Radiation Oncology/Ecological Footprint

Ecological Footprint of Health Care

General Carbon FootprintEdit

  • University of Bergen, Norway; 2021 PMID 34711584 -- "Priority setting and net zero healthcare: how much health can a tonne of carbon buy?" (Bhopal A, BMJ. 2021 Oct 28;375:e067199.); Link
    • Proposal to use carbon as part of health care priority setting
    • Clinical decision-making; health system perspective; and a global perspective
  • UK NHS; 2021 PMID 33581070 -- "Health care's response to climate change: a carbon footprint assessment of the NHS in England" (Tennison I, Lancet Planet Health. 2021 Feb;5(2):e84-e92.). Overview Link. PDF Link
    • Model using Scope 1 (direct emissions from owned or controlled sources), Scope 2 (indirect emissions from purchased electricity, heat, cooling), Scope 3 (other indirect costs associated with organization's operations, including medical equipment and food/catering, as well as staff commute), and Non-Protocol (patient and visitor travel)
    • Outcome: In 2019, NHS emissions were 25 megatones of CO2 equivalent (reduction of 26% since 1990). Footprint included supply chain (62%), direct delivery of care (24%), staff and patient/visitor travel (10%), and commissioned private health care services (4%)
  • US National Expenditure Accounts
    • 2020 PMID 33284703 -- "Health Care Pollution And Public Health Damage In The United States: An Update" (Eckelman MJ, Health Aff (Millwood). 2020 Dec;39(12):2071-2079.)
      • US health care emissions 1,693 kg CO2 per person in 2018, slowly risking since 2012
      • Contribution to emissions: 1) Direct emissions from health care operations (7%), 2) Indirect emissions from purchased energy (11%), 3) Indirect emissions from supply chain (82%). Largest supply chain contribution from pharmaceuticals/chemicals, food, energy, plastics
      • Variation in state-level emissions, which were not highly correlated to quality
    • 2016 PMID 27280706 -- "Environmental Impacts of the U.S. Health Care System and Effects on Public Health" (Eckelman MJ, PLoS One. 2016 Jun 9;11(6):e0157014.). Article Link
      • Estimate of direct and indirect emissions attributable to health care sector using economic input-output life cycle assessment modeling using National Health Expenditures from 2003-2013
      • Greenhouse gas emissions 655 million metric tons CO2 equivalent (9.8% national total). Health care (36%), physician and clinical services (12%) and prescription drugs (10%) were largest categories.
      • Direct emissions from on-site operation 2.5%; majority of the emission from supplies of energy, goods, and services. Power generation (36%)
      • Additional impact in producing acid rain (12%), GHG (10%), smog formation (10%), air pollutants (9%) causing 470,000 DALYs lost. The are commensurate with 44k-98k of patients who die in hospitals from preventable medical errors
    • 2009 PMID 19903917 -- "Estimate of the carbon footprint of the US health care sector" (Chung J, JAMA. 2009 Nov 11;302(18):1970-2.)
      • US health sector contributed 8% of greenhouse gas emission nationally, and 7% of CO2 emission.
  • NHS, 2016 PMID 31098080 -- "Reducing the carbon footprint of hospital-based care" (Tomson C, Future Hosp J. 2015 Feb;2(1):57-62.). Article Link

