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We read with great interest the article by Namburar et al. ‘Estimating the environmental impact of disposable endoscopic equipment and endoscopes’.1 The paper brilliantly investigates the environmental impact of gastrointestinal endoscopy, highlighting the large amount of waste generated, especially from disposable instruments. Transitioning to single-use endoscopes may reduce emissions from reprocessing but would increase net waste. Awareness of the need for sustainable development of the health sector is driving consideration of the ‘triple bottom line’ of the social, financial and environmental impacts of clinical practice.2 3 We want to emphasise that sustainability is a fluid concept. The three elements of the equation (environment, economy, society) are influenced by numerous factors. For example, availability and the price of resources and, as a consequence, the social, environmental and financial impacts of a health product or intervention, are not static. Consequently, the sustainability of gastrointestinal endoscopy, as well as of all health products and interventions, may frequently change and the sustainable practices of today could become the unsustainable practices of tomorrow.
Since the end of February, the war in Ukraine has seized the attention of the world. The dramatic collateral effect of a global energy crisis has caused an unprecedented surge in energy prices. Therefore, the Ukrainian war and the West’s response will have multiple negative effects on the cost and availability of materials for endoscopy. The supply chain crisis and the increased expenditure on endoscopic equipment, electricity and waste disposal may last a long time, especially in the European Union which particularly depends on foreign goods and energy, and where access to an adequate supply of energy is still far away. Furthermore, the switch to renewables and hydrogen to replace gas in heating and power generation could involve higher energy costs and impact the supply of materials. In addition, people on lower incomes are likely be the most affected by increased health costs.
In light of the current situation, gastrointestinal endoscopy professionals should carefully consider the increased supply chain costs and try to reduce the impact of interventions. Indeed, the use of single-use endoscopes has already raised doubts in terms of sustainability due to the heavy economic burden and significant environmental and social implications.1 4 In addition, there is little available information on the incidence of infections directly attributed to duodenoscopes. It is estimated that, taking account of the infections prevented, the cost of a single-use duodenoscope must be set at US$612 in order to be economically viable for an endoscopic unit.5 This price is far below the current cost of disposable duodenoscopes in western countries, especially after the recent sharp rise in energy costs.
Could we do more to improve the efficiency of the reprocessing of reusable endoscopes? What is the rate of clinically relevant contamination of reusable devices? Should we follow the recent US Food and Drug Administration recommendation to transition to disposable duodenoscopes and caps or can we just select patients who can benefit most from the use of disposable devices? We believe that these, and the questions from Baddeley et al ‘what level of infection risk should be deemed acceptable, and what are the environmental implications if the single-use model were extended to include gastroscopes and colonoscopes?’3 should be reconsidered in light of the ongoing supply chain crisis and the steep increases in device costs, which mainly affect underprivileged and poor countries and patients.6
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Footnotes
Contributors LE, GET, AS, LS, NN, FC and MV Concept, design, drafting and revision of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.