Nicolas Perry

Matthew Eckelman

Roland Hischier

Matthias Finkbeiner

Axel Tuma

Christoph Helbig

Andrea Thorenz

Tobias Gaugler

Andreas Rathgeber

Isabel Quispe

Ramzy Kahhat

Ian Vázquez

Aina

Alice Alexandre

Anish, Bastien, Dieuwertje, Dimitra, Edis, Elkin, Emmanuel, Eskinder, Haji, Javier Juliana Amélie

Julien

Nemanja, Noémie, Philippe Rachel Marc

Thibaut Thank

Audrey

Karine Fabrice

Laëtitia Véronique

A La Abuelita Grise

Pr Guido Sonnemann

Pr Steven

B Young

 J Santillán-Saldivar

End of Life -Recycling Input Rate ESP Economic Scarcity Potential ESSENZ Integrated method to assess resource efficiency EU European Union EV Electric vehicle

Keywords: Life Cycle Assessment, Raw Materials Criticality, Healthcare Sector, Environmental Sustainability

The activities required to provide healthcare services bring challenges to environmental sustainability. The sector relies on diverse products, services and facilities, including disposable products, complex equipment and transportation. This domain has not been well explored from a sustainability lens and the level of awareness around healthcare sustainability is low. Life-cycle based methods have the potential to characterize systems related to the healthcare sector and many others; however, these methods are mostlyif not exclusivelyrelated to an inside-out pathway to assess impacts. From an outside-in perspective, there is potential for raw material criticality to assess resource availability in the healthcare sector, especially after the proposal to integrate it into the Life Cycle Sustainability Assessment (LCSA) framework.

A pending task around this proposed methodological pathway is to explore the applicability and readiness of supply risk methods, specifically the geopolitical supply risk (GeoPolRisk) method has been proposed to assess resource related impacts. This research provides and integrates methods to assess environmental sustainability from a life cycle perspective with focus on enhancing criticality indicators as an outside-in impact pathway associated with the Area of Protection "Natural Resources" in Life Cycle Assessment (LCA); moreover, their applicability is validated with multiple case studies, being one of those a part of the healthcare sector.

The thesis is divided in 9 chapters along two branches: "Healthcare Sustainability" and "Raw Material Criticality in Life Cycle Assessment". The first chapter provides an introduction to the manuscript and presents the research question and objectives of the thesis; it is followed by the state of the art in chapter 2. Chapter 3 presents the development of a novel framework to help address sustainability challenges in the healthcare sector through life cycle thinking. Chapter 4 and Chapter 5 propose and test methodological enhancements to the geopolitical supply risk method required to better address resource related impacts in life cycle assessment. Chapter 6 presents an integrated assessment taking into account the enhanced method and its relation to more traditionally used environmental impact categories in LCA. In chapter 7, the GeoPolRisk method is used to better understand the relevance of assessing outside-in impacts associated to an element used in the healthcare sector. Chapter 8 integrates the methodological enhancements previously presented to study inside-out and outside-in impacts for a case study associated with medical imaging. Finally, accomplishments and future opportunities for development on the field are discussed as part of the last chapter of the manuscript.

Along the branch of "Healthcare Sustainability" this work contributes to the development of an integrated framework to support research in this domain and the first application to a case study in the healthcare sector of an integrated life cycle assessment incorporating environmental indicators and the GeoPolRisk method. Along the branch of "Raw Material Criticality in LCA", the PhD develops new approaches and proposes methodological enhancements to advance the assessment of resource use in LCA.

EXECUTIVE SUMMARY Titre : Évaluation Intégrée de Matériaux Sélectionnés pour leur Criticité et Durabilité Environnementale -Application dans le Secteur de la Santé et Améliorations Méthodologiques

Résumé : Les activités nécessaires pour fournir des services de santé posent plusieurs défis en termes de durabilité. Le secteur de la santé repose sur divers produits, services et installations, notamment des produits jetables, équipements complexes et moyens de transport. Ce domaine a été peu exploré sous l'angle de la durabilité et le niveau de sensibilisation à ce sujet est faible. Les méthodologies basées sur le cycle de vie ont le potentiel de caractériser la durabilité liée au secteur de la santé et à bien d'autres; toutefois, ces méthodes sont principalement -sinon exclusivement -liées à une voie inside-out pour évaluer les impacts. D'un point de vue outside-in, la criticité des ressources a le potentiel de répondre aux préoccupations relatives à la disponibilité des ressources pour le secteur de la santé, en particulier après son intégration dans le cadre de l'évaluation de la durabilité du cycle de vie (LCSA).

Une tâche en suspens autour de cette voie méthodologique proposée est d'explorer l'applicabilité et l'état de préparation des approches de risque d'approvisionnement, en particulier la méthode de risque géopolitique d'approvisionnement (GeoPolRisk), proposée pour évaluer les impacts liés aux ressources. Cette recherche fournit et intègre des techniques d'évaluation de la durabilité environnementale dans une perspective de cycle de vie, en particulier sur l'amélioration des indicateurs de criticité en tant que voie d'impact outside-in associée au domaine de protection "Ressources naturelles" dans l'analyse du cycle de vie (ACV); en outre, leur applicabilité est validée par de multiples études de cas, dont l'une fait partie du secteur de la santé.

La thèse est divisée en 9 chapitres et suit deux branches: "Durabilité des soins de santé" et "Criticité des ressources dans l'ACV". Le premier chapitre fournit une introduction au manuscrit et présente la question de recherche et les objectifs de la thèse ; il est suivi par l'état de l'art dans le chapitre 2. Le chapitre 3 présente le développement d'un nouveau cadre pour relever les défis de la durabilité dans le secteur de la santé par le biais de la pensée cycle de vie. Les chapitres 4 et 5 proposent et testent des développements méthodologiques pour évaluer le risque d'approvisionnement géopolitique. Ces aspects sont nécessaires pour mieux aborder les impacts liés aux ressources en ACV. Le chapitre 6 présente une évaluation intégrée de la criticité des ressources avec les catégories d'impact environnemental traditionnellement utilisées en ACV. Dans le chapitre 7, la méthode GeoPolRisk est utilisée pour mieux comprendre la pertinence de l'évaluation des impacts outside-in associés à un élément utilisé dans le secteur de la santé. Le chapitre 8 intègre les développements méthodologiques présentées précédemment pour étudier les impacts inside-out et outside-in dans le cadre d'une étude de cas associée à l'imagerie médicale. Enfin, les perspectives de développement sur le terrain sont examinées dans le dernier chapitre du manuscrit.

Dans la branche " Durabilité des soins de santé", ce travail contribue à l'élaboration d'un cadre intégré pour soutenir la recherche dans ce domaine et à la première application à une étude de cas dans le secteur de la santé d'une analyse intégrée du cycle de vie intégrant des indicateurs environnementaux et la méthode GeoPolRisk. Dans la branche "Criticité des ressources dans l'ACV", la thése développe de nouvelles approches et propose des améliorations méthodologiques pour faire progresser l'évaluation de l'utilisation des ressources dans l'ACV.

LIST OF FIGURES

Chapter 1: Introduction

The topics discussed in this chapter partially inspired the development of a perspective paper in preparation for publication:

G. Sonnemann; J. Santillán-Saldivar; S. Valdivia (to be submitted to Resources, Conservation and Recycling) Positioning the areas of protection Natural Resources and Human Health used in Life Cycle Impact Assessment within Life Cycle Sustainability Assessment.

The challenge of healthcare sustainability

There is a phrase made popular by Quino in Latin-American culture through his most famous character, Mafalda: "As usual: the urgent doesn't leave time for the important". This phrase can be applied to many aspects of our life and is highly featured in the Time Management Matrix, commonly used in business development and project management to classify tasks according to their urgency and profit potential [START_REF] Covey | The 7 habits of highly effective people: Restoring the character ethic[END_REF]. Being healthcare one of the most important and urgent services required for the population, it is one of the topics at the top of the list for many societies.

Healthcare is a fast-growing sector around the globe; in 2017 it was estimated that public spending represents 60% of the global spending on health (WHO, 2019). In line with the sustainable development goals, overall trends suggest an ongoing transition towards universal health coverage, although a great breach is evident between the expenditure on health per capita for low-income countries (~USD 40) and high-income countries (~USD 2940) (UN DESA, 2019). Health spending is growing faster than the gross domestic product (GDP), with an estimated growth of 3.9% from 2000 to 2017 versus a 3% GDP growth on the same period. As seen in Figure 1.1, this gap becomes wider in low-income and high-income countries, being an indicator of the increasing investment in healthcare infrastructure and services (WHO, 2019). Studies have presented the combined direct and indirect carbon footprint of the healthcare sector in multiple developed countries. Greenhouse gas emissions from this sector have been estimated at 4.6% of the national total in Canada [START_REF] Eckelman | Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis[END_REF], 5% in the United Kingdom (NHS Sustainable Development Unit, 2016); 7% in Australia [START_REF] Malik | The carbon footprint of Australian health care[END_REF] and 10% in the United States [START_REF] Eckelman | Environmental impacts of the U.S. health care system and effects on public health[END_REF]. Climate change is the result of the constant release of greenhouse gases mainly attributable to human activity in the past century. As stated in a report by 35 globally recognized health institutions including, among others, the United Nations, the World Health Organization and the World Bank, climate change has become a health emergency [START_REF] Watts | The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate[END_REF].

Based on the concerns raised after studying the contribution of the healthcare sector to environmental impacts at a global scale; multiple definitions of sustainability in healthcare have been discussed. From a management point of view, sustainable healthcare is defined by the resilience of the healthcare system: the ability to delivery healthcare services despite of external limitations [START_REF] Schroeder | Sustainable healthcare[END_REF]. On the other hand, a broader definition of healthcare sustainability considers the continuous delivery of healthcare to the population guarantying a minimal consumption of natural resources and minimal impact on the environment and society, now or in the future (NHS, 2014;[START_REF] Schroeder | Sustainable healthcare[END_REF].

The most recent global sanitary crisis, the COVID-19 pandemic, brought to surface different challenges that need to be addressed before achieving healthcare sustainability at global scale (IRP, 2020). The most important questions were related to the access to healthcare services and the availability of supplies to attend the needs of the patients; along with concerns on the financial situation of the sector after the global crisis (WHO, 2020). Among other efforts, research initiatives have been deployed around the world to understand the behaviour of the SARS-CoV-2 virus and to develop a vaccine (GAVI, 2020);

production and trade of respirators, masks, medications and other medical items required to diagnose and treat the disease have increased (European Commission, 2020c); and, new facilities have been or

are being constructed and reconditioned to serve as temporary treatment centers (BBC News, 2020).

These and other new efforts add up to the regular activities that are part of the healthcare sector.

The urgency of the global sanitary crisis is understandably diverting attention from other important sustainability aspects of the healthcare sector. Representing a non-negligible percentage of the total carbon footprint of multiple developed countries, the healthcare sector is causing direct and indirect damages to the environment. The global yield potential for the most consumed crops in the globe has been decreasing since 1960; as a result, the younger generations have a high risk to suffer from the permanent effects of malnutrition [START_REF] Smith | Human health: impacts, adaptation, and co-benefits[END_REF]. The temperature increase in the past few decades has led to a higher transmission of infectious diseases; dengue and cholera are some of the infections that propagate at higher rates in new areas affected by climate change [START_REF] Hoegh-Guldberg | Impacts of 1.5ºC global warming on natural and human systems[END_REF].

With the reported increase of extreme weather events such as wildfires and droughts, more people are suffering from respiratory illness associated to exposure to low air quality [START_REF] Black | Wildfire smoke exposure and human health: significant gaps in research for a growing public health issue[END_REF] which is only exacerbated by an increase of air pollutants caused by industrial activities in highly populated areas.

In the complex world we live in, the healthcare sector is not only generating a significant footprint, but also suffering from its consequences: more common and new conditions that need to be treated, a higher number of patients and, as made evident during the COVID-19 pandemic, the potential supply disruptions of resources required to guarantee uninterrupted activities [START_REF] Miller | Vulnerability of the medical product supply chain: the wake-up call of COVID-19[END_REF]. Unfortunately, the sector has done little to address this major challenge and further work is required to identify opportunities for improvement towards healthcare sustainability [START_REF] Sherman | The Green Print: Advancement of Environmental Sustainability in Healthcare[END_REF].

Life Cycle Assessment to assess healthcare sustainability

Along the past few decades, advancements in the healthcare sector and the improvement of living conditions for the population have led to an increased life expectancy with a continuous population growth around the globe [START_REF] Chang | The relationship between population growth and standardof-living growth over 1870-2013: evidence from a bootstrapped panel Granger causality test[END_REF]. Being healthcare one of the most important and urgent services required for the population, governments around the world are required to invest more to guarantee maximum coverage to a constantly growing and aging population [START_REF] Mendelson | The effects of aging and population growth on health care costs[END_REF]. Intuitively, overall environmental impacts associated with the healthcare sector could be reduced by increasing the efficiency of the resource use to provide healthcare services.

First reports of efforts to reduce environmental impacts of production processes were identified during the 70's. Specific environmental aspects were assessed by companies to compare and decide between multiple options for a similar product; therefore, laying the baseline for the first life cycle assessments (US EPA, 2006). The environmental life cycle assessment (LCA) methodology is considered a relevant and recommended decision-making tool to analyze and compare environmental impacts associated to the design, manufacturing, transport, use and disposing of goods and services (ISO, 2006). As exemplified in Figure 1.2, a typical product life cycle will consider all its life cycle stages for analysis. By compiling information on the inputs and outputs of product systems throughout their life cycle, the LCA methodology provides insights from a multicriteria perspective, allowing to quantify environmental impacts in different categories [START_REF] Guinée | Life cycle assessment: past, present, and future[END_REF]. LCA provides an overlook of the full life cycle of product systems and allows to identify opportunities for improvement in production processes based on environmental considerations (Moltesen and Bjorn, 2017).

After the publication of the Brundtland report in 1987; the concept of sustainable development was formally introduced and defined as ensuring the fulfillment of needs of the present without preventing future generations to meet their own needs (WCED, 1987). The discussion around this novel term added new layers to be addressed when reducing impacts of human activity. Two main dimensions were added to the already existing and analyzed environmental dimension: social and economic sustainability [START_REF] Passet | L'Économique et Le Vivant[END_REF]. With the introduction of the now called "three pillars of sustainability", several new approaches to assess sustainable development were proposed and used by public and private organizations; these would later be compiled and used to study and measure the progress towards the sustainable development goals proposed by the UN (UN DESA, 2014).

From a life cycle thinking perspective, enhancements were needed to address the contribution of product life cycles to sustainability in the three introduced dimensions. As a result, new methods were introduced and promoted as complements to environmental LCA as part of a Life Cycle Sustainability Assessment (LCSA) Framework (Figure 1.3) (UNEP, 2011).

Figure 1.3 -Integration of life cycle methods in LCSA From a social perspective, Social Life Cycle Assessment (S-LCA) is proposed to assess the social and sociological aspects of product systems, accounting for potential positive and negative impacts in society; with a mix of quantitative and qualitative data, S-LCA explores topics such as human rights, working conditions, health and safety, among others (UNEP, 2009[START_REF] Unep ; Reuter | Metal Recycling: Opportunities, Limits, Infrastructure, A Report of the Working Group on the Global Metal Flows to the International Resource Panel[END_REF]. From an economic perspective, a methodology based on management and costing was developed to include economic considerations in LCA. Life Cycle Costing (LCC) has the aim to assess total costs of products, services or activities over its lifetime as a complement to environmental LCA [START_REF] Swarr | Environmental life cycle costing: a code of practice[END_REF]UNEP, 2007).

Economic Life Cycle Assessment (EcLCA) was later proposed to better represent the economic dimension in LCSA, with the aim to account for an economic impact pathway, not only focusing in the cost-driven approach provided by LCC [START_REF] Neugebauer | From life cycle costing to economic life cycle assessment-introducing an economic impact pathway[END_REF].

Life-cycle-based methodologies have been used as decision-making tools for multiple sectors; most notorious applications compare two or more products, technologies or variants of them in order to choose the one with less impacts. A common example is evident in studies that compare the environmental impacts of electric vehicles against those of combustion-engine vehicles; providing insights on the energy transition from fossil fuels to renewable energies and the associated consequences, such as the increasing demand for energy storage technologies such as batteries [START_REF] Borah | On Battery Materials and Methods[END_REF][START_REF] Hawkins | Comparative environmental life cycle assessment of conventional and electric vehicles[END_REF].

The healthcare sector, as any other in our society, has the potential to benefit from the application of life-cycle based methodologies. As will be presented in future chapters, efforts are being made towards the sustainability of healthcare systems. However, from a life cycle perspective, the sustainability assessment efforts are focused on understanding the impacts of healthcare-related activities inherent to the sector on the society and environment; also known as "inside-out" impacts [START_REF] Porter | Strategy & society: The link between competitive advantage and corporate social responsibility[END_REF]. Certain sustainability concerns relevant to the healthcare sector are not covered under this approach, such as supply constraints [START_REF] Miller | Vulnerability of the medical product supply chain: the wake-up call of COVID-19[END_REF], policy, regulations, extreme weather events, among others that are considered "outside-in" impacts; this relation describes how companies and organizationsin this case, the healthcare sectorare impacted by external socio-economic and environmental conditions [START_REF] Porter | Strategy & society: The link between competitive advantage and corporate social responsibility[END_REF].

Raw Material Criticality: Assessing impacts from the outside-in

In the context of environmental LCA, impacts are assessed in relation to three main areas of protection (AoP) (Figure 1.3b). The AoP Human health refers to the impacts of product systems in the quality of life for humans; the AoP Ecosystem Health is related to how the ecosystems are affected by human activities in a product life cycle and the AoP Natural Resources seeks to analyze how biotic and abiotic resources are consumed to serve product systems in LCA [START_REF] Finnveden | Recent developments in life cycle assessment[END_REF][START_REF] Guinée | Life cycle assessment: past, present, and future[END_REF].

It can be said that more progress has been made in relation to the AoPs Ecosystem Health and Human

Health than in Natural Resources; an adequate level of consensus has been achieved regarding impact categories such as ecotoxicity [START_REF] Rosenbaum | USEtox-the UNEP-SETAC toxicity model: recommended characterisation factors for human toxicity and freshwater ecotoxicity in life cycle impact assessment[END_REF], water use [START_REF] Boulay | Regional characterization of freshwater use in LCA: modeling direct impacts on human health[END_REF][START_REF] Boulay | The WULCA consensus characterization model for water scarcity footprints: assessing impacts of water consumption based on available water remaining (AWARE)[END_REF] or global warming potential (IPCC, 2014). However, there is not a practical consistent alignment among the diverse LCIA methods to address the impacts of resource use; this is due not only from a difference between the current methods, but from a conceptual divergence on what sustainable resource extraction is and why natural resources should be protected [START_REF] Sonnemann | From a critical review to a conceptual framework for integrating the criticality of resources into Life Cycle Sustainability Assessment[END_REF].

The AoP natural resources considers elements extracted for human use (Udo de [START_REF] Udo De Haes | Life-cycle Impact Assessment: Striving Towards Best Practice[END_REF]; and considers both biotic and abiotic resources. The main goal of most methods is to quantify the depletion due to their use to support the development of human activities and their value in the economy in the present and future. Commonly used methods are focused on reduced resource availability due to geological depletion [START_REF] Guinée | A proposal for the definition of resource equivalency factors for use in product life-cycle assessment[END_REF]van Oers et al., 2002;[START_REF] Oers | The Abiotic Depletion Potential: Background, Updates, and Future[END_REF] or additional efforts required to guarantee continuation of human activities in the future [START_REF] Itsubo | Iwatani Corporation. Commencement of Supply from Qatar Helium-2 and Launching Helium Joint Venture in Qatar. Incorporating Helium Transfilling, Container Logistics and Container Maintenance to Expand the Helium Business Effectively in the MENA[END_REF][START_REF] Ponsioen | Surplus cost as a life cycle impact indicator for fossil resource scarcity[END_REF][START_REF] Vieira | Surplus Cost Potential as a Life Cycle Impact Indicator for Metal Extraction[END_REF], both of which do not cover questions regarding accessibility to resources due to socio-economic factors [START_REF] Sonnemann | From a critical review to a conceptual framework for integrating the criticality of resources into Life Cycle Sustainability Assessment[END_REF].

Accessibility considerations are studied in criticality assessments as part of the efforts to evaluate technical and economic dependency on a certain material for a defined stakeholder in a certain timeframe [START_REF] Schrijvers | A review of methods and data to determine raw material criticality[END_REF]. The topic of raw material criticality has served the industry and governments alike, notably to define policies associated with production, trade and risk mitigation strategies at regional and national level (Graedel, 2012;[START_REF] Graedel | Six years of criticality assessments: what have we learned so far?[END_REF]. Significant examples of the use of criticality indicators are the "criticality lists", published on a regular basis by multiple countries or regions (European Commission, 2017, 2020a;[START_REF] Nstc | Assessment of critical minerals: updated application of screening methodology[END_REF][START_REF] Bgs | Risk List 2015 -An Update to the Supply Risk Index for Elements or Element Groups That are of Economic Value[END_REF] to identify critical raw materials for the development of key industries such as energy generation and storage; robotics; information and communication technologies (ICT), mobility, aerospace, among others (European Commission, 2020b).

The question of accessibility to resources appears when analyzing impacts from the outside-in perspective. Based on this clear methodological gap in LCA; the concept of raw material criticality was introduced as a new perspective in LCSA to evaluate environmental, social and economic aspects that affect product systems. As proposed by [START_REF] Sonnemann | From a critical review to a conceptual framework for integrating the criticality of resources into Life Cycle Sustainability Assessment[END_REF], the LCSA framework has the potential to develop a more meaningful assessment of the impacts of resource use in the AoP Natural Resources.

A new question arises when following this methodological pathway: are the "outside-in" considerations associated with the AoP Natural Resources exclusively achievable through LCSA by exploring its economic dimension? Or, is the scope of E-LCA broad enough to include these aspects? (Figure 1.3, Figure 1.4) [START_REF] Berger | Mineral resources in life cycle impact assessment: part IIrecommendations on application-dependent use of existing methods and on future method development needs[END_REF][START_REF] Sonderegger | Mineral resources in life cycle impact assessment-part I: a critical review of existing methods[END_REF]. For the time being, these topics have been associated to the AoP Natural Resources in LCA [START_REF] Cimprich | Raw material criticality assessment as a complement to environmental life cycle assessment: examining methods for product-level supply risk assessment[END_REF] as the links to the overall LCSA framework are not fully defined. Moreover, a similar situation is seen when addressing impacts associated with the AoP Human health; an overlap between E-LCA and S-LCA is visible (Figure 1.4) since health is considered both a social issue and an area of protection in E-LCA (Figure 1.4). This is also evident when acknowledging considerations of access to healthcare and potential impacts of the healthcare sector. , 2009, 2020); efforts to assess water use in LCA [START_REF] Boulay | Regional characterization of freshwater use in LCA: modeling direct impacts on human health[END_REF][START_REF] Boulay | The WULCA consensus characterization model for water scarcity footprints: assessing impacts of water consumption based on available water remaining (AWARE)[END_REF]; methods to assess environmental impact well covered by LCA such as IMPACTWorld+ [START_REF] Bulle | IMPACT World+: a globally regionalized life cycle impact assessment method[END_REF], ReCiPe [START_REF] Goedkoop | ReCiPe 2008: a Life Cycle Impact Assessment Method Which Comprises Harmonised Category Indicators at the Midpoint and the Endpoint Level[END_REF][START_REF] Vieira | Surplus Cost Potential as a Life Cycle Impact Indicator for Metal Extraction[END_REF] or ILCD (European Commission, 2012).

Overall, given the literature discussed above, the way impacts were defined in the AoP Natural

Resources was not considered particularly meaningful. [START_REF] Sonnemann | From a critical review to a conceptual framework for integrating the criticality of resources into Life Cycle Sustainability Assessment[END_REF] proposed the integration of raw materials criticality into the LCSA framework and identified one main methodological gap required to better assess raw material criticality from an LCA perspective: to identify and measure the availability of raw materials related to geopolitical considerations as part of an economic dimension in LCSA (highlighted in Figure 1.5). The result of the exploration of this research opportunity is the development of the Geopolitical Supply Risk Method (GeoPolRisk). [START_REF] Gemechu | Import-based Indicator for the Geopolitical Supply Risk of Raw Materials in Life Cycle Sustainability Assessments[END_REF] originally developed the GeoPolRisk method as a measure for the supply risk from the perspective of a country, region or company. It was designed following the proposed integration of raw material criticality into the LCSA framework and takes into account global production concentration and trade flows between multiple trade partners. In a recent publication by the UNEP Life Cycle Initiative, life cycle impact indicators for addressing abiotic resources were comprehensively reviewed to develop recommended practices; the result of this effort was the volume 2 of the Global Guidance on Environmental Life Cycle Impact Assessment Methods [START_REF] Frischknecht | Global Guidance on Environmental Life Cycle Impact Assessment Indicators[END_REF]. The GeoPolRisk method was discussed and reviewed as part of the proposed methods for product-level supply risk assessment and a series of recommendations were given to advance its maturity and applicability. These aspects will be further explored in Chapter 2:.

Problem setting and research question

The activities required to provide healthcare services to a rapidly growing and aging population bring several challenges in terms of sustainability. The healthcare sector relies on diverse products and services such as facilities, disposable products, complex machines, transportation, among others that have been only superficially explored from a sustainability lens. Efforts exist to understand and act upon sustainability aspects associated with the healthcare sector, however the level of awareness around this topic is considered low [START_REF] Sherman | The Green Print: Advancement of Environmental Sustainability in Healthcare[END_REF]. Further endeavors are required to identify knowledge gaps and to arrive to a common baseline to assess healthcare sustainability.

Life-cycle based methodologies have the potential to address sustainability concerns related to the healthcare sector; however, these methods are mostlyif not exclusivelyrelated to an inside-out pathway to assess impacts. From an outside-in perspective, there is potential for raw material criticality to address the concerns of resource availability to the healthcare sector, especially after the proposal to integrate it into the LCSA framework. As illustrated in Figure 1.6, a pending task around this proposed methodological pathway is to explore the applicability and readiness of the GeoPolRisk method, proposed to assess resource related impacts.

Figure 1.6 -Proposed integration of methodologies to assess resource related impacts in the healthcare sector

Based on the mentioned concerns; the research question for this thesis is defined as follows:

How to assess environmental sustainability aspects in the healthcare sector using life cycle assessment and advancing its methodological readiness to evaluate raw material criticality in an integrated way?

Hypotheses, objectives and thesis outline

The following hypotheses are formulated to answer the proposed research question:

 Hypothesis 1: LCA is an appropriate methodology to measure environmental sustainability impacts, extending the traditional scope to include an outside-in perspective.

 Hypothesis 2: Raw material criticality has the potential to address outside-in impacts associated with the AoP Natural Resources.

 Hypothesis 3: Products and services related to the healthcare sector can be analyzed in an integrated manner to account for impacts from the inside-out and outside-in pathways in LCA.

These hypotheses determine the starting point of this thesis project and set the direction of the research for this PhD dissertation. Therefore, the main objective of this thesis is: to provide and integrate methods to assess healthcare environmental sustainability from a life cycle perspective with focus on enhancing criticality indicators as an outside-in impact pathway associated with the AoP Natural Resources.

The following specific objectives (S.O.) are defined to support the main objective of the thesis: a. To provide a detailed state of the art of the LCA applications in the healthcare sector while identifying the main methodological challenges for assessing healthcare systems from a life cycle perspective.

b. To provide a detailed state of the art of the methodologies to address outside-in impacts resulting from the integration of raw material criticality and LCA while identifying the main methodological challenges for its readiness.

c. To develop a framework to address healthcare sustainability from a life cycle perspective and provide its potential applications. d. To enhance the existing geopolitical supply risk method to include recycling considerations as a mitigation strategy.

e. To advance the scope of the geopolitical supply risk method from a midpoint level indicator to an endpoint level indicator associated to the area of protection Natural Resources.

f. To demonstrate the added value of the geopolitical supply risk method at midpoint and endpoint level as a complement to environmental LCA with a case study.

g. To demonstrate the added value of the application of a method based on an outside-in impact pathway with a case study relevant to the healthcare sector.

h. To demonstrate the relevance of the application of an integrated assessment based on LCA considering outside-in and inside out impact pathways for the healthcare sector.

This thesis covers the completion of the main objective and associated specific objectives (S.O.); it is divided in 9 chapters. These chapters are classified in two branches, as illustrated in Figure 1.7, and contain the following information:

This introduction is the Chapter 1 of the thesis and it is followed by Chapter 2: State of the art. That chapter is divided into two main sections: a state of the art that compiles the most relevant LCA applications to the healthcare sector and serves to identify knowledge gaps towards the application of life-cycle based methodologies to the healthcare sector (S.O. a); and, a state of the art of the methodologies to address outside-in impacts resulting from the integration of raw material criticality in LCSA (S.O. b). Methodological challenges for the operationalization of this impact pathway associated with AoP Natural Resources are identified and a special focus is given to the geopolitical supply risk method, which will be a focal point in following chapters.

Chapter 3 presents the development of a novel framework to address sustainability challenges in the healthcare sector based on LCA (S.O. c). The applicability of this framework is tested by its association with previous and potential new studies in the field of healthcare sustainability. These examples will serve as a starting point for a case study presented later on in this thesis.

After the challenges to operationalize the geopolitical supply risk as a midpoint indicator in LCA were identified in Chapter 2, Chapter 4 depicts the development and proposed application of a methodological enhancement that allows to consider recycling as a mitigating factor for supply risk (S.O. d). The method is tested with an application to materials relevant to Information and Communication Technologies (ICT) in the European Union.

Chapter 5 has as main focus the extension of the geopolitical supply risk method from a midpoint indicator in LCSA to an endpoint level indicator associated with the AoP Resources (S.O. e). A new method for quantifying the effects of supply disruption events in the price of resources is introduced and tested with a case study on Lithium-ion batteries (LIB) for the country members of the Organisation for Economic Co-operation and Development (OECD).

Chapter 6 integrates the advancements from chapters 4 and 5 by demonstrating the applicability of the methodological developments associated with the geopolitical supply risk method as a complement to environmental LCA (S.O. f). The results of the application to a case on LIB for the European Union are compared with results for other relevant impact categories more commonly used to assess environmental impacts.

Based on the proposed framework in Chapter 3, Chapter 7 presents an application of the geopolitical supply risk method to a resource of great importance in the healthcare sector (S.O. g). Helium is selected as a case study to demonstrate the relevance of analyzing impacts from an outside-in pathway for the healthcare sector. The results are presented from a multinational perspective.

Chapter 8 presents an integrated study of MRI scans following the LCA methodology. It focuses on the helium used in MRI machines for medical diagnosis (S.O. h). The results obtained in Chapter 7 are used as a complement to achieve an integrated assessment that contains both impact pathways relevant to the healthcare sector: inside-out and outside-in. The case study is developed from the perspective of selected countries analyzed in Chapter 7.

Finally, the hypotheses are tested and the research question is answered in Chapter 9. A general conclusion highlighting overcome challenges and found limitations is presented and perspectives for future work are explored.

Figure 1.7 -Structure of the thesis associated to the Specific Objectives (S.O.)

As described in Chapter 1:, the PhD thesis considers two branches. The first one is associated with the concept of healthcare sustainability and has as main objective the study, integration and application of LCA-based methodologies applicable to the healthcare sector. The second branch of the PhD thesis seeks to enhance criticality indicators to obtain a more mature outside-in impact pathway associated with the AoP Natural Resources in LCA.

The first section of this chapter provides a detailed state of the art on the application of sustainability assessment methods, with focus on the main methodological challenges for assessing healthcare systems from a life cycle perspective. It is partially based in a section of the publication entitled "Potential for industrial ecology to support healthcare sustainability: Scoping review of a fragmented literature and conceptual framework for future research", for which the author conducted literature searches and analyzed multiple publications discussed in this chapter. Moreover, the second part of the chapter studies current methodological efforts to address outside-in impacts resulting from the integration of raw material criticality and LCA, with special focus on the Geopolitical Suppy Risk method and its readiness to address impacts on the Area of Protection Natural Resources in LCA.

Scoping Review on Healthcare and Sustainability

Healthcare Sustainability

Climate change has been named the number one public health issue of the 21 st century [START_REF] Costello | Managing the health effects of climate change[END_REF]. Estimations point to a potential loss of a quarter million lives between 2030 and 2050 directly attributable to climate change. From a healthcare perspective, the main type of conditions to increase in the nearby future because of climate change will be related to poor air quality, malnutrition, infectious diseases, limited access to water, and hazards from extreme weather events (WHO, 2009). However, 5% to 10% of greenhouse gases emissions can be associated with the healthcare sector in many developed countries around the globe [START_REF] Eckelman | Environmental impacts of the U.S. health care system and effects on public health[END_REF]NHS Sustainable Development Unit, 2016;[START_REF] Eckelman | Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis[END_REF][START_REF] Malik | The carbon footprint of Australian health care[END_REF].

The previously mentioned environmental impacts of healthcare are conceptualized as "inside-out" impacts: those inherent to the sector and affecting the society and environment [START_REF] Porter | Strategy & society: The link between competitive advantage and corporate social responsibility[END_REF]. On the other hand, healthcare systems are affected by other situations such as the effects of climate change (e.g. damage from extreme weather events), limited access to resources (e.g. supply disruptions of medical supplies, as seen during the COVID-19 pandemic) and other external influences.

These aspects of healthcare sustainability can be conceptualized as "outside-in" impacts on healthcare.

Awareness on the environmental impacts from the healthcare sector have been increasing in the past years, but is still considered low [START_REF] Sherman | The Green Print: Advancement of Environmental Sustainability in Healthcare[END_REF]. International healthcare organisations have pointed the role of the sector in indirectly increasing the number of conditions related to sustainability issues (WHO, 2017;World Bank, 2017;[START_REF] Watts | The Lancet Countdown: Tracking progress on health and climate change[END_REF]. One of the first suggestions was given by the Institute of Medicine Roundtable on Environmental Health Sciences Research and Medicine (2013), encouraging the healthcare sector to be an example by reducing its own environmental footprint and improve planetary health. Several efforts towards healthcare sustainability made by actors in the healthcare sector have been documented.

Following the need to understand how life cycle assessment is being applied to the healthcare sector, this section is dedicated to identify the current state of the art on the topic of healthcare and sustainability; with the aim to understand the main methodological challenges for assessing healthcare sustainability from a life cycle perspective.

Scoping Review Methodology

Unlike typical approaches used to perform systematic reviews that focus on summarizing the collective findings on specific subjects or research questions, this review aims to map the literature associated with the topic of healthcare sustainability from an exploratory perspective. A main goal of this review is to obtain a broad picture of the work currently done on healthcare and sustainability, highlighting knowledge gaps and opportunities for future research. With this objective in mind, the development of a scoping review is proposed to study the field of healthcare sustainability. [START_REF] Peters | Guidance for conducting systematic scoping reviews[END_REF] developed the scoping review methodology to bring together literature in emerging disciplines. Figure 2.1 illustrates the followed methodology; in the first stage, identification, two large international databases were selected as starting point: Scopus and PubMed. The search criteria aimed to obtain results around environmental and resource-related considerations in healthcare; however, other sustainability aspects were included as part of the social and economic dimensions. Different search phrases were constructed; the main being obtained with the combination of the keywords "sustainability" and "healthcare", along with general terms on the subject such as "environment", "social responsibility". Additionally, specific terms related to the studied fields were applied: (1) in the field of life cycle assessment and industrial ecology, "energy efficiency", "carbon footprint", "environmental management", "waste management", "life cycle", "material flow analysis" among others. And (2) in the medical field, "x-ray", "ultrasound", "surgery", "medical device", among others. For the specific case of the PubMed database, which focuses on medicine and health sciences, only keywords relating to sustainability were used. In total, 134 literature searches were performed between September and November, 2017 (details are presented in Annex A).

During the screening stage, the review was limited to academic journal articles in English, published after 1987; corresponding with the publication of the Burtland report (WCED, 1987). Duplicates were eliminated from the database and over 1700 pieces of literature were identified as part of the review.

For practical reasons and representing an overall limitation of the review, a stratified random sampling was conducted to reduce the numbers of articles to study; the sampling frame of 1748 articles resulted in a sample of 157 articles to be included. The list of articles that were part of the review are presented in Annex B.

Literature Review -Results and Discussion

Among the general characteristics of the body of literature studied for this review, a highlight is that a 65% of items was published between 2007 and 2017. The articles are distributed in different and various journals, being the main type medical journals, followed by journals in environmental sciences; however, this fragmentation represents a new challenge when targeting appropriate audiences for dissemination.

The articles were clustered taking into consideration (1) a medical activity or resource (e.g. diagnostic procedures, therapeutic procedures, administrative services, pharmaceuticals, medical supplies) and

(2) an approach to assess sustainability aspects (e.g. life cycle assessment, ecological footprint, energy efficiency). The topic of waste management is addressed in approximately 25% of the studied articles.

Among these, some highlights found are related to compliance of regulatory requirements [START_REF] Takatsuki | Appropriate disposal of medical wastes--according to the manual on disposal of infectious wastes[END_REF][START_REF] Haylamicheal | A review of legal framework applicable for the management of healthcare waste and current management practices in Ethiopia[END_REF][START_REF] Botelho | The impact of regulatory compliance behavior on hazardous waste generation in European private healthcare facilities[END_REF]; results of surveys on best practices on waste management [START_REF] Idowu | Profile of medical waste management in two healthcare facilities in Lagos, Nigeria: a case study[END_REF][START_REF] Ul-Rahman | Knowledge and attitude of nurses regarding healthcare waste management practices in a tertiary care hospitals of Lahore[END_REF][START_REF] Askarian | Results of a hospital waste survey in private hospitals in Fars province, Iran[END_REF][START_REF] Aseweh Abor | Medical waste management practices in a Southern African hospital[END_REF][START_REF] Saad | Management of hospitals solid waste in Khartoum State[END_REF][START_REF] Thiel | Attitude of US obstetricians and gynaecologists to global warming and medical waste[END_REF][START_REF] Jovanović | Management of pharmaceutical waste in hospitals in Serbiachallenges and the potential for improvement[END_REF][START_REF] Gupta | Knowledge, attitude and practices of health care professionals regarding biomedical waste management in Indian oral pathology laboratories[END_REF] and toxicological studies on healthcare waste [START_REF] Gupta | Genotoxicity evaluation of hospital wastewaters[END_REF]. The visibility and direct impacts of waste from the healthcare sector are probably why this issue is highly featured in the analyzed sample.

