Geisel and Thayer Investigators Partner to Reduce Medical Waste

Professor Benoit Cushman-Roisin

The study is the first to quantify the amount of waste generated from disposable endoscopic equipment and endoscopes, the instruments used by gastroenterologists to visualize the upper or lower part of the digestive tract. Gastroenterologists perform an estimated 18 million endoscopic procedures annually in the US, the majority of which are colonoscopies.

The study has found that each year roughly 38,000 metric tons of garbage is produced nationwide from the use of disposables in endoscopic procedures, which is enough waste to fill 11 million trash cans and exceeds the weight of 25,000 passenger cars.

A single endoscopy generates as much waste as the average American does in one day, the study shows.

Investigators Heiko Pohl, MD, a professor of medicine at Geisel, third-year Geisel student Sathvik Namburar '22, John Damianos D '16, MED '20, and Benoit Cushman-Roisin, PhD, a professor of engineering at Thayer, worked in close relationship with hospital partners at Dartmouth-Hitchcock Medical Center, the Veterans Affairs Medical Center (VA) in White River Junction, VT, and Elliott Hospital in Manchester, NH, where waste audits were performed.

"It pained me to see how much waste we produce with every endoscopy knowing most of it will end up in the landfill without any recycling," says Pohl, a gastroenterologist at the VA.

Healthcare activity generates several billion pounds of garbage annually and 8.5 percent of US greenhouse gas emissions. Medical waste comes from many sources, but little is known about how much any given medical procedure contributes to this mountain of trash.

"Generally, there is little thought given to the waste that each procedure generates," Namburar says. "Most doctors are not present when waste containers are emptied. If we were to become more purposeful about waste, we could make a huge dent in the amount produced per procedure."

Namburar, who published research (https://www.sciencedirect.com/science/article/pii/S2451993618301701) on healthcare waste as an undergraduate at Johns Hopkins University, draws on his experience studying the waste from eye surgeries in the US and India. When comparing the exact same procedure, Namburar found that US hospitals produce significantly more waste per eye surgery than do hospitals in India, with no difference in surgical outcomes.

The appeal of disposables is fueled in part by efficiency, higher costs of reprocessing reusable supplies, and the simplicity of keeping treatment practices sterile. Out of concern for the risk of infection transmission between patients, the Food and Drug Administration has recently approved the use of disposable endoscopes.

"Infection transmission is a real problem, but on the grand scale this is a very rare event," explains Pohl. "The question is whether a single-use device is the only solution to reducing the risk."

Unsurprisingly, large single-use instruments and their sterile packaging generate considerable solid waste. Their study shows that transitioning exclusively to disposable endoscopes would amount to a 25 percent increase in annual waste mass from endoscopy.

"We need to keep a global perspective and take the environmental impact into account when considering the harms and benefits of endoscopic procedures or healthcare in general," says Pohl. "Cost-effectiveness analyses should not just consider the financial cost to the society, but also the environmental cost and the potential impact on health."

With an eye on sustainability, Pohl sought out Cushman-Roisin, whose expertise crisscrosses industrial ecology and environmental engineering, to understand the true "life cycle" of single-use medical supplies. By studying the total environmental impact from the production, transport, utilization, and disposal of single-use endoscopes, the researchers look to capture a more complete carbon footprint.

Pohl and Cushman-Roisin agree that solid waste generation is one of a number of important metrics. Other environmental consequences also exist upstream and downstream in healthcare, including manufacturing impacts, air pollutant emissions from incineration of infectious waste, and the disposal of radioactive medical waste.

"Since the healthcare system contributes substantially to the global carbon footprint, we in healthcare can no longer ignore how our actions impact the environment, which in turn adversely impact health outcomes," says Damianos, who contributed to the study while at Geisel and is now an internal medicine resident at Yale-New Haven Hospital.

"It is imperative that health systems critically examine their energy usage and waste production, and invest in more sustainable practices," Damianos urges. "Leading the charge should be the procedure-heavy specialties who, by becoming more sustainable, can make a considerable impact."

Waste abounds in healthcare. By building a body of research that demonstrates the environmental effects of single-use supplies, the goal is to discover ways to shrink the carbon footprint of medical procedures, likely through a combination of more economical supply usage and increased utilization of reusable materials.

"Our hope is that this research can serve as a proof-of-concept that waste from endoscopies, and indeed all procedures, can be significantly reduced while maintaining patient safety," Namburar says.