Health care in the United States — the largest industry in the world’s largest economy — is notoriously cost inefficient, consuming substantially more money per capita to deliver far inferior outcomes relative to peer nations. What is less widely recognized is that the health care industry is also remarkably energy inefficient. In an era of tightening connections between environmental destruction and disease, this widely neglected reality is a major cause behind many of the sicknesses our hospitals treat and the poor health outcomes they oversee.
The average energy intensity of U.S. hospitals is more than twice that of European hospitals, with no comparable quality advantage. In recent years, less than 2 percent of hospitals were certified as energy efficient by the U.S. Environmental Protection Agency’s Energy Star program, and only 0.6 percent, or 37 in total, have been certified for 2023. As a result, in 2018, the U.S. health care industry emitted approximately 610 million tons of greenhouse gases, or GHGs — the equivalent of burning 619 billion pounds of coal. This represented 8.5 percent of U.S. GHG emissions that year, and about 25 percent of global health care emissions.
If U.S. health care were its own country, it would rank 11th worldwide in GHG pollution. If every nation produced an equivalent per capita volume of health care emissions, it would immediately consume nearly the entire global carbon budget required to limit global warming to 1.5 degrees Celsius (2.7 degrees Fahrenheit) by 2030. Without even considering their global impact, air pollution from U.S. emissions accounts for an estimated 77,000 excess deaths annually in the U.S. alone. And according to one 2016 study, emissions from the U.S. health care system lead to the loss of more than 400,000 years of healthy life among Americans. This level of harm is commensurate with the tens of thousands of deaths attributable to medical errors each year, around which a massive patient safety movement has been organized in response. But despite these human costs — along with sizable financial costs — there has been no parallel policy movement to address the health care industry’s role in undermining health through its GHG emissions.
The climate crisis is not just another problem among many. It is instead a meta-problem that layers onto countless other problems, exacerbating their consequences for health. Research suggests that particulate matter resulting from burning fossil fuels can damage every organ in the human body. In light of this, efforts to improve public health, health care quality, and patient safety without confronting the role of emissions are, at best, compromised once one accounts for the health care industry’s substantial contribution to a climate crisis that is driving an ongoing and accelerating sixth mass extinction.
In addition to the general disaster this presents for global public health, it also constitutes a specific problem for U.S. health policy, as the health harms associated with GHG emissions disproportionately harm the populations who constitute Medicare and Medicaid’s roughly 145 million beneficiaries, including the 30 million patients treated at community-based Federally Qualified Health Centers. These care systems are meant to protect poor and vulnerable populations, but the means by which they attempt to do so are causing the very harm they seek to address. Consistent with what Ivan Illich described in his 1975 book “Medical Nemesis: The Expropriation of Health” as cultural iatrogenesis — a phenomenon by which the supposed means of treating disease under capitalist health care regimes becomes not a cure but rather a cause of the debility it claims to alleviate — what we are seeing now is a form of environmental iatrogenesis.
Largely because of fossil fuel combustion, nearly the entire global population now breathes air that exceeds the World Health Organization’s air quality limits, but exposure to unhealthy air and associated health risks are not evenly distributed. In the U.S., Medicare beneficiaries, who are 65 and older and far more likely to suffer chronic lung disease, are particularly threatened by bad air quality. This is inseparable from the fact that fossil fuel-related air pollution, the leading environmental cause of human mortality, accounts for 58 percent of excess annual U.S. deaths, which joins 8.7 million — or one in five, prior to Covid-19 — excess deaths globally, according to a 2021 study.
Beyond breathing polluted air, Medicare seniors, already compromised by higher incidence of comorbidities, are also at greater risk of serious outcomes from climate-related arthropod-borne, food-borne, and water-borne diseases. The climate crisis can exacerbate the spread of over half of known human pathogens. And risk from extreme heat is especially severe: Globally, over the past 20 years, heat-related mortality among seniors has increased by over 50 percent.
Children, 46 percent of whom are Medicaid beneficiaries, are also especially vulnerable. Fine inhalable particles resulting from burning hydrocarbons, called PM 2.5 (particles 2.5 micrometers or less in diameter), are particularly harmful because children breathe more air than adults relative to their body weight, giving these particles more opportunity to diffuse into their bloodstreams and throughout their bodies. Research published last year found that climate-related adverse health effects to fetuses, infants, and children include low birth weight, death, hypertension, kidney and lung disease, immune-system dysregulation, structural and functional changes to the brain, and a constellation of behavioral and mental health diagnoses. Furthermore, evidence published by UNICEF in 2016 indicates that air polluted by fossil fuels contributes to more than half of the 1 million annual pneumonia deaths worldwide among children aged five and younger.
With respect to racialized and economically dispossessed groups, a study published in 2021 found that racial and ethnic minorities, regardless of income and geographic location, are disproportionately exposed to higher levels of 11 of 14 sources of particulate air pollution. In a United Nations report titled “Climate change and poverty,” Philip Alston concluded that governments “have failed to seriously address climate change for decades,” and that “climate change threatens to undo the last 50 years of progress in development, global health and poverty reduction.”
The health care industry’s environmental disregard can be explained in part by what three bioethicists recently termed “lifeboat ethics framing.” In their book “Bioethics Reenvisioned: A Path toward Health Justice,” Nancy King, Gail Henderson, and Larry Churchill argue that bioethics has operated in a way such that any problem outside the lifeboat — that is, beyond the hospital bedside — is dismissed as irrelevant.
U.S. health officials have often exhibited the same narrow, clinically focused tunnel vision when it comes to health care emissions and the climate crisis. Public health’s widespread takeover by narrow medical mentalities that sideline root-cause analyses and associated policy action is now one of the most pernicious threats to health.
To add insult to injury, it is in the health care industry’s financial interests to decarbonize. New solar and wind energy are now the most affordable source of generating electricity in 96 percent of the world and cheaper than existing fossil fuels in 60 percent of the world. It is more expensive to continue to operate 99 percent of U.S. coal-fired power plants than to build and operate entirely new solar or wind energy generating stations.
Today, it is cheaper to save the climate than continue to destroy it. But federal policymakers and health care leaders continue to allow the industry to contribute to the climate crisis, which in turn is harming or killing those who are the most vulnerable. And if not stopped, GHG emissions could irreversibly undermine the possibility of health for all. Health care institutions should take a leading role in implementing immediate change to their own energy-use practices. As a core part of their ethical obligation to care, they should also use their enormous lobbying power to demand broader policy action to stop the environmental destruction to which they have been world-leading contributors.
David Introcaso, Ph.D., is a health care research and policy consultant.
Eric Reinhart, M.D., is a political anthropologist of law and public health.