Gradually, then suddenly: Singapore’s journey towards sustainable medicine

Field: Health Professions (Health Sciences)

INTRODUCTION Healthcare systems around the world are built on a foundational but unstated assumption that the environment and the climate in which they operate will not change. With the global average temperature now at about 1.45°C above the preindustrial levels,[1] this has turned out to be a poor assumption, with dire consequences for the health of our patients and the public. No longer only in the realm of projections and atmospheric models, climate change is damaging human health today, and its effects are already keenly experienced by communities and healthcare systems across the world. The last decade has seen the ten warmest years on record,[2] leaving vulnerable populations worldwide exposed to twice as many dangerous heatwave days as they faced between 1986 and 2005.[3] Singapore is no less vulnerable to the impacts of climate change, with recent evidence suggesting Singapore's average daily temperature could rise by as much as 5°C by 2100.[4] The exacerbation of many climate-sensitive diseases, cardiovascular and renal sequelae, and a projected 36% increase in dengue transmission potential should collectively make a powerful case for urgent climate action.[3] Merely bracing for impact is insufficient. Being responsible for some 4%–5% of carbon emissions globally (more than shipping and aviation),[5] healthcare providers must play their part and rapidly decarbonise their services. There are two simple pieces of good news. The first is that interventions that respond to climate change often yield direct and substantial benefits to human health through cleaner air, healthier diets and more efficient health services.[6] The second is that the health profession is taking notice. HEALTHCARE'S GLOBAL RESPONSE Shortly after the passage of the Climate Change Act 2008, the National Health Service (NHS) of the UK created the sustainable development unit and conducted its first carbon footprint in the same year.[7] It has since achieved massive emission reductions and stayed ahead of national targets, all while demonstrating how healthcare decarbonisation initiatives improve patient care quality and reduce overall costs.[8] Today, the UK NHS is joined by many other health systems that are taking bold steps towards delivering low-carbon healthcare. Close to 30 countries have committed to reduce emissions to net zero latest by 2050, with many more pledging to conduct a baseline carbon footprint assessment for their healthcare systems [Table 1].[9] These healthcare systems — from France to Indonesia — are rapidly assembling the expertise required to better understand their carbon footprint, while new decarbonisation teams from the Netherlands and Australia are finding firmer footholds to begin reducing emissions.[10,11]Table 1: Members of ATACH with net zero commitmenta.Both medical research foundations and the broader healthcare industry are adding wind to the sails of these large health systems. Driven in part by a UK–US alliance on sustainable healthcare procurement,[12] many of the largest players in the health industry, including Medtronic, Novo Nordisk, Johnson and Johnson and AstraZeneca, have committed to reach net zero on their full emissions profile well before the mid-century.[13] In 2023 alone, National Institute for Health and Care Research announced a new £30 million funding scheme to support the transition to net zero,[14] while global financial institutions have committed an aggregated USD 1 billion to respond at pace to the health challenges of climate change.[15] On the ground, the interventions are about as diverse as the field of medicine itself: gastroenterologists across Europe are making the transition to lower-carbon endoscopy pathways;[16] with the support of the Royal College of Anaesthetists, operating theatres across England are removing desflurane from their stocks altogether;[17] in Manila, human immunodeficiency virus clinics are being funded by savings that are generated from a new solar array installed at a local hospital;[18] and in the Netherlands, some pharmacists are redispensing unused cancer drugs to reduce waste and make cancer treatment more affordable for patients.[19] For every medication, procedure, scan, test and operation, it seems there is a clinician somewhere exploring ways to deliver higher-quality, lower-carbon care. SINGAPORE: A POTENTIAL GLOBAL LEADER IN SUSTAINABLE MEDICINE Anyone peering into Singapore's healthcare system would quickly notice that something special is happening here. Almost every part of Singapore's healthcare system is now responding to climate change swiftly, intentionally and resolutely. Like the innate and adaptive components of the immune system, these efforts are often a combination of ground-up clinical engagement and strategic marksmanship. The tiny island boasts numerous healthcare decarbonisation initiatives. In the eastern region, sustainability champions are being identified across SingHealth's clinical specialties to accelerate decarbonisation from the ground up, complementing emission-reducing infrastructural enhancements, like Changi General Hospital's 50 MW h-generating solar array.[20] In the north, Khoo Teck Puat Hospital, Singapore's 'garden hospital', has won numerous awards for its biophilic therapeutic green spaces.[21] The Centre for Healthcare Innovation is turning the spotlight on 'Sustainability in Healthcare' at its 2024 annual conference.[22] In the west, Ng Teng Fong General Hospital has a robust strategy for optimising energy efficiency,[23] while multidisciplinary teams in the National University Health System have ambitiously slashed waste, scaled up recycling and swiftly implemented solid green procurement frameworks.[24] Both government and industry are also making significant strides. Becton Dickinson, a medical device company producing everything from needles to infusion pumps, is establishing a Sustainability Centre of Excellence in Singapore. A new Sustainability Office within the Ministry of Health Holdings has been charged with coordinating and supercharging efforts across the public healthcare sector. The Agency for Logistics and Procurement Services, a public healthcare supply chain agency, recently unveiled its green procurement guidelines to improve energy and water efficiency and to reduce waste in public healthcare delivery.[25] In the world of research and innovation, a collaborative tripartite initiative is taking shape at the National University of Singapore. Leveraging the diverse expertise of the Climate, Environment and Health Programme, the Heat Resilience and Performance Centre and the Centre for Sustainable Medicine, the consortium is synergising to equip communities and health systems with evidence-based solutions amidst a changing climate. PAVING THE WAY TO NET ZERO HEALTHCARE A few years ago, the challenge in sustainable medicine was raising its awareness among health professionals. Today, four in five of Singapore's health professionals have expressed their desire to work for an environmentally sustainable healthcare system. The question is no longer 'should we', but 'how do we' decarbonise healthcare. To accelerate and sustain progress, the healthcare sector must undergo three pivotal transformations: Educating future medical leaders: The net zero transition requires engagement from every clinical speciality; every part of medicine needs to be equipped with the tools to tackle climate change. Diversity in learning modalities is key. While embedding the principles of net zero healthcare in undergraduate medical education is a necessary step, more advanced training is equally required to achieve rapid system-wide transformation. For the Centre for Sustainable Medicine, this takes the form of a new clinical fellowship programme to a year-long masters-level degree. Generating clinically relevant evidence: While the path to net zero is broadly well defined, the brick-by-brick steps in healthcare decarbonisation require more sophisticated answers to questions around health, cost and carbon consequences of everyday clinical activities. Robust guidance for clinicians is needed for every specialty and area of practice, beyond guidelines on reduction of high-carbon gases in anaesthetics. Supporting national policymaking: New standards and expert support are needed to help conduct national footprints, verify sustainability declarations around pharmaceutical and medical device products, and support collaboration and shared learning within and between countries. CONCLUSION The health profession's response to climate change and the health sector's journey towards net zero will be complex and challenging. But when one country turns into 25, and one clinician turns into a 100, healthcare decarbonisation stops being a 'nice to have' and starts becoming a new pillar of excellence for Singapore and around the world. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.