Personal View

Climate change: challenges and opportunities to scale up

surgical, obstetric, and anaesthesia care globally
Lina Roa*, Lotta Velin*, Jemesa Tudravu, Craig D McClain, Aaron Bernstein, John G Meara

Climate change affects human health in a myriad of ways, requiring reassessment of the nature of scaling up care Lancet Planet Health 2020;
delivery and the effect that care delivery has on the environment. 5 billion people do not have access to safe and timely 4: e538–43

surgical care, and the quantity and severity of conditions that require surgical, obstetric, and anaesthesia care will *Joint first authors

increase substantially as a result of climate change. However, surgery is resource intensive and contributes Program in Global Surgery and
Social Change, Department of
substantially to greenhouse-gas emissions. In response to climate change, the surgical, obstetric, and anaesthesia
Global Health and Social
community has a key role to play to ensure that a scale-up of service delivery incorporates mitigation and adaptation Medicine, Harvard Medical
strategies. As countries scale up surgical care, understanding the implications of surgery on climate change and the School (L Roa MD, L Velin,
implications of climate change on surgical care will be crucial in the development of health policies. C D McClain MD,
Prof J G Meara MD) and Center
for Climate, Health and the
Introduction which we deliver care such that we improve human and Global Environment,
Climate change is one of the biggest threats to human planetary health and economic wellbeing at the same Harvard T H Chan School of
health. It will affect everyone; however, climate change time. In particular, when accounting for health co- Public Health (A Bernstein MD),
Harvard University, Boston,
will have the most devastating effects on people who are benefits (ie, positive benefits related to the reduction of
MA, USA; Department of
poor and marginalised. Climate change results from the greenhouse gases) of decreased air pollution, renewable Obstetrics and Gynecology,
accumulation of greenhouse gases that trap heat in energy programmes are cost-saving, and carbon pricing University of Alberta,
the atmosphere, resulting in rising temperatures. The has been estimated to deliver $211 in health co-benefits Edmonton, AB, Canada (L Roa);
Surgery and Public Health,
most common greenhouse gas from human activity is per ton of CO2 reduced by 2030.9 There is also a cost that Department of Clinical
carbon dioxide (CO2), followed by methane, nitrous oxide, comes with an absence of preparation for extreme events Sciences, Faculty of Medicine,
and fluorinated gas.1 The main sources of CO2 emis­ because opera­tions and utilities are disrupted, resulting Lund University, Lund, Sweden
sions are electricity, transportation, industry, com­mercial in increased capital, operating, and supply chain costs.10 (L Velin); Ministry of Health and
Medical Services, Suva, Fiji
and resi­ dential use, and agriculture.1 As a result of Climate change will affect human health in a myriad of (J Tudravu MD); Department of
the increased global burning of coal and fossil fuels, ways, which requires reassessment of the effect that care Anesthesiology, Critical Care
concentrations of CO2 are rising at unprecedented rates. delivery has on the environment and the importance of and Pain Medicine
Climate change affects health and is changing the scaling up care delivery. (C D McClain), Department of
Pediatrics (A Bernstein),
burden of disease.2 Air pollution is worsening, par­ and Department of Plastic and
ticularly in rapidly growing economies, such as China Climate change and surgery, obstetric, and Oral Surgery (Prof J G Meara),
and India, leading to an increase in pulmonary diseases.3,4 anaesthesia care Boston Children’s Hospital,
Rising temperatures have resulted in approximately Growing evidence exists that climate change affects Boston, MA, USA; and Climate
and Health Initiative, Harvard
125 million more people who have health issues related human health, but the intersection of surgical care and Global Health Institute,
to heat, such as dehydration, heatstroke, and cardio­ climate change has received little attention. Anthropogenic Harvard University, Cambridge,
vascular disease, in 2016 compared with in 2000.5 greenhouse gases have resulted in increasing tempera­ MA, USA (A Bernstein)
Extremes of precipitation and flooding are increasing in tures, rising sea levels, air pollution, and increasing Correspondence to:
severity and continue to have a health and economic natural disasters, all of which affect surgical, obstetric, Dr Lina Roa, Program in Global
Surgery and Social Change,
effect.6 For example, in 2017, the Atlantic storms that and anaesthesia (SOA) care (figure 1). Rising tempera­ Department of Global Health and
devastated Puerto Rico, Texas state (USA), and Florida tures are changing the obstetric and neonatal burden of Social Medicine, Harvard Medical
state (USA) resulted in more than US$300 billion in School, Harvard University,
economic damage.7 Increased severity and frequency of Boston, MA 02115, USA
Key messages lroa123@gmail.com
natural disasters increase the need for trauma care and
resilient health systems.1 Furthermore, in addition to the • Climate change is a threat to global public health, which
direct effect that climate change has on health, it also will change the burden of surgical disease and exacerbate
affects the social determinants of health, including existing health disparities.
