So today we have Doctor Hillary Ong joining us uh she's a pediatric emergency medicine physician at U CS F Benioff Children's Hospital in San Francisco. Um She has a special interest in the intersection of pediatric emergency medicine and the health impacts of climate change on Children. Um And this is the subject of her research. She is the sustainability team lead at U CS F Benioff Children's Hospital, Oakland and San Francisco um in the department of pe pediatric Emergency Medicine. And she is also the climate hub lead for the, the U C Center for Climate Health and Equity. Uh Doctor Ag earned her medical degree at U CS F. She completed her residency in pediatrics at C H L A, followed by a fellowship in pediatric emergency medicine at Children's National Hospital in Washington DC. And we're very excited to have her join us today. Um So I will turn it over to Doctor Ag. Oh, thank you so much uh doctor for that kind introduction and I'm really so grateful and this is truly an honor to be able to, to speak with you all uh this morning. So again, thank you for inviting me to speak at um our children's uh Oakland Grand rounds on health care, environmental sustainability. Um A topic that is um uh like doctor mentioned, a core part of my work in climate change and pediatric health. And I do think more importantly, perhaps I think a critical aspect of our care delivery in uh and in protecting the health of our patients and our communities. Uh So I don't have any disclosures uh uh Three main uh objectives really to lay the groundwork um on health care sustainability. Um In order to start a conversation and a discussion as to what can we do and how can we take action? So, first is uh describing health care's uh contributions to climate change. Um Second, describe the health impacts from health care pollution on our patients and our communities. And third main uh um see how clinicians can engage and lead in environmental stewardship. So the W H O defines an environmentally sustainable health care system as a health system that improves maintains or restores health while minimizing negative impacts on the environment and leveraging opportunities to restore and improve it to the benefit of a health and well-being of current and future generations. So then I asked if, if you think um our US health care system system is sustainable, environmentally sustainable. And I would argue that no, uh we are not. Um We in the US. Um uh really uh our health care system is energy and resource intensive and our expenditures and health care um greenhouse gas emissions continue to increase and really without demonstration of improved patient um health outcomes or safety outcomes um compared to other countries. So let me draw from my clinical work in the pediatric emergency room uh to really demonstrate how resource intensive uh we are in our care delivery and the high amount of waste we produce from our care. So this is a case of a three day um old um neonate uh who presents the emergency room and respiratory failure in requiring intubation and within 15 minutes of our care in the E D, this is the amount of equipment that we use. So all single use um equipment except for maybe the intubation, mac blade and handle and 90% of this is plastic based, non recyclable, non reprocess B um and everything is thrown away. So uh do I think these are the equipment and materials are necessary for me to provide the best care for this neonate? Yes, absolutely necessary. But if that's the question, uh if this is a clinical opportunity for us to reflect on whether there are more environmentally sound products out there rather than single use, can we use more reprocess or recyclable products? And does this equipment need to come in these multiple layer of plastic wrappings? And does it truly improve infectious control? And we know from um neonatal studies that um the E E T tube I V tubing medications and also the saline bags, some contain B P A and other palates and other endocrine disrupting chemicals that potentially can cause long term harm and impact on our patients. Um And I do think this is truly an area and opportunity for us clinicians to work with our sustainability officers in the hospital or hospital administration um to make a change or consider a change. Next case, it sounds like, you know, half the emergency department sometimes. Uh this is the case of a five year old who comes in with a forehead, forehead laceration that requires a laceration repair with sutures. Um And uh this is me opening a laceration repair kit from the emergency room and these medical kits are really commonly used to perform procedures in the E D. Um I counted every single item in this kit and it's a total of 36 items. Um Again, everything is single use and I maybe only routinely use two instruments from this kit which I'm holding in my hands, uh the scissors and the needle drivers and anecdotally. Um I, I do think my colleagues do as well. Um Everything else is thrown away. Uh It's difficult for me to even find a, a single package and individually packaged um instruments uh if I want to and, and, and this is uh um something again that uh we can potentially change. Um as clinicians, we really are the end users of clinical care. Uh products and equipment. But within hospital system, historically, there has been no feedback mechanism for physician input to influence purchasing of these materials and materials management. So again, an opportunity for us to um influence uh um more sustainable practice. So health care products are polluting at each stage of its life cycle. The