Transcripts For CSPAN Health 20240703

Joanne we are about ready for the panelists if people will take their seats. I want to add a few tiny additional notes to the bios. Jeremy is working on a book about medical waste. It is called the working title is called syringe ties. It does have a jersey shore angle. Jody i also wanted to mention the work she is doing at yale. She serves on the National Academy of medicine collaborative on decarbonization. She is plugged in to the nexus of where an awful lot of people are an awful lot of things are happening. When diana talks about caregivers, she means the doctors and nurses. I really wanted a nurse on this panel because nurses are doing in Health Sectors in Health Systems i have visited nurses are doing a lot of the work on the ground. We have a lot of control over what is used and in some cases what is bought and how to do how to throughout less stuff. Thank you for including us. Joanne student nurses too. Medical students and residents come a lot of things are bubbling up from the generation. I kids are very concerned about are they going to have a planet. On the ground in Health System come a lot of the work is for nurses. When dan and i started talking about this many months ago, at first i think he thought it was he was glad i was so enthusiastic but i think he and my colleagues began to understand this is a health issue. It is also a business issue because health care is 18 of our gdp. Around 1 5 the amount of waste as we have heard is extraordinary. So much of what you use is thrown out. I want to start. It may be Getting Better but you also work in the clinic one day a week in baltimore. Clinic for low income people. You are an anesthesiologist. You are a Womens Health nurse. I want to each of you think of something in your clinical lives recently where you looked to the stuff and thought am i really throwing this out. That everybody here is a clinician. Give us an example of stuff like scissors that you actually throw out. Do you want to start . This is one of them. We have these suture removal kids and it is fascinating. What i wanted to start is the speculum. Joanne he is going to give us a history. I want people seeing on cspan to understand everything you touch gets thrown out. I have not been in medical practice that will. I work at a Community Health center. The pelvic exam is an important part of committee health. The physical substance of what we use when i was in training we used a medical speculum which where every reasonable. Sometimes they could be cold. Sometimes they could be warm depending on who was using them. The plastic speculum was more reliably warmer. It would still have a reusable light source. It is only in the past five years my clinic has shifted to using a plastic speculum that has a disposable light source. So now in addition to all the extra plastic we are putting into the waste stream every time we do a pelvic exam, there is a earth metals. There are these better resources and leds being thrown out. That is part of what woke me up to realizing that actually all of the objects in my clinic were moving toward increasing disposability. The moment in which most of the rest of the sectors were trying to grapple more concretely with sustainability. We keep on producing new kinds of costly trash. I can talk about speculums all day. In our system in order to pass the joint commission inspection, we were using metal speculums. The problem came up with just this cleansing. Somebody said is like washing your dishes off before they go into the dishwasher. So instead of what would be the costeffective way of reeducating the caregivers of how to properly wash off the speculums, the whole Health System had to switch over to plastic. Once you go there, there is no coming back. But my thing is disposable pillows. Joanne disposable pillows . There was somebody that did a project that showed we could save the Health System money if we change from reusable to disposable pillars. What they did not display will pillows. What they did not take into federation is disposable pillows are vacuum sealed. They come in so much plastic. The staff hated them. The patients hated them. The nurses are putting six disposable pillows per bed for a labor woman to get to a pillow that might be this big. The battle to change back to reusable which i recently just won took so long. Hospitals have so many different meetings. What was a Good Intention at first it never really thought out. Our labor ladies have more reusable pillows that are great for the environment. It is really challenging to pick one item. Things from low risk devices like linens, the bed linens as well. Blood pressure probes. Things that are the risk in terms of infection transmission. All the way to things that are complex Surgical Equipment that cost hundreds if not more than 1000 each have become single use disposable. And yet we use thousands of things every day in the hospital including thousands of surgical instruments. Just because something needs to be sterilized does not mean it needs to be disposable. We can transmit infections with a single use disposable device just as readily as we can with a reusable device so we need to dispel this notion single use disposable is utter for Patient Safety. For things that are difficult to clean, things that are cheap come of course we are not going to reuse those things. Something we use every day in my profession as an it is teleology as an anesthesiologist, this has become disposable as well we can go. To restaurants and use reusable silverware, tableware without any issues. Why do we think something that goes in the mouth needs to be single use disposable . Joanne that is one of the big myths and we are going to come back to that which is it has to be single use or else we are we are going to kill everything. That is not true and that will come up. I want to turn to jeremy because he is a historian and he can help explain how we got to this point because plastic did not even exist when medicine began. How did we get to this disposable culture and what does that what does the history tell us about the future . This reflex on both of your recent comments in terms of how do you switch back and how difficult it is to switch how do we take these assumptions built in that we need to valorize disposable . That it would be responsible for health care to use things that are not single use. If you go back 60 years, you see the Health Care Economy in which the