Practise as you preach: climate stewardship in healthcare integrating top-down and bottom-up approaches with clinician as positive role models for the community

The conference of the parties under the auspices of the United Nations framework convention on climate change has declared global warming and climate emergencies as a threat to planetary health and life since its inaugural meeting in 1995,¹ with each meeting having to deal with worsening threats of global climate change.

Climate change is in crisis mode, imposing significant existential risk for healthcare systems as well as the long-term environmental sustainability of healthcare systems.² Healthcare systems, including hospitals, have a significant impact on the ecology of the planet. Hospitals and laboratories are responsible for between 4.4% and 4.6% of total worldwide carbon emission.³ Healthcare professionals should be involved at all levels of the response to climate change to help deliver evidence-based responses to climate change health challenges across community and hospital-based settings. Urgent actions and proactive attitudes taken in the healthcare setting act as important drivers of innovation leading to more resilient healthcare systems.

As significant contributors to greenhouse gas emissions and resource consumption, healthcare practitioners are well positioned to try to reduce the adverse impact of a carbon-intensive healthcare practice on climate change.⁴ Climate change is escalating demand for health care in community practice, emergency departments, outpatient clinics, hospitals and disaster response units. Rising global average temperatures and increased intensity of extreme weather events worsen symptoms across mental health, heat stress, respiratory, cardiovascular and neurological disorders including asthma, coronary artery disease, chronic neurological disease, reproductive and climate change anxiety.^5-8

Rather than a one-size-fits-all approach, there is a need for climate stewardship that is able to accommodate a wide range of interests and advocacy, incorporating the involvement of a broad range of healthcare professionals across a diversity of healthcare settings.

How healthcare practitioners deal with the impact of climate change within current healthcare frameworks impacts the health of future generations and health system adaptability and resilience. As high levels of respect and trust are bestowed on healthcare practitioners by Australian and UK society,^{9, 10} medical practitioners are well-positioned to advocate for, and influence, changes in climate change policy across healthcare settings. The attitudes and actions of healthcare professionals and modelling these to patients who still respect doctors and nurses could benefit from pro-active climate change stewardship. There is an urgent need to go beyond environmental stewardship¹¹ to our proposed new interdisciplinary framework around climate stewardship.

Given the significant carbon footprint of the healthcare sector,³ how do we prepare and insulate healthcare systems against climate change harms? Key lessons can be extrapolated from antimicrobial stewardship (AMS) to a climate setting. AMS is a broad framework to enhance the safe and appropriate use of antimicrobial agents, thereby reducing patient harm and containing antimicrobial resistance.¹²

The use of antibiotics transformed many areas of medicine, which meant that it was more likely that clinicians were successfully able to treat infections. AMS also facilitated the development of new immune tolerance agents, leading to organ transplants. A high point was the reduction of antibiotic misuse that led to widespread microbial resistance, posing a serious risk to public health.

Similar to microbial risks that led to AMS, climate change continues to lead to a range of challenges across all areas of health, which will potentially impact the health of patients and healthcare practice. Regulatory actions as well as decisions related to the use of healthcare resources need monitoring. Putting in checks and balances to avoid wasteful use of healthcare resources requires high levels of collaboration and coordination between government, local hospital management and healthcare bodies.

The core elements of AMS are leadership, commitment, accountability, stewardship expertise, action, tracking, reporting and education. These themes could be applied to healthcare systems in the development and implementation of climate-friendly policies that will positively impact healthcare delivery at the same time minimising threats to communities.

There is an increasing commitment to developing an effective and sustainable approach to climate change with the release of the national health and climate strategy in 2023¹³ to support insulating and enhancing sustainable and resilient health systems. Implementing these recommendations will require new systems of accountability and feedback to track the roll-out, compliance and performance of policies and changes that improve long-term resilience of healthcare systems to withstand climate change and disasters.

Climate stewardship improves healthcare system accountability in responding to increased demand whilst minimising waste. Notably, a recent systematic review found a positive relationship between environmental stewardship programmes and the health and wellbeing of vulnerable indigenous and First Nations peoples.¹⁴

Being able to monitor, track and adapt to the impact of climate change across different healthcare settings will require a greater level of understanding and coordination of key performance indicators that address the context-dependent effects of climate change.^{15, 16} There is need for transparent benchmarking and reporting the impact of climate change as well as effectiveness of specific interventions that ensure the long-term sustainability and resilience of healthcare systems.¹⁷

There has been a position statement from the American Medical Association in relation to doctors’ roles in stewardship of healthcare resources,¹⁸ although further work needs to be done to define stewardship in relation to climate. Peer education is recognised by the United Nations Educational, Scientific and Cultural Organization (UNESCO) as central to addressing challenges posed by climate change to healthcare professionals. This is critical to mitigate acute and chronic health impacts posed by climate change across both the developed and developing world.^{19, 20}

Creating hospital-based interventions requires heightened collaboration between consumers and healthcare practitioners as well as taking into account indigenous knowledge systems to help curb rising global temperature and climate change. Integrating the diverse viewpoints of healthcare practitioner advocates under the auspices of stewardship umbrellas positively influences professional peer networks, which in turn influences patient lifestyle after discharge from hospital.²⁰ We have a duty of care to the planet, ourselves, our families and patients, as well as non-human life.

As healthcare professionals, talking about and acting on climate change is not going ‘outside’ our core clinical duties but is our responsibility for ourselves, colleagues and for patients and communities we care for. Developing a broad framework around climate stewardship relies on the best available evidence as well as integrating different advocacy perspectives. It isn't too late to think about practical measures and actions most likely to mitigate the adverse impact and human harm of rising temperatures and climate change across our ever more busy and congested healthcare systems.

Recent successes include less wasteful use of medical and surgical devices or equipment,²¹ more efficient anaesthetic consumable and gas use²² and virtual rather than in-person medical conferencing.²³ These are but three examples where AMS top-down directives have led to individualised advocacy and personal finetuning by doctors to adapt his/her clinical practice and role modelling to “bottom-up” on-the-ground recommendations tailored to their practice type, casemix and what is feasible on a routine workday. This is surely congruent with more sustainable hospitals and clinics so cherished by hospital management and kinder to our natural world.

With Cyclone Alfred bearing down on Brisbane as we furnish these final edits on the 5 March 2025, we reminded that battening down the hatches for this once-in-a-generation extreme weather event confers only temporary safety. Catastrophic weather events and disaster responses from rescue and healthcare workers are going to become the norm rather than the outlier in the gloom-laden future that is here now,²⁴ right on our doorstep.

Associate Professor Nina Lansbury is an environmental public health research and teaching academic at The University of Queensland and a former Lead Author on the Intergovernmental Panel on Climate Change (IPCC AR6 WG II).