housing, poverty, food and water availability, and air • Surgical, obstetric, and anaesthesia care is one of the
quality. major contributors to climate change within the health
Despite working to improve patient and population sector. The global need to scale up surgical, obstetric,
health, the health-care sector is contributing to climate and anaesthesia care could lead to further acceleration of
change. For example, 4% of global carbon emissions climate change if measures of adaptation and mitigation
come from health-care systems in two member countries are not taken.
of the Organisation for Economic Co-operation and • To face climate change, resilient health systems that
Development: India and China.8 Promoting population include sustainable solutions to scale up surgical,
health and addressing climate change are not mutually obstetric, and anaesthesia care are needed.
exclusive goals; it is possible to modify the methods by

www.thelancet.com/planetary-health Vol 4 November 2020 e538

 Personal View
Increased anthropogenic greenhouse-gas emissions
Increased climate pressures
Increasing temperatures Increasing natural disasters Rising sea levels
Effect on surgery, obstetrics, and anaesthesia care
Effect on Adverse birth Increased trauma Relocation of
perioperative care outcomes burden population and overburden of surgical
health services
Figure 1: Effects of greenhouse gases on surgery, obstetrics, and anaesthesia care
diseases: changes in vector ecology result in increased
pathogen spread, such as Zika virus, and a rise in
congenital anomalies, such as neural tube defects, has
been associated with increasing temperatures.11,12 Heat­
waves, forest fires, and high concentrations of pollution
have also been associated with an increased risk of
adverse neonatal and maternal outcomes. For example,
18% of all preterm births globally are associated with
anthropogenic fine particulate matter (ie, PM2·5).11
Climate change can have specific adverse effects on
perioperative care. Examples include a potential increase
in the rate of surgical site infections as a positive
association exists with warmer seasons and months.13
Also, as climate change exacerbates food insecurity, the
adverse effects of malnutrition on wound healing might
become more pronounced. Decreased availability of local
produce is expected to drive vulnerable populations to
less nutritious food, which, together with decreased land
for recreational areas, might further drive the increased
burden of non-communicable diseases. Respiratory and
cardiovascular diseases due to air pollution, forest fires,
heatwaves, and natural disasters can also negatively affect
perioperative care. For example, after Hurricane Sandy in
October, 2012, myocardial infarction incidence increased
by 22%.14 Although chronic management of non-com­
municable diseases is often non-surgical, surgery, such as
coronary artery bypass grafting surgery for ischaemic
heart disease, is often required.
Natural disasters and rising sea levels also have large-
scale geopolitical effects as a result of mass migration.10
Climate change is increasing the strain on health systems
because they will require better disaster preparedness and
trauma care. Damage to infrastructure, power sources,
and communication net­ works presents a challenge to
the provision of SOA care of high quality. Production of
pharmaceutical and surgical supplies and equipment can
be affected. In fact, the shortage of medical supplies was
documented for over a year after Hurricane Maria struck
e539
Puerto Rico in September, 2017.13 Building resilient health
systems that include the provision of emergency and
essential SOA care will be crucial to ensure an adequate
response to natural disasters.15 However, cli­mate change
also presents a challenge to robust health systems, as seen
in the summer of 2018, when all operating rooms were
closed in Sollefteå, Sweden, during a severe heatwave as
the increased humidity prevented adequate sterility.16
Air pollution
Resilient health systems will be needed to respond
to climate change. Lessons about resilience related
to system disruption that can affect SOA care and
outcomes can be learned from SOA workforce who have
expe­rience practising in resource-constrained set­tings.