construction of medical devices were all built to be durable Precision Instruments meant to be reused. That was a value structure. It was built into how engineers worked, how industry pretty to their markets and if you look at the transition that happened as disposable started entering health care, a huge wave in the 1960s. Journals like journals for hospital administrators and purchasers are all fretting about the problem of how difficult it is to switch over to disposable. This the same problem you are dealing with. It was a tremendous amount of work to make Health Care Single use. It was not cheaper. Disposables were more expensive. They were not clearly safer. There all of these processes that happen in the transformation which were the result of human decisions and ultimately they made sense and i can pinpoint a year. It seems 1965 when it finally became costeffective to use plastic single use syringes. Until that point, there were other reasons besides economics that drove the transition. Once the behavior had changed, the economics matched up as well. It reflects back on one of secretary becerras comments. If we actually drive a set of value choices, that can derive market that can drive markets in the right direction. There is nothing and evitable about the use of disposable objects. Joanne except it is good business. If you are making things that are used only once, you have to keep buying them. Well talk about how you change the market in a minute but the market changed once. We can have some hope that we can change it again. Dr. Greene my point is we should not accept the objects in our everyday life and the things we need things we assume the need to be the way they are as being fixed things in the world. Even the statement disposables are cheaper was not initially true. Joanne we switched to garbage even though it cost more. Dr. Greene exactly. If i may respond, on the case of syringes, we are not going to go back to glass i will say by and large for this may not go across the spectrum but for every device ive looked at that there was reusable a reusable and disposable option, if you do the internal cost analytics, everything ive looked at has favored reusable. It is a myth to think single use disposables are cheaper. You have to be very careful who does the analytics. Across the entire organization. Not just the essential sterilization department. You have to figure how many uses and the cost of refurbishment, of cleaning. All that has to factor in and by and large reusables tend to be cheaper but the challenge culturally of switching back now is if you lost the infrastructure, the staff, the set up to be able to handle those devices, that becomes a huge change in management issue and becomes too much for leaders who are oppressed with multiple crises particularly coming out of the pandemic. Even with financial crises, when there are clearly going to be financial wins here to be able to divert some staff to start the change management process. It becomes too much to consider. Joanne you are both a National Expert on this but youre also a change agent at your own Health System at yale. Talk about how you are beginning to get people to buy in. You have to get all the right stakeholders in the room. In the case of medical devices, you have to work with a value Analytics Team. It is challenging because everything you purchase is bundled with other things you purchase and have contracts. To take one device even if there is a clear win and try to switch it back to reusables, you have to look at how the how long the contract is. How it is tied with other products. It becomes a complex issue for the value Analytics Team to investigate what it is going to take to unwind the contracts. You have to get the buyin from the clinical staff that it is ok to reuse these to use these reusable devices. It is a challenge to move back. Joanne i dont want to get the whole panel but talk ruefully about it. 2 but talk briefly about it. Two of the most common gases are bad for the earth. There are cheaper, it safe and actually cheaper alternative anesthetic agents that have been endorsed by the professional society, the American Association of american anesthesiology. Has yale switched over . Is it a little here and a little there . Dr. Sherman just to explain a bit more if people are not aware, the gases we use for general anesthesia are potent Greenhouse Gases, the body does not transform them. Your body takes them and then they are exhaled and the gases is blown off the hospital rooftop. They live there anywhere from a few years to over 100 years. We do have in some instances alternatives. Sometimes anesthesia can be done with Regional Anesthesia where you just numb up a body part. They are not essential for all procedures. By and large, it is the most predominant method for providing general anesthesia. Of the four main gases, two are much more potent. By thousands of times compared to Carbon Dioxide as the equivalent measure. The other two gases are much lower in potency. One of the most expensive gases is also the worst for the environment. The Health System got rid of the gas in 2013. Were the first to do so in the world on environmental grounds. This started a wave globally. It has now been banned in scotland. It is being removed from england this year. There is movement to ban it in europe by 2026. Joanne how common in the u. S. Is that switchover . Dr. Sherman dr. Sherman we dont have data on that. I can tell you anecdotally it is becoming more common. We saved 1. 