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GI multisociety strategic plan on environmental sustainability

Published:October 18, 2022DOI:https://doi.org/10.1016/j.gie.2022.08.017
      It is clear that the evolving climate crisis, with its deleterious effects on planetary ecosystems, also poses harm to the health of humankind.
      • Romanello M.
      • McGushin A.
      • Di Napoli C.
      • et al.
      The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future.
      • Salas R.N.
      • Solomon C.G.
      The climate crisis—health and care delivery.
      • Swinburn B.
      • Kraak V.
      • Allender S.
      • et al.
      The global syndemic of obesity, undernutrition, and climate change.
      • Ingle H.E.
      • Mikulewicz M.
      Mental health and climate change: tackling invisible injustice.
      • Ebi K.L.
      • Hess J.J.
      Health risks due to climate change: inequity in causes and consequences: study examines health risks due to climate change.
      Human activity has brought about changes that not only affect the climate but also other earth systems, including biodiversity, freshwater use, land use, and nitrogen flows, which already compromise the well-being of our generation and may have negative ramifications for future generations.
      • Steffen W.
      • Richardson K.
      • Rockstrom J.
      • et al.
      Sustainability. Planetary boundaries: guiding human development on a changing planet.
      It is imperative that we prevent further destruction of our ecosystems and modify detrimental behaviors to prevent escalation. This is true for the practice of medicine in general and our field of gastroenterology and hepatology in particular. With this in mind, the leadership of 4 major GI (see Table 1 for glossary of terms) societies in the United States—American Association for the Study of Liver Diseases (AASLD), American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), and American Society for Gastrointestinal Endoscopy (ASGE)—came together and established a task force to develop a joint strategic plan that our societies can adopt to mitigate the effects of climate change on digestive health and healthcare systems and to decrease the environmental impact of GI practice.
      Table 1GLOSSARY OF TERMS
      • Romanello M.
      • McGushin A.
      • Di Napoli C.
      • et al.
      The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future.
      Carbon footprintMeasure for greenhouse gas emissions representing the total amount of greenhouse gases generated directly or indirectly by an individual, organization, product, or event and their activities. Carbon footprint is the representative unit for measuring global warming.
      • Romanello M.
      • McGushin A.
      • Di Napoli C.
      • et al.
      The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future.
      Circular economyA model of economy that involves activities that are restorative or regenerative by design and aims for the elimination of waste through the superior design of materials, products, and systems.
      • Salas R.N.
      • Solomon C.G.
      The climate crisis—health and care delivery.
      Climate changeShifts in weather and climate patterns that occur over long periods of time, acknowledging that the current warming temperature is caused primarily by human activity.
      • Romanello M.
      • McGushin A.
      • Di Napoli C.
      • et al.
      The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future.
      ,
      • Swinburn B.
      • Kraak V.
      • Allender S.
      • et al.
      The global syndemic of obesity, undernutrition, and climate change.
      EcosystemA geographic unit of living organisms and their interaction with the physical environment in which they live.
      • Romanello M.
      • McGushin A.
      • Di Napoli C.
      • et al.
      The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future.
      Greenhouse gasesGases (primarily CO2 but including CH4, N2O, and others) that absorb, trap, and re-emit heat and radiant energy back into the earth’s atmosphere.
      • Romanello M.
      • McGushin A.
      • Di Napoli C.
      • et al.
      The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future.
      GIAll disciplines of the field of digestive health and disease including adult and pediatric gastroenterology, hepatology, neurogastroenterology, and pancreatology.
      Planetary healthAn emerging concept that prioritizes solutions that simultaneously benefit human health and advance environmental sustainability.
      • Ingle H.E.
      • Mikulewicz M.
      Mental health and climate change: tackling invisible injustice.
      ResilienceCapacity of a system (individual or organization) to use available resources (eg, energy, food, transportation, communication) to respond to, withstand, and recover from adverse situations and conditions.
      • Ebi K.L.
      • Hess J.J.
      Health risks due to climate change: inequity in causes and consequences: study examines health risks due to climate change.
      ,
      • Steffen W.
      • Richardson K.
      • Rockstrom J.
      • et al.
      Sustainability. Planetary boundaries: guiding human development on a changing planet.
      SustainabilityMeeting the needs of the present without compromising the ability of future generations to meet their own (UN Brundtland Commission).
      • Ebi K.L.
      • Hess J.J.
      Health risks due to climate change: inequity in causes and consequences: study examines health risks due to climate change.
      ,

