The World Gastroenterology Organisation Climate Change Committee: Meeting the Challenge of Environmental Change

Vol. 29, Issue 2 (June 2024)

	Desmond Leddin, MB, MSc, FRCPC, FRCPI Dalhousie University Chair, WGO Climate Change Committee Halifax, Canada
	Anahita Sadeghi, MD Tehran University of Medical Sciences Vice Chair, WGO Climate Change Committee Tehran, Iran
	Rui Jorge Guedes Morais, MD Gastroenterology Department, Centro Hospitalar Universitário de São João Faculty of Medicine,University of Porto Porto, Portugal

Objectives

The purpose of this report is to raise awareness in the global digestive health community of the implications of environmental change for digestive health, to outline the steps which are being taken by the World Gastroenterology Organisation (WGO) and to suggest some actions which you can take.

Background

The atmosphere is the thin layer of gas which surrounds the earth. It is a narrow band and when flying at 10,000 meters almost all of it is between you and the ground. The atmosphere has been warming steadily since the onset of industrialization. The gases released by extraction and combustion of fossil fuels, and those released from other processes, such as manufacturing, agriculture, and healthcare, have warmed the atmosphere by holding back heat, which would normally be radiated into space. Currently, global mean surface temperature is over 1°C above pre-industrial measurements.^{1, 2}

A 1° change in temperature may not seem like much, but it represents a huge change in the amount of energy retained in the atmosphere and oceans. It is more than sufficient to lead to global changes in regional temperatures, weather patterns, and precipitation. It is enough to raise the level of the oceans thereby threatening island states and coastal communities.

Environmental change is not confined to changes in global temperature. The burning of fossil fuels, agriculture, and industrial processes release large amounts of pollutants. In addition, biodiversity, the variety of all the living creatures and plants on the planet, is in decline under the twin threats of climate change and pollution. Wider biodiversity is important in preventing disease, ensuring access to clean water, and ensuring the growth of agricultural crops.^{2, 3}

Lower income countries are particularly vulnerable to environmental change because they are often located in the regions, which will be most severely affected.⁴ In addition, lower income countries are less able to withstand the damage posed by infrastructure loss due to extreme weather events and the consequences arising from decreased access to water and crops.

Effects of Environmental Change on Health

The health effects of environmental change have primarily been linked with respiratory and cardiovascular disease, but digestive health is also affected.⁵ On a societal level, changes in temperature, rainfall, and the frequency and severity of storms are already affecting access to the fundamentals of life - water, nutrition, and shelter. On an individual level virtually every part of the digestive system can be affected either by environmental change. This topic has recently been reviewed in detail.⁶

Figure 1. The effects of the three main drivers of environmental change on digestive health. Global warming, pollution and biodiversity loss are driving Increasing temperatures, increasing extreme weather, and decreasing air quality. These is turn are affecting digestive health and disease. References for each of the conditions listed can be found in a recent narrative review.⁶

For each of the conditions listed in Figure 1 there is plausible, albeit not definitive, evidence of a connection between environmental change and digestive health. Air pollution is emerging as a particular concern. Particulate matter (PM) refers to a wide variety of microscopic particles which are suspended in the air. These vary in composition and size. They can be inhaled and cross into the blood circulation, or they can be ingested and reach the gastrointestinal tract. PM has been linked to a variety of digestive diseases, including esophageal cancer.⁷ Plastic pollution is now ubiquitous and can be found in stool samples and in the intestinal wall.⁸ It is not yet clear what the effects may be, but they may have a role in intestinal disease.⁹

Effects of healthcare on the Environment

While environmental change is affecting health, the converse is also true, healthcare delivery is affecting the environment. Healthcare is responsible for 5% or more of greenhouse gas emissions in some countries.¹⁰ Much attention has been focused on endoscopy since it is a high-volume procedure and associated with the generation of a considerable amount of emissions and waste.^11-13 The carbon footprint and the amount of emissions associated with endoscopy are becoming clear. Travel to and from the endoscopy suite by patients and staff and the energy required to run the endoscopy suite are both major contributing factors.¹⁴ Waste and the carbon emissions associated with the use of disposables are also important, however these issues are not as significant even if more apparent. Several national peer societies and endoscopy groups have issued guidance on how to reduce the environmental impact of endoscopy.^15-20

Physician Engagement

Even though environmental change represents a major public health threat, physicians have been slow to engage. There are many reasons why this needs to change.²¹ There is the issue of intergenerational justice. It is not fair nor just to live beyond our means now and let future generations deal with the problems we have created. As physicians, we have an ethical duty to not harm patients. We know that pollution, global warming, and biodiversity loss associated with healthcare are all harming patients. Therefore, it follows that we must do as much as we can to reduce this. It makes financial sense, and it is simply good management to practice sustainable healthcare.²² Finally, it is in our self-interest. If we do not bring this problem under control, then it will have very severe implications for future generations of our societies and our individual families.

