HealthcarePapers 19(3) October 2020 : 4-7.doi:10.12927/hcpap.2020.26378

Environmental Sustainability Must Be on Our Agenda for Healthcare

Neil Stuart


I am increasingly alarmed by climate change and environmental degradation. Many of you share my concerns, no doubt. I worry that we are not dealing with these issues in a manner that promises meaningful or timely results, and I believe we must reorder our priorities. There is also a fundamental unfairness that runs through what is happening. Environmental harm compounds existing inequities within and among our communities, inequities between richer and poorer nations and, most insidiously, generational inequity – deferring the consequences of our inaction to a future generation. Adding to these concerns is the realization that in my own professional field, healthcare, we have given little thought to the sector's role in and responsibility for environmental sustainability. To date, these issues have not been part of the mainstream healthcare conversation.

The Paradox of Healthcare as a Threat to Humanity

In 2018, Fiona Miller and some of her colleagues at the Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, launched several initiatives to explore how health systems are implicated in environmental sustainability. Last year, Miller established IHPME's Centre for Sustainable Health Systems. Through the work at IHPME, I have come to understand better the mark that the health sector is leaving on the environment. I was particularly troubled to realize that the health sector, dedicated as it is to promoting and restoring health, is, in fact, causing significant harm. What about the Hippocratic oath (Eidelman 2018; Wabnitz et al. 2020)? In the last two decades, we have made great progress with patient safety, but what about making healthcare safe for humanity's future?

We know there is a convincing and ever-growing body of evidence that humanity is on a course that will, within a generation or two, render our planet much less habitable. Scientists tell us this (Cook et al. 2016). We see it. But we seem to be paralyzed in terms of taking the kind of measures that will avert the looming disaster. For most of us who work in healthcare, we have spent remarkably little time on questions of the environmental impact of healthcare itself. Environment and sustainability receive little attention in our strategic plans, in corporate score cards, in quality improvement programs, in accreditation standards, in the health information we collect and in funding priorities and accountabilities. We are still a long way from promoting carbon accounting alongside the more traditional financial accounting and making it a fundamental governance responsibility. The environment is simply not on our agenda.

This Issue of Healthcare Papers

The lead article in this issue by Miller and Xie (2020) seizes our attention and requires us to address these profoundly important issues for our health systems. It is a must-read for anyone in healthcare leadership, academia or front-line care. The paper provides an explosive picture of the sustainability and environmental impact of our health systems. It delves into the longer-term harms and their consequences for social equity. Miller and Xie (2020) also discuss how the health sector should provide leadership on environmental stewardship. The commentaries that follow their article give us an array of vital insights and perspectives on the issues. Some of the commentaries also offer promising guidance on how healthcare decision makers and those framing government policy might more effectively tackle the challenges involved.

Among the commentaries, Duane's (2020) piece draws on lessons from the UK and its National Health Service. The UK is widely recognized as having made significant progress in greening its healthcare sector. Environmental impact and sustainability are part of the conversation at the NHS. They are on the agenda. And the NHS is getting results. Duane shares several, perhaps surprising, insights: the importance of a legislated framework and clear governance and accountabilities. He also underlines the need for a commitment of resources to pursue this agenda, and he notes how the agenda itself has to be allowed to evolve over time.

The commentaries also include a very instructive piece from Born and Levinson (2020) at Choosing Wisely Canada. The authors share relevant lessons from the Choosing Wisely program and how it has been able to successfully engage stakeholders, particularly practising clinicians. Choosing Wisely appeals to clinicians in terms of what matters most to them, to their professionalism and to their commitment to effective and safe practices.

In a thoughtful analysis, Morris (2020), at the Canadian Institute for Health Information, reflects on why we have found it so difficult to come to grips with the issues of environmental impact and climate change. She asks whether we really care enough about the issues to embrace the required measures and whether our experience with COVID-19 will change this. Morris introduces an array of fresh and relevant data to this discussion.

One of the most fundamental challenges in addressing climate change has been that the dominant economic theories shaping public policy have been ones that seek, above all, to maximize productivity and economic growth, with little consideration of environmental degradation and impact on ecosystems. This issue of Healthcare Papers also includes a critical commentary from Martin Hensher, an economist. Hensher (2020) outlines the limitations of traditional economic analysis and introduces several new competing economic frameworks, which, to varying degrees, do more to take account of environmental consequences.

Zelmer (2020), of the Canadian Foundation for Healthcare Improvement, examines how to incorporate the reduction of environmental impacts into healthcare-improvement agendas. She also makes the case that resilient, high-performing healthcare systems that are able to bring about transformative change are key to realizing any new goals for environmental sustainability.

