For most of the past decade, sustainable health care meant one thing: cutting carbon. Hospitals chased lower energy bills. Pharmaceutical companies announced net-zero targets. Policymakers measured the sector by its emissions.Health careThat frame is too narrow now. Emissions matter, but they are one part of a larger problem that also runs through pharmaceutical waste, antimicrobial resistance (AMR), and supply chains that buckle under climate stress.The World Health Organization (WHO) estimates that health care accounts for up to 5% of global greenhouse gas emissions. If the sector were a country, it would be the fifth-largest emitter on the planet. On current trends, the WHO warns those emissions could triple by 2050. Yet emissions alone do not capture the damage. Pharmaceutical waste, environmental contamination, and climate disruptions to medicine supply are becoming just as consequential.For India this matters more than for most. The country is one of the world’s largest suppliers of generic medicines. Its pharmaceutical system sits at the centre of several global shifts at once: rising climate risk, a deepening AMR burden, and harder questions about environmental accountability.Much of health care’s environmental damage begins after the medicine leaves the factory. Across India, unused antibiotics and expired tablets are thrown into household bins or flushed into sewage. Almost none of it is tracked. That is a blind spot, and it is widening.A study of disposal practices in Odisha, published on PubMed Central, found that 82% of people threw expired medicines into the dustbin and only 2.6% returned them to a pharmacy. The pharmacies were little better. Most disposed of expired stock in ordinary waste. The system is built to get medicines to people. It pays almost no attention to what happens when those medicines go unused.AMR makes this far more dangerous. For years, resistance was framed as a problem of bad prescribing and patient misuse. Both still matter. But the environment is now a driver in its own right. When antibiotic residues reach rivers, soil, and wastewater, they create the exact conditions in which resistant bacteria thrive. Even trace concentrations apply selective pressure, letting resistant strains survive and spread.I have spent more than a decade working on AMR, and the environmental route is the one our policy conversation still underweights. India is already close to the edge on AMR. Preventing the conditions that accelerate it is now part of the fight. Responsible stewardship cannot stop at how a drug is made and prescribed. It has to cover how the drug is disposed of, how manufacturing effluent is treated, and how well the system keeps antibiotic residues out of water.Pharmaceutical supply chains were built for efficiency in stable conditions. The assumption was that plants, transport, and distribution would keep running in a predictable climate. That assumption is failing.India’s drug supply is heavily domestic and geographically concentrated, which leaves it exposed to heatwaves, floods, and erratic monsoons. Covid-19 showed how fast a single shock can expose a brittle supply chain. Climate disruption is making the same argument for redundancy and preparedness, only on a longer timeline.Policy is starting to catch up. In May 2025, the Central Drugs Standard Control Organisation issued detailed guidelines for disposing of expired and unused medicines, with separate pathways for anti-infectives, cytotoxic drugs, and controlled substances, and a requirement to return expired stock to suppliers within 30 days where possible. Kerala has gone further. Its nPROUD programme, the first state-level medicine take-back scheme in India, collects unused drugs from households and incinerates them under environmental controls. Internationally, the WHO and UNEP are pushing harder on wastewater management and pharmaceutical disposal.The thread running through all of this is simple. Health care sustainability has to cover the full life of a medicine, not just the smokestack at the plant. Production, distribution, use, disposal: Each stage leaks into the environment, and each one is now a stewardship question.The case is not purely environmental. Cleaner manufacturing, better effluent treatment, green chemistry, and take-back systems are becoming conditions of long-term competitiveness for Indian pharma, especially as export markets tighten their own standards.These were once separate conversations. They are converging into a single test: Can the system protect the environment, keep medicines working, and stay resilient under stress at the same time?India is well placed to lead here, and it should want to. It is both a vast health care market and a global manufacturing hub. Few countries have as much reason, or as much leverage, to show that access, resilience, and environmental responsibility can hold together.The question is no longer whether health care sustainability should go beyond carbon. It is how fast we move to build systems that treat climate resilience, pharmaceutical stewardship, and antimicrobial resistance as the same problem.(The views expressed are personal)This article is authored by Saransh Chaudhary, executive director, Venus Remedies Limited, and CEO, Venus Medicine Research Centre.