A second highlight cluster is related to energy efficiency; two main aspects stand out: the use of heating, ventilation and air conditioning in healthcare facilities [START_REF] Radwan | Retrofitting of existing buildings to achieve better energy-efficiency in commercial building case study: Hospital in Egypt[END_REF][START_REF] Khalil | Energy efficiency, air flow regime and relative humidity in air-conditioned surgical operating theatres[END_REF] and energy consumption for medical imaging [START_REF] Burke | Energy efficiency in the radiography department: An Irish perspective[END_REF][START_REF] Esmaeili | Scope for energy improvement for hospital imaging services in the USA[END_REF]. This last set of articles is the first found in the review that focus on a specific medical specialty (radiology). The interest to address concerns related to resource efficiency is evident. Climate change and greenhouse gas emissions are also topics shared by multiple articles in the sample. Carbon footprint studies on pharmaceutical production [START_REF] Tvrdinić | Environmental footprints of a flexible pharmaceutical production facility: a life cycle assessment analysis[END_REF][START_REF] Markarian | Reducing the environmental impact of manufacturing[END_REF], anesthetics [START_REF] Yasny | Environmental implications of anesthetic gases[END_REF] and operating room procedures [START_REF] Thiel | Environmental impacts of surgical procedures: life cycle assessment of hysterectomy in the United States[END_REF][START_REF] Campion | Life cycle assessment perspectives on delivering an infant in the US[END_REF] follow a life cycle thinking approach to address "inside-out" impacts associated with specific medical products and activities. On the other hand, "outside-in" impacts are addressed in an article by [START_REF] Paterson | Health Care Facilities Resilient to Climate Change Impacts[END_REF] which focuses on climate change adaptation and resilience of healthcare facilities.

Overall, four main conclusions can be formulated from the review findings, these are illustrated in Table 2.1 as opportunities for improvement for this novel field. First, from the medical perspective, only a few areas in the field are covered; therefore, the healthcare system is understudied from a sustainability lens. Second, from a methodological perspective in the field of sustainability, there is not a unified approach to address the concerns of the sector. Life cycle assessment is used in selected articles from the review and could have the potential to support further research in the field (e.g. LCA of childbirth In the US by [START_REF] Campion | Life cycle assessment perspectives on delivering an infant in the US[END_REF]; LCA of the Canadian healthcare system by [START_REF] Eckelman | Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis[END_REF]; LC emissions of anesthetic drugs by [START_REF] Sherman | Life Cycle Greenhouse Gas Emissions of Anesthetic Drugs[END_REF]. Third, only one of the articles clearly focused on an "outside-in" impact pathway by assessing the resilience of healthcare facilities in the context of climate change [START_REF] Paterson | Health Care Facilities Resilient to Climate Change Impacts[END_REF]; therefore, further efforts need to be made to provide and/or enhance methods that support the healthcare sector (or others) when addressing "outside-in" impacts.

At last, a broader systemic foundation was not found in the existing literature, an effort needs to be made to provide scholars who would like to develop research in the topic of healthcare sustainability with guidelines or a conceptual framework to support future research [START_REF] Sherman | The Green Print: Advancement of Environmental Sustainability in Healthcare[END_REF]. Proposals to address these four opportunities for improvement will be further explored in the thesis.

Life Cycle Assessment (LCA) and Raw Material Criticality

LCA: An Overview

As mentioned in section 1.2, early efforts to identify and quantify environmental impacts associated with product systems were conducted in the decade of 1970. It is not until the end of the century that international organizations worked together to provide guidelines and frameworks that allow to apply the LCA methodology on a mature and standardized way. Clear examples of the strong efforts made by international bodies are the publication of the ISO14040/44 standards on life cycle assessment as part of the environmental management family (ISO 2006a(ISO , 2006b) ) which provided the first consensed definition of LCA as an environmental management tool to calculate the environmental impact of products and services throughout their life cycle; and the creation of the UNEP Life Cycle Initiative (LCIni) as an organism to achieve global consensus on LCA [START_REF] Sonnemann | The UNEP/SETAC Life Cycle Initiative[END_REF].

As depicted in Figure 2.2, LCAs are developed for a variety of reasons: develop new products, reduce the footprint of product systems, marketing, compliance, comparison of similar products, among others.

There are four phases according to the international guidelines provided by ISO (2006aISO ( , 2006b)). First, the goal and scope definition allow identifying the main objectives of the study and marking the boundaries of the analyzed system; the life cycle stages and functional unit of the study are defined in this first stage. Second, primary and secondary data is collected to form a life cycle inventory (LCI) that contains inputs and outputs along the life cycle under study. Next, an association is made between the inputs and outputs of the LCI and the impacts of the product system on the environment with the life cycle impact assessment (LCIA) phase. In parallel to the development of the three previously presented steps, the interpretation phase allows to identify limitations and make adjustments while the study is under development. From the four mentioned phases, LCIA refers to the steps that link the inputs and outputs in a LCI with potential or tangible impacts in the environment, society or economy. Traditionally in LCA, these impacts can be associated to three AoPs: Human health, Ecosystem health and Natural Resources (JRC, 2011;[START_REF] Finnveden | Recent developments in life cycle assessment[END_REF][START_REF] Guinée | Life cycle assessment: past, present, and future[END_REF], as illustrated in Figure 2.3. Currently available methods for LCIA provide guidelines to categorize and characterize inputs and outputs from the LCI to specific impact categories at the so-called midpoint level. The contribution of multiple impact categories at the midpoint level is then integrated and associated to one or multiple AoPs. These represent the endpoint level indicators in LCA (Jolliet et al., 2003b;[START_REF] Rosenbaum | Life Cycle Impact Assessment[END_REF]. It is possible to say that a scientific consensus has been reached between the methods to quantify and analyze how product systems affect human health and ecosystem health. However, a misalignment has been identified among diverse LCIA methods on how to address resource use impacts [START_REF] Dewulf | Rethinking the area of protection "natural resources" in life cycle assessment[END_REF]Drielsma et al., 2016a, b;[START_REF] Finnveden | The resource debate needs to continue[END_REF][START_REF] Stewart | A consistent framework for assessing the impacts from resource use: A focus on resource functionality[END_REF]. This was made evident after the publication of the first Global Guidance for Life Cycle Impact Assessment Indicators, which excluded the topic of resources due to not obtaining a similar level of consensus as the other areas (UNEP, 2017). This dissonance is not only a result from multiple modeling methods, but also a consequence of a conceptual divergence on what sustainable resource extraction is and why natural resources must be protected [START_REF] Sonnemann | From a critical review to a conceptual framework for integrating the criticality of resources into Life Cycle Sustainability Assessment[END_REF].

The AoP natural resources refers to all elements extracted from the environment for human use (Udo de [START_REF] Udo De Haes | Life-cycle Impact Assessment: Striving Towards Best Practice[END_REF]; these include biotic and abiotic resources. The main goal of existing methods associated with this AoP is to quantify resource depletion due to potential intensive resource use to support human development. Current models focus on reduced availability due to geological depletion [START_REF] Guinée | A proposal for the definition of resource equivalency factors for use in product life-cycle assessment[END_REF]van Oers et al., 2002;[START_REF] Oers | The Abiotic Depletion Potential: Background, Updates, and Future[END_REF] and additional efforts required to guarantee future resource extraction [START_REF] Itsubo | Iwatani Corporation. Commencement of Supply from Qatar Helium-2 and Launching Helium Joint Venture in Qatar. Incorporating Helium Transfilling, Container Logistics and Container Maintenance to Expand the Helium Business Effectively in the MENA[END_REF][START_REF] Ponsioen | Surplus cost as a life cycle impact indicator for fossil resource scarcity[END_REF][START_REF] Vieira | Surplus Cost Potential as a Life Cycle Impact Indicator for Metal Extraction[END_REF]).

However, these methods explore long-term scenarios and do not address resource accessibility considerations [START_REF] Frischknecht | Global Guidance on Environmental Life Cycle Impact Assessment Indicators[END_REF]. Based on this methodological gap; raw material criticality was proposed as a new perspective in LCSA to evaluate environmental, social and economic impacts related to the AoP Natural Resources with the aim to support decision-making processes [START_REF] Sonnemann | From a critical review to a conceptual framework for integrating the criticality of resources into Life Cycle Sustainability Assessment[END_REF].

Raw Material Criticality as a complement to LCA

Based on the framework presented in Figure 1.5 (Chapter 1:); multiple motivations exist to support the integration of raw material criticality and life cycle assessment. The potential for methods to associate criticality considerations of materials to a functional unit in LCA would support decision-making processes for product design (Cimprich et al., 2017a,b). The capacity for LCA to identify hotspots in a products life cycle would allow highlighting materials with a high criticality in a life cycle inventory; with an additional opportunity to link the physical flows in the inventory to their associated criticality [START_REF] Mancini | Characterization of rawmaterials based on supply risk indicators for Europe[END_REF].

Criticality assessments contain multiple dimensions for analysis such as environmental, economic and social implications [START_REF] Bach | Integrated method to assess resource efficiency -ESSENZ[END_REF][START_REF] Graedel | Methodology of metal criticality determination[END_REF][START_REF] Kolotzek | A company-oriented model for the assessment of raw material supply risks, environmental impact and social implications[END_REF][START_REF] Schneider | A comprehensive approach to model abiotic resource provision capability in the context of sustainable development[END_REF][START_REF] Achzet | How to evaluate raw material supply risks-An overview[END_REF]; these are already covered in LCSA through S-LCA, E-LCA and LCC from an "inside-out" perspective. However, the concept of supply risk and vulnerability to supply disruptions, which corresponds to an "outside-in" pathway, is not fully developed. The notion of supply risk in criticality assessment refers to considerations of global production concentration, country risks (e.g.

political stability, development level, government type) and supply mixes [START_REF] Achzet | How to evaluate raw material supply risks-An overview[END_REF]. In terms of vulnerability to supply disruption, factors such as substitutability, recycling and stockpiling were identified as supply risk mitigating strategies worth including in criticality assessments (Hebig et al, 2016b).

Three methods based on supply risk aim to provide insights on the criticality of materials within environmental LCA; these are designed to serve as a complement to the Abiotic Depletion Potential method (ADP), used to quantify the contribution of product systems to the depletion of mineral resources [START_REF] Guinée | A proposal for the definition of resource equivalency factors for use in product life-cycle assessment[END_REF]van Oers et al., 2002;[START_REF] Oers | The Abiotic Depletion Potential: Background, Updates, and Future[END_REF]. First, the geopolitical supply risk method (GeoPolRisk), introduced by [START_REF] Gemechu | Import-based Indicator for the Geopolitical Supply Risk of Raw Materials in Life Cycle Sustainability Assessments[END_REF] and subsequently extended by Helbig et al. (2016a) and Cimprich et al. (2017a,b). Then, the Economic Scarcity Potential (ESP), developed by [START_REF] Schneider | The economic resource scarcity potential (ESP) for evaluating resource use based on life cycle assessment[END_REF]; and the Integrated Method to Assess Resource Efficiency (ESSENZ), which is an extension and update of the ESP method [START_REF] Bach | Integrated method to assess resource efficiency -ESSENZ[END_REF]. Cimprich et al. (2019b) proposed the term "product-level supply risk assessment" as a way to refer to the GeoPolRisk, ESP and ESSENZ methods, which address "outside-in" impact pathways.

The three methods for product-level supply risk assessment use proxy indicators for supply disruption and vulnerability. As a comparison, Table 2.2 summarizes the impact mechanisms that link the political stability of raw material producing countries to supply risk (midpoint level indicator in LCIA) and the potential socioeconomic impacts relevant for countries or companies manufacturing a product from an "outside-in" perspective (endpoint level indicator in LCIA).

Socioeconomic impact on country or company manufacturing a product

As a country level measurement of political stability, the three methods consider the Worldwide Governance Indicators (WGI) developed by the World Bank (2019). The GeoPolRisk method only considers the indicator "political stability and absence of violence and terrorism" (WGI-PV); the ESP method integrates three WGIs (voice and accountability, political stability and absence of violence and terrorism, and government effectiveness). Finally, the ESSENZ method considers the previous ones, along with "regulatory quality", "rule of law" and "control of corruption"; other variables included in the ESSENZ method aim to characterize the overall resource availability based on physical and economic considerations (reserves, feasibility of exploration, price volatility, among others).

Supply risk depends also on mediating factors that complement the risk associated with the political instability of producing countries. The GeoPolRisk method considers the supply mix of importing countries and domestic production of the country from which the supply risk is measured to achieve a weighted risk average. This value is later integrated with the global production concentration measured by the Herfindahl-Hirschman Index (HHI) [START_REF] Herfindahl | Concentration in the steel industry[END_REF][START_REF] Hirschman | National power and the structure of foreign trade[END_REF]. The ESP and ESSENZ methods calculate a global weighted risk with the shares of producing countries. This is the first main difference between the methods; whereas ESP and ESSENZ provide global average characterization factors; the GeoPolRisk method is designed to provide supply risk values for particular cases (e.g. for regions, countries or companies).

While the result indicator for the GeoPolRisk method can be directly interpreted as the mass share at constant risk of supply disruption; the ESP and ESSENZ method apply a "distance-to-target" approach [START_REF] Müller-Wenk | Methodik für Ökobilanzen auf der Basis ökologischer Optimierung[END_REF][START_REF] Frischknecht | The ecological scarcity method-Eco-factors 2006[END_REF]: a calculated risk is compared to a "target" value and the excess indicates a high probability of supply disruption. In the GeoPolRisk method, the supply risk is independent from the magnitude of the inventory flows (Cimprich et al., 2017b); this is explained from a life cycle perspective by the fact that every input to a product system is equally necessary for the product, regardless of their amount [START_REF] Peck | Prometheus missing: Criticalmaterials and product design[END_REF]. On the contrary, the supply risk measured with the ESP and ESSENZ methods is exacerbated proportionally to the size of the analyzed inventory flow.

Each method has an applicability in order to achieve impact assessment from the "outside-in" perspective as a complement to "inside-out" environmental LCA. However, certain limitations are shared: there is not yet a way to associate the midpoint level indicators to an impact in the AoP natural resources at the endpoint level; and, information is obtained with proxy data to quantify political stability, adding several layers of uncertainty. The ESP and ESSENZ methods could serve to obtain global average supply risk values and the GeoPolRisk method could be applied at a more granular level for regions, countries or companies.

In order for LCA to support the assessment of product systems in an integrated fashion, works needs to be done to enhance the methods for product-level supply risk assessment. As one of the suggested methods by the UNEP LCIni Task Force on LCIA methods to address natural resources [START_REF] Frischknecht | Global Guidance on Environmental Life Cycle Impact Assessment Indicators[END_REF] and given the possibility to address supply risk from different perspectives, the GeoPolRisk method shows the most potential to be further developed into an endpoint level indicator to assess socioeconomic impacts associated with the AoP Natural Resources based in criticality considerations. Worldwide production information at mining and refining stages is usually obtained from the United States Geological Survey (USGS 2016(USGS , 2017(USGS , 2018)). The import supply mix data is obtained from the United Nations International Trade Statistics Database -UN COMTRADE (UN, 2020) and the WGI-PV provided by the World Bank is scaled to a range from 0 to 1 (0 representing the absence of risk). The results will also be between 0 and 1; where 0 can be interpreted as the complete absence of geopolitical supply risk and 1 represents a situation in which a 100% of the material supply going to the importing country is at imminent risk of disruption.

The Geopolitical Supply Risk Method

The two components of the GeoPolRisk formula provide different components of risk. The production concentration of a raw material (measured by the HHI) gives an overview of the criticality of the commodity; while the weighted political stability provides a country-specific contribution to the supply risk. The GeoPolRisk method can be used to compare the supply risk of a commodity from the perspective of various countries.

A previous application of the GeoPolRisk method to a case study of electric vehicles (EV) serves to show the potential for the method to assess the supply risk dimension of criticality and to complement environmental LCA. In [START_REF] Gemechu | Geopolitical-related supply risk assessment as a complement to environmental impact assessment: the case of electric vehicles[END_REF], the method was applied to materials used in electric vehicles. Among these materials, magnesium, neodymium, dysprosium and lithium have been identified as critical due to (1) the geopolitical issues in the region where they are sourced from and (2) having a hig production concentration in a few countries. The study exemplifies the application of the GeoPolRisk method under the framework of LCSA and compares the results with the midpoint indicators of a traditional environmental LCA.

The inventory data in the study includes materials, energy requirements and associated emissions throughout the analyzed life cycle stages of an EV. Although previous studies show that the use phase of an EV dominates the environmental impacts; only the resources consumed at the production stage are considered for the application. The inventory data was extracted from a publication by [START_REF] Hawkins | Comparative environmental life cycle assessment of conventional and electric vehicles[END_REF], in which the functional unit of one EV is considered. The application focuses on the following fourteen metals: steel and iron, aluminum, copper, neodymium, zinc, lead, magnesium, boron, bronze, tin, nickel, chromium, silver and the platinum group metals. USGS and UN-COMTRADE were the main sources for the application to the year 2013. The method was applied to thirteen countries/regions: Australia, Canada, China, the EU, France, Germany, Greece, India, Italy, Japan, Norway, the UK and the USA. Partial results of the study are illustrated in Figure 2.5. As main findings, magnesium and neodymium have the highest geopolitically related supply risk from the group for most countries. Neodymium alloyed with iron and boron is used as permanent magnet in multiple applications that include wind turbines, magnetic resonance imaging (MRI) equipment and electric motors for EV. China is responsible for the 95% of neodymium supply to most of the countries; therefore contributing to the high geopolitical-related supply risk of Nd, especially from the point of view of Canada, India and Norway. Australia relies on the USA for 75% of its neodymium imports, which translates into a lower risk than the other countries/regions because the USA is considered more geopolitically stable than China for the analyzed year. Although the USA is a producer of rare earth elements, it imports from other countries; therefore, the USA has high geopolitical-related supply risk due to the imports from China. The high GeoPolRisk value for magnesium in this study is primarily due to its high production concentration, since China accounts for 86% of global production.

From an LCA perspective, the most significant environmental impacts associated with metals are attributed to mining, extraction and refining activities. For the case of EVs, steel and iron are part of mainframe parts, doors and wheels; copper is found in wiring of electric motors and connectors; and, aluminium is utilized in the motor and other powertrain components. As presented in Figure 2.6, an E-LCA conducted using the ReCiPe midpoint method shows that aluminum and steel have the highest contribution to global warming potential and copper dominates the human toxicity and freshwater ecotoxicity midpoint indicators. E-LCA depends heavily on the mass share of the materials; therefore, copper, aluminium and steel become the resources with highest environmental impacts per functional unit. Unlike E-LCA indicators, GeoPolRisk provides a relative supply risk measure among multiple resources. The relative low contribution of magnesium and neodymium to the environmental impacts is due to their low mass requirements; however, this is not the case in the supply risk assessment. The GeoPolRisk values indicate that elements in small quantities become relevant from a criticality perspective. This case study supports the argument that the GeoPolRisk indicator complements the E-LCA, when presented together, policy makers and businesses can take more informed decisions for better product development and material management. In a recent publication by the UNEP Life Cycle Initiative, life cycle impact indicators for addressing abiotic resources were comprehensively reviewed to develop recommended practices; the result of this effort was the volume 2 of the Global Guidance on Environmental Life Cycle Impact Assessment Methods [START_REF] Frischknecht | Global Guidance on Environmental Life Cycle Impact Assessment Indicators[END_REF]. The GeoPolRisk method was discussed and reviewed as part of the proposed methods for product-level supply risk assessment (ESP and ESSENZ). Similarities and differences between these methods were discussed in section 2.2.2.

The guidance document highlighted certain limitations in the GeoPolRisk method. First of all, it relies on not always detailed or inaccurate public data regarding production and trade patterns around the world, which represents a significant challenge when estimating the geopolitical supply risk of certain materials.

In this context, the GeoPolRisk method is a snapshot in time of the supply risk of one material at the early stages of production; therefore, constant efforts need to be made to guarantee up to date values that represent the global situation of raw materials criticality.

Two main improvement opportunities are mentioned by a review on supply risk methods in LCSA (Cimprich et al., 2019b). First of all, the inclusion of recycling considerations as a supply-risk mitigation strategy and their effect in the GeoPolRisk calculations. A second main recommendation is referred to the extension of the GeoPolRisk method from a midpoint characterization factor in LCSA to an endpoint characterization factor directly related to the AoP Natural Resources. These two improvement opportunities will be further explored as part of the objectives of this PhD thesis.

As previously mentioned in Table 2.1 (Chapter 2:), there are multiple identified opportunities in the field of healthcare and sustainability: to explore understudied areas in healthcare from a sustainability lens, to investigate life cycle assessment as a method to support future research and to develop a conceptual framework that allows to integrate healthcare and sustainability aspects for future applications by academics and practitioners. This chapter develops the latter by defining and proposing a framework that allows visualizing and classifying activities related to the healthcare sector from a sustainability lens.

The Healthcare Sector

From a LCA perspective, healthcare can be seen as a system that encompasses multiple and diverse activities and flows. These activities can be directly seen when addressing a hospital environment, where doctors, nurses, technicians and other medical staff have direct contact with patients; however, countless other jobs are associated with the provision of care which are many times overlooked [START_REF] Walshe | Healthcare management[END_REF]. For example, a peripheral vision of the processes associated with the healthcare sector helps identify medical research and laboratory analysis as medical activities; while procurement, maintenance and food supply as non-medical support activities [START_REF] De Mast | Process improvement in healthcare: Overall resource efficiency[END_REF]. However, other processes such as the production of pharmaceuticals and medical devices, or the construction of healthcare facilities escape this classification. In life cycle assessment, it is possible to identify a similar behavior when categorizing specific processes as part of the life cycle inventory. The foreground system contains processes that are under the control of the decision maker carrying out the study, while the background system refers to process outside of their control [START_REF] Frischknecht | Life cycle inventory analysis for decision-making[END_REF].

The foreground and background systems associated with healthcare provision constantly exchange resources, emissions and information. This network functions underneath a regulatory and legal context depending on the country in which the studies on healthcare sustainability are conducted. Therefore, moving forward in this manuscript, it is possible to define the healthcare sector as the group of activities in the foreground and the background that allow the provision of healthcare services to the population under a regulatory system provided by a governmental body.

As discussed in sections 1.3 and 2.1, when addressing sustainability aspects of the healthcare sector, it becomes necessary to focus not only on the so-called "inside-out" impacts to understand how the activities of the healthcare sector are affecting the environment and society, but to acknowledge how the social, environmental and economic context affect the delivery of healthcare. Based on the previous mentioned points, a first mental map for the design of an integrated framework to support research on healthcare sustainability is presented in Figure 3.1. It includes the main classification for activities in the foreground system, their connection with the background system and the regulatory context; these are linked with the "inside-out" and "outside-in" impact pathways and examples of methods to address them from a sustainability perspective.

Studying healthcare systems

With the aim to better understand the activities associated with the healthcare sector and to provide a more detailed version of the framework, it becomes necessary to explore the three main defined classifications in Figure 3.1. A first proposed approach to the study was to list the most common medical specialties; following this train of thought and as reference for the discussion of future applications, a list of documented medical specialties by the Association of American Medical Colleges (AAMC) is presented in Table 3.1. Further discussion with experts in the field showed that all specialties behave similarly and depend on other transversal activities under a life-cycle-thinking perspective.

Name Description Allergy and Immunology

Management of disorders related to the immune system.

Anesthesiology

Medical study and application of anesthetics.

Dentistry

Prevention, diagnosis and treatment of disorders of the oral cavity.

Dermatology

Management of disorders related to the skin.

Emergency Medicine

Treatment of illnesses or injuries that require immediate attention.

Family Medicine

Comprehensive health care for people of all ages.

Internal Medicine

Prevention, diagnosis and treatment of adult diseases.

Medical Genetics

Management and study of hereditary disorders.

Neurology

Management of disorders related to the nervous system

Obstetrics and Gynecology

Care of female reproductive organs and management of pregnancy.

Ophthalmology

Management of disorders related to the optic system.

Otolaryngology

Management of disorders of the ear, nose and throat.

Pathology

Study of pathogens and diseases.

Pediatrics

Prevention, diagnosis and treatment of children diseases.

Physical Medicine -Rehabilitation

Enhancement of functional ability and quality of life.

Preventive Medicine

Study and management of measures to prevent diseases.

Psychiatry

Prevention, diagnosis and treatment of mental disorders.

Oncology

Prevention, diagnosis and treatment of cancer.

Radiology

Production and analysis of medical images for diagnosis and treatment.

Sleep Medicine

Prevention, diagnosis and treatment of sleep disorders.

Surgery

Prevention, diagnosis and treatment of conditions by manipulation of live tissue in the human body.

Urology

Prevention, diagnosis and treatment of disorders affecting the urinary and male reproductive system.

A second option to classify the activities was to use the levels of care delivery, this notation considers the complexity of patients' conditions, the level of specialty providers and the average resource requirements to provide healthcare services; therefore, it is more in line with a life-cycle-thinking perspective. This classification, as presented in Table 3.2, provides a more feasible way to address sustainability aspects and associated impacts based on the consideration of resources, time and location. However, there are still multiple medical activities that are transversal to the levels of care; therefore, additional work must be done to address these.

Level of care Description

Primary Care

Medical care required on a regular basis (e.g. routine checkups) or after the discovery of emerging mild symptoms; primary care providers are usually responsible for referring patients to specialists as needed.

Secondary Care

Specialized medical care beyond the one provided by primary care practitioners.

Tertiary Care

Further specialized care that requires specific equipment found in specialized healthcare facilities. Most complex therapeutic procedures are included in this level.

Long-term Care

Refers to services provided over a long period of time to meet the needs of patients with disabilities, chronic illnesses or in terminal state.

In-home Care

Activities directly related to the care of patients in their own homes. It includes, but is not limited to, home visits, palliative care, and specialized medicine administration.

The use of the levels of care allowed to provide categories of medical activities based on the proximity to the patient. Following previous work by Santillán-Saldivar (2017); a new layer was added to consider a business management perspective, in which all activities required to deliver healthcare to the population could be accounted for.

As seen in Figure 3.2, core medical activities can be classified based on the level of care, specialties and required resources. Ambulance Services are those dedicated to provide acute medical care outside of healthcare facilities and/or to transport patients to proper establishments to receive care. Consults refer to the acceptance of incoming patients to conduct checkups, these can be done at multiple levels of care. Diagnostic Activities are those directly aimed to understand and detect medical conditions and their severity based on parallel studies; they can be classified in Laboratory Activities (Testing of samples in a controlled environment with specific and standardized methods) and Imaging Activities (Production of medical images to represent the state of the human body). Management and Administrative services are part of the Non-Medical Support Activities, these do not directly involve the treatment of patients, but are necessary to guarantee a good healthcare delivery.

Administrative Activities within the healthcare systems include, but are not limited to, human resource management, financial management, information technology services, among others (Figure 3.3). On the other hand, management operations are physically related to the provision of care. Procurement refers to the management of supply chains relevant to healthcare, including acquisition and storage.

Plant Operations involve construction and maintenances of facilities and equipment, taking into considerations security and safety services. Food Services are those designed to provide nourishment to patients and staff. Waste Management is directly related to the management of residues, these include effluents, solid waste and hazardous waste, among others.

Potential Applications

Based on the presented life-cycle-thinking based framework, potential applications can be proposed and mapped. The framework has the aim to help identify research gaps and to support future research on healthcare sustainability from a life cycle perspective. Along the course of the PhD, multiple alternatives to apply life-cycle based methods to the healthcare sector were explored: Identification of criticality hotspots in the life cycle of catheters required for cardiothoracic surgery; comprehensive life cycle assessment of a healthcare facility; carbon footprint of anesthetic gases used in a surgical environment and the identification of criticality hotspots in the development of medical imagery.

The feasibility for the development of two studies was analyzed for a final selection of the case study.

The two proposals were established as follows: Carbon footprint of anesthetic gases used in a surgical environment; and, the integrated environmental and criticality assessment of helium used in MRI machines for medical imagery. In this section, the application of the framework to these two research proposals is presented.

Anesthetic gases in a surgical environment

Medical activities are diverse and numerous, among them, anesthesia delivery services are transversal and required for multiple medical specialties. The gases used for anesthetic purposes have been identified as having a significant Global Warming Potential (Sulbaek-Andersen et al., 2010) and limited studies on the delivery and use of such substances have been developed [START_REF] Sherman | Life Cycle Greenhouse Gas Emissions of Anesthetic Drugs[END_REF]Parvatker et al., 2018). Main results showed a larger carbon footprint of gaseous anesthesia delivery (sevoflurane and desflurane) compared to intravenous anesthesia delivery (propofol); however gaseous anesthesia delivery is preferred for patient comfort and fast effect.

Under a life cycle perspective, the study and analysis of environmental impacts generated by anesthetic drugs should include the accounting and assessment of all impacts: from the extraction of raw materials to the disposal, release or final disposition of residues after their use. There are available technologies in the market designed to reduce emissions originated by the delivery of anesthetic drugs, mainly oriented to automated control of gas delivery; however, other alternatives such as gas capture are

available but yet to be studied [START_REF] Sherman | Life Cycle Greenhouse Gas Emissions of Anesthetic Drugs[END_REF][START_REF] Thiel | Strategies to Reduce Greenhouse Gas Emissions from Laparoscopic Surgery[END_REF].

Anesthesia delivery services are transversal in healthcare services, appearing as part of the processes to be followed in therapeutic and diagnostic procedures. Reports and guides of good practices promoted by The French Society of Anesthesia and Intensive Care Medicine (SFAR) have touched the topic of green anesthesia as part of initiatives on developing a more sustainable operating room [START_REF] Muret | Le bloc opératoire durable[END_REF].

Following a life cycle perspective, the study and assessment of environmental impacts caused by the use of anesthetic drugs must include all impacts along the life of the analyzed products; focus has been already given to production and use stages; however, an apparent gap is seen when trying to understand improvements that can be proposed to reduce the carbon footprint of anesthetics delivery to patients; especially when exploring gaseous options. Figure 3.6 shows the application of the framework to support research on healthcare sustainability to the study of anesthetics in a surgical environment.

Figure 3.6 -Application of the framework for healthcare sustainability -Use of anesthetic gases in a surgical environment

The framework allows to identify the relevant aspects in the healthcare sector that will need to be explored in order to assess the carbon footprint of anesthetic gases used in a surgical environment.

Focusing on the life cycle stages; multiple product systems are identified in the background (e.g.

anesthetics, anesthetic delivery equipment, energy, reusable and disposable medical supplies, among others). Procurement is a non-medical support activity that will need to be assessed to identify the supply chain of selected products used for anesthetic delivery.

With focus on the medical aspect, a proposed study on this subject will involve the tertiary level of care, because specific instruments and equipment are required to deliver the service in a healthcare facility.

The associated medical specialties are surgery and anesthesiology; and the involved medical activities will be Non-ICU hospitalization (Pre-operatory), OR procedures (surgery), Pharmacy services (anesthetics delivery) and ICU hospitalization (Post-operatory). Waste management will have a big role for assessing this case, since one of the main questions would be how to reduce the direct emissions of leftover anesthetic gases into the atmosphere.

Specifically, in this scenario, the addressed impacts will be those that follow an inside-out pathway and life cycle assessment is proposed as the main methodology to evaluate the carbon footprint of this system. The use of this methodological pathway would allow to identify hotspots in the life cycle that contribute to the carbon footprint and, analyze mitigating strategies to reduce emissions, especially those associated with the delivery of anesthetic gases in surgeries.

Efforts were made to take this project to fruition as part of this PhD; however, administrative requirements and conflicting schedules delayed the development of the proposal. This situation was only exacerbated by the global sanitary crisis. This case won't be further explored in this manuscript as it was preferred to move forward with the case presented in section 3.3.2 based on having a better access to data and a closer connection to the work developed as part of the component on criticality considerations in LCA for this PhD thesis.

Helium for medical imaging

Another transversal activity to multiple medical specialties is medical imaging. In radiology, complex machines are used to obtain images of the human body that support the diagnosis and treatment of multiple conditions. Some of the most typical imaging producing technologies are the x-rays, magnetic resonance imaging (MRI), ultrasounds and tomography. In the case of MRI machines, strong magnetic fields are used to visualize tissues in the body rich in water and lipids [START_REF] Hoult | NMR Signal Reception: Virtual Photons and Coherent Spontaneous Emission[END_REF]. Most of the magnets used to create these fields require liquid helium to maintain an optimal working temperature [START_REF] Weishaupt | How does MRI work? An introduction to the physics and function of magnetic resonance imaging[END_REF].

Unlike other materials used in the healthcare sector; helium is subject to two impact pathway mechanisms in terms of sustainability. First, there are environmental impacts associated to the production, delivery and use of helium for MRI machines, specially associated to the energy required to store helium at low temperatures and avoid leaks [START_REF] Lvovsky | Novel technologies and configurations of superconducting magnets for MRI[END_REF]. On the other hand, concerns have been raised regarding potential supply risk constraints of helium [START_REF] Glowacki | Beyond the Helium Conundrum[END_REF], a nonrenewable resource considered irreplaceable to modern science and technology [START_REF] Jaffe | Energy Critical Elements: Securing Materials for Emerging Technologies[END_REF].

These characteristics found in helium raise questions not only about availability of the resource, but also about its accessibility; which were key points in the discussion on how to address impacts in the area of protection Natural Resources in LCA (Section 1.3).

There

has not yet been a study that addresses both environmental and supply risk considerations of helium for the healthcare sector; however, helium has been the focus for limited publications on critical materials. Following a life cycle perspective, a study focused on helium should include impacts associated to the production, transport and use of helium; additionally, supply risk considerations (impacts measured from an "outside-in" perspective) should be explored to understand how external aspects not associated to the healthcare sector can affect the future delivery of care.

Figure 3.7 illustrates the application of the framework for healthcare and sustainability to support a study on the sustainability aspects of helium for the healthcare sector. It is possible to identify that liquid helium, MRI machines, energy and multiple medical devices can be associated to a case on the use of helium as background systems in LCA; being helium considered a resource with supply constraints, procurement is a relevant activity to consider.

As previously mentioned, a potential case study on the use of helium in MRI machines would be associated to imaging activities as part of diagnosis processes, which are the focus of the medical specialty of radiology. Given the requirement of complex machinery and specialized professionals, these fall under the tertiary level of care in healthcare.

The impacts that should be studied when addressing helium follow both pathways: "inside-out", for the study of emissions along the life cycle of helium and "outside-in", in close relation with the limited availability of helium. The duality when addressing the sustainability aspects of helium in the healthcare sector makes this case attractive from a research stand point. Further in this manuscript, the use of helium for medical imaging will be addressed in an integrated way, by considering both environmental assessment considerations and supply risk considerations.

However, the current indicators used in life cycle assessment are not yet fully prepared to address "outside-in" impacts; therefore, as previously discussed in section 2.2.2, product-level supply risk assessment methods need to be enhanced to provide more relevant information for decision-making processes in industry and government. Based on the maturity assessment of the existing indicators that aim to address "outside-in" impact pathways in LCA, before conducting a life cycle assessment to a case study in the healthcare sector, it becomes necessary to explore the potential of the geopolitical supply risk method to address the concerns and suggestions raised by the UNEP LCIni Task Force on LCIA methods to address natural resources [START_REF] Frischknecht | Global Guidance on Environmental Life Cycle Impact Assessment Indicators[END_REF].

The following chapters will deviate from the branch of healthcare sustainability in this PhD thesis towards the exploration of raw material criticality in LCA with the objective to propose methodological enhancements that could help position the GeoPolRisk method as a new indicator to assess the impact category supply risk in LCA. As previously discussed in section 2.2.1, opportunities for further development when addressing the AoP Natural Resources in LCA have been identified [START_REF] Frischknecht | Global Guidance on Environmental Life Cycle Impact Assessment Indicators[END_REF]. Differences in problem formulation and modelling have generated debates and confusion among LCA practitioners (Drielsma et al., 2016a(Drielsma et al., , 2016b;;[START_REF] Sonderegger | Towards harmonizing natural resources as an area of protection in life cycle impact assessment[END_REF]; therefore, in 2017, the UNEP Life Cycle Initiative (LCIni) established an expert task force to review existing LCIA methods that address mineral resource use [START_REF] Cimprich | Raw material criticality assessment as a complement to environmental life cycle assessment: examining methods for product-level supply risk assessment[END_REF]. As a result, recommendations were formulated to support further methodological development in supply risk and to study how impacts in resources should be defined [START_REF] Berger | Mineral resources in life cycle impact assessment: part IIrecommendations on application-dependent use of existing methods and on future method development needs[END_REF][START_REF] Cimprich | Raw material criticality assessment as a complement to environmental life cycle assessment: examining methods for product-level supply risk assessment[END_REF].

Among the analyzed methodologies, the GeoPolRisk method stands out for providing country-specific supply risk characterization factors and focusing on the geopolitical (in)stability of trade partners as a driver of supply risk; one of the main recommendations provided by the UNEP LCIni Task Force was to explore the risk-mitigating potential of recycling. In this chapter, the recommendation on assessing recycling as a risk mitigation strategy is addressed and the GeoPolRisk method is enhanced to include domestic recycling considerations.

Methodological Enhancement: Recycling as a Supply-Risk-Mitigation Strategy

The methodological proposal is based on the study of two independent effects: a "reduction effect", which is related to an overall reduction of material requirement due to recycling; and a "redistribution effect", which is the result of exploring changes of the import supply mix from the perspective of an analyzed country or region. In Figure 4.1 it is possible to visualize these effects on a fictive trade network for one commodity that includes one importer and four exporters with different risk profile measured by their political (in)stability. The graphic refers to a case in which the reduced requirement has the reduction of imports from country "A" as a direct consequence; in this fictive network, country "A" is both the biggest supplier and the riskiest trade partner. Inherently, a lower new requirement will contribute to a reduction of the supply risk (reduction effect); however, a second mechanism is in place when a new supply mix is visible for the importer (redistribution effect). However, the graphic shows only one ideal scenario in which the reduced requirement is taken from the riskiest partner; in reality, more considerations are in place and it's not possible to predict how the supply mix will behave after a requirement reduction. In order to cover this limitation, two scenarios must be defined: The best-case scenario (BCS), already presented in Figure 4.1, and the worst-case scenario (WCS), in which the reduced requirement would be taken from the more stable partners. It is possible to define the domestic recycling production (RAc) as a percentage of the total requirement of the commodity for country A. The indicator End of Life -Recycling Input Rate (EoL-RIR), is defined as the ratio between the sum of flows of secondary material recovered from end-of-life products and reinserted into the economy through domestic recycling, and the sum of supply flows from both primary and secondary sources (European Commission, 2014).An EoL-RIR ranges from 0% to 100%, in which 0% means that recycling is non existent and 100% represents a case in which all material used in the economy is domestically recycled.

Based on these definitions, it's theoretically possible to assign a BCS and WCS values of the GeoPolRisk indicator to every EoL-RIR percentage as presented in Figure 4.2. All the potential values of the GeoPolRisk indicator as a function of the EoL-RIR will range from a best-case scenario (BCSbetter supply risk improvement) to a worst-case scenario (WCSworst supply risk improvement); capturing all possible outcomes for the specific cases. Moving forward it will be possible to see how this graphic behaves depending on the supply profile of the analyzed commodity.

The case of ICT in the European Union

The Information and Communication Technologies (ICT) sector constitutes 4.8% of the EU economy and accounts for 17% of expenditures in research and development within the EU (European Commission, 2019). The increasing use and relevance of a wide range of products in the ICT category raises questions about the amount and variety of critical raw materials needed for these applications; moreover, there are growing concerns about the potential recovery of these materials from end-of-life products in the EU [START_REF] Horta | From waste management to supplier of secondary raw materials: development of indicators to support WEEE chain management -focus on the French system[END_REF]. Since the GeoPolRisk method is applied at material level from the perspective of a country or region, it is possible to say that a first test application of the proposed enhancement would not only be relevant for the ICT industry, but could provide insights for other sectors that use some of all of the analyzed raw materials.

To test and demonstrate the enhanced GeoPolRisk method, a set of 13 raw materials (or groups of raw materials) was used. These materials are considered relevant for, among other things, developing and strengthening the information and communication technologies (ICT) sector in the European Union. The complete list was obtained by crossmatching the Report on Critical Materials for the European Union (European Commission, 2017) and the raw materials listed in the report on material efficiency of the personal computers' product group [START_REF] Tecchio | Analysis of material efficiency aspects of personal computers product group[END_REF]. Based on data availability, the study was conducted for the year 2016.

Four main pieces of information are required to calculate the GeoPolRisk values under the extended method: production volumes of each producing country, geopolitical (in)stability of each trade partner country, import volumes from each trade partner, and domestic recycling rates for the analyzed region, in this case the EU. The geopolitical instability was measured using the country WGI-PV scores available from the World Bank (2019). These were normalized from a 0 to 1 scale as has been common practice for other previous applications of the GeoPolRisk method. The full set of re-scaled WGI-PV scores, for all countries in 2016 is provided in Annex C. Raw material production and trade data were primarily obtained from the United States Geological Survey (USGS) annual Mineral Commodity Summaries (USGS 2016(USGS , 2017(USGS , 2018) ) and the United Nations Comtrade Database (UN, 2020) respectively.

To fill gaps in these datasets for some raw materials (namely germanium, iridium and ruthenium), the Critical Raw Materials Factsheets from the European Commission were used (European Commission, 2017). Table 4.1 provides an overview of the data sources used to calculate the trade and production components of GeoPolRisk for the EU in 2016 (i.e., primary production by country and the import shares of each trade partner) for each raw material (or group). Grouping some raw materialsnamely gallium group metals, platinum group metals (PGMs), and rare earth elements (REEs)was necessary given data limitations.

Given the lack of data on domestic recycling of manufacturing scrap in the EU, the most recent values (i.e., from 2016) for the "end-of-life recycling input rate" (EoL-RIR) are used, available from Eurostat (2017) as a conservative estimate of the total supply of domestically recycled materials in the EU.

Previous applications of the GeoPolRisk method have been conducted using basic spreadsheet software. This approach is computationally burdensome. Especially for this case in which multiple scenarios must be analyzed. To facilitate the calculations, the author used a novel application developed on Python programming language by Shaikh (2020). Among other functionalities, this tool allows users to calculate GeoPolRisk values for a given country, sourcing a given raw material, under a range of domestic recycling rates. The GeoPolRisk results for all 13 raw materials (or group of materials) are presented in Figure 4.3 for values of the EoL-RIR ranging from 0% to 50%; results for the full range (0-100%) are provided in Annex D. For platinum, palladium, and "other PGMs," the redistribution effect is greater than the reduction effect at the present EoL-RIR. For magnesium and cobalt, in contrast, the reduction effect is greater than the redistribution effectto the point where the latter is indiscernible. In the case of magnesium, this result reflects the present import supply mix to the EU, which relies heavily on China and Iran as the largest trade partners, both of which are relatively unstable countries (as measured by their relatively high WGI-PV values). The case of cobalt can be explained by highly concentrated production, namely in the Democratic Republic of Congo (which has a high WGI-PV value). The magnitude of the redistribution effect mainly depends on the variation of WGI-PV values between various trade partners (see Annex C for a full set of WGI-PV values); the greater the variation, the greater the potential redistribution of the import supply mix towards more stable trade partners. In the case of tantalum and germanium, the present EoL-RIR is low enough that neither the reduction effect nor the redistribution effect are significantthough they become increasingly significant at higher recycling rates (e.g., a 30% EoL-RIR, combined with strategic redistribution of the import supply mix, could reduce the GeoPolRisk of germanium to about 0.2, compared to the present value of 0.3). In the case of beryllium, borates, cobalt, gallium group metals, and silicon metal, the EoL-RIR is presently 0%, so the GeoPolRisk values are the same as they would be if calculated per the original method (as in Equation 2.1). However, except for beryllium (for which production is dominated by the U.S., a relatively stable country), the results suggest that domestic recycling has significant risk-mitigating potential, especially when the import supply mix is redistributed towards more stable trading partners. Silicon metal, for example, is not currently recovered from post-consumer waste given that many of the applications of this commodity have a dissipative nature (e.g. additives in coating processes), but recycling processes are being developed for some applications (European Commission, 2017). Given data limitations, it is assumed that the EoL-RIR of natural graphite and REEs is presently 0%; nonetheless, the enhanced GeoPolRisk method enables to illustrate the potential risk mitigation that could be achieved through increased domestic recycling rates, especially when combined with redistribution of the import supply mix.

Discussion on the inclusion of recycling considerations in the GeoPolRisk method

The application of the extended GeoPolRisk method to 13 raw materials (or groups of raw materials) used for, among other things, information and communication technologies (ICT) in the European Union supports the notionwidely reflected in the literature on critical raw materialsthat recycling can mitigate raw material supply risk [START_REF] Erdmann | The Criticality of Non-Fuel Minerals: A Review of Major Approaches and Analyses[END_REF][START_REF] Graedel | Six years of criticality assessments: what have we learned so far?[END_REF][START_REF] Gaustad | Circular economy strategies for mitigating critical material supply issues[END_REF]. As in other supply risk assessment methods developed from an LCA perspective, like the Economic Scarcity Potential (ESP; [START_REF] Schneider | The economic resource scarcity potential (ESP) for evaluating resource use based on life cycle assessment[END_REF]) and ESSENZ [START_REF] Bach | Integrated method to assess resource efficiency -ESSENZ[END_REF], this enhancement considers that recycling can mitigate supply risk by relieving pressure on primary sourcing. However, given the regionalized nature of the GeoPolRisk indicator, another layer to the assessment is added by considering the relative geopolitical (in)stability of both primary and secondary sources. The enhanced GeoPolRisk method considers two mechanisms through which recycling can affect supply risk: first, a reduction of total imports (the "reduction effect"), and second, a potential redistribution of the import supply mix (the "redistribution effect"). Thus, to maximize risk mitigation, recycling should ideally take place domestically (or recycled materials should be imported from relatively stable countries), and the recycled material should be reinserted into the domestic economy. Importing recycled materials from foreign economies might bring environmental benefits compared to using virgin materials, but this does not maximize the mitigation of geopolitical-related supply risk. In fact, it could exacerbate supply risk if the recycled materials are imported from geopolitically unstable countries or regions. To further mitigate supply risk, the import supply mix should be consideredespecially given that the redistribution effect sometimes exceeds the reduction effect.

The enhanced method is subject to several limitations in theory and practice. First, from a practical perspective, it can be difficult to obtain the necessary production and trade data with sufficient granularity for all raw materials under consideration. The UN Comtrade database, for example, often lacks an appropriate commodity code (e.g., the rare earth metals neodymium and gadolinium), or aggregates multiple commodities into a single commodity code (e.g., HS 26 15 90 for "niobium, tantalum, vanadium ores and concentrates"). Therefore, in this case, some raw materials were aggregated into groups (namely "other PGMs," gallium group metals, and REEs), which masks variations in supply risk between commodities within these groups.

There can also be significant uncertainty around domestic recycling rates, which are influenced by a variety of factorsincluding, among other things, current metal stocks, future demand, quality policies, technology restrictions, and economic feasibility (UNEP, 2013). The end-of-life recycling input rate (EoL-RIR) was used as a conservative estimate, though this value is not available for all raw materials.

However, as demonstrated through the case study, the extended GeoPolRisk method can simulate what the risk-mitigating effect could be under any given recycling rate. The results of the case study suggest that increased domestic recycling rates, combined with strategic redistribution of the import supply mix, can be an effective risk-mitigation strategy. Problems of data availability and quality, though limiting in practice, do not constitute a theoretical limitation of the method itself.

The theoretical limitations of the GeoPolRisk method have been extensively discussed in earlier publications [START_REF] Gemechu | Import-based Indicator for the Geopolitical Supply Risk of Raw Materials in Life Cycle Sustainability Assessments[END_REF][START_REF] Gemechu | Geopolitical-related supply risk assessment as a complement to environmental impact assessment: the case of electric vehicles[END_REF]Helbig et al. 2016a;Cimprich et al. 2017a, b) and by the Life Cycle Initiative Task Force on Mineral Resources [START_REF] Cimprich | Raw material criticality assessment as a complement to environmental life cycle assessment: examining methods for product-level supply risk assessment[END_REF]. In particular, while the methodological advancement presented in this chapter addresses one of the main Task Force recommendations for "supply risk methods" (i.e., incorporating considerations of material recycling), the others (i.e., increased spatial resolution, improved modelling of multiple supply-chain stages and improved modelling of effects in the AoP Natural Resources) remain largely open questions.

With respect to spatial resolution, the GeoPolRisk method models supply risk as a function of commodity trading between macroeconomic units (i.e., countries or regions), whereas supply-chains actually comprise market relationships between microeconomic units (i.e., companies). The same argument applies to environmental and social sustainability aspects in supply-chains [START_REF] Goldstein | How to track corporations across space and time[END_REF].

With respect to modelling multiple supply-chain stages, though an extension of the GeoPolRisk method was developed for this purpose (Helbig et al. 2016a), the application of this extension was made on only (part of) a single product system (polyacrylonitrile used as a precursor for carbon fiber production); and, from an LCA perspective, it remains unclear how to link the multi-stage GeoPolRisk calculation to the functional unit of a given product.

Finally, the GeoPolRisk method can be considered equivalent to a "midpoint" approach in LCIA, as it serves to indicate (or at least give a proxy for) the relative likelihood of geopolitically-induced supply disruptions of a given raw material for a given macroeconomic unit. Further development could extend the method to an "endpoint" approach (e.g., to assess the impacts of supply disruptions as manifested in physical raw material shortages and/or price spikes) for the "natural resources" AoP in the life cycle sustainability assessment (LCSA) framework; this last potential improvement will be addressed in the next chapter.

With this enhancement, recycling considerations are assessed as strategies for criticality mitigation, as suggested by members of the International Round Commission, 2015). Despite of the limitations, the enhancement of the GeoPolRisk method presented in this chapter directly addresses the UNEP Life Cycle Initiative Task Force recommendation to incorporate the potential risk-mitigating effects of material recycling into supply risk methods; therefore, advancing the maturity of the method for further applications.

As discussed in section 2.2.2, raw material criticality has been proposed as a complement to environmental life cycle assessment by addressing resource accessibility as part of the LCSA framework. Moreover, resource accessibility has been accepted as an environmental impact category associated to the AoP Natural Resources in LCA; it provides the notion of a socio-economic pathway to address impacts associated with resource utilization. Product-level supply risk assessments follow this perspective by assessing outside-in impacts.

The GeoPolRisk method [START_REF] Gemechu | Geopolitical-related supply risk assessment as a complement to environmental impact assessment: the case of electric vehicles[END_REF]Cimprich et al., 2017) has been interim recommended to quantify potential accessibility issues to raw materials related to short-term geopolitical and socioeconomic aspects. This suggestion was made by the Task Force on mineral resources of the Life Cycle Initiative hosted by UN Environment [START_REF] Berger | Mineral resources in life cycle impact assessment: part IIrecommendations on application-dependent use of existing methods and on future method development needs[END_REF][START_REF] Frischknecht | Global Guidance on Environmental Life Cycle Impact Assessment Indicators[END_REF]. However, the accessibility issues currently addressed belong to a midpoint level in LCA and thus, so far, there has been no applicable method to associate the supply risk at midpoint level to a tangible endpoint socioeconomic damage.

The current methodological challenge is to estimate a socio-economic damage through a cause-effect chain of potential geopolitical supply disruptions. Addressing damages to the AoP Natural Resources would require the inclusion of a damage factor linking supply risk to potential increased costs. Among the current efforts related to natural resources, the Abiotic Depletion Potential (ADP) method explores the contribution of a product system to the depletion of mineral resources [START_REF] Guinée | A proposal for the definition of resource equivalency factors for use in product life-cycle assessment[END_REF]van Oers et al., 2002;[START_REF] Oers | The Abiotic Depletion Potential: Background, Updates, and Future[END_REF], the LIME2 (Itsubo and Inaba, 2012) method quantifies future externalities of mineral resource use, the ESSENZ method considers price volatility as an indicator that contributes to a measure of criticality [START_REF] Bach | Integrated method to assess resource efficiency -ESSENZ[END_REF], and the Surplus Cost Potential (SCP) explores costs increases of future resource extractions [START_REF] Ponsioen | Surplus cost as a life cycle impact indicator for fossil resource scarcity[END_REF][START_REF] Vieira | Surplus Cost Potential as a Life Cycle Impact Indicator for Metal Extraction[END_REF].

However, these methods explore long-term scenarios and do not address accessibility considerations [START_REF] Frischknecht | Global Guidance on Environmental Life Cycle Impact Assessment Indicators[END_REF]. This chapter has the objective to propose and apply a novel endpoint-level indicator to address short-term socio-economic effects of geopolitical supply risk based on the GeoPolRisk method.

The Economic Impacts of Supply Disruption

It is argued that supply disruption events are linked to monetary socio-economic damage through a cause-effect chain. According to economic theory, in the case of a geopolitical tension causing a supply disruption, the supply curve shifts, meaning that less material is offered to the market for the same price [START_REF] Mceachern | Economics: A contemporary introduction[END_REF][START_REF] Varian | Intermediate microeconomics with calculus: a modern approach[END_REF][START_REF] Baumol | Microeconomics: Principles and policy[END_REF]. Such a disruption is more likely for critical raw materials, which have more limited production, and the disruption causes undesired economic damage [START_REF] Graedel | Six years of criticality assessments: what have we learned so far?[END_REF]. In contrast, the demand curve does not move in the case of a supply disruption event, assuming that substitution options are not immediately available and supply disruption does not affect consumption. Therefore, as illustrated in Figure 5.1, following basic economic principles the new market equilibrium after the event will be at a higher price; and the price increase will remain for as long as the supply disruption persists. However, when addressing supply risk, it becomes necessary to examine events at which the raw material supply changes unexpectedly; events further studied in this chapter are unexpected and, therefore, the risk of damage in the short term is not included in the market prices [START_REF] Koch | Using event studies to assess the impact of unexpected events[END_REF].

By looking at specific events involving sudden supply disruptions, it could be possible to estimate the slope of the demand curve. Natural catastrophes with documented effects on mining or processing activities can be addressed, since their occurrence is considered a risk for mineral production [START_REF] Schnebele | Natural hazards and mineral commodity supply: Quantifying risk of earthquake disruption to South American copper supply[END_REF]. The slope of the demand curve implies the economic damage: given a low demand slope, a reduction of the supply would cause an increase in price and, consequently, a reduction of welfare. In contrast, a high slope would imply sharply rising prices. This would result in a high wealth reduction on the demand side driven by a large consumer price increase. The "price elasticity of demand" indicates the effect of a (marginal) price change of a commodity on the requested quantity. For this calculation, the quantity and world market price changes (in percentages) are set in relation to each other as per Equation 5.1 [START_REF] Varian | Intermediate microeconomics with calculus: a modern approach[END_REF] supply curve (2) and as a result, (B) the price increases from p (1) to p (2). This leads to (C) a decline in demand from q (1) to q (2). The extent of the price increasewhich corresponds to the slope of the (dotted) demand curveresults from the ratio between the change in quantity and the change in price.

For the application that will be later presented in this chapter, proxies for price elasticity values will be obtained after studying the effect of short-term shortages of supply caused by natural disasters on global commodity prices.

Methodological Enhancement: GeoPolEndpoint

The proposed extension takes on previous work on the integration of criticality considerations into LCSA [START_REF] Sonnemann | From a critical review to a conceptual framework for integrating the criticality of resources into Life Cycle Sustainability Assessment[END_REF] and the inclusion of supply risk as an impact category associated to the AoP Natural Resources in LCA based on social and economic considerations [START_REF] Cimprich | Raw material criticality assessment as a complement to environmental life cycle assessment: examining methods for product-level supply risk assessment[END_REF]. As mentioned in section 2.2.3, For a given material, year and region, the GeoPolRisk method provides an In LCA, the functional unit represents the service provided by the product. Given the assumption that production is still possible despite the event, the damage of a geopolitical supply shortage is equivalent to the geopolitically-driven increased costs for the production due to higher raw material costs. The result provides a damage value in monetary units related to specific raw materials and applicable for the assessed year.

In order to develop an endpoint indicator based on the GeoPolRisk method, it becomes necessary to apply it at a larger scale because most metals are traded in a global market. As a first proof of concept, the method is applied from the perspective of the group formed by the members of the Organization for Economic Co-operation and Development (OECD). The decision on the use of the OECD members as reference group is based on its design as a global network with high impact on economic, environmental and social policies around the globe (OECD, 2019a); and for its focus on stimulating economic development and global trade (OECD, 2019b). The adjusted formula for the global fraction at risk of a commodity for a given year to be further used and referenced in this chapter is determined by:

Equation 5.2 ………………………………………..… 𝐺𝑒𝑜𝑃𝑜𝑙𝑅𝑖𝑠𝑘 𝑂𝐸𝐶𝐷 = 𝐻𝐻𝐼 * ∑ 𝑔 𝑐 𝑐 * 𝑓 𝑐,𝑂𝐸𝐶𝐷 𝑃 𝑂𝐸𝐶𝐷 +𝐹 𝑂𝐸𝐶𝐷
Where gc is the score of the country in the WGI-PV transformed to a 0-1 scale; fc,OECD is the trade flow of a commodity from country c to the group of OECD countries; FOECD represent the total imports of OECD countries for the commodity and POECD is the production of a commodity in the group of the OECD countries.

Based on the adjusted formula for the case of the OECD countries and the idea of implementing the concept of a price elasticity value to an endpoint-level indicator, the GeoPolEndpoint method is proposed to provide a measure of the socio economic damage to the AoP Natural Resources in LCSA. The formula for one defined resource and one year is described as follows:

Equation 5.3……………𝐺𝑒𝑜𝑃𝑜𝑙𝐸𝑛𝑑𝑝𝑜𝑖𝑛𝑡 𝑂𝐸𝐶𝐷 = 𝐺𝑒𝑜𝑃𝑜𝑙𝑅𝑖𝑠𝑘 𝑂𝐸𝐶𝐷 × ε × 𝑝̅ = 𝐶𝑜𝑠𝑡 𝐼𝑛𝑐𝑟𝑒𝑎𝑠𝑒 𝐹𝑎𝑐𝑡𝑜𝑟 × 𝑝̅
Where ε is the inverse price elasticity of the resource, which is assumed to be iso-elastic, (constant on the entire curve) [START_REF] Sah | Can government collect resources without hurting investors? Taxation of returns from assets[END_REF] and 𝑝̅ is the average price of a resource a in year t. The product of ε and GeoPolRiskOECD will be further referred as the Cost Increase Factor.

For a given resource and year, the result of this calculation is interpreted as an average cost increase of facing a sudden geopolitically-driven supply disruption per unit of mass of the material under analysis.

If the supply disruption occurs, the material flow is reduced by this amount, leading to a price increase defined by the elasticity. Consequently, the measure approximates the potential loss in economic welfare of the material-processing countries facing a potential disruption. These damage factors are intended to be multiplied by the mass flows in a LCA inventory and provide a measure of the damage caused by the use of the individual resource as part of LCSA. The geopolitically-driven increased costs from all considered resources can be summed at the end for assessments at product level.

The case of Lithium-ion Batteries

Lithium-ion batteries (LIB) demand has increased steadily after the year 2000 primarily due to mobile consumer electronic devices. LIB demand growth is determined by the growing market share of electric vehicles [START_REF] Pillot | The Rechargable Battery Market and Main Trends[END_REF]. Aluminum, cobalt, nickel and copper are all used in LIB, as either current collectors or metals in cathode materials [START_REF] Peters | A Critical Assessment of the Resource Depletion Potential of Current and Future Lithium-Ion Batteries[END_REF]. Materials like cobalt, nickel or lithium are main contributors to supply risks of LIB [START_REF] Helbig | Supply risks associated with lithium-ion battery materials[END_REF]. For this application, it is foreseen to model the geopolitically-driven increased costs of selected materials in LIB as potential short-term increased costs on the product system of LIB due to unexpected supply disruptions.

Based on the inventory provided by [START_REF] Peters | A Critical Assessment of the Resource Depletion Potential of Current and Future Lithium-Ion Batteries[END_REF], two types of cells of LIB will be studied:

nickel-cobalt-aluminum (NCA-C) and nickel-manganese-cobalt (NMC-C) cathode active material, both with graphite anode material. NCA-C battery cells are estimated to have and energy density of 133.1

Wh/kg and NMC-C, of 130.4 Wh/kg. The most relevant materials in the inventory of these batteries are lithium, aluminum, manganese, cobalt, nickel, copper, carbon and phosphorus; however, this application will focus only on aluminum, cobalt, copper and nickel due to being the only ones for which it is possible to obtain values for price elasticity according to the method proposed in section 5.1. Table 5.1 shows the mass contribution of these four selected materials to the inventory of NCA-C and NMC-C LIB. The supply risk, and contribution to the socio-economic impacts of these materials as part of the inventory of LIB will be analyzed for the period between the years 2015 and 2017. This period was selected due to data availability for geopolitical supply risk and for price elasticity calculations at the time of the beginning of the study. The average prices in 2017 for the four metals range in between 1.97 USD per kg for aluminum and 55.6 USD/kg for cobalt. Nickel and copper have been traded in 2017 at 10.5 USD/kg and 6.17 USD/kg, respectively. Prices refer to LME (London Metal Exchange) market prices (Thomson Reuters, 2019). The same prices are used for the calculation of price elasticity proxies, the average price values for the analyzed years are displayed in Table 5.2.

Price Elasticity Data and Calculations

As previously discussed in section 5.1, to estimate the slope of the demand curve and the impact of a supply shock, it becomes necessary to focus on situations in which the supply changes due to sudden external events. Natural disasters are situations where producers are forced to reduce their capacity, because the mines or the transportation infrastructure are destroyed [START_REF] Benson | Understanding the Economic and Financial Impacts of Natural Disasters[END_REF]. For this study, it is irrelevant whether the infrastructurewhich includes transport, power, and communications networksis completely or only partially destroyed. In any case, the supply of the raw material is impaired. As a first step, natural disasters during which mines were affected are analyzed. For this purpose, the "NatCat"-database of Munich Re ( 2019) is used to identify the dates and the type of each disaster (e.g. earthquake and tsunami, tropical cyclone, flood and flash flood) as well as the affected country and the geographical coordinate of each natural disaster. On the other hand, the location of the mine as well as the prices of the commodities concerned are of interest. Mining data was taken from the annual Minerals Yearbook (USGS, 2016(USGS, , 2017(USGS, , 2018)).

As previously stated, price information was obtained from the London Metal Exchange (Thomson Reuters, 2019). Only events in which more than 1% of the global mining was affected are considered.

For lower affected mining volumes, it can be assumed that their possible influence on the global price is negligible. In addition, the distance between the disaster and the affected mine should not be greater than 100 kilometers measured by the great circle (longitude and latitude of event and mine).

Furthermore, the focus is given to events that are followed by a price increase of the commodity affected.

On the basis of these criteria, the natural disaster best fitting the criteria for each commodity is identified and the associated price changes are examined.

For this application, and following the impact pathway in Figure 5.2, we define ε as the quotient of the change in price and the change in quantity. Hence, ε is the inverse of the elasticity defined in Equation 5.1. With this approach, it is possible to identify commodity-specific disasters and the associated shortterm impact measured by the inverse price elasticity of demand specific to one material (ε), which is defined as the percentage price change of the concerned metal divided by the percentage of global mining affected [START_REF] Varian | Intermediate microeconomics with calculus: a modern approach[END_REF]. Available data allows obtaining price elasticity values for aluminum, cobalt, copper and nickel, being this the main constraint for the development of the study. The selected events are displayed in Table 5.3, the table includes information on the dates of the natural disaster and the global estimated affected production.

Overall GeoPolEndpoint Results

As previously mentioned in this chapter, the proposed endpoint indicator is applied to Al, Co, Cu and Ni, four materials in the supply chain of LIB from the perspective of the group formed by the country members of the OECD. Subsequently, the obtained results at midpoint and endpoint level are compared with the inventory in order to assess the overall contribution of the four focus materials to the supply risk and to the socio-economic damage attributable to LIB. The GeoPolRiskOECD values and estimated Ɛ for the analyzed materials are multiplied to obtain a Cost Increase Factor, Figure 5.3 gives a graphical representation of these factors. Note that the proxy for price elasticity is calculated as a general factor for each metal and is assumed not to be dependent on the year of analysis. Aluminum and copper share cost increase factors with values that range from 0.0008 to 0.001 and 0.0017 to 0.003 respectively, followed by nickel with a range from 0.0042 to 0.0055.

However, the value for cobalt ranges from 0.065 in 2015 to 0.079 in 2017. This difference in the values is further extended with the calculation of the GeoPolEndpoint factor, which results from the product of the cost increase factor and the average price of the materials.

Based on Equation 5 USD/t-Co for cobalt. The overall socio-economic damage at endpoint level attributable to the supply risk of Al, Co, Ni, and Cu in NCA is equivalent to 1.78%, 1.83% and 3.13% of the total costs of these materials in the battery inventory for the years 2015, 2016 and 2017 respectively. For the case of NMC, this overall contribution to the damage is higher, comparable to 3.37%, 3.48% and 5.20% of their cost. More details for these calculations are provided in Annex H.

Figure 5.4 shows the relative contribution of aluminum, cobalt, nickel and copper to the raw material costs in the battery cell and the socio-economic damage at endpoint level; this last one obtained as the product of the GeoPolEndpoint value, the mass share and energy density. From an inventory perspective, the mass share of copper and nickel is superior to aluminum and cobalt in the case of NCA.

While the mass share of copper is even higher in the case of NMC, cobalt and nickel have a similar contribution in the latter case (see Table 5.1). In terms of raw materials cost, the relevance of cobalt and nickel becomes evident, especially in the year 2017 when an increase on the price of cobalt makes its cost share more dominant in the LIB inventory.

The relative contribution of the raw materials to the supply risk has remained stable over the analyzed period. However, the GeoPolRiskOECD indicator for cobalt emerges as a reflection of the supply chain of this material, for which a large percentage of its production is located in high risk countries. Results at endpoint level rank cobalt as of even greater importance in the assessment of socio-economic damages, representing between 82% and 92% of the total damage associated with Al, Co, Cu and Ni in NCA (values for the period between 2015 and 2017). Nickel also plays a role in this case with a smaller share attributable to a high contribution in mass and having a relevant GeoPolRiskOECD value. For the case of NMC, however, the effect of cobalt displaces the contribution of the other materials, making them negligible in comparison for the case of NMC. In absolute terms, the economic impact of the use of Al, Co, Cu and Ni can be modeled as a potential increased cost of materials for the production of Li-ion batteries. In the case of NCA, this cost is calculated as 0.34, 0.30 and 0.72 USD/kWh for the years 2015, 2016 and 2017 respectively;

contrastingly, the increased cost for NMC is 0.81, 0.74 and 1.86 USD/kWh. More details on these results are available in Annex H.

Discussion on the extension of the GeoPolRisk method to and Endpoint level in LCSA

As previously discussed in section 2.2.3, the GeoPolRisk method originated from the integration of criticality considerations in the LCSA framework and is designed as a regionally differentiated tool to complement environmental LCA for decision making processes based on accessibility to natural resources. The extension of the method to an endpoint indicator represents a challenge because price considerations for minerals are usually given at a global scale. Therefore, for this first application of the GeoPolEndpoint method, the selection of the OECD country members as a reference group was based on their active participation in the global economy. This decision opens an opportunity to assess the GeoPolEndpoint results from different perspectives; taking advantage of the versatility provided by the regional approach of the GeoPolRisk method, future applications could also focus on other country groups given that these could be considered to have a relevant role in global economy and trade market.

This first application of the GeoPolEndpoint method focuses on LIB. This case study was selected given the availability of information related to the estimation of price elasticity for a large portion of the materials present in the used inventories: 29.7% in the case of NCA and 30.9% for NMC. Based on the inventories, a main future challenge is the obtention of elasticity values for lithium and manganese; these, despite not being great contributors in mass, could become relevant sources of socio-economic damage when assessing supply risk or subsequent potential increased cost, similar to cobalt.

The main challenge when designing the method is the obtention of price elasticity values as these are calculated based on event studies (natural disasters); therefore, these results are not yet statistically significant. The use of a small set of datapoints forces to assume iso-elasticity of the demand function in order to apply the obtained values in the presented endpoint method [START_REF] Sah | Can government collect resources without hurting investors? Taxation of returns from assets[END_REF]. The analysis of other types of events that also cause supply disruption other than natural disasters is encouraged to study effects on the prices of commodities.

In economics, there are other indicators more w idely used and more easily obtained to characterize price behavior. Specifically, price volatility (BRG, 2021) is used in the ESSENZ method to characterize price fluctuations [START_REF] Bach | Integrated method to assess resource efficiency -ESSENZ[END_REF]; however, this is designed as a measure of dispersion and focuses on medium or long-term price variations that cannot be applied to the impact pathway presented in this chapter. The GeoPolEndpoint aims to measure the immediate (short-term) economic damage caused by a supply disruption, rather than a measure of probability of harm happening. This makes the GeoPolEndpoint quite unique in LCA methods as an inside-out indicator associated to the AoP Natural Resources. Further work could focus on modeling socio-economic damages based on an impact pathway that considers long-term scenarios.

Some efforts have been made to develop resource scarcity indicators in LCA. Among these, examples include the ADP method for resource depletion [START_REF] Guinée | A proposal for the definition of resource equivalency factors for use in product life-cycle assessment[END_REF]van Oers et al., 2002;[START_REF] Oers | The Abiotic Depletion Potential: Background, Updates, and Future[END_REF], the LIME2 method to quantify future externalities of resource use [START_REF] Itsubo | Iwatani Corporation. Commencement of Supply from Qatar Helium-2 and Launching Helium Joint Venture in Qatar. Incorporating Helium Transfilling, Container Logistics and Container Maintenance to Expand the Helium Business Effectively in the MENA[END_REF], and the SCP method for future mineral extraction costs [START_REF] Ponsioen | Surplus cost as a life cycle impact indicator for fossil resource scarcity[END_REF]Vieira et al., 2016), all focused on a long-term perspective. Unlike other methods designed to assess the increase in scarcity of resources, the GeoPolRisk method (midpoint) and the GeoPolEndpoint method (endpoint) are based on the integration of criticality considerations in LCA through the LCSA Framework [START_REF] Sonnemann | From a critical review to a conceptual framework for integrating the criticality of resources into Life Cycle Sustainability Assessment[END_REF]. The causes and effects of criticality considerations are analyzed in the short term; a continuous assessment of the geopolitical supply risk of raw materials is required to provide upto-date information. Data on elasticities can be updated once relevant natural disasters are added to the respective databases, which cannot be regular due to the stochastic nature of disasters.

In this chapter, an endpoint indicator is designed to study the implications of mineral resources supply risk in the AoP Natural Resources as part of LCA and based on the GeoPolRisk method within the LCSA Framework. This enhancement addresses an area of methodological development identified in the work of the Life Cycle Initiative Task Force on Mineral Resources: linking the midpoint-level supply risk indicators to endpoint-level socio-economic damages in LCSA due to the geopolitically-driven increased costs [START_REF] Berger | Mineral resources in life cycle impact assessment: part IIrecommendations on application-dependent use of existing methods and on future method development needs[END_REF][START_REF] Sonderegger | Mineral resources in life cycle impact assessment-part I: a critical review of existing methods[END_REF]. With the developed method, it becomes possible to assess how the use of certain raw materials could have a substantial economic impact when developing new technologies; moreover, the possible shifting of burden from environmental damages, in particular in relation to climate change impacts for low carbon solutions, to new economic costs due to supply constraints is visible. It becomes evident that there is an overlap when assessing these impact pathways: geopolitical supply risk as a driver of impacts in the AoP Natural Resources in LCA and geopolitical supply risk as a link to the economical dimension in LCSA, as first mentioned in section 1.3.

Similar to other assessments of material criticality, this method faces data limitations, particularly in terms of price elasticity, primary production and commodity trading (e.g. as reflected in the focus on four key materials that represent about 30% of the mass in the inventory of LIB). Subsequent efforts should be focused on obtaining more comprehensive data on supply disruption produced by different events setting the foundations to obtain proxy price elasticity values for other relevant materials. Further applications of the method could also analyze results from different perspectives and study a procedure to better aggregate countries. Application of the GeoPolEndpoint method is encouraged for the assessment of socio-economic impacts from the point of view of the European Union, the Asia-Pacific Cooperation, or non-OECD countries, among others. An application to the European Union will be presented in the next chapter.

The method provides results based on resource supply risk and with a focus on primary production of the analyzed materials. It follows an impact pathway based on an outside-in perspective, in which the analyzed system is affected by external factors. A limitation the method carries from previous applications that study geopolitical supply risk is that potential disruptions are only analyzed at mining and refining stage; further methodological enhancements are required to determine how to assess supply risks at intermediary stages.

With the designed endpoint method, it becomes possible to quantify the effect of the use of mineral resources in the AoP Natural Resources by providing geopolitically-driven increased costs, a socioeconomic indicator measured in monetary units proposed as complement to LCA and within the LCSA framework; therefore providing a new decision-making tool based on the integration of criticality considerations to life cycle sustainability assessment. This first application serves as a proof of concept in which the geopolitical supply risk is associated to the mentioned AoP; however, the main barrier for increasing its usability is the obtention of values of price elasticity linked to a wide variety of resources.

In Chapter 4:, the effect of recycling as a risk mitigation strategy is explored and a method is provided to better estimate the geopolitical supply risk taking into consideration the domestic recycling activities.

A further integration of these proposed methods could serve to estimate the potential economic benefits or costs of implementing risk mitigation strategies such as recycling or substitution. The next chapter in this manuscript includes an integrated assessment that considers both approaches along with more traditionally used midpoint indicator in environmental LCA.

The methodological enhancements proposed and applied in chapters Chapter 4: and Chapter 5: have been developed following the original design of the GeoPolRisk method: A complement to environmental life cycle assessment based on the concerns around resource accesibility. In both case studies, results

show that a perspective based on materials criticality has the potential to provide insights to support both company and policy decisions. Both efforts exist only as first applications; therefore, further work must be developed towards improving the readiness of the overall methodological impact pathway previously mentioned.

With the objective to extend the applications of this notion and to integrate both proposed improvements in chapters 4 and 5, this section compiles the outcomes of applying the GeoPolRisk method with the inclusion of recycling considerations and the GeoPolEndpoint method to the same case study, along with most commonly used midpoints and endpoints in environmental LCA.

Criticality concerns for a low-carbon transition

The efficiency of fossil fuels as energy carriers has made these the main drivers of technological development in the past century [START_REF] Smil | Energy Transitions: Global and National Perspectives (Second Expanded and Updated Edition)[END_REF]. According to [START_REF] Hannah | What Share of Electricity Comes from Fossil Fuels?[END_REF], more than 60% of the global electricity in 2019 had its origin in a mix of coal, natural gas and petroleum. A proposed gradual change to renewable sources has been proposed by several organizations due to the severe environmental impacts of the use of fossil fuels: scientific reports show that approximately 40 billion metric tons of CO2 are released to the atmosphere on a yearly basis (IPCC 2018). The use of renewable energy has promoted innovation in the energy, transport and technology sectors, while bringing to the surface new challenges for efficient energy storage, materials demand and electronic waste management [START_REF] Findlay | Dark side of low carbon[END_REF].

A significant part of the literature on low-carbon transitions focuses on improved means for energy storage, a key element to support the increasing demand for technologies that use renewable energy sources [START_REF] Sovacool | The decarbonisation divide: Contextualizing landscapes of low-carbon exploitation and toxicity in Africa[END_REF]. Batteries have been improving in efficiency with the introduction of new materials to increase energy density; however, the increased demand for these metals and minerals makes evident new problems along the supply chain: accessibility to materials and waste management [START_REF] Sovacool | Decarbonization and its discontents: a critical energy justice perspective on four low-carbon transitions[END_REF]. From the perspective of resources accessibility, efforts are required to understand the real and tangible costs of using critical raw materials, along with alternatives to mitigate these impacts with strategies such as recycling and substitution, as previously discussed in Chapter 4:.

