The climate crisis requires decarbonisation across all major emission sectors, including healthcare, which contributes 4–5% of global emissions due to its complex supply chains, high energy use, and waste. Ninety-three countries have committed under a WHO initiative to develop environmentally responsible health systems. Addressing healthcare emissions needs a multi-faceted effort involving manufacturers adopting low-carbon materials and eco-friendly production, while clinicians must advocate for sustainable procurement, adopt efficient practices, and support waste reduction.
Advances in critical care have improved ICU outcomes through advanced technology, protocols, and strict infection control (IC). However, ICUs are highly resource-intensive, producing nearly three times the emissions of general wards. Major emission sources include disposable gloves, masks, gowns, linen, syringes, packaging, and IV medications. Many IC practices are driven by industry or precautionary guidelines rather than solid evidence, creating sustainability challenges such as balancing infection control with environmental impact, managing pharmaceutical waste safely, aligning regulations with sustainability, and reducing energy use without harming care quality. This complexity highlights the urgent need to evaluate current practices and their effects on clinical outcomes.
Low- and middle-income countries (LMICs) have traditionally modelled their healthcare systems after high-income countries (HICs). However, LMICs often have a larger carbon footprint per dollar spent due to greater reliance on fossil fuels, inefficient supply chains, and higher spending on carbon-intensive pharmaceuticals and devices. With over 85% of the global population in LMICs and expanding healthcare coverage, scaling up ICU care based on resource-heavy HIC models could have significant environmental consequences.
LMICs present a valuable opportunity for developing “Green” ICUs, as their resource constraints have led to leaner, potentially more environmentally sustainable care models. Healthcare systems in resource-limited settings often use innovative methods to reduce consumption and waste, such as reusable metal instruments and cloth gowns instead of disposables, and boiling for sterilisation instead of energy-heavy autoclaving. They also extend the use of disposable PPE across multiple non-sterile tasks and safely reuse single-use items through controlled programmes like the RUSUI at Aga Khan University. These practices differ from high-income country norms and suggest potential for developing a balanced, context-appropriate approach that is less resource-intensive than HIC standards but safer than current LMIC methods.
Innovative LMIC healthcare practices include: Aravind Eye Care’s high-volume cataract surgeries producing only 5% of HIC waste; Ghori Tuberculosis Clinic’s passive ventilation design minimising energy use; Aga Khan University’s Tele-ICU programme using low-bandwidth tools like phone and WhatsApp to provide effective remote care; locally made cardboard neonatal incubators reducing plastic and electronics; and a low-cost portable resuscitation device as a ventilator alternative with lower emissions. These solutions effectively meet clinical needs with much less environmental impact but remain under-researched, under-publicised, and rarely included in global ICU guidelines.
Sustainability efforts in global health have mostly flowed from high-income to low-income contexts, but the reverse holds significant potential. Bidirectional partnerships are needed to adapt low-resource innovations across settings. High-income institutions offer research expertise and funding, while LMICs provide real-world, resource-efficient practices and flexible regulations. Programmes like WHO’s African Partnerships for Patient Safety show the benefits of shared learning. Strong LMIC partners, such as the Aga Khan Development Network with its WHO-endorsed Carbon Management Tool, are crucial for identifying and monitoring decarbonisation opportunities in ICU-related areas like procurement, medical gas use, and waste management.
Dedicated research is essential to evaluate ICU practices that balance clinical effectiveness with environmental sustainability. This requires structured studies like randomised trials, implementation science, and health systems research to assess clinical and environmental trade-offs. De-implementation frameworks aimed at reducing ineffective or excessive practices can also guide these efforts. Potential focus areas for such research are outlined in international “Green ICU” agendas.
Modern ICUs aiming to balance clinical excellence with environmental responsibility should recognise that valuable innovations often come from resource-constrained healthcare settings, not just high-tech labs. By appreciating insights from diverse contexts, fostering collaborative research, and encouraging mutual learning, the global critical care community can develop ICU models that are effective, equitable, and sustainable.
Source: Intensive Care Medicine
Image Credit: iStock
References:
Dogar SA, Kugele M, Latif A (2025) Rethinking environmental sustainability in intensive care medicine: a call for global collaboration for mutual learning. Intensive Care Med.
