Vittoria Bellato interviews Victoria Pegna, co-founder of RCSEng Sustainability in Surgery, for ESCP sustainability month.
Victoria Pegna is an ST7 trainee in Colorectal and General Surgery and co-founder of the Sustainability in Surgery (SiS) Committee at The Royal College of Surgeons of England.
Part A: Your outlook
Vittoria Bellato: What does sustainability in surgery mean for you?
Victoria Pegna: For me it means thinking about every second of my day at work and what I can do to reduce my carbon footprint. I cycle into work. I only use gloves with patients where necessary and wash my hands before and after instead. I try to encourage the use of single use devices such as staplers where necessary and when using a stapling device try to use that same one with reloads through out the whole operation. I use washable drapes and gowns. I wear my own washable scrub cap. I don’t open equipment until definitely needed intra operatively. I don’t waste suture material. I use reusable laparoscopic ports where available. I use reusable clip appliers rather than single use. I suture rather than clip skin in general. I don’t buy lunchtime meal deals with plastic bottles of drink, rather cans instead. I try to encourage and carry out phone clinics or order remote tests where possible to reduce the carbon footprint from patients travelling.
VB: Should sustainability be mainly driven by governments, doctors and patients or companies?
VP: All of the above! They all account for different areas. Governments should be promoting and facilitating and funding. But equally doctors needs to vote with their feet, they need to use less, ask for reusable instruments to be provided rather than single use ports and instruments. They need to sign contracts with companies that have good ethical and sustainability principles and move towards companies that are UK-based and source they products from the UK and are not single use and are at the minimum are participle reusable.
Companies need to also lead the way and make changes and fund research into re-usables and provide their products in packaging that is minimal, not plastic, and biodegradable or compostable.
This will be the future and we will get there, but we need to do it more quickly than the current trajectory.
VB: Which in your opinion is the greatest misconception on sustainability in medicine?
VP: That it’s not possible, but it is. As I’ve listed above, these are really easy first steps that we can all change over night.
VB: Which is the biggest goal already achieved in terms of sustainability that can serve us as a positive thinking when feeling overwhelmed by the current situation?
VP: Telephone clinics have had a big impact on carbon emissions from patients not having to travel. It will always be necessary to see patients face to face and indeed I really enjoy that. But we can minimise unnecessary travel sometimes by trying to book scans and clinics together and really considering whether the patient needs a face to face discussion or can it be over the phone.
Part B: Sustainable surgery for environment
VB: Recently, the sustainability of health systems has been placed among the long-term goals of some nations. For example in England the NHS [1] has set two targets:
- For the emissions we control directly (the NHS Carbon Footprint), reach net zero by 2040, with an ambition to reach an 80% reduction by 2028 to 2032;
- For the emissions we can influence (our NHS Carbon Footprint Plus), reach net zero by 2045, with an ambition to reach an 80% reduction by 2036 to 2039.
In your experience, which nation has most implemented sustainability in the medical-surgical field?
VP: I feel we need to operate more in line with those in low-income countries. There is far less waste when resources are poor. And we need to learn from this and try to reduce unnecessary usage of items and reduce packaging and waste.
VB: Can you think of some virtuous examples made by national policies made to implement sustainability in the medical-surgical field?
VP: I think far more could be done and we have a long way to go, so no policies spring to mind that have been imposed to reduce our carbon footprint. Washing our hands instead of using gloves unnecessarily could be one! And the NHS net zero target is a good goal, but the date is too far away and changes need to be made now not in 20 years.
VB: Medical equipment accounts for 10% of the carbon footprint of NHS, which is 4% of England’s overall carbon footprint. Operating theatre is the most resource intensive area of the hospital, and account for 25-30% total hospital waste. Are surgeons aware of the situation and how many are actively searching for ‘green solutions’?
VP: There are some surgeons and some scrub teams that are aware and actively trying to seek out solutions. I think more surgeons could be more aware. I don’t think surgeons and scrub teams in general consider the environment as much as possible. But we need to take an example from those that do. We also need support from hospital management and procurement as often they are the stumbling block.
Often money is the driver and the bottom line, but sometimes a product may be cheaper to buy, but when it has to be disposed of and transported and burned that may actually cost the hospital more money. But that isn’t in the procurement budget so it isn’t taken into account and so disposables are often seen as cheaper when they aren’t (apart from the fact they are costly for the environment too).
VB: In which practical directions companies should be moving to ensure a more sustainable surgical practice in the future?
VP: Companies have to start producing re-usable or semi-reusable instruments. They need to put their products in less packaging and packing that isn’t plastic or compostable. They need to ethically and environmentally dispose of their packaging and instruments that they produce themselves. They need to procure their products and materials from traceable and ethically sourced areas, ideally UK manufactured. If they don’t do these things I feel we should stop using those particular companies.
Part C: Affordable surgery for all countries
VB: It has been estimated that every year there are 16.9 million deaths related to lack of surgical treatment (four times the number of deaths caused by AIDS, tuberculosis and malaria combined) [2, 3]. How can governments and companies make a difference in promoting affordable surgeries services in low income countries?
VP: They can provide low cost instruments and fund training and design reusable versions of their single use instruments.
VB: How much can a surgical instrument price can vary between different income countries? Are there controlled prices?
VP: Yes there’s very different in price even from hospital to hospital! There is no control or regulation.
VB: The development and use of reusable surgical instruments could lower the demand for purchases in high income countries but this strategy would make them accessible to more countries; recent studies [4-6] advocate the safety of reusable instruments: what is your point of view on this topic? What are the major limits?
VP: This absolutely needs to be done. This is a responsibility of the companies producing them to design reusable instruments and to make them affordable for low income countries. It is possible but it’s not in their financial interest to make re-usables so they don’t. But this has to - and will - change as the future is not single use plastic.
VB: What are the most important steps to make in order to achieve affordable surgeries services to low income countries? How we can get industries on board?
VP: For the big countries to make affordable instruments. To make reusable instruments. To ring fence some of their huge profits to low income countries to help provide equipment.
References
- https://www.england.nhs.uk/greenernhs/wp-content/uploads/sites/51/2020/10/delivering-a-net-zero-national-health-service.pdf
- Nepogodiev D, Martin J, Biccard B, Makupe A, Bhangu A; National Institute for Health Research Global Health Research Unit on Global Surgery. Global burden of postoperative death. Lancet. 2019 Feb 2;393(10170):401. doi: 10.1016/S0140-6736(18)33139-8. PMID: 30722955.
- Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, Bickler SW, Conteh L, Dare AJ, Davies J, Mérisier ED, El-Halabi S, Farmer PE, Gawande A, Gillies R, Greenberg SL, Grimes CE, Gruen RL, Ismail EA, Kamara TB, Lavy C, Lundeg G, Mkandawire NC, Raykar NP, Riesel JN, Rodas E, Rose J, Roy N, Shrime MG, Sullivan R, Verguet S, Watters D, Weiser TG, Wilson IH, Yamey G, Yip W. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015 Aug 8;386(9993):569-624. doi: 10.1016/S0140-6736(15)60160-X. Epub 2015 Apr 26. PMID: 25924834.
- Siu J, Hill AG, MacCormick AD. Systematic review of reusable versus disposable laparoscopic instruments: costs and safety. ANZ J Surg. 2017 Jan;87(1-2):28-33. doi: 10.1111/ans.13856. Epub 2016 Nov 23. PMID: 27878921.
- Eckelman M, Mosher M, Gonzalez A, Sherman J. Comparative life cycle assessment of disposable and reusable laryngeal mask airways. Anesth Analg. 2012 May;114(5):1067-72. doi: 10.1213/ANE.0b013e31824f6959. Epub 2012 Apr 4. PMID: 22492190.
- Overcash M. A comparison of reusable and disposable perioperative textiles: sustainability state-of-the-art 2012. Anesth Analg. 2012 May;114(5):1055-66. doi: 10.1213/ANE.0b013e31824d9cc3. Epub 2012 Apr 4. Erratum in: Anesth Analg. 2012 Sep;115(3):733. PMID: 22492184.