Life Cycle Assessment has been used to address the environmental benefits of the use of renewable energies over fossil fuels; among these studies, the assessment of electric vehicles (EVs) represents a good example of the shift of the burden from greenhouse gases emissions from combustion of fossil fuels to other environmental impacts associated to EVs [START_REF] Hawkins | Environmental impacts of hybrid and electric vehicles-a review[END_REF][START_REF] Hawkins | Comparative environmental life cycle assessment of conventional and electric vehicles[END_REF][START_REF] Nordelöf | Environmental impacts of hybrid, plug-in hybrid, and battery electric vehicles-what can we learn from life cycle assessment?[END_REF]. More specific studies focus on the batteries in EVs, recognizing them as one of the main contributors to the overall environmental impact attributed to these vehicles [START_REF] Notter | Contribution of Li-Ion Batteries to the Environmental Impact of Electric Vehicles[END_REF]Peters andWeil, 2016, 2017).

The readiness of LCA to address resource accessibility

As previously discussed in section 2.2, LCA focuses on three main Areas of protection (AoP) to study the impacts of the use and production of goods and services: Human health, Ecosystem health and Natural resources [START_REF] Finnveden | Recent developments in life cycle assessment[END_REF][START_REF] Guinée | Life cycle assessment: past, present, and future[END_REF]. As a complement to environmental life cycle assessments, the concept of criticality has been introduced to assess accessibility to raw materials in relation to the AoP Natural Resources [START_REF] Cimprich | Raw material criticality assessment as a complement to environmental life cycle assessment: examining methods for product-level supply risk assessment[END_REF]. Also, as stated in section 2.2.3, the genesis of the GeoPolRisk method is based on the integration of criticality considerations in LCA, making it recognized as a suggested midpoint indicator method by the Task Force on mineral resources of the Life Cycle Initiative hosted by UN Environment (UNEP) for quantifying "the relative potential accessibility issues to certain raw materials for a product system related to short-term geopolitical and socioeconomic aspects" [START_REF] Berger | Mineral resources in life cycle impact assessment: part IIrecommendations on application-dependent use of existing methods and on future method development needs[END_REF][START_REF] Frischknecht | Global Guidance on Environmental Life Cycle Impact Assessment Indicators[END_REF].

As part of the recommendations provided by UNEP, some opportunities for improvement were presented in relation to the GeoPolRisk method [START_REF] Cimprich | Raw material criticality assessment as a complement to environmental life cycle assessment: examining methods for product-level supply risk assessment[END_REF]. The inclusion of recycling considerations as a supply risk mitigation strategy, and its subsequent effect on the GeoPolRisk indicator was already presented in Chapter 4:. In this methodological update, the domestic recycling of selected materials in the EU is analyzed to update supply risk values based on a reduced dependency from importers. The second addressed recommendation is related to extending the GeoPolRisk method from a midpoint characterization factor in LCSA to an endpoint characterization factor directly related to the AoP Natural Resources. In Chapter 5:, the GeoPolEndpoint method was also introduced, serving as a link between the supply risk of raw materials to a tangible socio-economic impact with the inclusion of price elasticity considerations to assess the effects of supply disruptions in commodity prices. In that section, an assessment from the perspective of the member countries of the OECD was conducted to obtain an estimation of the potential increased costs associated with the geopolitical supply risk of four materials in the inventory of lithium-ion batteries (LIB).

This chapter provides an integrated assessment of four key materials in the inventory of LIB based on the previously presented methodological enhancements (Chapter 4:, Chapter 5:). The GeoPolRisk method is used to address how recycling considerations mitigate the supply risk of aluminum, cobalt, copper and nickel in the European Union and how their supply risk translates into a potential economic damage related to the AoP Natural resources. These assessments at midpoint and endpoint level are presented as a complement to commonly used environmental LCA impact categories.

Similarly to Chapter 5:, this section is based on an already published LCA inventory of two types of LIB currently in the market by [START_REF] Peters | A Critical Assessment of the Resource Depletion Potential of Current and Future Lithium-Ion Batteries[END_REF]. The following section explores the feasibility of the application of the method to aluminum, cobalt copper and nickelkey materials in LIBfrom the perspective of the European Union; along with the LCA methods used to assess environmental impacts

Methodology for the Integrated Assessment

In the domain of raw materials criticality and, as explored in section 2.2.3, the Geopolitical Supply Risk method was developed to calculate the supply risk of a material from the point of view of a country, region or group of countries and serves as a complement to environmental LCA. Figure 6.1 presents a LCIA framework for the integrated assessment at midpoint and endpoint level to address environmental and geopolitically-driven resource impacts. Available data allowed to calculate the updated GeoPolRisk indicators for materials from the EU perspective, given that Eurostat provided values for the EoL-RIR that compile recycling information at regional level.

In Chapter 5:, the GeoPolEndpoint method was introduced to connect the supply risk of a material with the potential economic damage associated to the AoP Natural Resources in LCSA. As part of the newly introduced definitions, the term "Cost Increase Factor" is presented as the product of the supply risk (GeoPolRisk) and the inverse price elasticity; this non dimensional result is further multiplied by the average price to also obtain the GeoPolEndpoint (measured in monetary units per unit of mass).

According to the discussion, the application of this formula is suggested only from the perspective of country groups with relative high influence in the global economy given that the prices of the analyzed materials are defined by the global market.

For a defined resource and year, results can be interpreted as average increased costs caused by geopolitically-driven supply disruptions. Therefore, the values are a proxy for a potential economic loss for the country/region that uses the material. By integrating these factors with the inventory information of a product, it becomes possible to measure the damage caused by the use of multiple resources in a product system.

With the two methodological limitations previously mentioned, the integrated assessment is applied to four materials in LIB: aluminum, cobalt, copper and nickel. This is taken from the perspective of the European Union for the years 2015, 2016 and 2017. The selected period is based on the available information required for the application of the enhancement proposed in Chapter 4:, finding EoL-RIR values applicable to the EU only available for 2016; moreover, the life cycle inventory data is referred to a similar period.

Two types of LIB are analyzed to obtain results at the product level: NCA-C and NMC-C (as previously introduced in section 5.3), following the inventories obtained from [START_REF] Peters | A Critical Assessment of the Resource Depletion Potential of Current and Future Lithium-Ion Batteries[END_REF]. For the GeoPolRisk and GeoPolEndpoint application, the United States Geological Survey is used as the main data source for the world-wide production in mining or refining activities (USGS, 2016(USGS, , 2017(USGS, , 2018)). The trade data necessary to estimate the supply mixes was sourced from the United Nations International

Trade Statistics Database -UN COMTRADE (United Nations, 2020). The WGI-PV is provided by the World Bank (World Bank, 2019), and rescaled from 0 to 1 (0 representing an absence of geopolitical risk) to be used in the calculations. Price information was obtained from the London Metal Exchange (LME) (Thomson Reuters, 2019) and price elasticity values are from Chapter 5:.

The environmental life cycle impacts were assessed at midpoint and endpoint level for selected impact categories. For midpoint level assessment, the CML 2001 method [START_REF] Guinée | Handbook on Life Cycle Assessment: Operational Guide to the ISO Standards[END_REF] was used to evaluate the relative contribution of each resource to the following impact categories: acidification potential, global warming potential, depletion of abiotic resources (elements, ultimate reserves), ecotoxicity (freshwater, marine and terrestrial), eutrophication, human toxicity, ozone layer depletion and photochemical oxidation. The reasons to apply this method are the inclusion of characterization factors designed specifically for the European Union and the inclusion of the abiotic depletion potential impact category, which has been explored earlier in this thesis as one of the most common indicators to assess resource availability at midpoint level.

Similar midpoint category indicators were considered in an earlier electric vehicle case studied by [START_REF] Hawkins | Comparative environmental life cycle assessment of conventional and electric vehicles[END_REF], and followed by [START_REF] Gemechu | Geopolitical-related supply risk assessment as a complement to environmental impact assessment: the case of electric vehicles[END_REF]. This last one was the first approach towards an integrated assessment based on the GeoPolRisk indicator. Specifically, abiotic depletion evaluates the accessibility potential based on the concept of reduction in natural stock as a result of current extraction rate [START_REF] Guinée | A proposal for the definition of resource equivalency factors for use in product life-cycle assessment[END_REF][START_REF] Oers | The Abiotic Depletion Potential: Background, Updates, and Future[END_REF] and answers questions of raw materials availability. The acidification potential refers to the increase in proton (H+) due the anthropogenic emissions of acid-base substances such as sulfur oxides, nitrogen oxides and ammonia.

Eutrophication is the occurrence of excess nutrients such as nitrogen and phosphorus in aquatic or terrestrial ecosystems [START_REF] Smith | Eutrophication: Impacts of excess nutrient inputs on freshwater, marine, and terrestrial ecosystems[END_REF]; phosphorus equivalents (PO4-3 eq.) is used to measure the eutrophication potential in freshwater [START_REF] Helmes | Spatially explicit fate factors of phosphorous emissions to freshwater at the global scale[END_REF]. Human toxicity measures the health impacts due to exposure to chemicals released in the life cycle of a product system.

The endpoint impact assessment for this application is based on the ReCiPe method (Huijbregts et al., 2016) with a hierarchist perspective in order to include a measure of the impacts associated to the three Areas of protection previously discussed in this manuscript; this method includes the damage to resource availability measured in monetary units, similarly to the design of the GeoPoEndpoint method presented earlier in this manuscript. The environmental life cycle assessment modeling was performed using the openLCA 1.10.2 platform (GreenDelta, 2020). The Ecoinvent 3.4 database was used as a data source for the background system [START_REF] Wernet | The ecoinvent database version 3 (part I): overview and methodology[END_REF].

The integrated assessment is based on the LIB inventories provided by [START_REF] Peters | A Critical Assessment of the Resource Depletion Potential of Current and Future Lithium-Ion Batteries[END_REF]. The study focuses on the contribution of four key materials (aluminum, cobalt, copper and nickel) to two types of batteries: those with cells with nickel-cobalt-aluminum (NCA-C) and those with nickelmanganese-cobalt (NMC-C) cathode active material, both with graphite anode material. The supply risk assessment requires a focus on a specific year and a group of countries; this study is conducted for three analyzed years: 2015, 2016 and 2017. The selected perspective is that of the European Union, in accordance with the available data for EoL-RIR obtained from Eurostat, and following the recommendation first mentioned in Chapter 5: to select a country group with significant influence and participation in the global market. Presented results will be associated to the functional unit of a tonne (1000 kg) of produced LIB.

Results of the Integrated Assessment

This section describes the values obtained for the relevant impact categories with the aim to assess the contribution of each analyzed material to the overall impacts from the environmental and the geopolitical perspective. Table 6.1 presents the GeoPolRisk values for the four analyzed materials from the perspective of the European Union between 2015 and 2017. Since these sets of results are based on the methodological enhancement that was first introduced in Chapter 4:, two values for the geopolitical supply risk from the perspective of the EU can be obtained for each combination of resource and year (BCS and WCS, given an EoL-RIR value higher than 0%). For purposes of this application, the calculations that will be further presented in this chapter will consider the simple mean of these two values; this simplification is made under the assumption that domestic recycling in the EU mitigates the supply risk by reducing the resource requirements and affecting the supply mix of the analyzed resources. A full set of the obtained values can be found in Annex I. The previously presented values represent economic damages associated to a geopolitically-driven impact pathway, and from a LCA perspective, related to a tonne of produced LIB. Figure 6.2 shows the relative contribution of aluminum, cobalt, copper and nickel to the inventory of LIB, the geopolitical supply risk at midpoint level and the economic damage at endpoint level following the GeoPolEndpoint method.

Endpoint Economic Damage (Product)

Similarly to the case study in Chapter 5:, the relative contribution to the supply risk of aluminum, cobalt, copper and nickel can be considered stable over the analyzed period. However, cobalt stands out as having the highest supply risk among the analyzed materials, a reflection of its supply chain, which includes countries with perceived high geopolitical risk at the early stages (Congo and China). The transition to an endpoint level only increases the role of cobalt in the economic damages associated to resource use. Nickel appears also with a smaller share attributable to a high contribution in mass and relatively-high geopolitical supply risk. For the case of NMC-LIB, the effect of the use of cobalt displaces the contribution of other materials, making them negligible in comparison. A question remains on how these compare to other environmental impacts at midpoint and endpoint level, as described in section 6.3.

As mentioned in section 6.3, the integrated assessment at midpoint level was conducted with the CML 2001 method [START_REF] Guinée | Handbook on Life Cycle Assessment: Operational Guide to the ISO Standards[END_REF]. The overall results at this level are available in Figure 6.3, these include the contribution of the four analyzed materials to the inventory of two LIB (mass contribution; NCA-C and NMC-C), along with those corresponding to the impact categories included in the method; for comparison, these results are presented next to the supply risk, assessed with the GeoPolRisk method for the years 2015 to 2017. More details on the results are available in Annex K for further reference.

From the results in Figure 6.3, it is possible to divide the midpoint impact categories into two groups.

The first group is composed by acidification and photochemical oxidation indicators, and the contribution of nickel to these impacts is higher than other resources, regardless of the mass share of this material in the inventory of LIB in both types: (a) NCA-C and (b) NMC-C; this is explained by the sulfur dioxide and nitrogen oxides emissions associated with nickel production. A second group is formed by the rest of the impact categories in the CML 2001 method; in these, the contribution to the impacts is mostly divided between copper and nickel and depends on the mass share, given the different composition between NCA-C and NMC-C LIB. The last three impact categories show similarly relevant contributions from the four materials: global warming potential, abiotic depletion potential and ozone depletion potential.

Specifically for the comparison between abiotic depletion potential and the supply risk, cobalt and aluminum gain higher visibility when using the GeoPolRisk method. This is a reflection of the supply constraints in the cobalt supply chain and the increasing participation of China and Russia in the supply mix of aluminum to the European Union during the analyzed period. Thus, the GeoPolRisk method provides another layer of assessment by highlighting barriers to the accessibility of materials rather than their overall geological availability. A wide gap is visible between the contributions of the four materials to the damages to natural resources measured with the ReCiPe endpoint method and the contributions analyzed with the GeoPolEndpoint method. The predominance of cobalt from a geopolitical supply risk perspective is not yet captured, therefore the use of the GeoPolEndpoint offers a new perspective on how to measure the damages to the AoP natural resources.

Discussion on the integration of GeoPolRisk and GeoPolEndpoint to environmental assessments

With the presented case study, an integrated assessment based on the geopolitical supply risk method as a complement to environmental LCA was conducted. Four key materials in the inventory of LIB were the focus of the application and allowed to understand their contribution to the impacts at midpoint and endpoint level in life cycle assessment. The assessment was made for the years 2015, 2016 and 2017 from the perspective of the European Union.

The presented application demonstrates the potential use of the GeoPolRisk method (midpoint) and the GeoPolEndpoint method (endpoint) as a complement to traditional environmental life cycle assessment and following the methodological path proposed by the integration of criticality considerations into the life cycle sustainability assessment framework. As previously presented in Figure 6.1, this methodological pathway is oriented towards the assessment of damages to the area of protection natural resources, positioning its results as a part of the environmental impacts in LCA.

Multiple advantages of using the methods associated with geopolitical supply risk become evident when applying these along other more commonly used life cycle impact assessment methods. First of all, it is possible to identify once again the flexibility of the method, making it possible to tailor the results to selected years the analyzed country (in this case, region), through the consideration of its supply mix and recycling capabilities. This goes along with the idea that risk is a perception that depends on situations specific to each country, region or company that faces the risk.

Following the concept of perceived risk, the introduced methods focus on raw material accessibility as a driver of impacts in the AoP natural resources, associating an economic damage to the use of critical raw materials. This approach is different than the one followed traditionally in LCA to assess resource use damage; in this case, a comparison at midpoint level was made with the abiotic depletion potential impact category. As previously explored, the method allows to add a new layer for the assessment of impacts at midpoint level, shifting the focus from materials that are overall scarce around the globe to materials that are critical for specific economies.

At the endpoint level, a similar phenomenon occurs: the comparison is made between the results provided by the ReCiPe endpoint method and the GeoPolEndpoint method. At this stage in the impact assessment, the concept of raw material accessibility translates into a socio-economic damage measured in monetary units through geopolitical supply risk; when, typically, damages to the AoP resources under the ReCiPe method are measured as costs of future obtention of materials. Again, the introduced methodological pathway adds another layer that can support relevant stakeholders in their decision-making processes regarding the use of critical raw materials in specific technologies.

As discussed in this manuscript and mentioned in previous publications associated with the GeoPolRisk method (Cimprich et al., 2017a;Cimprich et al., 2019b;[START_REF] Gemechu | Import-based Indicator for the Geopolitical Supply Risk of Raw Materials in Life Cycle Sustainability Assessments[END_REF][START_REF] Gemechu | Geopolitical-related supply risk assessment as a complement to environmental impact assessment: the case of electric vehicles[END_REF]Helbig et al., 2016), the method at midpoint level did not consider the mass of the resource in the life cycle inventory as input in the calculations. This aspect is taken into account as part of the

GeoPolEndpoint method providing insights on potential economic damage due to resource use.

With the presented application it is also clear that there is a methodological background that allows to further assess materials and products considering limited resource accessibility as a source of impacts.

However, the methodological enhancement is not free from limitations. A first main concern is data availability, specifically when trying to understand how materials move around economies; trade databases are not always reliable or complete, preventing a 100% accuracy of the method.

Most open and available data sources focus on the mining and refining stages, the further a material moves through its life cycle, the more challenging it is to track. This is also evident when addressing recycling considerations as a supply risk-mitigating factor, as previously discussed in Chapter 4:. More work is required to identify other sources of impact associated to the accessibility to materials at further stages in their supply chain.

Specifically focusing on the GeoPolEndpoint method, its application is only valid when assessing countries or regions with a significant influence in the global economy; this limitation comes from the fact that the economic impacts are measured based on commodity prices, which are typically handled in international markets. Aditionally, the requirement of data associated with price elasticity restricts the amount of materials that can be assessed (for more information, please refer to Chapter 5:).

The flexibility of the methods comes with another challenge: constant updates. In order for the method to support further applications, it becomes necessary to construct, revise and update the information associated to global production, global trade and political (in)stability ate least on a yearly basis. As also discussed in Chapter 4:, future users could benefit from a computational tool that reduces the amount of work necessary to obtain indicators of geopolitical supply risk from multiple perspectives.

Overall, with this case study, the methodological pathway proposed by [START_REF] Sonnemann | From a critical review to a conceptual framework for integrating the criticality of resources into Life Cycle Sustainability Assessment[END_REF] has been demonstrated applicable with its limitations as a part of LCA and as a complement to traditional environmental assessments under the LCSA framework. The indicators associated with the geopolitical supply risk method measure a concept until now overlooked by traditional life cycle assessment: resource accessibility. Therefore, the enhanced method has the potential to support future decisionmaking processes when addressing potential damages associated to the AoP natural resources.

The GeoPolRisk method provides new insights that complement other methods addressing recource use in LCA; especially due to its versatility when providing information that depends on specific locations or time periods. The exploration of computational environments to facilitate the calculations and data processing is encouraged to make its application easier and more feasible for LCA practitioners.

As part of other proposed applications, and specifically focusing on the healthcare sector, the next chapter presents a case study designed to assess the supply risk of a resource with peculiar and exclusive chemical and physical properties: the case of helium. Emphasis will be made on how specific characteristics of the supply chain of this element are an opportunity to use the GeoPolRisk method as a tool to support decisions in the healthcare sector.

The past three chapters have focused on enhancing and extending the GeoPolRisk method, developed to understand, analyze and measure the impacts of resource use as a complement to environmental LCA. Methodological advancements were suggested of importance for the development of integrated assessments that consider environmental impacts and criticality considerations to better inform relevant stakeholders.

The healthcare sector is no stranger to the concerns around resource accessibility for technological development. As previously mentioned in section 3.3.2, an opportunity to explore criticality considerations for helium has been identified; later in this chapter, the chemical and physical characteristics of helium are presented along the peculiarity of its supply chain. This chapter focuses on measuring and understanding the supply risk of helium from the perspective of different countries, with the objective to compare the perceived supply risk of this valuable and unusual resource for the healthcare sector.

Helium: An unusual resource

Advancements in scientific and industrial innovation during the decades leading to the XXI century have extended the range of elements in the periodic table that are studied and used to design complex materials and technologies. This growth has led to the search for new sources and the extension of extraction activities to obtain a fuller list of useful non-renewable natural resources [START_REF] Chen | Anthropogenic Cycles of the Elements: A Critical Review[END_REF].

The healthcare sector provides urgent, important and technology-intensive services; it uses a wide range of elements for multiple purposes that range from the production of pharmaceuticals to the construction and maintenance of complex equipment. Among the elements relevant to the healthcare sector, helium (He) is unique for its chemical simplicity. Oddly, it is rare on earth despite being the second most abundant element in the universe [START_REF] Bradshaw | Nuclear fusion and the helium supply problem[END_REF].

Helium is a consumable in healthcare facilities using magnetic resonance imaging (MRI) machines; its purpose is to cool the magnets in this equipment to extremely low temperatures due to having the lowest boiling point among all elements in the periodic table. However concerns have been raised regarding its availability for scientific, military and other uses [START_REF] Hurd | Energy-critical elements for sustainable development[END_REF]National Research Council, 2010;[START_REF] Nuttall | The Future of Helium as a Natural Resource[END_REF]. Moreover, few efforts have been made to better understand, predict or improve the "use it or lose it" nature of helium supply [START_REF] Hayes | Critical minerals: A review of elemental trends in comprehensive criticality studies[END_REF].

Helium is formed from the decay of the radioactive uranium (U-238) and thorium (Th-234) in the Earth, from where helium permeates upwards through the Earth's crust to the atmosphere, where it is subsequently lost to outer space [START_REF] Mckay | Helium Resources and Developments in Australia[END_REF]. Some fraction of helium accumulates in the same geological formations that hold natural gas deposits, which typically contain a mixture of hydrocarbons and other gases such as nitrogen and carbon dioxide (National Research Council, 2010).

Only a very small fraction of the naturally formed helium accumulates in the Earth's crust, with an approximate ratio of accumulated over produced He equal to 10E-7 [START_REF] Bradshaw | Nuclear fusion and the helium supply problem[END_REF].

Helium in the atmosphere maintains an equilibrium concentration of approximately 5.2 ppm, which is assumed to have remained constant over geological time. A mass balance that estimates the amount of helium released into the atmosphere confirms that most of it has escaped to the space. This suggests a new dimension of raw material dissipation: the gas not only evades potential human use by escaping specific receiving environments in the Earth's crust, but crosses the boundaries of our planet with an estimated exit rate of 50 g per second or 1600 tonnes per year. The opportunities for future recycling once helium leaves the technosphere are practically null [START_REF] Catling | The Planetary Air Leak[END_REF][START_REF] Challoner | The Atom: The Building Block of Everything[END_REF].

Due to this constraint, the production and consumption of helium is linear and results in a high rate and volume of direct loss.

Currently, the most common and efficient way to obtain helium is by separating it from natural gas. It becomes economically feasible to do this when a content of approximately 0.3% is available [START_REF] Kryc | What's up with helium? GSA Today[END_REF][START_REF] Ku | Manage Raw Material Supply Risks[END_REF][START_REF] Rufford | A Review of Conventional and Emerging Process Technologies for the Recovery of Helium from Natural Gas[END_REF]. As of 2020, approximately 75% of global helium supply is provided by two countries: the United States and Qatar [START_REF] Kornbluth | Evolution of the Global Helium Business[END_REF][START_REF] Cockerill | Qatari helium: Back on-stream, but still caught in a political storm[END_REF].

The US Bureau of Land Management (BLM) has played an essential role in the management of helium resources since the 1930s with its long-term artificial storage facility for crude helium, known as the US Federal Helium Reserve [START_REF] Bingaman | Helium Extraction Act of 2017[END_REF]. Helium is mostly transported in its cryogenic state to increase the efficiency of this process; however this state is not naturally found on Earth. Compression processes early in the supply chain are always required (National Research Council, 2010).

The unique properties of helium give it a vital role in the development of technologies not only for the healthcare sector, but also in electronics, aerospace, military, physics research and communications applications. It may be used as a cryogenic liquid or gaseous state. As a cryogenic liquid, helium is predominantly used as a cooling agent for superconducting magnets in medical imaging [START_REF] Weishaupt | How does MRI work? An introduction to the physics and function of magnetic resonance imaging[END_REF]. In gas application, helium is used in welding, electronics manufacturing and leak detection.

Concerns have been raised by different sectors regarding the supply constraints associated with helium [START_REF] Anderson | Economics, Helium, and the U.S. Federal Helium Reserve: Summary and Outlook[END_REF][START_REF] Bare | Responding to the U[END_REF][START_REF] Glowacki | Beyond the Helium Conundrum[END_REF][START_REF] Liu | Helium conservation and supply and demand projections in the USA[END_REF][START_REF] Nuttall | The Future of Helium as a Natural Resource[END_REF][START_REF] Olafsdottir | Assessing the Past and Future Sustainability of Global Helium Resources, Extraction, Supply and Use, Using the Integrated Assessment Model WORLD7[END_REF][START_REF] Uri | Supply and demand projections in the USA reconsidered[END_REF]. Helium is considered critical for one or more energy-related technologies, been positioned among energy-critical elements as an irreplaceable and non-renewable resource to modern science and technology [START_REF] Jaffe | Energy Critical Elements: Securing Materials for Emerging Technologies[END_REF]. The relevance of helium for the healthcare sector has also led to supply constraints among other industries who don't play such an urgent role in society [START_REF] Robson | Helium shortage prompts scientist's balloon use warning[END_REF][START_REF] Murphy | The Global Helium Shortage is Real, but Don't Blame Party Balloons[END_REF].

Given the importance of helium placed by the scientific community in modern science and industrial development [START_REF] Bare | Responding to the U[END_REF], and the concentrated production in a small number of countries around the globe, this noble gas was identified as a critical raw material by the European Union in 2017 (European Commission, 2017), but removed from the same list in 2020 due to a decline in its economic importance (European Commission, 2020a). However, the USA remains to consider helium in their list of critical resources (USGS, 2018).

occurrence of these supply disruptions is very high [START_REF] Achzet | How to evaluate raw material supply risks-An overview[END_REF][START_REF] Dewulf | Criticality on the international scene: Quo vadis?[END_REF][START_REF] Erdmann | The Criticality of Non-Fuel Minerals: A Review of Major Approaches and Analyses[END_REF][START_REF] Graedel | Methodology of metal criticality determination[END_REF]. For this study, the supply risk will be considered the defining criticality aspect for helium, since the raised concerns are referred to its supply chain rather than its economic importance (European Commission, 2020). The GeoPolRisk method is selected to assess raw material accessibility, taking into account how geopolitical aspects, such as geographical proximity, trade networks and political instability have a superior effect on supply risk than overall geological availability of resources [START_REF] Sonnemann | From a critical review to a conceptual framework for integrating the criticality of resources into Life Cycle Sustainability Assessment[END_REF].

Previous applications of the GeoPolRisk method have focused on metals and minerals used for specific technologies (Cimprich et al., 2017(Cimprich et al., , 2018)), as also exemplified in chapters 4, 5 and 6; however as of 2021, this application will be the first one in which a resource typically traded in liquid or gaseous state is studied under this approach. The method is expected to provide significant values for the geopolitical supply risk of helium regardless given that the formula focuses on trade flows that can be measured in volume, mass and/or monetary units as long as the units and proportions remain the same over the calculations.

In order to get a comprehensive view on how different countries perceive the supply risks associated to helium, the application of the GeoPolRisk method is proposed from the perspective of ten nations:

China, Japan, South Korea, Taiwan, Germany, France, the United Kingdom, Mexico, Canada, and

Brazil. These countries are among the top net importers of helium, have a high level of industrial development and an advanced health care system that translates into a high density of MRI machines, one of the main indicators of high liquid helium use (OECD, 2019).

Helium transport is complex and expensive due efforts to maintain its liquid state and reduce loss rates.

For this reason, importers are motivated to keep distances as short as possible; however the small number of producing countries means that transport often takes place over long distances and across regions; some examples are those countries geographically insulated such as Japan, which requires the design of long supply routes. In other cases, nations are located between producing countries such as those in the European Union (importing from Poland, Russia and Algeria) or are in direct proximity to producers, like the case of Canada, which imports from the USA.

As previously presented in Chapter 4:; the information required to apply the GeoPolRisk method are the global production, the trade flows between producing and importing countries, the political instability indicator of exporting countries and the end of life recycling rate. The global helium production is obtained from the US Geological Survey (USGS, 2016(USGS, , 2017(USGS, , 2018(USGS, , 2019)), the data used for this application is available in Annex M. The trade information for helium is extracted from the UN COMTRADE database (United Nations, 2020); the scaled WGI-PV indicator from the World Bank (World Bank, 2019) provides the political instability indicator (0: minimum risk; 1: maximum risk); and, a domestic recycling rate of 0% is assumed because it is practically impossible to recover helium from the technosphere.

An initial look at the available trade information in the UN COMTRADE database showed that multiple of the analyzed countries import helium from non-producing countries; this is explained by the existence of countries that serve as intermediary ports between the suppliers and the consuming countries. This data limitation is overcome by allocating the flow from each intermediary port to the producing country with the biggest supply share of said redistribution location. Unlike other resources, this assumption is supported by the fact that helium is a noble gas and does not react with other elements, and is thus traded in its elementary form; therefore, no additional production processes are completed in the intermediary countries. In order to keep the consistency required for the method to be applied, flows are measured in monetary units under the assumption that price variations do not significantly impact the aggregated declared values. The full dataset used in this application is available in 2.Annex NAnnex N.

For further reference in this chapter, Figure 7. Scaled WGI-PV Figure 7.1 -Scaled WGI-PV index (from 0: absence of risk to 1: maximum risk) for the most important helium exporting countries. Qatar provides a stable increase in the flow of helium during the entire period under examination; therefore, the decrease of helium supply is attributed to a reduction in exports from the two other main producers: the USA, and Algeria. Smaller producers like Australia, Ukraine, Poland and Russia do not have a significant participation on the overall supply yet, but they may be crucial as some of these suppliers are geographically proximate to major user countries like Germany and Japan, this last one being the largest net importer in 2015, and China, which overtook Japan as the largest net importer for the years 2016-2018.

Results for the geopolitical supply risk of helium

In terms of the supply mix of each importing country; in 2015 and 2016, France, which displays a consistently higher supply risk throughout as compared to other countries under consideration, relied on the imports from Algeria and Qatar, however, the overall quantities from Qatar are reduced significantly in 2017, whereas Algeria remains the leading supplier for the country throughout the study period.

Germany's overall helium imports from 2015 to 2016 fluctuate with a significant decrease in 2017 and a small increase in 2018, overall along a significant growth of the helium supply share from Qatar; this new trade level remains relatively stable in the subsequent years with a varied supply mix from all five main exporting countries. After experiencing a significant decrease in imports in 2016, Japanese imports remained relatively stable throughout the analyzed period, with Qatar and the USA as its main suppliers.

Amongst all the countries considered, China has the lowest geopolitical supply risk despite relying on only two suppliers, this peculiar situation is further explored in the next section. Finally, according to the trade information, countries like Mexico, Brazil and Canada rely almost exclusively on imports from the USA; this means that the geopolitical supply risk of helium for these countries will depend mostly on the WGI-PV indicator for the USA, a country considered relatively stable for the analyzed period.

Discussion on the supply risk of helium

During the studied period, the countries with a larger traded value of helium were Qatar, the USA, Algeria, Australia and Russia. Although Qatar is not the main producer, it is a top exporter and is the primary supplier to most of the analyzed countries in the chapter. A decrease is visible in the overall helium trade flows from 2015 to 2017 with a slight increase in 2018; this last one attributable to the increasing demand in China.

Qatar is responsible for approximately 25% of the world's helium supply. In 2017, as noted above, it experienced a blockade by its neighbour countries that generated a realignment of the usual supply routes. Despite this situation, Qatar continued providing a stable flow of helium to each of the ten analyzed importing countries, but certain nations had to request more supply from other producers, for example the USA or Algeria. The countries who mostly relied in helium from Algeria had their overall supply risk indicator increased in the analyzed period, with the most notable case being France, which has an historical colonial link to this African country.

It is worth pointing out that these results are a direct reflection of using the WGI-PV indicator as a proxy of political (in)stability of the supplying countries. A limitation of this metric and the GeoPolRisk method becomes apparent. Qatar's overall low contribution to the supply risk is explained by a lower WGI-PV than the USA, indicator that arguably represents a relatively more stable political environment and less prevalence of violence within the country, despite the tense situations with neighbor nations in 2017.

Further analyzing the results, the ten countries under assessment can be clustered in three main importing groups. The first group is formed by the rapidly growing economies in Asia: China, Japan, South Korea and Taiwan; these countries rely mostly on the USA and Qatar to cover their needs. The second group of countries is in America (Brazil, Mexico and Canada) and are virtually fully dependant on the USA as a single supplier and represent the second cluster. A third group is formed by the United Kingdom, France and Germany, that each use a relatively diverse supply mix, and represent the main destination for helium from Algeria.

With the current supply mix, China shows the lowest supply risk because of its reliance on mostly Qatar and USA, the two countries with two of the lowest WGI-PV indicators; the third country that China primarily imports from is Australia, whose WGI-PV indicator is even better than Qatar's and reduces China's overall supply risk. A low supply risk in Japan is explained by the role of two companies: Taiyo Nippon and Iwatani which both have long term contracts for helium supply that is imported to Jthis nation from the USA and Qatar [START_REF] Buzwair | Buzwair Industrial Gases Factories. Helium joint venture in Qatar[END_REF]Iwatani, 2013).

The reliance of Canada, Mexico and Brazil on the US for all of its helium supply keeps their supply risk lower than those of most analyzed countries which are reliant on Algeria and Qatar as well (United Kingdom, France and Germany). However, the indicator is slightly higher than China, South Korea and Japan, countries that benefit from Australian and Qatari supply. A question appears on how these results could vary in following periods with a potential change of the WGI-PV for the USA due to its political climate between 2018 and 2020.

Overall results of the analyzed snapshot show that for a resource such as helium, with limited number of suppliers and very much dependent on an efficient supply chain, risk management is a considerable challenge. Building networks to allow steady flows of this resource is key, as the case of Japan clearly demonstrates. Some successful strategies are those associated with the signing of long-term contracts with the most stable countries in the supply mix. As new producing countries such as Russia, Poland and the Ukraine start appearing in the mix, the overall picture might change; it is encouraged to continue this type of assessments to understand the evolution of the risk in the next years.

The use of the GeoPolRisk method allows to understand the perceived risk from the perspective of the analyzed importing countries; this further translates to potential risks for the sectors who use this element. Among them, the healthcare sector needs to rely on the adequate management of helium supply at national level and can have certain comfort on the fact that healthcare is considered a priority in most countries around the globe. However, other sectors not considered essential have already suffered from helium shortages as is the case of recreational use of helium and research [START_REF] Robson | Helium shortage prompts scientist's balloon use warning[END_REF][START_REF] Murphy | The Global Helium Shortage is Real, but Don't Blame Party Balloons[END_REF].

Discussion on the methodological outcomes of the assessment

In this chapter, the criticality of helium has been explored from the perspective of ten countries over a period of four years. Concerns around the supply of helium as a key resource to the healthcare sector remain in place with the understanding on how a complex and critical supply network can be affected and result on disruptions. As previously mentioned in section 2.2.3, the geopolitical supply risk method provides an estimation of the proportion of the required material at constant and imminent risk of supply disruption from different perspectives. In the specific case of helium, several factors become more visible when addressing such a peculiar supply network: A limited number of suppliers means that there is an increase of the Herfindahl-Hirschman Index (HHI) as an indicator for global production density; different supply mixes extend the breach of the perceived risk for three main clusters of countries; and, the effect of the WGI-PV indicator is more evident given the differences among the producing nations. The GeoPolRisk method tries to measure accessibility to materials rather than availability, highlighting how geopolitical aspects have a greater effect on supply risk than geological availability [START_REF] Sonnemann | From a critical review to a conceptual framework for integrating the criticality of resources into Life Cycle Sustainability Assessment[END_REF].

One of the main contributions of this chapter is the expansion of the applicability of the GeoPolRisk method beyond metals and minerals. For this application, a raw material that is traded as a cryogenic liquid or as a gas is analyzed; also, the resource is extracted, transported and used in its most elementary form. These characteristics allow to further show the versatility of the GeoPolRisk method, allowing it to be applied to a wide range of resources and sectors.

A second contribution is the evaluation of the supply risk of a raw material that evades the general methodological definitions of dissipation, since it does not dissipate into any of the more traditionally discussed areas such as the environment, landfills or other material flows [START_REF] Beylot | Accounting for the dissipation of abiotic resources in LCA: Status, key challenges and potential way forward[END_REF][START_REF] Charpentier-Poncelet | A necessary step forward for proper non-energetic abiotic resource use consideration in life cycle assessment: The functional dissipation approach using dynamic material flow analysis data[END_REF]; on the contrary, helium does not remain within the planet, from which some may think it could be retrieved and reused at a later time. This goes beyond the the possibility to obtain this resource from the tecnosphere, alternative discussed by multiple authors [START_REF] Yellishetty | The steel industry, abiotic resource depletion and life cycle assessment: a real or perceived issue?[END_REF][START_REF] Klinglmair | Assessing resource depletion in LCA: a review of models and methodological issues[END_REF][START_REF] Frischknecht | Impact Assessment of Abiotic Resources: the Role of Borrowing and Dissipative Resource Use[END_REF][START_REF] Schneider | The anthropogenic stock extended abiotic depletion potential (AADP) as a new parameterisation to model the depletion of abiotic resources[END_REF]. These considerations make more evident the need for a sustainable and resilient supply chain.

A limitation of the use of the GeoPolRisk method for this study is that it relies on the WGI-PV scores, which are qualitative and cannot reflect a full picture of the risk level of trade partners. This is a common limitation for other methods designed to measure supply risk [START_REF] Schrijvers | A review of methods and data to determine raw material criticality[END_REF]. Specifically for this case study, the WGI-PV scores for Qatar reflect a relatively adequate level of political stability within the country; however, restrictions imposed by neighbouring countries were not captured by these measurement, therefore not being translated to the overall results.