Surgery, obstetrics, and anaesthesiology are cross-
Damage or cutting specialties that address a broad burden of
disease across the entire health system, in contrast to
infrastructure traditional global health work, which tends to focus on
single disease categories. Strengthening SOA systems
will strengthen entire health systems, making them
resilient to a growing and changing burden of disease.
Although climate change will affect everyone, it is
exacerbating existing inequities, increasing the risk of
detrimental health effects on people who are poor,
resulting in increased expenditure and disability and
subsequently decreasing their access to care.17 Globally,
5 billion people do not have access to safe and affordable
surgical and anaesthesia care, and it is estimated that
143 million surgical procedures are needed every year,
mostly in low-income and middle-income countries,
to address the current burden of surgical disease.18,19
Furthermore, scaling up surgical care will help to
achieve the Sustainable Development Goals, not only
related to health but also goals related to gender equity,
poverty, and economic growth.20 However, delivery of
health care and surgical care is resource intensive. As
the global health community works to scale up SOA
care, considering sustainable practices and anticipating
the increasing and changing needs of the surgical
systems is crucially important. The quantity and severity
of conditions that require SOA care will increase sub­
stantially as a result of climate change, making scale-up
and integration of surgical care into universal health
coverage essential.
Solutions
Two complementary strategies to tackle climate change
have been suggested by the Intergovernmental Panel on
Climate Change: mitigation and adaptation.5 Mitigation
refers to efforts to reduce greenhouse gases, for example,
by replacing fossil fuels with renewable energy sources,
whereas adaptation involves efforts to adjust to climate
change. Both strategies are necessary for the health sector
to address its contribution to climate change. There are
opportunities within the delivery of SOA care to imple­
ment adaptation and mitigation strategies at the levels of
the facility or operating-room, academia and professional
society, and national health system (figure 2).
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Mitigation strategies
To mitigate the health sector’s contribution to climate
change, we should decarbonise health care. High-income
countries contribute the most greenhouse gases and
have a responsibility to lead these changes in the health-
care sector. More research on the carbon footprint of the
processes at all levels of surgical and anaesthesia care
(from surgical procedures to supply chains) is needed to
design effective strategies to reduce emissions.
Anaesthetic agents and energy consumption are the
two largest sources of greenhouse gases in the operating
room.21 Volatile anaesthetic agents are halogenated orga­
nic compounds and represent a combined atmospheric
concentration of approximately 100 000 times less than
CO2, yet these compounds contribute to 10–15% of the
total anthropogenic warming effect on the climate.22 In
addition to the halogenated agents, the frequently used
anaesthetic gas, nitrous oxide, has also been shown to
be a greenhouse gas. There is growing evidence that
fre­quently used agents to induce and maintain general
anaesthesia are anthropogenic sources of climate
change. In 2010, Sulbaek Andersen and colleagues22
described the global effect of inhaled anaesthetic agents
using infrared spectroscopy and estimated the effect of
a single general anaesthetic as equivalent to releasing
approximately 22 kg of CO2 into the environment.
This value was extrapolated to estimate the worldwide
use of volatile anaesthetic agents to be equivalent to
the CO2 emissions from 1 million cars.21 Further work
by MacNeill and colleagues21 compared three academic
medical centres to assess the volume of anaesthetic
agents used and reported an association between the
increased use of desflurane and an increasing carbon
footprint. Other studies have supported the larger
contribution of desflurane to global warming relative to
isoflurane and sevoflurane.23 Despite the known detri­
mental effects, the available literature on the climate
effect of volatile agents does not address what is likely
to be the most frequently used agent, halothane.24 This
scarcity of research is most likely because halothane is
no longer used in high-income countries. However, it is
widely used in low-income and middle-income countries
due to its reliability, widespread availability, and low cost.
