemic globally, we are all vulnerable to disruptions of services. We're seeing images here from on the left, this is in Brooklyn, New York. On the right, this is in England where very early on in the pandemic, we were completely out of PPE and resorting to very unsafe practices. And of course, many healthcare workers have gotten ill and have died from this. And this is in large part because of over-reliance or single use disposable devices. Whether it's COVID or climate change, global supply chains are vulnerable to interruptions and manufacturing, transportation, and distribution. And so we need to develop sustainable solutions that increase supply chain resilience.

And so if we follow this curve here, we see infection rates, at least iatrogenic infection rates diminishing over time, asymptotically approaching zero. But what we're seeing is more and more disposable goods through being used, trying to reach zero healthcare acquired infections. But we really need to ask if that is a realistic goal. The vast majority of healthcare acquired infections are due to poor hygiene amongst healthcare staff, and also poor host health, post immunity. We're not going to cure problem like diabetes and cancer by throwing more and more disposables at the problem. We're not going to cure deficiencies in hand washing by throwing more and more disposables at the problem. And we're ignoring the indirect effects that the consumption of more and more resources is having on public health. And really we need to strike a better balance.

And with the pandemic, we've been forced to extend the life of disposable devices. Here we see masks and gowns, and I'm actually an anesthesiologist and so we're seeing both and... We certainly we've run out of video laryngoscope covers, which are predominantly disposable. And so we've had to extend the life of these disposable devices, even though they weren't designed, no cleaning protocols were designed. We've had to clean them and we've had to revert to reusables when we can get ahold of them, which is a problem because the demand has suddenly increased and the availability has been quite small. So we've seen a surge in demand and not enough to reach those demands. Well, ultimately we've realized that we can reuse disposable devices safely. Not that it's ideal, but we can do so and really it begs the question, what's the difference between a reusable and a disposable device anyway?

And as Dr. McClellan said, we really need to shift to what's called the circular economy. So healthcare needs to turn away from this linear what's called take-make-waste economy where we're just consuming more and more disposables, and shifting to the circular economy remains redesigning our equipment with fewer embodied materials, chemicals, and energy. Using principles of green chemistry and green design, we need to extend the life of products, building them for durability, with module of construction to make it easy to clean and repair them for reuse and long life. We need to change our business models to incentivize this reuse. And that can be done through a whole business structure called servitization. Where rather than buying the devices where the business model's incentive is selling more devices, the business model could be to buy the service or the function of that device and ownership is retained with a company, so that they are incentivized to keep them in use for much longer.

And then ultimately we need to recover materials that are no longer able to reuse and repurpose them. And in nature, there is no such thing as waste, and we really need to model after how nature does things.

And so ultimately the question is, what's best practice for patients and public health? This needs to be [inaudible]nature. It needs to come through application of the public health principle of health in all policies. And finally, we must address how we deliver care. Again, building on Dr. McClellan was saying, if we're ever to reach net zero emissions. The concept of planetary healthcare expands the principle of first do no harm, beyond care to the individual patient, to duty to protect Earth's natural systems on which intergenerational health and wellbeing depend. This framework sets out three strands of action, reducing emissions embodied within healthcare services, that means we have to do more electrification and simultaneously shift to cleaner energy, and we need to shift more to the circular economy, and we need to be better stewards of our resources, both as patients and as clinicians.

Matching supply of the demand. This means avoiding inappropriate low value care, including excessive care, excessive consumption of resources, and also under utilization of care that can lead to more intensive care requirements with more advanced disease. And we need to move upstream, reducing demand for healthcare to begin with. That means better health promotion and disease prevention. And that means addressing the social determinants of health, including provision of livable wages, affordable housing and food and clean air. Ultimately, this means redefining what we mean by value. High value care maximizes effective and desired care for the most patients, and minimizes environmental and social arms in addition to financial costs. And with that, I say, thank you.