Another drawback is the existence of intermediaries in the supply network between helium producers and helium consumers. As mentioned earlier in this chapter, the impacts of this limitation are mitigated by allocating flows from intermediaries to the original producers. This assumption is supported by the fact that helium is not chemically transformed along the supply chain, no extra processes are required, remaining a pure element until its use.

As exemplified with the case of Japan, global helium trade is organised between a relatively small group of private companies, which enter into joint ventures with state-owned enterprises in some countries [START_REF] Buzwair | Buzwair Industrial Gases Factories. Helium joint venture in Qatar[END_REF]Iwatani, 2013). From a national perspective, one of the main drivers of supply risk in a market with a reduced number of suppliers is the management of the supply mix. A balance is achieved when the risk is diversified among various trade partners which are classified as politically stable countries. Is in this plane that questions on public health come into play, transforming the case of helium in a priority for multiple nations.

Sustainable management of helium supply becomes even more important due to the nature of this element. Unlike other resources, helium dissipates completely evading future recovery from the anthroposphere and escaping Earth's gravitational pull. There are several fronts to consider when managing helium supply; in preparation for the future, efforts by the sector should be directed to reduce helium losses along the supply chain, study ways to reuse helium in their main and most important applications, and guarantee a stable and low-risk supply mix.

As discussed thoroughly in Chapter 6:, supply risk is only one layer of many concerns surrounding sustainability, representing one of various environmental impacts in LCA. An assessment oriented to understand impacts of the use of resources benefits from the analysis of other midpoint indicators. In order to provide better information and tools for decision-makers in the field of healthcare sustainability, the next chapter focuses on an integrated assessment based on the results from this section and the application of the LCA methodology to the case of MRI scans from the perspective of different countries.

Chapter 7: presented the first application of the geopolitical supply risk method to helium, an element considered of importance for the healthcare sector. Additionally, the case study allowed to analyze for the first time the geopolitical supply risks associated to an element typically transported and used in liquid or gaseous state. As previously discussed, the GeoPolRisk method is designed as a complement to environmental life cycle assessments based on concerns about resource accessibility. It was demonstrated in Chapter 6: that the method and its associated enhancements provide a new layer of analysis worth considering by LCA practitioners provided relevant information is current and available.

With the objective to evaluate the overall readiness and applicability of LCA with the proposed inclusion of criticality considerations as a way to assess outside-in impacts with the GeoPolRisk method, this section presents the application of the life cycle assessment methodology to evaluate magnetic resonance imaging (MRI) scans at the midpoint level in an integrated way. This is done from the perspective of four countries (Canada, Germany, France and Japan) for the year 2018. The main focus in the assessment is on helium as one of the key elements required for this technology.

The life cycle of MRI scans: Goal and Scope

In section 3.3.2, the first approach to understanding the relevant considerations from a life cycle perspective surrounding the use of helium for medical imaging was presented. The LCA-based framework designed to support healthcare sustainability from Chapter 3: was used and one highlight of this exercise was identifying medical imaging as a key transversal activity to support the delivery of care.

Among the multiple options available to produce medical images, magnetic resonance imaging (MRI) is arguably one of the most expensive and resource intensive given the use of superconducting magnets that require specific infrastructure and energy demands [START_REF] Sarracanie | Low-Cost High-Performance MRI[END_REF][START_REF] Young | What does an MRI cost? Healthcare Financial Management[END_REF].

MRI allows healthcare practitioners to visualize specific anatomical structures non-invasively and without exposing patients to ionising radiation; MRI techniques produce high resolution images of the soft tissues in the body in several layers, allowing to identify anomalies, typically tumors, herniations, hemorrhages, among others. MRI machines use powerful magnets to create a magnetic field that aligns the molecules of water in the body, radio waves disturb the polarity of these molecules and a sensor identifies the time that it takes these to reposition. Essentially, the water content and the characteristics of the fluids in the body are identified, allowing to visualize any abnormalities. In some cases, contrast agents may be injected to enhance certain soft tissues [START_REF] Westbrook | MRI in Practice[END_REF].

Helium is used in its liquid form as a cooling agent for the superconducting magnets used in MRI machines to maintain the temperature below -296°C and guarantee the levels of conductivity required for ideal performance. Currently, there is no alternative to helium to keep current and most common MRI machines functioning. More recent MRI equipment is designed to not consume helium and guarantee continuous operation with minimum to zero losses; this new technology is expected to be more widely used in the medium term future (Cosmus and Parizh, 2010;[START_REF] Notardonato | Zero boil-off methods for large-scale liquid hydrogen tanks using integrated refrigeration and storage[END_REF][START_REF] Laine | Zero Helium Boiloff MEG Technology[END_REF].

As previously explored in Chapter 7:, concerns have been discussed about limited global helium availability [START_REF] Hurd | Energy-critical elements for sustainable development[END_REF]National Research Council, 2010;[START_REF] Nuttall | The Future of Helium as a Natural Resource[END_REF] and its accessibility in the global market due to supply constraints and specific logistics considerations [START_REF] Bare | Responding to the U[END_REF][START_REF] Glowacki | Beyond the Helium Conundrum[END_REF][START_REF] Olafsdottir | Assessing the Past and Future Sustainability of Global Helium Resources, Extraction, Supply and Use, Using the Integrated Assessment Model WORLD7[END_REF]. Helium production is concentrated in few countries, making its supply chain an interesting case study from a geopolitical and an environmental sustainability perspective.

Following the work presented in the previous chapter, the application of the life cycle assessment methodology to the case of MRI scans aims to understand what are the main environmental impacts associated with the production of a medical image; special focus is given to the contributions of the helium supply chain and energy use. Specifically, potential correlations between overall impacts, energy mixes and the supply mixes of consuming countries are studied to identify hotspots along the life cycle.

The selected functional unit is one MRI scan (digitally produced in the year 2018); the assessment is conducted from the perspective of four countries that have the most MRI machines per capita yet they do not produce helium: Canada, Germany, France and Japan (OECD, 2017). For purposes of practicality, it will be assumed that scans are performed in Toronto (CA), Berlin (DE), Paris (FR) and Tokyo (JP), abbreviated by their two-letter country code. The year under assessment is 2018 considering that, at the time of the development of the study, it was the latest period for which helium production and trade information were available. Figure 8.1 shows the main inputs and outputs of the analyzed process (For further details, please refer to Annex W). As previously mentioned, the assessment will focus on helium as a main constraint in the supply chain.

The amount of liquid helium required to provide cold for the production of one MRI scan will serve as the reference flow; this value varies according to the use scenario. As shown in Figure 8.2, the study will include three main life cycle stages associated with the helium supply chain: international helium supply, local helium distribution and helium use in MRI machines. The international helium supply considers the production of helium, local transport to port of export and international transport to the country of destination. The local distribution includes transport from the port of import to a helium transfill center, the transfill process and local transport to hospitals. Finally, the use phase considers helium consumption, energy consumption, infrastructure and MRI electronic equipment (excluding the production of magnets) (Figure 8.1).

Three scenarios of helium use and two scenarios of energy consumption are considered in order to cover a range of available levels of technology in MRI machines. The study does not include the production of natural gas that traditionally accompanies helium production. An end-of-life stage in the life cycle is not considered nor the production, transport and maintenance of magnets in the MRI machine. Supporting equipment to manage, deliver or print MRI scans is not accounted for as the study considers a system boundary after the image is digitally available in the MRI machine.

Figure 8.2 -Stages in the helium to MRI scan life cycle. System boundaries for the study Background information was obtained from the Ecoinvent 3.4 database [START_REF] Wernet | The ecoinvent database version 3 (part I): overview and methodology[END_REF] and the environmental life cycle assessment modeling was performed using the openLCA 1.10.2 platform (GreenDelta, 2020).The following section will present the information required to construct the life cycle inventory, as well as the impact categories used for the assessment.

Understanding the life cycle of MRI scans: Life Cycle Inventory

As previously illustrated in Figure 8.2, the study considers helium production as a starting point; this assessment does not take into account natural gas production. Five models of helium production are considered based on the helium producing countries relevant to the studied supply network: Algeria (ALG), Poland (POL), Qatar (QTR), Russia (RUS) and the USA (USA), abbreviated by their three-letter country code; the Ukraine was not included because it represents less than 2% of the supply in 2018.

Table 8.1 presents the parameters used to differentiate the processes modeled for the helium production stage of the life cycle. A same level of technology is assumed due to insufficient data on specific processes for each country, however, the differentiated energy mixes were included in the assessment (Detailed information is available in Annex P). Specific information for a representative plant in each producing country was also taken into account; for the specific case of the USA, the 'Liberal' plant in the State of Kansas was chosen due to being the largest one and being in a virtual average location among other helium plants in the country. The other plants were chosen due to being the most important in each of the studied exporting nations (Skidka, ALG; Odonalow, POL; Ras Laffan, QTR; Orenburg, RUS).

Detailed information on the plants is available in Annex Q; the base bill of materials for the production stage is presented in Annex R.

Efficiency of the process

Assumed the same for all producing countries (losses in the production stage).

Energy mix

Specific for each country, considers information for the year 2018 (except for Kansas, USA: 2019 as proxy).

Plant characteristics

Tailored for each plant; contains specific data on plant size, plant capacity and location in the analyzed countries.

As part of the international supply stage in the life cycle, a next step on the modelling considers local transport from the plant to the port of export. The international supply network is presented in Following what was presented in section 7.2, a direct transport from producing to importing country without intermediaries is assumed to simplify the model. Maximum efficiency is assumed during the international transport; containers at this stage are designed for losses of less than 1% over 60 days [START_REF] Linde | UN portable tanks for helium (HELICS TM)[END_REF], period that is never surpassed in the analyzed trade network. The model considers local transportation between the port of entry in the importing country and a transfill center located in the city in which the use phase takes place. Details on this stage are available in Annex U. A transfill process in which helium is put into 500L containers is also part of the chain; these containers are delivered to medical centers for provision to MRI machines. Similar to the production stage, the transfill process is assumed of the same technology level in the four destination countries (energy and helium efficiency); however, differences associated to the local electricity mix are considered. The electricity mixes used for this model and details on the transfill process are available in Annex V. A final local transportation stage between the transfill center and the final destination is also included in the model (for further details, please refer to Annex U).

For the last analyzed stage, energy consumption, helium consumption, electronic component use and facility use were included in the model. As mentioned in section 8.1, the production, transport, use and maintenance of magnets is not considered as part of the calculations due to lack of data. Moreover, the model considers as a final output the provision of cold for the production of one MRI scan, but does not account for its management or delivery. In order to capture a range of technology levels for the MRI machines, two scenarios of energy consumption and two scenarios of helium use were considered based on estimations found in PE International (2012) and compared with experts' opinions. The details on the differences between these scenarios are presented in Table 8.2. MRI machines are assumed to have an 11.5 years lifetime working at maximum capacity (For more details, please refer to Annex W). As also considered for the transfill stage, each individual electricity mix in the analyzed countries is part of the calculations for the use phase in the life cycle (for more information, please refer to Annex V).

Based on the mentioned parameters, a total of 24 combinations were defined (4 countries, 2 energy consumption levels and 3 helium use scenarios). Further details on the bill of materials for this stage are available in Annex W.

Following the above presented information in this section, the computational model in the OpenLCA software is completed according to the scope described in Figure 8.2. The 24 scenarios of the model were run following the CML impact assessment method (midpoint level); indicator results for the following impact categories were obtained: acidification, eutrophication, fresh water ecotoxicity, global warming, human toxicity, marine aquatic toxicity, ozone layer depletion, photochemical oxidation and terrestrial ecotoxicity. For resource accessibility, the results are complemented with the GeoPolRisk method applied to helium for the year 2018 from the perspective of the importing countries; helium is used as proxy due to being the main supply constraint in the analyzed supply chain, results for this last impact category are available in section 7.3.

Results of the integrated study on MRI scans

In this section, the overall results of the model will be presented. A top-down approach is followed: from general results to specific details in the analyzed system. The description of results starts with an overview of the behavior of all scenarios for MRI scan production in the four analyzed countries with the objective to identify general trends and main contributors; a next stage will focus on understanding how this contributions change depending on selected scenarios for helium consumption based on two main impact categories. Finally, a focus will be given to the international supply stage with the aim to understand the contribution of the supply mix to the global warming potential.

Figure 8.4 shows a comparison between the results on the impact categories global warming potential and ozone layer depletion potential for the scenarios A1, A2, C1 and C2 (A: low helium use, 1: low energy consumption) run for the four countries under assessment (CA, DE, FR, and JP). These two impact categories were selected for this graphic due to representing the two main trends in impact behavior at midpoint level (A full set of the overall results for the 24 scenarios is available in Annex X in the form of a colored table to identify these trends). All categories, with the exception of ozone layer depletion potential and geopolitical supply risk show significantly higher impacts for all the scenarios run for Germany and Japan compared to the results for Canada and France. Moreover, scenarios of high energy and helium consumption (C2) in Canada and France have a better environmental profile than scenarios of low energy and helium consumption (A1) in Germany and Japan.

The impact category of supply risk is measured using the GeoPolRisk indicator for helium. The results do not change over the use scenarios, because they depend on the helium supply mix for the importing countries and the year of assessment (as seen in section 7.3). As reference, Figure 8.5 shows a comparison between the supply risk and the previously discussed impact categories with the results for the scenario A1 (low helium use, low energy consumption).

Global Warming Potential

Supply Risk

(Units: adimensional) (0: absence of risk, 1: imminent risk of supply disruption)

Figure 8.5 -Global warming potential and ozone layer depletion per scan for scenario A1 and helium GeoPolRisk from the perspective of Canada, Germany, France and Japan As previously discussed in section 6.5, the use of the GeoPolRisk method provides a new layer for the assessment of impacts that is not captured with other impact assessment methods. Supply risk considerations associated with the political (in)stability of helium-supplying nations make the case of France visible: potential disruptions associated with the heavy reliance on one trade partner with a high risk profile (Algeria). This situation was not reflected by the other categories, specially considering that the electricity mix of the country in which the MRI scan is used has the highest contribution to overall impacts.

Since the electricity consumption associated with the use phase appears to be the dominant stage on the life cycle; a second layer of assessment is proposed to better understand the contribution of previous processes, namely the international supply (production and international transport) and the local distribution (refill and local transport). In Figure 8.6 it is possible to visualize the contribution of the three analyzed life cycle stages to the global warming potential impact category for the scenario C1 (high helium use and low energy consumption, selected to help visualize the role of helium supply in the impact category). The contribution associated to the international supply from the five main producing countries (ALG, POL, QTR, RUS and USA) is enhanced and compared with the supply mix of each importing country.

differences between the percentages are captured by the model. The information presented on Figure 8.7 is the result of a further assessment with the aim to identify the absolute value of the GWP for having the equivalent to 500L of helium available in the destination country depending on its origin. The figure also contains values for the percentage of the impacts associated to international transport (from production plant to port of destination in the consuming countries).

GWP (kg CO2 eq)

Contribution of production stage (%) Contribution of international transport (%)

Figure 8.7 -GWP associated to 500L of helium available in the country of destination for the scenario C1

In the case of Japan, it is possible to identify a higher impact associated to having available helium in the country. This is explained by the international transportation stage being a big contributor to the impacts in the route USA to Japan; in this case, the transportation is responsible for over 30% of the impacts of having the equivalent to one 500L of helium available in the port of Kawasaki. With the exception of the Japanese case, the proposed model is not capable of identifying further significant differences between the international supply profiles; this is a reflection of assuming a similar model for the production of helium in the different countries of origin. In contrast to the overall GWP associated to the production of one MRI scan in Japan and the environmental profile of helium available in the port of Kawasaki, the supply risk of helium supplied to Japan remains the lowest among the four importing countries. This is visible in Figure 8.5 and was previously discussed in section 7.4 for the period of years between 2015 and 2018. Japan might be the best ranked in terms of managing a relatively stable and continuous supply of helium; but most environmental impacts associated to their supply chain and, specially, energy consumption for MRI scan production could be addressed to improve their overall environmental profile.

An opposite case is seen for France, the GeoPolRisk indicator shows a high supply risk compared to the other analyzed countries due to its reliance on Algeria for helium supply; however its potential environmental impacts appear lower for most impact categories (with the exception of ozone layer depletion, which is associated to the use of nuclear energy). This confirms that supply risk and other more commonly used environmental impacts do not correlate and should be analyzed as complements to each other to better inform decision-making processes.

By focusing on GWP as the main category for this assessment, it is possible to see how multiple stakeholders could improve the environmental profile of MRI scans. First, energy efficiency of MRI machines should be a main concern of producers; second, medical centers using MRI equipment could focus on best practices for energy efficiency; and, third, government agencies could prioritize the transition towards a cleaner energy mix to achieve a less impactful use of this key technology in healthcare. A second layer of recommendation is associated with helium supply, promoting the study of the supply mix to mitigate its geopolitical risk.

The presented results highlight the relevance of energy consumption and the energy mix in the late stages of the life cycle, as they surpass most of the effect associated with the origin of the helium. This findings make more apparent the role of specific practices in healthcare that contribute to the carbon footprint of the sector (As previously highlighted by [START_REF] Eckelman | Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis[END_REF]NHS Sustainable Development Unit, 2016;[START_REF] Malik | The carbon footprint of Australian health care[END_REF][START_REF] Eckelman | Environmental impacts of the U.S. health care system and effects on public health[END_REF]. From an integrated perspective, healthcare is partially responsible for and being affected by climate change, making this global phenomenon a health emergency [START_REF] Watts | The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate[END_REF].

Discussion on limitations and future steps

The integrated study presented in this chapter represents a cross section of a life cycle assessment that takes into consideration geopolitical supply risk as an impact category at the midpoint level. The energy consumption at the use phase was identified as the main contributor to the impacts of MRI scan production. However, the analysis of previous stages associated to the production and international transport and the inclusion of the GeoPolRisk indicator show a new assessment level worth exploring for this case study.

From a geopolitical perspective, concerns on helium accessibility are apparent. The Japanese case shows efforts towards management of supply networks to secure reliable provision (for further details, please refer to section 7.4). France appears among the better ranked for clean energy, but the supply risk associated to helium is the highest. Supply constraints are not visible with a traditional environmental LCA; therefore the GeoPolRisk method has the potential to support future studies interested in supply of raw materials.

The study has its limitations and further information could be extracted for future assessment. Similar analysis to the one presented in this chapter could help reveal other interesting hotspots along the life cycle for impact categories other than GWP, ozone layer depletion and supply risk. Moreover, the study focused on analyzing the contributions of the helium supply chain and the energy consumption, not accounting for important components in the MRI machine such as the magnets, or for further life cycle stages after the obtention of the digital medical image.

Early stages in the helium supply chain considered the same level of technology, energy requirement and efficiency for the production of helium in different nations, which is most likely not the case; this prevented a deeper assessment on the contributions to impacts from the international supply stage. The use of a simplified trade network, in which the resource is transported directly from point of production to point of use allowed to better understand the supply constraints associated with the commercial relations between countries. However, this impeded to better consider potential helium losses along the supply chain associated to longer transit times. Also, costs associated to helium supply were not part of the study, these could provide further insights on the decisions made by countries regarding their supply mix.

The production, trade and maintenance of magnets used in MRI machines were not considered on the study; further assessment could help better understand the impacts associated to this part of the life cycle. This would not only be worth exploring from an environmental perspective, but also from a supply risk point of view by accouting for the potential use of specific resources deemed critical (e.g. rare earth elements). Also related to the use phase, the management, storage and delivery of MRI scans were not part of the model, but it would be encouraged to include them for more information on the role that medical centers can take to mitigate impacts in late stages of the life cycle.

Considering all limitations discussed around the model, only the surface has been scratched; this chapter provides a starting point to further assess the impacts of MRI scan production. The study of further scenarios that considers a variety of production technologies, more detailed losses along the supply chain, supply costs and a temporal variable could inform medical centers and government agencies on how to work towards constructing supply mixes that not only secure helium supply, but also decrease environmental impacts.

Moreover, this case study serves as an example of the application of indicators associated to an outsidein perspective in life cycle assessment. In this specific case, the GeoPolRisk indicator allowed to obtain information that was not captured by other impact assessment methods. This shows how the integration of raw material criticality and life cycle assessment, operationalized with the GeoPolRisk method, supports decision-making processes not only in a sector as complex as healthcare, but with the potential to be applied to others.

Chapter 9: General Discussion and Conclusions

The final chapter of this thesis contains a discussion on the topics presented along the manuscript. The outcomes of each chapter are analyzed to understand the overall contribution to the main and specific objectives initially introduced. Here, the hypotheses that were formulated in Chapter 1: are tested based on the findings and results. Finally, this chapter includes conclusions and perspectives associated with the two branches in this PhD project: (1) Healthcare and Sustainability and (2) LCA and Raw Material Criticality.

Responses to the objectives

As presented in Chapter 1:, the work in this thesis was developed to answer the following research question:

How to assess environmental sustainability aspects in the healthcare sector using life cycle assessment and advancing its methodological readiness to evaluate raw material criticality in an integrated way?

Thie main objective of this thesis was defined based on the research question and is: to provide and integrate methods to assess healthcare environmental sustainability from a life cycle perspective with focus on enhancing criticality indicators as an outside-in impact pathway associated with the AoP Natural Resources. Following this rationale, eight specific objectives (S.O.)

were completed along the chapters of this manuscript:

In Chapter 2:, a scoping review allowed to complete S.O.a: to provide a detailed state of the art of the LCA applications in the healthcare sector while identifying the main methodological challenges for assessing healthcare systems from a life cycle perspective. Multiple previous efforts in the field were identified; however opportunities for methodological development and further research emerged. Among these the potential to explore understudied areas in healthcare, to promote life cycle assessment as a suggested method to support the path towards healthcare sustainability, to provide and enhance methods to address outside-in impacts and to develop a conceptual framework to support research in the field. These findings became motivators for the work presented in following chapters.

Also as part of Chapter 2:, the S.O.b was completed: to provide a detailed state of the art of the methodologies to address outside-in impacts resulting from the integration of raw material criticality and LCA while identifying the main methodological challenges for its readiness. Following previous work developed by the UNEP Life Cycle Initiative, a review on the life cycle impact indicators for addressing abiotic resources was performed. The GeoPolRisk method was selected to assess its potential for further enhancements as a complement to LCA, specifically related to the AoP Natural Resources.

Opportunities for methodological development were identified and motivated the work completed in the next chapters.

As the first chapter fully dedicated to the branch of the thesis related to healthcare sustainability, Chapter 3: follows up on previous findings and responds to the S.O.c: to develop a framework to address healthcare sustainability from a life cycle perspective and provide its potential applications. This section shows the rationale behind the construction of said framework and presents two cases for future application. One of these potential applications was further explored and serve as base case study for the the development of two chapters of the thesis: the case of helium for MRI scan production.

Opening the branch of LCA and raw material criticality, Chapter 4: followed up on the S.O.d: to enhance the existing geopolitical supply risk method to include recycling considerations as a mitigation strategy.

This is a direct result from the methodological limitations previously identified. The objective was completed after proposing a methodological enhancement and testing its applicability to a case study on the supply risk of critical materials used for Information and Comunication Technologies in the European Union. This chapter also responds to recommendations provided by the UNEP Life Cycle

Initiative.

Also as part of the proposed areas of improvement for the GeoPolRisk method, S.O.e was completed in Chapter 5: to advance the scope of the geopolitical supply risk method from a midpoint level indicator to an endpoint level indicator associated to the area of protection Natural Resources. A novel method to address potential socio-economic impacts of the use of resources was developed with the inclusion of price and proce elasticity information. A proof of concept is presented with the application of this method to selected materials in the inventory of lithium-ion batteries for the case of the country members of the OECD.

Following up on the two methodological enhancements for the GeoPolRisk method, Chapter 6: is based on their application to a case study on LIB for the European Union. With the use of the indicators based on geopolitical supply risk at midpoint and endpoint level, S.O.f is completed: to demonstrate the added value of the geopolitical supply risk method at midpoint and endpoint level as a complement to environmental LCA with a case study. The application allowed to identify relevant information that is not currently visible when using more traditional impact assessment methods in LCA.

Chapter 7: was developed to respond to the S.O.g: to demonstrate the added value of the application of a method based on an outside-in impact pathway with a case study relevant to the healthcare sector.

The GeoPolRisk method is applied to the case of helium, important resource for the healthcare sector, from the perspective of the top ten helium importers in the world. This application allowed to show information that is currently only obtainable when analyzing geopolitical supply risks. This chapter starts bringing together both branches explored in the thesis: (1) Healthcare and Sustainability and (2) LCA and Raw Material Criticality.

Chapter 8: responds to S.O.h: to demonstrate the relevance of the application of an integrated assessment based on LCA considering outside-in and inside-out impact pathways for the healthcare sector. In this chapter, a study based on the LCA methodology of MRI scans is performed to identify hotspots along the supply chain that contribute to environmental impacts. The GeoPolRisk method was used to address supply risk as part of the outside-in impacts associated to helium use. With the study conducted from the perspective of four countries, it was possible to verify the relevance of addressing outside-in impacts when performing environmental assessments.

Hypotheses testing

Three hypotheses were formulated to answer the research question. In this section, the hypotheses will be discussed considering the outcomes of the thesis.

Hypothesis 1: LCA is an appropriate methodology to measure environmental sustainability impacts, extending the traditional scope to include an outside-in perspective.

From the review on the state of the art, it was concluded that the LCA methodology has a high maturity level when addressing inside-out impacts for multiple sectors. This is a result of continuous work on life cycle impact assessment methods and best practices to communicate results. However, as also identified in the early chapters of the manuscript, efforts are being made to extend the application of LCA in the context of outside-in impact pathways. The UNEP Life Cycle Initiative has listed a number of methods designed to address these aspects, with multiple levels of maturity.

Overall, opportunities for further methodological development were identified. In this thesis, the Geopolitical Supply Risk method was selected for its potential based on the suggestions provided by the Task Force in charge of studying product-level supply risk assessment methods. The recommendations were addressed and new proposals were presented at midpoint and endpoint level.

Certain limitations remain, especially when discussing the applicability of indicators at the endpoint level due to lack of information; however, the use of the method, associated with an outside-in impact pathway, has been proven relevant by providing new and relevant information to LCA practitioners.

Hypothesis 2: Raw material criticality has the potential to address outside-in impacts associated with the AoP Natural Resources.

In this manuscript, the work previously developed on the integration of raw material criticality in the life cycle sustainability assessment framework is followed up by the enhancement of the GeoPolRisk method. The proposed methodological advancements have been proven adequate to address impacts associated to resource use in LCA by modeling potential socio-economic damage. Therefore, raw material criticality provides a new layer for the assessment of impacts in the AoP Natural Resources in LCA. However, further work is encouraged to mainstream the use of methods associated with this impact pathway.

Hypothesis 3: Products and services related to the healthcare sector can be analyzed in an integrated manner to account for impacts from the inside-out and outside-in pathways in LCA.

The scoping literature review in this thesis allowed to identify multiple previous efforts to address concerns on healthcare sustainability with the use of the LCA methodology. As previously discussed,

LCA has a high level of maturity that allows it to be used in multiple sectors to support decision-making processes; however, outside-in impact pathways are not usually taken into account. As presented earlier in this manuscript, material criticality has been identified as a relevant topic for the healthcare sector (and several others), but a consensus on how to address it as part of life cycle assessment has not yet been achieved.

In this thesis, both inside-out and outside-in impact pathways were deemed relevant for the integrated study of a technology used in the healthcare sector. This resulted on the obtention of insights that serve as complement to each other, demonstrating that this is a methodology worth considering for future studies in the field of healthcare sustainability.

LCA as a tool to support the path towards healthcare sustainability

As illustrated by the literature presented in this manuscript, healthcare is a fast growing sector around the globe; studies have estimated that the contribution of this sector to total greenhouse gas emissions are between 5% and 10% in developed nations [START_REF] Eckelman | Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis[END_REF][START_REF] Eckelman | Environmental impacts of the U.S. health care system and effects on public health[END_REF]NHS Sustainable Development Unit, 2016;[START_REF] Malik | The carbon footprint of Australian health care[END_REF]. Climate change, a direct consequence of human activities, has been recognized as a global health emergency; moreover, climate change itself is associated with potential supply disruptions, decrease in air quality, malnutrition, proliferation of infectious diseases, limited access to fresh water, and increase on the frequency of weather events (WHO, 2009).

The previous statements are not only a reflection of the healthcare sector being both responsible for and affected by climate change, but an example of two impact pathways: inside-out and outside-in. As explored in the scoping review, documented efforts to address environmental impacts of healthcare activities exist in the literature and most of them are focused on the inside-out pathway, addressing environmental related issues such as waste management and potential greenhouse gas emissions.

Life cycle assessment is a methodology designed to understand the environmental impacts of products and services; it has provided information to support decision-making processes in diverse sectors and it has been used to address environmental aspects of the sustainability of healthcare following an insideout perspective. With this thesis, it is expected to contribute to the use of LCA to also address outsidein impacts relevant to the sector and to support future research on the field, as demonstrated with the application of the GeoPolRisk method to the case of helium in medical imaging. It is worth mentioning an example of the impact of supply disruptions in the healthcare sector in 2020 and 2021: the COVID-19 pandemic, which has impacted healthcare-related supply chains (pharmaceuticals, personal protective equipment) as they are facing shortages, increased costs and multiple delays [START_REF] Miller | Vulnerability of the medical product supply chain: the wake-up call of COVID-19[END_REF][START_REF] Idc | Solving the COVID-19 pharma supply chain struggle[END_REF]. These cases of supply risk have not been explored in this thesis, as a multi-stage and product-specific approach in the supply chain would be required and the GeoPolRisk only considers early life cycle stages as sources of supply risk.

However, the healthcare sector is complex and involves multiple activities, materials, infrastructure, technology, personnel and services. Moreover, the levels of care and the medical specialties are factors to consider when addressing impacts from and to the sector. This manuscript presents a framework that can support future research in healthcare sustainability by compiling parameters associated to the study of impacts in healthcare activities from a life cycle perspective. In Chapter 3:, this framework was applied to two cases; a first one directed towards the environmental assessment of anesthetic gases, however further development of the proposal was interrupted due to the COVID-19 pandemic; the project remains in stand-by at the time of writing of this chapter. A second application served as a starting point for the development of an integrated assessment based on the life cycle methodology including the use of the GeoPolRisk method to the case of helium in MRI scans (Available in Chapter 7 and 8). Overall, the full potential use of this framework remains to be achieved and it is expected for this first set of applications to serve as reference for future implementation and test in other case studies for the healthcare sector.

With the development of a framework to study healthcare activities, this manuscript has addressed the environmental pillar of sustainability in healthcare. By further extending the use of the concepts of raw material criticality, this thesis also shows one possible way to analyze aspects associated to outside-in impacts in healthcare. In Chapter 7:, the criticality of helium was explored from the perspective of ten nations based on the GeoPolRisk method to follow up on this research opportunity. This allowed to identify certain hotspots related to the supply risk of helium, mostly associated with the countries of origin of said element. The results allow to extract information that would not be normally captured by the more traditionally used impact assessment methods in environmental LCA.

With the study of an integrated life cycle assessment methodology, Chapter 8: presented the case of MRI scan production in four countries (Canada, Germany, France and Japan) under different energy consumption and helium use scenarios. Following up on the previous work, the focus was given to helium as a main constraint in the studied supply chain with the objective to understand the role of helium supply in the environmental profile of MRI scans. A main outcome of this study was the finding of energy use in the MRI machines as the main contributor to the most impacts, highlighting the relevance of energy efficiency in the late stages of the life cycle and the energy mix of the countries in which the MRI scans are produced. As suspected from the results in Chapter 7:, the use of the GeoPolRisk method provides a new layer for the assessment. This is exemplified by analyzing the cases of France and Japan, MRI scans produced in France account for less environmental impacts than those produced in Japan, mainly due to the difference between the energy mixes of these countries; however, the helium supply risk for Japan is lower than the one from France because of the different helium supply mixes. A baseline for future studies is given, other aspects could be explored: different technologies of helium production, more detailed losses along the helium supply chain, costs of helium for different countries and more complex supply networks.

This integrated assessment aimed to serve as an example of the potential of LCA to support decisionmaking processes in the healthcare sector, even more so with the introduction of outside-in indicators that could offer complementary information usually overlooked by more traditional impact categories in life cycle impact assessment. However, work remains to be done to fully understand the implications of healthcare activities in society, the economy and the environment; and, by extent, studying how these have a potential effect on healthcare delivery.

The development of a life-cycle based framework to support research in the field of healthcare sustainability and the first application of an outside-in indicator as part of an integrated study based on the life cycle methodology for a product in healthcare are the main outcomes in this branch of the thesis.

As previously discussed, multiple opportunities for future research became evident along the manuscript; the presented framework has the potential to be further applied and tested in multiple areas, being this a reflection of the complexity and vastness of the healthcare sector. The GeoPolRisk method, an outside-in impact indicator featured in this thesis, was applied to the case of helium in medical imaging with a limited scope. Specifically for the case study, multiple materials in the life cycle of MRI scans could be further analyzed under this method, for example on rare earth elements in magnets.

Moreover, supply risks at intermediate levels in the supply chain are not taken into account, future use of the method could focus not on raw materials, but also intermediate or final products such as pharmaceuticals or personal protective equipment.

The work presented here is an effort to enhance and apply the life cycle assessment methodology to the largely unexplored domain of healthcare. Only the surface has been scratched, but with this thesis it is expected to contribute to the work already done by scholars in the field of healthcare sustainability.

As described above, the healthcare sector is a vast and complex system; various medical activities, technologies and products remain understudied from a life cycle perspective. Healthcare delivery is urgent and important, but the assessment of the sustainability of healthcare activities is also relevant. A

next key challenge is to mainstream the use of environmental information as a new input for decisionmaking processes in healthcare management.

The integration of LCA and raw material criticality:

The future of the GeoPolRisk method

The second branch of this PhD thesis responds to the need to enhance and extend outside-in impact indicators in LCA designed for the AoP Natural Resources. The work associated to this branch in the thesis was completed with the aim to address the suggestions provided by multiple scholars around the design and application of the GeoPolRisk methodology.

As presented in this manuscript, the GeoPolRisk method was developed as a result of the integration of raw material criticality considerations in the life cycle sustainability assessment (LCSA) framework. It was conceived both as a midpoint indicator in LCA related to potential impacts in the Area of protection Natural Resources and as a complement to environmental LCA in the economic dimension of LCSA.

The method has been subject to a comprehensive review on product-level supply risk assessment indicators conducted by the UNEP Life Cycle Initiative. Opportunities for improvement were identified in said review and this thesis presents methodological enhancements to address them.

A first main suggestion relates to the use of recycling indicators in the method. The inclusion of recycling considerations allowed to model the risk-mitigation potential of recycling practices in countries or regions that use critical raw materials, which was not possible under the method up until now. A case study presented in Chapter 4: demonstrated the existence of two mechanisms through which recycling mitigates supply risk: a requirement reduction of imports (the "reduction effect") and a potential redistribution of the supply mix (the "redistribution effect"). The enhanced method is able to capture these effects under the assumption that recycling practices take place domestically, that the recycled material is reinserted in the local economy and that the reintroduced material is usable on the same way as virgin material.

The enhanced method is still subject to limitations in theory and practice. The information required to calculate GeoPolRisk values might not be sufficient or available in the required granularity for the application; for the presented case study, certain materials had to be aggregated to match the available data. Also, the scope of the case study was limited by the availability of recycling indicators, which were obtainable only at the EU level and for a specific period of time. In order to partially overcome these challenges, simulations were made to analyze diverse recycling scenarios, which allowed to understand in which cases potential improvement opportunities could be directed towards advancing recycling technologies or towards redistributing the supply mixes of the studied materials.

All the previous work on the GeoPolRisk method has been made from a midpoint level perspective in LCA; however, a second major recommendation was to extend the scope to model potential impacts associated to the AoP Natural Resources at the endpoint level. The novel GeoPolEndpoint method was introduced in this manuscript; it serves as an indicator at the endpoint level in LCA based on the GeoPolRisk method and allows to measure the short-term impacts of resource use as a potential socioeconomic damage depending on price considerations. The conception of this method allowed to associate life cycle inventory flows measured in mass units with the geopolitical supply risk, which is adimensional. The method takes a unique approach by adopting price elasticity values based on historical information for natural disasters that caused supply disruptions in the past; this allows to model potential increased costs associated to the use of critical raw materials. Limitations still exist for a widespread application of this extension, the most important being related to the availability of price elasticity values for a wider range of resources. The case study in Chapter 5: serves as a first proof of concept for this modelling process, showing a measure of potential increased costs associated to the use of four materials in specific technologies. From a LCA perspective, the method is designed to better inform about potential tangible economic impacts linked with resource use and supply risk, however more work is required from the field of economics to support the use of the GeoPolEndpoint method.

The work presented in Chapter 6: shows the kind of information that can be extracted from analyzing the supply risk of raw materials as part of an integrated life cycle assessment. Although limited due to the data constraints at both midpoint and endpoint level mentioned above, the case study allowed to show how the GeoPolRisk and the GeoPolEndpoint methods provide additional information that serve as a complement to other impact assessment methods in LCA. Further work remains to be done in order to allow these methods to be widely used by practitioners, efforts should focus on producing and obtaining information that can support their application, namely end-of-life recycling input rates and short term price elasticities.

In order to explore the field of healthcare sustainability, an opportunity was identified in the case of helium. This element is of interest due to its peculiar characteristics: it is produced and used in its elementary form, it is transported and traded in liquid or gaseous state, and is produced by few countries around the globe. The work presented in Chapter 7: was the first application of the GeoPolRisk method to an element of these attributes. The case study allowed to measure the risk of potential supply disruptions tailored to different countries that was not possible to identify from the application of other impact assessment methods in LCA; it also helped support the integrated study on the production of MRI scans in Chapter 8:. This application is not free from limitations, a simplification of the real supply chain was considered to study the supply risk under the assumption that helium is not chemically modified along the supply chain, however this weakened the capacity of the life cycle model to quantify helium losses in the transportation stages. Also, an important potential source of supply risk for the case of MRI scan production was not considered: REE in magnets.

