BackTable / OBGYN / Podcast / Transcript #49

Podcast Transcript: Women’s Health at Risk: Climate Change Realities

with Dr. Alexandra Melnyk and Dr. Jane van Dis

In this episode of BackTable OBGYN, host Dr. Amy Park joins Dr. Jane Van Dis and Dr. Alexandra Melnyk to discuss the impact of climate change on women’s health and the effect of healthcare-related activities on the environment. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Climate Change Explained

(2) The Impact of Climate Change on Women’s Health

(3) The Health Effects of Microplastics

(4) Plastics in Healthcare

(5) The Environmental Cost of the Healthcare Industry

(6) Reducing Healthcare’s Carbon Footprint: Doing the Work

(7) Life Cycle Analysis: Institution Impact

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Women’s Health at Risk: Climate Change Realities with Dr. Alexandra Melnyk and Dr. Jane van Dis on the BackTable OBGYN Podcast)

Ep 49 Women’s Health at Risk: Climate Change Realities with Dr. Alexandra Melnyk and Dr. Jane van Dis

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[Dr. Amy Park]
It's Amy Park and it's my great pleasure to host another episode of our podcast, BackTable OBGYN, a physician-facing podcast on the issues facing OBGYNs today and the greater community. It is my great pleasure to have some dear colleagues, influencers, leaders in this space; Drs. Jane Van Dis and Dr. Alexandra Melnyk, also known as Allie. Welcome. Welcome. I'm just going to turn it over to you guys to give us a little intro and insight into yourselves. Jane, why don't you go first?

[Dr. Jane van Dis]
Amy, thanks so much for having me and Allie. I'm really excited. Obviously, we're super passionate about this topic. I'm actually an assistant professor at the University of Rochester and I've been reading on the climate crisis, really since my twins were born in 2008, but more seriously over the last few years.

I actually am a climate migrant. I moved to the University of Rochester from Los Angeles where there were a lot of fires, there was a lot of heat, drought, and it was an urban place that didn't make me feel very safe in terms of what's going to happen in the years to come with the climate crisis. I moved to a place near the Great Lakes and now I'm really happy to be publishing on this topic, working with Allie at OBGYNs for a Sustainable Future, and excited to talk to you tonight.

[Dr. Amy Park]
Just a little plug about Jane. I was at the University of Rochester Medical School and I'm actually from California and I can attest that it's a lot of connections there. Also taught at ACOG in a course together. I think there's a lot of interest in this topic and, yes, the climate crisis is real in California. Between the earthquakes which always have been there with the fires and the atmospheric rivers and the flooding and the mudslides and all the things. There's quite a lot going on there. Well, Allie, tell us a little bit about yourself.

[Dr. Alexandra Melnyk]
Thank you so much for having us tonight. I echo Jane's excitement and sentiment. I am on staff with you at your gynecology at Cleveland Clinic. I got involved in this topic during my fellowship where honestly, I was doing a literature review on a different topic and I stumbled upon a really, really exciting piece, looking at the carbon footprint of hysterectomies, which hit home and it was fascinating to me and appalling how much waste we were producing in the operating room. This invisible footprint that I had never thought about with the production of all of the materials that we use and how much gets thrown away and I'm sure we'll talk a little bit more about that later, but, really, from stumbling upon this literature, it really opened the door to me.

From then, I did a couple of research projects. I started the Greening the Urogynecology Operating Room initiative in fellowship and through that work, I applied for this award. Which is for CleanMed, a really great conference that's held every year that brings together physicians, building engineers, folks from central sterilization and linens, all these different groups of people who care about greening medicine essentially. I again opened the door to me and it really opened my eyes into this field.

From then, I continued to do some work and write. Jane and I hooked up and we created OBGYNs for a Sustainable Future. You can reach us at obg4sf.org, shameless plug, where we have a website and we put on webinars that are specific to OBGYN and greening our field. Since I've graduated fellowship several months ago and started at the Cleveland Clinic with Amy. I've been onboarding and trying to get some new projects off the ground here and I'm excited to share them all in due time, I'll say.

(1) Climate Change Explained

[Dr. Amy Park]
I think that this topic and on all your efforts in this sphere is more timely than ever. Last year, 2023 was one of the hottest, I think the hottest year on record and it just felt like there was crisis after crisis; heat, rain, flooding, all the things. Can you tell us what's happening today in terms of climate change? What's going on?

[Dr. Jane van Dis]
I can kind of speak to that. I follow these scientists every day. I'm somewhat addicted to the conversations that are going on. The really hard part for people to understand and I actually gave Grand Rounds on Friday at Southview down on Long Island, the Department of OBGYN there. I've said if there was a way that I could make every American understand what Six standard deviations from the mean means because that's how far off of normal our seas are right now.

As most people know, the seas have absorbed the majority of our carbon emissions since the Industrial Revolution. I read Bill McKibben, I think it was back in 2018, that our land surface temperature, if the seas had not absorbed all of that excess CO2 and methane, would be 97°F hotter on land. Obviously, completely uninhabitable for almost all forms of life.

The idea is then that all of that energy has now gone into the oceans, which obviously comprise the majority of the surface area of the earth. Having said that, the oceans are sort of, I feel like the oceans are now talking back. Because for them to be Six standard deviations from the mean hotter than they normally would be means I think that we're in for a lot of rapid change.

Now there's a lot of debate going on as to whether or not we're in an accelerated period, which is to say we're not going in a linear fashion as the models had predicted that there's an aberration and an acceleration of heating and change. You'll see the climate scientists debate that, but I've actually read a couple of papers now that seem pretty convincing that we are in an accelerated phase.

What that means is that all the models are a little bit off. For instance, when we saw the COP and we saw people talking about 1.5°C as, like, "Hey, we better not cross that." Well, we crossed it in 2023. I believe we're at 1.78°C above normal, above pre-industrial 1850 means.

