Cutting Into Climate Change: A Step Toward Global Surgical Equity

After another record-breaking year, climate change has become a recurrent “hot” topic. As surgeons and anesthesiologists, we recognize that the same populations most vulnerable to climate change have the least access to crucial anesthetic and surgical care. Surgery and anesthesiology leaders must therefore proactively address climate change mitigation and adaptation in our roadmap toward global surgical equity.

Unequal Culpability

Innovations powered by fossil fuel combustion have enabled uncountable advances in modern technology, quality of living, and medicine. But these benefits are concentrated in high-income countries (HICs), while low- and middle-income countries (LMICs) largely pay the price for the byproducts of combustion. The United States has contributed the most excess carbon dioxide (CO₂) to the atmosphere (20 percent of the global total) yet is among the least vulnerable nations to the effects of climate change. On the other hand, LMICs contribute exponentially less to global warming but have far fewer resources to cope with, and adapt to, the negative public health effects of climate change.

Importantly, the global health care industry is itself a major player in this ecosystem; if it were a country, the industry would be the fifth largest producer of greenhouse gasses (GHGs) in the world. Surgical and anesthetic care are especially high-emitting components of health care. Surgical care often requires high energy use and generates significant waste, while inhaled anesthetic agents are themselves GHGs with global warming effects several fold stronger than CO₂.

Unequal Effects

Climate events, such as droughts, hurricanes, and extreme temperatures, endanger everyone’s health, but their effects are not felt equally. Low-income individuals and people of color are more likely to live in areas with higher air pollution, less access to health care, and poorer-quality housing, among other risk factors. As a result, these individuals are more vulnerable to the adverse health effects of climate change, including lung and infectious diseases, heat-related illness, and food insecurity.

Climate change will worsen the burden of surgical disease, from increased trauma to worse pregnancy outcomes to higher burdens of infectious disease with potential surgical complications. Yet, as of 2015, five billion people lacked access to surgical care, primarily concentrated in LMIC nations. Major storms, sea-level rise, and extreme heat all threaten existing surgical, obstetric, and anesthesia (SOA) infrastructure and pose unique challenges for constructing new climate change-ready surgical systems.

Adaptation And Mitigation Strategies

Surgical equity means ensuring equal access to the timely and safe delivery of necessary SOA care for everyone in the community, regardless of sociodemographics or ability to pay. In the context of an unstable future climate, surgical systems globally must incorporate:

1. adaptation strategies to prepare surgical infrastructure and workforces for an unstable climate, especially in LMICs, and
2. sustainable technologies and processes to mitigate the carbon footprint of surgical care.

Adaptation starts with consciously selecting the location, structural design, and energy supply of new surgical infrastructure to address long-term reliability in the face of climate change risks, including rising sea levels and natural disasters threatening grid energy. Existing older structures will also require energy-efficient and climate-resilient retrofits. Our surgical workforce also needs better education on the growing burden of surgical disease associated with climate change, from traumatic injuries after major storms to pregnancy complications in extreme heat.

As renewable energy becomes increasingly cost saving compared to fossil fuels, LMICs can bake in mitigation strategies by building surgical systems that avoid fossil fuel dependency. Herein, there lies an opportunity to flip the current global health paradigm by enabling LMICs to become leaders in the green surgery movement. Realizing such an opportunity would, of course, require massive financial support from HICs.

Furthermore, in HICs, we can no longer ignore the paradox that the operating rooms where we deliver life-saving surgical care carry a heavy carbon footprint and contribute to the climate change public health crisis. We must swiftly mitigate our emissions by implementing best practices from the green surgery literature including energy-efficient HVAC and lighting techniques, anesthetic techniques with lower environmental impact, and reusable supplies. Encouragingly, efforts toward surgical sustainability have recently been bolstered by more frequent commitments from national-level policy makers to support the reduction of health care-associated carbon emissions.

Policy Levers

The National Surgical Obstetric Anesthesia Planning (NSOAP) process is an implementation approach to support surgical system development in LMICs. As policy makers develop such plans, they should integrate both climate change adaptation and mitigation strategies across all six domains of planning: infrastructure, workforce, service delivery, information management, governance, and financing.

Some communities in LMICs are already pioneering novel green solutions. Examples include a hospital in Rwanda using natural ventilation from the surrounding landscape and improved outcomes in primary care centers with primary or backup solar photovoltaic power across Chhattisgarh, India. But the upfront cost and delayed benefits of sustainable interventions represent prohibitive financing challenges for many LMICs. This challenge is exacerbated by the low rate of external investment in LMICs—currently 5 to 10 times lower than what is actually needed, according to the 2021 United Nations Environment Programme report. Furthermore, despite the clear health implications, almost no climate change financing is directed toward global health.

Contextualizing climate change in relation to the global scarcity of surgical resources highlights the interdependence of these international challenges. To that end, climate change funding (including the Green Climate Fund) should be available to LMICs to support green global surgical system infrastructure. NSOAP could bolster this call for funding by explicitly incorporating climate change adaptation and mitigation language.

But policy making regarding climate change and surgical equity can no longer occur in silos. The major vehicles of climate change policy include national adaptation plans (NAPs) under the United Nations Framework Convention on Climate Change and nationally determined contributions (NDCs) under the Paris Climate Accord. NAPs are country-driven planning and implementation strategies to address anticipated effects of climate change. NDCs serve as external declarations of a nation’s climate change goals, often emphasizing emissions reductions targets but also incorporating climate change adaptation priorities. When optimized, these two policy mechanisms should bolster each other. Global surgery leaders should proactively advocate for surgical system planning to serve as a target for adaptation and mitigation strategies in both NAPs and NDCs.

Ultimately, we must pursue global health equity with climate change awareness. Surgical care delivery is especially impacted and impactful in this context. With mounting and irrefutable evidence regarding the intersection of surgery, climate change, and their public health consequences, implementing effective policies is a matter of political will. Therefore, surgery and anesthesiology leaders worldwide have a responsibility to engage with climate change policy making now to proactively address global surgical equity in the context of a future unstable climate.