The different definitions of “sustainable” health system – US and Europe

I was curious when I got back from CleanMed Europe (see my series of posts here) about what American scholars say when they talk about a “sustainable health care system,” because what I heard in Oxford seemed so different from what I am used to. (see: CleanMed Europe LastDay: “Sustainable health system” definition : different here | Ted Eytan, MD)

So, I pulled these two articles to see the differences.

And there are pretty big differences.

In the American article, written by Harvey Fineberg, M.D., Ph.D, and published in the New England Journal of Medicine (@nejm), the attributes mentioned are

  • affordability
  • acceptability
  • adaptability

…and adaptability is not mentioned in the context of a changing environment or external forces. Climate change or carbon emissions aren’t mentioned at all.

because health and health care needs are not static (i.e., a health system must respond adaptively to new diseases, changing demographics, scientific discoveries, and dynamic technologies in order to remain viable).

In the European article, written by Dr. Frances Mortimer and published in Clinical Medicine (Royal College of Physicians), the attributes are

  • better at preventing illness
  • give greater responsibility to patients in managing their health
  • be leaner in service design and delivery
  • use the lowest carbon technologies


  • Money is mentioned a lot in the Fineberg article. Carbon isn’t mentioned once, nor is environmental stewardship.
  • Money isn’t really mentioned in the Mortimer article at all. If it is, is is in the currency of environmental impact globally

As she (Frances) states:

In the near future, environmental cost effectiveness will become as important as financial cost effectiveness in medical care.

The Fineberg article feels more “health care system” focused – the recommendations surround improving the quality of medical care

The Mortimer article feels more “health” focused – that health care is a means, not an end:

The public funding of medical care inevitably diverts resources from health-sustaining investment in education, social welfare and housing. In return, health services are asked to demonstrate a measure of cost effectiveness. The provision of medical care, however, incurs not just financial costs, but also significant environmental ones, in the form of greenhouse gas emissions, pollution of air and water, changes to land use, and so on. This could be viewed as spending eco- logical capital, which is equally essential to population health.

This leads me to believe, that in this country, we are just beginning to understand all of the determinants of health, and the role of our amazing health system in impacting change, far beyond our medical offices or hospitals.

Or as Gary Cohen famously said as he was being celebrated at The White House:

“What is health care here for?”

(see: What health care is here for: White House Champion of Change Gary Cohen | Ted Eytan, MD)

I am so happy to have the opportunity, with Kaiser Permanente and leading experts, to facilitate a first-ever tweet chat on climate change in health care. November 12, 2013, 2:00 pm. Hashtag: #GreenHealthChat.

I think health care is here to help society be sustainable, not just medical care. There, I said it 🙂

Ted Eytan, MD