“It is the best of times, it is the worst of times, it is the age of wisdom, it is the age of foolishness.” [1]

I chose to begin with this ode to ‘A Tale of Two Cities’ owing to how eloquently its title works as an allegory to sustainability, especially in the context of healthcare.

Two cities, one in the present and one in the past.

One harbouring the developed nations, one the developing ones.

Two cities, distant yet not different.

Ghost of an unsustainable past: Whilst we boast of our improved mortality and morbidity and gloat about the strides made in academic medicine, we mustn’t forget that the progress as impressive as it might’ve been, hasn’t been innocent. Relentless animal testing without ethical boundaries [2], countless abhorrent human experiments that disproportionately target marginalized and vulnerable populations [3][4], and mismanaged disposal of medicinal waste which was instrumental in the propagation of disease and pollution [5] [6] are just some of the travesties on the backs of which we’ve built our healthcare system.

Ghost of the unsustainable present: And yet again, we return to our allegory, our two cities. One finds itself amidst over-consumption in the form of excessive testing, diagnostics, and imaging [7] in lieu of the classic history and examinations. Prescriptions here take precedence over palpation and percussions. The empathetic ears of physicians have been replaced by the cacophony of typed computer notes, whilst the global burden of their hospital waste is rivaled solely by the undulating electronic and moral burden. Not far off (geographically or otherwise) resides another population, which struggles to access even basic and potentially life-saving healthcare [8], whose mental wounds are admonished in lieu of somebody else’s physical ones, whose lack of healthcare insurance results in a lack of healthcare assurance, the city denied healthcare simply because its people were born into systematic and inescapable poverty. Writing this as a citizen of a third-world country, the irony isn’t lost on me that whilst I have the privilege of advocating for agency and sustainability, someone in a hospital close by is dying due to postpartum hemorrhage, dying because a few units of blood couldn’t be arranged.

People suffer in these two cities, some are resistant to all existing antibiotics owing to past overzealous prescriptions [9] whilst some can’t afford any at all. Some develop ailments due to unnecessary radiation whilst the lung mass in some isn’t even X-rayed. Some get disfigured because of botched procedures, others because they couldn’t access anti-leprosy medication. Some continue to produce and unethically dispose of sharps and other hospital waste, whilst some wait weeks in line for vaccination and iron tablets. Somewhere within the rich and famous hoarding Ozempic injections and the child with Diabetic Ketoacidosis whose family cannot afford insulin injections, lies the nuance, spectrum, and state of sustainable healthcare.

Ubiquitous as it may be, the discourse surrounding sustainability must address those who are especially aggrieved. These include women [10], who are more likely to suffer from chronic illnesses [11], more likely to be the caregivers of those with communicable diseases, and yet less likely to be the cohort that is the focus of healthcare research and policy building. It must also be stressed that it is usually the people occupying the fringes of society, the ones subjected to perpetual physical and moral injury, the population for whom healthcare should be a solace, who are failed by healthcare’s historic inability to accommodate them. These include people with mobility and intellectual disabilities, transgender/non-binary people, those who are neurodivergent, indigenous people, refugees, prisoners of war, and those battling chronic illnesses, amongst others. [12].

The Ghosts of the unsustainable future: The harsh truth about sustainability and healthcare as it pertains to the future is unfortunately, we might not have one. Amidst the climate change crisis, the obscene amounts of biomedical waste being produced, the inequitable healthcare systems, and the dubious collective conscientiousness, talking about the future of sustainable healthcare is a futile exercise if it is based solely on jargon and literature. What is required in its stead is a personal, professional as well as collective undertaking of responsibility, armed with strictly enforced legislative reforms and legal ramifications. Incentivizing sustainable practices, making educational and awareness groups, and effective use of technology might be great undertakings but the onus should be put on equitable [13] and patient-centered healthcare. We must come together to advocate for and alongside our present patients so we can serve future ones, all whilst learning from those we’ve cherished to have known in the past.

In conclusion,

It is the best of times, it is the worst of times but we must remember as we tread, to sustain this path for those who shall tread it after our time.