Diabetes detritus and climate change
As the world looks towards urgent discussions at the COP27 meeting, we need to acknowledge the significant impact healthcare makes to climate change through the generation of waste. In recognition of this, the environmental impact of diabetes care was discussed for the first time at the EASD’s recent annual meeting.
Healthcare systems contribute over 4% of the world’s greenhouse gas emissions, but there is scope to reduce this without compromising care. “Many of the things that improve people’s health can also be good for the planet,” said Dr Fiona Adshead, Chair of the Sustainable Healthcare Coalition (SHC, shcoalition.org), which looks for ways of introducing sustainable change into healthcare systems. “There are lots of opportunities for change. For instance, in the UK in England our health service has declared it will be net zero by 2045 and that is now legally binding. So care pathways need to change and environment needs to be at the heart of decisions on healthcare.” The SHC will be spreading this message at COP27.
Dr Adshead referred to a study that showed that in diabetes, a person’s glucose control can have a variable – and measurable – environmental impact. Someone with poorer glucose control accounts for 7% more emissions than someone with good control. To put it in real terms, that’s the equivalent of travelling 200 km by car. “This might seem quite small, but once you’ve multiplied that across the country with five million people with diabetes, it has a large impact,” she says. Looking at different aspects of diabetes care, the largest environmental impact comes from footcare and general diabetes care, with GP visits, blood glucose testing and medication. All of this could be analysed in more detail, as the SHC has already done for renal dialysis.
One obvious opportunity for reducing environmental impact is using digital healthcare – capitalising on experience gained during the pandemic – as it saves on travel. And there are many more areas of healthcare that could reduce their carbon footprint. For instance, clinical trials also need to be decarbonised and the SHC is part of a consortium, led by Cancer Research UK, which is looking at developing low-carbon trials. They will eventually create an online calculator tool from this, so that people can look at the potential environmental impact of their clinical trial work. This will follow the Care Pathway Carbon Calculator, which is already available on the SHC’s website, and calculators for pharmacy and dentistry are also being looked at.
Environmental impact can also be reduced by reusing or recycling diabetes equipment. For instance, pre-filled Novo Nordisk pens can now be recycled through the pilot PenCycle project in the UK (pen-cycle.co.uk). High street pharmacies have return bins that people can put pens in and then they are taken to Denmark to be turned into products like lamps and chairs.
“At SHC, we want to work out how to change healthcare systems to both improve outcomes and reduce environmental impact. We are always looking for new case studies in clinical care and it would be wonderful to have some in diabetes,” Dr Adshead concluded.
Cutting diabetes waste
Dr Lutz Heinemann, Managing Editor of the Journal of Diabetes Science and Technology, focused on the need for less waste and more recycling in diabetes technology. “There is an increasing awareness in the diabetes community about this topic. The only way forward is to work together. Thinking ‘it’s nice we talked about this’ is not sufficient. We need to go to the next step,” he said.
He showed an eye-opening photo of the waste that one person with type 1 diabetes collected over three months, relating to insulin application and blood glucose measurement, packaging, continuous glucose monitoring (CGM) systems, infusion sets and sharps, and including potentially infectious waste. “It’s complex – the products themselves and their packaging are two different stories,” he said.
Dr Heinemann carried out a study of 1048 people with diabetes, of whom 89% said that diabetes waste was ‘a relevant topic’ for them, 67% expressed a desire for more reusable equipment and 54% said that they do think about the packaging waste they are generating. However, when asked if they would select a CGM system based on the amount of waste it generated, only 13% said ‘Yes’. “So, waste and recycling may not guide these choices now, but that could change,” he said.
People are complaining about waste, but don’t know how to separate their diabetes waste. “We all, people with diabetes included, know how to deposit paper, plastic, glass and so on, but have a different attitude to medical waste.” Dr Heinemann thinks that there should be dedicated disposal boxes issued for different devices and this issue should be addressed in diabetes education. He believes that the EU Plastics Strategy will result in stricter rules and guidelines, which could have a big impact on managing diabetes waste. Waste is also mentioned in the EU’s new Medical Device regulations – not as a main topic, but he is sure that will change.
Diabetes products are complex, with many separate parts. Developers need to step up to the challenge of recycling, besides making their products as cheap and usable as possible. “New devices should be better. The industry is aware of this pressure, for they talk of zero carbon and produce sustainability reports.”
Packaging is another important issue. If LEGO™ can have disposable plastic, then why can’t diabetes technology? In answer, companies are at least thinking about re-usable rather than disposable pens and other insulin products. As mentioned above, Novo Nordisk are recycling their insulin pens and the FlexPen and FlexTouch now contain only two types of plastic now, which helps a lot when it comes to the recycling effort.
But the prospect of recycling diabetes technology does raise a lot of questions. For instance, in Brazil it is now the law that insulin pens must be collected and recycled. But without an onward plan, they will just be burned. Heinemann says this is a high risk in many countries. “There is a need for a good market in recycled items, and we must beware of ‘greenwashing’ fraud. We need to start some pilot schemes and not be surprised if the ecological balance is not as expected. It can be tricky when you come to the details.”
The Diabetes Technology Society in the USA have started the Green Diabetes Initiative. “We went ahead and organised a meeting where we tried to describe the next steps.” He has a concern that ‘greener’ products might be more expensive and companies developing them would lose out to those offering cheaper conventional versions, particularly where healthcare budgets are stretched. “Those that are willing to invest in our future should not only be applauded, they should have a clear advantage that is playing back to them,” he said.
In the end, he believes people with diabetes will push for change. “Political pressure will increase, because of changes in the regulatory environment. I’ve sent letters to all the manufacturers in Germany and I was impressed with their response. I am not sure how much activity there is on this in the diabetes associations, though.” Having diabetes and climate change discussed, for the first time, at one of the leading diabetes organisations – EASD – was, therefore, especially significant and hopefully will act as a catalyst to further action on diabetes and climate change.
Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.