The coronavirus disease 2019 (COVID-19) pandemic has led to radical curtailing and
reconfiguring of health services across the world to slow the spread of the disease.
Planning for acute COVID-19 services has inevitably resulted in a precipitous reduction
in endoscopy activity, but in the deceleration phase of the pandemic, endoscopy units
will aim to restart. The primary concern will understandably be to protect patients
and staff, while providing enough capacity to meet demand and manage postponed appointments.
However, it is crucial that we also use this time to analyse current practice in the
context of another sustained and serious threat: climate change. The climate crisis
has major consequences for global health, including food insecurity, respiratory and
vector-borne diseases, and excess heat-related deaths, even in the UK.
The National Health Service (NHS) accounts for 5·4% of UK carbon dioxide emissions,
which, in 2015, amounted to 26·6 million tonnes of carbon dioxide equivalent—equating
to 39% of all public sector emissions in England.
Even during the brief period of lockdown around the world, the reduction in global
activity has led to a decrease in greenhouse gas emissions by as much as 5·5%,
and potentially thousands of lives saved through cleaner air.
This drop might seem substantial but emissions will rebound rapidly once lockdowns
end. If there is to be any chance of limiting global heating to less than 1·5°C above
pre-industrial temperatures, year-on-year reductions of more than 7·6% are required
for the next decade.
Radical change is necessary across every part of society, and health care must be
included in the process, both because of the health service's role as a major contributor
to the problem but also because of the serious public health risks posed by climate
Endoscopy appears to be a major contributor to the environmental footprint of health
care, generating about 3·09 kg of waste per bed per day (the third highest emitting
High throughput caseloads, multiple non-renewable waste streams, numerous hospital
visits for patients and relatives, and resource-heavy decontamination processes all
contribute. Although some processes are necessary, others are ripe for change. Endoscope
decontamination, for example, requires high volumes of water per decontamination cycle
and multiple disinfectants, and has a major environmental impact as a result. There
are no robust data on transport for patients and relatives, departmental energy use,
and reusable versus disposable equipment.
The call for evidence to inform the NHS Net Zero
plan is an important development, seeking practical ideas to achieve net carbon zero
by 2050. The National Institute for Health and Care Excellence (NICE) has placed sustainability
at the centre of their strategy,
and numerous other organisations are springing up among concerned health-care professionals
to make a difference on a regional, national, and international level. The gastroenterology
community should be a part of this movement. Practitioners ought to review procedures
against the principles of sustainable health care—prevention, patient empowerment
and self-care, lean systems, and low-carbon alternatives—and identify areas amenable
We can begin by looking at the total number of procedures done, the reasons leading
to potentially unnecessary processes, and the waste products involved (figure
). Small but successive steps to analyse and change practice can have a substantial
cumulative benefit. The magnitude of the problem as a whole should not engender inertia
or act as a barrier to change.
Potential targets for greener endoscopy
(A) Reducing unnecessary procedures by analysing the drivers behind them. (B) Reducing
the environmental impact of each procedure through identifying areas of excess waste.
PPE=personal protective equipment.
Undoubtedly, the approach likely to have the greatest impact will be to do fewer procedures,
while recognising that endoscopy is a key component in the management of digestive
diseases. Robust management of demand is axiomatic but will require an honest appraisal
of our current values—for many, the natural inclination is to do more procedures,
yet a reduction in endoscopic burden could be beneficial for patients. There are many
drivers of increased endoscopy activity (figure, A), many of which result in unnecessary
endoscopies. Identifying these unnecessary procedures and their primary drivers is
an important first step. Potential solutions include rigorously checking the appropriateness
of referrals, using low-waste alternatives (eg, faecal immunochemical tests, faecal
calprotectin, video capsules, or CT where appropriate), or home testing to reduce
travel (where technology allows and after effectiveness and safety have been established).
Such a strategy could pose a challenge for health-care systems that rely on the income
generated by low-risk, high-throughput endoscopy. A considerable change in outlook
from society as a whole is required but we argue that, although eschewing value-based
health care for financial gain remains very much part of the problem, sustainable
health care is not necessarily associated with financial losses in most settings.
A clear indication of the environmental impact of each procedure is required (figure).
This insight could generate targeted interventions such as improved waste segregation,
increased recycling, or the avoidance of single-use items where possible. Detailed
analyses of the sustainability of each step in endoscopy activities would allow the
identification of small but cumulative beneficial changes that could decrease our
There is an urgent unmet need for research on sustainable practice in endoscopy: from
optimal service delivery models to greener technology and the effects of climate change
on the health of patients with gastrointestinal disease. As our knowledge base develops,
there needs to be a renewed drive to disseminate this information. Sustainable health
care should be a central theme in undergraduate and postgraduate curricula, and a
major consideration for patient groups who educate patients about developments in
practice and technology.
Finally, physicians and researchers need to re-invent what endoscopy will look like
in the long term. Practitioners should commit to importing the principles of sustainable
health care into a new system for doing endoscopy. National bodies could also assist
by evaluating endoscopy units, which could involve so-called green accreditation through
meeting certain standards of sustainable practice. Action can, and must, also be taken
at an individual level: an all-or-nothing approach risks inertia and prevents adoption
of small changes that together could have a large effect.
This vision for disruptive innovation seemed challenging just a few months ago, but
the COVID-19 pandemic has shown how rapidly processes can change when faced with a
crisis. Although the recent pause has given us time to reflect on current practice,
the climate crisis is still accelerating. Endoscopy and its associated specialities
remain part of the problem. As we consider restarting endoscopy services, we should
use this opportunity to rapidly embed sustainability principles into everyday practice
and trigger action in a timely and strategic manner. We can and must act quickly and
radically with our colleagues across health care, the public, and government. We must
reinvent endoscopy and how we live our professional lives with a view to protecting
the planet on which we rely.
For organisations engaging health-care workers in action on climate change see http://noharm.org/,
https://www.medact.org/, and http://www.ukhealthalliance.org/