life cycle of product starts from really fossil fuel extraction, refinement and then manufacturing of the final products that we use and gets shipped and delivered to our hospitals. Then uh we dispose of these products and assessment of our carbon emissions during different stages of medical product life cycle. Um found that more than half of carbon emissions arise from a production and uh from a final product assembly like these multi layer packaging and the transport of products and materials. Really what peeves me most about these, this kit, in particular, the laceration repair kit. Um is this styrofoam blue styrofoam thing that I I really don't know why it's there. Um And so this is really, I've taken on a mission to tackle this uh down the line. So uh from our use to waste disposal and, and to the left, it's a picture of um our waste bin in Michi Bay E D. Uh just a random waste bin that I found it and took a picture of and this is a repetition of our general health care waste uh which we uh there's three different types um of health care waste one is this kind of landfill or solid waste and there's regulated medical waste. So our sharps containers are red back waste. Um And lastly are recyclables. These then um get uh shipped to either uh for incineration or to landfill. That's, that's where the majority of uh health care waste goes to. And landfill generates methane gas, which is greater than 25 times the global warming potential of carbon dioxide and incinerator waste produces greenhouse gasses that emits toxic substances that includes dioxins. And that um also has an effect on the ozone and these all produces and contribute to our greenhouse gas effect that um causes global warming. I put this um down uh that health care waste also causes water pollution because it uh uh a lot of, especially during COVID um when we had an uptake in P pe uh uh waste disposal is that a lot of that waste actually leaked out and got into our waterways. Uh really have not a third of our health care facilities globally lack basic waste management facilities. And uh studies from COVID um pandemic had um found that our waste management uh facilities are really stretched to the maximum and a lot of waste are actually goes to illegal dumping sites and illegal as sites and waste disposal. Um accounts for approximately 5 to 10% of carbon emissions of the health sector. So really paying attention and reducing whispering in ST will help uh with mitigation strategies for carbon emission reductions. Uh So a friend and uh a colleague of mine uh emergency medicine, uh physician from Massachusetts General Hospital, uh worked with uh now currently a um an internal medicine resident at U CS S Sarah Shu. And he published this very nice paper about two years ago. Um He did a 24 hour waste audit. Um and uh their level one trauma center and found that in uh one day, uh the E D produced 670 kg of waste and that is equivalent to 270 tons of waste annually. And only 5% of that waste uh went to recycling and everything went to landfill and in and astounding 65% of that waste is plastic. Again, a fossil fueled byproduct. Uh So what does that mean to us? Um They calculated that the polluting emission for one day of E D waste disposal is equivalent to driving 7, 700 miles in a gas and filled car, which is a lot, a lot of um carbon emissions um that uh the uh health care is contributing. So, um on that note, um the US health care activities accounts for 4.6% of global greenhouse gas emissions and around 9.8% around 10% of national greenhouse gas emissions. Um This value is continuously increasing um over the past decade and uh to put this in perspective, um if us health care were a country. It would rank 13 in the world for emissions ahead of the entire United Kingdom. That's astounding to me what aspects of the US health care is contributing to greenhouse gas emissions. Well, greenhouse gas emissions are directly proportional to health care spending and this table um is illustrating um health care greenhouse gas emissions. So in metric tons of carbon dioxide um which are the two columns to the the right of your screen uh by ear. So 2003 and 2013 and this is by national health expenditure category um in the US over a decade. So 2003 to 2013 and I have highlighted the top health care expenditures in uh greenhouse gas emitters and uh number one is hospital care. Um Hospitals are really the largest contributor um contributor among expenditure care categories to environmental and health impacts accounted for approximately 35% of the total U US health care um greenhouse gas emissions. Plus it's mostly because hospitals are energy intensive. Uh We worked in usually large buildings. They're open, we're open 24 hours a day, seven days a week and um have a lot of energy intensive activities. Uh so heating, cooling, ventilation, uh systems, etcetera. The next um on the list are physician and clinical services and um this is really from our direct patient care services. So um lab testing um images that are ordered um and performed uh clinical monitoring devices, et cetera. Um Coming in 3rd and 4th place are um structures and equipment and that's referring to really the hospital building, structure and equipment like a big MRI machine, et cetera. Um And interesting to me or our prescription drugs are uh a large expenditure and also a large emitter. And that's because pharmaceuticals accumulate an environment through their life cycles from really manufacturing to distribution and disposal. And uh pharmaceuticals are responsible for about 10% of um health care