This text has been translated with assistance of Artificial Intelligence and may therefore not accurately reflect the message I am trying to convey in my Dutch speech. It will however give a good impression of the subjects and my overall point of view on the subject of effective and sustainable healthcare.

Individual versus collective

Inauguration speech Wouter Hehenkamp 6th of December 2024

"It is your moral duty to stay optimistic."
Immanuel Kant (1724-1804)

This was one of the propositions in my dissertation, which I defended 17 years ago, right here in this place. Today, I accept the professorship with the assignment of "effective and sustainable care," and I begin with the same words.

Dear Rector Magnificus, Dean, members of the Amsterdam UMC Board, colleagues, friends, and family,

We are living in turbulent times, where optimism can be hard to find. We cannot rely on hopeful political power plays on a national or global scale, and often feel isolated in this. Optimism is also not the central word I would use to describe my five years of sustainability work. After all, working for a sustainable world while surrounded by forces opposing it is not easy. However, while optimism achieves more than focusing on worst-case scenarios, it must never be an excuse to ignore reality. So optimism cannot exist without realism. In the next 45 minutes, I will present the world we are rapidly heading towards—a world we can only keep livable for future generations if we all take a step back. And of course, I will explain the role that healthcare plays in this. The title of my lecture is "Individual vs. Collective." I believe individual choices shape the collective's fate, especially in the turbulent times we live in. Our agency lies in the options we have as individuals. Therefore, I address you as individuals today. I propose that we speak informally, because a sustainable future concerns each of us personally. It’s about you, everything you hold dear, but most of all, your children—whether they are your own or close to you. I ask you to think of those children now. For which children do you want to create the most beautiful future possible? Picture them on your lap and view my message through their eyes. Immanuel Kant says it is my moral duty to remain optimistic, so let me make a promise: If you here in this room are willing to absorb the world I am about to describe and honestly reflect on your own role, my message will be one of hope.

"We are colonizing the future of our children, depriving them of their freedom, health, and perhaps even their lives, just as colonizers did in the past. We are plundering our grandchildren, poisoning our descendants."
David van Reybrouck (1971-present)

The 2023 report from the Intergovernmental Panel on Climate Change (IPCC), a scientific work by the world’s top climate experts, is as clear as it is alarming: climate change is driven by human activity, with fossil fuels as the leading cause of the crisis. If no global action is taken, Earth’s temperature could rise by 4°C by the end of the century, making our planet unrecognizable and uninhabitable for future generations. The first signs are already here: floods, droughts, and wildfires are destroying our nature and food and water supplies. Species our children dream of are disappearing rapidly, and biodiversity is collapsing. Even with the inevitable warming of 2–2.5°C, large parts of the planet will become uninhabitable, with an estimated 400 million to 1.5 billion climate refugees by century's end. The only way to prevent this is by respecting Earth's limits and balancing our emissions and consumption with what the planet can sustain. Unfortunately, these limits are currently being ignored. As David van Reybrouck poignantly put it in his 2021 Huizinga lecture: just as colonizers terrorized the past, we are doing the same to the future of our children.

To save the planet, every person should not exceed 2,500 kg of CO2 emissions per year—this is called the "carbon budget." In the Netherlands, however, the average individual emits 8,800 kg annually. Even with strict measures like not flying, buying fewer goods, and eating mostly plant-based, you barely reduce emissions below 3,200 kg per year. In fact, living within planetary limits is impossible in the Netherlands today. And this doesn't even include "extras" like flights: a round-trip flight to New York alone emits over 2,000 kg CO2, effectively borrowing from our children’s future well-being. Imagine this: the CO2 we are allowed to emit is like a money pot for us and our children to live off. If you stay within your allowance, you guarantee a good future for your children. But if you exceed it, you’re taking money from their future. This illustrates exactly what Van Reybrouck means by parasitizing the future of our children. Most of us here are highly educated and have good incomes. We know how urgent the climate crisis is, yet we often look away: many of us consume meat from animals that suffer in poor conditions, and fly, which disproportionately contributes to global warming. The wealthiest 1% emit as much CO2 as the poorest 66%. This isn’t just about billionaires; it's anyone earning over €130,000 annually—perhaps even you.