      Reich A, Ulman A, Berkower C. National Academies of Sciences, Engineering, and Medicine; Division on Earth and Life Studies; Environmental Health Matters Initiative. Communities, climate change, and health equity: proceedings of a workshop—in brief. 2022. Available at: https://nap.nationalacademies.org/catalog/26435/communities-climate-change-and-health-equity-proceedings-of-a-workshop. Accessed September 6, 2022.

      Sustainable health careProvides high-quality health care for all that includes patient empowerment and self-care, prevention, lean-care pathways, and low-carbon alternatives.
      National Institutes of Health
      Sustainable economyAn economy that provides for the greatest amount of general well-being without depleting natural resources and harming the environment.
      World Health Organization
      Sustainable value careExpanding the traditional value of care definition (patient outcomes relative to cost) to include benefits of care for the patient and larger population against environmental, social, and economic cost.
      National Institutes of Health
      ∗See Appendix 2 (available online at www.giejournal.org) for references related to this table.
      Several recent position statements and detailed information from the National Academies of Sciences, Engineering and Medicine,

      Reich A, Ulman A, Berkower C. National Academies of Sciences, Engineering, and Medicine; Division on Earth and Life Studies; Environmental Health Matters Initiative. Communities, climate change, and health equity: proceedings of a workshop—in brief. 2022. Available at: https://nap.nationalacademies.org/catalog/26435/communities-climate-change-and-health-equity-proceedings-of-a-workshop. Accessed September 6, 2022.

      National Institutes of Health,
      National Institutes of Health
      World Health Organization,
      World Health Organization
      and Centers for Disease Control and Prevention
      Centers for Disease Control and Prevention
      have highlighted the importance and impact of climate change on health and healthcare systems. In October 2021, the World Health Organization 26th United Nations Climate Change Conference special report on climate change and health identified climate change as “the single biggest health threat facing humanity.”
      World Health Organization
      The British Society of Gastroenterology has developed a strategic document,
      • Veitch A.M.
      Greener gastroenterology and hepatology: the British Society of Gastroenterology Strategy for Climate Change and Sustainability.
      whereas the World Gastroenterology Organization has established a climate change working group that highlighted the importance of climate change to our discipline.
      • Leddin D.
      • Omary M.B.
      • Veitch A.
      • et al.
      Uniting the global gastroenterology community to meet the challenge of climate change and non-recyclable waste.
      The results of a recent World Gastroenterology Organization global survey of GI societies’ leaderships strongly support the need for a climate change strategic plan with actionable measures, such as targeted education and the establishment of working groups.
      • Leddin D.
      • Omary M.B.
      • Metz G.
      • et al.
      Climate change: a survey of global gastroenterology society leadership.
      Furthermore, recommendations for endoscopy practice have recently been released by the European Society of Gastrointestinal Endoscopy and the European Society of Gastroenterology and Endoscopy Nurses and Associates,
      • de Santiago E.R.
      • Dinis-Ribeiro M.
      • Pohl H.
      • et al.
      European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) position statement for reducing the environmental footprint of gastrointestinal endoscopy.
      and several GI and non-GI medical organizations have released climate change position statements.
      • Leddin D.
      • Omary M.B.
      • Metz G.
      • et al.
      Climate change: a survey of global gastroenterology society leadership.
      • de Santiago E.R.
      • Dinis-Ribeiro M.
      • Pohl H.
      • et al.
      European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) position statement for reducing the environmental footprint of gastrointestinal endoscopy.
      • White S.
      • Shelton C.
      • Gelb A.
      • et al.
      Principles of environmentally-sustainable anaesthesia: a global consensus statement from the World Federation of Societies of Anaesthesiologists.
      • Crowley R.A.
      Climate change and health: a position paper of the American College of Physicians.
      • Eskenazi B.
      • Etzel R.A.
      • Sripada K.
      • et al.
      The International Society for Children's Health and the Environment commits to reduce its carbon footprint to safeguard children's health.
      • Baddeley R.
      • de Santiago E.R.
      • Maurice J.
      • et al.
      Sustainability in gastrointestinal endoscopy.
      Member societies. Medical Society Consortium on Climate and Health
      Climate change affects many social and environmental determinants of health, including water and food security, shelter, physical activity, and accessible health care
      • Romanello M.
      • McGushin A.
      • Di Napoli C.
      • et al.
      The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future.
      ,
      • Salas R.N.
      • Solomon C.G.
      The climate crisis—health and care delivery.
      ,
      • Ebi K.L.
      • Hess J.J.
      Health risks due to climate change: inequity in causes and consequences: study examines health risks due to climate change.
      ,