emissions, which is, which is a substantial amount in my opinion. So the carbon footprint of the hospital is vast. And um if um you will uh let me take you on a tour of the hospital. So we know that uh about 10% of us greenhouse gas emissions uh come from us health care um activities and they occur directly from health care facilities and fleet vehicles and but in larger part, indirectly from the upstream production. So we're talking about electricity, drugs, medical devices, supplies, et cetera and also from our team um that dispose of pharmaceuticals. So kind of taking a uh a tour uh starting on the bottom left or uh our supply chain. So the supply chain is second large, just expensive health care after labor and it uses huge amounts of energy and gene generates a huge amount of waste going back to that laceration repair kit. Um Every single item in that kit was produced somewhere and shipped uh to us uh for use. And that's really constitutes um a supply chain of a single product. And imagine um all the supplies and equipment we have uh in a hospital next up um waste. Um And uh we briefly talked about this but overall, um the US generates a total of 14,000 tons of waste. Um And 20 to 25% of that waste are plastic products. Um uh Other component um are fleet vehicles. So these include uh transportation like uh um um entities like our ground ambulances or helicopters or delivery vehicles, um et cetera. And they all add to health care's carbon footprint. Uh I mentioned that um energy use in a hospital um is is large and it is the second most energy intensive commercial buildings in the entire US. And we use also a lot of water and um the US uh hospitals um are the third most water intensive uh facility type waste anesthetic gasses. I think this is unique to hospitals where um uh in anesthesia we use, I inhaled an anesthetic drugs that are potent greenhouse gasses and they are vented directly off of facility roofs after use where their emissions directly go to the outdoor atmosphere and uh are presently unregulated um in many parts of the world um of not inhaled acetic gasses like des fluorine and nitrous oxide produce at least four times more greenhouse gas emissions than our I V alternatives like propofol. By comparison, uh our meat production and food transport. Um uh how contributes to our emissions mostly through um indirect means. So, in the methods of uh production, processing, packaging, et cetera. And lastly, our hospitals are, are um large employers. Um I need a large workforce and employees commuting to and from work contribute then to our health care emissions. So hospital systems break down their greenhouse gas emissions into three categories. So scope 12 and three uh scope one to your left are direct emissions from hospitals. So these are on site um um energy use like heating systems, uh fleet vehicles, we mentioned waste MS a gasses and refrigerants. Scope two are indirect emissions. So um things that we purchase um so purchase electricity, purchase steam and scoop three are sources that are not owned or directly controlled by the EPA but uh really upstream. So really talking about our supply chain and that also includes our business travel, um uh waste disposal. Um So downstream effects as well and score emissions really account for the largest piece of the pie for hospital emissions and also the most difficult to tackle because these emissions come from us, tractors across the whole supply chain that uh uh is really hard to control and Ridic the reporting of scope one and two um is mandatory for many um hospitals and it's really gaining an understanding of um our breakdown for scope 12 and three emissions that um enable hospital systems to set um uh reduction targets and design and deliver effective climate solutions. So, with its contribution of a significant portion of global greenhouse gas emissions, again, the number is 4.6% and uh roughly 10% of national greenhouse gas emissions. The US health care contributes to climate change and to global warming. Uh with every increment of global warming creates global climactic changes. Um Question is this norm for us in the Bay Area. Um Are we gonna have bomb cyclones throughout this winter months? And then um um the extreme end uh wildfire and extreme heat season, um this is worrisome for us uh locally but of course, nationally and globally as well. And for us as pediatricians, um Children are really most affected by climate change. Um We know that uh Children born today experience a world that is more than four degrees warmer than the preindustrial average that increases the likelihood of child nutrition and susceptibilities to uh diseases such as diarrheal disease and dengue fever. Um And this is a graph um illustrating our annual anthropogenic so, human cause emissions um over a period of 2015 to 2100. Um and its associated global surface temperature increase these projected lines. Uh the S S P uh 1 to 5. So the colored lines um are the shared uh socioeconomic pathways and they're used to derive uh greenhouse gas emissions scenarios with different climate policies and also different projected uh socioeconomic uh global changes. Um So the best case scenario, um is this light blue line down? Um So S S P one, the worst case scenario where we're heading toward a climate catastrophe truly is S S P five. Um The number, if you've heard, um over the news is global warming needs to be less than a 1.5 and we're, um, we are on target are ready to hit that um global warming uh uh of 1.5 degrees. And I think there's uh a new report out um from the UN just a couple of days