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• Reports show that the healthcare sector accounts for 4.6% of Japan’s greenhouse gas emissions. Other countries have reported similar proportions of emissions for the healthcare sector.
• Overseas, over 600 healthcare organizations have pledged to take action to protect the environment and human health, and examples of concrete initiatives are now being shared.
• For several years, actions for the environment have also been seen in Japan, such as measures to decrease hospital energy consumption, but there are also strong voices calling for subsidy programs and case studies. Expectations are high for more concrete proposals and measures in the future.
  

Introduction

Health and Global Policy Institute (HGPI) has kicked off a new initiative in the field of planetary health, an area that is attracting growing attention in the major global trend toward decarbonization. To ensure sustainable health for the Earth and for its people, we will work to outline a clear agenda for a nationwide response through multi-stakeholder collaboration, to build understanding toward that agenda, to communicate that agenda in Japan and overseas, and create opportunities to take steps forward. In this column, the third installment of our series, we will introduce initiatives for planetary health from the healthcare sector in Japan and overseas.

On a personal note, I recently had the opportunity to attend the 13th Annual Conference of the Japan Primary Care Association in Yokohama. I was surprised to find that two items in the program included the words, “climate change.” The first was a symposium on the latest topics in global health which featured lectures from physicians who are currently researching climate change and health. Among other topics, they spoke about the reasons that planetary health has recently been attracting attention in the context of global health, which we discussed in the second installment of this column. In the other part of the program, participants formed small groups around themes they were interested in to exchange opinions or information and to identify issues and targets. One group discussed what they do for climate change in their capacity as healthcare professionals serving in primary care settings. I heard various opinions in my group, such as, “It is heartbreaking to see the huge amount of personal protective equipment that is thrown away after infectious disease examinations” – an opinion everyone nodded in agreement with – as well as ideas that other people might be able to adopt tomorrow, like “We started composting in our community to dispose of food waste.” There were also opinions looking to the near future, like “When purchasing items for use at our clinic, it might be smart to start prioritizing products from companies that are making real efforts to reduce their carbon footprints.” Participating in that event made it clear that interest in climate change is growing among healthcare professionals and gave me an opportunity to think about small steps forward I can take.

The environmental footprint of the healthcare sector

When looking at how we influence the Earth’s environment, I believe that many of us have recently had opportunities to hear terms like “greenhouse gas emissions” and “carbon footprint.” From a planetary health perspective, there are various anthropogenic factors that cause environmental changes on the global level other than climate change, including loss of biodiversity, global pollution, and land use change.*1 However, to grasp the burden placed on the environment by the healthcare sector, we mainly focus on tracking greenhouse gases (GHGs), the main drivers of climate change. This includes GHGs emitted at each stage of the life cycles of goods and services, from when their raw materials are procured to when they are disposed of or recycled. Below, we will take a look at the Carbon Footprint of Products (CFP) and other indicators that show the total amount of CO2 generated.

Based on estimates from the Greenhouse Gas Inventory, *2 an inventory of domestic GHG emissions, sinks, and precursors (such as nitrogen oxides (NOx), carbon monoxide (CO), non-methane volatile organic compounds (NMVOCs), and sulfur oxides (SOx)) compiled by the Ministry of Economy, Trade and Industry (METI) in accordance with the United Nations Framework Convention on Climate Change (UNFCCC), a report *3 on Japan’s FY2019 energy-related CO2 emissions found that, after electricity and heat distribution, 38% of emissions were produced by the industrial sector, 20% by the transportation sector, and 19% by the business sector and other sectors. Taking a detailed look at the latter, we see the health and welfare sector was the third largest emitter, which produced 11% of emissions (after the wholesale and retail sector and the accommodation and food services sector, which produced 21% and 13%, respectively). A 2015 paper *4 on CFPs in the Japanese healthcare sector reported this accounted for 4.6% of total domestic GHG emissions. In other countries, reported shares of healthcare sector GHG emissions as a percentage of total emissions were 8.0% in the United States (2007), 5.0% in the United Kingdom (2016), 5.0% in Canada (2018), and 7.2% in Australia (2018).*5 A breakdown of Japan’s CFPs in the healthcare sector shows that health services like inpatient care, outpatient care, and dispensing services account for approximately two-thirds of the total, followed by long-term care services and fixed assets like facilities, machinery, and equipment. The report also provides many suggestions for areas to target in the future, such as by pointing out that CFPs are larger for inpatient care than outpatient care, and that GHG emissions from leftover prescription drugs are higher than those from over-the-counter drugs.

Healthcare sector initiatives overseas

As discussed above, the climate impact of the healthcare sector is by no means smaller than other industries, and action must be taken to reduce it. Here is a look at some of the healthcare sector initiatives being taken outside of Japan.

Independent initiatives from various healthcare professional associations and organizations

There are various associations and organizations for health and medical professionals around the world and many of them have already issued statements regarding the health impacts of climate change. For example, in 2020, the World Medical Association (WMA) presented the “WMA Resolution on Protecting the Future Generation’s Right to Live in a Healthy Environment,” ⁵ which provides various recommendations like updating medical school curricula to include mandatory courses that will give healthcare professionals a detailed understanding of climate change so they can help generate solutions to secure the rights and good health of future generations. In 2018, the International Council of Nurses (ICN) released a position statement titled, “Nurses, Climate Change and Health,”*6 which states that nurses “have a shared responsibility to sustain and protect the natural environment from depletion, pollution, degradation and destruction,” and outlines roles for individual nurses to play in their governments and communities.

As introduced in the second installment in this column, an open letter called “Healthy Climate Prescription”*7 was presented to the 26th Session of the Conference of the Parties to the United Nations Framework Convention on Climate Change (COP26) by the World Health Organization (WHO) has been signed by over two-thirds of the organizations representing health workforce. The list of signatories includes over 600 organizations including the Japanese Association of Occupational Therapists. While the details of specific initiatives vary from organization to organization, as demonstrated by the fact that so many organizations around the world are devoted to addressing climate change, we can see the human health impacts of climate change and measures to address them are issues of great concern in the healthcare sector.

For an example of an initiative on the organizational level, the National Health Service (NHS) in the United Kingdom, the largest healthcare workers’ organization in Europe, started a program called Greener NHS *8 which encompasses a variety of efforts to protect the Earth’s environment and human health. One example of an effort on the individual level is an initiative in which an anesthetist collaborated with their colleagues to suspend the use of one of the most harmful anesthetic gasses to stop a major source of GHG emissions.*9 Another initiative adopted electric cars and electric bicycles for use in providing in-home visits to lower fuel consumption and reduce emissions.*10 Greener NHS introduces several other examples with videos which are sure to be a helpful source of information when each facility considers its own first steps.

Healthcare sector initiatives in Japan

Then, what are some planetary health-related initiatives from the healthcare sector in Japan? Below, we will take a look at actions taken in recent years to help address climate change and initiatives and reports from various organizations.

Long-standing initiatives from the Japan Medical Association

The Japan Medical Association (JMA) presented the “Japan Medical Association Declaration on the Environment”*11 in April 2009. It states the JMA will make proactive efforts in four main areas: (1) promote healthcare activities that are environment-friendly; (2) promote environmental health education; (3) provide the general public with education on the importance of environmental health and support practicable environmental health activities; and (4) lobby the Government to create a safe and secure environment.

Taking a closer look at these four efforts and potential future developments,  action (1) describes promoting energy conservation or GHG reduction measures in hospitals and clinics, the proper management of chemical substances, and the proper disposal of infectious medical waste. In the future, it is likely these efforts will also take into account events that occurred after the declaration, such as changes in the circumstances surrounding energy production after natural disasters and other emergencies, or the increase in medical waste that occurred as a result of the Coronavirus Disease 2019 (COVID-19) pandemic. Action (2) mentions, “Enhance provision of environmental health-related information to schools and industries.” Moving forward, the challenge for this is likely to be supporting activities in educational settings and workplaces aiming to heighten awareness toward the health impact of global climate change from a planetary health perspective. Action (3) describes educational activities related to the health impacts of environmental issues and promoting environment-friendly lifestyles as a part of measures to prevent lifestyle-related disease. These actions are likely to emphasize evaluation, analysis, and specific measures on the health impacts of climate change in Japan. Action (4) touches on promoting global efforts on environmental preservation and supporting the balance between healthcare environments and global warming countermeasures that are likely to encourage the nationwide implementation of policies for meeting global standards.

In 2017, a presentation of the JMA’s efforts to-date was given at the International Summit on Air Pollution hosted by the Indian Medical Association.*12 New activities currently being considered include the creation of a textbook on environmental health. A bulletin from the WMA (of which JMA is a member) also gave updates on various global efforts for “Our Planet, Our Health,”*13 the theme of World Health Day on April 7, 2022. We look forward to seeing reports of concrete action taken in Japan publicized globally in the future.

The annual “Report on the Ideal State of Hospitals” from the All Japan Hospital Association and initiatives at individual facilities

In the 2021 edition of its annual “Report on the Ideal State of Hospitals” (also referred to as “What Hospitals Ought to Be”),*14 the All Japan Hospital Association (AJHA) reports on discussions examining how to best structure provision systems in healthcare, long-term care, and welfare based on our anticipated state of the world in 2040. The section of the report on environmental issues examines the health impacts of global warming and issues a call to AJHA hospitals, saying “In our roles as healthcare providers, we must work to adopt low energy consumption practices and switch from fossil fuels to renewables.” The report also highlights noteworthy efforts by hospitals that are taking real action to address environmental issues. At the Kawakita Medical Foundation, for example, they have set targets and introduced assessments for waste separation and emissions reduction led by managers in each department, introduced motion sensors and energy-saving light fixtures in areas with low foot traffic, and have adjusted the brightness of their computer monitors to consume less energy. Recognizing their various initiatives both large and small, the Ministry of the Environment (MOEJ) awarded them the Corporate Award for Environmental Human Resource Development in 2015.*15 The report also details a number of other innovative environmental measures, including waste reduction and reducing unnecessary use of chemicals and medical materials. Similar measures for the environment undertaken on the organizational level are sure to be indispensable in the coming years.

The Council for the Promotion of Global Warming Measures in Hospitals

The Council for the Promotion of Global Warming Measures in Hospitals includes six organizations (JMA, Japan Hospital Association, AJHA, Japanese Association of Medicalcare Corporations, Japan Psychiatric Hospital Association, and Tokyo Medical Association) and works to compile and publicize private hospital sector progress on the Commitment to a Low Carbon Society. These reports provide details on real-world energy consumption and CO2 emission status at private hospitals each year from 2017 to 2021 (the most recent version),*16 which are items that must be tracked to advance energy-saving activities and global warming countermeasures at each hospital. They also include the opinions of people serving in hospitals. According to these reports, items that require action the most include, “Establishing and introducing subsidies and low-interest loans for investing in countermeasures,” “Cost-effectiveness of investments,” “Taking energy-saving efforts into account in the medical service fee schedule,” and “Actively collaborate with energy providers like electricity and gas companies.” Financial difficulties related to factors like the COVID-19 pandemic have made it difficult for hospitals to introduce energy conservation measures on their own, so there have been many requests to expand subsidies for energy conservation in particular. Certain voices called for cross-ministry efforts like combining surveys conducted separately by METI, MOEJ, and the Ministry of Health, Labour and Welfare (MHLW) to make responding to them less complicated. Surveys that gauge actual conditions like these demonstrate the need to continue discussions on how to strike a balance between voluntary bottom-up initiatives from people who serve in hospital settings and regulations, incentives, and other top-down initiatives from the Government.

Initiatives to address climate change from healthcare professionals

Finally, we will consider suitable methods of addressing the enormous challenge of planetary health at the individual level for those who work in the medical, health, or welfare fields. To begin, a report on a roundtable discussion held by two physicians and a MOEJ official under the theme, “How Should Physicians Confront Climate Change?” was published in March 2020.*17 Among various environmental issues, the report places particular emphasis on responding to global warming and describes actions that healthcare professionals can take from two perspectives: mitigation, or taking action to reduce CO2 emissions; and adaptation, or how to respond to changes that have already occurred or are likely to occur in the future.

First, on the topic of “mitigation,” as demonstrated by the societal impact of physician leadership during anti-smoking campaigns, healthcare professionals can have significant influence on individual patients. Changes in society may be possible if a similar approach can be used for environmental issues, and if physicians are given more opportunities to identify environmental issues surrounding their patients (for example, when someone has diabetes and insufficient opportunities for exercise due to increased use of motorized transportation).

Next, regarding “adaptation,” representative topics in this area include the increase in cases of heat stroke or changes in infectious diseases, both of which are expected to occur as average temperatures rise in the future. For example, it is quite common for primary care physicians, family doctors, and other physicians to recommend exercise to their patients, saying things like, “You should exercise to improve your health.” During summertime In the future, they may have to say, “Please avoid exercising to avoid heat stroke” more often. It has been predicted that changes in natural habitats due to climate change will cause zoonotic diseases to emerge in new regions or that infectious diseases of interest will change due to flooding and other natural disasters. It is likely education will have to cover environmental factors in the future.

Regarding which actions physicians can take to adapt and respond to these issues, a list was shared at the aforementioned roundtable discussion titled, “Climate Change: What Can Doctors Do?”*18 It contains many items of great interest to everyone involved in healthcare, we encourage anyone who wants to learn more about this topic to take a look.

In Conclusion

This installment of our column took a look at existing measures at the organizational and individual levels in Japan and abroad in light of the environmental footprint of the healthcare sector in Japan and overseas, and provided a glimpse at measures we look forward to seeing in the future. In the past, people advocated for measures to protect the environment for lofty objectives like, “Protect the earth for our descendants.” Many people may have felt individual efforts to protect the environment would not benefit members of the generations making those efforts. However, in the current era, in which we emphasize planetary health and advocate for taking a sincere and direct look at the human health impacts of global climate change, we must consider efforts for climate change that are more closely related to our daily lives with a perspective that includes us as members of those future generations.

In our next installment, we will introduce planetary health initiatives in Japan with a focus on those from ministries and agencies like the MOEJ, METI, and the MHLW.

 

Works referenced 

*1. Nagasaki University (Supervised Translation). “Planetary Health: Protecting Nature to Protect Ourselves.” Maruzen Publishing Co., Ltd. Pp 7, Fig. 1.4. 2022:18.
*2. Ministry of the Environment, Government of Japan. “Greenhouse Gas Inventory Overview, Calculations and Reports of Greenhouse Gas Emissions and Sinks.”
*3. Ministry of Economy, Trade and Industry. “Current Status of Greenhouse Gas and Other Emissions.”
*4. Nansai, K. et al. Carbon footprint of Japanese health care services from 2011 to 2015, Resources, Conservation and Recycling, Volume 152, 2020.
*5. WMA RESOLUTION ON PROTECTING THE FUTURE GENERATION’S RIGHT TO LIVE IN A HEALTHY ENVIRONMENT. 2020. World Medical Association
*6. Nurses, climate change, and health. 2018. International council of nurses.
*7. Healthy Climate Prescription.
*8. Greener NHS. NHS England.
*9. ‘Healthier Planet, Healthier People’ staff engagement campaign. NHS England.
*10. Green transport delivers life-saving drugs and improves patient experience. NHS England.
*11. Japan Medical Association, 2009. “Japan Medical Association Declaration on the Environment.”
*12. Machinaga, M. 2017. “Efforts from the Japan Medical Association for Protecting the Public from Air Pollution.”
*13. WMA Members Share Perspectives related to World Health Day 2022 (“Our Planet, Our Health”). World Medical Journal. 2022. pp37-40
*14. Committee on the Future of Hospitals. 2021. “Report on the Ideal State of Hospitals, 2021 ed.” All Japan Hospital Association.
*15. Health Industry Information. “Kawakita Medical Foundation Awarded MOEJ Corporate Award for Environmental Human Resource Development in the Large Company Category for All-Hands-On-Deck Response and Awareness-Raising.”
*16. Japan Medical Association. “Responses to the Commitment to the Low-Carbon Society Plan in Hospitals – Follow-up Fact-Finding Survey Report.”
*17. Hasegawa, T., Hirashima O., and Tokuda, Y. 2020. “How Should Physicians Confront Climate Change? A Roundtable Discussion.” Medicina Vol 57, No. 8. Igaku-Shoin. Ltd.
*18. Thomas Micklewright. Climate Change: What Can Doctors Do? EMJ. 2017;2[1]:12-14.

 

Column authors

• Sayaka Honda (Program Specialist, HGPI)
• Shu Suzuki (Associate, HGPI)
• Joji Sugawara (Senior Manager, HGPI)

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