Technological medicine or a habitable planet: you have to make a choice

We translated a very well-documented article by Kris de Decker, editor for the Low-Tech Magazine (to consult the numerous references given by the author, see the original article^[1]). Published in 2021, the text details why it is illusory to hope to drastically reduce GHG emissions and stop the ecological carnage without deeply questioning the modern health system. Kris de Decker first looks back at the carbon footprint and the cataclysmic material footprint of the medical industry. He then details why betting everything on decarbonization and energy efficiency is illusory, and discusses other interesting themes to get an overview of the problem (law of diminishing returns, preventive medicine versus palliative medicine, concentration of health expenditure at the end of life, etc.). In the conclusion, he states that keeping people alive as long as possible, using technological innovations that consume more and more resources, is tantamount to sacrificing the health of future generations.

We will probably have to accept a decrease in life expectancy if we want to stop the global carnage caused by the techno-industrial system. If Kris de Decker seems aware of the madness of this system (he writes: “industrial society has given us effective medical treatments, but it also makes us sick”), we would have liked a philosophical exploration — in particular the place of illness and death in the Western imagination —, and above all, more pragmatism. After a while, you have to face reality. To get out of the trap, you will have to organize, resist and confront Big Pharma, dismantle its factories, the banks, the firms, and the energy plants that supply them, and get rid of the cohort of parasites—propagandists in ties and white coats, CEOs, and billionaires—who binge themselves by degrading the human race and consuming nature. We already have a competitive advantage over these pests: the fear of dying is foreign to us. Aux Armes, Naturiens^[2] !

Is technological medicine ecologically sustainable? (by Kris de Decker)

Can we decarbonize modern medicine and maintain the levels of care, pain relief, and longevity that we take for granted?

The environmental footprint of the health sector

The medical sector is one of the most important economic sectors in high-income countries, but their environmental footprint is both underestimated and rarely taken into account. Most studies on the sustainability of the modern health system are less than five years old. A document from 2019 estimates that the sector accounts for between 2 and 10% of the national carbon footprint in OECD countries, China and India, with an average share of 5.5% overall.

The data refer to 2014, when the health care sectors in all of these 36 countries combined were responsible for 1.6 Gt of greenhouse gas emissions. This corresponds to 4.4% of global emissions that year (35.7 Gt) — almost double the share of aviation. The United States has the most carbon intensive health system; it accounts for up to 10% of national CO2 emissions. It also causes 9% of national air pollution, 12% of acid rain, and is responsible for 10% of Smog [industrial pollution composed of fine particles and ozone, NdT].

The environmental footprint of the medical sector is constantly increasing. For example, in the United States, greenhouse gas emissions from the health sector increased by 30% between 2003 and 2013. This increase in emissions goes hand in hand with increased spending — in fact, emissions are often calculated based on spending. In the United States, national health spending as a percentage of gross domestic product (GDP) increased from 3% in 1930, 5% in 1960, 10% in 1983, 15% in 2002, and 17.7% in 2019. In the EU, health spending per capita more than doubled between 2000 and 2018, and total spending now accounts for 9.9% of GDP.

The 36 countries whose health systems produce 4.4% of global emissions account for only 54% of the world's population. The remaining 46% of the population produce few or no emissions related to their health system, because they do not have access to modern care. If we were to expand the modern health system from the OECD, China, and India globally, emissions would double to around 8% of the global total. In addition, there are very big differences between these 36 countries. If the whole world copied the American healthcare system, the sector's global carbon footprint would be around 16 Gt, or nearly half of the total global emissions in 2014.

Intense lights, high power medical equipment

Why is the modern health system so resource intensive? First of all, modern hospitals are large consumers of energy, mainly due to medical devices, lighting, ventilation, and air conditioning. In operating rooms, high energy consumption is mainly due to the use of powerful lighting and ultra-clean ventilations. In intensive care units and medical imaging departments, equipment accounts for the bulk of electricity consumption.

Like so many other sectors of modern society, medicine has come to depend on all sorts of machines and devices. Some of this medical equipment consumes a lot of electricity. For example, an MRI scanner, one of the most powerful diagnostic imaging technologies, can consume as much electricity as more than 70 average European households. A study conducted in 2020 came to the conclusion that advanced medical diagnostic technologies (MRI and CT scanners) were responsible for 0.77% of global carbon emissions in 2016.

