By December 2020, several potential covid-19 vaccines were showing promise in clinical trials. And by the middle of 2021, a vaccine was available to the public. Very few people had been optimistic that such a feat could be achieved. In many ways, it was a perfect storm. The fast development of covid-19 vaccines benefited from years of previous research on related viruses and vaccine trials that used mRNA. It’s said the research matured at just the right time, and that mRNA technology would not have been ready even five years ago.

But the time-consuming part of bringing a vaccine to market is not necessarily the initial research, but everything that follows, including rigorous clinical trial testing, regulatory application approval, manufacturing and communication. On average, this takes just shy of a decade. But advanced digital tools and regulatory levers for faster approvals were at the ready, giving stakeholders the means to move at—relatively—lightspeed. The process was a whirlwind that is likely to affect regulatory practices for years to come, prompting new mindsets and applications of tools to the wider biotherapeutic landscape.

We asked experts in regions with advanced regulatory systems—the UK, the US, the EU and Japan—what happened and what changes are likely to stick. The most significant takeaways are highlighted in this report.

Notable findings include:

• Co-operation and collaboration between the industry, regulators, governments, clinical investigators, academic scientists and non-government organisations (NGOs) has been unprecedented. For many, this was seen as the most effective tool in bringing the covid-19 vaccine to market so quickly. This could set the stage for further alignment in decision-making, de-risking for research and development (R&D), and establishing plans for programmes and standards across the biotherapeutic regulatory landscape. But for this to carry forward successfully, elements of nationalism and competition need to be revisited.

• Rolling reviews and Emergency Use Authorisation (EUA) were essential tools for speed. Coupled with an all-hands-on-deck mindset from industry and regulators, processes that typically took years instead took months, and those that took months accelerated into weeks. Post-pandemic, our experts think a middle ground can be found. Where the balance lies, of course, may be conditional for years to come. Some believe that such measures may be best for crisis situations, but others feel that these efficiencies can trickle down to the wider pool of biotherapeutic therapies.

 • Digital tools—onwards and upwards. Digital tools adopted in the pharmaceutical sector have soared. Decentralised and remote clinical trials, remote inspections, digital submissions to regulators, and more data-driven discovery were always likely to be part of the future, but the pandemic sped up that eventuality. Many of these tools were already there for the taking but underutilised due to concerns about introducing risk to process and regulatory approval. There’s little turning back now. Many regulators have been quick to offer guidance in these areas and show willingness to engage with industry to expand on them as needed.

 • Too often, manufacturing is an afterthought. The high demand for drug manufacturing, and general shortfall of manufacturers available to produce new or additional drugs, means that, even if the rest of the pharmaceutical ecosystem sped up drug development and approvals, a bottleneck could slow time to market. Covid-19 put a spotlight on the issue, as well as supply chain challenges, and the need for flexible manufacturing procedures to allow for more parallel planning with drug development. These needs may help speed the adoption of continuous manufacturing processes, which offer more flexibility than batch manufacturing and faster delivery times.

• Global standards are in the pipeline. Operating in multiple jurisdictions often introduces all manner of complications from a compliance and regulatory perspective, as well as data standards. Consortiums of global regulators and industry bodies have long tried to harmonise standards to ease the increasing number of global R&D initiatives and streamline applications for marketing approval. Progress was slow, but it helped lay the groundwork for the global collaborations that came to light during the pandemic. This momentum, stakeholders say, has continued, helping them carry on developing for the future benefit of global efficiencies.   

In a survey of hospital doctors and nurses in France, Germany and the UK, many agreed they need to better prepare patients and adapt their healthcare systems to be more sustainable.

Executive summary

Healthcare professionals (HCPs) are actively treating an increasing number of patients affected by climate change factors. But healthcare facilities, activities and supply chains are a large contributor to climate change, unintentionally reinforcing the very problems they aim to solve. In total, healthcare represents 4-5% of total global carbon emissions.

Fortunately, the healthcare sector is starting to understand the significant role it can play in decarbonisation efforts to better protect patients and the planet from climate change. How then, can healthcare move forwards in the best interests of its patients and the planet?

This topic is gaining traction across Europe, and globally. At COP26 in Glasgow in 2021, the Health Programme was extensive. Proposals to build climate resilient and low-carbon, sustainable health systems were presented. Initiatives were raised around research for healthcare adaptation and inclusion of health priorities in Nationally Determined Contributions. Raising the voice of HCPs as climate change advocates was also highlighted.

To bring new insight to this conversation and help decision-makers navigate the big issues, Economist Impact, with sponsorship from Johnson & Johnson, spoke with subject experts and surveyed hospital doctors and nurses in three major carbon-emitting countries in Europe—France, Germany and the UK. They shared their perspectives on how healthcare systems and professionals can play a role in decarbonisation and better support patients.

The results highlight a passionate reaction from HCPs, who are deeply concerned about the growing impact of climate change and eager to see sustainability rise on the agenda in their workplace and at a national level. Additionally, interviews with senior experts shed light on priority issues, and how healthcare bodies can better overcome common roadblocks.

Notable findings include:

HCPs say they want to educate patients about climate change—but first, they need more education themselves. When asked what personal responsibility they’d like to take around sustainability, most selected the role of educator to patients around sustainable lifestyles (33%) and various climate risk factors (25%). However, sustainability education is not part of HCP’s core responsibility, so it is unsurprising that others expressed that they lacked the time and resources (12%) and education (9%) to do this effectively. Most (74%) said that thus far they have not been supported in green literacy efforts. HCPs might be more proactive if they had more support and incentives. On the theme of personal responsibility, following educating patients, HCPs gave a moderate response to taking proactive personal responsibility. For example, 18% said they would like to help redesign clinical pathways to be more sustainable. This is disappointing, as HCPs can be a powerful force in addressing the climate footprint of their practice across all emission areas. To change this, particularly in areas where national plans are absent, incentives and a greater sense of empowerment and support will be needed, ideally coming from their employers. Small changes add up, and the healthcare ecosystem will transform. To reach zero carbon emissions (net zero) across the value chain of hospitals, change needs to happen at every level. Several experts we spoke with are calling on HCPs to push for sustainable changes in clinical pathways, models of care, the types of prescriptions they give patients and beyond. To reach ambitious sustainability goals, the system will be much different than it is today—and nobody is quite sure what that outcome will look like. Healthcare systems protect patients but are also major producers of carbon. In our survey, hospital doctors and nurses confirmed that they are already seeing patients impacted by climate change factors, and they expect to see a rise in those visits in the decade ahead. Yet the European region’s healthcare system produces nearly 5% of the region’s carbon footprint. Making healthcare systems more sustainable is now paramount to reaching national net-zero goals and to the wellbeing of populations. Emissions need to be addressed across healthcare’s entire value chain. There is a collective rise in consciousness around the issue of sustainability in healthcare, but much of the attention is landing on Scope 1 and Scope 2 areas (direct emissions and indirect energy). When asked to identify priority sustainability areas in their practise, only about a third (31%) of healthcare professionals in our survey name Scope 3 (medical supply chain). However, Scope 3 is where the bulk of emissions come from. Education is needed to raise collective awareness of all emission sources and how they can be jointly reduced. National plans to address the system’s sustainability vary across Europe. Of the three countries studied for this report, only the UK has a detailed plan for reaching net zero in the healthcare sector. Germany and France lack commitments and roadmaps for this. Even so, grassroots actions may be under way, as many (63%) HCPs surveyed are aware of some form of sustainability plan in place or soon to be in place at their hospital. Still, HCPs are sensitive to direction from above, and the absence of national plans (other than in the UK) is likely delaying progress.

Conclusion

Big, systematic change is time-consuming and often slow. And health services are already resource constrained. But there is no time to wait. The climate emergency is only worsening. 

Our survey confirms that HCPs are already aware of the impact of climate change on the health of the populations they serve. However, they would benefit from:

More information and more support at all stages of their educational and employment journey to better understand the risks to their patients. Help and support in putting advocacy into practice in their healthcare institutions or clinical settings. Support for proposed changes to clinical pathways that can help reduce any unnecessary medical production and waste in patient treatment and long-term care.

From a clinical perspective, further evaluation to support mitigation and adaptation initiatives is required. This includes:

Establishing an evidence base to support any changes to clinical activities and ensure that there is no ambiguity that doing the right thing for the climate is also the best thing for the patient. Understanding how clinical practices could change to help patients and especially target vulnerable groups (eg, elderly and chronically ill people) adapt to climate risk. 

Out of the three European countries assessed (France, Germany and the UK), only the UK is showing leadership in measuring healthcare emissions and setting targets. For further effectiveness, healthcare systems need to:

Measure their emissions on a regular and systematic basis (including indirect Scope 3 emissions from the supply chain, a major contributor). Bring in well-thought-out activation plans with key roles specified for HCPs, consider resourcing changes with local healthcare sustainability leaders, and transforming industry production lines and supply chains.

Methodology

This research was undertaken in three phases, starting with a literature review of how healthcare systems in France, Germany and the UK are responding to climate change and the role of healthcare professionals (HCPs), followed by a survey of 75 doctors and 75 nurses working in hospitals in France, Germany and the UK in February and March 2022. We also interviewed experts from government, hospitals, medical professional associations and NGOs to build on the research and shed light on our survey findings.

Climate change is a health issue with particular effects on respiratory health. This research summarises the direct and indirect evidence that links climate change to lung health and maps out policy priorities to prevent and curb the effects of climate change on lung health.

This independent report is the result of multiple research phases. First, we conducted a pragmatic literature review of the evidence and policy frameworks across the academic and grey literature to develop an initial set of policy priorities. Second, we convened an advisory board on May 19, 2021, drawn from the academic, climate change, environment and healthcare sectors, whose advice shaped the priorities of the study and the content of the report. Third, we conducted 12 interviews with respiratory clinicians, academics, policymakers and climate change and health experts to obtain an in-depth view of the issues involved. Finally, supporting the research, and feeding into this publication, has been substantial desk research.

There is evidence that emissions linked to global warming have an adverse impact on respiratory health, in particular emissions from combustion of fossil fuels and biomass by power stations, industry, homes and vehicles.

The need for action is recognized by the environmental sector and increasingly by the heath sector and the European general public, who are also beginning to demand tougher action. More awareness of climate change’s impact on lung health among these groups is vital for effecting change.

There is only so much one engaged individual can do in terms of cutting emissions and living sustainably. Mass change is needed, and most importantly the policies and systems in societies—controlled by governments and public authorities—need to support efforts to reduce emissions and tackle climate change.

Increasing awareness among the health sector and the general public of the need for urgent action on climate change is the path to achieving it by putting pressure on politicians to act.

Our thanks are due to the following for their time and contribution (listed alphabetically by surname):Advisory board members

Isabella Annesi-Maesano, research director at the French NIH (INSERM) and deputy director of the Desbrest Institute of Epidemiology and Public Health (IDESP), INSERM and University of Montpellier, France Nicholas Hopkinson, National Heart and Lung Institute, Imperial College London, UK  Dan McDougall, senior fellow, Climate and Clean Air Coalition Mariam Maglakelidze, dean of the School of Medicine, Petre Shotadze Tbilisi Medical Academy, Georgia James Milner, assistant professor, London School of Hygiene and Tropical Medicine, UK Susanna Palkonen, director, European Federation of Allergy and Airways Diseases Patients Association Gerardo Sanchez Martinez, expert in the environment, health and wellbeing, European Environment Agency Paul Wilkinson, professor of environmental epidemiology at the London School of Hygiene and Tropical Medicine, UK

Interviewees

Isabella Annesi-Maesano, research director at the French NIH (INSERM) and deputy director of the Desbrest Institute of Epidemiology and Public Health (IDESP), INSERM and University of Montpellier, France Nathan Borgford-Parnell, scientific affairs co-ordinator, Climate and Clean Air Coalition Nicolás González Casares, MEP, Spain (Spanish Socialist Worker’s Party, Group of the Progressive Alliance of Socialists and Democrats); member of the Special Committee on Beating Cancer Sandra Cavalieri, urban health initiative coordinator, Climate and Clean Air Coalition Tiy Chung, communications officer, Climate and Clean Air Coalition Gennaro D’Amato, professor of respiratory medicine, University of Naples Federico II; director, division of respiratory diseases and allergy, High Specialty Hospital A. Cardarelli, Napoli, Italy, and member of the G7 International Committee on Climate Change and Health Vijoleta Gordeljevic, health and climate change coordinator, The Health and Environment Alliance Frank Kelly, Battcock Chair in Community Health and Policy, Faculty of Medicine, School of Public Health, Imperial College London Sean Kelly, MEP, Ireland (Fine Gael, Group of the European People’s Party); member of the Lung Health Group James Milner, assistant professor, London School of Hygiene and Tropical Medicine, UK Gerardo Sanchez Martinez, expert in the environment, health and wellbeing, European Environment Agency Anne Stauffer, director for strategy and campaigns, The Health and Environment Alliance

Join us for a webinar to discuss the report findings: