Potential for industrial ecology to support healthcare sustainability: Scoping review of a fragmented literature and conceptual framework for future research

Healthcare is a critical service sector with a sizable environmental footprint from both direct activities and the indirect emissions of related products and infrastructure. As in all other sectors, the “inside-out” environmental impacts of healthcare (e.g., from greenhouse gas emissions, smog-forming emissions, and acidifying emissions) are harmful to public health. The environmental footprint of healthcare is subject to upward pressure from several factors, including the expansion of healthcare services in developing economies, global population growth, and aging demographics. These factors are compounded by the deployment of increasingly sophisticated medical procedures, equipment, and technologies that are energy- and resource-intensive. From an “outside-in” perspective, on the other hand, healthcare systems are increasingly susceptible to the effects of climate change, limited resource access, and other external influences. We conducted a comprehensive scoping review of the existing literature on environmental issues and other sustainability aspects in healthcare, based on a representative sample from over 1,700 articles published between 1987 and 2017. To guide our review of this fragmented literature, and to build a conceptual foundation for future research, we developed an industrial ecology framework for healthcare sustainability. Our framework conceptualizes the healthcare sector as comprising “foreground systems” of healthcare service delivery that are dependent on “background product systems.” By mapping the existing literature onto our framework, we highlight largely untapped opportunities for the industrial ecology community to use “top-down” and “bottom-up” approaches to build an evidence base for healthcare sustainability.