      Reich A, Ulman A, Berkower C. National Academies of Sciences, Engineering, and Medicine; Division on Earth and Life Studies; Environmental Health Matters Initiative. Communities, climate change, and health equity: proceedings of a workshop—in brief. 2022. Available at: https://nap.nationalacademies.org/catalog/26435/communities-climate-change-and-health-equity-proceedings-of-a-workshop. Accessed September 6, 2022.

      (Fig. 1), with a disproportionate impact on marginalized populations, including those of lower socioeconomic status, the uninsured, the elderly, and those with chronic medical conditions.
      • Romanello M.
      • McGushin A.
      • Di Napoli C.
      • et al.
      The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future.
      ,
      • Salas R.N.
      • Solomon C.G.
      The climate crisis—health and care delivery.
      ,
      • Ebi K.L.
      • Hess J.J.
      Health risks due to climate change: inequity in causes and consequences: study examines health risks due to climate change.
      ,

      Reich A, Ulman A, Berkower C. National Academies of Sciences, Engineering, and Medicine; Division on Earth and Life Studies; Environmental Health Matters Initiative. Communities, climate change, and health equity: proceedings of a workshop—in brief. 2022. Available at: https://nap.nationalacademies.org/catalog/26435/communities-climate-change-and-health-equity-proceedings-of-a-workshop. Accessed September 6, 2022.

      ,
      World Health Organization
      The downstream effects of climate change on health may affect GI practice in a variety of ways. Food insecurity and malnutrition can contribute to obesity and fatty liver disease, for example,
      • Swinburn B.
      • Kraak V.
      • Allender S.
      • et al.
      The global syndemic of obesity, undernutrition, and climate change.
      ,
      • Fanzo J.C.
      • Downs S.M.
      Climate change and nutrition-associated diseases.
      ,
      • Donnelly M.C.
      • Stableforth W.
      • Krag A.
      • et al.
      The negative bidirectional interaction between climate change and the prevalence and care of liver disease: a joint BSG, BASL, EASL, and AASLD commentary.
      which in turn may further derange the microbiome and impair gut immune function.
      • Iddrisu I.
      • Monteagudo-Mera A.
      • Poveda C.
      • et al.
      Malnutrition and gut microbiota in children.
      • Keusch G.T.
      The history of nutrition: malnutrition, infection and immunity.
      • Yao X.
      • Li H.
      • Leng S.X.
      Inflammation and immune system alterations in frailty.
      Climate change has led to a changing pattern of infectious diseases with an increased risk for diarrheal diseases and hepatitis,
      • Romanello M.
      • McGushin A.
      • Di Napoli C.
      • et al.
      The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future.
      with morbidity and mortality often exacerbated by the unsanitary conditions of forced migration and limited access to clean water.

      Reich A, Ulman A, Berkower C. National Academies of Sciences, Engineering, and Medicine; Division on Earth and Life Studies; Environmental Health Matters Initiative. Communities, climate change, and health equity: proceedings of a workshop—in brief. 2022. Available at: https://nap.nationalacademies.org/catalog/26435/communities-climate-change-and-health-equity-proceedings-of-a-workshop. Accessed September 6, 2022.