The highlights in this branch of the thesis respond to the suggestions made by the UNEP Life Cycle

Initiative task force on natural resources around the GeoPolRisk method, specifically the inclusion of recycling as a risk-mitigation factor and the extension of the approach to allow assessments at the endpoint level with the inclusion of price and price elasticity considerations to estimate impacts associated with the AoP Natural Resources in LCA. As mentioned above, the biggest future challenges are the obtention and production of viable information to support the use of the proposed methods, namely the availability of end-of-life recycling input rates for multiple materials in various countries and regions, and the calculation of short term price elasticity values for critical raw materials. Overcoming these obstacles would help to further operationalize the GeoPolRisk and GeoPolEndpoint methods to support LCA practitioners.

Based on the current profile of the GeoPolRisk method, future work could also focus on four main areas.

First, to expand the application of the method, to move from assessments at country/region level to analysis that can support decision-making processes at company or facility level. This is feasible in theory, but private partners are yet to be found for these applications. Second, the GeoPolRisk method currently focuses on the mining and refining stages to address potential supply disruptions; a previous application has explored the supply risk at different stages in the supply chain of one product (Helbig et al., 2016a), but this work has not been replicated to other applications; as previously mentioned, this could specifically contribute to the supply risk of intermediary and finished products used in the healthcare sector and made evident in the context of the COVID-19 pandemic. Third, the GeoPolRisk method relies on the WGI indicators as a measure of political (in)stability, however further exploration of other social or economic indicators could provide more insights relevant to supply risk assessments;

a first approach was presented by [START_REF] Shaikh | Tool to Assess Raw Material Social Supply Risks[END_REF], but further work is encouraged. Finally, with its current level of maturity, the method allows to obtain a wide range of values for geopolitical supply risk based on geographical locations and years of analysis, this information needs to be updated on a yearly basis.

The inclusion of this calculations in a software package could facilitate future studies and provide extense databases to support the development of integrated life cycle assessments.

Reflection

This PhD project was first conceived to apply life-cycle-thinking and raw-material-criticality analysis to the healthcare sector. Early stages in the project showed research opportunities on the enhancement of these to better inform decision-making processes not only in the field of healthcare sustainability, but applicable to multiple other sectors by considering outside-in impact pathways in life cycle assessment.

The enhancement of the GeoPolRisk method to include the risk mitigation potential of recycling practices allowed to understand how multiple factors can support the path towards more reliable supply chains.

In the field of raw material criticality, the method can now provide new insights to inform companies and government agencies. Withstanding limitations, tangible economic impacts associated with resource use and supply risks can now be modeled with the application of the GeoPolEndpoint method, hopefully promoting the application of integrated assessments that do not focus only on environmental impacts, but also on how resource use has social and economic implications.

Mainstreaming the use of life cycle assessment and raw material criticality in the healthcare sector is a remaining challenge that can not be accomplished by one PhD project. Discussions on the topic of healthcare sustainability with medical practitioners have revealed an understanding and clear interest for studying and reducing the impacts associated with healthcare; however the urgency of daily medical tasks does not provide time and resources to address sustainability ambitions.

This situation takes us back to the phrase made popular by Mafalda, a character created by Quino in Latin-American culture: "As usual: the urgent does not leave time for the important". Healthcare is both urgent and important, however we might not be noticing that its impacts are part of what is creating the urgency.

Annex A. Literature searches for Healthcare Sustainability Scoping Review

This annex lists all literature searches performed between September and November, 2017 in order to conduct the Healthcare and Sustainability Scoping Review. Each entry specifies the used database, the search phrase and the date of the query.

Database

Search phrase Date

Scopus

("carbon footprint" OR "greenhouse gas*" OR "climate change" OR "global warming") AND ("diagnostic equipment" OR "diagnostic technique*" OR "computer assisted diagnos*" OR "medical technolog*" OR "medical laborator*" OR "laboratory diagnos*") September 29, 2017 Scopus ("carbon footprint" OR "greenhouse gas*" OR "climate change" OR "global warming") AND ("diagnostic imaging" OR "x-ray*" OR radiograph* OR "computed tomography" OR ultrasound* OR "magnetic resonance imaging")

Figure 1 . 1 -

 11 Figure 1.1 -Health spending and GDP growth by country income group from 2000 to 2017 ...............

Figure 1 . 2 -

 12 Figure 1.2 -Graphic representation of a product life cycle ....................................................................

Figure 1 . 3 -

 13 Figure 1.3 -Integration of life cycle methods in LCSA ............................................................................

Figure 1

 1 Figure 1.4 -The Areas of Protection of LCA as overlap of methodologies in LCSA ................................

Figure 1 . 5 -

 15 Figure 1.5 -Integration of criticality components within the LCSA framework .....................................

Figure 1 . 6 -

 16 Figure 1.6 -Proposed integration of methodologies to assess resource related impacts in the healthcare sector ................................................................................................................

Figure 1 . 7 -

 17 Figure 1.7 -Structure of the thesis associated to the Specific Objectives (S.O.) ..................................

Figure 2 . 1 -

 21 Figure 2.1 -Inclusion methodology for the scoping review .................................................................

Figure 2

 2 Figure 2.2 -LCA Framework ..................................................................................................................

Figure 2

 2 Figure 2.3 -Life Cycle Impact Assessment Framework ........................................................................

Figure 2

 2 Figure 2.4 -Trade dynamics captured by the GeoPolRisk method ......................................................

Figure 2

 2 Figure 2.5 -GeoPolRisk values for 14 resources relevant to the inventory of EV in 2013 ...................

Figure 2 . 6 -

 26 Figure 2.6 -Comparison of environmental impacts and the GeoPolRisk indicator at the midpoint level ..........................................................................................................................................

Figure 3 . 1 -

 31 Figure 3.1 -Mental map for the integration of activities in the healthcare sector and methodologies to assess sustainability ......................................................................................................

Figure 3 . 2 -

 32 Figure 3.2 -Medical Activities (Foreground Systems) ..........................................................................

Figure 3

 3 Figure 3.3 -Non-Medical Support Activities (Foreground Systems) ....................................................

Figure 3 . 4 -

 34 Figure 3.4 -Related Product Systems (Background Systems) ..............................................................

Figure 3 . 5 -

 35 Figure 3.5 -Framework for LCA to support healthcare sustainability ..................................................

Figure 3 . 6 -

 36 Figure 3.6 -Application of the framework for healthcare sustainability -Use of anesthetic gases in a surgical environment ........................................................................................................

Figure 3 . 7 -

 37 Figure 3.7 -Application of the framework for healthcare sustainability -Use of helium for medical imaging ..............................................................................................................................

Figure 4 . 1 -

 41 Figure 4.1 -Reduction effect and redistribution effect of domestic recycling on the supply risk of a commodity ........................................................................................................................

Figure 4

 4 Figure 4.2 -WCS and BCS GeoPolRisk values as a function of the EoL-RIR indicator ...........................

Figure 4 . 3 -

 43 Figure 4.3 -GeoPolRisk values for 13 raw materials (or groups of materials) under a range of scenarios for the end-of-life recycling input rate (EoL-RIR) and the import supply mix ..

Figure 5 . 1 -

 51 Figure 5.1 -Shift of the supply curve caused by a sudden change in available resources ...................

Figure 5 . 2 -

 52 Figure 5.2 -Methodological impact pathway for the development of an endpoint indicator based on Geopolitical supply risk considerations (GeoPolEndpoint) ...............................................

Figure 5

 5 Figure 5.3 -Cost increase factors for Al, Co, Cu, and Ni in 2015, 2016 and 2017 ................................

Figure 5

 5 Figure 5.4 -Contribution of Al, Co, Cu, and Ni to raw material costs and endpoint damage ..............

Figure 6

 6 Figure 6.1 -LCIA framework for an integrated assessment based on the GeoPolRisk method ...........

Figure 6 . 3 -

 63 Figure 6.3 -Contribution of Al, Co, Cu and Ni to the environmental impacts at midpoint level in the integrated assessment of two types of LIB .......................................................................

Figure 6 . 4 -

 64 Figure 6.4 -Contribution of Al, Co, Cu and Ni to the damages at endpoint level in the integrated assessment of two types of LIB .........................................................................................

Figure 7

 7 Figure 7.1 -Scaled WGI-PV index (from 0: absence of risk to 1: maximum risk) for the most important helium exporting countries. ..............................................................................................

Figure 7 . 2 -

 72 Figure 7.2 -Helium trade flows and helium GeoPolRisk for the analyzed countries ...........................

Figure 8 . 1 -

 81 Figure 8.1 -Block diagram for MRI scan production. System Boundaries ...........................................

Figure 8 . 2 -

 82 Figure 8.2 -Stages in the helium to MRI scan life cycle. System boundaries for the study .................

Figure 8 . 3 -

 83 Figure 8.3 -Helium supply mix in 2018 (CA, DE, FR and JP) .................................................................

Figure 8

 8 Figure 8.4 -Global warming potential and ozone layer depletion potential per scan for scenarios A1, A2, C1 and C2 from the perspective of Canada, Germany, France and Japan .................

Figure 8

 8 Figure 8.5 -Global warming potential and ozone layer depletion per scan for scenario A1 and helium GeoPolRisk from the perspective of Canada, Germany, France and Japan .....................

Figure 8

 8 Figure 8.6 -Contribution of the main life cycle stages and the international supply mix to the impact category global warming potential under the scenario C1 for CA, DE, FR and JP ............

Figure 8

 8 Figure 8.7 -GWP associated to 500L of helium available in the country of destination for the scenario C1 ......................................................................................................................................

Figure 1 . 1 -

 11 Figure 1.1 -Health spending and GDP growth by country income group from 2000 to 2017 (Adapted from WHO, 2019)

Figure 1

 1 Figure 1.2 -Graphic representation of a product life cycle (UNEP Life Cycle Initiative, 2018)

Figure 1

 1 Figure 1.4 -The Areas of Protection of LCA as overlap of methodologies in LCSA Among the previously mentioned methodologies, notable approaches to the assessment of raw material criticality are proposed by Graedel et al. (2012) and the European Commission (2017). The methodology presented by Graedel et al. (2012) considers three key dimensions to assess raw material criticality: supply risk, vulnerability to supply disruption and environmental implications. These are presented as

Figure 1 . 5 -

 15 Figure 1.5 -Integration of criticality components within the LCSA framework (Adapted from[START_REF] Gemechu | Import-based Indicator for the Geopolitical Supply Risk of Raw Materials in Life Cycle Sustainability Assessments[END_REF]

Figure 2 . 1 -

 21 Figure 2.1 -Inclusion methodology for the scoping review

Figure

  Figure 2.2 -LCA Framework (Adapted from ISO, 2006a)

Figure 2

 2 Figure 2.3 -Life Cycle Impact Assessment Framework

  [START_REF] Gemechu | Import-based Indicator for the Geopolitical Supply Risk of Raw Materials in Life Cycle Sustainability Assessments[END_REF] originally developed the GeoPolRisk method as a measure for the supply risk from the perspective of a country, region or company. It was designed as a midpoint indicator in LCA following the proposed integration of raw material criticality into the LCSA framework. The method focuses on the perspective of a country or region importing a raw material from multiple trade partners.It integrates (1) the global production concentration and (2) the political instability of the trade partners weighted by their corresponding supply share for the analyzed importer. The production concentration is evaluated with the HHI index and the political instability is estimated with the "political stability and absence of violence" dimension of the WGI (WGI-PV).Helbig et al. (2016a) introduced domestic production into the GeoPolRisk method to account for the local production in supply requirements. A visual representation of the dynamics that the method captures is available in Figure2.4.

Figure 2 . 4 -

 24 Figure 2.4 -Trade dynamics captured by the GeoPolRisk methodThe formula to obtain the GeoPolRisk of a material "A" from the perspective of a country "c" in a given year is described by:

Figure 2

 2 Figure 2.5 -GeoPolRisk values for 14 resources relevant to the inventory of EV in 2013 (Adapted from[START_REF] Gemechu | Geopolitical-related supply risk assessment as a complement to environmental impact assessment: the case of electric vehicles[END_REF]

Figure 2

 2 Figure 2.6 -Comparison of environmental impacts and the GeoPolRisk indicator at the midpoint level (Adapted from[START_REF] Gemechu | Geopolitical-related supply risk assessment as a complement to environmental impact assessment: the case of electric vehicles[END_REF]

Figure 3

 3 Figure 3.1 -Mental map for the integration of activities in the healthcare sector and methodologies to assess sustainability

Figure 3

 3 Figure 3.2 -Medical Activities (Foreground Systems)Therapeutic Procedures can be defined as those designed to treat and cure diseases or to restore patient health. In order to account for the amount and type of resources required to perform these procedures; they have been divided in Non-OR Procedures and OR Procedures (OR: Operating Room).Non-OR procedures don't require full body anesthesia and can normally be conducted outside of the Operating Rooms, it includes rehabilitation processes. OR Procedures require a controlled and sterile environment for their optimal performance, most invasive procedures are part of this category.

Figure 3

 3 Figure 3.3 -Non-Medical Support Activities (Foreground Systems) Healthcare delivery systems require resources to function on an optimal fashion; the Related Product Systems are those producing fixed assets, inventory items and other resources used in healthcare. This classification takes into account a life-cycle-thinking perspective, establishing these as part of the background systems in healthcare, they can be seen in Figure 3.4.

Figure 3

 3 Figure 3.4 -Related Product Systems (Background Systems) Pharmaceuticals are all the chemical products used for treatment and prevention of diseases, these include medicine, anesthetics, among others. Medical Equipment are fixed assets used for diagnosis, monitoring and treatment of medical conditions. Implants and Prosthetics are devices destined to be placed inside the body to replace body parts, deliver medication, monitor vital functions or enhance organ function. Reusable medical supplies are instrument that can be reused for diagnosis or treatment; some examples are surgical instruments, endoscopes, accessories, among others. Disposable Medical Supplies or consumables are materials, instruments or devices designed for a single use, in this category it is possible to identify syringes, masks, needles, etc.

Figure 3

 3 Figure 3.5 -Framework for LCA to support healthcare sustainability

Figure 3 . 7 -

 37 Figure 3.7 -Application of the framework for healthcare sustainability -Use of helium for medical imaging

Figure 4 . 1 -

 41 Figure 4.1 -Reduction effect and redistribution effect of domestic recycling on the supply risk of a commodity With the described effects under consideration, the GeoPolRisk calculations will differ from the original formula presented in Equation 2.1 (Section 2.2.3). The updated version follows the structure presented in Equation 4.1.

Figure 4

 4 Figure 4.2 -WCS and BCS GeoPolRisk values as a function of the EoL-RIR indicator In order to test the applicability of the enhanced GeoPolRisk method, it is required to obtain detailed trade data from the perspective of one importer for a variety of materials with reported EoL-RIR values. These pieces of information were obtained for a group of materials deemed relevant for Information and Communication Technologies (ICT) in the European Union.

Figure 4

 4 Figure 4.3 -GeoPolRisk values for 13 raw materials (or groups of materials) under a range of scenarios for the end-of-life recycling input rate (EoL-RIR) and the import supply mix

Figure 5

 5 Figure 5.1 -Shift of the supply curve caused by a sudden change in available resources Despite this cause-effect chain being plausible in theory, empirical evidence is difficult to find. As an example, price volatility indicators can be assessed as part of long-term price data series for markets (BGR, 2021); unfortunately these do not allow to observe supply and demand curves, since the equilibrium price is determined on the stock exchange (Varian 2014). Supply curves can change due to new exploration, depletion of individual mines, new extraction technologies, among other reasons that make supply relatively stable. However, the demand is strongly influenced by factors like global economic activity, monetary policy, technological changes and trade policies. This yields to the fact that most equilibrium price changes are determined by changes in the demand and only allow to derive the slope of the supply curve. Nevertheless, Fu et al. (2019) quantify long-run price elasticities, values that allow to estimate a change in price based on demand or supply changes, for three by-product metals.

Figure 5 .

 5 Figure 5.1 illustrates this relationship: In case of a supply shortage, (A) the supply curve (1) shifts to

  indicator of the proportion of mass at risk in a life cycle taking into account the production concentration at global level and the import mix of the analyzed country or region(Cimprich et al. 2017). The novel impact pathway uses the GeoPolRisk indicator to achieve a measure of a potential increased cost due to geopolitically-driven supply disruptions. The steps and required information to obtain this new endpoint indicator (GeoPolEndpoint) for one resource, from the perspective of one importer and for one year is illustrated in Figure5.2.

Figure 5

 5 Figure 5.2 -Methodological impact pathway for the development of an endpoint indicator based on Geopolitical supply risk considerations (GeoPolEndpoint)

Following

  Equation 5.3, the GeoPolRiskOECD values of the four selected raw materials are calculated for the years 2015, 2016 and 2017. The overall results can be identified in Table5.4. More details on the GeoPolRisk calculations are available in Annex F and Annex G. In the case of aluminum, GeoPolRiskOECD values obtained for 2015, 2016 and 2017 are 0.023, 0.020 and 0.019 respectively. The contribution to the supply risk is attributed to the increasing participation of Russia, countries in the Middle East and China in the import shares for OECD members. Bauxite is used for the calculation of the GeoPolRisk indicator to guarantee a consistency with the elasticity values, which were calculated for an event that affected bauxite production. GeoPolRisk values could also be calculated for aluminum smelting countries, or as aggregated values for multi-stage supply chains as shown at the example of petrochemical supply chains byHelbig et al. (2016a). Results for cobalt (0.080, 0.081 and 0.097) are explained by a highly concentrated production in countries outside of the OECD, with DR Congo being the main producer with a strong and increasing participation in the global market. Additionally, the contribution from countries in the OECD decreased in the last analyzed year. The production of nickel and copper is relatively well distributed around the globe with strong participation of members from the OECD. Therefore, the supply risk of these materials is substantially lower in comparison to the first two (0.015, 0.012 and 0.014 for nickel; 0.008, 0.014 and 0.012 for copper).

  Figure 5.3 -Cost increase factors for Al, Co, Cu, and Ni in 2015, 2016 and 2017 (Plot is in a double logarithmic scale) The smallest GeoPolEndpoint value is attributed to aluminum with a relative damage at the endpoint level of 1.69, 1.45 and 1.63 USD/t-Al (for 2015, 2016 and 2017 respectively; 1 t= 1000 kg). It is followed by copper with corresponding values of 9.33, 14.8 and 15.5 USD/t-Cu. Increased endpoint factors are obtained for nickel and cobalt, with 65.4, 41.0 and 53.0 USD/t-Ni for nickel and 1860, 1690 and 4370

Figure 5

 5 Figure 5.4 -Contribution of Al, Co, Cu, and Ni to raw material costs and endpoint damage

Figure 6

 6 Figure 6.1 -LCIA framework for an integrated assessment based on the GeoPolRisk method In Chapter 4:, recycling considerations are introduced as a risk mitigation strategy by modeling a requirement reduction of materials and the potential redistribution of import shares due to this reduction.

Figure 6

 6 Figure 6.2 -Contribution of Al, Co, Cu and Ni to the inventory, the supply risk and the economic damage to the AoP resources of LIB from the EU perspective

  Figure 6.3 -Contribution of Al, Co, Cu and Ni to the environmental impacts at midpoint level in the integrated assessment of two types of LIBOverall results at endpoint level can be seen in Figure6.4; these were obtained with the ReCiPe endpoint assessment method. The graphic shows the contribution of the four analyzed materials to the inventory, the damages to the three AoPs and the socio-economic damage, this last one obtained with

  1 shows the scaled values of the WGI-PV indicator from 0 to 1 for the main exporting countries (Algeria, Australia, Poland, Qatar, Russia and the USA); these values are a reference for the contribution to the risk based on geopolitical considerations. The information was computed for the period of 2015 to 2018 with the objective to capture important developments surrounding the trade and use of helium for the analyzed countries.

Figure 7 .

 7 Figure 7.2 is a multi-part figure that contains the main findings for all the years under assessment (Part 1: 2015 and 2016, Part 2: 2017 and 2018). The visualization presented in Figure 7.2 is an amalgamation of two main components to represent the supply risk of each of the ten countries for the discussion. The first component is a Sankey diagram (SankeyMatic, 2020); in this, the width represents the quantity of helium traded from producing countries (on the left) to consuming countries (on the right). The width at the end of each flow represents the total amount of helium imported by the country measured in monetary units.

Figure 7 . 2 -

 72 Figure 7.2 -Helium trade flows and helium GeoPolRisk for the analyzed countries (1)

Figure 8

 8 Figure 8.1 -Block diagram for MRI scan production. System Boundaries

  Figure 8.3 -Helium supply mix in 2018 (CA, DE, FR and JP)

(

  Units: kg CO2 eq)Ozone layer depletion potential(Units: E-06 kg

Table 2 .

 2 1 -Identified opportunities for improvement in healthcare sustainability .............................Table 2.2 -Comparison between methods for product-level supply risk assessment. Impact mechanisms in LCIA ............................................................................................................. Table 3.1 -List of Medical Specialties ................................................................................................... Table 3.2 -Levels of health care delivery ............................................................................................. Table 4.1 -Data sources (production and trade) for calculating GeoPolRisk values for the EU in 2016 ............................................................................................................................................. Table 5.1 -Mass contribution of selected materials to the LCA inventory of LIB ................................ Table 5.2 -Average prices for the selected materials from 2015 to 2017 ...........................................

Table 5.3 -Events affecting the supply of selected materials in the study .......................................... Table 5.4 -GeoPolRiskOECD values for the analyzed materials (2015-2017) ......................................... Table 6.1 -GeoPolRisk results for the selected materials from 2015 to 2017 (EU Perspective) ......... Table 6.2 -GeoPolEndpoint (Damage Values) for Al, Co, Cu and Ni and their contribution in the inventory of LIB for the EU .................................................................................................. Table 8.1 -Summary of parameters for the model of helium production ........................................... Table 8.2 -Parameters required to determine the analyzed scenarios for MRI scan production .......

Table 2

 2

.1 -Identified opportunities for improvement in healthcare sustainability

Table 2

 2

		.2 -Comparison between methods for product-level supply risk assessment. Impact
				mechanisms in LCIA
				(Adapted from Cimprich et al., 2019)
		Political (in)stability impact mechanism	GeoPolRisk	ESP	ESSENZ
	(equivalent to LCIA midpoint)	Supply Disruption Probability	Political in(stability) of… ⇩ Mediating factors	...trade partners (+) Production concentration (+/-) Supply mix of importing country (-) Domestic Production Disruption of inventory flows …global mining countries (+/-) Global Production Shares (+) Distance-to-target ratio >1	…global mining countries (+/-) Global Production Shares (+) Distance-to-target ratio >1 (+) Magnitude of
	Supply Risk	Vulnerability	⇩ Mediating Factors Supply	(-) Substitutability …importing countries	(+) Magnitude of Inventory Flow …the company purchasing	Inventory Flow (-) Overall global production amount …the company purchasing
			risk for…	where a product is made	the inventory flow	the inventory flow
	Equivalent	⇩ Mediating factors	Not applicable	Not applicable	Not applicable
	to LCIA endpoint

Table 3

 3

	.1 -List of Medical Specialties
	(Adapted from AAMC, 2018)

Table 3

 3

	.2 -Levels of health care delivery
	(Adapted from WHO, 2004)

Table 4 .

 4 1 -Data sources (production and trade) for calculating GeoPolRisk values for the EU in 2016

	Raw material	Source for production data	Source for trade data	Notes	Label used in this document
	Beryllium	USGS	Comtrade	-	Beryllium
	borates	USGS (boron as proxy)	Comtrade	-	Borates
	cobalt	USGS	Comtrade	-	Cobalt
	germanium	USGS	EC -Critical Raw Materials Fact Sheets	-	germanium
	magnesium	USGS	Comtrade	-	magnesium
	natural graphite USGS	Comtrade	-	natural graphite
	palladium	USGS	Comtrade	-	Palladium
	platinum	USGS	Comtrade	-	Platinum
	silicon metal	USGS	Comtrade	-	silicon metal
	tantalum	USGS	Comtrade	-	Tantalum
	gallium hafnium indium niobium	USGS USGS (aggregated with zirconium) USGS USGS	Comtrade (Aggregated as Ga, Hf, In, Rh and Nb)	Zr and Rh added to the group to match available information	gallium group metals
	iridium ruthenium	EC -Critical Raw Materials Fact Sheets	Comtrade (aggregated as Ir, Os and Ru)	Os production disregarded	other platinum group metals (other PGMs)
	dysprosium
	erbium
	gadolinium			Sc production
	ytterbium neodymium praseodymium	USGS (Aggregated as REEs and Yttrium)	Comtrade (Aggregated as REE)	added to the group to match available	rare earth elements (REEs)
	samarium			information
	terbium
	yttrium	USGS (aggregated with REEs) Comtrade (Aggregated with Sc)

Table 5 .

 5 1 -Mass contribution of selected materials to the LCA inventory of LIB

	Material	Mass share in NCA-C	Mass share in NMC-C
	Aluminum (Al)	5.8%	3.5%
	Cobalt (Co)	2.0%	5.4%
	Copper (Cu)	11.2%	16.5%
	Nickel (Ni)	10.7%	5.4%

Table 5 .

 5 2 -Average prices for the selected materials from 2015 to 2017

	Material	Price 2015 (USD/t)	Price 2016 (USD/t)	Price 2017 (USD/t)
	Aluminum (Al)	1,662.26	1,604.97	1,968.30
	Cobalt (Co)	28,477.06	25,528.56	55,583.43
	Copper (Cu)	5,503.03	4,867.39	6,173.23
	Nickel (Ni)	11,877.33	9,647.89	10,469.19

Table 5 .

 5 3 -Events affecting the supply of selected materials in the study For the case of aluminum, cyclone Hudhud affected 16.94% of global Bauxite supply in October 13, 2014 and the calculated Ɛ value is 0.04. Hurricane Matthew had an impact on the production of cobalt in Cuba (global mining affected: 2.23%); the event is dated on October 4, 2016 and its associated calculated Ɛ value is 0.81. A flood on July 4, 2005 had an impact on copper mining in Romania, accounting for 4.66% of global mining with associated 0.21 Ɛ value. Typhoon Parma (Pepeng) crossed the Philippines on October 5, 2009, leading to a decline in nickel ore production (global mining affected: 4.12%) and an estimated value of 0.37 for Ɛ. More details on the calculation of the price elasticities are available in Annex E.

	Commodity	Country	Disaster	Date	Affected mass
	Aluminum	India	Cyclone	13/10/2014	16.94%
	Cobalt	Cuba	Hurricane	04/10/2016	2.23%
	Copper	Romania	Flood	04/07/2005	4.66%
	Nickel	Philippines	Typhoon	05/10/2009	4.12%

Table 5

 5

		.4 -GeoPolRiskOECD values for the analyzed materials (2015-2017)
	Material	GeoPolRiskOECD 2015 GeoPolRiskOECD 2016 GeoPolRiskOECD 2017
	Aluminum (Al)	0.023	0.020	0.019
	Cobalt (Co)	0.080	0.081	0.097
	Copper (Cu)	0.008	0.014	0.012
	Nickel (Ni)	0.015	0.012	0.014

Table 6 .

 6 1 -GeoPolRisk results for the selected materials from 2015 to 2017 (EU Perspective)

	Material	GeoPolRisk 2015	GeoPolRisk 2016	GeoPolRisk 2017
	Aluminum (Al)	0.082	0.085	0.084
	Cobalt (Co)	0.108	0.132	0.168
	Copper (Cu)	0.018	0.025	0.023
	Nickel (Ni)	0.028	0.024	0.022

As part of the geopolitical supply risk impact pathway, at the midpoint level, copper and nickel can be considered as low-risk materials due to their relative high availability and low global production concentration, with GeoPolRisk values ranging from 0.018 to 0.025 and 0.022 to 0.028 respectively.

The values for aluminum (Bauxite) vary from 0.082 in 2015 to 0.084 in 2017, with relatively no change in the analyzed period, these are mainly attributed to the supply shares for China, Russia and the Middle East. Among the studied materials, cobalt is the one with the highest GeoPolRisk values (0.108 in 2015 and 0.168 in 2017), this numbers are explained by an increasing participation of countries deemed as high-risk regions in geopolitical terms, with DR Congo being the highest contributor.

At the endpoint level, it is possible to obtain a relative economic damage in monetary units based on the GeoPolRisk indicator, prices of the materials and price elasticities associated with them; these values can be found in Chapter 5. As per Table

6

.2, Aluminum and copper share relative low values, with an

Table 6 .

 6 2 -GeoPolEndpoint (Damage Values) for Al, Co, Cu and Ni and their contribution in the inventory of LIB for the EU

Table 8 .

 8 1 -Summary of parameters for the model of helium production

	Parameter	Status in the life cycle inventory
	Helium production technology	Assumed the same for all producing countries; contains data on energy consumption.

Table 8 .

 8 2 -Parameters required to determine the analyzed scenarios for MRI scan production

	Parameter	Description	Values
			CA: Toronto, Canada
	Country -City	Location in which the MRI scans are produced	DE: Berlin, Germany FR: Paris, France
			JP: Tokyo, Japan
	Helium use	Quantity of helium required to provide cold for MRI scan production. (Industrial expert information).	A: 380 L/y B: 1130 L/y C: 1948 L/y
	Energy	Quantity of energy consumed to produce one MRI	1: 13 kWh/scan
	Consumption	scan (PE International, 2012)	2: 15 kWh/scan

