🍎 Listen on Apple Podcasts

What happens when a doctor applies the rigour of clinical research to the carbon footprint of surgery?

In this episode, Frederik speaks with Anna Roe Rasmussen, MD, MSc Health Policy — a scientific researcher at the Regional Unit for the Green Transition in Region Zealand. Anna recently defended her PhD at the University of Copenhagen and the Technical University of Denmark, where she applied lifecycle assessment (LCA) to total hip replacement surgery, working towards the integration of environmental impact into clinical decision-making.

About Anna: Anna has spent over a decade at the intersection of climate and health — as a co-founder of Doctors for Climate Denmark (Læger for Klimaet), as part of the working group that drafted the Danish Medical Association’s climate and health policy (published 2022), and as a scientific researcher applying LCA methodology to surgical care pathways.

Three things you’ll take away:

• Why the field needs to distinguish more clearly between carbon footprint screenings and full ISO-compliant LCAs — and what gets lost when clinicians can’t tell the difference.
• Why specialty-level carbon literacy is the missing link between organisational sustainability targets and meaningful action on the ground in clinical departments.
• Why acting — finding someone to act with — is Anna’s personal antidote to climate anxiety.

Timestamps:

What happens when a doctor applies the rigour of clinical research to the carbon footprint of surgery?

In this episode, Frederik speaks with Anna Roe Rasmussen, MD, MSc Health Policy — a scientific researcher at the Regional Unit for the Green Transition in Region Zealand. Anna recently defended her PhD at the University of Copenhagen and the Technical University of Denmark, where she applied lifecycle assessment (LCA) to total hip replacement surgery, working towards the integration of environmental impact into clinical decision-making.

About Anna: Anna has spent over a decade at the intersection of climate and health — as a co-founder of Doctors for Climate Denmark (Læger for Klimaet), as part of the working group that drafted the Danish Medical Association’s climate and health policy (published 2022), and as a scientific researcher applying LCA methodology to surgical care pathways.

Three things you’ll take away:

• Why the field needs to distinguish more clearly between carbon footprint screenings and full ISO-compliant LCAs — and what gets lost when clinicians can’t tell the difference.
• Why specialty-level carbon literacy is the missing link between organisational sustainability targets and meaningful action on the ground in clinical departments.
• Why acting — finding someone to act with — is Anna’s personal antidote to climate anxiety.

Timestamps:

• 00:00 — Introduction
• 03:00 — Anna’s PhD: applying LCA to total hip replacement surgery
• 08:00 — From medical student at COP to co-founding Doctors for Climate Denmark
• 10:00 — The Danish Medical Association’s 2022 climate and health policy
• 13:00 — A passionate but fragmented global movement of healthcare workers
• 17:00 — The publication explosion in healthcare LCA — and why quality must keep pace
• 21:00 — Carbon screening vs. ISO-compliant LCA: the precision vs. direction trade-off
• 27:00 — Specialty-level carbon literacy as the next step for healthcare decarbonisation
• 33:00 — Carbon budgets and financial budgets: an uncomfortable but necessary analogy
• 38:00 — The hard conversations healthcare systems avoid
• 41:00 — What makes Anna hopeful: engaged colleagues and the power of acting together

References and links mentioned:

• ISO 14040/14044 standards for lifecycle assessment (see iso.org)
• DTU Centre for Absolute Sustainability
• Doctors for Climate Denmark / Læger for Klimaet — Facebook [Joachim/Frederik: add official website if available]
• Danish Medical Association climate and health policy 2022 [Frederik: add direct link]
• International Federation of Medical Students’ Associations: ifmsa.org

Guest links:

• Anna Roe Rasmussen on LinkedIn
• Sjællands Universitetshospital
• DTU Centre for Absolute Sustainability

You might also enjoy:

• Episode 097: Visualising Circular Healthcare — Tamara Hoveling (TU Delft) on LCA methodology in healthcare
• Episode 101: Sustainable Healthcare: Implementation and Hope — Maria Gaden
• Episode 088: Circular Material Flow in the ICU — Nicole Hunfeld (Erasmus UMC)

[Episode Spotify/platform links to be added by Frederik]

Hosts:

• Joachim Almdal on LinkedIn
• Frederik van Deurs on LinkedIn
• Care Pathway Consulting

Pull quote:

“If you want to do something — act. And find someone to do it with. That’s always both more fun and more productive.” — Anna Roe Rasmussen

—

---

Full transcript

Frederik: [00:00:00] Hello, and welcome to the Sustainable Healthcare Podcast. I am your host. My name is Frederik van Deurs. Day to day, I work at Care Pathway Consulting, where we advise major pharmaceutical companies on their green transition — turning strategies into concrete actions. But when I’m not working on those projects, I love hosting this show and sharing the knowledge we acquire in and between projects.