Specific Carbon FootprintEdit

Cataract SurgeryEdit

  • Cochin University, France; 2021 PMID 34823888 -- "The carbon footprint of cataract surgery in a French University Hospital" (Ferrero A, J Fr Ophtalmol. 2021 Nov 22;S0181-5512(21)00538-6. doi: 10.1016/j.jfo.2021.08.004.)
    • One day of surgery. Greenhouse gas emission related to patient and staff transportation, building energy consumption, and life cycle assessment (LCA) of equipment and sterilization processes
    • Outcome: LCA of disposable items was 59.5 kg CO2 per procedure. Single procedure generated 2.8 kg of CO2. Average patient transportation per procedure was 7.3 kg of CO2. Sterilization was 2.1 kg. Energy consumption of the building was 0.8 kg and staff transport 0.08 kg.
    • Conclusion: Total carbon footprint of one cataract procedure was 81.1 kg CO2 equivalent.
  • University of Otago Welligton, NZ; 2021 PMID 34531593 -- "The carbon footprint of cataract surgery in Wellington" (Latta M, N Z Med J. 2021 Sep 3;134(1541):13-21.)
    • Use of Eyefficiency tool. Carbon footprint at 4 hospitals. 142 cataract surgeries.
    • Outcome: a cataract surgery produced on average 152 kg of CO2 equivalent. Greatest contribution from disposable materials and from patient travel
  • Multi-institutional; 2021 PMID 34104796 -- "Improving productivity, costs and environmental impact in International Eye Health Services: using the 'Eyefficiency' cataract surgical services auditing tool to assess the value of cataract surgical services" (Goel H, BMJ Open Ophthalmol. 2021 May 20;6(1):e000642.)
    • Use of Eyefficiency tool. Carbon footprint at 9 cataract surgical facilities worldwide. 1 week or 30 consecutive cataract surgeries continuously.
    • Outcome: 475 cataract extractions (mix phacoemulsification and manual incision). Greenhouse gases ranged from 41 kg of CO2 equivalent to 130 kg CO2 equivalent
    • Conclusion: Global diversity in metrics
  • University Hospital of Wales; 2013 PMID 23429413 -- "The carbon footprint of cataract surgery" (Morris DS, Eye (Lond). 2013 Apr;27(4):495-501.)
    • Component analysis for one patient, including building/energy use, travel, and procurement
    • Outcome: Carbon footprint 182 kg CO2eq. Given total 2230 patient treated in 2011, overall footprint 405.5 tonnes CO2eq. Building/energy use 36%, travel 10%, procurement 54% (medical equipment 33%).

Head&Neck SurgeryEdit

  • Dalhousie University, Canada; 2021 PMID 33875009 -- "Carbon footprint reduction associated with a surgical outreach clinic" (Forner D, J Otolaryngol Head Neck Surg. 2021 Apr 19;50(1):26.)
    • Self-administered survey of 113 patient travel patterns to outreach clinic vs regional centre. 12/2019 - 02/2020.
    • Outcome: Own car (86%). Median distance to outreach clinic 29 kg vs regional centre 327 km. Mean CO2 emission 117 kg to 144 kg per person; equivalent to individual's 2.5% of annual carbon footprint.
    • Conclusion: Surgical outreach clinics decrease carbon footprint associated with patient travel


  • University of Pittsburgh; 2015 PMID 25517602 -- "Environmental impacts of surgical procedures: life cycle assessment of hysterectomy in the United States" (Thiel C, Environ Sci Technol. 2015 Feb 3;49(3):1779-86.) Link
    • LCA analysis
    • Outcome: Different mix of hysterectomies, impact ~400 kg CO2 per case

Operating RoomsEdit

  • Multi-Institutional, Canada; 2017 PMID 29851650 -- "The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems" (MacNeill AJ, Lancet Planet Health. 2017 Dec;1(9):e381-e388.)
    • Three academic hospitals in Canada (Vancouver General Hospital), USA (University of Minnesota) and UK (John Radcliffe), 1 year period in 2011
    • Outcome: Total annual footprint 5,188 tons kg at JRH, 4,182 tons kg at UMMC, 3,219 tons kg at VGH. Per unit area in m2 JRH 1,702 kg/m2, UMMC 2,284 kg/m2, VGH 1,951 kg/m2. Per operation JRH 173 kg, UMMC 232 kg, VGH 146 kg. Largest sources of consumption anaesthetic gases and energy consumption. Surgical theatres 3x-6x more energy-intense than hospitals as a whole due to HVAC requirements.

General Surgery PracticeEdit

  • University of Leeds; 2013 PMID 23998839 -- "Carbon footprint of patient journeys through primary care: a mixed methods approach" (Andrews E, Br J Gen Pract. 2013 Sep;63(614):e595-603.) Link
    • 650 daily journeys. 306 patient filled travel survey in March 2012.
    • Outcome: 55% by car (62% <2 miles), 30% walked (64% <1 mile), 10% bus. Total carbon footprint 63 tonnes CO2 per year

Renal ServiceEdit

  • Dorset County Hospital, UK; 2010 PMID 20719900 -- "The carbon footprint of a renal service in the United Kingdom" (Connor A, QJM. 2010 Dec;103(12):965-75.)
    • Activity data for building energy use, travel, and procurement
    • Outcome: Carbon footprint 3,0006 tonnes CO2 eq per year; building energy 13%, travel 15%, procurement 72% (pharmaceuticals 35%, medical equipment 25%). Emissions 161 kg CO2 eq per bed per day inpatient and 22 kg outpatient.
  • Geelong Hospital, Australia; 2013 PMID 23731962 -- "The carbon footprint of an Australian satellite haemodialysis unit" (Lim AEK, Aust Health Rev. 2013 Jun;37(3):369-74.)
    • Suburban satellite hemodialysis unit in 2011.
    • Outcome: Annual per-patient 10.2 tonnes CO2 equivalent. Contributions pharmaceuticals 36%, medical equipment 23%. Contribution of water (4% to 12%) and electricity (5% to 19%) varies throughout Australia