GeoPolRisk values for 13 raw materials from the EU perspective for 2016

  Assessment under a range of scenarios for the EoL-RIR and supply mix

	September 29, 2017 September 29, 2017 September 29, 2017 September 29, 2017 September 29, 2017 September 29, 2017 Date September 30, 2017 September 30, 2017 September 30, 2017 September 30, 2017 September 30, 2017 September 30, 2017 September 30, 2017 Date September 30, 2017 September 30, 2017 September 30, 2017 October 8, October 8, October 8, October 8, October 8, October 8, October 8, October 8, October 8, October 8, October 8, October 8, October 8, October 8, October 8, October 8, October 8, October 8, October 8, November 11, Trinidad and Tobago ("critical material*" OR "critical metal*" OR "critical raw material*" OR criticality) AND ("diagnostic equipment" OR "diagnostic technique*" OR "computer assisted diagnos*" OR "medical technolog*" OR "medical laborator*" OR "laboratory diagnos*") ("critical material*" OR "critical metal*" OR "critical raw material*" OR criticality) AND ("diagnostic imaging" OR "x-ray*" OR radiograph* OR "computed tomography" OR ultrasound* OR "magnetic resonance imaging") ("eco-efficiency" OR "energy efficiency" OR "material efficiency" OR "resource efficiency") AND ("diagnostic equipment" OR "diagnostic technique*" OR "computer assisted diagnos*" OR "medical technolog*" OR "medical laborator*" OR "laboratory diagnos*") ("eco-efficiency" OR "energy efficiency" OR "material efficiency" OR "resource efficiency") AND ("diagnostic imaging" OR "x-ray*" OR radiograph* OR "computed tomography" OR ultrasound* OR "magnetic resonance imaging") ("ecological footprint" OR "environmental footprint") AND ("diagnostic equipment" OR "diagnostic technique*" OR "computer assisted diagnos*" OR "medical technolog*" OR "medical laborator*" OR "laboratory diagnos*") ("environmental management" OR "ISO 14001") AND ("diagnostic equipment" OR "diagnostic technique*" OR "computer assisted diagnos*" OR "medical technolog*" OR "medical laborator*" OR "laboratory diagnos*") Search phrase ("eco-efficiency" OR "energy efficiency" OR "material efficiency" OR "resource efficiency") AND ("medical equipment" OR "medical device*" OR "medical supplies" OR "ancillary device*" OR "ancillary equipment") ("eco-efficiency" OR "energy efficiency" OR "material efficiency" OR "resource efficiency") AND (Drug* OR pharmaceutical* OR "active pharmaceutical ingredient*" OR "medicinal ingredient*" OR vaccin*) ("ecological footprint" OR "environmental footprint") AND ("diagnostic imaging" OR "x-ray*" OR radiograph* OR "computed tomography" OR ultrasound* OR "magnetic resonance imaging") ("ecological footprint" OR "environmental footprint") AND ("long-term care" OR "palliative care" OR "prevent* care") ("ecological footprint" OR "environmental footprint") AND ("medical equipment" OR "medical device*" OR "medical supplies" OR "ancillary device*" OR "ancillary equipment") ("ecological footprint" OR "environmental footprint") AND (Drug* OR pharmaceutical* OR "active pharmaceutical ingredient*" OR "medicinal ingredient*" OR vaccin*) ("environmental management" OR "ISO 14001") AND ("diagnostic imaging" OR "x-ray*" OR radiograph* OR "computed tomography" OR ultrasound* OR "magnetic resonance imaging") ("environmental management" OR "ISO 14001") AND ("long-term care" OR "palliative care" OR "prevent* care") Search phrase (Environment* OR "social* responsib*" OR "sustainable development") AND ("diagnostic imaging" OR "x-ray*" OR radiograph* OR "computed tomography" OR ultrasound* OR "magnetic resonance imaging") (Environment* OR "social* responsib*" OR "sustainable development") AND ("long-term care" OR "palliative care" OR "prevent* care") (Environment* OR "social* responsib*" OR "sustainable development") AND ("medical equipment" OR "medical device*" OR "medical supplies" OR "ancillary device*" OR "ancillary equipment") ("carbon footprint" OR "greenhouse gas*" OR "climate change" OR "global warming") AND (Hospital* OR clinic*) ("carbon footprint" OR "greenhouse gas*" OR "climate change" OR "global warming") AND (Implant* OR prosth*) ("critical material*" OR "critical metal*" OR "critical raw material*" OR criticality) AND (Hospital* OR clinic*) ("critical material*" OR "critical metal*" OR "critical raw material*" OR criticality) AND (Implant* OR prosth*) ("critical material*" OR "critical metal*" OR "critical raw material*" OR criticality) AND (Medic* OR healthcare OR "health care") ("critical material*" OR "critical metal*" OR "critical raw material*" OR criticality) AND (Surger* OR surgical) ("eco-efficiency" OR "energy efficiency" OR "material efficiency" OR "resource efficiency") AND (Implant* OR prosth*) ("eco-efficiency" OR "energy efficiency" OR "material efficiency" OR "resource efficiency") AND (Surger* OR surgical) ("ecological footprint" OR "environmental footprint") AND (Implant* OR prosth*) ("ecological footprint" OR "environmental footprint") AND (Surger* OR surgical) ("environmental management" OR "ISO 14001") AND (Implant* OR prosth*) ("environmental management" OR "ISO 14001") AND (Surger* OR surgical) ("hazardous waste" OR "biohazard* waste" OR "waste management") AND (Implant* OR prosth*) ("life cycle assessment" OR "life cycle management" OR "life cycle sustainability assessment") AND (Implant* OR prosth*) ("material flow analysis" OR "material flow account*" OR "substance flow analysis") AND (Hospital* OR clinic*) ("material flow analysis" OR "material flow account*" OR "substance flow analysis") AND (Implant* OR prosth*) ("material flow analysis" OR "material flow account*" OR "substance flow analysis") AND (Medic* OR healthcare OR "health care") ("responsible sourcing" OR "sustainable supply chain management") AND (Hospital* OR clinic*) ("responsible sourcing" OR "sustainable supply chain management") AND (Implant* OR prosth*) ("responsible sourcing" OR "sustainable supply chain management") AND (Medic* OR healthcare OR "health care") ("water footprint" OR "water consumption") AND (Hospital* OR clinic*) ("life cycle assessment" OR "life cycle management" OR "life cycle sustainability (Environment* OR "social* responsib*" OR "sustainable development") AND (Medic* OR healthcare OR "health care") Cyprus Database Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Database Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus 196 0.379 474 Martinique 0.300 780 0.443 203 Czech Republic 0.305 478 Mauritania 0.649 784 United Arab Emirates 204 Benin 0.500 480 Mauritius 0.297 788 Tunisia 0.728 5% 0.433 0.436 0.252 0.267 0.144 0.150 0.229 0.240 0.356 0.372 0.387 0% 0.457 0.457 0.273 0.273 0.154 0.154 0.246 0.246 0.382 0.382 OR clinic*) November 11, 192 Cuba 0.363 470 Malta 0.284 776 Tonga 0.316 EoL RIR BCS WCS BCS WCS BCS WCS BCS WCS BCS WCS (Environment* OR "social* responsib*" OR "sustainable development") AND (Hospital* 191 Croatia 0.367 466 Mali 0.823 768 Togo 0.534 assessment") AND (Medic* OR healthcare OR "health care") 188 Costa Rica 0.368 462 Maldives 0.416 764 Thailand 0.698 November 11, 180 Congo 0.604 458 Malaysia 0.473 762 Tajikistan 0.656 October 8, Scopus ("life cycle assessment" OR "life cycle management" OR "life cycle sustainability assessment") AND (Hospital* OR clinic*) 178 Congo 0.604 454 Malawi 0.523 757 Switzerland 0.239 November 11, 174 Comoros 0.493 450 Madagascar 0.558 752 Sweden 0.296 October 8, Database Search phrase Date Scopus (Environment* OR "social* responsib*" OR "sustainable development") AND (Anesth*) October 9, 2017 Scopus (Environment* OR "social* responsib*" OR "sustainable development") AND (Surger* OR surgical) October 9, 2017 Scopus "life cycle assessment" AND inhaler* October 16, 2017 Scopus ("eco-efficiency" OR "energy efficiency" OR "material efficiency" OR "resource efficiency") AND (Hospital* OR clinic*) November 10, Scopus ("ecological footprint" OR "environmental footprint") AND (Hospital* OR clinic*) November 10, Scopus ("environmental management" OR "ISO 14001") AND (Hospital* OR clinic*) November 10, Scopus ("hazardous waste" OR "biohazard* waste" OR "waste management") AND (Drug* OR pharmaceutical* OR "active pharmaceutical ingredient*" OR "medicinal ingredient*" OR vaccin*) November 10, Scopus ("life cycle assessment" OR "life cycle management" OR "life cycle sustainability assessment") AND (Drug* OR pharmaceutical* OR "active pharmaceutical ingredient*" Scopus (Environment* OR "social* responsib*" OR "sustainable development") AND (Drug* OR pharmaceutical* OR "active pharmaceutical ingredient*" OR "medicinal ingredient*" OR vaccin*) November 10, Scopus "green hospital*" Scopus "sustainable hospital*" November 11, Scopus ("carbon footprint" OR "greenhouse gas*" OR "climate change" OR "global warming") Scopus ("carbon footprint" OR "greenhouse gas*" OR "climate change" OR "global warming") AND (Medic* OR healthcare OR "health care") November 11, Scopus ("carbon footprint" OR "greenhouse gas*" OR "climate change" OR "global warming") AND (Surger* OR surgical) Scopus ("eco-efficiency" OR "energy efficiency" OR "material efficiency" OR "resource Scopus ("ecological footprint" OR "environmental footprint") AND (Medic* OR healthcare OR "health care") November 11, Scopus "health care") Scopus ("hazardous waste" OR "biohazard* waste" OR "waste management") AND (Hospital* Scopus ("hazardous waste" OR "biohazard* waste" OR "waste management") AND (Medic* OR Scopus 170 Colombia 0.676 446 China, Macao SAR 0.217 748 Swaziland 0.598 assessment") AND (Anesth*) November 11, 156 China 0.600 442 Luxembourg 0.216 740 Suriname 0.468 ("life cycle assessment" OR "life cycle management" OR "life cycle sustainability 152 Chile 0.417 440 Lithuania 0.334 736 Sudan 0.967 healthcare OR "health care") 148 Chad 0.760 434 Libya 0.957 724 Spain 0.417 November 11, 144 Sri Lanka 0.501 430 Liberia 0.587 716 Zimbabwe 0.624 90% 0.002 0.002 0.007 0.037 0.015 0.018 0.006 0.013 0.021 0.035 OR clinic*) November 11, 132 Cape Verde 0.323 422 Lebanon 0.824 705 Slovenia 136 Cayman Isds 0.266 426 Lesotho 0.547 706 Somalia 140 Central African Rep. 0.858 428 Latvia 0.404 710 South Africa 0.528 85% 0.003 0.003 0.011 0.050 0.024 0.028 0.011 0.019 0.032 0.052 0.971 80% 0.004 0.005 0.015 0.060 0.033 0.037 0.015 0.024 0.045 0.069 0.302 November 11, 124 Canada 0.249 418 Lao People's Dem. Rep. 0.394 704 Viet Nam 0.453 75% 0.006 0.006 0.018 0.068 0.042 0.046 0.019 0.030 0.060 0.084 ("environmental management" OR "ISO 14001") AND (Medic* OR healthcare OR 112 Belarus 0.472 410 Rep. of Korea 0.467 699 India 0.691 116 Cambodia 0.458 414 Kuwait 0.510 702 Singapore 120 Cameroon 0.712 417 Kyrgyzstan 0.629 703 Slovakia 0.356 70% 0.007 0.007 0.022 0.074 0.052 0.055 0.024 0.036 0.075 0.099 0.201 65% 0.008 0.008 0.025 0.077 0.061 0.064 0.030 0.042 0.091 0.115 100% 0.000 0.000 0.000 0.000 0.000 0.000 efficiency") AND (Medic* OR healthcare OR "health care") November 11, 100 Bulgaria 0.485 400 Jordan 0.598 688 Serbia 0.472 104 Myanmar 0.661 404 Kenya 0.771 690 Seychelles 108 Burundi 0.894 408 Dem. People's Rep. of Korea 0.636 694 Sierra Leone 0.532 60% 0.009 0.009 0.029 0.081 0.070 0.074 0.035 0.048 0.106 0.130 95% 0.012 0.021 0.004 0.012 0.003 0.007 0.353 55% 0.010 0.010 0.033 0.085 0.079 0.083 0.041 0.053 0.121 0.145 90% 0.024 0.041 0.010 0.022 0.007 0.013 November 11, 76 Brazil 0.575 384 Côte d'Ivoire 0.682 674 San Marino 0.310 84 Belize 0.488 388 Jamaica 0.438 678 Sao Tome and Principe 90 Solomon Isds 0.399 392 Japan 0.303 682 Saudi Arabia 96 Brunei Darussalam 0.269 398 Kazakhstan 0.498 686 Senegal 0.544 50% 0.011 0.011 0.036 0.088 0.088 0.092 0.047 0.059 0.136 0.160 0.036 0.061 0.016 0.031 0.010 0.020 85% 0.593 45% 0.012 0.012 0.040 0.092 0.098 0.101 0.053 0.065 0.151 0.175 80% 0.048 0.081 0.022 0.041 0.014 0.026 0.455 40% 0.013 0.014 0.044 0.096 0.107 0.110 0.059 0.071 0.166 0.190 75% 0.059 0.102 0.029 0.050 0.018 0.032 AND (Anesth*) November 11, 64 Bhutan 0.275 368 Iraq 0.963 646 Rwanda 0.511 68 Bolivia 0.550 372 Ireland 0.330 659 Saint Kitts and Nevis 70 Bosnia Herzegovina 0.580 376 Israel 0.659 660 Anguilla 72 Botswana 0.301 381 Italy 0.426 662 Saint Lucia 0.296 35% 0.015 0.015 0.047 0.099 0.116 0.119 0.064 0.077 0.182 0.206 0.071 0.122 0.036 0.060 0.022 0.038 70% 0.237 30% 0.016 0.016 0.051 0.103 0.125 0.129 0.070 0.082 0.197 0.221 65% 0.083 0.142 0.044 0.069 0.027 0.042 0.375 25% 0.017 0.017 0.057 0.107 0.134 0.138 0.076 0.087 0.212 0.236 60% 0.095 0.163 0.053 0.078 0.031 0.047 November 11, 51 Armenia 0.632 348 Hungary 0.369 634 Qatar 0.320 52 Barbados 0.305 352 Iceland 0.228 638 Réunion 56 Belgium 0.412 360 Indonesia 0.575 642 Romania 60 Bermuda 0.300 364 Iran 0.663 643 Russian Federation 0.689 20% 0.018 0.018 0.065 0.110 0.143 0.147 0.082 0.092 0.227 0.251 55% 0.112 0.183 0.063 0.088 0.036 0.051 0.445 15% 0.019 0.019 0.075 0.114 0.153 0.156 0.088 0.096 0.244 0.264 50% 0.133 0.203 0.072 0.097 0.040 0.056 0.437 10% 0.020 0.020 0.088 0.117 0.162 0.165 0.094 0.100 0.261 0.275 45% 0.153 0.224 0.081 0.106 0.045 0.061 OR "medicinal ingredient*" OR vaccin*) November 10, Albania 0.431 288 Ghana 0.526 584 Marshall Isds 0.458 12 Algeria 0.720 296 Kiribati 0.325 585 Palau 0.310 16 American Samoa 0.261 300 Greece 0.524 586 Pakistan 0.997 24 Angola 0.563 304 Greenland 0.107 591 Panama 0.418 28 Antigua and Barbuda 0.324 308 Grenada 0.296 598 Papua New Guinea 0.601 31 Azerbaijan 0.661 316 Guam 0.365 600 Paraguay 0.472 32 Argentina 0.459 320 Guatemala 0.609 604 Peru 0.540 36 Australia 0.290 324 Guinea 0.579 608 Philippines 0.776 40 Austria 0.318 328 Guyana 0.505 616 Poland 0.399 44 Bahamas 0.305 332 Haiti 0.649 620 Portugal 48 Bahrain 0.659 340 Honduras 0.587 624 Guinea-Bissau 50 Bangladesh 0.752 344 China, Hong Kong SAR 0.350 626 Timor-Leste 0.502 5% 0.021 0.022 0.105 0.121 0.171 0.175 0.100 0.104 0.279 0.286 40% 0.173 0.241 0.091 0.116 0.049 0.065 0.589 0% 0.023 0.023 0.125 0.125 0.182 0.182 0.107 0.107 0.296 0.296 35% 0.194 0.253 0.100 0.125 0.054 0.070 0.305 BCS WCS BCS WCS BCS WCS BCS WCS BCS WCS Beryllium Boron Cobalt Gallium Group Germanium EoL RIR BCS WCS BCS WCS BCS WCS 0% 0.336 0.336 0.170 0.170 0.096 0.096 5% 0.316 0.324 0.157 0.165 0.090 0.094 10% 0.295 0.312 0.147 0.160 0.083 0.090 15% 0.275 0.300 0.138 0.154 0.077 0.086 20% 0.255 0.288 0.128 0.147 0.070 0.082 25% 0.234 0.277 0.119 0.140 0.064 0.078 30% 0.214 0.265 0.110 0.134 0.058 0.074 Tantalum REE Silicon Metal Annex D. EoL RIR Annex E.
	Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus Scopus PubMed 208 10% 0.410 ("water footprint" OR "water consumption") AND (Implant* OR prosth*) ("water footprint" OR "water consumption") AND (Medic* OR healthcare OR "health care") (Environment* OR "social* responsib*" OR "sustainable development") AND (Implant* OR prosth*) ("critical material*" OR "critical metal*" OR "critical raw material*" OR criticality) AND (Anesth*) ("eco-efficiency" OR "energy efficiency" OR "material efficiency" OR "resource efficiency") AND (Anesth*) ("ecological footprint" OR "environmental footprint") AND (Anesth*) ("environmental management" OR "ISO 14001") AND (Anesth*) ("hazardous waste" OR "biohazard* waste" OR "waste management") AND (Anesth*) ("hazardous waste" OR "biohazard* waste" OR "waste management") AND (Surger* OR surgical) ("life cycle assessment" OR "life cycle management" OR "life cycle sustainability assessment") AND (Surger* OR surgical) ("material flow analysis" OR "material flow account*" OR "substance flow analysis") AND (Anesth*) ("material flow analysis" OR "material flow account*" OR "substance flow analysis") AND (Surger* OR surgical) "carbon footprint" OR "greenhouse gas*" OR "climate change" OR "global warming" Denmark 0.326 484 Mexico 0.626 792 Turkey 0.413 0.233 0.261 0.134 0.147 0.212 0.234 PubMed "critical material*" OR "critical metal*" OR "critical raw material*" OR criticality PubMed Chethana T et al. Situation analysis and issues in management of Journal of Community October 8, October 8, October 8, October 9, October 9, October 9, October 9, October 9, October 9, October 9, October 9, 0.334 November 11, 0.362 0.902 November 11, 212 Dominica 0.300 496 Mongolia 0.340 795 Turkmenistan 0.538 214 Dominican Rep. 0.450 498 Rep. of Moldova 0.561 798 Tuvalu 15% 0.387 0.390 0.218 0.252 0.125 0.143 0.197 0.227 0.312 0.352 0.217 218 Ecuador 0.517 499 Montenegro 0.445 800 Uganda 0.643 20% 0.364 0.367 0.203 0.240 0.115 0.138 0.183 0.218 0.290 0.339 "eco-efficiency" OR "energy efficiency" OR "material efficiency" OR "resource efficiency" November 11, PubMed "ecological footprint" OR "environmental footprint" November 11, PubMed "environmental management" OR "ISO 14001" November 11, PubMed "green chemistry" November 11, PubMed "green hospital*" November 17, PubMed "hazardous waste" OR "biohazard* waste" OR "waste management" November 17, PubMed "life cycle assessment" AND inhaler* November 17, PubMed "life cycle assessment" OR "life cycle management" OR "life cycle sustainability assessment" November 17, PubMed "material flow analysis" OR "material flow account*" OR "substance flow analysis" biomedical waste in select small health care facilities in a ward under Bruhat Bengaluru Mahanagara Health 222 El Salvador 0.520 504 Morocco 0.563 804 Ukraine 0.871 226 Equatorial Guinea 0.528 508 Mozambique 0.719 807 TFYR of Macedonia 25% 0.342 0.344 0.189 0.227 0.105 0.132 0.170 0.207 0.268 0.323 0.570 231 Ethiopia 0.824 512 Oman 0.348 818 Egypt 0.788 30% 0.319 0.321 0.174 0.214 0.096 0.126 0.156 0.196 0.246 0.305 Palike, Bangalore, India 18 Chiarini, A., Vagnoni, E. Environmental sustainability in European public healthcare: Could it just be a matter of leadership? 232 Eritrea 0.631 516 Namibia 0.358 826 United Kingdom 0.428 35% 0.296 0.298 0.160 0.200 0.086 0.119 0.143 0.183 0.224 0.283 Leadership in Health Services 19 Clegg, J.C. Influence of climate change on the incidence and impact of arenavirus diseases: a speculative Clinical Microbiology and 233 Estonia 0.365 520 Nauru 0.384 834 United Rep. of Tanzania 0.588 242 Fiji 0.316 524 Nepal 0.669 842 USA 40% 0.273 0.275 0.145 0.186 0.076 0.111 0.130 0.170 0.201 0.261 0.420 246 Finland 0.300 528 Netherlands 0.318 850 US Virgin Isds 45% 0.250 0.253 0.131 0.172 0.067 0.104 0.116 0.156 0.179 0.239 0.300 Infection 251 France 0.519 548 Vanuatu 0.397 854 Burkina Faso 0.673 50% 0.227 0.230 0.116 0.157 0.057 0.096 0.103 0.143 0.157 0.217 assessment 20 Cosford, P. Partners in clime': sustainable development and climate change -what can the National Health Public Health 254 French Guiana 0.390 554 New Zealand 0.196 858 Uruguay 0.287 262 Djibouti 0.625 558 Nicaragua 0.518 860 Uzbekistan 55% 0.204 0.207 0.102 0.142 0.049 0.086 0.090 0.130 0.135 0.195 0.555 266 Gabon 0.521 562 Niger 0.721 862 Venezuela 60% 0.181 0.184 0.087 0.128 0.042 0.077 0.076 0.116 0.113 0.172 0.705 November 17, PubMed "medical waste" OR "hospital waste" November 17, PubMed "responsible sourcing" OR "sustainable supply chain management" November 17, PubMed "supply risk" OR "supply disruption" OR "supply restriction" November 17, PubMed "sustainable healthcare" OR "sustainable health care" OR "sustainable health system*" November 17, PubMed "sustainable hospital*" November 17, 268 Georgia 0.563 566 Nigeria 0.876 882 Samoa 0.261 65% 0.158 0.161 0.073 0.113 0.035 0.067 0.063 0.103 0.091 0.150 Service do? 21 Costa TF, Felli VE, Baptista PC. Nursing workers' perceptions regarding the handling of hazardous chemical waste Revista da Escola de Enfermagem da U S P 22 Das, P., Horton, R. Pollution, health, and the planet: time for decisive 270 Gambia 0.587 579 Norway 0.260 894 Zambia 0.471 276 Germany 0.364 583 FS Micronesia 70% 0.136 0.138 0.059 0.099 0.027 0.058 0.050 0.090 0.070 0.128 0.288 75% 0.113 0.115 0.046 0.084 0.021 0.048 0.039 0.076 0.053 0.106 The Lancet 80% 0.090 0.092 0.033 0.070 0.015 0.038 0.028 0.063 0.038 0.084 action 23 De Blois, J. et al. The effects of climate change on cardiac health 85% 0.067 0.069 0.021 0.055 0.010 0.029 0.019 0.049 0.026 0.062 Cardiology 90% 0.044 0.047 0.013 0.040 0.007 0.019 0.012 0.034 0.016 0.040 October 9, Scopus ("responsible sourcing" OR "sustainable supply chain management") AND (Anesth*) Scopus Scopus ("water footprint" OR "water consumption") AND (Anesth*) October 9, Research surgical) October 9, PubMed Recycl* OR re-us* OR reus* November 17, 25 de Souza, A.L. Global warming and heatstroke Indian Journal of Medical ("responsible sourcing" OR "sustainable supply chain management") AND (Surger* OR PubMed Environment* OR "social* responsib*" OR "sustainable development" November 17, products in the healthcare sector October 9, PubMed "water footprint" November 17, PubMed "water footprint" OR "water consumption" November 17, 24 De Soete et al. Challenges and recommendations for environmental sustainability assessments of pharmaceutical Green Chemistry 95% 0.021 0.024 0.006 0.021 0.003
	Scopus	("water footprint" OR "water consumption") AND (Surger* OR surgical)	October 9,

Elasticity Calculations for Al, Co, Cu and Ni

	Annex G.
	Material	Aluminum
	Event	Cyclone Hudhud (13/10/2014)
	(T) Total production (t/y)	56,668,160
	(D) Disrupted Production (t/y)	9,600,000
	(d=100*D/T) Disrupted Production (%)	16.94%
	(p) Price increase ratio	0.7465
	Estimated Ɛ=p/d	0.044
	Material	Cobalt
	Event	Hurricane Matthew (04/10/2016)
	Total production (t/y)	134,239
	Disrupted Production (t/y)	3,000
	Disrupted Production (%)	2.23%
	Price increase ratio	1.8182
	Estimated Ɛ	0.814
	Material	Copper
	Event	Romanian Flood (04/07/2005)
	Total production (t/y)	19,319,839
	Disrupted Production (t/y)	900,000
	Disrupted Production (%)	4.66%
	Price increase ratio	0.9962
	Estimated Ɛ	0.214
	Material	Nickel
	Event	Typhoon Parma (05/10/2009)
	Total production (t/y)	2,206,513
	Disrupted Production (t/y)	91,000
	Disrupted Production (%)	4.12%
	Price increase ratio	1.5214
	Estimated Ɛ	0.369

GeoPolRiskOECD Calculations for Al, Co, Cu and Ni (2015-2017) YEAR: 2015

	Annex H.
		Aluminum	Cobalt	Copper	Nickel
	TOTAL OECD IMPORTS (KG)	2.63E+10	8.22E+06	1.23E+09	1.55E+08
	TOTAL OECD PRODUCTION (KG)	8.27E+10	1.10E+07	1.02E+10	5.33E+08
	TOTAL WGI*IMPORTS (KG)	1.44E+10	4.48E+06	7.26E+08	9.46E+07
	TOTAL IMPORTS + OECD PRODUCTION (KG)	1.09E+11	1.93E+07	1.14E+10	6.88E+08
	HHI	0.1748	0.3462	0.1255	0.1087
	GEOPOLRISK OECD	0.0231	0.0803	0.0079	0.0149
	YEAR: 2016	Aluminum	Cobalt	Copper	Nickel
	TOTAL OECD IMPORTS (KG)	1.99E+10	7.75E+06	1.44E+09	1.24E+08
	TOTAL OECD PRODUCTION (KG)	8.38E+10	1.04E+07	9.38E+09	5.14E+08
	TOTAL WGI*IMPORTS (KG)	1.09E+10	4.12E+06	8.56E+08	7.76E+07
	TOTAL IMPORTS + OECD PRODUCTION (KG)	1.03E+11	1.81E+07	1.08E+10	6.39E+08
	HHI	0.1946	0.3580	0.1793	0.0947
	GEOPOLRISK OECD	0.0205	0.0812	0.0142	0.0115
	YEAR: 2017	Aluminum	Cobalt	Copper	Nickel
	TOTAL OECD IMPORTS (KG)	1.80E+10	8.81E+06	1.23E+09	1.13E+08
	TOTAL OECD PRODUCTION (KG)	8.48E+10	9.54E+06	8.83E+09	4.23E+08
	TOTAL WGI*IMPORTS (KG)	1.03E+10	4.49E+06	7.05E+08	6.71E+07
	TOTAL IMPORTS + OECD PRODUCTION (KG)	1.02+11	1.83E+07	1.00E+10	5.36E+08
	HHI	0.1874	0.3947	0.1674	0.1094
	GEOPOLRISK OECD	0.0188	0.0967	0.0117	0.0137

GeoPolEndpoint Calculations for Al, Co, Cu and Ni as part of LIB (2015-2017)

	Annex I.
	MidPoint (GeoPolRisk -OECD) Cost Increase Factors EndPoint (Relative Damage)	0-1 Price % CostIncreaseFactor*price (USD/t)	GeoPolGlobal GeoPolGlobal GeoPolGlobal 2015 2015 2016 2017 2016 2017 GeoPolEndpoint 2015 GeoPolEndpoint 2016 GeoPolEndpoint 2017	Aluminum 0.023 0.020 0.019 0.10% 0.09% 0.08% 1.69 1.45 1.63	Cobalt 0.080 0.081 0.097 6.54% 6.61% 7.86% 1861.49 1687.15 4370.86	Copper 0.008 0.014 0.012 0.17% 0.30% 0.25% 9.33 14.78 15.49	Nickel 0.015 0.012 0.014 0.55% 0.42% 0.51% 65.43 40.96 52.96	Cost (Raw Materials Cost per kWh) Endpoint (Absolute Damage per kWh)	USD/kWh (NCA-C) USD/kWh USD/kWh (NCA-C) USD/kWh (NMC-C) (NMC-C)	2015 2016 2017 2015 2016 2017 damage Cost Contribution Cost Contribution Cost Contribution Cost Contribution Cost Contribution Cost Contribution Socio-economic 2015 Socio-economic damage 2016 Socio-economic damage 2017 Socio-economic damage 2015 Socio-economic damage 2016 Socio-economic damage 2017	Aluminum 0.73 0.70 0.86 0.45 0.43 0.53 0.001 0.001 0.001 0.000 0.000 0.000	Cobalt 4.31 3.86 8.41 11.87 10.64 23.18 0.282 0.255 0.662 0.776 0.703 1.822	Copper 4.63 4.10 5.19 6.96 6.16 7.81 0.008 0.012 0.013 0.012 0.019 0.020	Nickel 9.55 7.76 8.42 4.93 4.01 4.35 0.053 0.033 0.043 0.027 0.017 0.022	Total 19.22 16.42 22.89 24.22 21.24 35.86 0.343 0.301 0.718 0.816 0.740 1.864	1.78% 1.84% 3.14% 3.37% 3.48% 5.20% Damage/Cost

GeoPolRisk Values for Al, Co, Cu and Ni for the EU from 2015 to 2017 GeoPolRisk results: EU Perspective Interpreted

  as portion of the overall material at iminent risk of supply disruption (EU perspective)

	GeoPolRisk (mean)	2015	2016	2017
	Bauxite (Al)	0.082	0.085	0.084
	Cobalt (Co)	0.108	0.132	0.168
	Copper (Cu)	0.018	0.025	0.023
	Nickel (Ni)	0.028	0.024	0.022
	Scale: 0 to 1
	Original GeoPolRisk	2015	2016	2017
	Bauxite (Al)	0.094	0.097	0.096
	Cobalt (Co)	0.108	0.132	0.168
	Copper (Cu)	0.040	0.061	0.057
	Nickel (Ni)	0.043	0.036	0.034
	Scale: 0 to 1
	GeoPolRisk R -WCS	2015	2016	2017	EoL -RIR
	Bauxite (Al)	0.088	0.091	0.090	12.4%
	Cobalt (Co)	0.108	0.132	0.168	0.0%
	Copper (Cu)	0.022	0.031	0.027	55.0%
	Nickel (Ni)	0.034	0.029	0.025	33.9%
	Scale: 0 to 1
	GeoPolRisk R -BCS	2015	2016	2017	EoL -RIR
	Bauxite (Al)	0.076	0.079	0.078	12.4%
	Cobalt (Co)	0.108	0.132	0.168	0.0%
	Copper (Cu)	0.013	0.019	0.018	55.0%
	Nickel (Ni)	0.021	0.018	0.018	33.9%
	Scale: 0

to 1 Annex J. GeoPolEndpoint and damage associated to the use of Al, Co, Cu and Ni in LIB

		USD/t Li-ion Battery (NMC-C)	2015 2016 2017	0.42 0.42 0.51	271.24 297.19 823.55	6.78 8.56 9.77	13.01 9.03 8.97	291.45 315.21 842.80
		USD/t Li-ion Battery (NCA-C) USD/t	2015 2016 2017 2015 2016 2017	6.01 6.01 7.29 0.75 0.75 0.91	2502.23 2741.63 118.71 328.97 7597.36 108.35	4.96 6.27 7.16 20.59 26.02 29.70	27.75 19.26 19.12 120.50 83.64 83.04	141.81 145.00 356.16 Total Damage (USD/t Li-ion Battery)
			2017	0.37%	13.67%	0.48%	0.79%
		Price %	2016	0.37%	10.74%	0.53%	0.87%
			2015	0.36%	8.79%	0.37%	1.01%
	MidPoint (	0-1	2015 2016 2017	0.082 0.085 0.084	0.108 0.132 0.168	0.018 0.025 0.023	0.028 0.024 0.022
	Inventory	Mass %	Mass NCA-C Mass NMC-C	(Inventory) (Inventory)	12.50% 6.98%	4.33% 10.84%	24.10% 32.90%	23.03% 10.80%	63.96% 61.52%
					Aluminum	Cobalt	Copper	Nickel	Total

GeoPolRisk -EU) Cost Increase Factors EndPoint (Relative Damage) Endpoint (Damage) Annex K. Results of the Integrated Assessment of LIB (Midpoint) Mass Acidification Global Warming Potential Abiotic Depletion Potential Fresh Water Ecotoxicity Marine Ecotoxicity Terrestrial Ecotoxicity Eutrophicatio n Human toxicity Ozone Depletion Potential

	Annex L.
	Risk	GeoPolRisk 2017	0.084	0.168	0.023	0.022	Risk	2017 0.084 GeoPolRisk	0.168	0.023	0.022
	Geopolitical Supply	GeoPolRisk GeoPolRisk 2016 2015	0.08 0.085	0.11 0.132	0.02 0.025	0.03 0.024	Geopolitical Supply	GeoPolRisk 2015 GeoPolRisk 0.08 2016 0.085	0.11 0.132	0.02 0.025	0.03 0.024
	Photochemical	Oxidation	kg C2H4 eq	4.385E-04	1.089E-04	1.948E-03	2.757E-02	Photochemical Oxidation		kg C2H4 eq 2.449E-04	2.727E-04	2.660E-03	1.293E-02
			kg CFC-11	eq	3.860E-08	3.092E-08	1.150E-07	1.598E-07	Ozone Depletion Potential	kg CFC-11 eq 2.156E-08	7.740E-08	1.570E-07	7.495E-08
			kg 1,4-DB	eq	2.4560	0.2876	22.3344	6.6469	Human toxicity	kg 1,4-DB eq 1.3714	0.7201	30.4898	3.1171
			kg PO4 eq	1.667E-03	1.350E-03	3.353E-02	2.460E-02	Eutrophicatio n		kg PO4 eq 9.306E-04	3.379E-03	4.577E-02	1.153E-02
			kg 1,4-DB	eq	2.887E-04	2.044E-04	6.377E-03	8.178E-03	Terrestrial Ecotoxicity	kg 1,4-DB eq 1.612E-04	5.117E-04	8.706E-03	3.835E-03
			kg 1,4-DB	eq	2.4794	0.6078	33.4529	41.7278	Marine Ecotoxicity	kg 1,4-DB eq 1.3845	1.5215	45.6681	19.5684
			kg 1,4-DB	eq	0.696	0.165	8.793	11.168	Fresh Water Ecotoxicity	kg 1,4-DB eq 0.388	0.412	12.004	5.237
			kg Sb eq	7.031E-03	2.779E-03	8.424E-03	1.560E-02	Abiotic Depletion Potential		kg Sb eq 3.926E-03	6.958E-03	1.150E-02	7.317E-03
			kg CO2 eq	1.2093	0.4650	1.0217	2.5983	Global Warming Potential		kg CO2 eq 0.6753	1.1641	1.3948	1.2185
			kg SO2 eq	7.506E-03	4.177E-03	4.925E-02	6.926E-01	Acidification		kg SO2 eq 4.191E-03	1.046E-02	6.724E-02	3.248E-01
			Inventory	12.50%	4.33%	24.10%	23.03%	Mass		Inventory 6.98%	10.84%	32.90%	10.80%
		NCA-C			Aluminum	Cobalt	Copper	Nickel	NMC-C	Aluminum Cobalt Copper Nickel

Results of the Integrated Assessment of LIB (Endpoint)

			(USD)	0.91	328.97	7.16	19.12			(USD)	0.51	823.56	9.77	8.97
	Socio-economic Damage	(USD) 2016 (USD) 2017	0.75 0.75	108.35 118.71	4.96 6.27	27.75 19.26	Socio-economic Damage	(USD) 2016 (USD) 2017	0.42 0.42	271.24 297.19	6.78 8.56	13.01 9.03
			2015							2015
	Resources	USD	0.0425	0.0258	0.3515	0.7388	Resources	USD	0.0237	0.0647	0.4799	0.3465
	Ecosystem	loss	species.yr	1.020E-08	4.863E-09	1.318E-08	2.814E-08	Ecosystem	loss	species.yr	5.693E-09	1.217E-08	1.799E-08	1.320E-08
	Human	Health	DALY	2.766E-06	1.499E-06	2.099E-05	4.451E-05	Human	Health	DALY	1.544E-06	3.754E-06	2.866E-05	2.087E-05
	Mass	Inventory	12.50%	4.33%	24.10%	23.03%	Mass	Inventory	6.98%	10.84%	32.90%	10.80%
		NCA-C		Aluminum	Cobalt	Copper	Nickel		NMC-C		Aluminum	Cobalt	Copper	Nickel

Annex N. Raw helium trade database to top 10 consuming countries (2015- 2018)

	Exporting Country Exporting Country Exporting Country Exporting Country Annex O.	Net Import Net Import Net Import Net Import	Share Share Share Share	Importing Country Importing Country Importing Country Importing Country	Year Year Year Year	Allocation to original producer Allocation to original producer Allocation to original producer producer Allocation to original
	Algeria USD 11,734,542.00 Romania USD 48,822.00 Australia USD 1,027,893.00 Qatar USD 15,273,016.00	13.17% 0.06% 0.92% 24.25%	Germany Germany South Korea Taiwan	2016 2017 2016 2015	Algeria Exclude from analysis Australia Qatar
	Exporting Country France USD Net Import 13,003,679.00 Ukraine USD 2,363,199.00 Austria USD 4,903.00 Singapore USD 1,191,512.00 Australia USD United Kingdom USD 309,709.00 United States of America USD 6,881,407.00 Belgium USD 1,090.00 Ukraine USD 822,086.00 13,783.00 Austria USD Ireland USD 1,662.00 United Arab Emirates USD 153,275.00 Czechia USD 13,250.00 United States of America USD 33,179,684.00 7,557.00 Canada USD Israel USD 92,138.00 Belgium USD 19,185,104.00 Germany USD 333,537.00 Undeclared USD 1,124.00 2,098.00 Germany USD Luxembourg USD 20,543.00 China USD 1,040,217.00 France USD 1,320,304.00 Australia USD 6,219,780.00 54,394.00 Denmark USD Poland USD 629,455.00 Cyprus USD 126,804.00 United Kingdom USD 426,825.00 Belgium USD 6,896.00 1,722.00 France USD Portugal USD 539,142.00 Algeria USD 10,160,622.00 Japan USD 353,953.00 Czechia USD 18,453.00 4,907.00 United Kingdom USD 3,975,621.00 Qatar USD 21,624,955.00 Spain USD 33,907.00 Netherlands USD 16,650.00 Germany USD 8,959.00 Italy USD Romania USD 29,553.00 France USD 5,378,258.00 Norway USD 2,275.00 France USD 101,135.00 5,825.00 Netherlands USD Russia USD 1,699,123.00 United Kingdom USD 2,410,570.00 Qatar USD 20,540,523.00 United Kingdom USD 1,068.00 3,928.00 Portugal USD Sweden USD 332,006.00 Italy USD 760,599.00 Russia USD 310,932.00 Japan USD 925,786.00 69,139.00 Russia USD Qatar USD 74,867,255.00 Ukraine USD 958,388.00 Oman USD 536,632.00 Singapore USD 882,585.00 South Korea USD 1,598,082.00 19,294.00 United States of America USD 17,375,767.00 Russia USD 92,381.00 France USD 28,104,028.00 United States of America USD 8,959,100.00 Poland USD 6,696,434.00 Ukraine USD 7,051,506.00 Netherlands USD 1,111.00 Australia USD Singapore USD 768,429.00 United Kingdom USD 328,047.00 United Arab Emirates USD 6,816,839.00 Portugal USD 1,709,753.00 United States of America USD 79,521,446.00 Qatar USD 15,736,227.00 12,378.00 Austria USD United States of America USD 15,142,554.00 Greece USD 23,211.00 Belgium USD 20,100,285.00 Qatar USD 29,031,038.00 United Arab Emirates USD 7,476,943.00 Singapore USD 380,968.00 1,419.00 Germany USD Australia USD 12,922,166.00 Ireland USD 54,072.00 Cyprus USD 25,239.00 Romania USD 5,975.00 Australia USD 2,698,901.00 Ukraine USD 1,054,003.00 38,303.00 Algeria USD Czechia USD 4,195.00 Luxembourg USD 184,282.00 Algeria USD 10,418,988.00 Ukraine USD 1,570,679.00 Austria USD 4,207.00 United States of America USD 35,609,650.00 623,995.00 France USD Germany USD 856,435.00 Qatar USD 6,982,134.00 France USD 907,888.00 United Arab Emirates USD 163,240.00 Czechia USD 4,630.00 United Arab Emirates USD 9,474,181.00 198,511.00 United Kingdom USD Fiji USD 2,195.00 Romania USD 57,683.00 United Kingdom USD 457,518.00 Austria USD 10,884.00 Germany USD 73,528.00 Australia USD 2,858,725.00 1,899,965.00 Israel USD 264,641.00 France USD 646,367.00 Russia USD 2,583,900.00 India USD 121,459.00 China USD 22,352,748.00 France USD 3,173,496.00 China USD 228,093.00 Italy USD United States of America USD 19,680,815.00 United Kingdom USD 107,694.00 Ukraine USD 3,666,055.00 Oman USD 120,686.00 Germany USD 219,762.00 United Kingdom USD 12,644.00 Czechia USD 4,356.00 1,474.00 Netherlands USD South Africa USD 1,407.00 Hong Kong USD 3,663,210.00 United Kingdom USD 23,058.00 United States of America USD 5,587,044.00 Poland USD 5,014,661.00 France USD 4,516,104.00 Indonesia USD 351.00 Germany USD 4,565.00 6,998.00 Poland USD Austria USD 4,517.00 Italy USD 4,221.00 Hong Kong USD 4,073,610.00 Russia USD 4,071,770.00 Netherlands USD 2,446,320.00 United Arab Emirates USD 10,412,768.00 Portugal USD 545,343.00 United Kingdom USD 159,311.00 Italy USD 3,178.00 United Kingdom USD 3,731.00 161,899.00 Czechia USD 26,263.00 South Korea USD 11,043,844.00 Indonesia USD 94,219.00 Senegal USD 35,826.00 Oman USD 67,424.00 Belgium USD 18,762,623.00 Qatar USD 23,275,526.00 Hong Kong USD 18,293.00 Japan USD 699,714.00 Japan USD 580,912.00	Share 14.59% 3.07% 0.00% 1.89% 0.06% 0.35% 8.93% 0.00% 1.31% 0.04% 0.00% 0.19% 0.01% 52.67% 0.01% 0.10% 24.35% 0.30% 0.00% 0.25% 0.02% 1.32% 1.18% 10.09% 0.01% 0.71% 0.16% 0.38% 0.01% 0.02% 0.61% 12.89% 0.32% 0.03% 18.46% 24.27% 0.04% 0.01% 0.01% 0.03% 0.03% 6.83% 0.00% 0.16% 0.02% 1.91% 3.06% 18.37% 0.00% 0.32% 0.02% 0.37% 0.97% 0.28% 1.50% 0.09% 63.31% 0.03% 1.08% 0.68% 0.79% 2.59% 80.69% 0.08% 33.16% 10.05% 8.50% 6.31% 0.00% 0.06% 0.65% 0.39% 8.84% 2.17% 71.12% 25.52% 0.01% 12.81% 0.03% 26.07% 36.84% 6.51% 0.62% 0.20% 9.08% 0.06% 0.03% 0.01% 2.35% 1.71% 3.26% 0.00% 0.22% 13.51% 1.99% 0.00% 57.75% 1.04% 0.60% 8.24% 1.18% 0.10% 0.00% 15.89% 9.91% 0.00% 0.07% 0.59% 0.01% 0.06% 4.80% 1.38% 0.45% 3.05% 0.16% 14.04% 2.76% 0.38% 0.01% 99.34% 0.08% 0.02% 4.32% 0.16% 0.14% 0.01% 0.01% 0.04% 0.01% 2.57% 0.01% 6.59% 6.50% 2.84% 0.00% 0.01% 0.84% 0.02% 0.00% 2.15% 4.76% 3.47% 11.69% 0.71% 0.10% 0.00% 0.01% 0.13% 7.76% 0.05% 0.04% 0.10% 21.06% 30.19% 0.01% 0.61% 0.97%	Importing Country Germany Germany South Korea Taiwan Brazil Germany Germany South Korea Taiwan Brazil Germany Germany South Korea Taiwan Brazil Germany Germany South Korea Taiwan Brazil Germany Germany South Korea Taiwan Brazil Germany Germany South Korea Taiwan Brazil Germany Germany South Korea Taiwan Brazil Germany Germany South Korea Taiwan Brazil Germany Germany South Korea Taiwan Brazil Germany Germany South Korea Taiwan Brazil China Germany Germany South Korea Taiwan Brazil China Germany Germany Germany South Korea Taiwan Brazil China Germany Germany Germany South Korea Taiwan Brazil China Germany Germany Germany South Korea Taiwan Brazil China Germany Germany Germany South Korea Taiwan Brazil China Germany Germany Germany South Korea Taiwan Brazil China Germany Germany Germany South Korea Taiwan Brazil China Germany Germany Japan South Korea Taiwan Brazil China Germany Germany Japan South Korea Taiwan Brazil China Germany Germany Japan South Korea Taiwan Brazil Canada China China Germany Germany Japan South Korea Taiwan Brazil Canada China China Germany Germany Japan South Korea Taiwan Brazil Canada China China France France Germany Germany Japan South Korea Taiwan Canada China China France France Germany Germany Japan South Korea Taiwan	Year 2016 2017 2016 2015 2015 2016 2017 2016 2015 2015 2016 2018 2016 2015 2015 2016 2018 2016 2015 2015 2016 2018 2016 2016 2015 2016 2018 2016 2016 2015 2016 2018 2016 2016 2015 2016 2018 2016 2016 2015 2016 2018 2016 2016 2015 2016 2018 2016 2016 2015 2015 2016 2018 2016 2016 2015 2015 2015 2016 2018 2016 2016 2015 2015 2015 2016 2018 2016 2016 2016 2015 2015 2017 2018 2016 2016 2016 2015 2015 2017 2018 2017 2016 2016 2016 2015 2017 2018 2017 2016 2016 2016 2015 2017 2018 2017 2016 2016 2016 2015 2017 2015 2017 2017 2016 2016 2015 2017 2015 2017 2017 2016 2016 2015 2017 2015 2017 2017 2016 2017 2016 2018 2015 2017 2015 2017 2017 2016 2017 2016 2018 2015 2017 2015 2017 2017 2016 2018 2016 2018 2016 2018 2016 2017 2015 2017 2017 2018 2016 2018 2016 2018 2016 2017 2015 2017 2017	Allocation to original Algeria Ukraine Exclude from analysis Qatar producer Australia Exclude from analysis United States of America Exclude from analysis Ukraine Exclude from analysis Exclude from analysis Exclude from analysis Exclude from analysis United States of America Exclude from analysis Exclude from analysis Qatar Exclude from analysis Exclude from analysis Exclude from analysis Exclude from analysis Qatar Algeria Australia Exclude from analysis Poland Exclude from analysis Exclude from analysis Exclude from analysis Exclude from analysis Exclude from analysis Algeria Exclude from analysis Exclude from analysis United States of Qatar Exclude from analysis Exclude from analysis Exclude from analysis America Exclude from analysis Exclude from analysis Algeria Exclude from analysis Exclude from analysis Exclude from analysis Russia Qatar Qatar Exclude from analysis Exclude from analysis Exclude from analysis Exclude from analysis Qatar Russia United States of America Russia Qatar Exclude from analysis Ukraine Exclude from analysis Exclude from analysis United States of America United States of Russia Algeria United States of America Poland Ukraine Exclude from analysis America Australia Exclude from analysis Exclude from analysis Qatar Algeria United States of America Qatar Exclude from analysis United States of America Exclude from analysis Qatar Qatar Qatar Exclude from analysis Exclude from analysis Australia Exclude from analysis Exclude from analysis Exclude from analysis Australia Ukraine Algeria Exclude from analysis Exclude from analysis Algeria Ukraine Exclude from analysis United States of America Algeria Exclude from analysis Qatar Algeria Exclude from analysis Exclude from analysis Qatar Qatar Exclude from analysis Exclude from analysis Exclude from analysis Exclude from analysis Exclude from analysis Australia United States of Exclude from analysis Exclude from analysis Russia Exclude from analysis Qatar Algeria Exclude from analysis America Exclude from analysis United States of America Exclude from analysis Exclude from analysis Ukraine Exclude from analysis Exclude from analysis Exclude from analysis Exclude from analysis Exclude from analysis Exclude from analysis Qatar Exclude from analysis Qatar Algeria United States of America Poland Algeria Exclude from analysis Exclude from analysis Poland Exclude from analysis Exclude from analysis Qatar Russia Qatar Qatar Exclude from analysis Exclude from analysis Exclude from analysis Exclude from analysis Exclude from analysis United States of America Exclude from analysis Exclude from analysis Exclude from analysis United States of America Qatar Exclude from analysis Exclude from analysis United States of America

