Introduction
“Primum non nocere” is a basic tenet of medical practice, and the concepts of precaution and prevention have always been central in public health practice. However, mounting evidence shows that the health sector is a major contributor to climate change, which in turn is expected to cause a global health emergency in the next years (1). A recent report showed that the world healthcare systems' climate footprint equals 514 coal-fired power plants, accounting for 4.4% of global greenhouse gas (GHG) emissions. According to these estimates, if the global healthcare system were considered a single country, it would be the fifth largest emitter on the planet (1). This underlines the importance of including the evaluation of the environmental impact of healthcare systems in the global agenda. In this spirit, the European Academies' Science Advisory Council and Federation of European Academies of Medicine have recently called for an urgent need for the healthcare system itself to achieve ambitious targets of decarbonization across the EU and beyond (2).
Global, European, and Italian policies
In the last UN Climate Change Conference in Glasgow (COP26), fifty countries committed to developing low-carbon health systems, and fourteen of them have also set a target date to reach net zero carbon emissions on or before 2050 (3). These countries follow the path set by the UK, which was the first to commit its NHS to becoming “carbon net zero,” adopting interventions such as increasing community care, greening the vehicle fleet, reducing waste of consumables, constructing new hospitals with net-zero emissions, and training health staff on energy conservation (4).
The EU addresses the issue of climate change through various policies, mainly within the framework of the European Green Deal (5). However, in the case of healthcare systems, the emphasis is largely placed on adaptation to climate change (e.g., Article 5 of the European Climate Law) rather than on the mitigation of emissions (5). This could partly explain why only six EU countries (Belgium, Germany, Ireland, the Netherlands, Norway, and Spain) have submitted formal commitments to the COP26 Presidency to strengthen and develop sustainable healthcare systems (3). In these terms, EU countries could instead take advantage of already existing schemes such as (i) the Pharmaceutical Strategy for Europe, which underlines the importance of using environmentally sustainable and climate-neutral pharmaceuticals, (ii) the eHealth, the digital health strategy, which although specifically outlines improvements in access to care and its quality, could also have an important role in the decarbonization of healthcare systems, and (iii) the Farm to Fork Strategy, which can support the use of healthy and sustainable food in the healthcare system (2).
Notably, Italy is not on the list of signatory countries even though (i) its healthcare footprint is 4% of the national footprint (1); (ii) the country is currently investing in ecological transition; (iii) and climate policies promote infrastructure improvements at the national level and energy efficiency improvements at the regional level in public sector buildings, including hospitals. Moreover, despite the Italian National Prevention Plan recognizing that the health sector must contribute to climate change mitigation and improve its resilience (6), this sector is not explicitly mentioned when planned emission reductions are indicated.
The opportunity has also been missed in the implementation of the National Recovery and Resilience Plan (NRRP), which is supported by the EU with €68.9 billion in grants and €122.6 billion in loans, among which about 38% should support climate objectives (7). Indeed, although the NRRP aims for a progressive decarbonization of “all sectors” in Italy, the healthcare system is never explicitly mentioned. This is particularly striking, considering that two of the assets of NRRP are the strengthening of primary healthcare and the development of telemedicine, both of which, replacing hospital-based services, can become instrumental to reduce emissions as well (7). It is also noteworthy that in Italy, 82% of constructions were built before 1990, and 58% before 1970, well before the enactment of the law L10/1991, through which rational energy use began to be significantly regulated (8). Given these data, the road to greater community and home-health, in line with the NRRP, seems decisive to improve energy efficiency and, together with telemedicine, to decrease the demand on the supply chain by reducing and/or replacing hospital-based services (7). In this context, the investment foreseen in the NRRP for the development of community-oriented technical, and digital skills for healthcare professionals could also be strategic (7).
Discussion
As the healthcare system's contribution to the climate crisis is projected to further grow in the next years (1), specific decarbonization policies in this sector should be initiated and prioritized as soon as possible, using the existing schemes at the national and European levels. These should target the healthcare supply chain and its direct and indirect emissions, professional education, governance, and financing. Specifically, energy efficient infrastructure, toward power health care with 100% clean, renewable electricity and mitigation of temperature extremes in winters and summer; energy-saving and optimization (e.g., LED bulbs); green policies aimed to reduce the transportation emissions; encouragement of resource stewardship, food waste prevention and adoption of healthy, seasonal and sustainable diets; reduction of inefficient and unnecessary practices as well as unnecessary pharmaceutical use, while incentivizing the production of affordable climate-smart medicine and sustainable healthcare waste management (9).
Additionally, it would be essential to ensure the implementation of the monitoring system envisaged in the Ministerial Decree 77 (10), to direct specific interventions and decision-making, and to define the sustainability of NRRP, with an approach based on the integrated prevention, closely linked with community-based health care. Finally, dedicated research investments on the environmental impacts of the healthcare system and the costs and benefits of decarbonization interventions are warranted. Indeed, these are pivotal to direct policy-makers to effectively foster environmental sustainability and systems for health (11). These priorities should be framed around the principle of linking health to all-policies to (i) promote the circular economy and the bioeconomy, (ii) reduce GHG emissions also invest in the energy efficiency of existing facilities, and (iii) provide a more sustainable economic model.
Statements
Author contributions
BA and FB-A conceptualized the Opinion. BA drafted the manuscript. BF, SU, EM, CD, MPa, GO, MPi, MM, LM, and FB-A contributed to reviewing and finalizing the opinion. All authors approved the final version of the manuscript.
Conflict of interest
All authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
1.
Health Care Without Harm and Arup. Health Care's Climate Footprint Report. How the Health Sector Contributes to the Global Climate Crisis and Opportunities for Action. (2019). Available online at: https://noharm-global.org/ClimateFootprintReport. (accessed August, 2022).
2.
Federation of European Academies of Medicine. Decarbonisation of the Health Sector: A Commentary by EASAC and FEAM. (2021). Available online at: https://easac.eu/publications/details/decarbonisation-of-the-health-sector/ (accessed August, 2022).
3.
World Health Organization. COP26 Health Programme. Country Commitments. Available online at: https://www.who.int/initiatives/alliance-for-transformative-action-on-climate-and-health/country-commitments (accessed November, 2022).
4.
NHS England. NHS Becomes the World's First National Health System to Commit to Become ‘Carbon Net Zero', Backed by Clear Deliverables and Milestones. (2020). Available online at: https://www.england.nhs.uk/2020/10/nhs-becomes-the-worlds-national-health-system-to-commit-to-become-carbon-net-zero-backed-by-clear-deliverables-and-milestones/ (accessed November, 2022).
5.
European Climate and Health Observatory. European Policies on Climate Adaptation and Health. Available online at: https://climate-adapt.eea.europa.eu/observatory/policy-context/european-policy-framework/climate-adaptation-and-health (accessed November, 2022).
6.
Italian Ministry of Health. Piano Nazionale della Prevenzione 2020–2025. (2020). Available online at: https://www.salute.gov.it/imgs/C_17_notizie_5029_0_file.pdf (accessed November, 2022).
7.
European Commission. Italy's Recovery and Resilience Plan. Available online at: https://ec.europa.eu/info/business-economy-euro/recovery-coronavirus/recovery-and-resilience-facility/italys-recovery-and-resilience-plan_en (accessed November, 2022).
8.
CERGAS. Rapporto OASI 2021. Strategie di gestione e valorizzazione del patrimonio immobiliare delle Aziende del SSN, Fabio Amatucci, Niccolo' Cusumano, Alessandro Furnari, Veronica Vecchi. (2021). Available online at: https://cergas.unibocconi.eu/observatories/oasi_/oasi-report-2021 (accessed November, 2022).
9.
Global Road Map for Health Care Decarbonization. Health Care Without Harm. (2021). Available online at: https://healthcareclimateaction.org/sites/default/files/2021-06/Health%20Care%20Without%20Harm_Health%20Care%20Decarbonization_Road%20Map.pdf (accessed November, 2022).
10.
Ministero della Salute. Regolamento recante la definizione di modelli e standard per lo sviluppo dell'assistenza territoriale nel Servizio sanitario nazionale (22G00085). (G.U. Serie Generale, n. 144 del 22 giugno 2022) (2022). Available online at: https://www.trovanorme.salute.gov.it/norme/dettaglioAtto?id=87801 (accessed November, 2022).
11.
MissoniE. Global Health Determinants and Limits to the Sustainability of Sustainable Development Goal 3. In:A.Flahaut, editor. Transitioning to Good Health and Well-Being. MDPI (2022).
Summary
Keywords
climate change, healthcare carbon footprint, healthcare decarbonization, planetary health, public health policies
Citation
Armocida B, Formenti B, Ussai S, Missoni E, De Marchi C, Panella M, Onder G, Mancini L, Pistis M, Martuzzi M and Barone-Adesi F (2022) Decarbonization of the Italian healthcare system and European funds. A lost opportunity?. Front. Public Health 10:1037122. doi: 10.3389/fpubh.2022.1037122
Received
12 October 2022
Accepted
15 November 2022
Published
14 December 2022
Volume
10 - 2022
Edited by
Stefania Salmaso, Independent Researcher, Rome, Italy
Reviewed by
Francesco Forastiere, CNR Area della Ricerca di Palermo, Italy
Updates
Copyright
© 2022 Armocida, Formenti, Ussai, Missoni, De Marchi, Panella, Onder, Mancini, Pistis, Martuzzi and Barone-Adesi.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Benedetta Armocida benedetta.armocida@iss.it
This article was submitted to Public Health Policy, a section of the journal Frontiers in Public Health
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.