The environmental footprint of health care: a global assessment (2020 Jul) 

Lenzen M, Malik A, Li M, Fry J, Weisz H, Pichler PP, et al. The environmental footprint of health care: a global assessment. Lancet Planet Health. 2020 Jul;4(7):e271-e9.

Open access link to article:

Relevant to: 

Dietitians-Nutritionists working in a health care setting. 


The authors analyzed input-output data from 189 countries between 2000-2015 to provide a global assessment of wide-ranging environmental impacts of the health care sector. They measured seven environmental indicators, including: greenhouse gas emissions, particulate matter, air pollutants (nitrogen oxides and sulphur dioxide), malaria risk, nitrogen loss to water, and water use.

Bottom line for nutrition practice: 

Depending on the indicator measured, health care contributes between 1% – 5% of total global environmental impacts. See “of additional interest” for details under four categories of actions that can be taken to mitigate harm to the environment while adding social value to the community.


Background: Health-care services are necessary for sustaining and improving human wellbeing, yet they have an environmental footprint that contributes to environment-related threats to human health. Previous studies have quantified the carbon emissions resulting from health care at a global level. We aimed to provide a global assessment of the wide-ranging environmental impacts of this sector. 

Methods: In this multiregional input-output analysis, we evaluated the contribution of health-care sectors in driving environmental damage that in turn puts human health at risk. Using a global supply-chain database containing detailed information on health-care sectors, we quantified the direct and indirect supply-chain environmental damage driven by the demand for health care. We focused on seven environmental stressors with known adverse feedback cycles: greenhouse gas emissions, particulate matter, air pollutants (nitrogen oxides and sulphur dioxide), malaria risk, reactive nitrogen in water, and scarce water use. 

Findings: Health care causes global environmental impacts that, depending on which indicator is considered, range between 1% and 5% of total global impacts, and are more than 5% for some national impacts. 

Interpretation: Enhancing health-care expenditure to mitigate negative health effects of environmental damage is often promoted by health-care practitioners. However, global supply chains that feed into the enhanced activity of health-care sectors in turn initiate adverse feedback cycles by increasing the environmental impact of health care, thus counteracting the mission of health care. 

Details of results: 

Improvements occurred in energy, material, and water consumption as well as greenhouse gas emissions and pollutants between 2002-2015. However, environmental impacts still increased, mostly as a result of a doubling of global health care expenditures.

In 2015, the health care sector contributed 4.4% of greenhouse gases, 2.8% of particulate matter, 3.4% of nitrogen oxides, and 3.6% of sulphur dioxides to global emissions and pollutants. Much of these result from direct impacts of health care (e.g., through patient transport or space and water heating). Impacts related to malaria risk, nitrogen, and water use are indirect, as they enter mostly through supply chains originating from agriculture and forestry. The authors note that water scarcity can limit access to clean water and lead to cholera, diarrhoea, and typhoid fever. Deforestation is a key factor in creating ecological conditions to support the malaria and other disease vectors. Increasing disease increases the need for health care provision, which in turn increases both health care costs and the environmental impact of health care.

The findings highlight differences in health care challenges between high and low income countries. In many low income countries healthcare provision is inadequate and their health care expenditure and healthcare environment footprints are small; however, within this low expenditure, the environmental intensity of health expenditure is often high. The authors note that in these countries, improving the technological efficiency of basic systems of energy, buildings and transport would lead to improvements in health care and environmental impacts.

On the other hand, high income countries are associated with higher environmentally efficiency but higher health care expenditures and wasteful practices. The authors suggest that interventions in these countries should centre on reducing waste (“unnecessary plastics, single use items, drugs, journeys and interventions more generally”) p.e278. They also note that decreasing greenhouse gas emissions is equally important.

The authors also emphasize that health care can bring social benefits to communities as well as reducing environmental impacts; related actions are outlined under “additional information”.

Finally, they note that progress needs to be made in terms of monitoring and recording a triple bottom line which includes: social and health care outcomes (including equity); financial savings and environmental impacts.

The authors outline limitations to their study including: incomplete data, inability to project to the future, and concerns related to aggregation of data.

Of additional interest: 

Panel 1: Practical actions that health care organisations can take in mitigating environmental emergency through adding “social value” to the community it serves (reproduced from Supplemental appendix, p. 70)


  • Buy only from suppliers of goods and services that have a plan to address their environmental responsibilities quantifiably
  • Increase renewable energy use (and on-site generation) towards 100%
  • Monitor ethical and low carbon total supply chains


  • Engage staff (and their ideas/commitment) both as employees (a “duty of care”) and as citizens •Health services are often the biggest single employer in any community and the size, distribution and representativeness of the workforce’s behaviour can have a significant normalising and exemplary effect

Protecting resources and natural assets

  • Health services are significant owners and custodians of land
  • Health can be protected and improved, not just through harm reduction but also by protecting and improving biodiversity, tree planting and clean energy generation on health services estate

Incentivising, normalising, and exemplifying climate-safe and healthy models of care

  • Engage, support, and empower the public in their own health, illness and care, particularly using Information and Communication technologies
  • Industrialise prevention: “If preventable, why not prevented”
  • Move most care upstream (“Every unplanned admission to a health care facility is a sign of system failure until proved otherwise”) ensuring the primary locus of care is the home, then primary care, etc. Only do in hospitals what can only be done in hospitals
  • Prioritise community actions (in partnership) that: a) deliver multiple health benefits (diet, physical activity, social cohesion/equity) and b) save resources
  • Reward health outcomes not just health care activity to incentivise illness prevention

Editor’s comment:  

  • The authors included primary, secondary and tertiary food related sectors in the study. Given the high environmental footprint of food systems, it is surprising that this did not push the health care impact higher.
  • It was helpful to see a study that includes aspects not generally considered in food systems assessments (e.g., the health consequences of water scarcity and deforestation).

Conflict of interest/ Funding:  

  • Funding from: Australian Research Council, National eResearch Collaboration Tools and Resources project. The authors declare no competing interests.

External relevant links:  

See also on this ICDA SFS Toolkit website:

Corresponding author: 

Dr. Arunima Malik, Senior Lecturer, The University of Sydney,

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