      ,
      Centers for Disease Control and Prevention
      The shifting epidemiology of enteric infections may also carry with it an increased burden of functional GI disorders.
      • Stephen D.M.
      • Barnett A.G.
      Using microsimulation to estimate the future health and economic costs of salmonellosis under climate change in central Queensland, Australia.
      Finally, climate change affects mental health.
      • Ingle H.E.
      • Mikulewicz M.
      Mental health and climate change: tackling invisible injustice.
      Stress, anxiety, and depression can predispose to substance abuse, which in turn may increase the prevalence of alcohol-related liver disease and pancreatitis.
      • White A.M.
      • Castle I.-J.P.
      • Powell P.A.
      • et al.
      Alcohol-related deaths during the COVID-19 pandemic.
      Figure thumbnail gr1
      Figure 1Intersection between health care, climate change, and digestive health and possible intervention areas to affect change and help mitigate the climate crisis.
      Although the central goal of health care is to promote health, healthcare delivery itself contributes to climate change, which may paradoxically lead to population-level harm. The healthcare sector accounts for 4.4% of greenhouse gas emissions worldwide and 8.5% in the United States.
      • Pichler P.-P.
      • Jaccard I.S.
      • Weisz U.
      • et al.
      International comparison of health care carbon footprints.
      , If health care were a country, it would be the fifth largest emitter globally. Digestive health care is a major contributor to healthcare’s carbon footprint.
      • Baddeley R.
      • Aabakken L.
      • Veitch A.
      • et al.
      Green endoscopy: counting the carbon cost of our practice.
      As a procedure-intensive specialty, GI procedures use an abundance of single-use supplies and generate more waste than other fields of medicine. Site analyses have suggested that endoscopy is the third greatest source of medical waste within the hospital setting.
      • Vaccari M.
      • Tudor T.
      • Perteghella A.
      Costs associated with the management of waste from healthcare facilities: an analysis at national and site level.
      As is the case for the impact of climate change by and on healthcare systems,
      • Setoguchi S.
      • Leddin D.
      • Metz G.
      • et al.
      Climate change, health, and healthcare systems: a global perspective.
      there is a vicious cycle whereby climate change negatively impacts individual digestive health, which accelerates specialized healthcare activity, which further contributes to the climate crisis (Fig. 1).
      Urgent action is needed to help mitigate the effects of climate change and the broader environmental impact of our collective practice. We must transition to a more sustainable model that allows for the provision of high-quality digestive health care with access for all, now and for future generations.
      • Mortimer F.
      • Isherwood J.
      • Wilkinson A.
      • et al.
      Sustainability in quality improvement: redefining value.
      This transition will be challenging insofar as it requires modifying habits of current practice. In the long run, however, it will promote health, save cost, and, above all, correspond with a broader shared vision of planetary health. The proposed strategic plan suggests a roadmap toward a sustainable GI practice.
      The multisociety task force formulated a vision, mission, and 7 domains that are relevant to digestive health care and societal activities, with each domain coupled to a specific strategic goal (Fig. 2). Importantly, the strategic goals highlight not only the traditional society mission areas of clinical care, education, and research, but also emphasize the importance of individual and collaborative society efforts, governmental and nongovernmental advocacy, and industry partnerships.
      • Haddock R.
      • de Latour R.
      • Siau K.
      • et al.
      Climate change and gastroenterology: planetary primum non nocere and how industry must help.
      ,
      • MacNeill A.J.
      • Hopf H.
      • Khanuja A.
      • et al.
      Transforming the medical device industry: road map to a circular economy.
      Each strategic goal subsumes individual objectives that offer a framework for initiatives and practical solutions for future working groups to pursue.
      Figure thumbnail gr2
      Figure 2Vision, mission, and strategic goals.
      The strategic plan suggests an outline toward accomplishing the proposed objectives and initiatives (Appendix 1, available online at www.giejournal.org). These are not intended to be prescriptive in any way but rather provide opportunities to pursue a path toward an environmentally sustainable GI practice. All members of the task force unanimously approved the proposed strategic goals, objectives, and initiatives listed herein.

      Strategic Goals and Objectives

      Clinical setting

      Devise and foster sustainable clinical practices to reduce waste and carbon emissions.

