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. Mark McClellan from Duke University, former U.S. FDA Commissioner delivered a keynote speech at Health Development in the Post-Pandemic Era Session.

Good morning! And many thanks to Peking University Institute for Global Health and Development, including my friend Dean Gordon Liu, and his associate dean for bringing us together virtually so that we can look ahead together at this critical time. I also want to thank the US National Academy of Medicine, my friend, Dr. Victor Dzau , for their leadership on issues related to global COVID response and a low carbon economy.

I would like to make some complementary remarks to build on those from Dr. Dzau who gave an excellent overview of some of the challenges in COVID response and on how we all need to work together to aim to be low carbon in the post pandemic era. More efficient healthcare that requires fewer resources is a major topic for our policy research program at Duke University, the Margolis Center for Health Policy, and for our collaboration with professor Gordon Liu with his colleagues, and our bilateral initiative through the National Committee on US-China Relation. It is an area where the US and China have aligned goals and can provide important global leadership.

The main points that I would like to cover in my remarks are , first , there's one important way to lower carbon emissions where healthcare leaders should do the same as leaders in other businesses and other organizations. Take up to reduce their carbon footprints aiming to be carbon neutral. This is especially important in healthcare as Dr. Dzau described , because we know the health consequences of failing to stop global warming.

Second however, transitioning to a lower carbon economy can occur through many other steps besides making buildings more green and taking incremental steps to reduce energy use and more pollution. Other steps to build the kind of healthcare system that we need based on the lessons learned from COVID are also important for both COVID response and a more sustainable environment. One set of lessons from COVID relates to more resilient and efficient manufacturing and supply chains. And supply chains account for most of the carbon emissions related to the healthcare economy. So I'll talk about that.

I also want to talk about what I think is the most important lesson, which is that our healthcare should evolve to be based more at home and supported by digital technologies with strong capabilities for prevention and interception of health problems, reducing the use of advanced care in hospitals and other intensive facilities that use more resources and have more environmental impact.

So first I'd like to talk about supply chain reforms. As I said, manufacturing supply chain account for 70% or more of the health sector carbon footprint. Nations across the globe in their response to the pandemic have prioritized supply chain reforms. Some of these reforms will help. As Dr. Dzau mentioned shortages emerged around the world where countries do not have access to manufacturing abroad supplies. So there has been more emphases on building local response capacity and being able to provide services locally.

But some of the trends related to supply chains in the pandemic are complicating environmental sustainability. For example, healthcare has had trends over recent years towards more disposable medical devices that happened before the pandemic and COVID has increased that. Non- reusable products like personal protective equipment, disposable medical devices, and increased use of plastics have all increased the contributions of the health sector to environmental damage and non-sustainability.

Protection from infection is important especially in a pandemic. That's a reason for disposable products. But scientific evidence suggests that it's not always needed. Some important steps could address this , enabling both lower costs from less use of materials and supplies that go further in helping us surge in response to the pandemic. Importance for this is regulatory reforms. Many regulations at the US Food and Drug Administration and other medical product regulatory agencies around the world favor disposable single-use products.

Reform should emphasize an environmental impact analysis, including a determination of when design should reuse products or when alternative plastics can be used as part of the safety assessments and the risk benefit assessments of medical product regulation. And finally, while countries understandably want reliable local manufacturing and supply chains that are resilient to disruptions like we've seen in the pandemic, if countries like the United States and China do not also collaborate on transparency and promoting trade in critical products especially in health, then we will end up with greater manufacturing, a greater supply of products and inefficiencies that could adversely impact the environment.

I'd like to spend the last few minutes talking about learnings from the pandemic experience for post-COVID healthcare delivery. Building on some of Dr. Dzau's remarks, what we have seen is that much more healthcare than we thought possible in the past can be delivered at home through telehealth, remote monitoring, the use of care teams, not just relying on individual visits to a physician office, all of which can increasingly be enabled by electronic data and data analytics.

