May 18, 2020
The US healthcare system’s reliance on a global supply chain and just-in-time delivery has been good for the bottom line. However, critical shortages of personal protective equipment (PPE) have recently raised awareness of the vulnerability of supply chains across the country and around the globe, as many systems struggle to cope. While the current shortages are largely due to the Covid-19 pandemic causing an enormous surge in demand at the same time that supply chains are interrupted, similar disruptions can be expected in the coming years and decades as communities begin to experience the effects of climate change.
We joined Jodi Sherman, MD for a conversation on the need for sustainability in the healthcare supply chain, and some perspective on how we got to this point.
Dr. Sherman is Associate Professor of Anesthesiology at the Yale School of Medicine, and of Epidemiology (Environmental Health Sciences) at the Yale School of Public Health. She also serves as the Director of the Program on Healthcare Sustainability for the Yale Center for Climate Change and Health.
Responses have been condensed and edited for length and clarity.
What is driving supply-chain disruptions during the COVID-19 crisis?
The US is a wealthy nation, and we’ve been living in a bubble where supplies seem infinite and where wastefulness and disposability are normalized.
Not since World War II have we been so severely challenged to obtain essential goods. Now, because of Covid-19, we’re being forced to be extremely mindful about conserving resources. We’re trying to use only what is needed, which surprisingly is not the norm. We’re extending the use of supplies. And, we’re also challenged to be innovative, to create and repurpose materials.
Decades ago, nearly everything was reusable. Now, a large proportion of things we use in healthcare are disposable. Most of these are manufactured far from the point of use and delivered just in time in order to reduce the need for warehousing and to ensure supplies don’t expire. Unfortunately, this has left us very vulnerable to supply chain interruptions.
In the 1980s, the medical device industry recognized the money-making potential of manufacturing obsolescence by creating a new label called ‘single-use disposable’, or ‘SUD’. The more stuff you throw away, the more you have to buy, so it’s an advantageous business model for things not to be durable. Disposability can be good for things that are difficult to clean, to prevent infection transmission. But in reality, too many of our supplies have become disposable because of the availability of cheap materials, notably plastic, and especially because it’s convenient.
Initially there was no difference between reusable devices and those with the SUD label, so hospitals continued to clean and reuse them as they had always done. What industry then did was lobby Congress to change regulations so that facilities that clean (or “reprocess”) devices marked with the SUD label thereby assumed the responsibility of device function as if they were the original manufacturer. Although these reprocessed devices usually work perfectly well, health systems chose to not take on that risk. This was historically significant in driving our current throw-away culture in healthcare, and has left us vulnerable to the supply chain disruptions we are currently experiencing with Covid-19.
When hospitals started throwing away SUDs, a whole new third-party reprocessing industry sprung up willing to assume that risk—essentially outsourcing the cleaning of these devices. The reprocessing industry is tightly regulated by the FDA, and hospitals can now safely and routinely outsource the sterilization of many single-use disposable medical supplies. Only a small fraction of medical devices is reprocessed by third-party vendors, however, approximately 2-3% overall, and so there is tremendous capacity to reduce supply chain vulnerability.
This begs the question, what’s the difference between a reusable device and a reprocessed single-use disposable device?
How are supply-chain disruptions exacerbating the pandemic?
We have become extremely reliant on disposable products. Because hospitals don’t have protocols to safely clean single-use disposable items themselves, and few are taking advantage of third-party reprocessing, it took precious time and considerable effort for health systems to be able to cope with shortages—most notably PPE—due to the Covid-19 crisis.
The global response was rapid and demonstrated the ability to quickly come together with commitment and ingenuity as a community for a public health mission. Safe approaches to reprocessing PPE were quickly developed. In places where the pandemic surge occurred early, however, such as New York City and the Lombardy region of Italy, solutions lagged behind need, and many healthcare workers paid the price. That is the true lesson of supply chain vulnerability—there isn’t always time to pivot.
The most well-known shortages [right now] are PPE, but many of the supplies that we use to take care of critical patients — including many of our drugs such as propofol and other sedatives — are also in short supply. Shortages are not just because the supply chain was disrupted, but also because of the surge in critically ill patients driving up demand. This is why social/physical distancing to “flatten the curve” has been so vital to health care systems—to allow them time to figure out workarounds to supply chain disruptions and to replenish resources.
How does climate change pose a threat to global supply chains?
Many of our medical supplies, and their precursor materials, are manufactured all over the world. Climate change related extreme weather events increase the risk of supply chain disruptions. Whether caused by severe storms or a global pandemic, the disruptions are similar —sudden decreases in manufacturing, interruption of transport services, and surges in demands for supplies.
One example of disruptions in the US resulting from an extreme weather event was when Hurricane Maria devastated Puerto Rico. A large proportion of our nation’s drugs and intravenous fluids were manufactured there, and the hurricane very much impacted how we provide care across the nation. For example, stocks of some of our most common local anesthetic drugs ran out. Nationally, many anesthesiologists had to substitute non-standard drug formulations for spinal anesthesia, which is commonly used for Cesarean sections to surgically deliver babies, and this substitution increased the risk of otherwise preventable adverse events.
Because of climate change, extreme weather events are expected to become more frequent and more severe over the coming years and decades. It’s not a matter of “if” but “when” we will experience such crises.
How should we mitigate future supply-chain disruptions?
First, we need to be much more aware of how enculturated wastefulness is in healthcare [and our society as a whole]. We must be conscious of the fact that resources are finite, whether we feel shortages or not, and we must actively seek ways to conserve materials at every moment.
We need to move away from our over-reliance on single-use disposal devices. We need to reprocess more of them. And we need to find ways to move back toward reusable supplies. Infection prevention is essential in healthcare. But it is neither realistic nor necessary for everything to be disposable. There are long-standing guidelines, the Spaulding criteria, that guide what level of cleaning is required for different types of medical devices based on their invasiveness. These are often ignored, or manipulated, to favor disposability. The bottom line is that many devices need not be disposable.
We need to incentivize industry to design [those supplies] so that they are durable and easier to disassemble, clean, and refurbish. Modular design is one approach to accomplish this goal. These are some of the principles of what is called the Circular Economy, a system that aims to design waste out, and keep products and materials in use.
Finally, we need to expand the reprocessing industry and incentivize manufacture of things closer to where they are used. This will reduce supply chain vulnerability and provide employment opportunities for members of local communities.
How can the coronavirus pandemic response be applied to the climate crisis?
This messaging for Covid-19 about flattening the curve could not be any more brilliant in understanding what needs to happen with climate change. The Intergovernmental Panel on Climate Change (IPCC) came out with a special report in 2018 saying we need to rapidly change our economy to be able to reduce our greenhouse gas emissions by 45% by 2030, and to become carbon neutral by 2050, in order to keep average global temperature rise below 1.5 degrees centigrade and avert the worst predicted harms to global health.
Now is the time to take advantage of the Covid-19 disruption and make bold changes to do what is necessary to flatten the greenhouse gas curve. While we can’t stop climate change, if we dramatically reduce our greenhouse gas emissions now, we can slow down the effects. That would give society a chance to adapt, just like social distancing helped slow down the patient surge to hospitals from the Covid-19 pandemic.
The only difference between Covid and climate change is that the time scale is different. After the IPCC Special Report came out, people said that a decade wasn’t nearly enough time for societal transformation. Covid has disproven that. People and governments across the world have quickly come together to do what is necessary to flatten the Covid curve. By comparison, a decade is incredibly doable. And unlike the devasting economic shutdown with the Covid pandemic, flattening the greenhouse gas curve provides lots of opportunities for economic growth through a greener economy.