Surgical Waste Is a Growing Concern for UK Environmentalists
Holly Morris is a rare individual, holding dual professional accreditation across both surgical and medical textile industries. Morris is a hand and wrist surgeon specializing in the management of paediatric and congenital hand differences whose resume includes working at the Pulvertaft Hand Centre (UK) and membership of the Green Surgery Oversight Committee. In the report “Green Surgery – reducing the environmental impact of surgery care” commissioned by the UK Health Alliance on Climate Change in collaboration with the Royal College of Surgeons she urges: “We must also work with our procurement teams, industry partners throughout the medical supply chain, and supporting services (including facilities and estates, instrument and linen reprocessing, and waste facilities), to optimize emissions associated with use of surgical products.”
Her presentation at the Emerging Technologies Conference, held during AT EXPO 2024, focused on the environmental impact of surgical procedures looking at PPE and other medical textiles in particular. For a largely textile audience this was a unique perspective and opened to question many of the medical decisions around use, reuse and even repair that many, including this interviewer, had thought sacrosanct.
International Fiber Journal: Holly, thank you for taking this time to answer some questions for IFJ. I would like to begin with a point from your presentation that highlighted the impact of the health care sector on global pollution you cited 20-30% thought to originate in hospital operating rooms. How did it get to be this bad?
HM: In the 1990s, it became very sexy to have disposable garments, gowns and drapes because there was a belief that they were better for infection prevention and it was also cheaper because you didn’t have to launder. But nobody really considered the environmental footprint. Studies are now estimating that operating suites in North America and the UK during a typical operation produce a carbon footprint of 146-232 kg CO2e, that is comparable to emissions associated with driving 400-650 miles in an average petrol car. In the American private healthcare sector it was often seen as an advantage to have a new thing for every patient, while in the public/UK National Health Service (NHS) this was less so because of budget constraints.
IFJ: Are medical textiles a particular problem?
HM: Medical textiles have become the fastest growing sector of the technical textile industry, worth around $13 billion in 2020, growing to $33 billion in 2023, with the global orthopaedic market valued at $45 billion back in 2019. Global emissions from the health systems stands at 4.4%, higher than a sector such as aviation which comes in less at 2.5%. Taking the example of the British NHS carbon footprint, we see around 65% coming from medicines, equipment and the supply chain with the next highest figure, 15% coming from energy, water and waste. Medical textiles account for 14-31% of healthcare waste. This includes a really broad range of materials, mostly manufactured from synthetic fibres and includes implantables, personal and protective equipment (PPE), incontinence products, smart textiles and even components of devices for environmental control, for example air filters etc.
IFJ: Do you think that there is sufficient guidance available on repair and recycling?
HM: Much of the current guidance is pretty archaic and really needs to be revisited both on repair and recycling. Studies have shown that patching a hole in a surgical gown or drape does not increase the risk of contamination and patient infection. Disassembly is another consideration both for repair and the recovery of useful portions that might be reused in the healthcare system or elsewhere. Design plays an important role in the carbon footprint of an item as it impacts on construction, number of pieces in the garment or unit, type of seaming and material selection. It’s worth remembering that the full cost of an item needs to be considered when deciding whether an item should be repaired, this include energy, chemical and water use. I see so many items that just need a small repair in order to be reused but we need to have systems in place to make it happen.
IFJ: Medical and hospital staff as well as patients need to be safe, do you see a way that this can be done with less impact on the environment?
HM: The pandemic created unprecedented demand for medical textiles, particularly PPE. But it also highlighted the sheer quantity of material and waste being generated, much of it after a single use. This is now being looked at in terms of financial and environmental cost, with many countries now looking to encourage greater use of reusable drapes and gowns over disposable ones. One of the issues that needs to be addressed is the supply chain, and laundry in particular. Another is recycling and there is a hesitation in accepting surgical linens for recycling because of the fear that it will be heavily contaminated. A system of laundering and sorting linens after their final use would be one way of mitigating this risk. Putting the right systems in place would help to reassure stakeholders immeasurably.
IFJ: Do you see stringent medical standards as a major obstacle?
HM: There is a lot that can be done simply looking at behavior changes during surgery. Clinicians can evaluate how they drape their patients and assess whether they can reduce what they are using. It isn’t just drapes but also the equipment we use. Only opening the items that we use reduces waste and the need for reprocessing or disposal. At a hospital level, a change to reusable textiles such as theatre hats, sterile gowns, patient drapes and trolley covers would also improve the carbon footprint.
IFJ: You have said that 70% of emissions are primarily derived from the health care supply chain. Can you unpack that a little and indicate where there might be easy gains to be made here?
HM: The manufacture of items, the transport of these and the processing of effluents (air/waste water) all generate emissions. This area is harder to directly control as the supply chain is large.
I see laundry as an area where easy gains might be made on this. Clear guidance on optimising machine loading would certainly yield benefit. This should look to ensure the correct weight and ratio of textiles, factoring in the level of dirt and careful mixing so that heavily soiled linens are not being put together with lightly used ones. The use of environmentally preferable detergents and filters to capture microfibers would also bring benefits. Looking beyond the amount of energy to focus on renewable energy sources would also be good. Time and temperature alternatives for thermal disinfection can also be examined more closely. Currently there is work underway to revise and update the laundering guidance used within healthcare in the UK.
IFJ: In an academic paper earlier this year you claimed that there are lessons to be learned from the fashion-clothing retail supply chains, can you elaborate on this?
HM: My clinical practise is based in the Derby. Derbyshire was home to the great British fashion designer Vivienne Westwood who was well known for being a climate change activist – perhaps there is something in the water! It’s all too easy to dismiss the fashion sector as irrelevant but I see a lot that we might learn from the complex supply chains and relationships that the fashion industry has in place, particularly with the interest in reducing fast fashion and the disposal or recycling of the end product. To begin with, we must be aware that the stories of labor abuses and sweatshops are not confined to fast fashion. A report by the British Medical Association identified that there is state-sponsored Uyghur and North Korean forced labor found in the manufacture of PPE in China and forced labor of gloves in Malaysia and Thailand. One of the most important lessons I see is the need for oversight and accountability. Nothing operates on trust and you see retailers not just checking inventory, but checking all aspects from design to production visiting factories and warehouse facilities to see for themselves. This kind of connectedness generates better understanding on both sides that goes beyond the specification, and helps identify where and how improvements can be made.
IFJ: Are you seeing any new fiber or fabric developments that look promising?
HM: The new developments that I am most excited by are those that can be used to reduce the environmental impact of existing medical textiles. We need to be looking at whether other methods of laundry are viable, such as polymer bead laundering which are more effective. This method uses only around a third of the water that a conventional commercial laundry machine uses. The energy use drops by an estimated 88% because no hot water is used and 15% more water is removed so that there is less drying needed and an energy saving to be made there also. Microfiber pollution filters are essential. Currently available options can capture more than 99% of microfibers with their filtration technology. When you think that around 500,000 tons of microfiber flows into our oceans each year that offers quite a difference.
IFJ: Any final thoughts on how to move things forward?
HM: During COVID everything went up in price and that has a legacy. The problem is that procurement are focused on the upfront cost only, not the disposal cost. If they had to take account of the full lifetime cost then strategies like repair, reuse, laundry etcetera, more sustainable medical textiles would come out cheaper. If you were to add a carbon tax to that then the argument becomes even more compelling.