2 million just on our flagship hospital 11 years ago by getting rid of this. The other challenging gas as nitrous oxide. It is a different type of gas. It types through the hospital walls. A lot of gas is lost in the connections between joanne up to 80 . Dr. Sherman actually more than 90 . Getting away from the pipes and going to tanks at the point of use, you can eliminate 95 of that. Joanne lets go to dan. In your institution, you were the change agent. A small group of colleagues. The example of the nurse i was talking about. I did not know her when i was writing about this. I just met her on the phone this week. People like you are how a lot of change beginning in the Health Care System. And you are not as far along as yale and you are not as far along as the uc system where it is mandated. How did you start and just tell your story. I am definitely a bottomup change agent. The reason i am here today is because my teenage daughter has ecoanxiety. Those of you who dont know, they know Climate Change is happening. It is destroying life and species. There are things we can be doing now that they dont see adults doing. They carry the burden of saving the world on their own shoulders. Which is a lot of work for these young adults. To my daughter, i vowed to muddle to her adults are fixing the problem right now. The first thing i had to do was learn about environmentalism and Climate Change that i was so shocked about how much of the Health Care Industry ive been in the last one years contributes to Climate Change but we can also be the solution to what i had this knowledge i started to make power points about it. I figured i would just go to hospital leadership, and they would hear this and everything would change. I realized i was just one Nurse Practitioner and one powerpoint and i was not making the change could i dived in and i have followed dr. Shermans work and i made my power points better and i decided i was going to try to get in front of any group i could at the hospital to share this information because i wanted to turn the climate volume up in the Hospital System so everyone would hear it and change what happened. When my household system we did sign the pledge which is so great and we had an environmental governance Leadership Structure and part of the structure was the environmental sustainability caregiver community. I was asked to lead it. Once i had that committee, i have been running with it. The first thing i did was i scheduled meetings with key players. I wanted to talk with the lead of infection prevention. I went to talk to the lead. They all got my powerpoint. Which basically was sherman 2. 0 and how w pay so much for health care. Theres a lot of opportunity to decrease the low value care without sacrificing on quality. Ive made all the strategic meetings. At the same time, trying to engage caregivers because my main goal is to make health care the solution for the larger Greenhouse Gas problem. You have to engage the caregivers. That is the problem because our hospitals and all of our wonderful people who worked in the hospitals, they are from the community. They have been exposed to what the fossil fuels have injected, the Disinformation Campaign for decades. Even though i tell them this is an important issue, i can see it is not making the change. I just had a Conference Last Week that was the first conference at our hospital and my Health System supported it. It was a climate and Health Conference to educate caregivers about this issue so there can be more engagement to help with Hospital System and carbonization by larger purpose of going into the community and telling people about how this is connected and how we have to Work Together on this issue. Joanne as a historian, how are we going to look or how is the Net Generation going to look back at 2024 in terms of health . Dr. Greene historians are not as good at futures. [laughter] joanne as a clinician. Dr. Sherman all the things i might bring with me. Im very inspired by deannas story. This kind of thing is happening all over the place. The Sustainability Leadership Council has existed at Johns Hopkins for a while now. Last year was the first year we put a Health Care Section in our annual meeting. This year, there was a full days worth of events based on health care practitioners, policy researchers. People coming from different parts of the sector waking up to this issue and wanting to do something about it. It is not just us here on this stage. It is a tremendous amount of momentum building in this sector. I think it is a bottomup thing. Why we use so much plastic. I agree with jodis point the disposable syringe is unlikely to shift back to the glass syringe. Disposable gloves are unlikely to switch back. I can show you ads for glove washers. I dont see a market for those products. You look at this literature on surgical drapes and part of the reason it is wonderful to engage with anesthesiology is in addition to the gases, the or is the largest site of Waste Production in the hospital. All the stuff is left on the floor. When i was in my medical training, i did two surgical rotations in the 90s. When was at brigham winghams hospital the other was at the mass general. Mass general was using over usable. There was no evidence one was safer or costeffective. As we move towards as we have moved towards using all disposable drapes, that is a reckoning that no one has taken a close enough look at 10 i think what is happening in 2024 is we revisit these calculations. Not every item can go back away from single use but a lot of them can. Need to be asking these questions a lot more clearly. Jodi made a point which is crucial. Why did we shift away and what capacity did we lose in that shift and what does it take to rebuild that . In the 60s and 70s, it was shifting away from labor problems to supply problems. The Skilled Labor required to run the sterilization facility was seen as an unpredictable thing for hospital managers. Hospital managers saw themselves getting a benefit by turning into a supply chain problem. As long as we can further globalize the supply chain and have the access to these goods that worked for us who market the goods as well. What happened in the pandemic is we all recognized the dependence on these supply chains was an incredible liability. The question is how long we can keep open what we learned at that point there is a window of learning that happened of our dependency. The investment in individual capacity and Skilled Labor being something institutions should make which i hope we can extend to this point. 