I guess I feel like I still see in print a lot that people say, "Well, if we can stay under 1.5," and it's like, "Well, people, I'm not sure that we're ever going to see 1.5 again." We are in an El Nino and so that has affected a lot of the heat and a lot of the aberrations that we're seeing.

Having said that, some of the scientists are saying we're past 1.5 and we are going to pass 2 by 2030. That's a very different world than the one we're living in now because at 2°C, that's when we start to see some of the tipping points kick in where we have accelerated loss of sea ice, so accelerated sea level rise.

Right now, you hear people talk about sea level rise and they'll be like, "Oh, it's just a couple of centimeters a year," but if you talk to the people in Portland, Maine over the weekend, where there was 14 feet above the normal sea level due to the high tide plus the storm, they're absolutely saying that this is a new normal.

Amy, I can't actually answer your question because the fact is that we've left the Goldilocks Zone. We've left the zone that humans have evolved in over the last tens of thousands of years. We are in a new normal and we should expect that we are going to see continued aberrations like the one that we saw this week. Where the weakness of the polar vortex has allowed arctic air to go down to Dallas so that they had, it was 14 degrees in Dallas yesterday, so that's a new normal.

These atmospheric rivers and these hurricanes that sort of circle and stay in the same place like Hurricane Harvey did. Every single possible weather event I feel like is seen at a greater degree, a greater proportion. The proportionality has absolutely changed. We'll see. Like I said, it's a new normal and we're never going back.

[Dr. Amy Park]
I know it's interesting because you alluded to two things earlier in your intro that I think about all the time is my older son was also born in 2008. There's a lot of youth these days who do not want to have children because they don't want to bring their children into the environmental impact of having kids, bringing them into this environment. It's definitely become more of a thing. The other thing I was thinking of is I just remember Equilibrium Magazine had this article from, I think it was like sometime in the spring or summer of last year and it was like, "Is climate safe for climate refugees like yourself?"

Yes. To your point, a Great Lakes town and inland and, yes, of course, we have some pretty extreme weather, but not as extreme and dangerous as the wildfires, especially as in California.

[Dr. Alexandra Melnyk]
You have water and that's going to be a resource that's going to be in high, high demand. The New York Times has done some incredible reporting on the nation's aquifers and what a dangerous state that they are in. Actually, what's so fascinating is the satellites are taking photographs using magnetic imaging to determine how much water is in US aquifers. To me, that technology obviously is just so fascinating that you could take a picture from the sky and see underneath the rock and the earth. The fact of the matter is that there are places, like Arizona, like the Southwest, that are looking at a future where water will be the most valuable resource.

[Dr. Amy Park]:
Oh, yes, absolutely. There's subdivisions in Phoenix that they can't even build out anymore because they're not allotted any water, so you're right.

[Dr. Alexandra Melnyk]:
Yes. All of this is really, really making me remember all of those pictures of the Colorado River this summer, which is exactly what we're talking about. I think that not everybody knows that so much of the Southwest and the West rely on snow-capped mountains and all of that snow that'll then melt and go into these rivers and help to give us municipal water and energy, et cetera. You're right. Those are real things that we'll be fearing in the next several years. It's scary. It's absolutely scary.

(2) The Impact of Climate Change on Women’s Health

[Dr. Amy Park]
Well, how does climate change impact health? Specifically, women's health and reproductive outcomes?

[Dr. Jane Van Dis]
Yes. I'll take that and then maybe Allie wants to do the women's health, I'll do the maternal. It's absolutely profound, the manners by which the climate crisis is impacting reproductive health. I'll start with heat. As you might guess, women who live in areas that are hotter, where, for instance, even a wet bulb temperature is higher, we saw this in data coming out of Pakistan, they're more likely to experience preterm births, low birth weight, and even stillbirths. Then heat also affects fertility rates as well. We know that heat affects both the female reproductive system and the male reproductive system.

Interestingly enough on OBGYNs for Sustainable Future, obg4sf.org, we had Blair Wylie from Columbia University and she was talking with us about the fact that mosquitoes are more attracted to pregnant women. They off-gas more CO2 and they have a higher basal metabolic temperature. If you were to put a bunch of people in a room with mosquitoes, the mosquitoes would be more attracted to, they're more likely to bite a pregnant woman.

As we're seeing, especially in the US Southeast, we're seeing more rates of malaria, which was a disease that really didn't come to the US shores very often, especially not where the person contacted it in the US. Then, dengue, too. Dengue is moving northward as well. Then the problem we see, too, is that as the winters get less cold, obviously, our recent cold stuff notwithstanding, the tick seasons are longer, and so, increased risk for Lyme disease as well.

These infectious diseases do put pregnant women at increased risk. There was a great study in the AJOG, in the Gray Journal, that looked at how women who were pregnant during Hurricane Harvey, what their pregnancy outcomes were like. What they found was that since Houston, which is where they did the study, since Houston has 42% of all US petrochemicals are manufactured or refined in Houston, as that hurricane sat and caused leakage of some of these chemicals into the water tables.

Those petrochemicals then had effects on those women's pregnancies in a linear fashion such that the closer she lived while she was pregnant to a petrochemical manufacturing site, the more likely she was to have water that was contaminated. Then the more likely she was likely to have increased morbidity for her pregnancy. I believe it went up 20%, 27%. Then for fetal outcomes, neonatal morbidity went up like close to 50% for those women who were in close proximity to that contaminated water.

Flooding impacts pregnant women. Then wildfires also increase the risk of preterm births and full birth weight. Same with fossil fuel air pollution. Really, what we're looking at are particles 2.5 micrometers or less. These are exacerbating people who have asthma, but they're also affecting these pregnancies in profound, profound ways.