We've also learned that more healthcare can be prevention oriented by identifying patients at high risk and taking proactive steps to lower their risk. Vaccinations and early treatment for COVID through community- based outreach, drugs that are increasingly available and less expensive to control cardiovascular risk factors, advanced diagnostics to identify more and more people with risk factors for conditions like specific cancers, and treatments for those can keep them all out of the hospital much more than in the past. Healthcare can also become more personalized instead of treating everyone in the same way often with intensive treatments. We can use genomics, proteomics, other analytics to better assess the right combination of treatments for each patient and avoid any waste.

Technology and biomedical innovation that enables disease, interception and cures is increasingly making these reforms possible. And these steps will all help lower carbon emissions by reducing the need for carbon consuming hospitals and other major healthcare facilities and procedures.

In this regard, healthcare in the United States, China and elsewhere in the world could do better. Most of US healthcare is delivered in hospitals and big outpatient facilities, requiring transportation, energy, producing emissions from these large buildings and intensive sites. Fewer resources are directed to prevention in public health and to primary care that can be delivered at home in the community. Much of the healthcare that we get is of low value, including physician visits, treatments with unnecessary antibiotics or other prescriptions in the US imaging procedures that might not be needed, other procedures that have only limited supporting evidence. These low value services, not only add to healthcare costs, they also add to environmental impact.

So perhaps the most important way to reduce the healthcare carbon impact is also what's needed for the most important response to COVID and providing post-COVID healthcare. That is community-based services and healthcare delivery models that prevent complications and avoid hospital  use and intensive procedures. The greenest building is the one that does not need to be built. The least expensive and the least resources used hospitalization is the one that is avoided. There are many innovative healthcare organizations in the United States and China and elsewhere around the world that are showing how to do this.

For example, US Health systems like Kaiser Permanente and Intermountain Healthcare have 40 to 50% lower rates of use of hospitals and intensive procedures than many other facilities in the United States. They have lower healthcare costs because they are undertaking many steps to keep patients well at home, and avoiding those costly resource intensive services that also complicate our environmental protection.

Most important to change this are healthcare policies that focus on value and sustainability, both from the standpoint of personal health and the standpoint of our environment. Payments to healthcare providers should be reformed to stop rewarding volume and intensity, and instead, reward meeting patient wellbeing needs as efficiently as possible for both health and environmental reasons.

Healthcare or organizations around the world have been successful in efficient high value healthcare when they are paid not for specific services, but for better results for people and populations. Payments at the person level, at the population level to healthcare providers who are accountable for results, not just accountable for delivering specific services. Healthcare organizations that earn more when they improve outcomes and lower the cost of care, not when they provide more treatments is an important policy step to change the reality of healthcare around the world today to make it more sustainable and more prevention oriented.

These person level payments are more flexible and can be used to pay for things that typically are not reimbursed in traditional healthcare. To care at home help with social factors that influence health like smoking or poor living conditions. The use of care teams and digital tools to manage chronic disease risk factors, and to use medications and other treatments efficiently. And the person level payments amount to a subsidy for more efficient, less carbon intensive care. The usual fee-for-service payments traditionally in healthcare amount to a carbon subsidy. It's hard to have high value care that prevents costly complications and procedures if we pay for the opposite of that.

This is an important opportunity for the United States, China and other countries to work together, to change not only environmental impact, but to change health as well as we move on to the pandemic. Other reforms can help too. Setting and funding important public health and prevention goals like China is doing. Technical support to promote data sharing and digital healthcare that enables these new models of care. Workforce planning and support to enhance primary care and care in the community. Investments in the advanced diagnostic tests and the drugs and biologic treatments that help detect and intercept diseases early and avoid those costly and intensive procedures.

There are many other steps. Again, these are many of the same policies that we need for an efficient, equitable and sustainable healthcare system in our countries and around the world. This is not only the kind of healthcare that we need in the post-COVID world, but also the kind of healthcare we need for a health sector that can be a leader in truly creating a low carbon sustainable economy. Thank you all very much for the opportunity to join me today.