Sustainability in endoscopy

Dear colleagues,

In this issue of Perspectives, we explore sustainability in the practice of endoscopy. Rising health care costs, growing demand for endoscopic services, and increasing concern for waste and its environmental impact have placed new emphasis on maximizing our resources. Drs. Deepak Agrawal and Zhouwen Tang discuss their approach and recommendations for minimizing waste and using supplies and equipment more efficiently. They challenge some long-standing dogma — such as the routine use of sterile water over tap water — and examine the limited evidence behind many of our more costly practices. Notably, many of these questions first arose out of necessity: national shortages of sterile water, or supplies placed on back order, forced practical reconsideration of habits long taken for granted.

Drs. Jehovan Fairclough and Melissa Arthurs-Wadsworth offer a complementary perspective, describing their day-to-day approach to practicing gastroenterology and endoscopy in Jamaica, where only 12 gastroenterologists serve a population of 2.8 million. In a setting where scarcity is not a periodic disruption but the everyday operating condition, sustainable practice becomes inseparable from good clinical judgment. They also make the case that sustainability extends beyond the procedure room, to the referral relationships, multidisciplinary discussions, and global partnerships that allow a small workforce to stretch scarce resources without compromising care. As always, we welcome your questions and comments.

Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, and chief of endoscopy at West Haven VA Medical Center, both in Connecticut. He is an associate editor for GI & Hepatology News.

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Sustainability in endoscopy: the why and how

By Deepak Agrawal, MD, FASGE, and Zhouwen Tang, MD

Medicine is rife with difficult decisions. Yet it is human nature to occasionally succumb to the easier path. It is often easier to order an endoscopy rather than explain why it is not needed. It is easier to follow the habits of an endoscopy unit than question them and risk alienation. It is lucrative to choose what provides financial benefit or convenience when someone else bears the cost. The immediate rewards often outweigh consideration of harms to the health system or society.

This is the case with sustainable practices in endoscopy — decreasing the carbon footprint of our procedures to meet tomorrow’s needs. The increasing number of wildfires, flooding, and water scarcity across the US and the world indicates that tomorrow is already here. In 2009, The Lancet declared climate change the biggest threat to human health of the 21st century. More recently, 200 medical journals identified climate change as a health crisis, and the four major gastroenterology societies announced a commitment and strategic plan to promote sustainability in endoscopy. Since then, the carbon footprint of endoscopy has likely increased as more single-use accessories are introduced and adopted.

The total carbon footprint of endoscopy extends far beyond the procedure, but endoscopists influence a meaningful subset of those emissions. Recent life-cycle studies identify manufacturing, transportation, facility energy, reprocessing, anesthesia gases, water, and waste as major contributors. Our focus is on choices made by endoscopists, including endoscopic accessories and personal protective equipment, as well as waste segregation. Gastroenterology societies have put forth practical recommendations and solutions, but adoption remains limited.

Why have our actions significantly lagged our sustainability intentions?

Common to many wasteful practices is the seemingly unimpeachable pursuit of patient safety. Why not wash something twice to clean it more? Why wash it at all when you can throw it away? Who can argue when avoiding any theoretical risk of infection is treated as more important than the distant environmental harm that follows? This is the “zero-risk bias”: the tendency to pay disproportionately to reduce a small risk to exactly zero. It offers psychological closure that “low enough” does not. But when the risk is already very low, eliminating the last fraction of risk comes at a disproportionate environmental cost.

It is easy to overlook environmental costs because market prices rarely capture negative externalities. A disposable device may appear cheaper or more efficient because its price excludes the costs of resource extraction, manufacturing, waste, disposal, and emissions. Those costs are instead shifted to society and future generations. Heat-related deaths in the United States, for example, have more than tripled from 2016 to 2023. Although our individual choices contribute to this broader problem, its multifactorial nature makes it difficult to attribute any particular outcome to any single action. That, however, does not make the cumulative impact of those choices inconsequential.