In addition, studies showing that people who fight our fires have increased risks of miscarriage and infertility, so lots and lots of ways. I want to say, importantly, found studies showing that the closer you live to a major roadway, say, a freeway or highway, the increased risk for infertility. Say, if you're going through an IVF cycle. You will be less likely to conceive the closer you live to a roadway. Again, that's an air pollution correlation. So lots and lots of ways that these are external, I call them external impacts from fossil fuels and climate crises affecting the reproductive body. Maybe later we can talk in this podcast about how fossil fuels are getting into our body.

[Dr. Amy Park]
Oh, yes. I definitely want to talk about that. The other thing that I did want to bring up when you were talking was I was just thinking about these articles that I've been reading about how we talked about climate refugees and we're like, "Okay. LA to Rochester," but how about we're looking at the whole scale displacement of people from the Tigris and Euphrates rivers. Like there used to be very fertile areas and now, it's just a complete desert. People cannot survive. They are literally moving and cannot scrabble living together. It's crazy. It's displacing multiple populations, island nations, et cetera. Allie, did you want to say anything else about women's health in particular?

[Dr. Alexandra Melnyk]
I will, but you actually just brought up something that I wanted to touch a little bit more about. ACOG in 2016 put out a position statement on climate change and women's health. Then they restated it in 2020. They basically said that climate change is an urgent women's health concern and a major public health challenge. "We call on our national and international leaders to act to curb greenhouse gas emissions."

In this statement, they even said that the effects of climate change, food and water insecurity, civil conflicts, extreme weather events, all of these things that we've been talking about, spread of disease, for women in these affected regions at elevated risk of disease, malnutrition, sexual violence, poor mental health, lack of reproductive control, negative OB outcomes, and death.

While we're talking about this, we're talking about and having a conversation, but there's obviously a lot of literature on this subject and ACOG has recognized it as well. We're happy to talk about all this so that more people can hear and learn how bad things really are, I hate to say it that way.

To touch a little bit more on just women in general, overall, with extreme heat, women who are most vulnerable, or I should say adults who are most vulnerable are those greater than 65 years old and those with chronic illnesses, cardiopulmonary disease, and also very young children, especially under the age of five. We've been having more heat waves and these have been lasting longer.

Something that's interesting that I've learned in recent years is that in urban areas, this heat actually lasts for longer. It's called an urban heat island. The reason why is in cities where many of our listeners are listening to us, there's more asphalt, there's more surface area that's going to absorb the heat, and there's less greenery and less ability for the heat to get back into the atmosphere.

What happens is it's really hot during the day and then at night, it doesn't get cooler. That can persist for days and days. All of those people who are at higher risk and maybe, especially those in redline districts who maybe don't have air conditioning or maybe don't have access to a center where they can go to cool for several hours, things like that. They're going to be more at risk of having heat-related events because of that. We can expect to see more of this in the coming years because of these extreme heat waves. That's something I definitely wanted to touch upon.

Otherwise, I think that Jane said a lot of the literature that we know so far, you discussed it very nicely. We have learned a lot, especially about the nanoparticles and the fine particulate matter. With wildfires, one of the biggest things is that this fine particulate matter can last for weeks at a time and it can get into our respiratory system. It can get into our bloodstream and go to other vital organs.

I think that this hit home for so many of us this summer. Our skies were turning orange. We don't live anywhere near the wildfires of Canada, yet, we couldn't go outside where it was orange. I think for truly many Americans, it really hit home. As negative as that experience was for a lot of us, I think it was an eye-opening experience that this is happening and we need to take steps to curb what we're doing.

[Dr. Amy Park]
Yes. It's funny you mentioned that because last summer, I remember my brother, who lives in San Francisco, I'm from California originally, he was like, "Welcome to my world. It's been like this for a long time." Jane can attest to this. This has been Los Angeles. This has been California forever. Then these wildfires in Montreal, it was crazy. It was blanketing. I saw in New York pictures it looked like it was the dead of night when it was noon. It was crazy.

[Dr. Alexandra Melnyk]
Right. Right. That's not normal. That's not how it's supposed to be.

[Dr. Amy Park]
Yes. Even before the pandemic, my brother had air, like a HEPA filter in his house and had N95s because of the air quality being so bad. It's funny. Climate change really has prompted a lot of my personal friends to really move. I had a friend, he was working in the World Bank and she left Delhi because her son's asthma was so bad there, had to move to DC.

I had another friend of a friend who was living in New York City and moved out to California for asthma. Ha-ha, because now, the air quality there is also bad, but, yes, a lot of people are suffering from it.

I just wanted to pivot to something that Jane had alluded to earlier regarding the stuff that's in the air, the forever plastics and salites and those kinds of things because we were talking about reproductive outcomes and I just wanted to get into a little bit about, these are sort of man-made issues and changes that are affecting women's health as well. Can you talk a little bit more about that?

(3) The Health Effects of Microplastics

[Dr. Jane Van Dis]
Yes. It's interesting. I feel like it really comes home when you realize that 12% of all global oil is made into plastic. Plastic, our society runs on it. There's so many things. Obviously, we as doctors use plastic all the time. Medical care wouldn't happen. How would we deliver blood? How would we draw a lab with a syringe? Everything around us in the medical field is plastic. Our society absolutely runs on it.

It is important to note that the fossil fuel producers recognized that plastic was a great place to continue to make investments and push technology back in the '70s. This is when obviously they knew the impacts that their product was going to have on human health. Their own researchers like Big Tobacco knew that we were in for a world of hurt.

Having said that, I wonder if you guys remember. I just had this core memory unlocked the other day when I remembered that there were times when we'd go to a vending machine and the soda was in a bottle, was in a glass. Now if you said that to a kid, they'd be like, "What?" Yes, you can see some sodas once in a while, some of the specialty sodas, especially in glass, but our whole society has pivoted to plastic.

What that has meant, unfortunately, is that plastic is now polluting our bodies such that the American Cancer Institute said our babies are being born pre-polluted. In my grand rounds, I have a slide dedicated to the fact that three studies came out in 2023, all of which showed that these placentas that had been tested were positive for microplastics.