      Objectives

      • 1.
        Assess the carbon footprint and generation of waste within all areas of our clinical practice and identify low-carbon and low-waste practice alternatives (immediate, short, and long term).
      • 2.
        Encourage and support the implementation of environmentally friendly and organization-suited sustainable GI practices by providing a roadmap of possible practice alternatives including “the 3 Rs” of sustainability (reduce, reuse, and recycle) and specifying affordable testing and treatment alternatives with favorable environmental impact.
      • 3.
        Create a framework for GI practices to develop sustainability metrics, including methods for calculating practice-specific carbon footprints, alongside improvements in quality and access.

      Education

      Raise awareness and share sustainability practices with society members and patients regarding the interaction between climate change, digestive health, and healthcare services.

      Objectives

      • 1.
        Educate healthcare leadership, practitioners, and patients about the adverse effects of climate change on digestive health, the contribution of health care to climate change, and approaches to minimize its negative environmental impact.
      • 2.
        Educate healthcare leadership, practitioners, and patients about the necessity for change in digestive healthcare delivery without compromising access to care.
      • 3.
        Promote a discussion on the professional and ethical implications of old and new patterns of shared resource utilization within an environmentally sustainable practice paradigm.
      • 4.
        Incorporate the principles of sustainable care into all aspects of societies’ educational programs.

      Research

      Raise and allocate resources to support research at the intersection of the environment, climate change, and digestive health.

      Objectives

      • 1.
        Promote and support research related to the effects of climate change on digestive health and health care, with an emphasis on vulnerable populations.
      • 2.
        Facilitate research that examines the environmental impact of clinical practice and the beneficial effects of implementing sustainable low-carbon, low-waste practices on the overall financial cost and environmental footprint of digestive health care.
      • 3.
        Promote research that focuses on the implementation of sustainable care and sustainable value as a quality domain in digestive health care.
      • 4.
        Encourage the inclusion of environmental considerations into research proposals.

      Society efforts

      Achieve environmentally and organizationally sustainable activities across all society mission areas.

      Objectives

      • 1.
        Assess and monitor the current environmental impact of all activities.
      • 2.
        Identify, devise, and implement measures to decrease societies’ carbon footprint and reduce waste that is generated by societal activities.
      • 3.
        Track the financial costs, financial savings, and environmental benefits of efforts initiated and undertaken under a sustainability model.

      Intersociety efforts

      Collaborate with national and international GI and hepatology societies to advocate for and support implementation of sustainable practices.

      Objectives

      • 1.
        Collaborate with other GI and hepatology societies to support each other’s sustainability efforts.
      • 2.
        Work with medical and nonmedical climate advocacy organizations on joint advocacy opportunities. This could include organizations such as Healthcare Without Harm and Practice Greenhealth.
      • 3.
        Support each other on all other activities that underpin shared missions including education, clinical practice, and research.
      • 4.
        Encourage societies to use validated metrics to evaluate their efforts toward sustainability balanced against meeting their organizational missions.

      Industry

      Engage with GI- and hepatology-focused industry and pharmaceutical partners to develop environmentally friendly products rooted in sustainable economy principles.

      Objectives

      • 1.
        Partner with industry to provide product information on carbon footprint implications and options for recycling.
      • 2.
        Work with industry to focus on environmental product design that builds on principles of sustainability (eg, circular economy).
      • 3.
        Explore opportunities to engage industry to promote and support environmentally sustainable digestive health care.

      Advocacy

      Advocate for policies that promote environmentally sustainable GI practices.

      Objectives

      1. Identify and incorporate principles of sustainable health care among the goals of relevant political action committees.
      2. Leverage collaborative advocacy efforts, where applicable, to promote sustainable policies with national and international healthcare and research agencies, political leaders, and payors.

