While the healthcare industry is responsible for saving millions of human lives, its work comes at a considerable cost to the environment.

The healthcare industry accounts for 4.4 – 4.6% of worldwide greenhouse gas emissions and similar percentages of toxic air pollutants, putting it up there with the most carbon-intensive service sectors in the industrialised world.

The race to cut carbon emissions and reach net-zero by 2030 is on but to get anywhere near that goal in under ten years, healthcare needs a sustainability overhaul, and that includes clinical trials.

Around nine years ago, The Sustainable Healthcare Coalition (SHC) was brought together by the UK National Health Service (NHS) in response to evidence that pharmaceutical products were responsible for much of the NHS’s carbon footprint.

Originally called the Coalition for Sustainable Pharmaceuticals and Medical Devices, the group created world-first guidance on how to measure the carbon footprint of pharmaceuticals and medical devices. It went on to develop the Care Pathway Carbon Calculator, a tool to estimate the overall carbon footprint (kgCO2e) for a patient as they move through the health system.

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Now the coalition is set to do the same for clinical trials.

In an insightful paper for The Lancet, SHC chair Fiona Adshead and colleagues shared their strategy to reduce the carbon footprint of clinical trials.

Clinical Trials Arena sat down with Adshead to discuss the paper, the coalition’s ‘Eco-Design Tool’ to measure the carbon footprint of trials and their suggestions for new processes, incentives and competencies for clinical trial stakeholders.


Kezia Parkins: Please tell us about the SHC’s findings published in The Lancet around the carbon impact of clinical trials.

Fiona Adshead, chair of The SHC.

Fiona Adshead: In writing the paper we first looked at what we could find in the literature already published. A study in 2009 of 12 pragmatic randomised trials showed that the average carbon emission of the trials was about the same as that of nine people in the UK in one year.

We then went on to calculate the carbon footprint if we brought together all of the trials on clinicaltrials.gov where there were 350,000 national and international trials. We worked out that if you applied that average figure from that 2009 study, it would be the equivalent of 27.5 million tonnes, which is essentially a third of the total emissions of Bangladesh – a country of 163 million people.

Clinical trials are important and people will invest time, money and resources into them. What we are saying is that as the world moves towards tackling climate change, it’s really important that we think about the environment as part of how we can design and get ethical approval for trials.

We found with clinical trials, once you start to quantify the amount of carbon associated with each step like patient travel, for example, then you can begin to make choices to minimise them.

As part of the Covid-19 pandemic, clinical trials underwent a lot of innovative change with companies moving towards decentralised models seeing patients being assessed more at home. We think there’s a great opportunity to understand the environmental impact and put that alongside these methods.

It’s about not only thinking, ‘Is this trial going to add something to the world’s understanding of x treatment for x condition,’ but also, ‘What is its cost to the planet’. We want people to start to design this thinking into what they do.

The health service has always been based on the principle of ‘do no harm,’ but the impact of the health sector overall is about 5% of global emissions. We really need to think about how to still get the best patient outcomes, be as efficient and reduce waste and costs, and alongside that, consider the environmental impact. That’s what all our work is about.


KP: Can you tell us a bit about the eco-design tool you are developing?

FA: We know there are many ways to reduce waste in clinical trials and there’s been a big push to reduce paper, to conduct more virtual health visits to reduce travel, to use greener approaches to chemistry – so we know there are lots of opportunities.

A clinical trial has many different building blocks and processes so the idea of the tool is to first map them out and work out what the carbon footprint for those will be to begin to identify hotspots of opportunity.

It’s an area beginning to get interest as health systems like the NHS have told their suppliers that they want to have committed to being net-zero by 2030 and won’t buy goods or services from them unless they are net-zero too.

A lot of big companies get clinical research organisations [CROs] to do their research and soon, they will need to account for their carbon footprint. More and more organisations will need to understand their carbon impact across both what they do directly, and what they do through their supply chains and find ways to reduce it.

The SHC has brought together colleagues from the MRC-NIHR Trials Methodology Research Partnership, the Institute of Cancer Research’s Clinical Trials and Statistics Unit, the UK Health Alliance on Climate Change and others to really try to accelerate that and give people a tool to start to think about what might be possible.

We’ve now got funding to start designing the tool. At the moment we’ve got a very rough outline of what some of the processes would be based on an assessment that ERM, a privately owned sustainability consulting firm, has done in one clinical trial.

We want to build that out further and test it out with a broader range of academics.

We’d also love to get some commercial partners and collaborators to help us develop the tool and help them begin to footprint their trials as we want something that is flexible and applies to all situations.


KP: What have been the reactions of sites, sponsors and CROs when you express that the carbon footprint of clinical trials needs to be reduced?

FA: In the last month, I think you’d need to be on a different planet to not think tackling climate change and the emergency we’re in is important.

We’ve seen what’s been happening sadly across America with fires and the flooding happening here in London, as well as Germany and China. Those are the kinds of things that are going to get worse if we don’t take action.

From our experience with Care Pathways, we think that whilst on one level, it might seem as if [cutting carbon] is going to make clinical trials more complex, actually, reducing environmental impact, better patient outcomes and reducing cost go hand-in-hand because designing carbon impact out of processes actually means that you reduce waste, make things more efficient and often make them more patient-centred. I’m sure that most of us who we’re going to have to be part of a clinical trial would rather do it from the comfort of our home rather than travelling to a centre, for example. That will obviously reduce the carbon impact of a trial.

I think now that we all realise that we’re going to have to get really serious about tackling climate change and our impact on the environment, the more we can design it in at an early stage so the less bureaucratic it feels, and the more you get the benefits. It will become part of how we think and design rather an extra burden.


KP: How can clinical trial stakeholders be incentivised to reduce carbon emissions in their studies?

FA:  I think there’s a whole spectrum of incentives. As we said in the paper, we are very keen that in the academic public sector, funders of clinical trials consider prioritising trials with lower carbon footprint.

We think another way to incentivise is at the stage of ethics approval because everybody has to get ethical approval for trials. We think that there is an opportunity to build it in as part of that consideration. Again, it’s about doing no harm not just to patients but also to the planet.

Additionally, everybody really values having their research published so we want to encourage clinical journals to accept papers that consider the impact on the environment it took to develop that trial.

Finally, as mentioned, as health systems begin to procure drugs and devices with net-zero and carbon impact in mind, there will be a pressure on companies who have developed innovative products to be able to say what their impact is and clinical trials are part of that.

Another thing that we often forget is that organisations and companies are made up of people. People in many communities and many countries really care about climate change, just like they really care about health, so I think it’s a great way for companies to show their employees that they’re doing things that minimise the impact on the planet too. That’s an enormous motivation because that really impacts young talent.


KP: DCT uptake has skyrocketed during Covid-19. How can DCTs and decentralised techniques help reduce the carbon footprint of trials?

FA: An obvious one is that it’s much nicer for people to be at home whilst participating in clinical trials as not having to travel can be a real benefit. I think DCTs, particularly if they are focusing on making things more convenient, increasing retention and reducing waste – all the things that make a trial more efficient – absolutely should have a reduction in carbon impact. What we want to do with the Eco-Design tool is really prove that.

For example, one of the things we’ve done with our Care Pathways tool is taken parallel trends happening in healthcare like virtual home visits, and we’ve been able to prove that they actually really do reduce the carbon footprint of that patient’s care. We’d like to be able to do the same for DCTs, to quantify and demonstrate exactly why they are better – not just for factors that made them popular in the last year, but also because they reduce environmental impact.