Overwhelmingly, this was polyvinyl chloride and PET, the plastic that you see in the plastic water bottles. The plastics are crossing the placenta, but maybe they're crossing the blood-brain barrier as nanoplastics, too. Now we have studies showing that there is plastic basically in every organ in the body. When plastics cross into the brain, they are being linked to dementia. When plastics cross into other parts of the body, they're linked to cancers and autoimmune problems.

The problem is that the plastic water bottle that you drink out of has 10,000 other chemicals in it that haven't been approved by, say, the FDA or the EPA. There's a lot of exposure that we don't even know about. Then what happens, obviously, is that those plastics are breaking down. There was a study you guys probably saw published just this week showing that in one liter of water bottle, there were potentially 250,000 particles of nanoplastic.

Nanoplastic basically is small enough to cross every barrier in our body. It's interesting. I'm giving a talk at the library here in my town at the end of the month. I really want to have some more practical information, less academic. I just started this book about plastic. Interestingly enough, tonight I just finished the chapter on what the author terms petroplankton. This is plankton, which is a huge component of the ocean ecology and the ocean sea life. Plankton obviously are one of the backbones of all marine life.

Well, the plankton are uploading all this plastic into their bodies. He was talking about how he doesn't refer to them as plankton. He refers to them as petroplankton. The fact is that the phthalates are a key component of a lot of plastics. They make the plastics pliable. All of the catheter tubing, all the blood bags, all the gloves that we use in medicine, those all have phthalates in them.

Unfortunately, those phthalates have been associated with significant reproductive harm, and have been related to endocrine disruptions such as infertility, early puberty. There was a New York Times article this week saying, like, Why is the age of puberty, why does it keep getting lower and lower?" I'm like, "We know why. We know why. It's due to these phthalates. It's due to these plastics." It's affecting the birth weight of our babies. It's affecting whether our babies will be born with congenital anomalies.

They did a study showing the feces of a newborn versus the feces of a grown adult. The feces of the newborn had 20 times the concentration of plastics than the adult did. That's due to the body surface area to volume ratio of the infant compared to the adult. To be sure, the American Cancer Institute is right, our babies are being born pre-polluted. The problem is that if you were to say, like, "Well, Jane, what's the solution?" The solution is not to necessarily recycle the plastic because the recycling process actually can continue to leach out into the environment as well.

The answer is that we don't have a solution right now. That's a huge problem. There is increased cancers associated with exposure to these chemicals. I guess I feel like we haven't reached peak plastic yet. What do you think, Allie?

[Dr. Alexandra Melnyk]
I mean, actually, I would say that part of the solution is that we stop making it. We stop making it. Right? Obviously, easier said than done, but we just need to cut back our use of it and that's, we're laughing because that is so hard. We're up against so many barriers and because it's so ubiquitous in our lives and in our workplace and in what we eat and drink out of. If you get takeout, half of those containers are plastic or there's some of these forever chemicals like PFAS. They're going to coat the containers for the takeout food. That's what helps make them leak proof and waterproof and that is getting ingested.

Some of the reality is that we need to, well number one, educate, which we're doing. We try and try as best as we can, but then we do need to minimize making and using plastic. That's not going to necessarily stop where we're at right now. These studies will only show us more and more what's in our bodies and what's happening. However, it is a place to start.

(4) Plastics in Healthcare

[Dr. Alexandra Melnyk]
If it's okay, I'm going to pivot again a little bit just into some of medicine and how we see plastics in medicine. One of the things is so many people will say that, "Well, we have these stainless-steel instruments but they're more infection-risk than plastic, than the single-use stuff, because it's never been in another patient and it's never going to be used again”. But that's not necessarily true for all products and we can delve more into this a little bit later.

Even in our own field in the past several years, 5 to 10 years, there were some studies that came out, there were some instruments that were contaminated. Instead of fine-tuning these instruments that were being cleaned and washed, and it was maybe 25 cases or so, that's what was really documented in the record. However, what happened is all these companies, then instead of fine-tuning and innovating so that these reusable devices weren't having infections, they instead went to disposable.

Now all these devices that we use, duodenoscopes, bronchoscopes, laryngoscopes, all the scopes, many of them can be totally disposable, which is just an example of how plastic is coming more and more into our field and it's harder to get rid of that. In medicine, the hard part that we're up against is the risk for infection. That is nobody wants an infection, but also, we can't get to zero. It's just a part of life. It's a part of medicine.

We need to really start weighing all parts of medicine, OBGYN, the emergency room, internal medicine, the ICU. We need to evaluate everywhere. Yes. This is preventing infection, but are we doing more than we need to? Perhaps, take a step back and become more minimalist with all the things that we're using because there is so much waste, that's another topic, but so much of what we are using and opening is plastic to bring it back to the plastics conversation. We just really need to revisit and rethink that.

[Dr. Jane Van Dis]
Yes. I was just going to say, to piggyback on what Allie was saying, exactly the data regarding plastic speculum, for instance, versus metal speculum, there's no data to show that the plastic speculum is any less likely to prevent infection so long as protocols for disinfection are followed with the stainless steel. The stainless steel has 25%, one-quarter of the carbon emissions in its life cycle than does the plastic.

Not to mention, I didn't see this in the Gray Journal study, but like we use the lighted speculums at the University of Rochester, and those have two of those 25, CD25 button batteries in them. For 30 seconds that we've used it in the vagina, we're now also throwing out, in addition to the plastic, two lithium batteries.

There's a lot of ways that we haven't looked at how our practices might be impacting the health, not only of our patients, but also our communities. It's that plastic, that lithium, that's all going to get buried in a community near where we live.

(5) The Environmental Cost of the Healthcare Industry

[Dr. Amy Park]
What is the impact of healthcare, generally speaking, on the environment and the climate? It seems like it's got a huge impact, but can you put it in some numbers or in a way that I can really put my mind around it?