Allocation of supply mixes and GeoPolRisk calculations (2015- 2018) Year 2015 Year 2016 Adjusted Supply Mix

	Annex V.
					Year 2017									Year 2018
	Weighted GeoPolRisk WGI Net Import Total Weighted WGI GeoPolRisk Net Import	0.320 0.135 USD 118,249,121.00 100.00% 0.388 0.162 USD 147,774,979.00	0.362 0.153 USD 159,152,701.00 100.00% 0.424 0.177 USD 100,709,503.00	0.389 0.164 USD 124,837,871.00 100.00% 0.427 0.178 USD 114,880,158.00	0.564 0.238 USD 84,765,234.00 100.00% 0.439 0.183 USD 77,097,860.00	0.348 0.147 USD 62,994,191.00 100.00% 0.407 0.169 USD 59,613,241.00	0.452 0.191 USD 42,538,664.00 100.00% 0.471 0.196 USD 49,995,623.00	0.364 0.154 USD 35,749,906.00 100.00% 0.432 0.180 USD 39,383,840.00	0.364 0.154 USD 25,575,661.00 100.00% 0.432 0.180 USD 19,811,748.00	0.590 0.249 USD 89,338,297.00 100.00% 0.626 0.261 USD 74,860,744.00	0.365 0.154 USD 21,534,035.00 100.00% 0.437 0.182 USD 16,026,472.00	Weighted Total WGI Weighted WGI GeoPolRisk Net Import GeoPolRisk Net Import	0.359 0.152 100.00% 0.371 USD 142,318,174.00 0.154 USD 189,656,344.00	0.419 0.177 100.00% 0.400 USD 110,696,619.00 0.166 USD 107,821,082.00	0.433 0.183 100.00% 0.433 USD 111,807,672.00 0.180 USD 123,577,853.00	0.478 0.202 100.00% 0.446 USD 89,109,386.00 0.185 USD 78,799,867.00	0.389 0.164 100.00% 0.390 USD 61,662,118.00 0.162 USD 51,195,904.00	0.469 0.198 100.00% 0.496 USD 39,008,124.00 0.205 USD 55,266,847.00	0.420 0.177 100.00% 0.406 USD 33,578,126.00 0.168 USD 38,582,697.00	0.420 0.177 100.00% 0.406 USD 21,315,045.00 0.168 USD 20,981,652.00	0.587 0.248 100.00% 0.618 USD 85,587,398.00 0.256 USD 70,494,338.00	100.00% 0.422 0.178 0.406 USD 19,164,253.00 0.168 USD 14,564,328.00
	Total USA	100.00% 35.40%	100.00% 60.53%	100.00% 70.52%	100.00% 9.08%	100.00% 42.10%	100.00% 20.89%	100.00% 100.00%	100.00% 99.99%	100.00% 7.56%	100.00% 97.78%	Total USA	100.00% 29.37%	100.00% 45.90%	100.00% 66.67%	100.00% 0.00%	100.00% 52.40%	100.00% 3.80%	100.00% 100.00%	100.00% 100.00%	100.00% 0.00%	100.00% 99.66%
	USA Ukraine	25.40% 0.00%	53.21% 1.55%	76.30% 0.99%	32.84% 3.12%	56.35% 2.70%	48.53% 0.00%	100.00% 0.00%	99.99% 0.00%	2.22% 0.00%	99.85% 0.00%	USA Ukraine	39.93% 0.09%	69.55% 0.63%	72.44% 2.24%	31.58% 2.02%	62.37% 1.20%	38.19% 0.00%	100.00% 0.00%	99.97% 0.00%	5.98% 1.50%	84.76% 0.00%
	Ukraine Russia	0.00% 0.00%	2.37% 0.72%	4.48% 0.35%	4.36% 0.00%	1.31% 0.13%	0.02% 0.00%	0.00% 0.00%	0.01% 0.00%	2.57% 2.67%	0.00% 0.00%	Ukraine Russia	0.12% 0.00%	4.53% 0.62%	6.42% 5.80%	1.09% 0.00%	1.72% 0.34%	0.00% 0.00%	0.00% 0.00%	0.03% 0.00%	0.30% 7.38%	0.00% 0.15%
	Russia Qatar	0.08% 58.22%	0.36% 34.80%	0.83% 22.99%	3.07% 66.24%	0.00% 50.25%	0.00% 50.74%	0.00% 0.00%	0.00% 0.00%	0.00% 8.84%	0.09% 0.00%	Russia Qatar	0.36% 60.35%	0.02% 49.22%	0.28% 17.36%	1.94% 67.26%	0.00% 40.31%	0.00% 53.03%	0.00% 0.00%	0.00% 0.00%	4.79% 14.57%	0.00% 0.00%
	Qatar Poland	64.05% 0.00%	41.22% 0.00%	15.34% 0.00%	10.71% 6.62%	27.86% 0.00%	22.61% 0.00%	0.00% 0.00%	0.00% 0.00%	25.31% 3.17%	0.00% 0.00%	Qatar Poland	50.36% 0.00%	24.66% 0.15%	18.71% 0.00%	36.50% 8.59%	25.74% 0.00%	33.99% 0.51%	0.00% 0.00%	0.00% 0.00%	25.28% 1.16%	10.00% 0.00%
	Poland Australia	0.00% 6.38%	0.00% 0.00%	0.00% 2.37%	0.00% 0.00%	0.00% 4.81%	0.00% 0.00%	0.00% 0.00%	0.00% 0.01%	4.90% 0.00%	0.00% 0.08%	Poland Australia	0.00% 10.20%	0.00% 0.00%	0.00% 2.27%	0.72% 0.00%	0.00% 5.74%	0.00% 0.00%	0.00% 0.00%	0.00% 0.00%	3.86% 0.00%	0.85% 0.19%
	Australia Algeria	10.47% 0.00%	0.00% 2.40%	0.77% 2.78%	0.00% 14.95%	14.47% 0.00%	0.00% 28.38%	0.00% 0.00%	0.00% 0.00%	0.00% 77.75%	0.06% 2.14%	Australia Algeria	9.22% 0.00%	0.00% 3.50%	0.94% 5.68%	0.00% 22.13%	10.17% 0.00%	0.00% 42.65%	0.00% 0.00%	0.00% 0.00%	0.00% 75.40%	0.07% 0.00%
	Algeria Adjusted Supply Mix	China 0.00% China	Japan 2.85% Japan	South Korea 2.27% South Korea	Germany 49.02% Germany	Taiwan 0.00% Taiwan	United Kingdom 28.83% United Kingdom	Mexico 0.00% Mexico	Canada 0.00% Canada	France 65.00% France	Brazil 0.00% Brazil	Adjusted Supply Algeria Mix Adjusted Supply Mix	China 0.00% China	Japan 1.25% Japan	South Korea 1.20% South Korea	Germany 28.18% Germany	Taiwan 0.00% Taiwan	United Kingdom 27.82% United Kingdom	Mexico 0.00% Mexico	Canada 0.00% Canada	France 59.79% France	Brazil 4.33% Brazil

Electricity mixes for the assessed helium importing countries (CA, DE, FR and JP)

			Canada		Germany	France	Japan
			(Ontario 2018)	(National 2018)	(National 2018)	(National 2018)
			Source: CER-	Source: IEA,	Source: RTE,	Source: IEA,
	Energy source	REC, 2020	2020	2019	2020
	Nuclear	60.00%	11.82%	47.51%	6.25%
	Coal		-	37.16%	2.26%	32.62%
	Oil		1.00%	0.81%	2.58%	4.99%
	Natural Gas	3.00%	12.97%	9.14%	36.38%
	Hydroelectric	26.00%	3.75%	19.20%	8.51%
	Wind	7.00%	17.10%	11.37%	0.72%
	Solar	2.00%	7.12%	6.42%	6.03%
	Biofuels	1.00%	6.95%	1.52%	2.07%
	Waste		-	2.06%	-	2.19%
	Geothermal		-	0.03%	-	0.24%
	Base bill of materials for helium transfer
	Flow	Category	Amount	Unit	Provider
	building, hall	Construction of buildings	0.025		m2	building, hall
	Electricity mix Hellium	Electricity Mix	117.94	kWh	DEPENDS ON COUNTRY

Output: refined helium equivalent to the content of 1 DEWAR available for local transport to final use destination Annex X.

Results at midpoint level for the 24 scenarios of MRI scan production

	Scenario	Unit	kg SO2 eq	kg PO4---eq	kg 1,4-DB eq	kg CO2 eq	kg 1,4-DB eq	kg 1,4-DB eq	kg CFC-11 eq	kg C2H4 eq	kg 1,4-DB eq	GeoPolRisk	(0->1)
	Helium use	Energy Consumption	Country	Acidification	Eutrophication	Fresh water aquatic ecotoxicity	Global Warming	Human toxicity	Marine aquatic toxicity	Ozone layer depletion	Photochemical Oxidation	Terrestrial Ecotoxicity	Supply Risk 2018
	A		CA	4.26E-03	1.70E-03	0.53	0.87	1.19	1404.7	9.00E-07	2.12E-04	2.73E-03		0.168
	A		DE	2.03E-02	1.25E-02	2.56	7.40	3.08	12509.6	3.46E-07	7.85E-04	7.74E-03		0.185
	A		FR	9.07E-03	2.67E-03	0.69	1.98	1.39	2240.3	8.44E-07	4.29E-04	3.40E-03		0.256
	A		JP	2.68E-02	1.17E-02	2.17	8.35	2.97	10688.6	5.90E-07	1.18E-03	6.84E-03		0.166
	A		CA	4.78E-03	1.81E-03	0.56	0.98	1.28	1499.3	1.04E-06	2.36E-04	2.95E-03		0.168
	A		DE	2.33E-02	1.43E-02	2.91	8.51	3.47	14312.9	3.96E-07	8.97E-04	8.73E-03		0.185
	A		FR	1.03E-02	2.92E-03	0.76	2.26	1.52	2464.0	9.71E-07	4.86E-04	3.73E-03		0.256
	A		JP	3.08E-02	1.33E-02	2.46	9.61	3.34	12211.9	6.78E-07	1.36E-03	7.69E-03		0.166
	B		CA	4.57E-03	1.79E-03	0.54	0.95	1.22	1471.7	9.21E-07	2.32E-04	2.85E-03		0.168
	B		DE	2.06E-02	1.26E-02	2.58	7.46	3.11	12574.0	3.62E-07	8.03E-04	7.82E-03		0.185
	B		FR	9.34E-03	2.74E-03	0.71	2.05	1.42	2300.3	8.61E-07	4.46E-04	3.49E-03		0.256
	B		JP	2.71E-02	1.18E-02	2.18	8.41	2.99	10751.2	6.06E-07	1.20E-03	6.91E-03		0.166
	B		CA	5.10E-03	1.89E-03	0.58	1.06	1.31	1566.3	1.06E-06	2.56E-04	3.06E-03		0.168
	B		DE	2.36E-02	1.43E-02	2.93	8.58	3.50	14377.3	4.12E-07	9.15E-04	8.81E-03		0.185
	B		FR	1.06E-02	2.99E-03	0.77	2.33	1.55	2524.1	9.88E-07	5.04E-04	3.81E-03		0.256
	B		JP	3.11E-02	1.34E-02	2.47	9.67	3.36	12274.5	6.93E-07	1.37E-03	7.77E-03		0.166
	C		CA	4.94E-03	1.88E-03	0.56	1.05	1.26	1550.0	9.44E-07	2.55E-04	2.98E-03		0.168
	C		DE	2.10E-02	1.27E-02	2.60	7.54	3.14	12649.3	3.80E-07	8.23E-04	7.91E-03		0.185
	C		FR	9.65E-03	2.82E-03	0.73	2.12	1.45	2370.5	8.81E-07	4.66E-04	3.59E-03		0.256
	C		JP	2.75E-02	1.19E-02	2.20	8.48	3.02	10824.4	6.24E-07	1.22E-03	7.00E-03		0.166
	C		CA	5.46E-03	1.99E-03	0.60	1.16	1.35	1644.6	1.08E-06	2.79E-04	3.20E-03		0.168
	C		DE	2.40E-02	1.44E-02	2.95	8.65	3.53	14452.6	4.30E-07	9.35E-04	8.90E-03		0.185
	C		FR	1.09E-02	3.07E-03	0.79	2.40	1.58	2594.2	1.01E-06	5.24E-04	3.91E-03		0.256
	C		JP	3.15E-02	1.35E-02	2.49	9.74	3.39	12347.6	7.12E-07	1.40E-03	7.86E-03		0.166

2015 2016 2017 2015 2016 2017

September 29, 2017 Scopus ("hazardous waste" OR "biohazard* waste" OR "waste management") AND ("diagnostic equipment" OR "diagnostic technique*" OR "computer assisted diagnos*" OR "medical technolog*" OR "medical laborator*" OR "laboratory diagnos*") September 29, 2017 Scopus ("life cycle assessment" OR "life cycle management" OR "life cycle sustainability assessment") AND ("diagnostic equipment" OR "diagnostic technique*" OR "computer assisted diagnos*" OR "medical technolog*" OR "medical laborator*" OR "laboratory diagnos*") September 29, 2017 Scopus ("material flow analysis" OR "material flow account*" OR "substance flow analysis") AND ("diagnostic equipment" OR "diagnostic technique*" OR "computer assisted diagnos*" OR "medical technolog*" OR "medical laborator*" OR "laboratory diagnos*") September 29, 2017 Scopus ("responsible sourcing" OR "sustainable supply chain management") AND ("diagnostic equipment" OR "diagnostic technique*" OR "computer assisted diagnos*" OR "medical technolog*" OR "medical laborator*" OR "laboratory diagnos*") September 29, 2017 Scopus ("water footprint" OR "water consumption") AND ("diagnostic equipment" OR "diagnostic technique*" OR "computer assisted diagnos*" OR "medical technolog*" OR "medical laborator*" OR "laboratory diagnos*") September 29, 2017 Scopus (Environment* OR "social* responsib*" OR "sustainable development") AND ("diagnostic equipment" OR "diagnostic technique*" OR "computer assisted diagnos*" OR "medical technolog*" OR "medical laborator*" OR "laboratory diagnos*") September 29, 2017Scopus(healthcare OR "health care" OR medic*) AND sustainab* September 29, 2017 Scopus ("carbon footprint" OR "greenhouse gas*" OR "climate change" OR "global warming") AND ("long-term care" OR "palliative care" OR "prevent* care") September 30, 2017 Scopus ("carbon footprint" OR "greenhouse gas*" OR "climate change" OR "global warming") AND ("medical equipment" OR "medical device*" OR "medical supplies" OR "ancillary device*" OR "ancillary equipment") September 30, 2017 Scopus ("carbon footprint" OR "greenhouse gas*" OR "climate change" OR "global warming") AND (Drug* OR pharmaceutical* OR "active pharmaceutical ingredient*" OR "medicinal ingredient*" OR vaccin*)September 30, 2017 Scopus ("critical material*" OR "critical metal*" OR "critical raw material*" OR criticality) AND ("long-term care" OR "palliative care" OR "prevent* care") September 30, 2017 Scopus ("critical material*" OR "critical metal*" OR "critical raw material*" OR criticality) AND ("medical equipment" OR "medical device*" OR "medical supplies" OR "ancillary device*" OR "ancillary equipment") September 30, 2017 Scopus ("critical material*" OR "critical metal*" OR "critical raw material*" OR criticality) AND (Drug* OR pharmaceutical* OR "active pharmaceutical ingredient*" OR "medicinal ingredient*" OR vaccin*) September 30, 2017 Scopus ("eco-efficiency" OR "energy efficiency" OR "material efficiency" OR "resource efficiency") AND ("long-term care" OR "palliative care" OR "prevent* care") September 30, 2017

September 30, 2017 Scopus ("environmental management" OR "ISO 14001") AND ("medical equipment" OR "medical device*" OR "medical supplies" OR "ancillary device*" OR "ancillary equipment") September 30, 2017Scopus("environmental management" OR "ISO 14001") AND (Drug* OR pharmaceutical* OR "active pharmaceutical ingredient*" OR "medicinal ingredient*" OR vaccin*)September 30, 2017Scopus("hazardous waste" OR "biohazard* waste" OR "waste management") AND ("diagnostic imaging" OR "x-ray*" OR radiograph* OR "computed tomography" OR ultrasound* OR "magnetic resonance imaging") September 30, 2017 Scopus ("hazardous waste" OR "biohazard* waste" OR "waste management") AND ("long-term care" OR "palliative care" OR "prevent* care") September 30, 2017 Scopus ("hazardous waste" OR "biohazard* waste" OR "waste management") AND ("medical equipment" OR "medical device*" OR "medical supplies" OR "ancillary device*" OR "ancillary equipment") September 30, 2017 Scopus ("life cycle assessment" OR "life cycle management" OR "life cycle sustainability assessment") AND ("diagnostic imaging" OR "x-ray*" OR radiograph* OR "computed tomography" OR ultrasound* OR "magnetic resonance imaging") September 30, 2017 Scopus ("life cycle assessment" OR "life cycle management" OR "life cycle sustainability assessment") AND ("long-term care" OR "palliative care" OR "prevent* care") September 30, 2017 Scopus ("life cycle assessment" OR "life cycle management" OR "life cycle sustainability assessment") AND ("medical equipment" OR "medical device*" OR "medical supplies" OR "ancillary device*" OR "ancillary equipment") September 30, 2017 Scopus ("material flow analysis" OR "material flow account*" OR "substance flow analysis") AND ("diagnostic imaging" OR "x-ray*" OR radiograph* OR "computed tomography" OR ultrasound* OR "magnetic resonance imaging") September 30, 2017 Scopus ("material flow analysis" OR "material flow account*" OR "substance flow analysis") AND ("long-term care" OR "palliative care" OR "prevent* care") September 30, 2017 Scopus ("material flow analysis" OR "material flow account*" OR "substance flow analysis") AND ("medical equipment" OR "medical device*" OR "medical supplies" OR "ancillary device*" OR "ancillary equipment") September 30, 2017 Scopus ("material flow analysis" OR "material flow account*" OR "substance flow analysis") AND (Drug* OR pharmaceutical* OR "active pharmaceutical ingredient*" OR "medicinal ingredient*" OR vaccin*) September 30, 2017 Scopus ("responsible sourcing" OR "sustainable supply chain management") AND ("diagnostic imaging" OR "x-ray*" OR radiograph* OR "computed tomography" OR ultrasound* OR "magnetic resonance imaging") September 30, 2017 Scopus ("responsible sourcing" OR "sustainable supply chain management") AND ("long-term care" OR "palliative care" OR "prevent* care") September 30, 2017 Scopus ("responsible sourcing" OR "sustainable supply chain management") AND ("medical equipment" OR "medical device*" OR "medical supplies" OR "ancillary device*" OR "ancillary equipment") September 30, 2017 Scopus ("responsible sourcing" OR "sustainable supply chain management") AND (Drug* OR pharmaceutical* OR "active pharmaceutical ingredient*" OR "medicinal ingredient*" OR vaccin*)September 30, 2017 Scopus ("water footprint" OR "water consumption") AND ("diagnostic imaging" OR "x-ray*" OR radiograph* OR "computed tomography" OR ultrasound* OR "magnetic resonance imaging") September 30, 2017 Scopus ("water footprint" OR "water consumption") AND ("long-term care" OR "palliative care" OR "prevent* care") September 30, 2017 Scopus ("water footprint" OR "water consumption") AND ("medical equipment" OR "medical device*" OR "medical supplies" OR "ancillary device*" OR "ancillary equipment") September 30, 2017 Scopus ("water footprint" OR "water consumption") AND (Drug* OR pharmaceutical* OR "active pharmaceutical ingredient*" OR "medicinal ingredient*" OR vaccin*) September 30, 2017

ACKNOWLEDGEMENTS

This work would not have been possible without the support of many people and organizations. I am forever grateful to those whom I crossed paths with along this journey.

thank Bertrand Laratte and Manuel Gaudon for being part of my steering committee; your advice along the process was extremely helpful. Institutional support was key for the development of this project. Thank you to the Initiative of Excellence (IdEx) from the University of Bordeaux, which provided the funding for the PhD and encouraged me to work with diverse research groups inside and outside of France. Thanks to the IDS FunMatInno project for providing excellent training in their doctoral schools and financing the various research stays I completed. I am also grateful to the International Roundtable on Materials Criticality (IRTC) for allowing me to take part in multiple international meetings that were key to the exchange of ideas with experts in the fields related to my PhD. I would like to acknowledge the support of my colleagues at the University of Waterloo. I Siddhantakar and Noor Shaikh; our collaboration resulted in core deliverables as part of my PhD thesis. Thank you for providing valuable input and allowing me to be a part of your academic journey. I had the opportunity to work in close collaboration with colleagues at the University of Augsburg. I would like to express my gratitude to the ResourceLab for providing funding for the research stay I completed.

UNEP Life Cycle Initiative LCSA Life Cycle Sustainability Assessment LIB Lithium-ion batteries MRI Magnetic Resonance Imaging NHS United Kingdom National Health Service NSTC US National Science and Technology Council OECD Organisation for Economic Co-operation and Development. OR Operating Room REE Rare Earth Elements SDG Sustainable Development Goals S-LCA Social life cycle assessment UN United Nations UNEP United Nations for Environment Programme US/USA United States of America USGS United States Geological Survey WB World Bank WCED World Commission on Environment and Development WGI Worldwide Governance Indicators WGI-PV the WGI WHO World Health Organization The PhD project is the result of a long-term collaboration between the CyVi group, based in the Institute des Sciences Moleculaires (ISM) at the Université de Bordeaux, and the Waterloo Industrial Ecology Group, based in the School of Environment, Enterprise and Development (SEED) at the Following previous work on Life Cycle Assessment and Criticality Assessment, the two research groups displayed a strong interest on the application of these methodologies to the healthcare sector. As one outcome of the discussions, a PhD proposal was presented; the Initiative of Excellence from the Université de Bordeaux supported the thesis for a 3-year period and the IDS-FunMat-INNO provided a grant to finance research stays and facilitate the attendance to doctoral schools. The design of the thesis project, its structure, and the most substantial work presented on this manuscript was carried out at the Université de Bordeaux; additionally, the following research stays were completed to support the progress of the project: Visit supported by the ResourceLab at the University of Augsburg. The outcomes of this research stay are presented in Chapter 5.  Bureau de Recherches Géologiques et Minières (BRGM), Orléans,

United States of America USD 15,845,487.00 82.68% Brazil 2016 United States of America Australia USD 12,384.00 0.08% Brazil 2017 Australia Austria USD 8,063.00 0.05% Brazil 2017 Exclude from analysis Belgium USD 1,399.00 0.01% Brazil 2017 Exclude from analysis Germany USD 64,724.00 0.40% Brazil 2017 Exclude from analysis Denmark USD 2,030.00 0.01% Brazil 2017 Exclude from analysis Algeria USD 172,510.00 1.08% Brazil 2017 Algeria United Kingdom USD 8,304.00 0.05% Brazil 2017 Exclude from analysis Italy USD 61,806.00 0.39% Brazil 2017 Exclude from analysis South Korea USD 73,180.00 0.46% Brazil 2017 Exclude from analysis Portugal USD 165,538.00 1.03% Brazil 2017 Algeria United States of America USD 15,456,534.00 96.44% Brazil 2017 United States of America Australia USD 27,516.00 0.19% Brazil 2018 Australia Austria USD 7,098.00 0.05% Brazil 2018 Exclude from analysis Belgium USD 6,313.00 0.04% Brazil 2018 Exclude from analysis Germany USD 42,250.00 0.29% Brazil 2018 Exclude from analysis France USD 8,126.00 0.06% Brazil 2018 Exclude from analysis United Kingdom USD 44,384.00 0.30% Brazil 2018 Exclude from analysis Italy USD 4,996.00 0.03% Brazil 2018 Exclude from analysis South Korea USD 140,407.00 0.96% Brazil 2018 United States of America Netherlands USD 13,358.00 0.09% Brazil 2018 Exclude from analysis Portugal USD 145,293.00 1.00% Brazil 2018 Exclude from analysis Russia USD 20,778.00 0.14% Brazil 2018 Russia United States of America France USD 28,209.00 0.11% Canada 2015 Exclude from analysis United Kingdom USD 539,039.00 2.11% Canada 2015 United States of America Hong Kong USD 775.00 0.00% Canada 2015 Exclude from analysis Ukraine USD 2,204.00 0.01% Canada 2015 Ukraine United States of America USD 24,950,286.00 97.55% Canada 2015 United States of America Azerbaijan USD 1,849.00 0.01% Canada 2016 Exclude from analysis China USD 26,749.00 0.13% Canada 2016 Exclude from analysis Germany USD 12,875.00 0.06% Canada 2016 Exclude from analysis France USD 93,180.00 0.44% Canada 2016 Exclude from analysis United Kingdom USD 24,114.00 0.11% Canada 2016 Exclude from analysis Ukraine USD 7,150.00 0.03% Canada 2016 Ukraine United States of America USD 21,147,005.00 99.21% Canada 2016 United States of America South Africa USD 1,025.00 0.00% Canada 2016 Exclude from analysis Taiwan USD 1,098.00 0.01% Canada 2016 Exclude from analysis Australia USD 1,187.00 0.01% Canada 2017 Australia Austria USD 6,210.00 0.03% Canada 2017 Exclude from analysis China USD 16,319.00 0.08% Canada 2017 Exclude from analysis Germany USD 44,422.00 0.22% Canada 2017 Exclude from analysis France USD 58,375.00 0.29% Canada 2017 Exclude from analysis United Kingdom USD 3,013.00 0.02% Canada 2017 France USD 20,144.00 0.10% Canada 2018 Exclude from analysis Mexico USD 2,675.00 0.01% Canada 2018 Exclude from analysis Netherlands USD 2,505.00 0.01% Canada 2018 Exclude from analysis United States of America USD 20,861,853.00 99.43% Canada 2018 United States of America Australia USD 12,243,626.00 10.35% China 2015 Australia Belgium USD 3,331.00 0.00% China 2015 Exclude from analysis Germany USD 246,448.00 0.21% China 2015 Exclude from analysis France USD 217,321.00 0.18% China 2015 Exclude from analysis United Kingdom USD 93,468.00 0.08% China 2015 Exclude from analysis South Korea USD 14,547,682.00 12.30% China 2015 United States of America Philippines USD 26,626.00 Undeclared USD 2,494.00 0.00% China 2016 Exclude from analysis United Arab Emirates USD 1,889,834.00 1.28% China 2017 Qatar Australia USD 9,325,045.00 6.31% China 2017 Australia Germany USD 62,969.00 0.04% China 2017 Exclude from analysis France USD 578,081.00 0.39% China 2017 Exclude from analysis United Kingdom USD 137,907.00 0.09% China 2017 Exclude from analysis Hong Kong USD 2,223,644.00 1.50% China 2017 Qatar India USD 131,386.00 0.09% China 2017 Exclude from analysis South Korea USD 6,743,113.00 4.56% China 2017 United States of America Qatar USD 80,975,650.00 54.80% China 2017 Qatar Singapore USD 713,914.00 0.48% China 2017 Exclude from analysis United States of America USD 44,993,436.00 30.45% China 2017 United States of America United Arab Emirates USD 251,084.00 0.13% China 2018 Exclude from analysis Australia USD 19,223,031.00 10.14% China 2018 Australia Brazil USD 2,192.00 0.00% China 2018 Exclude from analysis Canada USD 37,113.00 France 2015 Exclude from analysis Algeria USD 57,615,351.00 64.49% France 2015 Algeria Poland USD 4,344,509.00 4.86% France 2015 Poland Portugal USD 598,104.00 0.67% France 2015 Exclude from analysis Qatar USD 22,437,259.00 25.11% France 2015 Qatar Slovakia USD 7,527.00 0.01% France 2015 Exclude from analysis Trinidad and Tobago USD 43,764.00 0.05% France 2015 Exclude from analysis Ukraine USD 2,275,406.00 2.55% France 2015 Ukraine United States of America USD 1,965,152.00 2.20% France 2015 United States of America South Africa USD 3,117.00 0.00% France 2015 Exclude from analysis United Arab Emirates USD 148,551.00 0.17% France 2016 Exclude from analysis Dominican Republic USD 30,226.00 0.04% France 2016 Exclude from analysis Algeria USD 50,792,482.00 59.35% France 2016 Algeria Hong Kong USD 66,457.00 0.08% France 2016 Exclude from analysis Poland USD 3,277,372.00 3.83% France 2016 Poland Portugal USD 343,356.00 0.40% France 2016 Exclude from analysis Qatar USD 21,474,320.00 25.09% France 2016 United Arab Emirates USD 3,544,712.00 4.74% France 2017 Qatar Belgium USD 74,765.00 0.10% France 2017 Exclude from analysis Brazil USD 6,948.00 0.01% France 2017 Exclude from analysis Denmark USD 2,984.00 0.00% France 2017 Exclude from analysis Algeria USD 57,864,139.00 77.30% France 2017 Algeria Poland USD 2,357,873.00 3.15% France 2017 Poland Portugal USD 294,546.00 0.39% France 2017 Exclude from analysis Qatar USD 3,035,923.00 4.06% France 2017 Qatar Russia USD 1,987,241.00 2.65% France 2017 Russia Suriname USD 10,292.00 0.01% France 2017 Exclude from analysis Thailand USD 9,708.00 0.01% France 2017 Exclude from analysis Trinidad and Tobago USD 6,997.00 0.01% France 2017 Exclude from analysis United States of America USD 5,629,562.00 7.52% France 2017 United States of America Undeclared USD 35,054.00 0.05% France 2017 Exclude from analysis Belgium USD 7,690,581.00 10.91% France 2018 Qatar Saint Barthélemy USD 8,444.00 0.01% France 2018 Exclude from analysis China USD 533,278.00 0.76% France 2018 Exclude from analysis Czechia USD 1,033.00 0.00% France 2018 Exclude from analysis Algeria USD 51,536,642.00 73.11% France 2018 France 2018 Poland Portugal USD 929,240.00 1.32% France 2018 Algeria Russia USD 5,133,920.00 7.28% France 2018 Russia Senegal USD 6,737.00 0.01% France 2018 Exclude from analysis Trinidad and Tobago USD 11,491.00 0.02% France 2018 Exclude from analysis Uganda USD 9,359.00 0.01% France 2018 Exclude from analysis Ukraine USD 1,041,590.00 1.48% France 2018 Ukraine South Africa USD 241,203.00 0.34% France 2018 Exclude from analysis Undeclared USD 27,680.00 0.04% France 2018 Exclude from analysis United Arab Emirates USD 2,024,321.00 2.39% Germany 2015 Qatar Belgium USD 22,027,994.00 25.99% Germany 2015 United States of America Algeria USD 13,115,212.00 15.47% Germany 2015 Algeria Spain USD 27,251.00

Annex C. Re-scaled WGI scores for the year 2016 Code Country Name Score Code Country Name Score Code Country Name Score

Chapter 2: State of the Art

The scoping review presented in this chapter is partially based on the publication: A. Cimprich; J. [START_REF] Santillán-Saldivar | Risk Management in a Nonprofit Organization[END_REF]C. L. Thiel;G. Sonnemann;S. B. Young (2019). Potential Chapter 5: Geopolitical Supply Risk in LCSA: From

Midpoint to Endpoint

The work presented in this chapter is partially based on the publication:

J. Santillán-Saldivar; T. Gaugler; C. Helbig;A. Rathgeber;G. Sonnemann;A. Thorenz;A. Tuma (2020).

Design of an endpoint indicator for mineral resource supply risks in life cycle sustainability assessment:

The case of Li-ion batteries. Helium has a geopolitically concentrated production; as a result, there is a need for understanding helium supply risk and its implications for relevant sectors such as healthcare, energy and research. A concerning situation during the Saudi-led embargo of Qatar in June of 2017 resulted in a short-term global supply shortage when approximately 25% of helium global supply was interrupted [START_REF] Cockerill | Qatari helium: Back on-stream, but still caught in a political storm[END_REF]. A not so different scenario is possible when the US Federal Helium Program closes in 2021, with possibilities of supply constraints [START_REF] Fortier | Draft critical mineral list-Summary of methodology and background information-U.S[END_REF][START_REF] Massol | Phasing out the U.S. Federal Helium Reserve: Policy insights from a world helium model[END_REF]National Research Council, 2010).

Advances in helium storage have resulted on minimum loses in early stages of the helium supply chain [START_REF] Kashinath | Stable storage of helium in nanoscale platelets at semicoherent interfaces[END_REF]. However long-term storage at late stages is not common due to the characteristics of this element [START_REF] Sears | Helium: The disappearing element[END_REF]. This dynamic has parallels with the use-it-or-lose-it adage, meaning that a resource should be used by a particular date before it is no longer available (Cambridge University Press, 2011).

The use-it-or-lose-it dynamic is unique to helium and understanfing it is crucial to its sustainability: achieving efficient production, storage, and consumption of this non-renewable resource. Countries perceive the importance of helium supply based on their different industrial and technological needs;

each country may identify this dependency on foreign sources as a strategic vulnerability for both its economy and military to adverse foreign government action, natural disasters, and other events that can disrupt supply (US Department of the Interior, 2018).

Helium is deemed critical due to its economic importance and given the likelihood and severity of potential raw material supply disruptions. As explored in section 2.2.2, the criticality aspects related to helium make it a clear example of impacts from the outside-in perspective: an impact mechanism in which external environmental or socio-economic conditions affect product systems, economic activities, corporations, among others [START_REF] Porter | Strategy & society: The link between competitive advantage and corporate social responsibility[END_REF]. Specifically, for the case of healthcare, healthcare systems are susceptible to the effects of limited accessibility to resources, and how these aspects are understudied in the medical sector.

The case of helium becomes of interest from a supply risk perspective due to its unusual supply chain;

the GeoPolRisk method could provide the flexibility required for a country-specific supply risk assessment. Since previous applications of the geopolitical supply risk method have focused on metals and minerals; an opportunity appears to analyze this element as the first case in which the studied resource is traded in liquid and/or gaseous state and in its pure form as a noble gas. In the following section, the feasibility to apply the GeoPolRisk method to this case will be explored.

Applicability of the GeoPolRisk Method to the case of helium

In this section, the feasibility of applying the GeoPolRisk method to the case of helium is explored. From the literature on raw material criticality, a material is deemed critical when certain key economic sectors in a country or region are severely affected by its supply disruption and/or when the potential for the

Chapter 8: Integrated Life Cycle Assessment: Environmental Impacts and Criticality of Helium in Medical Imaging

The work presented in this chapter is partially based on a paper in preparation for publication: focuses on scenario C1 (high helium use, low energy consumption) to demonstrate that even considering higher levels of helium use (associated to losses and efficiency in the supply chain) and low levels of energy consumption, this remains the case.

In the same figure, the contribution of the international supply of helium with origin in producing countries (Algeria, Poland, Qatar, Russia and The USA) is identified. This is compared to the helium supply mix corresponding to each consuming country (Canada, Germany, France and Japan), showing that no big

ANNEXES Annex B. Sample for Healthcare Sustainability Scoping Review

This annex lists all literature pieces considered for the Healthcare and Sustainability Scoping Review. Each entry specifies the authors, title of the article, name of the journal and year of publication.

Annex M. Global Production of helium and HHI calculations (2015-2018)

As per the HHI formula; the values are calculated as follows: