Waste opportunity: Can we design plastic out of healthcare?

Modern medicine has a dirty secret. While plastics have revolutionized healthcare, research increasingly shows that they’re also making us sick. Items such as PPE, syringes, gowns, IV bags and protective wrappings have allowed for a higher standard of sanitary patient care that vastly reduces the risk of cross-contamination. But all that plastic is adding up. Nearly a third of healthcare waste is plastics, and a report on 110 Canadian hospitals revealed the combined waste adds up to 87,000 tons of waste each year. These items break down into microplastics, which accumulate in our bodies and contribute to neurodegenerative, reproductive and overarching health problems. But what will it take to reimagine healthcare without plastic?

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Susan Freinkel: You couldn’t have modern medicine today without plastic. You just couldn’t. And at the same time, you know, we have discovered that there are ways in which plastic are used in medicine that are harmful to our health. And so it is the essential paradox of plastic in our lives.

Narration: In recent years, talk of those harms has become as common as the thing itself. For one, we’re drowning in the stuff. The world produces 400 million tons of plastic every year. We extract and refine fossil fuels to produce it. And while plastic does decompose eventually, it never truly goes away. It just gets smaller and smaller. Those tiny bits, which we now refer to as microplastics, pollute every corner of the world.

Ted Schettler: They’re in the bottom of the ocean, they’re on mountaintops, they’re in snow, they’re in all the soils of the Earth, they’re in all the living organisms on the Earth.

Narration: That, of course, includes us. Every year, on average, we consume about 50,000 pieces of microplastics.

Ted Schettler: So it’s a complex exposure that can have a whole variety of health effects. And we’re just beginning to learn what those are.

Narration: Reducing plastic use in medicine, then, should be a no brainer. But it’s quite a bit more complicated than that. Plastic production is expected to double — or even triple — by 2050. And it’s now so deeply integrated into our health systems that getting rid of it is almost impossible to imagine.

Susan Freinkel: Plastic sort of teases us with the idea of just perpetual abundance, like whatever we want, we can make, we can have, we can have it for cheap.

Narration: I’m Manjula Selvarajah, and this is Solve for X: Innovations to Change the World. On today’s episode, we’re going to look at how we might solve medicine’s plastic paradox.

Now people have been grappling with our plastic problem for years, looking for ways to curb its use. In one of the latest efforts, Canada and other countries around the world committed to developing a binding agreement to deal with plastic pollution. Those talks fell apart at the end of last year. Now, ratifying such a deal is no small feat. There’s so many nuances and proposed exemptions. Medicine, for instance, is often left off the table. There are thousands of different kinds of plastics, and they all have different properties, different textures and different capabilities. And then there’s the issue of understanding how all these different types of plastic affect our health. We’re going to get into some potential solutions being developed. But first, I wanted to find out how we got into this plastic mess in the first place.

Susan Freinkel: At this point, the idea that there is plastic all over the world, everywhere, on every beach, in every part of the ocean, is pretty well known. And yet, we haven’t figured out solutions to it. So we’re at this very vexing point where we sort of know there’s a problem, but we really actually don’t know how to solve it.

Narration: That’s Susan Freinkel. She’s a journalist and the author of Plastic, A Toxic Love Story, where she explores how plastic built the modern world. Take medicine. Before plastic, even a simple blood transfusion looked quite a bit different.

Susan Freinkel: Blood would be drawn from patients with metal syringes or metal needles stuck into their arms, the blood would be drawn through rubber tubing and then into a glass bottle. [sound of a glass bottle] There were a lot of problems with that system. The rubber tubing often harmed the blood cells, and this Harvard surgeon named Carl Walter started trying to think about if there was an alternative to this.

Narration: Walter began to explore the potential of using a kind of soft, malleable plastic. He went on to develop an early prototype of what we all know today as the blood bag.

Susan Freinkel: And he, you know, like, showed it off to his colleagues, he brought it into a meeting, and put it on the floor and stomped on it to show them that it was not breakable.

Narration: This ushered in the idea of blood banking.

Susan Freinkel: You could break out the platelets and the red blood cells and whatnot, and you could stretch the bag, a unit of blood, further.

Narration: Before we go any further, I want to pause for a second. When I say plastic, I’m referring to plastics — plural. At the back of her book, Susan lists the 14 most common types of plastic in a section she jokingly calls “a cast of characters.”

Manjula Selvarajah: [reading] So it’s polyethylene, polypropylene, polystyrene, polyurethane, polyvinyl chlor…. Polyvinyl chloride… OK, hold on.