[Dr. Alexandra Melnyk]
Yes. I mean, healthcare, US healthcare contributes 10% of all US greenhouse gas emissions. When you look at per capita US healthcare versus health care delivery in other countries per capita, we are double, triple, quadruple other industrialized nations. We are the largest user of single-use plastic. Healthcare is the largest industry use of single-use plastic in the world. We use more plastic in the US in healthcare than the entire country of the UK.

Then they just came out with a study published, I believe it was on Thursday, showing plastic chemicals were linked to a spend of about $250 billion in US healthcare costs in 2018. We're paying for all of our plastic. We're paying for it in the health that we then have to treat, the healthcare problems that we then have to treat in our patients. We really owe it to them to try and fix this.

[Dr. Amy Park]
Yes. It's not just the greenhouse emissions, but it's all the other things. Right? What other components of healthcare are contributing, do you think?

[Dr. Jane Van Dis]
Well, the majority of the greenhouse gas emissions in healthcare are Scope 3, 80% of all US greenhouse gas emissions in healthcare are Scope 3, it's all the supply chain problems. We tend to, let's face it. We have a for-profit healthcare system and that's what's really different between us and other industrialized nations. I would say if you were to take a doctor from Britain, France, Germany, Portugal, and ask them if they know any of their reps, all the reps that come to the hospitals to sell us stuff, I bet you they don't. There's a lot of capitalism in healthcare and I think that that consumption translates into a lot of emissions as well.

[Dr. Amy Park]
Absolutely. What does Scope 3 mean?

[Dr. Alexandra Melnyk]
Sure. I'll go ahead and explain that. Basically, the scopes divide the types of emissions from a system. It can be a healthcare system. It can be other types of systems. Basically, a Scope 1 is direct emissions. For example, things like fossil fuels, our facilities, the anesthetic gasses we use, the gas that goes into our fleet of vehicles that take people to and from parking lots or to and from offices to help carry equipment, et cetera. That's direct emissions into the environment. That can be many different types of greenhouse gasses.

Then Scope 2 is indirect emissions from our electricity. We can't necessarily change the grid that we're on. However, you can try and source your electricity from solar or hydro, et cetera.

Then Scope 3, what Jane was mentioning, this is indirect emissions from the supply chain. This is the devices themselves and the production costs that it took to make the devices. This is business services, inhalers. This is waste food and catering. This is transport for patients and staff to and from the hospital. If you're not really a fan of TeleMed, sometimes it can be great because it's saving both you and the patient potentially from getting to the hospital and that sort of thing. Medication.

Scope 3 is really, really a big factor here. To put it in perspective, when we look at global healthcare greenhouse gas emissions by the scopes, it makes up about 71% of the emissions from healthcare. Whereas, the direct emissions that are coming from the fleet, from anesthetics, et cetera, is really 17%. Scope 2, our electricity grid, is 12%.

It's a big deal. It's a big deal. People come to Jane and I all the time saying, "Where do we start? What do we do?" Part of it is doing an assessment in your own division, your department, your hospital of Scope 3, because that's going to be where we, as individuals, and departments on smaller scales, can make a difference because we know that that footprint is so large.

(6) Reducing Healthcare’s Carbon Footprint: Doing the Work

[Dr. Amy Park]
It's just so interesting to me about the supply chain stuff because these are all things that you really need to get into the nitty-gritty. Having interacted with you guys, I'm just amazed at how much you really have to get into environmental services, into contracting, into food service. Can you guys tell me about the work that you're doing as your local leaders and just doing a lot of this work, but like in discrete bites. I don't want it to sound overwhelming, but I just want to hear what you've been involved in and what you've had to do in your own institutions.

[Dr. Alexandra Melnyk]
I'll take this one. I just completed a project that I'm excited to present at SGS pretty soon. I guess depending on when this comes out, I don't know how much into the details I can get here, but I recently carried out a life cycle assessment of uterine manipulators.

For those of you who've not heard that term before life cycle assessment, that is essentially a cradle-to-grave approach where you're looking at a product or process all the way from the production, which could mean extraction of those materials to build that, all the way to production, manufacturing, the use cycle. For example, if you're using a bipolar energy device and you're plugged into the wall, you're taking energy, electricity, all the way to disposal, if the sterilization is involved or not, et cetera.

To carry out this type of work though, it is a lot of work as Amy has just mentioned. For example, you have to understand the sterilization process. For those of you who haven't really thought about it, you're like, "Oh, yes, it goes in the autoclave." No. It does not just go into the autoclave. For example, if we're looking at a manipulator that has, used in the operating room, it's a reusable manipulator like the Pelosi. Many of us, I think, listening to this very much miss the Pelosi very, very much. That was a totally stainless-steel manipulator.

Basically, the items are sprayed down with a detergent in the operating room and then they go down to central sterilization where all of the instruments in your trays get a hand scrub. If they're not very bloody or messy or any other bioburden on them, there'll be a quick scrub, but basically everything gets a quick hand wash. Then, before it goes to the next step.

In the operating room, yes, we don't want to be using too much water. However, some water on the field is good because it's going to minimize the bioburden on your instruments. You don't want to have too bloody instruments because then that's less work later on in the hand scrubbing station, so back to the scrub sink.

After that, then, the items go into a washing machine for a cycle, maybe an hour long, maybe less than that, maybe more than that, depends on your cycle. Then, after that, the items are placed in their trays to be sterilized again in the autoclave. That cycle can take maybe an hour or so, more or less, time to heat up, cool down, et cetera. Then, after that, they're ready to be reused.

That's, for example, what happens to a device. Finding out all of that information took a lot of phone calls, a lot of meetings, going down to central sterilization, meeting the leader down there who walked me through this whole process. Then, after that, we asked, "Okay. How much soap are we using?" Truly to figure out the data that we're talking about, how much soap, how many grams of soap were we using for washing the tray of instruments? How many trays go with one bit of soap down to how many items are in the tray? How long does that take? What is the labor?