      Next Steps

      The plan presented herein, which we view as a landmark joint effort, provides a framework for each of the 4 involved societies to undertake separately or by working together. The societies view the proposed goals and their associated objectives as an elective call to action with specific suggested initiatives and timelines (detailed in Appendix 1 and summarized in Fig. 3). Each society will prioritize and adapt their initiatives in accordance with their individual societal goals. Some initiatives may be undertaken by a single society, whereas other objectives and initiatives may be approached jointly (eg, educational programs). Each society may establish their own committee or working group, which we recommend, or do so jointly. We are grateful that several other GI organizations have endorsed our plan (Table 2), which reflects the importance and timeliness of the opportunity to work together and share best practices to overcome the burden of climate change on digestive health and help mitigate the environmental impact of GI practice (Fig. 1). As Desmond Tutu stated, “Twenty-five years ago, people could be excused for not knowing much, or doing much, about climate change. Today we have no excuse.”
      Figure thumbnail gr3
      Figure 3Summary of the multisociety 5-year strategic plan and proposed initiatives.
      Table 2GI and non-GI societies who have endorsed the strategic plan of the U.S. Multi-GI Society Task Force on Climate Change
      Society
      African Middle East Association for Gastroenterology
      American Neurogastroenterology and Motility Association
      American Pancreatic Association
      Asia Pacific Association of Gastroenterology
      Association of Black Gastroenterologists and Hepatologists
      British Association for the Study of the Liver
      British Society of Gastroenterology
      Canadian Association of Gastroenterology
      Crohn's & Colitis Foundation
      Digestive Health Physicians Association
      European Association for the Study of the Liver
      Gastroenterology and Hepatology Advanced Practice Providers
      Indian Society of Gastroenterology
      Iranian Association of Gastroenterology and Hepatology
      Israeli Association for the Study of the Liver
      Malaysian Society of Gastroenterology and Hepatology
      North American Society for Pediatric Gastroenterology, Hepatology & Nutrition
      Norwegian Gastroenterology Society
      Pan American Organization of Gastroenterology
      Society of Gastroenterology Nurses and Associates
      Women in Endoscopy
      World Endoscopy Organization
      World Gastroenterology Organisation
      Entries are listed in alphabetical order. Endorsement indicates support for the AASLD, ACG, AGA, and ASGE multisociety climate change strategic plan. It does not obligate the endorsers to carry out any of the proposed strategic goals or to interfere with an existing climate change–related strategic plan currently undertaken by the endorser or prevent the endorsers from developing an independent strategic plan that has similar or identical goals or objectives.

      Acknowledgments

      We greatly appreciate and thank all the societies who have endorsed the AASLD, ACG, AGA, and ASGE multisociety strategic plan. We thank the leadership of the 4 involved societies, including Drs John Carethers, Raymond Chung, Laurie DeLeve, David Greenwald, John Inadomi, Bret Petersen, Douglas Rex, and Samir Shah, for providing the opportunity, privilege, and support to work together to draft this joint plan. We thank Eden Essex for her essential administrative support and coordination and Drs Desmond Leddin, Geoffrey Metz, and Andy Veitch for providing input.
      The following authors represent the 4 GI societies: Adrian Reuben and Rohit Kohli (AASLD), Rabia de Latour and Swapna Gayam (ACG), Nitin K. Ahuja and M. Bishr Omary (AGA), and Heiko Pohl and Deepak Agrawal (ASGE).

      Appendix 1. Goal-Related Initiatives and Timeline That May Be Considered and Implemented by the GI Societies

      For each of the strategic goals highlighted in this document, we provide a list of specific initiatives that may be considered by GI societies. In general terms, we envision years 1 and 2 as periods of self-assessment and planning of initiatives and years 3 to 5 as implementation and assessment years that may extend beyond 5 years to also include planning of new initiatives as new knowledge of best practices becomes known.

      Clinical setting

      Devise and foster sustainable clinical practices to reduce waste and carbon emissions.

      Year 1

      • Facilitate an approach to measuring carbon footprint and waste in all clinical practice settings.
      • Recommend actionable low-waste, low-carbon endoscopy practice alternatives, including conserving energy and waste segregation at volunteer pilot sites.
      • Establish a working group on sustainable digestive health care with a focus on including sustainable value as a quality domain (includes patient and population outcomes when considering environmental, social, and financial impacts).

      Years 2 and 3

      • Support measuring the carbon footprint and waste generation of all aspects of clinical care, including all testing and treatment options.
      • Identify low-waste, low-carbon practice alternatives in all aspects of clinical care (immediate, short, and long term).
      • Facilitate the introduction and implementation of low-waste, low-carbon practice in all aspects of clinical care.
      • Introduce sustainable value care principles into clinical practice as a quality domain.