In his commentary, Nason (2020), of the Ontario Strategy for Patient-Oriented Research Support Unit, challenges us to place healthcare sustainability high on the agenda. He, like several other commentators, picks up on the equity implications of environmental sustainability and goes on to draw on lessons from Indigenous approaches to health and well-being. Nason proposes the addition of environmental sustainability as a fifth "aim" for the quadruple aim for healthcare. This recommendation directly addresses the concern that, to date, we have not succeeded in getting environmental sustainability on the agenda. It recognizes the crucial way in which the Institute for Health Improvement's Triple Aim – and now the Quadruple Aim – represents a widely accepted vision for where we need to take healthcare (Bodenheimer and Sinsky 2014).

Andermann et al. (2020) call for a new social accountability in our health systems, one that addresses harmful environmental effects and social inequities. They make an impassioned call to action. Drawing on the experience of some of the authors who have worked with Indigenous communities, they argue for combining traditional Indigenous wisdom with scientific knowledge to protect the environment and improve the well-being of all people.

Grundy et al. (2020), at the Bloomberg Faculty of Nursing, University of Toronto, provide a professional nursing perspective. They argue that as the largest professional group in healthcare, nurses must be engaged and mobilized in the drive to achieve a more sustainable health system. Furthermore, they propose that nurses are uniquely positioned to help lead in these efforts.

The Call to Action

Miller and Xie's (2020) paper represents what is undoubtedly one of the most comprehensive analyses to date of how our health systems are contributing to and implicated in broader environmental and climate concerns. With this paper and the accompanying commentaries, those in healthcare leadership can no longer ignore the issues of climate change and environmental degradation. It is not enough simply to acknowledge they exist at a more remote macro scale, beyond the health sector. We cannot shrug our shoulders or be complacent about what it is we have to do to play our part in improving environmental sustainability. The impressive contributions that make up this issue of Healthcare Papers mark the beginning of an understanding of these issues in relation to our health systems. And let us hope they also signal the beginning of a meaningful response.

So, please read on.

About the Author(s)

Neil Stuart, PhD, Adjunct Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON


Andermann, A., Y. Tcholakov, R. Tomatuk and S. Buchman. 2020. Creating an Environmentally Sustainable Health System Demands a Socially Accountable Approach in a Post-COVID World. Healthcare Papers 19(3): 61–6. doi:10.12927/hcpap.2020.26370.

Bodenheimer, T. and C. Sinsky. 2014. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Annals of Family Medicine 12(6): 573–76. doi:10.1370/afm.1713.

Born, K. and W. Levinson. 2020. Reframing Resource Stewardship and Sustainability as Professionalism: What Can Efforts for a Net-Zero Health System Learn from Choosing Wisely Campaigns? Healthcare Papers 19(3): 35–40. doi:10.12927/hcpap.2020.26375.

Cook, J., N. Oreskes, P.T. Doran, W.R.L. Anderegg, B. Verheggen, E.W. Maibach et al. 2016. Consensus on Consensus: A Synthesis of Consensus Estimates on Human-Caused Global Warming. Environmental Research Letters 11(4): 048002.

Duane, B. 2020. The UK National Health Service Is World Leader in Sustainable Healthcare: Recommendations for Canada. Healthcare Papers 19(3): 27–34. doi:10.12927/hcpap.2020.26376.

Eidelman, L. 2018, December 8. Why Doctors Need to Join the Fight against Climate Change. Fortune. Retrieved November 13, 2020. <>.

Grundy, Q., O. Krasik, N. Meleca, N. Mills, S. Nour and E. Whalen. 2020. Beyond Engagement: Realizing Nurses' Capacity to Lead Sustainable Health Systems. Healthcare Papers 19(3): 67–73. doi:10.12927/hcpap.2020.26369.

Hensher, M. 2020. Toward a Sustainable Health System: The Changing Economic Paradigm. Healthcare Papers 19(3): 47–52. doi:10.12927/hcpap.2020.26373.

Miller, F.A. and E. Xie. 2020. Toward a Sustainable Health System: A Call to Action. Healthcare Papers 19(3): 9–25. doi:10.12927/hcpap.2020.26377.

Morris, K. 2020. Making Practical Progress on Climate Change in Healthcare: Seizing Opportunities. Healthcare Papers 19(3): 41–6. doi:10.12927/hcpap.2020.26374.

Nason, E. 2020. Sustainable Health Systems: Who Will Answer the Call to Action, and How? Healthcare Papers 19(3): 57–60. doi:10.12927/hcpap.2020.26371.

Wabnitz, K.-J., S. Gabrysch, R. Guinto, A. Haines, M. Herrmann, C. Howard et al. 2020. A Pledge for Planetary Health to Unite Health Professionals in the Anthropocene [online first]. The Lancet. doi:10.1016/S0140-6736(20)32039-0.

Zelmer, J. 2020. Opportunities for Action toward a Sustainable Health System. Healthcare Papers 19(3): 53–6. doi:10.12927/hcpap.2020.26372.


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