Then if you're doing a cost analysis as well, which we did, "Okay. Well, how long does it take for these trays? How many trays do they do in an hour? What is the breakdown," et cetera. To Amy's point, it was a lot of work, a lot of conversations, a lot of back and forth, a lot of patience to get all this information.

Now, on the flip side for single-use instruments, that is information that our industry colleagues do not want to share. Granted, sure, it's proprietary information, and I surely don't want to go out and make a plastic manipulator. Anybody listening who knows me knows that. However, it's hard to find.

What a lot of us do in this field is we deconstruct instruments to their bases and using expert knowledge, or there are other devices that you can use, but when you do this enough, you know what materials are made of, and then you weigh them. You quantify the devices. Then there's programs and software out there that say, "Okay. Well, this is nylon. This takes X amount," and it quantifies the amount of emissions to make the nylon, "We have 0.000 grams of nylon," et cetera. That's how we get our information.

It takes a lot of work, and this is hard work for some people, it is a full-time job. When somebody recently emailed and said, "Hey, can you do this for my hospitals?" I'm so sorry, I cannot, because just doing one, a few different versions of one device took months and months and months and a significant amount of time.

With this work, I'm happy to share that, sure, the steel device, the reusable device, had the lowest carbon footprint, probably not surprising to many. The other important thing that I need to bring up, because it's one of the more important messages, is that many administrators will say, "What about the cost? What about the cost of the labor to sterilize everything? That's just so expensive compared to the plastic product that can be thrown away and doesn't need all this."

In reality, when you're looking at the life cycle of a reusable device, like a reusable stainless-steel device, many of those devices can be used hundreds and hundreds of times. One study quoted 300 times, but I will say that our Pelosi nucleators that we had at McGee Women's Hospital, where I did my training, were used more than 300 times. Amy Park used them before I came along and they're still being used, which just goes to show that, you put a little bit of upfront cost and they can last a long time. In reality, the labor pales in comparison when you were talking about 300 Pelosi's versus 300 disposable items, it doesn't add up. It's a lot of work to learn this information and we are going to carry out the same similar projects for a specula.

We know the life cycle analysis of specula, as Jane already told us, the plastic specula impacts are four times higher carbon footprint than stainless steel specula, but what about the cost? Stay tuned because hopefully in a few months, we'll be able to share that data and I suspect that the steel specula will be cheaper in the end.

(7) Life Cycle Analysis: Institution Impact

[Dr. Jane Van Dis]
I just want to add, if anyone is interested, I did take Columbia University's Life Cycle and LCA Boot Camp, which is for healthcare providers. If you're interested in learning about life cycle analysis, you want to do it at your institution, definitely check them out. It's a great course. If you have basic questions, Ali and I are happy to answer basic questions, but we cannot do a life cycle analysis at your institution for you.

[Dr. Alexandra Melnyk]
Correct. I wish, but we can't.

[Dr. Amy Park]
I have to say that the specula is such a hot topic because every time this comes up at a meeting or whatever, everybody in the audience is raising their hands and saying stuff like, "Jayco came and said.." It's actually not even Jayco, it's the fear of Jayco. I've never heard a citation saying "specula". Like, "Thank God, Ali came in the nick of time because we're about to switch to plastic specula, apparently, unbeknownst to us." No, please, God, no. So many places are going to do that because in the short term, they're thinking that it's cheaper and better.

We were talking about life cycle analysis and it's a way more sophisticated scenario, but you have to bring the arguments forward and fight.

[Dr. Jane Van Dis]
Exactly. A part of what we haven't mentioned yet is for the disposable devices, especially those that are made of plastic, but studies have shown us that 95% of the environmental impacts are from the production phase. That's part of the fact that many of them are plastic. We already talked a lot about that. If we're the solution for that is that we don't use plastic devices. Yes, every device on the market is going to have some emissions and impact from their production phase. We can't get around that but when you're making the mass quantities of these single-use items, that's what adds up.

That's what can be hard to wrap your head around. I think that what's visible and what we all see in the operating rooms where many of us work is the red bags. We all talk about the red bag waste and that we shouldn't be putting everything in the red bags. That's true. What should go into regulated medical waste is items that are truly saturated in blood as well as items that can theoretically cause infection. Really it's saturated in blood. I know that at a previous institution, when the case started, it was red bag waste and that was it because if it touched the patient, it had to go in there.

That's not backed by evidence. When you think about it, you're at home, like I have a toddler and we're still in diapers and there's potentially infectious waste. You know what is in diapers. That's going in the municipal trash. Foley catheter bags that have patient urine, that does not need to go in red bag waste. Regardless, we see waste. We see waste. That is easy for us to wrap our heads around. That gets a lot of press. It's like, let's do better recycling. In reality, getting back to the scope 3 conversation that we started, in reality, we need to stop using so many of these products.

We need to stop producing these products and we need more reusable devices that we can use. There have been some studies that have come out that are some commentaries that are really saying that surgeries and operating rooms are playgrounds for innovation. We have made incredible things. Think about the da Vinci robot. That's a beautiful invention. It truly is. However, do we need to throw the arms away after 10 uses? Why is it 10 when you know we're using them for practice, there's so many more uses. The trocars, it's really great that they are stainless steel trocars.

I like that feature but what about the trocar introducer? That's disposable. It's things like that, those little things, those add up. I do a lot of laparoscopy and all of my trocars right now are plastic and I hate that. I can only do so much. I'm working on it. Believe me, I'm working on it. I don't think that we have any contracts right now, so bear with me. That's another thing. When you think about all of the laparoscopic cases that go on in an institution and all of those trocars being thrown away. That's where innovation needs to happen.

We've been calling on our leaders, international and national, to help us. As physicians, we call on the industry to help us. We want reusable devices. We need more of them. That's where this needs to go. While we know that it's not as financially beneficial for the company to be focusing more on reusable devices in the long term, there's always going to be OB-GYN residents graduating every year. They're going to need items when they go to new institutions. There's always going to be a market. Items over time, they do break down and whatnot, but that is the big call here as well.