ago to say that um we are peak uh global um carbon emissions are global carbon emissions need to peak um in the next um year or two. And we need to reduce um these global carbon emissions by 43% roughly um in order to really bend this curve and we're kind of on target. Now, if we go, you know, uh business as usual um around uh this yellow um and lighter red line. And this is again, something that um is actually causing me some more climate anxiety. Now, as I'm speaking and an argument for uh uh an urgency for us to get involved in uh decarbonization of our health care space in mitigation and adaptation strategies uh um to really help with um curve uh bending this curve and, and with um uh uh carbon emissions. Um a note down here um uh note that uh there's an increase in C 12, what is C 12. And this is really the, um what I call the ironclad case of um um how rapid increase in global warming and climate change is a human cause. And uh the time scientists have measured the fingerprint of CO2 molecules with isotopes. And uh C 12 is a fingerprint of fossil fuel burning and over the past decade, um The C 12 ratio has um uh the C 12 sort of um has really increased over the um the past decade. And an argument that this is really uh human or anthropogenic caused. So why are we as clinicians involved in climate change? And it's because climate change impacts all aspects of health um and it impacts communities and health inequitably. So, communities and populations that contribute the least to carbon emissions and climate change are usually the most vulnerable and uh usually impacted the most. The W H O estimates uh that climate change causes around 100 and 40,000 additional deaths worldwide um annually and projected uh beyond 2030 an additional 250,000 annual deaths. So, looking specifically at us health care admissions, um Eckman and uh Sherman and all published this uh paper a couple of years ago in 2018 and estimated that um global uh circle greenhouse gas emissions associated with the US health care activities will cause an additional um $209,000. So disability adjusted life years or additional deaths per unit of greenhouse gas emission. And this was derived from an integrative assessment by and also to uh which is that uh X um access um and that looked at human health damages from uh carbon emissions from economic activities and the large potential health damage from carbon emissions associated with U health care were malnutrition which is the gray um great bars that you see um and uh particular effective regions with large populations in Africa and Southeast Asia um et cetera. Uh and of course, Children are amongst the most vulnerable. There's also uh they also reported an increased incidence of diarrhea and malaria. Um as uh other main contributors to Total Valley and this is because of global warming leng the warm seasons and expanding geographic ranges of disease factors. So adding the dollies of uh from uh greenhouse gas emissions and also non greenhouse gas emissions which are uh from um um uh sulfur oxides or particulate matter. Um Eckman and Sherman amount um reports um that uh there is a total six, around 614,000 dollies lost to dust um to due to us um health care related emissions and there that's more dollies from death due to preventable medical errors. Um So a a strong argument uh in my opinion that health care pollution is a matter of patient health. So now we get to the point of what to do about this. This is um uh scary. It's nerve wracking. Uh and what can we do? So hospitals invest, need to invest in decarbonisation and we need to act now and act fast. Um health care without harm is really the leading international organization that works to reduce environmental footprint of our um health care systems. Um And I developed a navigational tool or as decarbonisation road map for achieving zero health care associated emissions through uh like climate resiliency and through a health equity lens document as many pages, 100 plus pages. And I'm just gonna highlight the seven uh categories. So first uh powering health care with 100% clean renewable electricity investment in zero emissions, build uh zero emission buildings and infrastructure. Third, transition to zero emission, sustainable travel and transport. And uh he's just a medical student at a beautiful study on looking at uh residency interviews and travel and at the potential uh carbon uh reduction with uh virtual interviews. Um Fourth uh provide healthy sustainable grown food and support climate resilient agriculture. Fifth, incentivize and produce low carbon pharmaceuticals. Six implement circular health care and sustainable health care, waste management and lastly establish greater health system effectiveness. And really at all points of this, we as clinicians um can be a part of um um this road map um at U CS F. There's a Office of Sustainability and uh I'm really working uh towards this U C Y goal to achieve net zero carbon by 2025 a recent report, uh There are, you know, good uh positive milestones are accomplished by uh U CS F health and reducing at scope 12 and three emissions. And really the decarbonisation goal is to strive for all new buildings to be all electric and low carbon footprint design and to uh BC H Oakland. Um I had the great pleasure of um getting to know Laura Pippin who has been the Oakland uh Green team chair for many years. And I really want to send kudos and a round of applause to her for her hard work and also other members of um the BC H Oakland Green team. Um This is just a highlight of all the compliment compliments