From the Editor
Oct 2022

Why Health Care Needs Sustainable Waste Stream Management

Natasha Sood, MPH and Gaurab Basu, MD, MPH
AMA J Ethics. 2022;24(10):E915-918. doi: 10.1001/amajethics.2022.915.


Health Care Is a Major Polluter

Over the past 3 to 4 decades, evidence of climate change’s adverse influence on health has amassed.1,2 Climate change is fueled by burning fossil fuels, resulting in unprecedented, threatening atmospheric CO2 concentrations.2 The US health care sector is a significant contributor to global greenhouse gas (GHG) emissions, and, if it were its own country, it would be the 13th largest GHG emitter on the planet and the second largest industry contributing to landfill waste.3,4,5,6,7 In 2018 alone, pollution output from US health systems translated to a loss of 388 000 disability-adjusted life years.8 Health care not only contributes directly and indirectly to climate change, but also adversely influences communities’ health through solid, liquid, and gas emissions.

Our Fractured Relationship With Nature

Our health systems and economies are built on the assumption of infinite natural resources and the continued existence of healthy ecosystems, which are critical to human health. Investing in evidence-based solutions to reduce health care systems’ waste can safeguard the health of our planet now and in the future. The urgency to do this has never been clearer. The 2019 Intergovernmental Panel on Climate Change special report highlighted the need to make significant cuts in GHG—45% by 2030—in order to prevent temperature exceeding 1.5 oC above preindustrial levels.2,9 Yet the Earth’s surface has already warmed 1.1 oC relative to preindustrial levels.10 Although the margin of error is slim, we have the solutions needed to prevent irreversible warming and cut emissions and solid waste production significantly; the health sector must do its part.9 This issue of the AMA Journal of Ethics emphasizes that solutions needed to achieve a health system that is low waste and net-zero (ie, one in which GHG emissions released into and removed from the atmosphere are balanced) align with global sustainability targets and would incentivize fiscal and environmental stewardship.9,11

Health Care Must Do No Harm

When health professionals pledge to “do no harm” to patients, they seem to do so at the expense of local communities and the planet. Health professionals share ethical obligations to critically examine the sector’s carbon footprint, divest from fossil fuels, and reduce solid waste production by investing in climate-smart health care. Given changing climate, health professionals must renew their commitment and redefine what it means to do no harm.

Given the adverse health consequences of pollution and waste, the health care sector should be the one to lead the way toward a sustainable economy; by framing waste reduction as a health issue, it is well poised to provide a shared language and universally agreed-upon values.12 Sustainable health systems advance public health, promote equity, and respect planetary boundaries13 by restructuring supply chains to reduce dependence on single-use, disposable health care items and by transitioning to a clean energy health care grid.12,14

The decision-making body of the United Nations Framework Convention on Climate Change—the Conference of the Parties (COP)—ended its 2021 conference (COP26) with small but significant commitments to health care sustainability.12 While commitments to addressing the health impacts of climate change were not robust, for the first time in the history of the conference, climate-health issues had a large presence at the summit.12 COP26 paved the way for 50 countries to commit to developing low waste, low-carbon health systems.15 Furthermore, the US Department of Health and Human Services committed to reducing emissions at federal health facilities,16 and 19 private US health systems committed to reducing GHG emissions.16 We await meaningful action, but strides taken to include health system sustainability commitments at COP26 express growing understanding of the interdependence and interconnectedness of natural resource stewardship and successful, long-term health care.12

Environmental Injustice

Climate change exacerbates social inequity, disproportionately affecting marginalized and socioeconomically disadvantaged populations; its burdens fall heavily on the shoulders of Black, Indigenous, and people of color (BIPOC) around the world.17 These communities contribute least to the pollution and waste that fuel the climate crisis yet suffer disproportionately from increased rates of cardiorespiratory illness, mental health disorders, adverse birth outcomes, and toxic exposures as a result of it.1,2

The health care industry should consider its role in contributing to—and address—the unequal impact of waste on BIPOC communities, which is rooted in a history of environmental and systemic racism. Despite BIPOC communities’ efforts to address health consequences of environmental degradation during the US civil rights movement of the 1960s, the racial composition of communities continues to be the number one indicator of where toxic waste facilities, landfills, and waste processing centers are located in the United States.17 While policies to combat waste and pollution are slowly being implemented, minoritized communities are the last to benefit, and inequity persists.18,19