That's something that I'm trying to get more involved in is working with our industry partners to move the field in the direction that we need.

[Dr. Alexandra Melnyk]
I will say the red bag waste, remind me again, I know it either has to be incinerated or buried, right?

[Dr. Jane Van Dis]
It's really incinerated or like they say incinerated autoclaved.

It's sterilized. It is taken off-site. If you have municipal waste versus red bag waste, the red bag waste is taken off site somewhere where it's incinerated or autoclaved prior to then going into the landfill where it's final resting place is. For that process, that takes energy, that takes transportation, and for your institution, that takes money.

[Dr. Alexandra Melnyk]
Yes. It's 10 times the cost.

[Dr. Jane Van Dis]
Oh, exactly. Some 8 to 10 times the cost everywhere. You think that doesn't add up, but it truly does add up versus just taking something to the landfill.

[Dr. Amy Park]
I saw this study at JAMA Surgery. They just did this quick little analysis. You guys need to be doing these studies in JAMA Surgery. It was like the impact of using reusable hats, something we take for granted every day. It was like, just because of the scale of it, all those little hats that we're using, in an institution, we're probably using like 100 hats a day, right? At least. Then just doing that, we can really make a big impact. That's not that big of a deal. I do use the booties, I have to say, just because I don't want my shoes to be all gross and just wipe them off.

That's okay. I mean, the plastic.

I know I should use it. I should just wipe it off. You're right. Anyway, it's all these little things that add up because of the scale of it. I think some of the things that I've been listening to you guys and I follow what you're doing, it's just like, be mindful of what you're using. Try and use reusable, like uterine manipulators, reusable specula, try and be mindful of these other things. I think, thank God ACOG, like they retired our stance on reusable disposable instruments. I remember when I first started, I was like, "Oh my gosh, that's a problem with sterility."

All the subsequent studies have shown no problems. Truly, things like the Ligature, they really are amazing, the bipolar and cutting technology. It is so amazing for laparoscopic cases. I think that one way we can mitigate the impact and the cost really is to reuse them if possible. There's definitely lots of recycling programs, like huge recycling programs.

The concerns about sterility have never been borne out. Now there's big meta-analyses showing that there's no problems with them. Then some of the other things when I've heard you guys talk is just, I'm a big fan of vaginal surgery. That's the OG single port.

OG minimally invasive modality, but it's a lot less instrumentation and reusables and disposables. I do still love a good vaginal case. Not to say that I don't do laparoscopic cases. I think that that is a really big thing about partnering with industry because innovation can't happen without smart people's ideas like yourselves at the table. Also we rely on them for innovation and rolling out to the market. Also, we as surgeons and stakeholders have a lot of power by putting our dollars and our buying power towards companies who support those causes.

I think that's a circular virtuous cycle that I think people understand. Companies understand that if it's important to the constituents, then they will try and do programs to do better.

[Dr. Jane Van Dis]
Having said that, Ali, doing phenomenal work. Amy, you as well, all of us doing our best to make a difference. The fact is that we're little people in a really big system. Think for a second, what if the FDA required that there be a truthful statement of carbon emissions on every single product in the supply chain, right? StatHealth just ran an article a couple months ago saying, "What if we were to try and make pharmaceuticals report the carbon emissions for their products?"

We can't do that. No single individual, no group of individuals can tell JCAHO and CMS and the FDA, "Hey, climate change is a thing, hint, hint it was the hottest year in 125,000 years. Maybe y'all need to get on board with this idea." The fact of the matter is that we need people higher up to say, "What? That's a really great idea." Give hospitals the opportunity to know and to choose which supplies come into their facility based on their carbon emissions. If manufacturers were required to report, done and done, right? That would solve a huge part.

[Dr. Alexandra Melnyk]
At least there would be transparency. Yes. It would be like a nutritional label. You know what you're getting in readings.

[Dr. Jane Van Dis]
How many calories are in this?

[Dr. Amy Park]
How many calories? This is like your carbon footprint. I couldn't agree with you more. I think it's one of those things that-- and thank God you guys are doing the work in this space. I look in the mirror and I'm like, the problem is me, like that Taylor Swift song.

[Dr. Alexandra Melnyk]
Hi, it's me. The problem, it's me. I'm the problem. It's me. No, it's not.

[Dr. Jane Van Dis]
The thing is, what I have so much hope and faith in is that there are so many people out there who agree with us. Sage has retweeted and is like, there's like, UCSF is working on this, our residents and fellows are really into it. Ali's going to work with our fellows on a project. My former residents wrote a paper with us and Kat Schwartz, she's at UCSF, is doing projects on this. There's just a lot of interest in it. I think that if we can just carry that momentum forward, I think there's just a lot of people who are seeing that this is a huge problem and we can impact and mitigate this in a significant way.

Look at the Cleveland Clinic. It's a huge system.

[Dr. Alexandra Melnyk]
Oh, absolutely. Studies have shown that when physicians bring their voices to this exact topic, those are the ones that are sitting at the table helping make decisions. The actions go so much further. For example, yes, Cleveland Clinic, there's a sustainability office and we have a chief medical director of sustainability, Dr. Ilyssa Gordon. She's done incredible work in this field since 2009. When you have somebody leading who can blend the data that we have and bring together the administration piece as well as the clinical piece, you can go a lot farther.

To hit home a little bit more on what was already said, this is a systemic issue. We were joking about, it's me, I'm the problem, it's me. In reality, we're all individual people, but it's, as we said, mass quantities, in bulk, that's what's making this hard, but we can't change it. One person can make a lot of change, but we need systems changes. We need the FDA to make changes. We need the Joint Commission to make changes. There was such bad press last year for the Joint Commission because I believe they thought they tried to implement that, "We're going to also grade hospitals and health systems on their focus on sustainability in some respect."