Research to characterise the contribution of halothane to
the carbon footprint related to anaesthetics is essential as
low-income and middle-income countries scale up SOA
care. Given the substantial contribution that the delivery
of inhaled anaesthetics can have on the overall climate
effect of surgical care, anaesthesia providers should
be cognisant of various potential strategies to mitigate
this effect. Certainly, safety concerns for individual
patients should be considered but interventions, such as
reducing or avoiding nitrous oxide and desflurane, low
flow or closed-circuit anaesthesia, and the use of total
intra­venous anaesthetic techniques, will have important
roles in care delivery moving forward. Development of
technologies, such as agent recovery systems to capture,
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Personal View
Mitigation Adaptation
Operating rooms or facilities
• Make efficient use of energy-intensive equipment • Engage in active relocation of vulnerable
• Consider environmental effect when choosing health facilities
single-use versus reusable devices • Develop toolkits to reduce environmental
• Decrease use of nitrous oxide and halogenated harms of operating-room practices
agents for anaesthesia • Support SOA response to people affected by
natural disasters
Academia and professional associations
• Put pressure on academia and governments • Put pressure on academia and governments
to divest themselves of fossil fuels to divest themselves of fossil fuels
• Research sustainability of SOA practices and • Research sustainability of SOA practices and
innovate energy-efficient solutions innovate energy-efficient solutions
National health systems
• Set goals and national roadmaps to get to net • Ensure no one is left behind in surgical-care
zero emissions in line with the Paris Agreement delivery
• Promote the role of industry in innovation to • Consider climate change in national heath
mitigate climate change policies, including NSOAPs
• Improve waste management • Coordinate a sustainable scale-up of SOA care
Figure 2: Adaption and mitigation strategies at various levels
SOA=surgical, obstetric, and anaesthesia. NSOAPs=national surgical, obstetric, and anaesthesia plans.
reuse, or recycle agents, is also paramount as countries
scale up anaesthesia capacity, particularly in settings with
scarce resources.
Understanding the carbon footprint of frequent
surgical interventions is essential as SOA care is being
rapidly expanded. For example, studies have shown that
phacoemulsification has a much larger carbon footprint
than does manual small incision cataract surgery.25 The
environmental effect of CO2 insufflation for laparoscopic
surgery has not been thoroughly studied and as low-
income and middle-income countries scale up access
to minimally invasive surgery, the effect of innovative
alternatives, such as gasless laparoscopy, should be
assessed.26,27 Although the carbon footprint is only one of
many factors to consider when choosing a surgical
technique, it is an important consideration that has been
largely neglected. Operating rooms are three to six times
more energy intensive than hospitals as a whole, and
hospitals should ensure strategies to maximise the
effective use of operating rooms.21 To reduce unnecessary
energy consumption and minimise carbon footprint,
operating rooms can be ventilated on the basis of
occupancy.21 It is key to oversee and regulate the current
sources of energy in operating rooms, switch to more
efficient light-emitting diodes, and ensure a transition to
renewable power sources. Other strategies that can
reduce the environmental harms from operating rooms
include preventing non-biohazardous waste from being
treated as hazardous, as its management produces
more CO2.28 The environmental effect and safety of
single-use versus reusable devices will depend on the
instrument and the setting. Although reusable devices
are often considered better for the environment, in some
cases, the green­house-gas footprint of single-use devices
e540
 Personal View
can be lower, depending on the energy source used to
clean or manufacture the reusable equipment.29 Single-
use devices might be a more appropriate choice in low-
resource settings if access is scarce to the infrastructure
for decontamination of reusable equipment, which
could lead to increased postoperative infections.30 In
parallel to academic efforts to inform best practices,
immediate mitigation strategies can be implemented.
