Frederik: Hello and welcome to the Sustainable Healthcare Podcast. This is the show where we talk about anything sustainability in the healthcare sector. And today I have a really exciting guest on the show. Tamara has recently produced, or been part of a team that produced a visual that shows the entire circular economy of healthcare and maps it out on different circular economy models and different stages of maturity of how we are working with materials. And it reads a little bit like a mad man’s map of the world of circular economy in healthcare. It’s actually visually quite beautiful to look at. And yeah, I’m just really excited to have Tamara on the show to talk about it. So without further ado, Tamara, welcome to the show.

Tamara: Yeah. Thank you for having me and for the nice introduction.

Frederik: You are welcome. And I’m terribly sorry if I butcher your name. I’m just saying it like it’s spelled now. I’m thinking it works. But you’re a researcher by trade and you specialize in the realm of healthcare and circular economy. When you’re not working with healthcare and circular economy, what do you spend your time on?

Tamara: Yeah, this is not such an easy question because I’m finishing my PhD thesis and starting up a company. So I’m not doing very much on the side at this moment.

Frederik: This would be sleeping and eating maybe?

Tamara: Yeah, mostly. Sometimes working out a little bit, but yeah, until the PhD thesis is finished, I think there’s not much going on.

Frederik: Yeah there’s not many minutes left on the daily schedule. Can you… I know personally about your company project, because I follow you on LinkedIn and we’re connected there, but can you tell our audience just the elevator pitch about the company?

Tamara: Yeah I will keep it really quick then. But so I was extremely frustrated with the current mostly used instrument for vaginal exams. So the vaginal speculum, it really is a painful experience for a lot of patients. And, yeah, we found out that it was designed 180 years ago and that a lot of patients even avoid checkups because of it and because of that I wanted to redesign the device. We did, we got a lot of media attention. So we want to bring this patient friendly alternative on the market. And we’re successfully starting this with a successful crowdfunding campaign that we had last year. So this company’s name is Noian and people who might have heard of the device before. It’s called Lilium. So that might sound familiar to some.

Frederik: Yeah, it’s a device that’s made of steel and it looks a little bit like the device you put into a fish’s mouth if you want to get the hook out. It’s a pretty medieval look in the design of the one you’re trying to replace with a more gentle and sleeker design. At least that’s my take. You can use that as a testimonial without any reference to personal experiences. But I’m cheering on you on the sideline for the company. So I am also happy to put a link in the show notes, so interested listeners can go and see this device that you’re working on. I wish you all the luck in the world with that venture.

Tamara: Thank you.

Frederik: But actually the visual, so I have the visual in front of me here, and I’ll post the link in the show notes so you can all see it. And it’s called the visual taxonomy of Circular Healthcare Flows. And if someone is looking at this for the first time, can you describe it for us so the ones that are not able to look at it can also understand what we’re talking about.

Tamara: Yeah, sure. What we actually see in the middle, we have a horizontal line with a lot of steps, and those are the steps that are generally taken in a linear economy. So it goes from the start, which includes the design phase. So you have an idea, you start to develop the device, and then flash forward, we go to the production of the device. It has the base materials, the production of the ports, and then it goes into use. And after use it will be disposed of, unusually. Currently, at least in the Netherlands, we go for incineration, which means that we burn the device. Now that’s not very ideal for the environment. So we actually want the products to, let’s say flow. That’s why we call it flows and then flow back into the system to, for example, be reused or refurbished, et cetera. However, often we don’t understand each other very well, and when we say reuse, we don’t always mean the same thing. And the same goes for all other flow strategies that we could possibly implement.

Frederik: Let’s answer that because so visually we are looking at a middle bar that shows the linear process of things, the design phase, the production phase, the use phase, and the end of life. That’s the old way of doing things. And what your visualization is showing is all the little opportunities for looping material back into the flow of how materials go about the system. So it looks a little bit like a version of the Double Butterfly diagram from Ellen MacArthur Foundation, but just with a lot more texture and a lot more nuance and not as, how can you put this in a polite way, not as simple as the double butterfly diagram is great in its simplicity. But it’s poor in its actionability in my opinion. It makes it really difficult to use because you have to… They’re not really guiding you to what’s the good path here? And when you’re saying this, I just wanted to pick up on that. When you say that there are often misconceptions when someone says reuse, it’s not usually what they mean. Can you fold that out for us a little bit? What are the misconceptions that you’ve seen a lot?

Tamara: There’s a lot of them. I will give one example first. It’s about, it’s one of the first papers I was reading when I started my PhD and it was about pacemaker recycling. So they would actually take the used pacemaker out of a patient and then implant it into a next patient. Later I came to realize that this is not actually recycling. We define recycling as shredding a product into its base materials, and then using those materials to produce something the same or something else again. And they were actually reusing the device because they did not alter the device. They just checked whether it still worked and then. So that’s just one example.

Frederik: But usually it’s the other way, right? That they say they reuse and then really they recycle it. I think, or what’s your experience here? Because I think it is really interesting. You bring up a case where they actually did something that’s better from a circular economy perspective than what they’re advertising.

Tamara: Yeah, that’s right because you can basically say, I’m reusing the materials. And that would not be a wrong way to describe it, but very confusing. And it’s often not done on purpose, but it can be a bit misleading. But I actually saw the most confusion around the word reprocessing. That’s one that’s only used in healthcare and of course circular economy practices have been separate from healthcare for a long time. So then when you’re bringing the circular economy expert and you tell them, I’m going to reprocess this, they have absolutely no clue what you’re talking about. So that’s there.

Frederik: Is there another word that is used outside of the healthcare sector that would be more relatable?

Tamara: Yeah, so I looked into a lot of literature and what we figured out is that even in healthcare, it’s not used in the same way. So some of them use it to describe decontamination. So the general cleaning of the products, that would be the reprocessing process. And others describe it as more an overarching term, which includes anything that brings like when you prepare a medical device for use, they call it processing, and if you reprocess, that would mean you do that again. So you do whatever is needed to prepare it for a new use. Then that would be reprocessing, so that would include reuse, refurbish, and remanufacturing.

Frederik: And then all of a sudden we have an umbrella term on our hands.

Tamara: Exactly.

Frederik: And isn’t there… Am I misunderstanding this? There’s also a regional difference in how it’s defined in the EU and how it’s defined in the US, isn’t there?

Tamara: Yeah I’m not sure if you are referring to what I’m about to say, but we see a lot of single use reprocessing in the US mostly. Which means that there’s a single use device and then you reprocess it for reuse, even though its intended use is for it to be disposed. And currently in a lot of countries in the EU, this is not permitted yet because it actually needs to be reregistered as a reusable device. It’s slowly changing, but it doesn’t happen that much in Europe.

Frederik: And if we are looking at this, I think it is visually quite pleasing. It’s a little bit off, it’s not completely symmetrical and there’s beautiful colors that you selected to it. So I think it reads really beautifully. But if we were to make this relatable to the audience, can you pick a concrete example where we look at a single use device or a reusable instrument? And can you walk us through how a team could use this taxonomy to choose the best circular pathway?

Tamara: Yeah. We can take an example of, laparoscopic device, maybe. So used in surgery, minimally invasive surgery. Let’s take a stapler which you can transect and connect tissue with. Because that’s a high risk device, but not super dangerous. Like it won’t affect your heart or brain. So we have been talking about reuse, refurbish, remanufacturing before, but there’s a lot more loops on the visual. And it’s mostly tailored towards those designing the device in the first stage. So it starts actually with refuse because there’s a lot of new devices that actually, we might not even need, and this is hard to say to a manufacturer, but we are really trying to trigger people to ask the question: do we really need this? And then if we do, is this the most sustainable way to come to the purpose of the product. So if we want to transect and dissect tissue, do we really need this stapler that I just described, which is embedded with electronics and very precise, maybe we’re working on a less risky area of the body and we can use, for example, a device that can transect and dissect tissue without needing this extremely complex device.

Frederik: Refuse is, it’s actually the start of the question. Any design phase of a medical device should be: do we even need this?

Tamara: Yeah. Would it be possible to run without it?

Frederik: Exactly and then a good example would be if you have a smart pill box that gives you reminders of when to take your medication to improve your medication adherence, but there’s absolutely no proof that these reminders improve your medication adherence in comparison to the simple pill box you already have at home. Then why bring on a new electronic device into this world?

Tamara: That’s the question we’re asking ourselves. And then we will all adhere to this program and make sure we are not producing and designing products that have no significant need in the world. Evidence-based, significant need.

Frederik: Exactly. And if it does have… If you do need the added value of the product, but the product is like not the most sustainable manner to solve the problem you’re trying to solve, then you could maybe replace the products or see what else is out there. After that we go more into system perspective, so we start rethinking the system. Because sometimes, for example, you need in this laparoscopic surgery where you have the stapler, you need a lot of different devices, which all are used one time, used for different functions, but look more or less the same, and then you throw all of them away after one use. But what if you could design a device which has all these different functionalities all in one for which you only need one battery and maybe a little bit more complex electronics, but it’s just one device that you can use during the surgery rather than throwing away six devices that you only need one or maybe two if you need them at the same time.