Today I have a very special guest in the online studio: Anna Roe Rasmussen, who is an MD by trade and working today as a scientific researcher at the Regional Unit for Green Transition in Region Zealand. Anna, we have known each other for quite a while — being some of the people who started working on the green transition in healthcare in Denmark. We’ve met at a ton of conferences and events and we’ve been talking about getting this podcast episode going for a while. I’m really excited to have you here and to get your story out to our listeners, because to me you are a beacon of making things happen. You had a LinkedIn post the other day about ten years of work on changing the pension fund for doctors in Denmark — advocating at the general assembly that maybe we should put our money somewhere less harmful, given the Hippocratic Oath and everything else we do as doctors. I’m paraphrasing, but I’m really excited to have you on the show.

Anna: [00:02:00] Thank you so much. I feel really fortunate to be invited to share my thoughts and to join this show, which has many listeners and which I also very much enjoy listening to — especially on my way to and from work. It’s always good to have episodes on hand for a long train ride.

Frederik: I’m really glad to hear that. One of the things that was postponing getting you on the show was that we’ve both had children — which is a messy business that takes people offline for a while. Congratulations to both of us on that. And you also had a PhD project that you’ve now finally submitted and defended. Can you tell us a little about that project?

Anna: [00:03:00] Yes, definitely. I could start by elaborating on my background, because that’s how everything led to my PhD project. My PhD was a joint research project between Sjælland University Hospital, the orthopedic department and the Center for Evidence-Based Orthopedics at the University of Copenhagen, and the Technical University of Denmark — the DTU Centre for Absolute Sustainability — where I applied lifecycle assessments to surgical procedures, with the broader aim of investigating how we can incorporate sustainability into clinical decision-making.

As clinicians, we’re used to taking into consideration clinical effectiveness and safety of the treatments we deliver. But in the future, we also have to be considerate of environmental impact. For my PhD, I applied lifecycle assessment — a method to quantify the environmental impact including the carbon footprint of processes and products — specifically to surgical treatment: total hip replacements for the treatment of osteoarthritis. It’s a common condition that will affect many of us as we age. I looked at how you can work with lifecycle assessment in the field of healthcare more broadly.

Frederik: I’ve never had one done, but I think you’re right that it’s increasingly likely I’ll become a patient one day. In layman’s terms, what do you actually do in a total hip replacement?

Anna: [00:05:00] In this procedure, you replace the hip joint with a prosthetic implant because of osteoarthritis — the structural breakdown of the synovial joint in the hip, which causes pain and functional decline. If you no longer benefit from preventive measures like physiotherapy or pain medication, surgical treatment can be a very effective option. You replace the joint with a prosthetic implant, usually metal or ceramic-based. It sounds like a complete replacement, but you’re actually replacing specific components of the joint to provide better support.

Frederik: That’s a relatively large bone, isn’t it? Are you taking out the entire hip?

Anna: No — it sounds like that, but you’re replacing components of the joint, not the whole bone. You insert different elements to provide better support of the hip.

Frederik: There’s also a jazz band called Total Hip Replacement. I think I saw them at the Copenhagen Jazz Festival last year. Anyway — thanks for clarifying. Your journey into sustainability in healthcare is still quite young in the world of doctors. How did your curiosity towards this topic start?

Anna: [00:08:00] It started a long time ago as a medical student — around 2012 — when I was working with global health and access to medicine. I got the opportunity to participate as a youth delegate for the International Federation of Medical Students’ Associations (IFMSA) in a COP meeting. Participating in one of those international climate meetings really opened my eyes to how big a challenge we’re facing in terms of health. The statement that “climate change is the greatest threat to human health in the 21st century” was quite new at that time. It made a big impression on me.

A few years after graduating in 2014 as a medical doctor, I decided I wanted to dedicate more of my time to this topic. The first step was to look into my own pension fund — working together with an NGO that supports pension fund members in advocating for divestment of fossil fuels. We were a group of doctors working on that.

Through that work, I joined the Danish Medical Association [Lægeforeningen]. I realised we didn’t have a climate and health policy, whereas I saw that other countries did. I advocated for a long time that we needed one. In the end, they invited me to be part of the working group that drafted the policy published in 2022, which was very broadly welcomed by politicians in Denmark. I’ve heard it described as one of the policies that received the most cross-party political support after publication, and also from the Danish regions that facilitate healthcare.

