Op Ed in NZ Doctor, 6 March 2024: Metered-dose inhalers No.1 villain

Op Ed in NZ Doctor, 6 March 2024: Metered-dose inhalers No.1 villain

GPs play a vital part in reducing emissions by adopting strategies including reducing medication waste and promoting active transport, writes OraTaiao Co-convenor Dermot Coffey in NZ Doctor Rata Aotearoa. We are grateful for permission to now republish his op-ed here. 

Metered-dose inhalers No.1 villain: General practice small emissions source but key influencer

One of the most frequent questions arising whenever climate change and health are discussed is how to reduce emissions within our practices and clinical work. Much of the research on healthcare climate emissions tends to focus on secondary and tertiary care, leaving primary care in a neglected position (in this, climate researchers take after our politicians, it appears). Fortunately, this has begun to change, and some critical research has been published over the past few years, providing clarity to help decision-making for those of us who would like to improve the climate footprint of our work.

The following studies are all European – from different countries with different healthcare systems and cultures, and different national energy use and climate emission profiles to Aotearoa New Zealand. Each also uses somewhat different criteria for inclusion in the emissions assessments. Even with both those caveats in mind, one can draw broad conclusions about primary care emissions, which should inform our emissions reduction actions in New Zealand.

In order of importance (to my mind), the studies are as follows:

1. The carbon footprint of GP practices across Humber and North Yorkshire integrated care system analysis(1) : this comprehensive of the emissions over this region in northeast England included “clinical” emissions (essentially, prescribed medications) and “non-clinical” emissions (everything else, including medical equipment). The clinical emissions dwarfed the non-clinical emissions by a 4:1 ratio with 40 per cent of clinical emissions coming from inhaler prescribing alone. Of the non-clinical emissions (remember they only make up one-fifth of the total emissions), the most significant contributor was staff and patient travel at just over 40 per cent (or just over 8 per cent of total emissions) followed by energy use from gas and electricity at 29 per cent. Medical goods and equipment comprised only 3 per cent of the non-clinical emissions, or under 1 per cent of total emissions.

2. This full assessment of the carbon footprint of NHS England in 2019(2) gave figures broadly like the Humber and North Yorkshire ones. Primary care rather than general practice was one of the subcategories, and prescribed medication was by far the highest contributor here, with personal travel also contributing just under 10 per cent of the total. Again, metered-dose inhalers had a heavy climate burden. Primary care contributed 23 per cent of the total emissions in NHS England in 2019.

3. A Swiss study looking at a sample of rural and urban practices(3) : this omitted prescribed medications from the analysis (the main reason being the difficulty in accessing prescribing data). Transport by patients and staff was responsible for just under half of the overall emissions, with energy use for heating making up just under one-third. One interesting domain analysed was the emissions from courier transport of test samples, which came in at 10 per cent of the total. The tiny contribution (5.5 per cent) from medical consumables and waste (1.6 per cent) was in keeping with the British studies above.

4. Finally, a French study looking at rural GP practices(4) : like the Swiss study, this omitted prescribed medication. Of particular interest to us is the low proportion of emissions coming from gas and electricity use because of low-fossil fuel French electricity generation, similar to the situation in New Zealand. Once again, transportation was the major contributor to emissions, responsible for 95 per cent of the total, probably a result of the rural nature of the practices. Medical equipment made up only a tiny proportion (2.7 per cent) of the overall emissions in this study as well. These latter two studies are helpful in confirming the profile of non-prescribed-medication-derived emissions, with the knowledge that this will be a minority of overall emissions.

So, what to make of all this? Putting aside the differences between our health system and those of the various countries above, there are clear common themes. First, despite the sheer in-your-face obviousness of the clinical waste we generate and the equipment we use, the contribution of general practice to climate emissions is miniscule.

There are other reasons to reduce waste, of course, such as worsening problems with environmental plastic build-up, but it’s the less visible emissions embedded within the medications that are by far the largest contributor. Second, within prescribing, the number one priority must be to continue the push away from metered-dose inhaler use.

Finally, we shouldn’t underestimate our role in emissions reduction. New Zealand’s health system is a major emitter, and as GPs, we are key drivers of that. We should support measures to switch to dry-powder inhalers where necessary, limit medication waste and not be afraid to deprescribe when indicated. We should support active transport for our staff and patients through end-of-trip infrastructure and advocacy to a seemingly car-obsessed government for a safe, active, public transport network. And given our global isolation, we should, wherever possible, limit travel for conferences and medical education, and strongly oppose international medical conferences being held in New Zealand.

In summary, then, think twice about the metered-dose inhalers, get on your e-bike, pat yourself on the back for adopting telehealth as part of your normal practice and don’t sweat using the extra pairs of gloves!

Dermot Coffey is a Christchurch-based specialist GP and co-convenor of OraTaiao – New Zealand Climate and Health Council



1 Sawyer M, Thrower H. Carbon Footprint of GP Practices Across Humber and North Yorkshire ICS. SEE Sustainability 2022; January online. [http://tinyurl.com/3s8s733s]

2  Tennison I, Roschnik S, Ashby B, et al. Health care’s response to climate change: a carbon footprint assessment of the NHS in England. The Lancet Planetary Health 2021;5(2), e84–92

3 Nicolet J, Mueller Y, Paruta P, et al. What is the carbon footprint of primary care practices? A retrospective life-cycle analysis in Switzerland. Environmental Health 2022;21(1). Doi 10.1186/s12940-021-00814-y

4 Houziel C, Prothon, E, Trinh-Duc A. Carbon footprint of general practice: Retrospective case study of GP offices in a rural department of France. The Journal of Climate Change and Health 2023;14(100273). Doi 10.1016/j.joclim.2023.100273

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