Narration: These different polymers do many amazing things, and they’ve allowed modern medicine to make many great advances.

Manjula Selvarajah: [reading] Nylon, polycarbonate. I don’t even know if I know how to say this one.

Narration: But they also have their dark side. The chief villain in Susan’s cast is PVC: Polyvinyl chloride.

Susan Freinkel: PVC blood bags revolutionized blood banking. They made it possible to deliver medicines to children, to babies. The assumption when they were developed was that this was inert, stable material. As far back as the early 1970s, it started to become clear that the plasticizer used in PVC, the stuff that makes it so pliable and so flexible and so useful, actually can leach out of it.

Narration: If we zoom out, PVC is the illustration of the plastic paradox in action. It’s helped save lives with things like blood bags and neonatal care, but it also brings risks we can’t ignore.

Ted Schettler: My name is Ted Schettler. I am the science director of an organization called the Science and Environmental Health Network, and I’m also the science advisor to Healthcare Without Harm.

Narration: As a physician, Ted’s now retired, but he’s the person to speak to on the toxic impact of using PVC in medicine.

Ted Schettler: I should be clear that we weren’t the first to notice the leaching. That actually had been a concern that had been raised when polyvinyl chloride was first introduced, but we documented the level of exposure.

Narration: Ted’s talking about a study he did in 2005 that measured the level of phthalates in baby boys in a hospital in Boston.

Ted Schettler: So we actually were able to quantify the exposures and we realized then that these boys were being exposed to excessive levels of phthalates, DEHP in particular, with the kind of therapy they were getting in these neonatal units.

Narration: DEHP is a plasticizer. It’s what makes PVC more soft and useful as a material, but it’s also one of the worst endocrine disruptors, and it’s particularly harmful to the developing fetus and the male reproductive system.

Ted Schettler: And those levels were higher in some cases than what was considered safe. So there was a pretty good string of evidence that came together saying we should be getting away from these phthalates and medical devices. And the best way to do that would be to get away from polyvinyl chloride altogether.

Manjula Selvarajah: Now you’ve been working on this issue for decades. Take me back to the moment when you realized the magnitude of the plastic problem for our health.

Ted Schettler: Well, I don’t think the magnitude was the first thing that caught my attention, but it was the nature of some of the plastics and their toxic properties. For example, when in the 1990s, when we learned that medical waste incinerators were a leading source of dioxin emissions into the environment, one of the major contributors to that dioxin was the polyvinyl chloride plastic that was present in medical waste.

Narration: When plastic trash from a hospital gets incinerated, it releases all kinds of chemicals, including dioxins. They are highly toxic and bioaccumulated, meaning they build up in the food chain and our bodies.

Ted Schettler: If you look at the medical waste stream and do an inventory of it, you find that polyvinyl chloride plastic is the most common plastic in the waste stream and is present at higher concentrations than residential waste streams. So there’s more PVC being used in healthcare than in other applications in society.

Narration: PVC is still commonplace in medicine. Ted’s been trying to address this and he knows that change is possible. For instance, Healthcare Without Harm put in 20 years of work to get mercury out of thermometers and blood pressure devices. In 2017, it created the first global agreement to do just that. But what about the other plastics around us? How do they affect our health?

Ted Schettler: The thing that was striking to me and to many others is wherever in the body scientists have looked, they’ve found these small micro- and nanoplastics literally everywhere, including the brain, breast milk, testicles, colon, pancreas, liver…

Manjula Selvarajah: What does that mean?

Ted Schettler: It’s a very complex issue to study and there is currently ongoing a multi-level research project that is trying to analyze this in a systematic way. Those efforts are really in their infancy. What we have learned is that these exposures can cause an inflammatory reaction, can alter the function of the immune system. There are data from animal studies that point toward them having a capacity to cause cancer, for example, in the colon, which would not be surprising since it’s where many of the ingested microplastics end up.

Narration: And as we learn more about the dangers posed by microplastics, the question of how to manage healthcare waste becomes even more urgent.

Ted Schettler: Well, we have to recognize that we’ve got an enormous problem because of the complexity of plastic polymers that are being used in healthcare. We need to think about essential uses. Are we using certain products in ways that are not essential? For example, surgical gowns and personal protective equipment. Studies have shown that moving away from those that are made out of various plastic polymers to reusable cloth do not increase the infection rate in the hospital. So that’s a change that a hospital could make tomorrow. And you know, I would point out that there are a lot of items that are plastic items now that are recyclable, but they’re not recycled in hospitals that could be much more readily recycled.