WGO recently conducted a survey of global gastroenterology leadership.²³ Several obstacles to physician engagement were identified including financial blocks, psychological factors, and systematic issues such as a lack of education. Many of these can be overcome through a combination of education, raising awareness, and systems change.

Global Response

The world is responding and peak carbon emissions per capita may have already been reached.²⁴ Emissions are falling quickly in many countries, although overall they continue to rise. The global gastroenterology community has also begun to mobilize with education of digestive health practitioners and raising awareness becoming clearer priorities.²⁵ WGO organized a series of webinars on the topic in 2023 and published summarized versions of the key takeaways.²⁶ This course was a comprehensive overview of the problem and could serve as a curriculum for individuals and societies who wish to learn more.

Mission of the WGO Committee

Recently, WGO has established the Climate Change Committee with a wide global representation. The mission of the committee is sustainability at the center and has four outside pillars - education, research, advocacy, and raising awareness. (Figure 2).

Figure 2

The mission of the WGO Climate Change Committee. At the center of the committee’s activities is sustainability. Movement towards that objective is supported by the four pillars of raising awareness, advocacy, research, and education.

Education

In alignment with our commitment to education and heightened awareness, WGO will continue its successful webinar series, addressing pivotal topics and providing various educational resources. These resources include slide decks and personal stories from gastroenterologists worldwide that showcase sustainable practices in their professional and personal lives.

• Webinar Series: We plan to host a seasonal webinar series. The first session titled "Navigating Sustainable Endoscopy Practices," was launched to coincide with the celebration of World Earth Day on April 22, 2024. This initiative is intended to appeal to a diverse audience, including physicians—particularly gastroenterologists—GI fellows, medical students, and nursing staff. Each 60-minute webinar will feature two experts leading talks followed by a Q&A session, ensuring a comprehensive discourse on pressing matters.
• Global Outreach: We encourage all GI societies to establish their own climate committees and integrate climate change sessions into their national congresses, fostering a unified approach towards sustainability within the field.

Awareness

Social media has become an integral part of our society and our daily life, being used by billions of people.²⁷ Considering the previously described difficulties in encouraging greater action by physicians regarding the adoption of sustainable practices, WGO considers that social media may be a significant tool to help raise awareness not only among physicians but also among the general population on this topic. The possible impact is expected to be more significant among younger generations, which are precisely the ones that are in a good position to act and further develop efforts to avoid further consequences of environmental change.

• We plan to focus mainly on Instagram, currently the most used social media platform, with a defined plan:
  • Critical review and sharing of relevant articles on the topic
  • Sharing tips and tricks for greener gastroenterology/endoscopy practice.
  • Interviews with experts on topics
  • Sharing real life stories around the world that had an impact on sustainability

Research

There is a great deal of research activity on environmental change and digestive health. It involves learning about new disciplines such as including life-cycle analysis and engineering, which are not traditionally part of the medical curriculum. WGO research activities to date have been primarily concerned with understanding the needs of the global digestive health community but the plan is to engage in original data procurement.

Advocacy

Physicians are in an excellent position to advocate for people who do not have an effective voice of their own. The WGO climate committee's advocacy efforts will be based on raising awareness, educating digestive health providers, and conducting targeted research.²⁷

Moving to Action

Healthcare providers can act at different levels, from micro (family and friend networks) to meso (community and regional scale), and macro (national and global policy). Physicians are role models in society and are trusted to act in the best interests of their communities. The scale of engagement clearly influences the impact of the intervention, and the scale is also determined by the position of the healthcare provider. An individual physician, for example, might engage only on a micro scale and that will have an impact within the family unit. That may seem small, but small actions can be very meaningful.²⁸ Children and teenagers are more vulnerable to the stress associated with the relentless barrage of bad news and images related to climate change.^{29, 30} Even if we can't bring about a global change, acting on a personal level will send a message to family and friends that this issue matters and that we are making a sincere effort.

As professionals in the field of endoscopy and health systems, we can make a significant impact by implementing even small changes in our practices.³¹ These changes can trigger a larger-scale shift in the system, creating a ripple effect that may inspire others to act. Those who possess greater influence in the digestive health community can even bring about global change, altering the culture and promoting action on a national and international level.

Figure 3. Five actions which can be instituted quickly and will have an immediate impact.

Five Actions You Can Take Now

Figure 3 shows potential actions, which can be taken in personal and professional life to have an immediate impact on reducing carbon footprint. There are many others which can be taken, but we have chosen five representative actions that are feasible and impactful.³²

The carbon footprint of an individual, the total carbon dioxide emissions for which we are responsible, is made up of all the components of living including food, clothing, shelter, travel, and consumables. The average per capita carbon footprint varies enormously by country.³³ The global average is about 4.7 tons(t) of carbon dioxide per person per year, in low-income countries it is 0.3 t while in North America it is 10.5t.

If you want to take the first steps, here is what you can do.

1. Educate Yourself and Others

Gaining and sharing knowledge on this issue is the first step towards generating solutions. The WGO has prepared a series of webinars on the subject and published the contents. This is a comprehensive review of the subject and a more than sufficient foundation. They can be accessed here. (https://www.worldgastroenterology.org/education-and-training/webinars/wgo-climate-course-for-global-gastroenterology)

1. Reduce Travel

The emissions associated with travelling by car or plane are amongst the most environmentally harmful actions most people take. Travel by car or plane emits roughly 170g of CO₂e per kilometer, although emissions do vary by car type and flight distance.³⁴ It is not often feasible for people to change their daily travel patterns and get away from cars, but it is often possible to reduce the amount of air travel. You could lobby your national peer to allow hybrid meetings, instead of in person meetings, thus reducing air travel.³⁵ The Canadian Association of Gastroenterology reduced travel related emissions to some of its annual meetings by over 40% simply by changing the geographic location.³⁶ In the United States, car and airline travel accounted for nearly half of the annual emissions of an academic gastroenterologist, so this is an area where environmental wins can be obtained.

1. Change Diet

The carbon footprint of different foods varies considerably. Beef production generates nearly 60 kg of greenhouse gases (GHG) per kg of meat. Peas and nuts, as an example, generate less than 1 kg per of GHG per kg of food.³⁸ In addition, the clearing of forest to produce pastureland for cattle decreases biodiversity, and the runoff manure associated with cattle farming is a potent source of water pollution. The Lancet - EAT commission has published a diet which is good for both human and planetary health.³⁹

1. Save Energy

Home energy is a significant contributor to household carbon footprint. There are many steps which can be taken to reduce this, including reducing heating and cooling, improving insulation, switching to LED lights, and changing clothes washing cycles.⁴⁰ Endoscopy uses considerable amounts of energy for lighting, heating and ventilation, processors, and computers. Estimates very between studies but is around 2.7 kWh per endoscopy.¹² The energy usage of endoscopy units can be reduced by changing lighting, making sure the equipment is turned off when not in use, and changing the temperature and air conditioning settings. These actions can become part of the sustainability plan for the unit.

1. Add Sustainability to Endoscopy Management

Once sustainability is on the agenda, environmental considerations may be factored into decisions on care provision, energy savings within the institution, temperature and air conditioning setbacks, and procurement. Telemedicine has been shown to be acceptable to patients, associated with good healthcare, and capable of producing significant reduction in emissions.⁴¹ In one report from Ontario, Canada over 3 billion km in travel was saved over the course of a 22-month period.⁴² Pre-procedure consultation and post procedure followed up by video or phone would have a significant impact on the reduction of endoscopy unit emissions.

Summary

Environmental change is now recognized as a contributing factor to the incidence and exacerbation of digestive disease. Paradoxically delivery of digestive healthcare is contributing to the problem. There are many actions which individuals can take. Moving the global digestive health community to a more sustainable practice will be facilitated by research, education, raising awareness and advocacy. Considerable progress has already been made. WGO, by working with its global network of member organizations, is committed to helping the digestive health community meet the challenge.

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