they've achieved uh which includes um reducing disposable pillows, uh converting the family handbook to electronic or reusable paper versions, putting E V charges in garages, eliminating straws from patient trays, um increasing um recycling compost um and uh encouraging individuals to form green teams which uh I in my opinion is really important um uh as a step going forward. Um So really thank you uh Loria and uh the Green team at Oakland. Um It's really not an easy path to push for sustainable li sustainability improvement projects in a hospital. Um And we really need continued support and investment for uh leadership um in order to do so. So clinicians really play a critical role in health care, environmental stewardship and sustainability. And you ask, why, why should we be involved in this? Um uh First, uh we vowed to do no harm. Uh But uh we're in an, a part of a health care system that does so if we're part of the problem, I, I think we should be part of the solution. And uh as pediatricians, we vowed to protect the health of Children and communities. Uh I think we have a responsibility to promote a healthy workplace and a healthy community. We have a responsibility to conserve and protect natural resources and we have a responsibility to prevent health care, pollution and decrease waste. So, back to this uh sort of timeline of a life cycle of medical products. Um and we're really kind of here as clinicians in the middle uh where we use these products. Uh And we're uh really should be at the bedside, paying attention to how um medical supplies are utilized or how the our services are delivered. Um And these seemingly small changes uh like getting rid of the laceration repair kits or uh switching out um uh uh disposable to reusable pillows. These seeming small changes really could have a substantial benefit for resource conservation and public health when magnified over large health care systems. So every small thing counts, in my opinion, um We have the voice and power to influence upstream factors by advocating for health care decarbonization, carbon emission adaptation and mitigation strategies of the hospital, state and federal level. Um and downstream, uh we can also influence downstream impact of waste disposal from decreasing use of unnecessary materials and equipment and on proper waste segregation. So, breaking down in uh down to really our multiple responsibilities. So as clinicians, we're involved in clinical care, oops right in uh clinical care and education and uh research and then leadership work. And uh I'm gonna make suggestions of how we can evolve in all prospects of our work. So in terms of our clinical care as end users of medical products, we need to evaluate again our use and need for certain products and we need to provide input and feed back to hospital operations and leadership and the pathway to that. It is not clear and I'm like knee deep in this space. Um But uh I think one way is uh to get involved in green teams or to develop green teams um and, and uh to lean and draw from um uh uh resources that are out there like uh health care without harm and practice green health. And uh this really should uh be based on, at least on the aim of improving health care, quality safety and value. Uh When we're uh discussing improvement uh projects or um uh with our hospital administration and our leadership and for many health professionals, uh uh the linking barrier to workplace uh workplace based environmental stewardship is a lack of knowledge and skills. So we need to educate ourselves and others on how clinical activities act as a major driver of resource utilization and waste in health care. Um There are evidence based practices practice in initiatives like choosing wisely getting it right the first time, um the wise list uh that include environmentally preferable um and waste bearing practices. And this is really again to reduce unnecessary medical testing, treatments and procedures, et cetera. And I've talked about like building a green team. And uh this is really, I think a way for us to uh implement sustainability initiatives uh through departmental green teams. Um And uh but implementation of these uh initiatives requires really support and oversight from departmental leadership. Uh So really en uh wanna encourage all hospital administrations and leadership to consider investing um in green teams and in sustainability teams um at, at department uh or the hospital um as clinicians, what we do is we interact with patients. Um And uh I, I think we can use existing Anti Spirit guidance as a framework for discussing climate change with families. And there's a uh a lot of um handouts if you will education material out there that I listed one of them, which is the National Climate um prescription uh that was developed by Boston Children's Hospital in terms of education. Uh There's, there's been studies that have shown that there's a critical knowledge gap that exists in the medical community uh in regards to indirect health consequences of wasteful and non value added clinical practices and uh to prepare our future health care workforces or our trainees, our medical students are uh we can consider integrating core learning objectives for um health care sustainably science into even our pre clinical and clinical training. And really foster the notion of environmental stewardship um as core professional responsibilities early um in our uh medical education, the development of education materials and um opportunities of sustainable um health care um is crucial and this is such a new and