Then they retracted that and they said, "No, it's more going to be like a extra credit type of thing." Those of us that are in the community are like, "What is this? We need you to put this forward because just as we have put infection control at the forefront, that is what we need. I'm going to give you a statistic here because it's pretty impactful. I think the year 2000 was when To Err is Human came out and we learned that 44,000 to 98,000 people die each year because of preventable medical errors. If you translate that, it becomes 44,0000 to 98,000 life years lost.

Data has come out showing that 470,000 disability-adjusted life years are lost. To health sector pollution, health damages. Those numbers are fairly similar. Our response should be proportional to the harm that we cause. Yes, bodies like JCAHO and the FDA, EPA, they can all stand up together. HHS.

Oh, they're a huge part of this. It's there's people that we're all siloed. We're trying to put it all together, but it's systemic. It's us, people, individual surgeons, individual OBGYNs, individual doctors, as well as the systems that we work in.

[Dr. Jane Van Dis]
Here's something. I just have one last thing. I know we're wrapping up here, but if you were to ask Americans, have they heard about sustainable jet fuel, chances are not all, but some people have heard about sustainable jet fuel. Maybe they heard about the plane that flew across the Atlantic a couple weeks ago on vegetable oil. Aviation only contributes 2.5%, not counting the contrails, but 2.5% of U.S. greenhouse gas emissions. We're at 10. How many U.S. healthcare CEOs are talking about what their healthcare system is doing in terms of addressing sustainability?

I would say Cleveland, you guys are a standout. Obviously, you guys get awards from Practice Greenhouse. You guys are amazing. I can't get my CEO to. There's a lot of CEOs who are like, "Yes, thanks. No. Okay. Next." There's a lot of leadership in aviation, which only contributes a tiny amount compared to US healthcare. We need to get leadership on board. There needs to be peer pressure among hospital CEOs regarding their carbon footprints and their sustainability. Right now it's not there. We need to push them. I go to my CMO's office and send him our articles.

I see him in the elevator, I'm like, "Hey, it's me."

[Dr. Alexandra Melnyk]
True to that, yes.

[Dr. Amy Park]
I think it's important for enough people to come forward and say, "This is important to me," and this is something, if you just do this, even just some work on the edges and demand it from stakeholders, I think people get it and are willing to listen. If there's no reason or agency to change, then they won't change because inertia is for real. I really applaud all of your efforts in this space. I just am so inspired by all the work that you do. I think just by talking about it. Actually, what I also am so inspired by is the residents of the fellows that are trainees, they're really listening.

There's a med student group, they introduced, remember the person, the medical student came up to us at ACOG and she had founded a group.

[Dr. Alexandra Melnyk]
Medical Students for a Sustainable Future.

[Dr. Amy Park]
Yes, exactly. I think that there's lots of hope out there and we're just idealists. That's what brought us to medicine. I think by just continuing that idealism, yes, sometimes I'm cynical, but I really do believe in our power to affect positive change. I don't want to lose that about myself. I'm continuing to be inspired by all the good work that you're doing. Thank you so much. Again, how should we reach out if people have questions or want to talk to you through the website or what's the best way? Tweet at you, DM?

[Dr. Alexandra Melnyk]
For Jane, I feel like your Twitter following is exceptional, but absolutely. I think that the website OBG4, letter four, sf.org, we keep it updated with our upcoming webinar, with opportunities. We put literature specific to OBGYN and so things, for example, climates, papers that come out about the health effects of climate change that goes there, stuff that goes on there is like the specula study. You can find them there. Then also links to other resources like Practice Greenhealth and Healthcare Without Harm.

These are national and international organizations that have been working on this for decades, honestly. Just if you're thinking, "Where do I start? How do I get some more information?'' Those are some great places. Otherwise, if you reach out to us on our website, we'll get an email and you can get in touch with us.

[Dr. Jane Van Dis]
Yes. It's so important to get a broad coalition because just the anesthetic gasses substituting one for the other and having an anesthesia champion, having champions in each department or institute in our case. I think it's easier for people who really want to listen to the OBGYN lecture if you're a urologist or ENT, it really helps to have someone in the fold who really understands what you're doing and can speak to what you're doing to talk. I'm hoping not only that we can talk about our field, but like across surgery, across healthcare, it's really important.

[Dr. Alexandra Melnyk]
As one of my closing thoughts, I just like to put a push for either making a change, a commitment to a change in one surgery. For example, we made a change in the way we conducted slings and observed how we were carrying out our sling cases. That was my first project. By constantly educating those that were in our operating room and educating and talking about and pointing out the trash and that the sterile blue towels don't need to go in the trash. It can be laundered. So many more people learned from just us doing it with this case every time.

They took it to other services, especially going back to trainees, like the trainees took it to other services and they even took it to other specialties. Then we did this again with our cystoscopy cases. We minimized the equipment that we were using. I had residents coming back saying, "Oh, we did this in ONC," and, "Oh, we did this in our benign cases that weren't urogyn cases."

Committing, if you're thinking, "What can I do?" Just start small, start small, low-hanging fruit, minimize something in your own operating room, and do it every time. You may be pleasantly surprised by what other people see you doing and that they're going to start doing that elsewhere. That is how we can make an impact.

[Dr. Amy Park]
That's awesome. Thank you guys so much for coming tonight. I really appreciate you sharing your insights. Again, inspirational work. Keep up the good work. We look forward to hearing more from you on this topic in the future.

Podcast Contributors

Dr. Alexandra Melnyk

Dr. Alexandra Melnyk is a urogyneologist with Cleveland Clinic in Ohio.

Dr. Jane van Dis

Dr. Jane van Dis is an assistant professor of obstetrics and gnecology at U of Rochester in New York.

Dr. Amy Park

Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.

Cite This Podcast

BackTable, LLC (Producer). (2024, March 19). Ep. 49 – Women’s Health at Risk: Climate Change Realities [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.