The energy consumption of small medical equipment is still poorly studied. But an inventory of two American hospitals recorded 14,648 and 7,372 energy-consuming devices there. Infusion pumps alone consumed more electricity than an MRI scanner. The high density of medical equipment also increases the electricity consumption of air conditioning in hospitals.

Use of resources along the supply chain

An even larger amount of energy — around 60% of the total — is used indirectly along the supply chain. This concerns the purchase of medical equipment, pharmaceuticals, and other products.

For starters, the increasing number of medical devices used in hospitals must also be manufactured and brought to market. This requires activities such as extracting resources, building and operating research laboratories, factories, and transport vehicles. This “intrinsic energy” [or gray energy, NdT] related to the medical equipment supply chain is very poorly studied. One study estimated that the production of an MRI scanner requires more than half of the fossil fuels used to produce an airliner, and that gray energy accounts for a third of the device's total energy consumption.

Modern health care is also highly dependent on pharmaceutical products, which account for between 10 and 25% of total emissions from the medical sector, depending on the country. A study published in 2019 revealed that the pharmaceutical industry produces more greenhouse gases worldwide than the automotive industry: 52 MtCO2 compared to 46 MtCO2. On the other hand, there is virtually no data on the environmental footprint of certain specific pharmaceutical products, as corporate secrecy prevents scientists from conducting life cycle analyses.

Single-use disposable products represent another source of energy consumption and pollution in the health sector. These products are worn by medical staff and patients (masks, gloves, overshoes, hats, sheets, gowns). Napkins, washbasins, sterile plastic packaging and utensils such as syringes, laryngoscope handles and blades, anesthesia breathing systems, and even surgical instruments are also single-use. These single-use products are supplied to hospitals in what is called custom packaging — sets of pre-packaged sterile products corresponding to every medical procedure imaginable. In principle, as soon as a package is opened, all items are thrown away, even if they have not been used.

When these practices are questioned, it is often because of the hospital waste they generate — the average patient in a hospital produces at least 10 kg of waste per day. But the environmental footprint increases dramatically if we also take into account the grey energy and waste produced along the supply chain to manufacture these disposable products. A study of cataract surgery in the United Kingdom — cataracts are the leading cause of blindness in the world — shows that the manufacture of disposable materials accounts for more than half of the total carbon footprint of the procedure.

Anesthetics and vaccines

Finally, some specialty drugs also produce emissions. A cornerstone of surgery to neutralize the central nervous system, inhalation anesthetics are powerful greenhouse gases that evaporate into the atmosphere after being inhaled by the patient (gases evacuated outside by high-energy ventilation systems in modern operating rooms). Maintaining a 70-kg adult in a state of anesthesia for one hour produces 25 kg (with isoflurane) to 60 kg (with desflurane) of CO2 equivalents, which corresponds to the emissions of an average European car (121 g CO2/km) traveling 200 to 500 km (or driving for about 4 hours).

Pressurized dose inhalers, which are used to treat asthma and chronic obstructive lung disease, also release powerful greenhouse gases. Around the world, around 800 million pressurized dose inhalers are manufactured every year, with a total carbon footprint corresponding to the annual emissions of more than 12 million private cars. Vaccines are another key part of modern health care. They generate carbon emissions not only through their development and production, but also through their intensive distribution of resources based on a special cold chain. I could not find references analyzing its environmental footprint.

Carbon footprint of medical procedures

Health services often include all of the emission sources mentioned above: medical devices, pharmaceuticals, and disposable materials. When emissions in hospitals and along the supply chain are combined, it becomes possible to calculate the environmental footprint of medical procedures.

For example, studies looking at cataract surgery and reflux control surgery in the United Kingdom have estimated their carbon footprint at 182 kg and 1 ton of emissions respectively, which corresponds to 1,517 km and 8,333 km by car. Kidney dialysis, a treatment aimed at replacing kidney function, produces 1.8 to 7.2 tons of emissions per patient per year, which corresponds to the emissions of a journey of 15,000 to 60,000 km in a car.