Tamara: So that’s the kind of rethink strategies. Examples we had here was to increase the functions, as I just said, but it could also be device sharing instead of buying different units for different departments when you don’t need them at the same time, just have one. Or yeah, enable sharing and more used locations because sometimes a device is only used in a specific place because it’s not movable. So those are just some examples of rethinking.

Frederik: Yeah, so that’s where we’re trying to start with refusing and now we are rethinking and trying to see if there are any opportunities for us to group efforts and materials and processes and make, I suppose basically make things simpler.

Tamara: Yeah. Yeah. It’s like that and it aligns very much to the next step, which is reduce, and that’s more about minimizing the amount of material that we use or the amount of energy that we need to use the device or water use, that kind of things. But also the actual use of the product. Maybe we are using products in procedures or in this example case in surgeries where maybe the surgery is very explorative and we expect nothing to be coming out of it, maybe we can first do some different steps and then decide the surgery is not needed. And maybe this is not a very good example with this example product, but I think you understand where I’m going with this.

Frederik: Yeah. Yeah.

Tamara: This all happens before the product even enters the hospital usually, but those steps can also happen in the hospital because you can also, as a practitioner who is responsible for choosing which devices to use, they take these things into account. Does that make sense? So where basically the way to use the taxonomy we have a significant step that is in the design phase. Before we put anything out, we should refuse the first step. Yeah. Really ask ourselves: is this necessary? That we should try and rethink and say: is there an opportunity to group efforts and material into simpler material flows and simpler use flows? And then looking at the reduction angle, is there a way to reduce the material input into the system going in. And now then we’re starting the production phase.

Frederik: Yes.

Tamara: What happens then?

Frederik: So even though the production phase often has the highest environmental impacts, not a lot happens there in terms of strategies because we are trying to minimize the impacts of the production phase through, for example, ensuring that we produce less products by, for example, reusing them. But first we want to ensure that products are used as long as possible so that they’re not thrown away because they become defective, and this differs a lot per product because some of them are used for 10 minutes and some of them are used for 10 years. But generally, if you want to use a medical device for a longer period of time, you need to ensure there’s maintenance and quality control to prevent failure. And if there is an issue, you need to have a repair program in place. So those always need to be taken into consideration. After use a lot of medical devices and especially the example stapler we described, they need to be decontaminated. It’s important to know, first of all, even if you cannot reuse it for some reason, it still needs decontamination if you want to recycle it. Otherwise there will be regulatory issues. So decontamination is always important. And it does circle so…

Frederik: It’s, sorry I’d just like to expand that a little bit. So we have a device that’s used in surgical, let’s say we cannot reuse it. But we may want to recycle it then. Stuff that has been inside a patient has, in Danish we call it the three Bs, but it’s basically there can be blood on it, there can be feces on it, there can be other bodily fluids on it. So it’s one big hot mess and you’re not allowed to just throw that in the normal waste bin. That’s a huge part of the issue because for various reasons. One side of it is that the waste collector, the staff that’s collecting the waste, we cannot accept exposing them to the biological hazard that could be from, say bacteria or virus that could be transferred on the waste. But it’s also that it can also be hazardous in other ways. It can have sharps, it can have glass, it can be all kinds of fuzzy, fussy problems related to the handling of this waste. And that’s why we can’t just throw everything in the bin, take it to the waste lot and sold it there. We need this decontamination step. Is that correctly understood?

Tamara: Yeah. That is what I understood is the current situation. So of course you can do incineration specifically for contaminated products. That is more impactful for the environment even than normal incineration. And we try to avoid that as much as possible. So if we want to go for recycling, most recyclers, if not all, will say we won’t accept contaminated materials because we’re not allowed, or it’s dangerous for our staff, so it’s easier to deliver to them clean.

Frederik: That makes sense.

Tamara: So what happens after decontamination? Or maybe I should also tell this: there’s different ways of decontamination based on how risky it is. For example, if you want to reuse it, does it need to be absolutely sterile or is, for example, high level disinfection enough, which also eliminates nearly all microorganisms except for maybe some very rare types of proteins. An example of this would be maybe with the vaginal speculum. There’s a debate going on. It’s currently sterilized, but it’s not used in a sterile environment like the vagina is not sterile at all, and it seems like maybe high level disinfection would be enough and have less impact on the environment. So these are also things to consider.