In Paul Schenderling's book "There is Life After Growth", he questions whether economic growth is possible within the planet's limits. He proposes "responsible shrinkage," taxing polluting consumption—like luxury goods, flights, and animal proteins—while lowering taxes on labor. This would encourage sustainable living, reduce income inequality, and shift the economy from consumption to well-being, fostering sustainable production. This is an appealing idea, especially in healthcare, where disposable products still thrive. Schenderling’s vision may seem radical, but if the alternative is the downfall of future generations, shouldn’t we consider all possibilities? Our focus on economic growth now sustains a system where the rich get richer, and CO2 emissions continue to rise each year. Without radical change, this will lead to our demise.

"As a doctor, you are aware of the relationship between health, climate, and the environment. You are committed to a sustainable healthcare sector and a healthy living environment."
Core Principle 14 of the KNMG Code of Conduct

A system change is also needed in healthcare. The Dutch healthcare sector is responsible for over 7% of the country’s CO2-equivalent emissions and more than 13% of resource consumption. According to a 2022 RIVM report, the production, transport, and distribution of medications and disposable products are the largest polluters in our sector. Other significant sources of pollution include energy consumption, food use, and transportation of patients and staff. All of these factors come together in a "care pathway," describing the journey a patient takes within the healthcare system for a specific treatment. These pathways can be quantified for their environmental impact, often measured in CO2-equivalents, but also including other factors such as water use, nitrogen emissions, and particulate matter production.

Quantifying care pathways allows us to understand the pollution associated with each step and compare treatments based on their environmental impact. From there, we can choose the most environmentally friendly option. However, before making that choice, another question must be asked: Is the treatment even necessary or appropriate? Appropriate care is effective, provided close to the patient, and not unduly burdensome to the environment, healthcare costs, or staff availability. It’s a flexible concept, closely tied to available resources, personnel, and—here’s where I strongly advocate—planetary limits. During the COVID-19 pandemic, for example, we scaled down elective surgeries to preserve ICU capacity. Many non-urgent operations were canceled. At the time, we deemed it appropriate to not treat people surgically for complaints that were not urgent. I’m currently working with Robert de Leeuw, Xander Koolman, and Eva Velthuijs to explore if we can learn from such periods of relative scarcity. To respect planetary limits, we must, just like during the pandemic, acknowledge that we can’t always provide everything for everyone. But this requires an open discussion among all stakeholders.

The message is clear: the future of our planet is under such pressure that sustainability must also become a central theme in healthcare. No matter which type of care you consider important—whether it’s for fibroids, endometriosis, prenatal diagnostics, rare hereditary cancers, diabetes, or oncology—if we don’t achieve climate neutrality and circularity soon, we won’t be able to make a difference in these areas either. When shaping patient care—regardless of the condition—sustainability must be the top priority. But how can we minimize the environmental impact of healthcare? It happens in two steps. The first is to make healthcare processes more environmentally friendly. This includes buying green energy, insulating buildings, purchasing reusable products, and finding alternatives to highly polluting substances, like anesthesia gases and asthma inhalers. The second step is true system change, which requires a shift in mindset, including ethical questions about making tough choices. Who do we treat, and who don’t we? Which treatments are disproportionately harmful to the environment? How do we maintain our obsession with safety? Sometimes, we perform an action 200 times just to prevent a single serious complication. How reasonable and sustainable is that in times of crisis and scarcity?

As healthcare professionals, it is our responsibility to collectively determine what is acceptable in a time of financial, personnel, and planetary scarcity. We all have a role in this, as each individual healthcare provider can help bring these topics to the table and translate them into policy.

“What is measured is known.”
Lord William Thomson Kelvin (1824-1907)

The foundation for change in healthcare largely lies in quantification. Where is the impact of medical products or treatments? How do these treatments compare to each other? Quantification is unnecessary for ineffective care: for example, offering palliative chemotherapy for prostate cancer does not improve survival and only makes the patient sicker in their final stage of life. It's better not to do that. However, when care at the patient outcome level is meaningful, quantification comes into play. The most reliable way to measure the environmental impact of a product or care pathway is through a Life Cycle Assessment (LCA). This method fully maps the environmental impact: from production to transport, and from use to disposal or recycling. The advantage of LCA is that it looks at more than just CO2-equivalent emissions, including other categories such as water and land use, raw material requirements, and particulate matter production.