The limits of decarbonization and energy efficiency

Although data on its environmental footprint is still incomplete, it seems fairly clear that the modern healthcare system is incompatible with a transition to a low-carbon society. The big question is whether this situation can be remedied without reducing the levels of care, pain relief, and longevity that people in high-income societies have been accustomed to.

Numerous efforts and studies on the sustainability of health care are aimed at reducing energy consumption and emissions. The authors often explicitly mention that this should be done without reducing the quality of medical treatments. For example, the authors of a 2020 study on the Austrian health system write that it is “crucial to understand how the medical sector can reduce its emissions without affecting the quality of its services.” Elsewhere, researchers write that “any solution that would reduce environmental impacts while reducing performance cannot be deployed.”

As a result, many researchers tend to focus on improving carbon footprints and energy efficiency. These strategies aim to provide the same “performance” or the same “quality of service”, but with less energy (thanks to more energy-efficient equipment), or with fewer emissions (thanks to more renewable energy sources).

The problem is that the quality of medical treatments is constantly improving, leading to additional energy consumption that erases the gains from decarbonization and energy efficiency. For example, in 2012, researchers calculated that MRI scanners could become 10 to 20% more energy efficient through relatively simple changes in their design and operation. Some of the proposed recommendations are now in action, but the energy consumption of MRI scanners has not decreased, quite the contrary.

The first reason for this is because MRI scanners now have higher field strength (which makes it possible to obtain more accurate diagnostic images) and wider apertures (which improves patient comfort and makes it possible to scan obese or very muscular individuals). These innovations have improved the quality of care, but they have done so at the cost of additional energy consumption. In the 2012 study, the average energy consumption per scan before the energy efficiency improvements was 15 kWh. A 2020 study measured energy consumption at 17 kWh and 23.6 kWh per scan for an MRI scanner with a field of 1.5 and 3 Tesla respectively.

Second, MRI scanners with better diagnostic capabilities also increase energy consumption in unexpected ways, as medical equipment, pharmaceuticals, and treatments shape and modify each other [see the phenomenon of “technique training” described by the history-sociologist Jacques Ellul, NdT]. For example, doctors used to diagnose a patient through a physical exam and verbal exchange, and only used diagnostic services to confirm their first diagnosis when needed. Today, diagnostic tests are carried out beforehand and determine the decision-making process, which leads to an increase in the number of tests, and therefore in energy consumption. The introduction of new pharmaceutical products can also promote increasingly energy-intensive diagnostic practices. For example, some cancer drugs are now designed to treat a very specific tumor subtype, requiring increasingly accurate medical imaging to identify the tumor subtype.

Adding additional renewable energy sources could potentially reduce emissions from hospital care and throughout the supply chain. But as the energy consumption of medical treatments continues to increase, this is an unlikely outcome. Moreover, a quick calculation shows that, even without additional growth in energy consumption, a decarbonized American health system would absorb all of America's renewable energy production—sun, wind, hydropower, wood, wood, geothermal, biofuels, and waste. The challenge is only slightly less daunting in other high-income countries. Finally, renewable energy would not solve all the environmental problems in the medical sector and would not even eliminate all of its carbon emissions.

Sufficient health care?

To reduce the ecological footprint of modern health care, we need to challenge the trend towards increasing use of energy-intensive technologies and services. The same is true in other areas of life.

However, while some recognize the charm and real benefits of the frugal lifestyles of the past when it comes to comfort or convenience, few would be tempted to apply the same principles to health or life expectancy. After all, traveling more slowly or wearing an extra sweater at home would mean, in health terms, living less, suffering more, or losing mobility as we age. For example, if we stopped using MRI scanners or if we only used MRI scanners with a field strength of 1.5 Tesla, reduced diagnostic accuracy would result in more undetected cancers, leading to lower cancer survival rates and lower average life expectancy. At least on the surface.

Looking at medicine in a historical context, it seems obvious that there is a powerful link between the use of energy-intensive medical technologies on the one hand, and the health and longevity of a population on the other. Even going back less than a century, health outcomes and survival rates for all sorts of diseases are much lower, and the current global average life expectancy (72.6 years) is higher than in any high-income country in 1950.

Hospitals date back to ancient times, but at that time they only welcomed the insane and the dying. In the Middle Ages, surgery took place at the barber shop, where “barber-surgeons” performed bloodletting, tooth extractions, and amputations, in addition to the usual haircuts and beard trims. They made their own anesthetics using herbs and alcohol, which could be just as deadly as the surgery itself. A look at today's “developing” world also seems to suggest a clear link between health system emissions, which are very modest, and life expectancy, which can be 20-30 years lower than in high-income countries.

However, if you dig a little deeper, the link between energy consumption and longevity is not as strong as it seems. This is shown by the example of the United States, a country that has the most expensive and least sustainable health system in the world, but ranks behind most European countries in the access and quality of care index (which measures death rates from 32 causes of death that could be prevented by effective medical care). American citizens also have a lower life expectancy than European citizens. Clearly there are other factors at play as well.

Disease resistance

For starters, the quality of a health system alone does not determine the health and longevity of a population. This is where the story gives us an important lesson. Ancient medical knowledge considered health more holistically and focused on strengthening the body's inherent resistance to disease. Consider the example of Hippocrates. Often considered the father of Western medicine, he prescribed diet, gymnastics, exercise, massage, hydrotherapy, and sea bathing.

One could argue that our ancestors had no choice but to focus on disease prevention because they had few treatments. However, the wisdom of their approach is more evident than ever. Today, in high-income societies, many patients turn to medical treatment because of lifestyle-related illnesses — those caused by poor or excessive diets, lack of physical activity, stress, or substance abuse. Known health risks include cardiovascular disease, type 2 diabetes, depression, obesity, certain types of cancer, and increased vulnerability to infectious diseases. Industrial society has given us effective medical treatments, but it is also making us sick.

This means that better health and greater longevity can be achieved in ways other than through an increasingly resource-intensive health system. By acting on the more general factors that influence health and longevity, we could evolve from curative to preventive medicine. Preventive medicine is not for the government to tell us to stop smoking (and then collect tax money on cigarette sales). Rather, it is about undertaking systemic changes that go beyond individual behaviour change.

For example, a significant reduction in the use of cars in our societies would bring a surprisingly high number of health benefits, which would reduce the need for energy-intensive medical treatments. The same goes for the health problems caused by road accidents, as well as by air and noise pollution, which would be reduced with a living environment devoid of cars. People would be more physically active (which would prevent many lifestyle-related illnesses) and that would free up lots of public spaces for people to gather, children to play, and trees to grow (all important factors for a population's mental health). Finally, reducing car use could easily save more greenhouse gas emissions than the health system produces.

Switching to a healthier food production system, addressing the environmental damage caused by the plastic industry, reducing poverty and social inequalities, introducing shorter working hours and more rewarding jobs are other examples of preventive medicine. We didn't achieve today's higher life expectancy just because of better health systems. We have also achieved it through improved education, hygiene, safety and traffic regulations, social protection systems, the fight against crime, and a more reliable food supply. The low average life expectancy in poor countries is also due in part to these factors.

Preventive medicine would also reduce the damage caused to health by the medical treatments themselves. These are health damages resulting from medical errors or the side effects of pharmaceutical products and, more indirectly, from pollution generated by the health care sector. For example, air pollution generated by the medical sector contributes to the prevalence of asthma, which in turn increases the demand for care. Climate change and other environmental threats threaten younger generations and future generations with an even greater impact on health, for example due to poor harvests, the spread of diseases, extreme weather events and natural disasters [all disasters that will contribute to increased profits for the medical industry, NdT].

The law of diminishing returns

Second, in a health system, the most energy-intensive medical practices do not necessarily lead to a proportionate improvement in health benefits. Like so many other sectors of industrial society, curative care is vulnerable to the law of diminishing returns: more and more energy is needed to achieve ever poorer health outcomes. Conversely, this means that a relatively small decrease in the quality or specifications of medical treatments could lead to comparatively large reductions in resource use and emissions.

Infection control is a good example. The development of general anesthesia in the 1840s made surgery possible, but at the time, over 90% of surgical wounds became infected, often resulting in death. The first significant decrease in infection rates was achieved following the introduction of antiseptic practices (1880-1900), and the second by the introduction of antibiotics (1945-1970). By 1985, the overall infection rate had fallen to around 5%. Since then, numerous resources have been invested to achieve gradual gains towards 100% sterility, mainly by replacing reusable supplies with single-use disposable products.

