See Article, page 1154

In their recent article, Baker et al1 explore the intersection of ethnic inequalities in health care with climate change. They highlight an issue of great importance––that disparities exist in the provision of anesthetic care to patients from Black, Indigenous, and people of color (BIPOC) communities. Furthermore, they argue that this disparate care can lead to increased health care-associated waste and greenhouse gas (GHG) emissions, the burden of which will fall disproportionately on individuals from the same populations. In this accompanying editorial, we clarify the relative impact of anesthesia on climate change and argue that tackling ethnic inequality in anesthetic care is a subject of standalone significance that needs no other justification.

THE POWER OF LANGUAGE

Climate change and racism rank high in any inventory of global challenges facing the 21st century. Both require multinational and multilevel interventions and solutions from individuals, corporations, and governments; both also require care and consideration in the language and rhetoric that is used. For this editorial, we adopt the terminology of the original paper and refer to patients from BIPOC communities; however, we acknowledge that any “terminology that conflates different groups of people does not just erase identities; it can also lead to broad brush policy decisions that fail to appreciate the nuance of ethnic inequality.”2

Similarly, the language of climate science has a vocabulary that is not interchangeable. The steps from the emission of GHGs through to a planetary energy imbalance, global warming, and climate impacts are complex and nonlinear. Collapsing this complexity into shorthand statements regarding the impacts of individual gases has led to misunderstandings and misplaced policy changes in the anesthetic community.3 Nevertheless, the burden of climate change remains real, and continues to fall more heavily on those who are the most vulnerable.4

THE BURDEN OF CLIMATE CHANGE

Baker et al1 rightly highlight that individuals from BIPOC communities in the United States face increased health care burdens associated with climate change. This vulnerability is compounded by reduced resources to protect against, and recover from, extreme weather events.5 While some environmental issues are spatially localized and experienced by specific populations––city air pollution, for example––the most damaging and long-lasting consequence of GHG emissions (namely, climate change) is not constrained to communities, countries, or continents.

The Intergovernmental Panel on Climate Change (IPCC) estimates that 3.3 to 3.6 billion people live in areas that are highly vulnerable to climate change.4 This vulnerability “differs substantially among and within regions, driven by patterns of intersecting socioeconomic development, unsustainable ocean and land use, inequity, marginalization, historical and ongoing patterns of inequity such as colonialism, and governance.”4 GHG emissions and climate change are not constrained by borders on maps––countries export much of the harm created by their GHG emissions because Earth’s atmosphere intermixes globally.6 Since the burden of climate change does not fall evenly on different countries and populations, there is potential for a global mismatch between emissions and consequent impacts. Indeed, it is well documented that an enormous global inequality exists, whereby “those who are disproportionately impacted by climate change tend not to be those most responsible for causing it.”6,7

In their article, Baker et al1 argue that the disparate anesthetic care received by individuals from BIPOC communities could result in increased health care-associated waste and GHG emissions––with consequent impacts on those who are already most vulnerable. The increase in resource utilization from postoperative complications, readmissions, and prolonged hospital stays would certainly generate more waste per person. As emphasized by MacNeill et al,8 the first principle of sustainable health care systems is to reduce demand for health services. Whether anesthetic choice on its own is enough to disproportionately increase GHG emissions requires some further consideration.

THE RELATIVE IMPACT OF ANESTHESIA ON CLIMATE CHANGE

The power of language, as introduced earlier, cannot be overstated. When writing or speaking about a topic outside one’s own area of expertise (climate science in the medical literature, for example), care is required to avoid inadvertent distortion of information and citations.9 Over the past decade, considerable interest and enthusiasm in sustainable health care has developed within the anesthetic community––this is to be celebrated. However, publications are written and policy changes are made that are founded on subtle, yet significant, misunderstandings and misapplications of the underpinning climate science.3

In their recent article, Baker et al1 describe that a “significant” portion of global warming is “attributed to GHGs such as methane, nitrous oxide, and hydrofluorocarbons” and that “halogenated compounds such as volatile anaesthetic agents … contribute to global warming by increasing planet temperature over 2,000 times that of CO2”. Neither of these statements correctly represent the science of climate change and the impacts of an inhaled anesthetic.

To be clear, the most important GHG that is increasing in atmospheric concentration because of human activities is carbon dioxide. Carbon dioxide emissions remain within the atmosphere for at least 100 years and have accumulated to such a degree that the atmospheric abundance is now 50 % higher than before the start of the industrial revolution in the 19th century. The relationship between cumulative CO2 emissions and decadal scale warming trends is almost linear,10 and it is “our emissions of CO2 in the coming century that will determine the character of the Anthropocene.”11 In contrast, even though the volatile anesthetic agents are potent GHGs, they are comparatively short lived and emission rates are very low. Consequently, their ensuing atmospheric concentrations are tiny and the radiative forcing (the energy added to the planet by a GHG) that they generate contributes <0.01% compared with the radiative forcing that results from carbon dioxide. This value is negligible; it will be lost within the natural variability of the climate system and contribute nothing to global warming trends.3 What this means is that any climate impact of a volatile anesthetic is vanishingly small.

RETURNING TO DISPARITIES IN ANESTHETIC CARE

Baker et al1 have used the lens of climate change to shine a light on racial disparity in anesthetic care. They highlight 2 key points––first, that individuals from different ethnic backgrounds receive different care; and second, that the burden of climate change does not fall equally. These are sobering messages.

The ultimate climate impact of this racial disparity in anesthesia is unclear, since we now recognize that the contribution of the volatile anesthetic agents to climate change has been greatly overemphasized in the medical literature. Sustainable anesthetic practice requires the following key principles––to give the best anesthetic to your patient; minimize fresh gas flows; reduce unnecessary waste; minimize the use of N2O; and to work to improve overall population health. These principles hold true regardless of race, ethnicity, or gender. Furthermore, we must continue to be mindful that GHG emissions, especially carbon dioxide, result in global change, with far-reaching consequences that will fall most heavily on those who are most vulnerable.

Baker et al’s1 article comes at a time when widespread racial and ethnic inequalities in the provision of general health care services have been emphasized, particularly within maternity and mental health.12–14 It is clear that more work is needed urgently across all aspects of health care, including anesthesia, to understand the mechanisms that underpin and drive these disparities. Only then can we enact the change that is so clearly necessary.14 We argue that the lens of climate change is not needed here––best, sustainable, anesthetic care should be given equally, without discrimination––and that a healthy well-educated population can lead to a healthy planet. E

DISCLOSURES

Name: Mary E. Slingo, DPhil, FRCA.

Contribution: This author helped in conceiving/designing the work, drafting the work or revising it critically for important intellectual content, and approving the final version to be published as well as agreed to be accountable for all aspects of the work, including ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Conflicts of Interest: M. E. Slingo is a member of the Royal College of Anaesthetists’ Sustainability Advisory Group.

Name: Julia M. Slingo, DBE, DSc, FRS.

Contribution: This author helped in conceiving/designing the work, drafting the work or revising it critically for important intellectual content, and approving the final version to be published as well as agreed to be accountable for all aspects of the work, including ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Conflicts of Interest: None.

This manuscript was handled by: Olubukola O. Nafiu, MD, FRCA, MS.

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