Most endoscopy units do not measure the waste they generate, and we cannot control what we do not measure. Waste is that rare health care outcome for which no one is responsible and no data is recorded. Sustainability metrics are not recorded and do not drive any key performance indicators.

A reusable device is sold once; a disposable device creates recurring revenue. This economic reality drives industry investment in R&D and marketing. Breakthrough devices have unquestionably advanced medicine, but incremental variations are more often marketed as the newest and greatest — at the environmental cost of additional R&D, manufacturing, transportation, packaging, and disposal, even when a device goes unused. Our own entanglement plays a role. Advisory boards, consulting agreements, honoraria, and sponsored courses, while not inherently inappropriate, can create strong advocacy for newer devices, while restraint rarely has an equally organized voice.

Industry-sponsored studies, reviews, and opinion pieces about devices often outnumber unbiased literature. Some of the recommendations about devices also come from private, self-governed, standard-setting organizations whose membership includes device manufacturers and experts with ties to the industry. Both cursory manual research and large language models (such as ChatGPT, Gemini, and Claude) pick up on the sheer volume of this sponsored literature. All this drives the narrative toward practices that are lucrative for the industry and convenient for the staff, but unsustainable for the health system and society. As more endoscopy units adopt these practices, they become “standards of practice,” forcing more endoscopy units to follow.

An example is the increasing number of endoscopy units switching from reusable to single-use EKG leads and endoscopy buttons. Internet searches and large language models cite numerous industry-written or sponsored articles claiming these reduce infection risk, despite no evidence to support this. A common theme is highlighting residual microbial contamination on equipment surfaces without demonstrating that it leads to infection.

Sustainability is a strategic and business imperative, and not an option

It is not difficult to practice sustainability if we apply the discipline we already bring to our professional lives. First, we must change our mindset. Negative externalities should not be ignored for convenience. Second, follow the available evidence (e.g., tap water is safe for irrigation, reusable EKG leads do not increase infection risk). Third, question the narrative (e.g., contamination does not mean infection, conflicts of interest among authors and sponsors). Fourth, move from passive observation to advocacy for sustainability (e.g., proper disposal of endoscopy accessories, use of reusable equipment when feasible). This also includes sending a message to device manufacturers to promote reuse and recycling. Finally, reduce unnecessary procedures, biopsies, and interventions. Many sustainable interventions offer substantial financial benefits, and these should be shared with management. A few sustainability practices are given in Table 1.

Sustainability is bonum in se, or intrinsically good. Every resource we waste is one that cannot aid those in need. Our silence and inaction may have contributed to unsustainability, but we can show that we are bigger than that by choosing to be part of the solution.

Dr. Agrawal is a gastroenterologist at Premier Health and professor and chair of medicine at Wright State University, Dayton, Ohio.

Dr. Tang is a gastroenterologist and assistant professor of medicine at Dell Medical School, University of Texas at Austin.

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Practicing gastroenterology and endoscopy in resource-poor settings

By Jehovan Fairclough, MBBS, MD, FRCP, FEBGH, and Melissa Arthurs-Wadsworth, BSc, MBBS, DM

There is great demand for gastroenterology care and gastroenterologists across the Caribbean, including Jamaica. Currently, Jamaica has 11 adult gastroenterologists and one pediatric gastroenterologist serving a population of over 2.8 million people. This stands in sharp contrast to the United States, where there are 4.6 gastroenterologists per 100,000 people — roughly one active specialist per 20,000 people — nearly all of whom have access to a dedicated endoscopy suite.

Beyond the sheer shortage of manpower, we face obstacles common to many developing nations: underdeveloped endoscopy infrastructure, limited capacity to build out new endoscopy units, and inconsistent access to supplies and equipment. Work is ongoing toward a national framework that would enable equitable access to care and reliable support services such as radiology, pathology, hepatobiliary surgery, and colorectal surgery. These realities directly shape our approach to patient care, where the focus remains on delivering the highest quality care possible within existing practice limitations.

