Planetary health

The ecological footprint of the healthcare sector contributes considerably to transgressions of a number of ‘planetary boundaries’.1–3 At the same time, resilient healthcare systems are the first line of defence against the health effects of transgressed planetary boundaries.4 Analysing possible solutions for more sustainable and resilient health systems, we encounter numerous opportunities to contribute effectively to the mitigation of, and adaptation to, multiple ecological crises, beyond the ecological footprint of our own specialty. This includes balancing public health and patient safety, education, avoiding the over-use of healthcare services, building resilient healthcare systems. This extends to our handprint, which accelerates the necessary ‘social tipping dynamics’ in order to achieve both a healthcare sector and an economy within planetary boundaries, protecting health and health systems.5 Before specifying concrete options for action, it is important to outline the bigger picture. We are now exceeding six out of nine of the planetary boundaries, among them climate change, biosphere integrity, land-system change, novel entities (such as synthetic chemicals including plastic), biogeochemical flows of phosphorus and nitrogen, and freshwater changes, thereby worsening living conditions for humanity, with those least responsible already being disproportionately impacted.6 At the same time as the ESAIC sustainability consensus document,7 a new study on the Atlantic Meridional Overturning Circulation (AMOC) was published.8 The study provides further evidence that AMOC is on tipping course. This implies that temperatures in Europe could fall by 10°C to 30°C within a century, depending on the region and leading to a completely new climate within just one or two decades. The AMOC study adds important evidence that this major global tipping point is nonlinear and progressing more rapidly than previously assumed. Such systems are physically too inert to be counteracted with short-term measures. As we cannot adapt to the associated fundamental changes, immediate and consequent mitigation of climate change is paramount. By emitting greenhouse gases (GHG), impairing biodiversity or by excessive land use, the industries of food, alcohol, tobacco, fossil energy and others, significantly stress our ecosystems, resulting in their rapidly declining resilience to absorb anthropogenic impacts. Globally, 78% of premature deaths from noncommunicable diseases are attributable to such products and activities.9 These commercial determinants of health, defined as ‘systems, practices, and pathways through which commercial actors drive health and equity’,9 are increasing the burden of disease and the need for anaesthesia and/or intensive care. Longer, more intense and more frequent heatwaves not only lead to productivity losses, but are associated with an increase in hospital admissions and tens to hundreds of thousands of premature deaths in Europe.10 Food security is declining while the likelihood of pandemics is increasing.11 The mental health of many people, especially young people, is severely impaired.12 Health gains that have been achieved in recent decades through the improved provision of adequate nutrition, hygiene, education, work, housing and medical, nursing and therapeutic care, are being jeopardised as a result.13 There is a considerable danger of underestimating the health risks of these changes.11 Healthcare systems exacerbate these changes through their own GHG emissions and high consumption of resources. This is the context in which we debate sustainability in anaesthesia. Adequate situational awareness of the Earth's vital parameters and their likely interaction is a prerequisite to identify the right answers to the challenges of the climate and environmental crises, beyond ideological societal discourses and health systems’ inherent inertia. By the transdisciplinary analysis of how human health depends on ecosystems’ health, the planetary health14 perspective provides important areas for transformative action, especially for those employed in the healthcare sector.5 The consensus approach of the ESAIC sustainability consensus document7 may be methodologically unsuitable for identifying the need for transformative action derived from the planetary health perspective. A consensus is not necessarily what is actually needed to address current and future crisis. It is more complex than the very urgent reduction of the CO2 footprint. Anaesthesiology and intensive care medicine are in a key position; we are very well trained to monitor dynamics in emergency situations and to avoid fixation errors. This is operationalised by pausing briefly, gathering information and re-evaluating our assessment. These skills are essential when healthcare is delivered to our patients. These skills are also transferable to care for the health of our planet. We play a central role within inpatient healthcare, interacting with almost all other specialties. We see the consequences of inaction in our daily work. We are involved in numerous diagnostic and therapeutic measures, have an understanding of interdisciplinary processes and can build alliances to increase the likelihood of necessary changes. There is a great opportunity for anaesthesiologists beyond the ESAIC Sustainability Consensus, not only to reduce our ecological footprint but more importantly to maximise our ecological handprint, by which we mean fostering change through small scale behaviour change towards planetary health.15 We describe additional important fields of transformative action below. Balancing public health and patient safety There is sufficient evidence to enable choosing the anaesthesia procedure with the fewest environmental side effects while, evidently, maintaining or increasing the quality of treatment.16 Limiting the use of inhaled anaesthetics is one of the most effective and easiest single measures for mitigation in the health sector. At least for the anaesthetics with the largest climate impact, a consensus should be reached on a limited number of indications that justify their use in view of the health risks of continued GHG emissions. Desflurane, which has a GHG potential 2540 times greater than CO2, is largely dispensable and has already been banned in Scotland since March 2023 and will be withdrawn in England's National Health Service. A growing number of life cycle analyses show that reusable products are superior to disposable products.16 Single-use products primarily create value for the manufacturing companies, while environmental and health costs are externalised. This incentivises manufacturers to promote the use of disposable products, often arguing that the latter are preferable for patient safety and liability reasons. Therefore, local hygiene regimes must be based on evidence, balancing the goals of public health and patient safety. Education To increase the resilience of healthcare systems associated with planetary boundaries transgressed, it is necessary to integrate planetary health into medical education, including residency programmes in anaesthesiology and intensive care.17,18 This applies, for example, to heat-related illnesses, infectious diseases, pandemics and other health effects of extreme weather events (droughts, forest fires, floods and so on). In addition to adaptation to these new and increasing health impacts of climate and other ecological crises,3 medical students should also learn about the avoidance of over-use of healthcare, including defensive medicine, which is responsible for up to 30% of emissions of the healthcare sector.19 Avoiding over-use of healthcare services European healthcare systems are heterogeneous and differ greatly in terms of the human and financial resources used in relation to population health.20 In face of declining human, financial and ecological resources, it is crucial to increase prevention and health promotion,9 and to avoid useless or even potentially harmful therapeutic or diagnostic measures.19 The latter not only applies to intensive medical care, especially to end-of-life medicine, but also to the central role of anaesthesia in inpatient care. Resilient healthcare systems Public health must be prioritised over commercial interests.9 Professional societies and their members can urge policy makers to promote health in all policy areas that impact people's health directly or indirectly, and to strengthen the resilience of healthcare systems in face of the ecological crises. This is not ideological, but in the interests of our patients, the professional ethos and therefore of our specialty. This includes regulation and legislation at the national and European level, adjustments in trade and agricultural policies, taxation of harmful products and subsidising health-promoting foods and other products, measures and sanctions and penalties for committing ecocide, ending subsidies for harmful industries, but with incentives for investment in business models that have a positive impact on health equity and operate within planetary boundaries. It may include the initiation of and participation in societal debates. For example in Germany, 68 health organisations signed the health-letter for a Fossil Fuel Non-Proliferation Treaty, among them the German Society of Anaesthesiology and Intensive Care (https://fossilfueltreaty.org/health-letter, Accessed 26 April 2024). Handprint Transgressing planetary boundaries will change the conditions under which healthcare will be provided in the future. It creates continuous pressure for transformation of healthcare systems. The transdisciplinary perspective is crucial in order to pursue the necessary transformation paths. New and unusual alliances are of strategic importance for overcoming inertia. This applies to cooperation with other medical disciplines and different professional groups, to the financing of the healthcare system and to the development of technical or regulatory solutions. We can be active politically or in advocacy, we can build networks and motivate others through examples of good practice. Our handprint contributes to the necessary social tipping dynamics in order to achieve a healthcare sector and an economy within planetary boundaries, protecting health and health systems.5 This is medically necessary political work. Only when we acknowledge this complexity, will we find the best answers to these challenges.