Professional societies, govern­mental regulatory agencies,
industry, and training programmes all have a role in
creating an environment where safe and climate-
friendly surgical and anaesthetic techniques can be
used. Academia and professional societies have a
respon­sibility to leverage their power to advocate for
divestment from the fossil-fuel industry, as the health of
the population should take precedence over financial
gains. Furthermore, these societies have the opportunity
to lead research and advocate for funding to investigate
the sustainability of surgical practices and minimise the
carbon intensity of SOA practice. Partnerships with the
private sector could accelerate innovation of products
and operating-room layouts that reduce costs and are
highly energy efficient.
On the level of national health systems, climate change
can be mitigated by setting goals and road maps to
decrease emissions to net zero in line with the Paris
Agreement. Governments could also embrace the role of
the private sector and industry to spur innovation for
new mitigation strategies. Engagement with industry to
scale up SOA care can be environmentally conscious
and help to achieve the Sustainable Development Goals.
For example, Sustainable Development Goal 7, to
“ensure access to affordable, reliable, sustainable and
modern energy for all”,31 is crucial for the provision of
safe surgery. To achieve this Sustainable Development
Goal, govern­ments should demand commitment from
industries to embed low-cost and sustainable infrastruc­
ture in a country’s efforts to strengthen health systems.32
Industry leaders have already started initiatives to reduce
environ­mental harms by use of renewable electricity
to power health facilities.33 One such example is the
Infrastructure Workforce Service delivery
• Relocate vulnerable health • Grow SOA workforce • Use telemedicine and technology
services • Train SOA workers in mitigation to reach people who are
• Build infrastructure that is energy strategies and disaster vulnerable
efficient preparedness • Evaluate the climate effect of
• Advocacy in professional surgical procedures
associations
Financing Information management Governance
• Innovative health financing • Sustainable systems for data • Ensure NSOAP implementation
through climate-change taxes collection • Engage the ministries of
• Financing for disasters and • Research for improvement of environment in NSOAP processes
victims of climate change outcomes and quality
• Electronic information systems
Figure 3: Adaptation strategies within each of the domains of the NSOAP framework
SOA=surgical, obstetric, and anaesthesia. NSOAP=national surgical, obstetric, and anaesthesia plans.
e541
US Sustainable and Climate Resilient Health Care
Facilities toolkit, which is a result of a public–private
partnership between the US Department of Health
and Human Services and the health-care industry.34
Industries should further consider systematic ways to
repurpose or recycle health equip­ment, reduce waste,
and commit to becoming carbon neutral. Now is the
time for innovative solutions for low-carbon health tech­
nologies, efficient building design, sustainable waste
management, and telemedicine to reduce transportation
needs and increase accessibility.28,33
Adaptation strategies
Climate change is happening now, and some environ­
mental disruptions are now inevitable. The demand for
the scale-up of SOA care is imminent, and, as a result, it
is of paramount importance to integrate the delivery of
SOA care into universal health coverage in a sustainable
manner, thus increasing the resilience of existing health-
care systems. To achieve this integration of SOA care
into universal health coverage, purposeful adaptation
strategies are urgently needed to complement the
mitigation of climate change.
Scaling up surgical care in low-income and middle-
income countries is an important adaptation strategy.
Climate change will increase the surgical burden of
disease burden through surges in trauma, injuries, and
non-communicable diseases, and marginalised com­
munities will face additional challenges in accessing
timely health care. As there is a move toward universal
health coverage with the motto of “leaving no one
behind”,35 it is key to ensure that this motto encom­
passes SOA care for vulnerable populations, including
children and migrants. From the climatic disasters that
have affected the Pacific islands, an increasing need to
organise and mobilise surgical teams has emerged. At
the Pacific Health Ministers Meeting in Tahiti in 2019,
22 ministers of health committed to the development
and imple­mentation of national surgical, obstetric, and
anaesthesia plans (NSOAPs).36 Countries around the
world have been developing NSOAPs in an effort to
integrate SOA planning into existing national health
strategies.37 The six major domains of the NSOAP
framework are infrastructure, workforce, service delivery,
information tech­­ nology, financing, and governance.
Adaptation stra­tegies within each of these domains could
ensure that climate change is included in plans for
surgical scale-up (figure 3).
As countries scale up infrastructure to provide SOA
care, the vulnerability of health facilities to climate
change should be addressed by strengthening facilities
at high risk and investing in infrastructure designs that
are energy efficient. The loss of habitat from rising sea
levels has resulted in the relocation of villages in the
Pacific islands with consequent relocation of health
centres and infrastructure planning.38 Strategies for
service delivery to reach vulnerable populations while
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minimising the effect of transportation, such as tele­
medicine for preoperative and postoperative consults
or drones for delivery of blood products, could be
considered as countries scale up SOA care. The NSOAP
requirement for information management includes
sustainable sys­tems for data collection and outcomes
research.37 As more countries transition from paper-
based to electronic medical records, electronic systems
should have a minimal carbon footprint. As care is
scaled up, parallel efforts to collect data on the carbon
footprint, energy consumption, and waste management
of different procedures and overall surgical care should
be pursued.
Scaling up of the SOA workforce should include training
in mitigation strategies to reduce environmental harms of
the operating room and disaster preparedness for the
impending increase of events related to climate change.
Furthermore, professional associations have successfully
elevated climate change to national agendas and should
lead advocacy efforts with various stakeholders, including
people in charge of operations and procurement, on
the importance of climate-proofing the expansion of
SOA care.39,40 Professional associations and colleges could
add value by collating evidence for emergent conditions
related to climate, developing guidelines to address system
disruptions, and providing a framework for clinics and
hospitals to guide the adoption of sustainable measures
in reducing the environmental harms of their practice.
Furthermore, these associations can act as educational
platforms for the SOA workforce and use existing
channels, such as conferences, to educate on the issues of
climate change and its effect on surgical patients.
Governance and environmental stewardship will be
needed during NSOAP implementation. Sensitisation
of all stakeholders to climate-change issues, including
engaging ministries of environment in decisions related
to infrastructure and information technology, are essential
strategies to ensure reduction of environmental harms
in practices. Furthermore, the WHO operational frame­
work for building climate-resistant health systems, pro­
vides guidance on how to best align health strategies with
environmental goals.41 For example, the UK’s National
Health Service announced that it will chart a route to net
zero emissions, becoming the first national health service
to make this bold commitment. This announcement sets
an example of how a health system can lead the way to
tackle the climate health emergency.42 Financing of
surgical care should account for the growing frequency of
natural disasters and large out-of-pocket expenditures for
patients. Opportunities for inno­vative financing to scale
up SOA care could be explored, such as taxing fossil-fuel
companies, similar to how tobacco taxes have been used
to reduce inequities in health care.43 Climate change has to
be considered in all political and financial decisions
regarding the scale-up of SOA care. Global health leader­
ship, funders, and all stakeholders should consider the
effect of climate change in their long-term strategies.
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Personal View
Conclusion
Climate change is the single greatest threat to planetary
and human health of our time. It is not a distant future
concern, but a process that is occurring here and now.
It will adversely affect human health by changing the
nature, severity, and frequency of disease presentation.
There is already an imminent need to scale up SOA care
to address an unmet surgical disease burden, primarily in
low-income and middle-income countries, and climate
change will exacerbate this need. However, these efforts
should be considered in the context of climate change
to ensure that our health systems are strengthened to
endure a rapidly changing environment while not causing
harm in the process. This strengthening will require the
scale-up of SOA care to address health equity and social
justice through innovative and disciplined systems and
processes that also reduce the population’s greenhouse-
gas emissions.
Contributors
All authors conceptualised the Personal View. LR and LV visualised the
tables and figures and wrote the original draft of the manuscript.
JT, CDM, AB, and JGM reviewed and edited the manuscript. All authors
revised the work critically for important intellectual content, approved
the final version, and agreed to be accountable for all aspects of the
work.
Declaration of interests
We declare no competing interests.
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