Narration: But what could this look like in a hospital setting? Picture an operating room: Sterile surfaces, bright lights, a surgical team scrubbing in, an anesthesiologist keeping a close eye on patients’ vitals. But then there’s something else, out of sight, that’s really starting to pile up.

Lyndia Dernis: Packaging. Packaging. And packaging. We have single-use things that have three packages over it. I’m Lyndia Dernis. I am an anesthesiologist working at St. Mary’s Hospital in Montreal, Quebec.

Narration: The waste is so overwhelming in the OR, Lyndia noticed that some nurses were taking plastic back home with them to recycle.

Lyndia Dernis: So this was what concerned them because they see it on a daily basis for every single patient. They have to open so many things, so many tools, and deal with the packaging.

Narration: So in 2019, Lyndia decided to start a recycling program in the OR.

Lyndia Dernis: At the right beginning, I started to try to know what packaging was made of what. I reached out to a lot of companies and I think one tenant only answered what the packaging was about. So just this shows how not invested they are in those matters.

Narration: For Lyndia, this was just the beginning. The three Rs: reduce, reuse, recycle, are not enough. We need a fourth: rethink.

Lyndia Dernis: I do think that we have to make people more aware that right now, the way we give our care, some of it is toxic for the future. And we have to rethink it. We have to explore solutions. And some solutions will work. Some solutions won’t work. And we have to be ready for this. And when it comes, yeah OK. This was not the right solution. Let’s try another one.

Narration: Right now, Lyndia knows that the city of Montreal isn’t properly dealing with the recyclables that come out of her hospital. So she’s looking for alternatives.

Lyndia Dernis: I’m trying to have connections with companies who want to make studies or work in taking our plastics and see what they can do out of them. We have soft plastic, we have hard plastic. We would be ready. I mean, the plastic is already sorted every day and so we’re just waiting for opportunities to get a better recycling and to get our plastics a second life to our plastic. That is much more interesting.

Narration: This iterative experimental approach is, of course, a necessary part of innovation and design. And Lyndia recognizes it’s a lot to ask of the medical system she works in, but she believes that healthcare could lead on this.

Lyndia Dernis: But it’s extremely difficult in a healthcare system that is already in so much difficulty. So it’s a real struggle. But we have to explain to patients and to healthcare workers and to our executives and to the industry: they have to be part of it. It’s their future, too. I mean, we’ll have to deal with so many people working in so many different fields. And that’s the complexity of planetary health. You have to work with doctors, with chemists working on alternatives to plastics. And it’s extremely complex. But we have to find solutions. And I think they’re amazing people out there that have ideas and we should listen.

Narration: Plastic might be the environmental and material problem of our lifetime, but it wasn’t always that way. If you look back at the invention of plastic, in the beginning, it was actually developed as a solution to a different, much older environmental problem.

Susan Freinkel: First plastics were invented in the mid-19th century, they really came out of growing concerns that certain natural materials were getting scarce.

Narration: Back to Susan Freinkel.

Susan Freinkel: The one that really pushed the invention of plastic was worries about ivory, which, in the mid-to-late 19th century, was being used for a lot of things, you know, buttons or buttonhooks or cane heads or whatever.

Narration: Also billiard balls. [sound of billiard smashing]

Susan Freinkel: And in the mid-1860s a billiard ball manufacturer put out an ad asking for any inventive genius who could come up with the substitute for ivory.

Narration: This inspired an amateur inventor, James Wesley Hyatt, to invent the very first plastic. It was called celluloid, and it looked and felt just like real ivory.

Susan Freinkel: And it was sort of the first plastic that began to make its way into people’s lives. And you know, ironically, celluloid was never used for billiard balls because it’s kind of a volatile material. So, you know, the problem it was invented to solve it wasn’t used for.

Narration: But celluloid showed that chemical synthesis could replace animal-based materials. This marked a major shift in how we innovate.

Susan Freinkel: Places like Standard Oil or IG Farben or Imperial Chemical, all had industrial chemistry departments. They were using fossil fuels, you know, the waste products of the processing of chemicals and oils, and that’s when you really start to get the plastics that we know today.

To me, the lesson about innovation is how rarely innovation is done with conscious thought to long-term consequences. It’s very hard to stuff the genie back in the bottle on technological breakthroughs, but technological breakthroughs are rarely made with a lot of thought to all of the possible consequences that they might unleash.

Ted Schettler: There’s no question that single-use plastics are necessary for certain applications, but they’re far, far overused.

Narration: Ted raises the question of whether we could develop a system to sterilize and reuse different plastics in healthcare.

Ted Schettler: Even now, without redesigning, there are some plastics that are almost exclusively single-use that actually can be, right now, reprocessed and reused.