      Years 3 to 5

      • Facilitate measurement of sustainable value care as a quality domain.

      Education

      Raise awareness and share sustainability practices with society members and patients regarding the interaction between climate change, digestive health, and healthcare services.

      Year 1

      • Establish an approach to incorporate climate change and sustainable care into societies’ strategic learning objectives and educational programs (eg, supporting local and hybrid virtual conferences to minimize air travel).
      • Pool currently available educational resources and collate them online.
      • Devise a blueprint for endoscopy units on how to measure carbon footprint and waste.
      • Develop an educational tool on appropriate waste segregation for endoscopy units with focus on medical waste and recycling.

      Years 2 to 5

      • Devise a blueprint for all other practice settings (outpatient, inpatient) on how to measure carbon footprints and waste.
      • Develop educational tools and programs related to climate change and sustainable care and implement these in societies’ educational programs.
      • Develop and disseminate practical information and tools to help GI society members make a difference in their own clinical practice or institutions.
      • Create educational material to inform patients about the changing face of digestive health care while prioritizing sustainability.

      Research

      Raise and allocate resources to support research at the intersection of the environment, climate change, and digestive health.

      Year 1

      • Develop an approach for supporting research in areas related to environment and digestive health.

      Years 2 to 5

      • Work within society means and with external funding sources to support impactful research in the areas related to environment and digestive health.

      Society efforts

      Achieve environmentally and organizationally sustainable activities across all society mission areas.

      Year 1

      • Begin an initiative to measure the societies’ internal and external carbon footprints, and examine the societies’ current approach to recyclable and nonrecyclable waste management including that generated through society publications.
      • Introduce immediately feasible measures to reduce societies’ carbon footprint and waste.

      Years 2 and 3

      • Complete measurements of the societies’ internal and external carbon footprint and waste management.
      • Identify additional measures to lower waste and minimize societies’ carbon footprint.
      • Initiate annual tracking of financial and environmental cost and savings.

      Years 3 to 5

      • Implement environmentally sustainable organizational practices in all societies’ activities.

      Intersociety efforts

      Collaborate with national and international GI societies to advocate for and support implementation of sustainability practices.

      Year 1

      • Establish a GI multisociety strategic plan to address the environmental impact of GI practice.
      • Establish initiative and working groups to accomplish the defined strategic goals.
      • Understand the interests of non-GI societies to collaborate on mutual sustainability efforts.

      Years 2 to 5

      • Collaborate with societies to assess the environmental impact of our common practice and identify measures to lower it (eg, services related to imaging, pathology, or provision of anesthesia).
      • Share blueprints for assessing environmental impact of our practice.
      • Collaboratively devise and share educational tools.
      • Establish collaborative approach to industry engagement and advocacy.

      Industry

      Engage with GI- and hepatology-focused industry and pharmaceutical partners to develop environmentally friendly products rooted in sustainable economy principles.

      Year 1

      • Establish a multisociety initiative to engage with industry representatives and to specify an approach to engage industry stakeholders (eg, dedicated meetings, mandatory disclosures of sustainability implications when presenting products during conferences).
      • Engage representatives in dialogue around achieving societies’ objectives and understanding the sustainability goals of industry partners.

      Years 2 to 5

      • Assess yearly progress and continued engagement.

      Advocacy

      Advocate for policies that promote environmentally sustainable GI practices.

      Year 1

      • Review, discuss, and revise current advocacy goals and leadership programs.
      • Identify medical and nonmedical climate advocacy organizations that are aligned with the societies’ missions to explore potential for collaboration and mutual support.

      Years 2 to 5

      • Enact revised advocacy leadership programs.
      • Initiate discussions with agencies like the U.S. Food and Drug Administration and the Joint Commission on Accreditation of Healthcare Organizations about nonevidence-based guidelines that may have a considerable environmental impact.
      • Engage with representative organizations at local, state, and national levels to promote efforts that mitigate the health-related aspects of the climate crisis.

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