Clinical Environmental Stewardship Amidst the COVID-19 Era: Ethical Considerations and Reformative Solutions

The unprecedented strain that the coronavirus (COVID-19) pandemic has put on our hospital system has led to irreversible environmental consequences related to municipal waste management (Kulkarni and Anantharama, 2020). Clinical management of the COVID-19 pandemic has far overshadowed the potential impacts of plastic use and downstream waste management. It has caused businesses to shift entirely to disposable bags, plates, and cutlery, as well as incited demand for single-use personal protective equipment (PPE). As such many cities have suspended their fight against single-use items. Months into the pandemic, these non-recyclable items have littered city streets and appeared in municipal solid waste streams (Sangal, 2020). As a result, there is a 20% average increase in the municipal solid waste collection from March to April 2020 in North America. The plastic consumer economy of the COVID –19 pandemic potentiates environmental consequences through associated greenhouse gas production and ecological degradation.

In addition to municipal solid waste, the pandemic has led to major challenges in the handling of medical waste. While medical waste typically has a predictable flow rate and composition, many hospitals have seen a dramatic increase in waste production (370%) during the pandemic and a larger contribution of plastic-based waste (Klemes et al, 2020). This is reflective of the growing demand for single-use, plastic items in the medical sector due to COVID-19 including face shields, gowns, vinyl gloves, disposable bags, tubes, and masks (WHO, 2018). The expected waste production far exceeds the available capacity for the treatment of hazardous medical waste as these systems were designed for waste quantities generated during normal operations (WHO, 2018). Medical waste from hospitals is particularly problematic due to the need to destroy any residual pathogens (WHO, 2018). Furthermore, the COVID-19 virus has a prolonged lifespan on plastic-based items further emphasizing the need for single-use plastics under the presumption that single-use plastic reduces viral transmission (Van Doremalen et al, 2020).

Additionally, guidelines state that reusable resources can safely be used to reduce viral transmission (Greenpeace International, 2020).While the standard of care for COVID-19 patients must be the highest priority, increased production of COVID-19 related waste raises environmental concerns. Navigation of the intersection between adequate medical care and environmental stewardship demands beneficence, an essential pillar of ethical medical practice. Although environmental mitigation efforts could negatively impact patient care, the implementation must be done strategically to maximize future environmental benefits and minimize disruption in care. Considering either patient care or climate change independently, effectively trading one problem for another, may lead to long-term consequences that are not in the interest of patients. These complications, such as exposure to pathogens and pollutants, would likely affect minority populations that have already disproportionately suffered during the pandemic through environmental racism (Washington, 2020). In addition to genetic or traumatic origins, social and environmental determinants of health are fundamental drivers of various morbidities (Braveman and Gottlieb, 2014). Even in unprecedented times, we must strive as medical professionals to maintain the basic tenants of medical practice while combating the virus. As such, we must strive to treat all patients with appropriate medical care but not lose sight of the environmental repercussions of our decisions.

These repercussions are a public health concern, as COVID-19’s impact on human wellness is not limited to direct viral transmission. The pandemic’s effect on municipal and hospital waste will exacerbate climate change (Bauman, 2019) and in turn negatively impacts human health (Greenpeace International, 2020) Examples of which include increased cardiovascular mortality, poor respiratory function, and spread of vector-borne illnesses such as Lyme disease. (Eisen et al, 2019) We also know that the impact of these disease processes is felt most acutely by already disadvantaged communities. (American Public Health Association, 2019 and Smith et al, 2020) Thus, tackling this issue is a matter of public health, environmental health, and equity.

Although the pandemic resulted in a significant improvement in China’s air quality and reduction in national carbon emissions during the first quarter of 2020, this was a temporary reprieve. (Wang and Su, 2020) Necessary responses to this virus have compounded the rate of the already accelerated climate change, due to erosion of established waste management streams and increased demand for hospital materials. COVID-19’s impact on healthcare, however, can be optimistically framed as a catalyst for change: this pandemic is an opportunity to improve waste management and plastic use in a time of heightened consumption.

At our institution, several innovations have been deployed to address COVID-19 related waste without compromising patient care. Examples of which include N95 mask sterilization schedules (M health Fairview, 2020), reusable facemask enclosures (University of Minnesota Office for Technology Commercialization, 2020), and improved PPE guidelines for MRSA and VRE patients (Minnesota Dept of Health, 2020). However notably underrepresented, on a national scale, is the development of biodegradable polymer alternatives to alleviate the environmental burden of single-use plastics and establish a circular economy (North and Halden, 2013). Reduction of hospital waste would also benefit from waste stream analysis to identify specific targets for improvement in ordering, use, and disposal of hospital goods (Sharma et al, 2020). Finally, statewide and national coordination of COVID-19 environmental impact response cannot be implemented without policy reform allocating resources for established waste management systems, empowering green initiatives, and holding stakeholders accountable. (Silva et al, 2020). The environmental footprint of this pandemic has irreversibly changed our environment on local and global scales. However, there are several multidisciplinary solutions to pioneer environmental stewardship, protect ethical medical practice, and emerge from these unprecedented times with systematic waste management reform.