Narration: Problem is they were registered by the manufacturers with the FDA for single use.

Ted Schettler: We also need to think, in addition to redesigning the polymers to make them less toxic, we need to think about the kinds of infrastructure that needs to be set up that would facilitate reprocessing and recycling of the plastics. So, this development of a reprocessing industry has been growing in recent years. There’s a lot of opportunity there for improvement.

Narration: One person working in this new reprocessing industry is Aditi Sitolay. She’s the founder of Synoro Medical Technologies.

Aditi Sitolay: We are an early-stage medtech, cleantech startup focused on developing reprocessing as a service to enable the shift to low-carbon healthcare.

Narration: Aditi is currently a graduate student in biomedical engineering at Imperial College London. But it was back during her undergraduate years that she recognized the opportunity to redesign something plastic had revolutionized 75 years ago: the IV bag.

Aditi Sitolay: A regular IV bag, it gets used once and then the bag, the tubing, packaging, everything will go into the garbage.

Narration: Aditi is pursuing a different approach. She came up with the idea to make an IV bag out of silicone that can be used and sterilized multiple times.

Aditi Sitolay: So essentially, it’s a bag, it’s compressible, it’s got the ports.

Narration: She was willing to show us a prototype over Zoom with the understanding that it’s early days and they’re still tinkering with the design.

Aditi Sitolay: Again, early proof of concept, but kind of gives the idea of like, it looks very much like an IV bag right now looks. The main difference is like obviously this is not quite transparent yet. However, like when I do fill it with water, you can definitely see the water line in it. But those are some of the things we’re working on. We have given this to doctors and nurses and got feedback on it. They’ve been pretty impressed with it so far.

Narration: The idea is to get hospitals on board to view IV bags as a service with pickup and sterilization included. But when you factor in all the steps of reuse and reprocessing, how much of an impact could this have on the environment?

Aditi Sitolay: In comparing, like, a traditional PVC plastic IV bag to, for example, a reusable IV bag and the process of sterilizing it and refilling it, we still end up being significantly lower in carbon emissions. We were able to achieve almost an 80 percent reduction in CO2 emissions, primarily because the carbon footprint of even just producing that PVC plastic is quite high.

Narration: And still, there’s the ick factor. We’ve become used to the idea that so much of what we come in contact with in the healthcare space is single use.

Aditi Sitolay: My response to this is, reusables are not new to healthcare. You know, a lot of surgical equipment is reusable equipment. And there are sterilization technologies and processes out there. And if you go through the sterilization process, it’s hygienic. Because I think initially when people think reusable bags, they’re thinking that the clinical workflow will be the bag is used on one patient, and then it’s used on another patient. And that’s where it’s like, no, that’s not what it is. It’s essentially, it will be used on a patient, it will go into a collection bin, it will go through a proper sterilization, reprocessing before it’s used on another patient.

Narration: Even though reuse in medicine isn’t a new concept, the idea of a reusable IV bag does have a long way to go.

Aditi Sitolay: My hope for the future of healthcare is that it is more sustainable than it is right now. But I also hope that health systems and policy-makers understand the importance of the climate crisis and how it’s impacting human health and that healthcare is a contributor and it also has a responsibility to be better. And I think for too long, healthcare has kind of been exempt from that.

Narration: Recycling and reusing are two ways of addressing the plastic paradox. But there’s a third way that Lyndia mentioned: rethinking. What if we could find a way to replace plastic with materials that are grown, and then returned to the environment without waste? For that, we’re going to a factory in Dartmouth, N.S..

Rashmi Prakash: [sound of factory] My name is Rashmi Prakash. I am the CEO of Aruna Revolution, and also an adjunct professor with the University of British Columbia.

Narration: Rashmi has created a sustainable alternative to an everyday plastic product: the menstrual pad. I called Rashmi to learn more.

Rashmi Prakash: So there’s a couple of things happening in the background right now. [sound of factory] Uh, we’re actually, we’re processing some materials and so it’s, it’s a mechanical processing of our fibres and kind of decorticating it.

Manjula Selvarajah: So talk to me about this, this material. What exactly is it?

Rashmi Prakash: When you look at the stems of corn, the stems of hemp, the stems of, you know, any kind of grain that we’re growing, and what we do as part of our process is strip away everything except the cellulosic fibre.

Narration: Those fibres are considered waste by farmers and are usually tilled back into the soil. But for Rashmi, they’re a valuable source material.