2024 is a year of reckoning, recalculating, reexamining this to shift from labor supply. And then rebalancing the table. Joanne in the Health Systems engaged in this effort to decarbonize on different levels, there is a lot of activity to some of it is topdown. A lot of it is bottomup. I would hear stories about a student nurse coming in and saying one example was all this material thrown out in the or i cannot remove or which California School it was where one of the student nurses piped up and said once the patient comes in, all of this plastic, we cannot recycle it if there is any exposure to bodily fluids. Why dont we keep the patient out there for 30 seconds longer . You think of a Health System the size of ucla, that is a lot of plastic from something really simple. Little things add up. Things like were not going to go back to glass syringes but providence is a Health System that has been doing sustainability work for decades. The sharp containers in you see them all over the hospital. Every clinic. They would fill them up and throw them out. Now they are used i think 60 times each so across the Health System that is truckloads of plastic not getting thrown out. How much of it are these little steps there are a lot of little steps and they are exciting and easy to replicate but do the little steps add up to matter workaday or do they become windowdressing . Im having where are we with all this in the early systems, there is stuff, there are ideas. Does it add up to much yet . Dr. Greene i think there is low hanging fruit and the big structural changes. If you are asking should we be moving past the low hanging fruit of the structural, my answer would be and. The question of green inhalers, theres been a lot of attention. Every time you use as an inhaler, it emits directly co2 into the atmosphere. That amount is nothing appeared to what is coming out of the or. You might say that is an easy thing to gain a symbolic win on but what really matters is what is happening elsewhere. That helps prepare the visibility of the need for further change. Ms. Benner i think all the Little Things do matter. Everybody is doing their part, i think you can have huge change. One thing in our Emergency Department is we realized we were putting gowns on the stretchers before the patient went into the room. Most people dont actually need a gallon. All the energy to wash and produce the gown goes into waste. One thing we are doing at the hospital is when i took over the committee and i engage caregivers, two think they cared about was changing from styrofoam to another alternative that was safer and recycling. Recycling does not affect ring gases. For caregivers, it is a visual thing people are concerned about i went to the recycling facility and learned what we recycled and i learned we were recycling incorrectly. We were sending the bags of recycling to the facility should the bags were being thrown in the trash. And very expensive way and a long way to get to the landfill. The one thing i learned during that tour was on were shipping the trucks off with the material that was recycled, i said where is it going . There were like, it is going overseas. Even when we do recycle perfectly, it is not the best option so we came home back to her Hospital System and we said how do we reduce waste further . We started a medical supply Donation Program where instead of trashing extra supplies, we are collecting them and i reestablished our Donation Program with project your care they collect nickel supplies and donate them overseas. I went there and we volunteered there and realized all of their expired stuff was being thrown in the trash at project cure because they did not have the capability. They could not get expired supplies overseas. I reached out to nursing schools. I said can you guys use of these expired supplies and i found out they can. We go through tubes. They have a date on them. Most of them working thrown in the trash. The nurses will pay . 75 for the same used and other Health Assessment monitor simulation. We to our hotel high schools are tech high schools and local community colleges. It is really helping to reduce the cost of educating the next generation of health professionals. Joanne because you dont have to throw them out if you are using them to train. Ms. Benner and at the same time all the supplies we are taking down we are inventorying them. Also makes the hospital leadership understands and Pay Attention to what is a waste. We can say we donated 15,000 worth of supplies the other day the project sure. They as a nonprofit can promote that as part of their community benefit. And also we now understand wherever waste goes. But he brought down cardiac there were 300 a piece. Those would normally be thrown in the trash. We can say that was 13 worth of supplies. We have to do a better job of going through and making sure those wires dont expire before we use them because that is waste. Joanne why is a piece of plastic to be expired in the first place . Is this just part of dr. Sherman firstly, i admire all you have done. I will say as you learned, recycling has very low environmental benefit and may cause harm as recycling processing may be skewing micro plastics and nano plastics through the waste stream which is another challenge we have. Recycling also requires such complex systems to be able to do so safely in clinical environment. In the or we have 12 different waste streams at my own institution and trying to figure out where we put that piece of plastic instructs you from other things you need to do to keep patients safe and continue to reeducate. Recycling is such while it may be something visible people care about, detract takes so much energy and attention from moving upstream and addressing problems which is generating the waste to begin with. We need to address many stakeholders and the problem expiration is one of the issues. I just want to say we are very wasteful in our clinical practices. We have the benefit of being a very wealthy society. Until the pandemic unless you have a medical mission in low resource setting, you have no sense of how wealthy we are in our Health Care System. It is like a candy store. You pull whatever supplies you want without any consideration to preventing waste to in the pandemic when we started to see patients dying in new york city because we were running out of supplies. New haven were a couple weeks behind them in the surge and we had similar fears we were going to experience this. Only then did people start paying attention to the fact maybe i dont need to be using all those things. Part of it is a cultural mindset. After our supply Chain Shortages when away went back to the same wasteful issue. As clinicians, we need to address our behavior around waste generation. Moving upstream. In terms of the Expiration Dates, this is a huge problem to to the best of my knowledge and perhaps jeremy has uncovered this in his studies. This is something that has to come through the fda and through the cdc. There needs to be in Interagency Working Group to sort out issues around things like Expiration Dates because part of what industry benefits from as consumerism. From is consumerism. Manufacturing more disposables, making it impossible taking reusables off the market is another strategy industry does to drive disposability and consumerism. The other thing that gets manipulated is Expiration Dates. This really came home during the pandemic. Patients were dying because we were running out of supplies. When expired medications, expired devices were found, we had to go through testing to make sure they were safe to use which caused a delay. Particularly the government, the federal Health System found warehouses of supplies that were still good and usable but had to go through testing. This can move upstream. The fda can require industry should prove with the end Expiration Date is. Not just randomly pick one and say we are good until that point. Joanne one of the things we were talking about the other day, until we have a different supply chain which is not going to be tomorrow, you were talking about things like inventory and keeping better track of things let you know we are throwing these things out because we ordered too many of them. Part of that is smarter management of the disposables until we get to reusables. I dont know if you can quantify. There is stuff sitting on shelves because somebody ordered too much because of the complicated contracting and purchasing world jodey described. How successful have you been in changing those practices . Are they ordering less of the stuff you end up throwing out . Ms. Benner we were just at the meetings with our key players in supply and talking to them. My first meeting with them was telling them about how harmful preventing what is going on. I had to present how harmful styrofoam was. The next meeting is about maximizing our medical device recycling program. There is a lot of confusion with programs we participate in. My job is to give mckay to the caregivers when the people who are organizing them, we need to get a little more organized with reusing to recycle and maximize our materials of recycling that. With supplies where i work, we have a medical supply for a Vaginal Speculum kit. Most of the time we just use the spec. That is the only place we have a metal speculum. I conducted an audit of family times we use the supplies. I found out cotton balls are like . 65. Weve been throwing away five of them all the time should i been trying to collect them up with in my donation bin. Muslim buddy else is throwing them away. The change mostly everybody else is throwing them away. The change of what goes into the pack has been difficult. Joanne i want to talk about what it is going to take to create new industry. What is that going to look like, what can government do and what can the consumers do. Before we get into it, i want to talk about the culture of change. There are people like you or all of you who are looking for you are doing a really granular way of looking at how many cotton balls and how may of this is getting exposed how many of this is getting exposed. You are looking at it in a really practical what can i do with the resources i have. Yale was 11 years ago . How much resistance. When you tell the colleague besides bureaucracy and contractors who do things a certain way and dont want to change, how easy is it to get your fellow physicians to do things differently than the way they are used to doing things . We know from the research and overuse and overtreatment how you were trained and how you start your medical practice, it is hard to get people to change. Even if they understand that everything is necessary, they are still doing it. Take that overtreatment over stuff. When you go to a colleague and say this is good for our patients and way better forever planet, to they say great sign me up for that is not how i do things or that is not how i do things . Dr. Sherman change management is really hard and you have to come from the perspective of the stakeholder. For example, if a nonclinician tries calling anesthesiologist to get rid of that is not going to go over well. If a nonanesthesiologist who is a physician tries to tell anesthesiologist, that is not going to go well. You need to understand why choices are made in the case of that drug as different characteristics than other drugs. In certain circumstances patients can wake up more quickly. Understanding why those decisions are made to begin with and presenting the facts because everyone of us in the Health Care Sector cares about health outcomes. That is why we come together. If one can present the fact about why one device or drug or way of doing things is desirable from a clinical standpoint and try to propose what is called clinical your different ways of doing things with similar outcomes. Being sensitive to the reasons why one chooses one way or another and present the facts. It helps to say in other Health Systems, other countries are doing this as well. Then there is the competitive nature we dont want to be laggards. We want to be ahead on leadership should you also need to consider who the stakeholders are. In the case of organizational leadership, the need to understand what is better for the bottom line, what is better for Patient Safety. Public health is an extension of Patient Safety but it is not the most immediate thing as Health Care Leaders. Understanding what is coming around in terms of wrigley torrey risks. Right now, these measures are voluntary. Both the joint commission and cms have voluntary environment of standards on board. That is a harbinger of requirement could there is a risk of not figuring out how to get on board now and overall, things like worker attraction and retention Health Care Leaders care about those things. There are plenty of studies that show the present generation care about making decisions on where to work and where to stay and where to study pit sending this information, there is a way to help engage them and get them on board. Dr. Greene i agree with all of this. Value alignment pragmatics and getting to equipoise is crucial because no Health Care Provider is going to accept a single bad outcome done in the name of an abstract seemingly abstract goal of sustainability. It helps to get around three principal areas of resistance and one is the scene of his out in opposition between sustainability and safety. The second is efficacy. Just ability and efficacy. The third as efficiency. If sustainability is fractionally more expensive, they can be equated with restricting the people who get access to health care. These are very common forms of opposition. It is all well and good to be interested in sustainability but if it takes away from these goals of health care, it