This Theme Issue

We can reimagine a world in which we do not have to practice medicine at the expense of the planetary resources that sustain us. This issue articulates why building a health care system centered on sustainability, resource stewardship, low waste, and zero-emissions is one that invests in cost savings, resilience, expanded capacity, and equity. The contributors redefine what waste in health care means and reflect on public health values at the heart of a sustainable health care system that prioritize preventative medicine.12 As the contributors illuminate, health systems must fully transform to meet sustainability standards and to uphold the commitment to safeguarding the health of patients, and must do so with an urgent sense of duty to future generations.11

Will the health sector rise to the occasion? This theme issue considers how to redesign our unsustainable health system to be one that delivers care not at the expense of future generations and our planet but for them. It explores how to use existing technologies to create a system well poised to adapt to the challenges that lie before us; discusses how a sustainable health system builds a resilient health care workforce and addresses environmental injustice; and investigates which entities bear ultimate responsibility for waste generated and consequent harms to patients and communities. Finally, the contributors outline mechanisms by which health systems science can prepare clinicians to become change agents, innovators, and sources of hope for a low-waste, net-zero health care system.


  1. Romanello M, McGushin A, Di Napoli C, et al. The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future. Lancet. 2021;398(10311):1619-1662.
  2. Shukla PR, Skea J, Calvo Buendia E, et al, eds. Climate Change and Land: An IPCC Special Report on Climate Change, Desertification, Land Degradation, Sustainable Land Management, Food Security, and Greenhouse Gas Fluxes in Terrestrial Ecosystems. Intergovernmental Panel on Climate Change; 2019. Accessed August 19, 2022.

  3. Eckelman MJ, Sherman J. Environmental impacts of the US health care system and effects on public health. PLoS One. 2016;11(6):e0157014.

  4. Eckelman MJ, Sherman JD. Estimated global disease burden from US health care sector greenhouse gas emissions. Am J Public Health. 2018;108(suppl 2):S120-S122.
  5. Stall NM, Kagoma YK, Bondy JN, Naudie D. Surgical waste audit of 5 total knee arthroplasties. Can J Surg. 2013;56(2):97-102.
  6. Hsu S, Thiel CL, Mello MJ, Slutzman JE. Dumpster diving in the emergency department. West J Emerg Med. 2020;21(5):1211-1217.
  7. Climate change, health, and health care: how physicians can help. Health Care Without Harm. Accessed March 15, 2020.

  8. Eckelman MJ, Huang K, Lagasse R, Senay E, Dubrow R, Sherman JD. Health care pollution and public health damage in the United States: an update. Health Aff (Millwood). 2020;39(12):2071-2079.
  9. Redvers N. Patient-planetary health co-benefit prescribing: emerging considerations for health policy and health professional practice. Front Public Health. 2021;9:678545.

  10. Tollefson J. IPCC climate report: earth is warmer than it’s been in 125,000 years. Nature. 2021;596(7871):171-172.
  11. MacNeill AJ, McGain F, Sherman JD. Planetary health care: a framework for sustainable health systems. Lancet Planet Health. 2021;5(2):e66-e68.
  12. Issa R, Krzanowski J. Finding hope in COP26. BMJ. 2021;375(2940):n2940.

  13. Steffen W, Richardson K, Rockström J, et al. Planetary boundaries: guiding human development on a changing planet. Science. 2015;347(6223):1259855.

  14. Meyer M. Health system sustainability centers: a remedy for climate catastrophe. Health Affairs Forefront. November 3, 2021. Accessed June 28, 2022.

  15. Countries commit to develop climate-smart health care at COP26 UN climate conference. Heath Care Without Harm Global. November 9, 2021. Accessed June 28, 2022.

  16. Choi-Schagrin W. More than 40 nations pledge to cut emissions from their health industries. New York Times. November 8, 2021. Accessed June 28, 2022.

  17. Environmental justice timeline. US Environmental Protection Agency. Updated August 3, 2021. Accessed June 28, 2022.

  18. Basu G. Want to prevent the next pandemic? This doctor is prescribing climate action. Grist. May 12, 2020. Accessed June 28, 2022.

  19. Environmental and climate justice. National Association for the Advancement of Colored People. Accessed June 28, 2022.

Editor's Note

Background image by Ryoko Hamaguchi.


AMA J Ethics. 2022;24(10):E915-918.



Conflict of Interest Disclosure

The author(s) had no conflicts of interest to disclose.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.