emerging and evolving field that clinicians are a part of uh um that there's a, a lot of opportunities um in uh to develop materials uh uh for uh education in uh this space. Um the from the U C R P, so uh U C Office of the President um and also the U C Climate Health um uh Center for Climate Health and Equity. There are programs out there to um encourage uh trainees to uh develop uh programs or, or curricula um um in this space. Um And uh because as health professionals, we interface with patients and the public, um there um our engagement really can serve as a multiplier to uh bring, you know, again, the information that we learned from research to the bedside and to the community. And it can be used as a multiplier to increase awareness um of the uh health impacts of health care pollution and climate change. Um And again, really use our voice. Um research, research is key a again, this is such a new and evolving space that uh we just need more data and uh in terms of clinical research, uh uh I think we can um encourage uh folks to think about addressing overuse or, or misuse of clinical resources and its impact on pollution and public health. Um There's been uh studies that focused on the O R and surgeries and anesthesia. Uh but research is really lacking in other clinical um areas. Um And I do think like a clinical research need to be in to a listen um with uh collaboration with uh sustainability scientists uh that can help like ensure that studies are both clinically relevant and measured appropriately. Um And there is AAA type of research methodology um called life cycle assessments and these are pretty intense, heavy kind of research. Um if you will and it calculates emissions for our products or seizures from cradle grave. And uh these uh uh life cycle assessments are really the gold standard and can provide um uh evidence based decision making when it comes to um material management, um advocacy as pediatricians, we have a long history for advocating for social policies, policies that protect the health and welfare of Children. Um So we should advocate at a local national international level um uh to reduce uh greenhouse gas emissions, health care pollution. Um And we need to educate our elective officials on this health risk of health care pollution and educate the public. Again, um can be through letters to the editor um to your local newspaper, et cetera. There are professional societies like our professional society, the A A P that um have interest groups that we can be a part of. I definitely wanna highlight climate health. Now, um one of the um directors and founder of Cliven Health. Now, actually, she is a, an, an provider at Children's Oakland uh Doctor Amanda Ws. So, Kudos to um her hard work of really leading um advocacy um on uh climate health issues. And again, um uh bringing in uh um an opportunity to work with health care with our arm that has a physician network and also really strong um nursing uh group as well. So encourage um all nurses, physicians, um health care providers uh to uh um explore opportunities in this organization, uh leadership really as clinicians. Uh We, I think drive evidence based change in the hospital setting and we can again, leverage our influence and our voice and our health expertise to achieve these organizational changes decreasing. Again, um hospital waste decarbonisation and consider being at the sustainability you need um in your unit or department. Um I do think when interfacing with leadership, um the finances are important and I do think the uh financial argument and potential cost savings is there. Uh And uh I think again, we need more data to uh really uh back up the cost savings. But um there are other hospitals that again we can draw from, we can lean on. Um And for example, the Virginia Mason Hospital um implemented a supply chain change um to buy reprocessed medical devices and I saved about three million uh during three years. Um and in a one year period, reprocess or recycled um more than £20,000 of devices. So, not only um there's a potential cost savings for our practice changes when we transition to more greener practices. Um But there's also a reduction in of course, environmental costs. Um And this again takes uh a village. So partnering with uh sustainability teams, partnering with patient safety and quality experts, infection control experts, um et cetera. So that really was a lot um of information I went through that uh at local whirlwind. Um And uh his work is overwhelming and these issues are heavy. Um And the road ahead to decarbonization is not easy. Uh It will take a vision but I believe and I maintain hope um that we are not alone and uh that we can only do what we can do. Um And this, I then diagram a draw from uh Anya Elizabeth Johnson um and really helps and help me find sort of a meaningful way to help address the climate crisis. So uh ask yourself, what are you good at? Think about skills like areas of expertise um and what work needs to be done? Um Think about system level changes or are there particular climate and justice solutions that, that pique your interest? And lastly what brings you joy and satisfaction? Um uh you know, don't pick things that like you're not gonna enjoy or feel miserable and that might bring you out and uh culmination or an overlapping um area is really where we can consider where our own climate action can take place. Um So with that, I want to summarize and happy to answer questions. So in summary, the US health care activities account for 4.6% of global um health uh sorry, greenhouse gas emissions and around 9.8 or around 10% of national greenhouse gas emissions, anthropogenic greenhouse gas emission contribute to climate change and global warming and impacts all aspects of health and clinical activities are major drivers of resource utilization and health care was waste. And as clinicians, we can play a critical role in environmental stewardship. So, uh these four are my references and, and happy to share them and thank you so much again for this opportunity. Um And this is my contact um information. Uh This is a book that my, my daughter is currently reading and I love it. So, um uh please check it out. All right. Thank you so much, Doctor Ong. That was such a interesting um and thought provoking talk. Um So we have a question in the chat um that I can start with. Um And folks can feel free to answer more questions or um raise their hands. Um So someone says, sounds like a big task. How do you suggest we start at our outpatient offices? Are there simple things identified um slash guidelines just to get started at um our, our offices specifically? Uh Thank you for that question. Um So I would suggest uh uh considering starting a green team. So uh based on experience uh uh kind of small steps forward um in uh trying to find like minded colleagues uh within your outpatient clinic. Um So, is it a, a fellow clinician? Um is it an ma a nurse? Um and start to brainstorm. Uh What are the things that you and clinic that you think is wasteful? Um And I would uh uh uh happy to share with you and I do think this is public facing. So the U CS F Office of Sus Sustainability has um a sustainability uh certification and uh it's basically a checklist of uh things uh that um can uh decrease energy use and produce less waste. So that's actually a good framework uh for us to start thinking about um how we can move forward with uh um more environmental uh stewardship in our own clinical space. Thank you so much. Um And just like related to that, is there any um are there any groups of people or folks that are working on like actually making packaging and the things that, that um all of our materials and supplies come in more, more environmentally friendly. Um Yeah, so, um again, I, I think about is sort of a, a in a large hospital system. It's sort of a top down approach and our sort of clinical aspect, a bottom up approach if you will. So, um again, take U CS F as an example, um uh The Office Sustainability, uh the academic side of sustainability has these sort of large uh uh goals and a task to look at energy use and uh decarbonisation product. And uh um folks like, like me as clinicians were interested in this space and, and deep in this space. Um For example, I'm looking at uh our, our laceration repair kit use and that's where the disconnect is I think is that uh I think we need more clinical input to input uh to um and feedback uh to uh these more high level uh discussions for really hospital wide system um uh decarbonization efforts. Um And uh uh so, um yes, so I I there are people looking at um uh these individual products, uh our medical equipment and uh myself, I'm looking at the laceration repair kits. Um And a lot of the work is being done um in the O R. So, in anesthesia in as a certain searchable as uh specialties uh that makes a lot of sense. Uh And then someone added. Um I think to the previous question, um you mentioned like a checklist. Um So is there, is there a resource or, or way that, that folks can reference that? Uh Yes. So um there um if you can Google the U CS F Office Sustainability. And I think on their website, there's a section called uh sustainability Initiative. Um They recently revamped the website. And so, um if you can explore that tab and I, I do think that um there is guidelines, uh guidelines or the checklist on there. If not, please email me and I'm happy to share that uh Excel checklist with you. Perfect. Um All right. And then another question with regards to things like the suture kits, do you keep the unused items for use in other procedures or donate those medical supplies until these kits are advised or is it possible to get only the items you need instead of taking an entire kit? Mhm. Um So really good question something I'm uh working on uh in our uh pediatric emergency department. So um yes, so you have multiple ways. Um and it needs a multipronged approach. So, uh for example, at, at San Francisco General where I, I also work clinically. Um um uh one of the uh clinicians um starts to work with meds share who um is a um organization that recycles um lightly used or unused um instruments like in the laceration repair kit. Um And uh that's sort of the, the feedback and the data that I'm trying to get or people should uh seek out is that um we need, I think uh data to, to present to hospital operations and materials management to say that um clinicians don't want uh the kits, we only need certain instruments. And again, that is an area of, of research and quality improvement um that uh uh is lacking and I think uh needs uh attention. Um Oh, I just lost my train of thought. Yeah. So essentially, uh we talked about uh recyclable and reprocess and instruments um that can, should be more readily available, but we need data to support um that uh clinicians actually want uh uh or need certain um instruments. Um And then there are opportunities uh to work with uh nonprofits or organizations that uh recycle or reprocess these instruments. Thank you. Um Let me see. I don't think I see other questions that haven't been answered. Um I'm just kind of curious from like a slightly um zoomed out lens