Triple Bottom Line

The following essay was a runner-up in this year’s ESCRS Henahan Prize Essay Competition. Writers were asked to address the question, “What can the field of ophthalmology do to meet the pressing challenges of climate change, sustainability, and social equity?”.

Change. The only constant in life, or so the saying goes. As I reflect on what this simple word means, I can’t help but realise that a lot has changed recently. For one, the climate is changing. While the climate crisis and loss of biodiversity affect us all, they have a disproportional impact on marginalised and disadvantaged communities. The current war in Ukraine, rising energy, and food prices further exacerbate these social inequalities.

So, what can our humble specialty really do to address these pressing issues? Enter the Triple Bottom Line (TBL). Though not without its critics, this framework has been implemented in the business and accounting world for years. Now, the time has come to introduce the concept to ophthalmology. At its core, the TBL urges companies to equally value the 3 Ps: profits, people, and the planet. As ophthalmologists, we need to re-assess our practice to ensure it is not only doing well by our patients and fiscally sound, but similarly appreciates the environment. In order to achieve this goal, a systems change is needed, so that the TBL does not merely become another popular slogan like “carbon neutral” or “zero waste”. Of course, a systems change can be a daunting undertaking—perhaps not dissimilar to the process of first learning cataract surgery. But, just like phacoemulsification, it can become less overwhelming by adopting a systematic approach and breaking it down into individual steps.

First, the Planet: Let’s take a closer look at improving ophthalmology’s ecological footprint.

We should start by getting the basics right. Switching off lights, computers, visual field, and OCT machines, when not in use, are simple, yet often forgotten measures to improve energy efficiency. After reducing our overall energy consumption, the next step is to transition to renewable energy sources. This transition will vary depending on the practice type and location and is certainly not without its challenges. However, we should not forget that healthcare is a large industry with significant collective purchasing power. By working with industry and governments, we can influence a change in practice that may initially seem almost impossible to achieve. Recently, the anaesthetic department at my hospital successfully managed to reduce the use of desflurane, saving about 30,000 kg CO2 per month. It is but one example of a recent paradigm shift in healthcare, showing that collaboration with industry leaders and sustainability experts can make more environmentally friendly alternatives a reality. A comparable problem in ophthalmology is our incessant use of single-use and non-recyclable plastic products. Sterility and convenience are frequently named reasons for our reliance on these items. Yet, alternatives to single-use non-degradable plastic are already used in other sectors with stringent hygiene requirements such as the food industry. Within the field of ophthalmology, examples of more sustainable practice also exist. Aravind’s lifecycle assessments, for instance, show that high-quality, low-carbon, low-waste cataract surgery is not just possible but can become the norm. Now the time has come for the ophthalmic community to not only share best surgical practices but also champion best sustainable practices.

Second, the Profits: Let’s turn our attention to the financial impact of these actions. There is no question that transforming our clinical practice requires an initial financial investment. Our specialty has an established history in investing in new tools and equipment to advance patient care. Buying phaco machines in the ’70s and ’80s seemed like a ludicrous and expensive idea to some. Nowadays, the initial scepticism is hard to comprehend. Challenging the status quo by switching to renewable resources, reducing waste and CO2 emissions will ultimately reduce our bills. Given the current energy prices, we may already regret not having transitioned sooner.

Finally, the People: Let’s consider our social responsibility. As ophthalmologists, we can advocate for disadvantaged communities, and highlight environmental, health, and social injustices where we see them. On social media, American ophthalmologist Dr Will Flanary, better known by his Twitter handle Dr Glaucomflecken, uses humour and unicorn props to shine a light on the idiosyncrasies and inequalities of medical education and the healthcare system. You may ask, what has an ophthalmologist on TikTok to do with tackling environmental and societal issues? Well, he gets people talking (and laughing). Raising awareness is the first step of meaningful change. You can’t change what you don’t acknowledge. As the recent EuroTimes edition on sustainability shows, ophthalmologists have started to talk about these issues. Many have taken practical steps to reduce their environmental footsteps. Yes, more collective action is needed, but it is a start. In the words of American civil rights activist Maya Angelou, “do the best you can until you know better. Then when you know better, do better”. I strongly believe that, as ophthalmologists, we can—and will—do better for the future of our patients and our planet.

Sarah Schimansky MD is an Ophthalmology specialist registrar, Bristol Eye Hospital, UK.
sarah.schimansky@gmail.com