Frederik: [00:11:00] Is Doctors for Climate part of a larger international formalised movement?

Anna: [00:12:00] When we established it — around 2021 [?] — we looked into becoming part of a formal network, but we didn’t find one. You can find many similar NGOs in other countries that resemble us, but we are not part of a formal umbrella organisation. We’re run by people with full-time jobs, so the organisational aspect of maintaining an international network is a challenge. To my understanding, there is not yet a formal international structure in place — though that would be terrific.

Frederik: [00:13:00] That matches what I’ve observed from various perspectives. This field is very fragmented country by country, and most people who choose to become doctors are quite passionate about being doctors and helping patients. In between day-to-day practice, research, and publishing, there’s very little time to put structure on a larger international movement. I was also asking to confirm my own finding that it’s still fragmented but there’s a lot of passion and grassroots movement — just not yet synchronised.

Anna: Yes. There’s a lot of energy and passion, but many of these movements are run by people who have many other commitments. That’s also part of what led me to consider going into research. I’d done clinical research before in paediatric endocrinology as a student, which I really enjoyed. And the work — partly in the pension fund, partly at the Danish Medical Association and Doctors for Climate — really made me realise how little scientific knowledge we actually had in this field. I was eager to have the time to actually dive into gaining more knowledge, and also to contribute to how we could make more informed decisions about what is the most sustainable option in clinical care. That motivated me to start my PhD, which I was fortunate to do together with my supervisor at Sjælland University Hospital and with [Mikal at?] the DTU Centre for Absolute Sustainability.

Frederik: [00:16:00] And I think something that comes to me here is that if you started poking at this around 2012, there was incredibly sparse literature. In the 2020s we’ve seen more and more peer-reviewed articles. But when I look at my knowledge library, very few are from before 2015, and most are from after 2020. How have you experienced watching this body of knowledge grow?

Anna: [00:17:00] Even when my PhD started, there were very few articles in this field. The systematic literature reviews had very few included studies on the carbon footprint of surgical treatments — whereas now the field has really expanded. We also have a literature review showing the growth is exponential in publications in this field. But I think it’s important to be mindful that publication volume doesn’t necessarily align with quality. There is very great interest among health professionals, but I also see a real need to develop this as a research field where we apply and align with methods established in technical science, follow published guidelines, and make rigorous, transparent research that enables clinicians to use the results in clinical practice.

I think we need frameworks and guidelines for how we apply carbon footprint and lifecycle assessment to healthcare — to products, care pathways, and organisations — so we have a common basis for comparison. I often see clinicians referring to different papers saying “this paper found X, that paper found Y, so we know product A has a larger carbon footprint than product B.” When you dive into the literature, you sometimes find that all aspects of such a comparison weren’t actually covered in the studies cited. We need to be critical — and I think health professionals have a unique advantage here, because we have a strong tradition of rigorous research with protocols and guidelines.

Frederik: [00:21:00] I want to pick up on something you said: there’s a binary trade-off between something that is directionally useful yet imprecise, and something that is precise and exact. In a field this young, we know comparatively little about carbon footprinting in healthcare compared to what we know about efficacy and safety of treatments — where we have very low tolerance for margin of error. All of a sudden we’re in a different field where at the end of the day we know comparatively little. How do you see the trade-off between something directionally useful but imprecise, versus applying best-in-class scientific rigour?

Anna: [00:22:00] I understand the trade-off, and I’m also practical as a researcher — I understand it’s not always feasible to get exact numbers because it would be too time-consuming. At the stage we are now, I think there is a need to distinguish between what I’d call a lifecycle assessment study that aligns with the ISO standards, and what is a carbon footprint screening. I think carbon footprint screenings are reasonable — they can be challenging to do a full ISO-compliant LCA — but you have to be quite transparent about what it is, what answers you gain, and what answers you don’t gain when you make these publications.

The people reading these papers are health professionals who don’t necessarily have the expertise to scrutinise the methodology. We’re at a stage where it’s acceptable to sometimes compromise and do a screening, but you have to be clear about what you’re reporting and what you’re not. And I think the area where you have to be especially careful is comparative studies of clinical care pathways — because people might turn to these results to recommend one treatment over another. If you don’t follow the ISO guidelines for comparative lifecycle assessment, you may end up recommending something that clinicians rely on — without having included the entire care pathway or compared on equal grounds.