um looking at like buildings and um construction in our hospital system. Um So as an example at some point, um there's a plan to, to build a new tower at the Oakland Campus. Um So, like, what would be the process to kind of advocate for you mentioned like a zero harm or, or zero emission um building um you know, like kind of that process? Like, what would that look like. Mhm. Mhm. Um So I think a wonderful opportunity for us again uh to raise our voices and to lever leverage our expertise um in this space when you have a new building that's uh being put up. Uh uh I, I think we need to identify the key stakeholders in making these decisions. Um And uh again, like, educate, educate, educate um these key stakeholders in that, like what we do um uh with our buildings and health care is harmful to our patients. And so I think it's uh this is a voice that um we can uh um elevate um in the space in terms of like building a new uh building and uh making it the greenest building um that uh we can ever imagine, right? That's really the gold standard. And uh we can lean on a lot of these guidelines that I mentioned um um in my presentation as uh offered by health care without harm and another organization called Brexit Green Health. So, uh um I think for us have a rough understanding of uh what that means to build a green building of kind of leaning on the those resources. Uh But uh I think most importantly is identify the key stakeholders and uh bringing uh a health spin um in, in uh the discussion and that this is important for us as clinicians. Um And this is because this is important for our patients and for our community to do this. Thank you. Um And we have another question in the, in the chat. Um Do you have data that shows that hospital waste uh increased significantly during the pandemic due to increased desire for single use products? Um I do and um it was one of the references. So uh Jody Sherman is really uh one of the leading uh uh an uh clogs and uh leading physicians that uh are, are looking at this exact question. And um uh echelon and Sherman, there's uh two papers that I reference to my talk. Um uh can uh I can send you uh the papers or, or um show you the references. Um uh And I'm off the top my head, I forgot the other group. Uh But I'm actually uh writing a paper on uh plastic waste um specifically on uh uh health care uh plastic waste. And uh there are a good number of studies that looked at that um specifically due to the pandemic because all our p pe equipment are plastic uh based. So our multi layer like face masks or N95 face shields, right? Disposable gowns, et cetera. Again. Uh Please email me and I, I'm happy to send you those references. I just can't remember the, the authors uh off the top. But Eckman and uh Sherman are uh the key uh researchers in uh this. Thank you. Um And then a question from Renada Kiefer. Um How difficult is it to convince the manufacturers of kits to produce a series of smaller ones, pressure may, may, may be needed to overcome their business decisions. Only um only big hospitals can ex exercise enough pressure. Um Yeah, a very good question and, and thank you for that. Um uh again, this is not easy. Uh I think at this, again, it's such a new space for clinicians and uh there is no true and tried sort of um pathway uh for us to, again, get at that feedback mechanism, right? Feeding back to um our purchasing department. Um So I, I, I don't have a like, you know, prescription that we uh should do it this way. Um But uh I, I would say that um it is again, like identifying um who are, is making those decisions. Um And that's really the first step is who are your purchasers for the department and who are, who are making these decisions to purchase these uh uh lock repair kits as an example. Again, that uh a lot of uh clinicians uh don't like and most products don't need um And going through um the uh sort of hospital bureaucracy really of changing these kits. Um That's a lot of work. Um So, uh I think that uh again, um there is no easy answer but I would um uh recommend uh really uh identifying um who um uh the key stakeholders and players are in uh making decisions and uh having discussion uh with them. Thank you. Um I think it sounds like one of the main themes is kind of identifying who the key players are um in any sort of sustainability effort and, and trying to identify those people and, and hopefully have a conversation. I think you're, you're absolutely right. Um And that, uh I, I think we are as clinicians been really siloed right in and focused on our clinical work. And uh I, I mean, I never got education, how really the hospital works, let alone, right? Like who purchases these equipment? And I'm also just educating myself and who's who and uh how really the hospital operates. Um uh uh And, and um yes, I think the first step is uh really getting to know um your colleagues um in the hospital, um administration and hospital operations side of things. Um Thank you so much. Uh Any last questions um from folks who are on the call, um either typed in the chat or um we have about two minutes left. All right. Well, then I think maybe we'll end a couple of minutes early. Um Thank you so much, Doctor Ag, this was such a great talk and um such an important thing to think about. Um especially as we see that climate change is kind of getting worse and worse as the years go on. Um So I really appreciate it. Ok, thank you doctor and thank you again for this opportunity and for everybody's attention um and time today. All right, thanks everyone. Hope everyone has a wonderful day.