Frederik: That makes sense. Yeah. I think you’re latching onto something that’s very important here because sterilization and the definition of sterilization is really important to determine if we want a circular economy it makes sense to ease the boundary just a little bit. And say, maybe this is not a hundred percent sterile, but it’s 99.99% sterile, or whatever the percentage might be. But the whole point is just in sustainability. Quite often we see this difference where if you are to transition, let’s say the whole societal economy away from fossil fuels, reaching a hundred percent independency from fossil fuels will be extremely difficult compared to 99%. So sometimes allowing a little bit of leeway gives us the needed flexibility to make things possible. And for sterilization, this is certainly the case where we’ve been talking about a lab-like environment of guaranteeing a hundred percent sterility on a device where you say: we are not operating in a sterile environment, so it’s not necessarily sensible to have this as a goal. Yeah, that’s just super interesting to pick up on that, what’s currently going on to make other definitions. You said that you can allow certain proteins to be there. Are there any terms that are used to replace sterilization or are we redefining sterilization now? How are we going about that currently in both academia and in the industry?

Tamara: Sorry, can you repeat your question? I don’t know if I completely understand it.

Frederik: It was super long-winded. I’ll try again. So basically with sterilization, how is that term being redefined now? Is it something that takes place in academia or is it something that takes place in a regulatory environment? Or is it something that takes place in the industry right now and how is it being redefined?

Tamara: I don’t know if sterilization is necessarily being redefined. I think it is a clear term that is well known all over the world and that it has a certain need to cure of everything on the device that could harm the patient for, as much as that is possible. But there’s there is different steps in cleaning a device and not all steps are always needed for every device. And sterilization is like the ultimate, highest step in sterilization that usually you need in like invasive surgeries, like open heart surgery, that type of situation. For the pill box examples I said earlier, you could use a cleaning wipe and that’s it. So that’s not sterilization at all, but still a medical product. And I think my message here is to just be cautious and ask: okay, it needs to be clean, but how clean does it need to be?

Frederik: Yeah. So it is basically a classification of cleanliness, you could say.

Tamara: Yeah, exactly.

Frederik: What would be the step below sterilization if we’re defining this ladder, that’s the classification of cleanliness and sterilization is the highest achievable standard. What would be one step below that?

Tamara: Yeah, so you have the disinfection and there’s low level disinfection and high level disinfection. And that’s what I said earlier: high level disinfection, which eliminates nearly all microorganisms. And sterilization goes even further. So there must be a very high risk if you want to sterilize something. And that’s like hot steam sterilization, which takes a lot of energy to do.

Frederik: Yeah. Do we know by any comparative measures how much more resource intensive is it to sterilize versus high level disinfection?

Tamara: I think there is data out there on what it is, what the impact is of sterilization. But we need to be very cautious because the disinfection can be done in different ways, so you need chemicals for it, which also have an impact. And so it really depends on the way you’re doing it.

Frederik: So there’s no rule of thumb. We cannot say it’s four times as resource intensive or anything along those lines. It will really depend a lot.

Tamara: I think it depends a lot and if there’s a rule of thumb for different methods, then I don’t know of it. But there’s definitely data out there that we can use to calculate the difference.

Frederik: Cool. Thanks a lot. I think as a last point to latch onto, the visual is showing the takeback and decontamination and also has three yellow bars for leakage. And I think that’s a good sort of way of showing that the leakage is the least desirable. That’s where we don’t want to go. As you said before, we really do not want to incinerate anything for energy recovery if we can avoid it because it’s resource wise, holistically speaking, that’s inefficient.

Tamara: But if we’re looking into the real world, and I know you’ve looked at so many cases of real world applications of circular economy in healthcare, so I’m just really curious to hear: what are the most common trade-offs that you have seen?

Frederik: I actually did some research into this a while ago, and the number one barrier comes back at something that we have already discussed, which is the difference between actual safety and perceived safety. And what that means is that people want to do well in healthcare. Like they don’t want to take risks because you’re working with a patient’s life in many cases. So it’s better to be safe than sorry, but this can have a lot of negative effects in the choices that we make. And I think this also is visible in collection and with collection, like the waste bins that we have. For example, there is a general waste bin and a medical waste bin, but it’s not always clear what belongs where. And just to be safe, we would more easily throw something in the medical waste bin, or just in general when we’re not talking about collection, throw away a device rather than trying to clean and reuse it. Which means that maybe unaffected waste would come up in medical incineration, be burned away more than is necessary. And that’s just one example, but this was the biggest barrier that I identified. And apart from that, yeah, we have logistics, which also comes back to the collection bins, for example. We need a system where you have as minimal bins as possible, but from a manufacturer’s perspective, if they want to collect their own devices, it sounds easy for them. If you don’t consider the hospital workers at all, so just put a bin with their brand on it and get all the same devices in there. But then we end up with 500 bins which is simply not feasible. And a lot of things need to be changed because currently everything we do is mostly in a linear logistic system. The changes take time, energy, and there is not a lot of time and energy in healthcare.

Frederik: True. That. And ironically, there is not a lot of time to meet the requirements to mitigate the climate crisis either. So we really have to act fast. Which is super complicated because this is also a life and death space.

Tamara: Yeah.

Frederik: And the priority is will always be the patient.

Tamara: Yeah, exactly. I really like this analogy of actual safety versus perceived safety. I think you’re really hitting the nail on the head here. In Denmark we have a collection project that’s called, I think it’s called Opin. And they have currently, or recently celebrated that now they are collecting 90%. They’re the consortium is covering 90% of the injection devices that are in the market in the Danish market. So 90% of the produced injection devices are represented by the companies that are joining this collection scheme. What would be your word of advice to an initiative like this?

Frederik: So what, sorry? What exactly are they doing?

Tamara: They have put up collection bins that allows for patients that inject themselves with medicine to collect their used injection devices.

Frederik: Yeah. Yeah. So something that we’re also trying to figure out in our project is whether if you have a smart collection box that recognizes what you put into the box, and perhaps even if it’s more advanced sorts, those that will make a lot of things easier, but we also have to kind of nudge the patients in the case of an injector to actually bring them back. Yeah, I don’t know. It’s not really my field of expertise, this collection part, which is why it’s so small in the visual, but it’s yeah, extremely important because if that part doesn’t happen, then the rest also doesn’t happen.

Frederik: Yeah. And there it’s called Opin is the formal name of it, and it’s also a trademark brand. But I think one of the issues that they have tackled well here is that it’s not a single producer that can, yeah take the devices back. It’s not a uniform drug picture. It’s not a uniform therapeutic area either. It’s not only for patient living with type two diabetes or something. It’s basically all injection devices where you have at-home drug injection. So I think that part works really well. But the issue that you put forward was this: we cannot have 500 bins.

Tamara: Yeah. So we need some kind of collaboration slash standardization. Sometimes even what I have been thinking of, maybe it should be sorted, not based on the manufacturer or product type, but based on where it should go afterwards. And what I mean by that is hospitals have, for example, collaborations with a recycler or it goes to a center where they sort it further. All those devices that are recycled will go to the same recycler, so maybe we can collect them together and just, I don’t know, color code or something to make it extremely clear where what goes. But I haven’t figured this issue out any further yet as well.

Frederik: That’s, you only spend a couple of years working full-time on this issue, so surely we will get the easy solutions soon enough.

Tamara: Yeah.

Frederik: I just joking here, Tamara. I think you’re absolutely right that this is super complex and that’s also what your visualization shows. This is not easy. Yeah. There’s no single simple way to solve these problems unless you go to step zero, which is refuse. Yeah. And that is probably a step we should visit more often as a society and have fewer materials going into the overall material flow.

Tamara: Yeah.

Frederik: Tamara, when we’re working in sustainability, there’s a lot of causes for concern and it’s really easy to feel down about the state of affairs in the climate crisis and with all the geopolitical issues that’s going on right now. There’s a lot of causes for distress and for concern, but I like to keep it a little bit optimistic. And then finish off by asking you: what gives you hope when you’re working with sustainability?

Tamara: I would say what gives me most hope is the fact that I’m working with medical device manufacturers, like big companies, that are willing to make a change. And even though they haven’t figured out how to, how exactly they want to address certain things, they are looking for solutions. They’re collaborating with each other even. And they are not stopped by any political change. They are putting this into their business plans. And yeah, I think that if we keep doing this and we keep collaborating and making this an important point on the agenda, then we will eventually get there.

Frederik: Amazing. I love to finish off on that note. Thank you so much for coming on the show, Tamara. It’s been a real pleasure having you on. To all of you, dear listeners, you’ve been listening to an episode of the Sustainable Healthcare Podcast. I am your host. My name is Frederik van Deurs. You can find me on LinkedIn if you want to connect. And I am super curious to hear your thoughts and feedback on this show. Please subscribe and share the show. Give us suggestions if there’s any guests that you would like for us to have on the show so they can share their knowledge, just like Tamara just shared her knowledge and her research. Once again, Tamara, thank you for coming on the show. I’m really grateful for you taking your time to share your research and your work with our listeners, and I wish you all the best in your endeavors in building the company and finishing the PhD work.

Tamara: Thanks a lot.