Frederik: [00:26:00] You’re touching on something I often see: “carbon screening” and “LCA” being conflated — entities saying “we have an LCA” when it’s actually a carbon estimate. It might be directionally useful, but it’s not a full ISO-compliant LCA. If we zoom out and apply a bigger picture lens — what is your perspective on the roadmap for how healthcare approaches this?

Anna: [00:27:00] I see it a little from the Danish perspective, because we’ve been working on this for over ten years now and there’s strong organisational and political interest in making healthcare greener. But what I see — as you’ve also experienced — is that we really need more knowledge in this field. Many of the current targets and measures for greening healthcare are very organisationally based. Whereas as a health professional, you see healthcare differently: you see the products used in your department, the treatments you deliver.

The path we need to get on now is gaining greater carbon literacy within different specialties. I can see many international societies — in anaesthesiology and other specialties — publishing international guidelines for how to work with sustainability within their field. What we need and what we’re already on the path to is understanding what the main contributors to the carbon footprint are within each specialty, so that individual clinicians know: “if we want to target something, this is the main emitter, and here is whether it’s feasible to reduce it without compromising effective and safe treatment for patients.”

Many of the supply chains — all the medicines and devices we use — have the largest environmental impact, both in Danish healthcare and globally. We need a much greater understanding of which treatments within each specialty are the main contributors, so we can target efforts without compromising effectiveness and safety.

Frederik: [00:33:00] Something that comes to me here — normally I’ve seen two approaches when specialists evaluate the cost of devices and procedures. One position an MD might take is: “I just don’t relate to that. I do whatever it takes to help the patient in front of me.” That’s not financially sustainable, but I understand the ethical need to remove yourself from the equation. Could we make an argument that carbon costs are similar — just a different budget? Not a financial one, but a carbon and resource budget?

Anna: [00:35:00] As a health professional, I’m of course very biased in thinking healthcare delivery is among the most important services a society can provide. But carbon is not endless either — there are planetary boundaries for how much we can emit. And as the same with finances, we are already mindful that there are certain medicines and treatments we cannot deliver even in Denmark, with universal healthcare access, if they are too costly relative to the effectiveness they provide.

I don’t think it’s being discussed much at this stage, but in the future we will have to take the environmental impact of care pathways and products into consideration when evaluating them — as we do with other criteria when deciding whether to provide a treatment or a medicine for a population.

Frederik: [00:37:00] During COVID we had a lot of very inconvenient conversations — about distributing scarce resources, about ICU care across patient groups. And politically and socially, that’s such a hot potato that I think we can expect it will stay that way for a while. As a society, I sit with the feeling we are not telling the whole truth — we’re letting it happen behind the scenes. I’m not a big fan of that, because if it’s true, it’s already so — and we might as well have an enlightened conversation about it.

Anna: [00:39:00] I agree and I disagree. I don’t think anyone is hiding it. But I think many citizens and politicians are neglecting the urgency of the climate crisis — caused by many different factors. An anthropologist would probably know more about this than me. I don’t think it’s not out there in the public debate — I just think we’re not debating it, because it’s inconvenient to discuss and challenging to solve, especially politically. But that’s society as a whole, not only healthcare.

Frederik: [00:40:00] We’re approaching the end of the interview. Something I love asking guests: in sustainability in healthcare, there are a lot of reasons to feel put down — the news is often quite grave. But you seem to be smiling most of the time when I meet you. What makes you hopeful?

Anna: [00:41:00] Speaking strictly towards healthcare — it really motivates me to meet so many colleagues who are interested in the type of research I’m involved with. Many other health professionals approach me or write to me wanting to collaborate scientifically — linking quantitative measures of carbon footprint to the clinical research we’re already performing. It’s great to meet so many colleagues who are enthusiastic about both the research and implementing changes here and now.

On a personal level: I once participated in a debate on climate anxiety as a representative of Doctors for Climate. One of the key messages was that one of the best things you can do when you feel anxiety about the climate crisis is to act. Every time I go down that pathway myself, I think that the best way to treat that kind of anxiety is to act. I’ve tried my best to act throughout both my student life and as a health professional — both in work and outside it. So: if you want to do something, act. And find someone to do it with. That’s always both more fun and more productive.

Frederik: That’s a really nice note to end on. Thank you so much, Anna. My expectations were fully met. So, everyone listening — you’ve been listening to the Sustainable Healthcare Podcast. Our guest today has been Anna Roe Rasmussen. You can like and subscribe to the podcast, share it with peers and friends, and we’re always very keen to get feedback and suggestions for guests. We record online, so we can take on guests from anywhere in the world. Thank you so much for listening.