  • Dalhousie University, Canada; 2021 PMID 34251875 -- "Operating in a Climate Crisis: A State-of-the-Science Review of Life Cycle Assessment within Surgical and Anesthetic Care" (Drew J, Environ Health Perspect. 2021 Jul;129(7):76001.)
    • Overview of life cycle assessment for surgery and anesthesia. 44 studies eligible
    • Outcome: Annual impact between 3,200,000 kg and 5,200,000 kg of CO2. Per case, range 6 kg to 1,007 kg CO2 equivalent. Main emission sources anesthetic gases, single use equipment, HVAC
  • Wichita State; 2020 no PMID -- "Quantifying hospital services by carbon footprint: A systematic literature review of patient care alternatives" Alshqaqeeq F, Resources, Conservation and Recycling, 2020 March. Link
    • Peer reviewed articles Jan 2000 - Dec 2016. 48 studies identified. Environmental scopes: 1) Travel-related energy, 2) Direct energy, 3) Procedural goods and equipment energy
  • NHS Systematic Review; 2020 PMID 32516230 -- "The Carbon Footprint of Surgical Operations: A Systematic Review" (Rizan C, Ann Surg. 2020 Dec;272(6):986-995.) Link
    • 8 eligible publications.
    • Outcome: Carbon footprint of single operation range 6 kg to 814 kg of CO2 equivalent. Major sources were electricity use and consumables
  • James Cook University, Australia; 2012 PMID 23078475 -- "The energy burden and environmental impact of health services" (Brown LH, Am J Public Health. 2012 Dec;102(12):e76-82.). Link
    • 38 publications
    • Review of National Level Health Service Emissions (16 studies); Hospital / Hospital Facilities (8 studies); Surgery (4 studies); Water consumption (4 studies)


  • University of Cambridge; 2021 PMID 33791483 -- "Does telemedicine reduce the carbon footprint of healthcare? A systematic review" (Purhoit A, Future Healthc J. 2021 Mar;8(1):e85-e91.)
    • Systematic review. CO2 savings per consultation 0.7 - 372 kg, highly context specific. Telemedicine unit energy use very low
  • University Health Network, Toronto; 2010 PMID 20958198 -- "The impact of telemedicine on greenhouse gas emissions at an academic health science center in Canada" (Masino C, Telemed J E Health. 2010 Nov;16(9):973-6.)
    • Travel distances for each appointment evaluated by Google Maps
    • Outcome: Avoided travel 757,234 km; equivalent to 185 metric tons of CO2 equivalent. Videoconference unit consumption 42 kg CO2. Air pollutants 360 kg avoided.

Environmental ImpactEdit

  • The Lancet Countdown
    • 2021 PMID 34687662 -- "The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future" (Romanello M, Lancet. 2021 Oct 30;398(10311):1619-1662.) Link
    • 2020 PMID 33278353 -- "The 2020 report of The Lancet Countdown on health and climate change: responding to converging crises" (Watts N, Lancet. 2021 Jan 9;397(10269):129-170.)
    • 2019 PMID 31733928 -- "The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate" (Watts N, Lancet. 2019 Nov 16;394(10211):1836-1878.)
    • 2018 PMID 29096948 -- "The Lancet Countdown on health and climate change: from 25 years of inaction to a global transformation for public health" (Watts N, Lancet. 2018 Feb 10;391(10120):581-630.) Link
    • 2017 PMID 27856085 -- "The Lancet Countdown: tracking progress on health and climate change" (Watts N, Lancet. 2017 Mar 18;389(10074):1151-1164.)
    • 2015 PMID 26111439 -- "Health and climate change: policy responses to protect public health" (Watts N, Lancet. 2015 Nov 7;386(10006):1861-914.) Link
      • Formation of The Lancet Commission on Health and Climate Change
  • Northeastern University/Yale University; 2018 PMID 29072942 -- "Estimated Global Disease Burden From US Health Care Sector Greenhouse Gas Emissions" (Eckelman M, Am J Public Health. 2018 Apr;108(S2):S120-S122.)
    • Estimate of disease burden from US health care sector LCA emissions of 614 million tons of CO2 equivalent in 2013
    • Outcome: 123,000 to 381,000 disability adjusted life-years of future health damage; malnutrition largest damage