However, an LCA is time-consuming, and its outcome depends heavily on the setting and assumptions involved. To quantify care pathways, a simplified methodology is needed. Thanks to our fantastic research group, including Niek Sperna Weiland, Lynn Snijder, Lisanne Kouwenberg, and Eva Cohen, we are conducting this research in-house. Together with Tim Stobernack and Hugo Touw from Radboud UMC and the RIVM, we are developing simplified methods that will allow us to incorporate care pathway quantification alongside existing research. This will enable us to factor the sustainability of treatments or diagnostics into their value assessment. It’s also a step toward creating a green label for treatments: What is the most sustainable form of contraception, heavy menstruation treatment, hypertension management, or even cancer care? Adding environmental impact to decision aids can help patients and their healthcare providers make greener choices. I hope to work on this with Kirsten Kluivers, Tim Stobernack, and Eva Cohen in 2025.

There is certainly support for this, as a study I conducted with Eva Cohen, Annemijn Aarts, Dionne Kringos, and others showed that gynecological patients are indeed open to it. A large survey by the Dutch Patients’ Federation also revealed that patients value sustainability and want to be informed about the environmental impact of treatments. While this may not apply to every condition, patients do have an important role, and we intend to continue this research line. We will also explore ethical questions: What is the patient’s responsibility? Should providing information on the environmental impact of treatments be part of the right to information? How far should we go?

“Within the system of Capitalism, a small privileged few are rich beyond conscience, and almost all others are doomed to be poor at some level. That’s the way the system works. And since we know that the system will not change the rules, we are going to have to change the system.”
Martin Luther King (1929-1968)

Alongside sustainable healthcare, my academic focus also emphasizes efficient care—what is sometimes called "appropriate care." Efficient care contributes to what the patient values, balancing quality and costs. Inefficient care is also unsustainable. Thus, efficiency is directly linked to sustainability. Despite its logical appeal, there is still much inefficient care in medicine—care that seems effective but lacks proven results. Let me share a couple of examples.

Early in my academic career as a gynecologist, I was asked join an advisory board for a manufacturer introducing a new drug for symptomatic uterine fibroids. Fibroids are very common, thus commercially attractive. Studies, funded by the manufacturer, showed great benefits compared to placebo, and the company advertised that this new treatment could eliminate the need for hysterectomies. However, the conflicts of interest of the study authors were extensive and the marketing was very successful. Within a short time, nearly a million prescriptions were written, generating over 350 million euros in sales. The focus of the advisory board was not on objective assessment or careful introduction of the new drug but on maximizing implementation.

For truth-finding and positioning in guidelines, objectivity is critical. That’s why we need specialists who don’t participate in such advisory boards. Realizing this, I withdrew and became more critical of the rapid implementation of new treatments. Together with my PhD students, Inge de Milliano, Mei-An Middelkoop, Marleen de Lange, Annika Semmler, and senior researchers Judith Huirne, Ben-Willem Mol, and Pierre Bet, we investigated this case. We found that the marketing authorization was based on patients with relatively mild symptoms and small fibroids. There was no comparison with standard treatments, such as hysterectomy. The claim that this treatment could replace hysterectomy was therefore unfounded. Only a comparative study could have answered this question, and it’s the responsibility of researchers like myself to conduct them. This is challenging, as obtaining funding in the competitive process for small Dutch grants is tough. Developing a drug costs hundreds of millions, while grants are typically only a few hundred thousand. Moreover, studies are often slow to include participants because drugs are rushed to market under industry pressure. This system is unsustainable, but it is how medicine currently works.

It is tempting to blame the pharmaceutical industry, but the real issue is the system governing drug development. The complex regulations from the European Medicines Agency (EMA) make drug development costly, and safety measures inflate investments, forcing manufacturers to prioritize return on investment. It’s unsurprising that they control study outcomes and marketing.

Another example of the need for comparative research before a treatment is introduced is uterine fibroid embolization. This procedure, which involves expensive particles and catheters, showed impressive benefits in early cohort studies—up to 99% of patients were satisfied with the results and avoided hysterectomy. However, these studies didn’t compare embolization with standard treatments. A comparative study, which I conducted for my PhD, followed these women for ten years. The result? 35% of the embolization group ultimately chose a hysterectomy. While embolization is less effective than initially thought, it remains a cost-effective alternative to hysterectomy. However, it’s underused in the Netherlands due to poor patient information and skepticism from gynecologists, leading to wide practice variation. In 2023, we developed a decision aid to help patients weigh the pros and cons of different treatments for myomas. Early feedback suggests that patient preference for embolization has increased. Whether this leads to more embolizations will be clear by 2025. But the broader question remains: Shouldn’t we prioritize cost-effective treatments in an expensive healthcare system?

Both examples show that implementation should occur only after completing the full quality cycle. For both drugs and surgeries, frameworks like the EMA’s ‘clinical phases of drug development’ and the ‘IDEAL criteria for surgical interventions’ exist. However, studies leading to reimbursement often involve non-representative patient groups or surrogate outcomes. If there’s doubt about effectiveness, independent research should precede reimbursement—without manufacturer interference but in collaboration with scientific associations, patients, and insurers. Here lies an opportunity for the entire healthcare system: New treatments should only be reimbursed in study settings before reimbursement from public insurance, compared to the treatment they replace. Relevant outcomes should be chosen in consultation with patient organizations. This would quickly answer whether a treatment is beneficial and for which population. As Gabe Sonke, oncologist, described in his inaugural address, this approach could save millions annually. The cost of conducting these studies could be covered by a fraction of these savings. I urge the government to collaborate with the Dutch Healthcare Institute, insurers, the Federation of Medical Specialists, and scientific associations to consider this model seriously. I have several dossiers ready for evaluation this way.

“There is no such thing as perfect security, only varying levels of insecurity.”
Salman Rushdie (1947-present)

A significant portion of medical treatments is done "just to be safe." Our obsession with safety—often driven by industry interests—spreads across all areas of healthcare. The perceived safety of disposable products, hygiene measures, personal protective equipment, and air handling in operating rooms is often fueled by the industry. Additionally, there are preventive treatments, such as using cholesterol-lowering drugs to prevent heart attacks. The effectiveness of these treatments can be measured by the Number Needed to Treat (NNT), which tells us how many people need to be treated to prevent one event. For cholesterol-lowering drugs in people with low risk, the NNT is about 250. This means 249 people are treated unnecessarily to prevent one heart attack. While this benefits the one person saved from a heart attack, it raises ethical and environmental questions. The environmental impact of producing and consuming all this medication is often overlooked.

Another example of an excessive NNT is the vaginal breech birth. The 2000 Term Breech Trial showed that vaginal delivery of breech babies had higher risks of death or serious conditions compared to a cesarean section. This led to a global shift toward cesarean births. However, years later, when long-term outcomes for vaginally born children were found to be similar to those born via cesarean, the trend did not reverse. While parents are informed of the risks, most opt for a cesarean due to the direct risk to the baby. The chance of death during vaginal breech birth is 2 in 1000, while for a cesarean it’s 0.5 in 1000. To save one life, 666 cesareans would need to be performed. However, cesareans have significant risks for the mother and future children, high costs, and an environmental footprint more than twice as large as a regular birth. In this context, the value of individual life is understandably prioritized, but this leads to a neglect of collective values, such as healthcare costs and environmental impact. Ethical debates are necessary to determine which NNT is acceptable in each situation and whether patients should make these decisions alone.

I often refer to IVF as an example. After the age of 43, IVF is no longer covered by basic insurance. This isn’t because IVF never works after 43, but because the likelihood of success (1-2%) is so low that society doesn't deem the cost worth it. Personally, I’m happy with this "rule" as it clearly defines when treatment is not considered useful on a collective level. In shared decision-making with patients, I often struggle to convince individuals that such care should be excluded. Healthcare professionals should take a firmer stance on what we deem acceptable and meaningful care.

“It is our collective and individual responsibility to preserve and tend to the environment in which we all live.”
Dalai Lama (1935-present)

A new dimension to the healthcare discussion is the environmental impact of treatment paths. Decades ago, we primarily focused on the effectiveness of treatments. In the second half of the 20th century, the focus shifted to evaluating treatments in relation to their societal costs, with guidelines suggesting we are willing to pay up to €100,000 for each year of good health gained.

The next step is to consider the environmental impact alongside cost-effectiveness. We need to ask how the effectiveness of a treatment compares with the costs and environmental burden society faces. This could change how we view cost-effectiveness. For example, in my doctoral research, we found that embolization and hysterectomy were similarly effective treatments for uterine fibroids, with embolization being more cost-effective. In the past year, Eva Cohen, Lisanne Kouwenberg, and Lynn Snijder calculated the environmental impact of both procedures. As expected, hysterectomy caused more than twice the environmental burden as embolization. However, if we include follow-up care, the environmental impact of embolization equals that of hysterectomy. Furthermore, when considering that 35% of embolization patients require a hysterectomy within 10 years, the overall environmental impact of hysterectomy turns out to be the most sustainable option. Our earlier research showed that most women are open to considering the environmental impact when choosing treatment for heavy menstruation. We are continuing this research to explore if other treatments for uterine fibroids also align with this environmentally conscious approach. This raises the question of how the healthcare system should respond to such findings, balancing individual versus collective interests.

A final example is the rise of robotic surgery. Introduced in the late '90s for complex procedures, these robots are incredibly expensive and have a significant environmental footprint due to high energy consumption and excessive use of disposable materials. There are only a few treatments where robotic surgery provides clear advantages. Yet, many people advocate for the continued use of robots. The question is why—given the financial strain on the healthcare system, such an expensive method should only be justified if it shows significant benefits for patient outcomes. Since these benefits are not proven for many surgeries, robotic surgery should only be used in clinical studies (in the case of no proven superiority over the old method). It’s puzzling to me that hospitals do not enforce stricter regulations in this regard.

“We are the first generation to feel the impact of climate change, and the last to be able to do something about it.”
Barack Obama (1961-present)

As individuals, we may not have control over the choices made by powerful entities like the United States, the banking sector, or oil tycoons. However, we do have influence over our own actions, and can impact those around us. When I look at my own ecological footprint, I feel I owe a debt to my children. That’s why I want to make choices that truly matter, rather than just following trendy, superficial greenwashing habits like drinking oat milk or eating vegetarian snacks.

To seriously reduce my footprint, I had to critically examine my own emissions, with buying goods, driving, and flying topping the list.

This brings me to another sustainability issue in healthcare: professional air travel. Together with a growing group of like-minded individuals, I’ve started discussions to reduce this harmful practice. There are few legitimate reasons to fly across the world; knowledge can be gained closer to home, and networking with international colleagues can be done online. A livable world for my children is far more important than attending a conference in Las Vegas. Along with colleagues such as Schelto Kruijff, Teun Bousema, Marijke van Gerwen, Linda Kampschreur, and Remko van Eenennaam, I aim to develop a new norm for our field. This would involve creating a “budget” per specialty, considering the type of practice and scientific responsibility. We must maintain quality while minimizing environmental impact. This requires a shift in perspective from healthcare professionals—phrases like "it’s fun" or "it’s part of my benefits" must be replaced with, "I take responsibility for my children’s future" and "I will look for alternatives." This calls for a behavioral change, and it’s a great opportunity for individuals to take responsibility for the collective.

"We cannot solve today’s problems with the mindset that created them."
Albert Einstein (1879–1955)

In the Netherlands, we are working hard to make healthcare processes more sustainable by using reusable instruments, replacing harmful medications with less harmful ones, and creating guidelines to reduce material use. While these efforts are commendable, they reinforce the notion of maintaining "business as usual," just in a slightly greener way. True system change, however, requires fundamentally different choices rooted in new values.

Jan Rotmans and Patrick Huntjens highlight the contrast between homo economicus (focused on individualism) and homo ecologicus (focused on collectivism). The issue lies with the self-centered homo economicus, while the solution is found in the communal mindset of the homo ecologicus.

The homo economicus prioritizes personal freedom above all and resists changing behavior for the planet, often shifting responsibility to others (governments, China, or the US). Green energy is fine as long as it doesn’t affect their travel, advanced technology use, or (pharmaceutical) consultancy work.

In contrast, the homo ecologicus makes deliberate, sustainable choices: flying less, using public transport, and eliminating waste in healthcare. Their value comes not from luxury or convenience but from preserving the planet for future generations. This requires stepping out of one’s comfort zone and taking real responsibility.

"I cannot believe that the purpose of life is to be happy. I think the purpose of life is to be useful, responsible, honorable, and compassionate. Above all, to matter, to count, to stand for something, to make a difference that you lived at all."
Leo Rosten (1908–1997)

We all know the world is facing serious challenges, and we are left with a choice: look away and pretend the problem doesn’t exist, or take responsibility to make the world better, fairer, and more sustainable. While businesses and governments must also act, change begins with ourselves.

What can you control? Your own actions—and through them, your surroundings and your work. This mindset can spark global change, but only if we all act, each in our own way.

Rutger Bregman explains in his inspiring book Moral ambition that everyone has a threshold for action, and it’s closer than you think. He cites resistance during WWII: why did some join the resistance while others didn’t? Resistance heroes weren’t extraordinary; they were ordinary people, like you and me, who chose to act when they were asked. Once you take the first step toward a better world, the desire to do more naturally follows.

So, I invite everyone here today: Your threshold for action is nearer than you think. Don’t look away—take responsibility. Stand against the greatest crisis of our time. Be the change you wish to see. Inspire those around you—for your children, nieces, nephews, and everyone you love. I believe in this potential within me, within you, within us all.

As individuals, we serve the collective, and the collective enriches us as individuals. As David Bowie sang: We could be heroes, just for one day. Let today be that day.

"For the yesterdays and the todays, and the tomorrows I can hardly wait for—thank you."
Cecilia Ahern (1981–present)

I wish I could personally thank everyone here for their contribution to this chair. Please forgive me if I don’t mention you by name, but know I’m grateful for your support and attentive presence during this oration.

First, I thank the Board of the University of Amsterdam for appointing me, and the Dean of Amsterdam UMC for nominating me. Hans van Goudoever, your pivotal role reflects the board’s commitment to sustainability—not just in words but in action. It’s a privilege to work in such fertile ground, a rarity in the Netherlands.

Christianne de Groot, your support as department head was crucial in bringing this chair to life. Thank you for your indispensable help. To my colleagues in gynecology, thank you for standing by me, even during my relative absence from shared activities.

My collaborators at the Center for Sustainable Healthcare, including Dionne Kringos, Niek Sperna Weiland, and Maurits Ros, have been a true inspiration. To my PhD candidates and postdocs: I often wonder how I got so lucky. Your work is of such high quality that it humbles me. You are the driving force behind this chair. Special thanks to the four masters of ceremony today: Eva Cohen, Lisanne Kouwenberg, Noa de Smit, and Eva Velthuijs.

Efficiency research wouldn’t be possible without inspiring colleagues like Judith Huirne, Robert de Leeuw, and others dedicated to studying women’s health. Thank you, Peggy Geomini, Marlies Bongers, Paul Lohle, Martijn Boomsma, and more, for your unwavering dedication.

The discussions on efficiency and sustainability with Anne Timmermans, Berber Kapitein, Schelto Kruijff, and others have been invaluable. The Gynae Goes Green committee marked the start of my sustainability journey—a rewarding experience that led to developing a subsidized guideline and online tool.

There are five people I must thank individually. I hope I can keep my composure, though I’ve inherited my grandfather Karel Batenburg’s tendency to get emotional when thanking loved ones.

  • Judith Huirne, thank you for helping me find my “niche” and supporting the mission behind this chair. I admire your grace in letting me shape this oration while continuing our shared research.
  • Niek Sperna Weiland, your optimism about sustainability inspires me. The Center for Sustainable Healthcare thrives on your energy and vision. You are the true professor of sustainability.
  • My mother, Wilma van de Velde, you gave me the foundation to grow. Your unwavering belief in me allowed me to believe anything was possible.
  • My partner, Roald Leuven, systemic change inevitably impacts our family system. Your support, organizational talent, and willingness to shoulder so much enabled me to be here today.
  • My children, Oscar and Ramses, you are my greatest motivation for fighting for a sustainable future. I dedicate this oration to you.

Finally, my love for classical music brings this oration to a fitting close. I leave you with a fragment from Morgen by Richard Strauss, sung by Jessye Norman—a legendary artist who inspired many as a Black woman in a predominantly white opera world. Morgen symbolizes hope and optimism, for a future where the sun shines again on all of us, and on the children we hold dear.

I have spoken.