Rashmi Prakash: We’re able to take these cellulosic fibres and turn them into these menstrual products. And these fibres can then be taken and implemented into gauze, it can be implemented into medical PPE, so the hats, the gowns, the face masks, all the way to the foot coverings, and so on and so forth. And so this is a demonstration that we can create these consumable products that will generate the economic value for the company in a way that is more sustainable and doesn’t need to be harmful for the environment.

Manjula Selvarajah: Do you anticipate a challenge in getting healthcare to adopt something that’s made from a waste stream or a waste product?

Rashmi Prakash: Certainly, yes, but I think the way that we’re going to solve this is by moving away from the perception that what we’re actually using is waste and more so just recognizing it as the output of one industry into the input of ours.

Narration: What Rashmi’s talking about is a fundamental principle of the circular economy.

Rashmi Prakash: One thing that we see is that a lot of composting facilities are struggling to take in menstrual products because they’re like, “Oh, the menstrual blood is a biocontamination. There’s challenges associated with it. You know, it’s dirty.” But at the same time, they’re able to take in meat. They’re able to take in other types of products that could have worse types of contamination. And so, I think one thing that we will do by proving that we can create these circular menstrual products is we’ll be able to demonstrate blood can be handled by composting facilities.

Manjula Selvarajah: You know what Rashmi, I don’t think I just understood that until you said it now. What you’re trying to actually prove is that something with blood can be put into this sort of recycling and reusing loop.

Rashmi Prakash: The menstrual pads would go into the compost, turn into compost, turn back into the plant, and then the plant would be used to create more menstrual products, if that makes sense.

Manjula Selvarajah: So I just wonder, is there a reason that this hasn’t been done before? Why isn’t, you know, other types or more ideas around using plastic-free material more broadly available in the healthcare sector?

Rashmi Prakash: Well, I think that it hasn’t been something that has been at the forefront of attention because there’s just been so much focus on improving medical innovation to improve clinical outcome, which I think is very important. But now as we’re starting to see more and more signs of the environmental damage and, you know, as a result, the floods, the fires, all of the challenges that are coming with this environmental crisis, it’s causing a lot more people to think about their own personal impacts — how they’re behaving, how they’re consuming these products, what they could be doing better. And so we’re starting to see more and more people look for this, but the solution hasn’t been there yet just because the engineers that have been developing these products, they’ve never been taught to think about sustainability.

While you’re healing one person today, all of this waste is going to harm a million people in the future.

Narration: It’s clear that if we’re ever going to solve the plastic paradox, we need to bring together different communities and common purpose: patients and doctors, hospitals and governments, plastic companies and environmentalists.

Ted Schettler: I think it’s important to go back to the origin of the word health.

Narration: Here’s Ted Shettler again.

Ted Schettler: It comes from a term that actually means wholeness, and one of the things that we’re trying to stress in Health Care Without Harm is the link between individual health, community health, and public health and ecological health. When we begin thinking in those terms, it becomes actually kind of surprising that healthcare would not be interested or concerned about these impacts on the communities they serve. So I think that breaking down these barriers in our thinking are the way to begin to make the case that healthcare has a real obligation, not only to provide safe care, but also to think about the impacts far outside of the medical facility.

Narration: That’s easier said than done. Remember the treaty that was supposed to be signed last November to end plastic pollution? Delegates from 170 countries met in Busan, South Korea to hammer out a binding agreement. But after a week of discussions, the only thing they could agree on was to postpone talks further. This two-steps-forward, one-step-back trajectory is disappointing. And, on top of that, healthcare’s specific plastic problem is particularly thorny, particularly paradoxical. If innovators can develop solutions for one of the most critical sectors, it could just be the spark that inspires change.

And before we let Susan Freinkel go, my producer had one last question: Can we ever break up with plastic?

Susan Freinkel: I love the fact that I have glasses on my face that, you know, are not breakable. I like the fact that if I go to a hospital, it’s going to be safe and hygienic. And, you know, if I get cataracts, that I can get replacement lenses that are made from plastic. The short answer is we can’t break up with plastic, but we need to, you know, be more thoughtful and sustainable in the way that we produce it, in the way that we use it, and the way that we dispose of it. And, you know, that sounds really simple, but that’s a really, really complex… that is the definition of a wicked problem.

Solve for X is brought to you by MaRS. This episode was produced by Ellen Payne Smith and written by Jason McBride. Lara Torvi and Sana Maqbool are the associate producers. Mack Swain composed the theme song and all the music in this episode. Gab Harpelle is our mix engineer. Kathryn Hayward is our executive producer. I’m your host, Manjula Selvarajah. Watch your feed for new episodes coming soon.

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Photo illustration by Workhouse and Kelvin Li