How your asthma inhaler emits the same carbon as driving from Dublin to Achill

Rite & Reason: Healthcare systems are destroying the world while saving lives - that’s why we need to apply the principle of ‘first do no harm’

The Bible story of our origin tells of Adam and Eve. They were very happy, but were tempted by a serpent to break the rules. This catastrophically bad decision led to their expulsion from the garden of Eden.

Science’s version of our beginning is that early humans survived as hunter-gatherers. With our toolmaking abilities we were more than a match for other animals and were the primary driver of the extinction of many species. We developed technologies that appeared to make our disappearance from the planet very unlikely.

The “advances” that led to enormous increases in our population included farming and the mechanised exploitation of fossil fuels. However, buried within these apparent blessings were seeds of our own ruin. Environmental destruction has been hard-wired into almost every field of human activity, including that most apparently life-sustaining of endeavours: healthcare.

Surprisingly, the global healthcare industry has a larger carbon footprint than aviation.


If healthcare was a country, it would be the fifth-biggest carbon emitter in the world, estimated at two billion tons of carbon dioxide equivalent in 2014. It’s impossible to reconcile healthcare’s enormous greenhouse gas emissions with the consensus that the climate crisis is the largest threat to human health we have yet encountered.

Healthcare professionals are beginning to realise the contradiction between their main aim at work – which is improving the health and wellbeing of their patients – and the environmentally destructive effects of the way in which this is achieved. We administer treatments to individual patients but those treatments themselves harm the health of all by polluting the air we breathe and contaminating the water we drink.

Dr Jodi Sherman of Yale University’s Centre for Climate Change and Health has called for the ancient premise underlying medical intervention of “first do no harm” to be broadened to include consideration of the environmental impact of medical treatments.

A concrete example of the kind of healthcare we need to modify is the inhalers that are used to treat respiratory disease. In order to push drugs into patients’ lungs many inhalers use hydrofluorocarbon gases as propellants. Unfortunately, these hydrofluorocarbons are super-potent greenhouse gases.

One of the most commonly used inhalers in Ireland has an astounding carbon footprint of 28kg per inhaler. This means that using one of these inhalers contributes the same amount to global warming as the carbon dioxide released driving a small car with an internal combustion engine from Dublin to Achill Island (about 280km).

There’s a more environmentally friendly type of inhaler called a dry powder inhaler which doesn’t contain hydrofluorocarbon propellants. These have a carbon footprint per dose of just 10 per cent of each dose from the hydrofluorocarbon inhaler. A dry powder inhaler could suit the majority of patients but they simply aren’t prescribed for many of those for whom they would be appropriate.

Clinicians have a responsibility to administer treatments in the most sustainable manner possible. We hope that patients will also begin to ask the questions of midwives and family doctors that will enable them to receive greener therapies.

Anecdotally, there seems to be an enormous appetite to make the Irish healthcare system more environmentally friendly. The HSE recently launched its Climate Action Strategy 2023-2050. It has also begun to improve the energy efficiency of its buildings and aims for its built infrastructure to be carbon neutral by 2040. The strategy needs to receive the administrative and financial support it deserves.

Public and private providers must match the enthusiasm of their employees for greener practices to allow environmentally friendly systems to become embedded.

It seems logical to expect the statutory training bodies of groups such as physicians, nurses and pharmacists to be key in contributing to the changes required to make Irish healthcare more sustainable. If they do not educate and lead their members and graduates, then who will?

We urge training bodies and universities who are educating professionals for roles in healthcare to refine their programmes in a manner appropriate to and commensurate with the magnitude of the threat posed by climate change.

The expulsion of Adam and Eve from the garden of Eden isn’t just an account of our beginning, it’s a warning of a possible future. The best climate and environmental scientists in the world are hoarse from warning about the apocalypse we are enthusiastically engineering.

If we do not begin to respect the safe operating limits of the planetary systems that support all life by keeping our development within sustainable boundaries, then, just like Adam and Eve, we will cast ourselves out from this paradise we currently inhabit.

Our politicians must begin to govern as if life on earth depended on them, because it does. And we must vote and act as if everything was hanging in the balance, because it is.

Dr Ola Løkken Nordrum and Dr Dónall Ó Cróinín are members of the sustainability committee at the College of Anaesthesiologists of Ireland.