will not work. These are false dichotomies. In the case of the disposable syringe, we can point to a lot of data that suggests moving to disposable syringes has done equitable things from a safety perspective. In terms of drapes, there is no reliable body of data. These tradeoffs here and there makes sense. They are not absolute dichotomies. There is a way of disarming each of them. And actually performing an alignment on sentiment of value of wanting health care to improve the health of all of our patients. So many Health Care Providers are experiencing the distress. They want to get toward the alignment. We can help them pass the divides between sustainability and fundamental values of health care. We actually produce change. Joanne we talk to secretary becerra they cannot mandate. It is hard youll know where we are historically. For now, it is always hard to mandate. The whole process is really cumbersome and you often dont end up where you want to end up between what congress can do and what the courts can do. Theres investment on hhs. It is not doing anything you would do at the perfect world. It does having we have an office dedicated to this and putting money into the ira. A huge part of it was about climate to was about climate. It does matter in some way and helps create some momentum to can one of you or all of you address the joint commission . It seems to be it is outside of government it is not partisan. How important is it to a Health System to have the certification . Is that something you can go to o the leadership and say the joint commission has this sustainability certificate, i want us to have one. Is that a tool for you . The joint commission drives so much unnecessary practice. I would go to do a prenatal visit and all of a sudden there is a plastic sandwich bag around the doppler machine. They are to prove it is clean. You just cleaned it because that is your job and you put it back. Why do we need a plastic bag on top of that . It is all because to make the joint commission happy and to show them we are doing the right thing. The ultrasound machines are coming around with large plastic garbage bags to prove that it has been sanitized. Why dont we just sanitize it and not have to put the plastic back and say we know we are doing our jobs because that is what we do . Having joint commissions to have it being a military option for the sustainability part would be much more effective. Can i Say Something about the change agents . You guys are talking about the Amazing Things happening from the top down to have the change happen. From the bottom up, im trying to engage caregivers. To really communicate to them they need to care. Climate change is such a distant problem so the nurses coming in, the younger ones dealing with young families and making sure their children are good or adolescence are not dealing with mental stress and the older ones are caring about taking care of their parents. They are really not that engaged. In few research, Climate Change and providing the environment is 14th on the list of concerns. These caregivers, im trying to engage them to say this is really important. That is why i do all of my presentations. If i can have five minutes in a nursing meeting, i will present something about how climate and health are connected. Im like you just have that baby. We should care about him so we are going to advocate for reusable pillows today because we care about his future. I throw that personal narrative because i have got to engage. Ago to engage all these caregivers so we can meet in the middle. The Climate Conversation at the hospital is so loud hospital leadership knows the people doing the care care about how they are delivering so we are going to follow the joint commission standard. It works on both ends. Joanne are you doing everything you were doing clinically on top of the clinic . Have they changed your job and given time to do your claim at work . Ms. Benner i do it all on top. I worked 212 hour shifts in my Womens Health Emergency Department. I do everything sustainable on top of it. Joanne i should point out in addition to coming down from yale which is by train so flying is not so good for the environment is going back and doing an overnight shift tonight. She is also another [applause] joanne he has to go back to his computers. Dr. Sherman of course we need a groundswell from the bottom up. If we dont have the top down to enable, it is not going to go as far as it needs to. Coming back, the example of reusable pillows, we still have a problem clinically of using too much stuff unnecessarily whether it is reasonable or disposable. That is a culture issue we need to address. When it comes to Something Like the joint commission and having to cover the ultrasound machine is the example you provided with singleuse plastic to prove sanitation, the joint commission would argue they hold us accountable to our own policies and procedures. They dont write them. They dont have policies and procedures in place that support reusable cleaning at have some proof of cleaning and that our staff when they do the site visits are aware and demonstrate those procedures, they will leave us alone. Part of this is it has become so easy to throw things away and not have those policies that it a barrier. Even if you are commission that cares, it is so common to hear i cannot do anything about it because the joint commission requires it. We can rewrite our policies. The joint commission will hold us in account to those policies. Joanne christiana care has made decisions. Some of that is them using the plastics. Become incredibly burdensome. The initial example i gave, 10 years ago there was a wave across the country going to singleuse disposables. I asked my manager what was happening. He told me when they dug in further i understood a got in the cdc language. Industry jumped in this to start writing making it a higher class device. For epidemiologists, we deem the infectious risk classification not industry. The joint Commission Said that the followthrough, the gap, its a big regulatory loophole. Lets talk about what a greener supply chain would look like. Since it is a hypothetical, we dont really know yet. Making a switch to disposables, how will they make the switch. Right now supply chains make money through disposables and singleuse plastics. When i started thinking about this in writing about the scum of the supply chain, for those of you that speak climate, there are three levels. The supply chain is the third and hardest. Its pretty easy to compost and a lot harder to market these devices, and get them to accept them and are the things we are talking about. First i thought it would be creating a critical mass. So that it will be demand driven. Consumers, hospitals, Health Systems will demand a change. That is happening slowly. Then i began thinking, if you were looking for were there will be money a few years from now thinking, i want to do a start up Health Care May be that is where it will change. There will be a demand for green stuff and i will get there first. When i started researching this, there are a few that consider doing things like biodegradable and companies capturing the anesthetic gases waste but there arent a lot of them. They are isolated. To the extent, how do you glean from the massive supply chain . Will there be enough people like you trying to encourage staff . That is part of the strategy. To create demand. They are also working with the nhs, two countries creating more demand. Or will it be the equivalent of Silicon Valley chipmakers, the Silicon Valley plastic tube bakers . Do we have signs how this transformation will come . Theres already a lot of consumer pressure outside of and within health care for products to be better. There absolutely is a market. Without even getting to the examples you gave, which are actually not green solutions, this does bring up the topic of greenwashing. Just because a Company Sells a product is greenert does not mean it is. What is happening with the nhs in england and also throughout the ep you is very important. Nhs is using the Largest National Health System the world, with 65 million members, using their procurement power to require industry, any company they do business with, if they want to contract with the nhs first they need to do he has two reporting through the Carbon Disclosure Project that requires them to measure emissions in a standard way, to make it transparent and verifiable, and have a plan in place and measure progress drawing down the emissions in the Intergovernmental Panel on Climate Change scientific recommendations that we need to cut emissions by 50 by 2030. The acquiring companies they do business with to do that reporting and drawdown missions and have it be verifiable and transparent is a very important lever of using purchasing power. That is what hhs is now committed to for the federal Health System. Large gpos in the country can use the power to do the same thing. Even if we had complete complete clean energy right now, i know we are talking a lot about Climate Change. Beyond that we need to understand the level of the product. What are the emissions embodied within a particular product . There is no movement with the British Standards Institute and International Standard organization to create reporting standards at the level of the product, something we need to both avoid greenwashing and create competition in the marketplace and allow us to do accounting at the level of health organization, the level of the provider. How are we doing with procedures . How is our organization comparing to . Burton is developing some of that data because they have the ability with their national Health System and government structure to do something that is not possible. Most of these products are Global International organizations, companies. So, there are standards in europe. It will certainly help the united states. Even though right now we are volunteering and we still need to understand the model and promote what is happening. That could be shifting from the demand side in europe. Creating criteria that the market will have to respond to it and we benefit. Correct. When it is becoming the right thing to do for health care organizations, to be more sustainable, we should be leading the effort. If Initiative Even if it is not mandated we need to really get the word out there that this is irresponsible. It reminds me of the tobacco story. Clinicians would smoke at the bedsides. Although organizations would invest in tobacco. None of that is successful now. The same as to be true for environmental sustainability. I think you are pointing out where industry is and where hospitals are. If we assume it has a static relationship, that is not economic basis that all of us have this in itself back in the 19 30s responded to a very different ecosystem in which reusability was a virtue. Take a company like that in the 40s and 50s his pioneering new cleaner technologies. In the 1960s, it is part of wholesale medical device manufacturing. Plastic, the most visible plastics brand in the world. The shift is mentally because dickinson has a Strategic Plan in the space reflecting what is happening from the market purchasers as the hospital realizes its labor problem can be turned into a supply chain problem. I see that they just signed the hhs pledge. Thinking about a Becton Dickinson invested in vallow rising sustainability as a set of design features. The risk of greenwashing is always there and i am glad jody brought that up. This form of government needs to hold industry pledges in this area accountable. All of these things are the results of conscious units. Even though we are accustomed, none of these things are static. The triangle is pretty malleable. How do you shift it from a vicious cycle technologically speaking into a Virtuous Cycle . The nhs scotland is another interesting place to look. They have a Plastics Reclamation plant. I saw a presentation in which one innovation towards greater suitability stability was to shift from plastics in hospitals to metal. Biodegradable. Yes. Many of these solutions once we place sustainability into the engineering of medical devices, which it simply has not been. Opening up that space. Going back and rediscovering the practice in 1960 worked really well. We have new techniques of restarting this with the Purposeful Group of materials, we can find solutions to create a financially successful and ecologically sustainable system. V. A. Other health services, the federal hospitals do have to meet climate reduction goals. Well that told the market in a healthier way in the country . I dont know what the timetable is or how fast they have to do that. Is that something that builds from the government hospitals and everyone else were we dont know . Anything coming out of nhs really means a lot. The fact the department of health and Human Services says this is important will shift culture and raise awareness around us. The federal Health System only covers about 25 of our population. It would require legislature. Once you tart start tying sustainability to cms, at the centers from repayment, then you will get momentum. The rule proposed the other day it was new and innovative. What they proposed was mostly data collection. Even though it is small i think it can be a useful space for modeling viability. We have seen it in things like pharmaceutical prices. Where the ability of federal health players to achieve forms of changes that were thought impossible in the Health Care Center in general also occupy health care policy. The bottom up approach is when i go under the supply closet, there are no prices on anything. Health care and nurses dont know what things cost. If you have the price next to it, like the calorie count of food, say, eight dollars, all of a sudden the patient comes in and gets monitored. If the nurse says its eight dollars, the belt you would take off and throw in the trash, all of a sudden, she is like, hold onto these, throw them into your prayers and we will hook you back up. There is awareness of how much things cost. It does not have to be regulation. Just more transparency to let caregivers and nurses and everybody know the price of delivering health care. Just have a price tag on there. What do see happening . What do you want to let people know about where we are and what we need . My closing message in general is something i have said as a through line. Every item we have are that we take for granted in the political world behind it has a human value that may not measure the present day. If i have a moment for another closing issue i want to pick up on something sarah mentioned at the beginning. Its important to realize we may all not benefit from disposability of our Health Care System that has been dollarized but we dont all suffer equally the cost of that. All of us need to think of our localities. Who pays the price for health care excesses . Our patients but also neighborhoods. A corporation was renamed but until last fall was the largest private veterinary brand in america. Last fall it accepted the last. It was burning thats medical waste. Only one third of that waste came from her or even the state of maryland some of its waste, the smoke, was actually floating over the neighborhood. The neighborhood, some of you may know, has the highest in the city of baltimore. How do we understand that these localized costs will be visible until we make an effort through Environmental Science and Community Partnerships . A lot of this was made possible through forms of. A lot of it is happening through partnerships with local communities trying to bring to life to light the local aspect here. It was just announced, there was a city Hall Baltimore march 20 where people were held accountable they would do. Hopkins has made a careful analysis and study diverting waste that will no longer be burned in the facility or at all. I say this to suggest this is probably true in a lot of places. What are the local costs . How are they born in evenly . How do we partner in communities most affected by medical waste . You are working on a national scale. I was interested in what you had to take to say and forgot to ask the audience. Does dan have a question . Ok. I wanted to say that there is a lot of out of the pandemic that everyone in the country can relate to, that resources are limited. We have very little awareness being in a rich nation until we were challenged in this way. Think of climaterelated disasters, a 14 billion storm last year alone when hospitals and Health Systems are locally affected, the populations are displaced to nearby Health Systems, the people in those communities are affected by the displaced population. When you start the supply chain and Human Resources to address the needs it starts pulling resources throughout the u. S. It requires us to think beyond our localities and how we are all all are all connected. Its not going away. This issue is only getting bigger phenomenal panel. Thank you so much. I wanted to give voice to some of the research happening here. Wonderful. I agree. I am an associate Research Professor at the Johns Hopkins Bloomberg School of public health. There is one area where the drug pricing and Climate Change have intersected, the inhaler market. Benefiting from a generic pressurized inhaler using an hfa propellant. The inhaler its about 36 kilogram equivalent of Carbon Dioxide. Astrazeneca, gsk, there are all developing new, better propellants. The question is tomorrow is a new, green product can be launched market how do we balance patient affordability with Climate Change, sustainability, those different domains. Thank you. I would like to open the rest of the panel. On some level the great irony of the hsa incident was a result of prior ecological damage being done by inhalers, the ozone hole. The way we dealt with the problem was we took generic albuterol of the market and put the burden on the backs of People Living with asthma, a disease that correlates with poverty. So the burden on the patients, i think the short answer is we need different ways. I would like to get to the structural issue behind that. A minor clarification. I dont think there is a green alternative. Prescribing things like medications to connect more with members of the communities. Lifestyle approaches like dietary modifications and movement. Thats what i would call green medicine. I dont think there is a green medicine, green and a static, or green surgery. It is what is the least polluting that we are talking about. You raise an important point and it also holds true with other inhalers on the marketplace now. Our government sponsored insurers and private insurers need to make the cost of making environmental waste comparable. I dont know how to do that. I have two closing things to say. One, i want to thank darren and my colleagues who really got into this topic and began to see how complicated and interesting it is. The second is an anecdote about greenwashing. The medicine comes with a cold pack, is refrigerated. You had to spread them out. The first innovation was you can clip it and pour it down your drain. Then we got one thats a fertilizer. You can make that with water and pour it on your plate. We know this is an environmental piece of progress. If my various die. Thank you joanne, thank you to the panel. And happy earth day, everybody