Performing advanced procedures such as endoscopic retrograde cholangiopancreatography (ERCP) in low- and middle-income countries like Jamaica presents a distinct set of challenges: a limited specialized workforce, financial and resource constraints, and delayed or late clinical presentations among the patients we serve.

Currently, only two formally trained advanced endoscopists serve the entire island of Jamaica. This acute workforce shortage places an immense burden on existing specialists, limits training opportunities, and creates severe bottlenecks in service delivery for a population whose need for complex biliary interventions continues to grow.

Compounding these structural deficits is a pattern of late clinical presentation. Driven by the insidious onset of disease — particularly biliary malignancies — along with poor health-seeking behaviors, patients frequently present with advanced pathology and significant physiological instability. These delayed presentations heighten technical difficulty, narrow the therapeutic window, and can elevate procedural risk.

Practice considerations in delivering high-quality care

We place strong emphasis on our broad referral network, encouraging referring physicians to provide detailed clinical information with each gastroenterology consultation request. This allows for appropriate and equitable triage of patients.

In an era of rapid technological advancement, including the evolving role of artificial intelligence, we continue to rely on excellent clinical skills — thorough history taking, careful clinical examination, and judicious selection of appropriate testing. This tailored approach minimizes unnecessary, and often costly, testing without compromising the quality of patient care.

We actively foster close relationships with colleagues, allowing for open discussion of best practices appropriate to our local setting and consistent with accepted standards of care.

Critical, long-standing, and emerging global partnerships — with international GI societies, GI device companies, NGOs, and nonprofit organizations — support education and training, equipment and supply donations, and ongoing maintenance. These collaborations are actively pursued and have contributed significantly to the delivery of care in our local setting.

Procedural cost considerations

In a resource-poor setting, ensuring adequate indications for procedures and remaining creative and cost-conscious are essential to reducing costs where appropriate.

This begins with discussion among referring colleagues, review of prior endoscopies and imaging, and consideration of previous procedural challenges. Cases requiring expert input are reviewed at our multidisciplinary meetings, where the optimal care pathway is determined.

Careful intraprocedural assessment guides the selection of appropriate strategies and disposables when intervention is required. For example: using a single snare rather than both a snare and biopsy forceps for multiple polypectomies; taking time to select the appropriately sized snare and ancillary tools for large polyp resections; carefully assessing stricture length and characteristics to guide stent selection; and performing single-session procedures for removal of multiple stones. These practices are important in minimizing procedural cost, and these skills are also taught to our gastroenterology fellows.

The use of noninvasive testing, and avoidance of unnecessary biopsies for histological assessment, is carefully considered where appropriate. Rapid urease testing, stool antigen testing, or urea breath testing for Helicobacter pylori is one such example: in low-risk patients, this strategy not only reduces cost but also helps bridge the gap created by long wait times for endoscopic procedures that may not be necessary to guide treatment.

Health care system considerations

The considerations discussed above reflect our day-to-day practical approach to care. We also recognize that policy change at the regional and national level is needed to address several ongoing systemic issues.

Improving health infrastructure throughout the country — building and strengthening facilities capable of delivering gastroenterology and endoscopy care at the community level — is essential. This would decentralize basic gastroenterology care away from urban centers and improve both access and efficiency. Studies to assess population needs, paired with a stepwise plan to support formal gastroenterology training and increase the number of specialists, will further improve access to quality care.

Local gastroenterology groups and cross-territory consortia are now being established to provide data-driven regional and national guidance on relevant systemic changes. These efforts will be pivotal in bridging existing gaps as we continue to deliver and advance the practice of gastroenterology.

Dr. Fairclough is a gastroenterologist and interventional endoscopist at the University Hospital of the West Indies, Mona, Jamaica.

Dr. Arthurs-Wadsworth is a first-year gastroenterology fellow at the University Hospital of the West Indies, Mona, Jamaica.