When properly decontaminated, reusable supplies do not present an increased risk of infection. But cross-contamination between patients sometimes happens by mistake. Nevertheless, some scientists have called for a return to reusable products, whose environmental footprint is much lower in most cases. For example, using reusable laryngoscope handles produces 16 to 25 times fewer greenhouse gases than single-use disposable sleeves. The researchers admit that their approach may increase deaths from surgical infections. However, they say the health damage caused by the production of single-use disposable supplies is even greater.

When it comes to maximizing performance, less wealthy companies are giving us a few lessons. Comparisons between cataract surgery in the United Kingdom and India have shown that the same treatment (phacoemulsification) in Aravind Eye Clinics Indian is much cheaper and produces only 5% of emissions and 6% of solid waste compared to the same operation across the Channel. This is mainly due to the fact that Indian surgeons reuse as many supplies, devices, and medications as possible on as many patients as possible. Additionally, they use locally made supplies, implants, and medications and have opted for a two-bed system. One patient is operated on while another is positioned and prepared in the adjoining bed.

Although these practices flout infection control regulations in high-income countries, cataract surgery in India provides similar or even better results and does not cause more infections than in the United Kingdom or the United States. Therefore, it may well be that the law of diminishing returns has reached its ultimate limit, in the sense that medical practice that is ever more expensive and more impacting on the environment does not seem to provide any health benefits at all. Indian ophthalmological clinics demonstrate that an effective care model is possible with cheap and environmentally sustainable resources and equipment. Medical innovation is possible without new technologies.

Guided by profit

The law of diminishing returns and the emphasis on curative medicine are explained by the primary motivation for medical innovation: profit. Private companies that develop and sell medical equipment, pharmaceuticals, and other health products have nothing to gain if the demand for new technologies and curative health products falls, or if medical technologies are judged on their resource consumption. The medical industry logically wants to increase the sales of its products. To achieve this goal, it has huge marketing budgets and significant power to lobbying.

The WHO estimates that 20% to 40% of health spending is wasted, and says that “the cost-effectiveness, real need, and supposed usefulness of many innovative technologies are questionable.” A growing body of academic literature shows how patients in high-income countries are “overdosed, overtreated, and overdiagnosed.”

This is not a fatality. A modern health system could also work in a different economic context. For example, some have suggested the open source development of medical equipment and pharmaceutical products, in which medical technology would become a common good*. Shifting the tax burden from work to resources could be another part of the solution. In high-income countries, medical equipment, pharmaceuticals, and disposable products are used in part to reduce expensive health workforce.

* [it is absurd to believe that high medical technology can be reappropriated, or even that this objective is desirable because of its global social and ecological implications, NdT]

Age and sustainability

Based on the fragmentary evidence available, it seems likely that the use of resources by modern health systems could be significantly reduced, without taking us back to the barber-surgeons of the Middle Ages. A healthcare system that focuses more on preventive medicine and operates outside the logic of the market could reduce emissions without having a negative impact on health, or even improve it.

On the other hand, the law of diminishing returns highlights the possibilities of reducing the environmental footprint of health services. For example, if this environmental footprint were halved, life expectancy is very unlikely to decrease proportionally. Almost half of health expenditure over a lifetime — and therefore energy consumption and related emissions — occurs at an advanced age (+65). For people aged up to 85, more than a third of lifelong expenses will occur in the remaining years.

Advocating for a decrease in average life expectancy — even if it is a very modest decrease — seems to be a problem. However, denial is just as problematic. Because of the enormous ecological footprint of modern medicine (an impact that is constantly growing), health and longevity today are, at least in part, at the expense of the health and longevity of younger and future generations, who have no say in this debate.

If a person's recovery today is likely to make others sick tomorrow, this care becomes counterproductive. Health is not only a private good, it is a common good. As the material footprint of medical treatments continues to grow, it is increasingly likely that the damage caused to public health by treatment will outweigh the gain achieved by a patient (especially in old age).

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Kris De Decker

Merci à Elizabeth Shove

Relecture par Alice Essam & Eric Wagner