Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

The International Criminal Court and the rebels’ commitment problem

This article argues against the common view that the International Criminal Court (ICC) prevents peace since rebels will not accept accountability. In the presence of an international criminal authority, accountability may be unavoidable. This is true for rebels, but also for state agents. Should the government renege on agreed provisions, it risks ICC attention on its own actors, including into the future. In this way, the ICC functions as a permanent third-party guarantor of the provisions and reduces the commitment problem for the rebels, conditional on certain circumstances. A case study of Colombia finds support for the theoretical proposals.This work was supported by the AXA Research Fund [2016-SE-POSTDOC] and Agència de Gestió d’Ajuts Universitaris i de Recerca [2014-ICIP