As carbon pricing and net-zero targets reshape health policy 1-3, rheumatology must confront its own contribution to greenhouse-gas emissions. Low-carbon models of care that preserve clinical benefit while managing costs are now a strategic priority for the specialty 4. The intricate relationship between climate change and systemic autoimmune rheumatic diseases—such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), psoriatic arthritis (PsA), and systemic sclerosis (SSc)—has become a central challenge for our field rather than a peripheral concern. The American College of Rheumatology highlights how climate-amplified environmental factors can trigger or worsen these conditions, creating a feedback loop in which a warming planet drives disease activity, increasing demand for resource-intensive care and further enlarging healthcare's carbon footprint 4. In this editorial, we focus on RA and selected systemic rheumatic diseases where links to environmental change and healthcare-related emissions are best described, and where low-carbon interventions are beginning to be quantified. For other rheumatic and musculoskeletal conditions—such as osteoarthritis, regional pain syndromes, and crystal arthropathies—the evidence base is more limited, and our proposed low-carbon strategies should be extrapolated cautiously and adapted to predominantly degenerative or mechanical conditions. Long-term exposure to fine particulate matter (PM2.5), largely generated by fossil-fuel combustion, is associated with a 1.3-fold increased risk of developing arthritis, including rheumatoid arthritis (RA) 5, in international cohorts. Environmental hazards amplified by climate change—such as heat and air pollution—already account for an estimated 25% of the global burden of disease 6. Increased heat vulnerability is linked to higher odds of recurrent hospitalizations and affects up to 18% of patients with systemic rheumatic conditions in some cohorts 7. In Taiwan, a nationwide cohort linking National Health Insurance data with air-quality monitoring reported a modestly increased risk of incident RA in people in the highest versus lowest PM2.5 exposure quartile (adjusted hazard ratio, aHR ≈ 1.053) 8. Systemic autoimmune rheumatic diseases, as prototypical chronic inflammatory diseases, require frequent outpatient visits for ongoing monitoring and treatment adjustment, creating a substantial cumulative travel burden that exemplifies how sustained rheumatology care itself generates avoidable transport-related emissions when not redesigned through a low-carbon lens 9. At the same time, our own practice contributes to the crisis. The global healthcare sector is responsible for an estimated 4.4%–5.2% of net greenhouse-gas emissions 1. Within rheumatology, a major contributor is the carbon-intensive supply chain for biologic therapies, whose annual carbon emissions can vary dramatically—for example, from about 1.1 kg CO2e for benralizumab to 188.9 kg CO2e for dupilumab (a 172-fold difference), depending on the specific agent and delivery model 10. Broader pharmaceutical life-cycle assessments (LCAs) and monoclonal antibody manufacturing studies similarly report large differences in cradle-to-gate between molecules and across alternative production scenarios, reinforcing that these figures should be treated as order-of-magnitude estimates rather than definitive product-level values and highlighting the need for rheumatology-specific, peer-reviewed LCAs 11, 12. To break this cycle, rheumatology must pursue a dual transformation: precision medicine and low-carbon care. Precision medicine—using the right drug, at the right time, for the right patient—aims to shorten ineffective treatment sequences and achieve low disease activity earlier, as shown in recent real-world and systematic treat-to-target (T2T) studies in systemic autoimmune rheumatic diseases. Achieving stricter, consistently applied targets is associated with better disease control and fewer flares, which can reasonably be expected to reduce downstream emergency visits and hospitalizations, the most carbon-intensive elements of care 13, 14. In the UK, effective disease control that prevents a single hospitalization can avoid an estimated 246–369 kg CO2e per patient per year 15, while switching an in-person consultation to telemedicine can save between 0.7 and 372 kg CO2e, primarily through reduced travel-related emissions 16, 17. In China, a recent study shows that telemedicine visits emit about 19 kg CO2e per visit and on average reduce emissions by around 85.5 kg CO2e compared with in-person care, with national networks potentially cutting millions of tons of CO2e annually and particularly benefiting patients in mountainous and remote regions 18. Telemedicine thus exemplifies how digital transformation can support low-carbon rheumatology. For patients with stable chronic rheumatic disease, virtual consultations can safely replace many in-person visits, improving access while substantially reducing travel-related emissions and time costs. When supported by appropriate reimbursement and community-based monitoring, telemedicine can further enhance access for patients living far from tertiary centers in Taiwan and across Asia. Together with locally tailored precision-medicine strategies and a progressively decarbonized biologic supply chain, telehealth can become a cornerstone of resilient, low-carbon rheumatology care. The scale of this cycle—from environmental triggers to healthcare-generated emissions and the potential impact of targeted interventions—is summarized in Table 1. Total emissions ranged from 1.1 kg CO2e for benralizumab to 188.9 kg CO2e for dupilumab; a 172-fold difference (Product-level carbon footprints from 10 derive from early-stage LCAs, preprints and is therefore used here as preliminary, order-of-magnitude indicators rather than definitive estimates.) Switching to electric vehicles reduces emissions ~3.5 kg CO2e Replacing 40% of petrol car travel with public transport saves up to 6.6 kg CO2e In parallel, emerging work in “Green” Health Technology Assessment (HTA) shows how LCA can be embedded alongside clinical effectiveness and cost-effectiveness, allowing environmental metrics to be integrated into routine therapeutic decision-making 2, 3. In rheumatology, this means that better phenotyping and earlier, targeted treatment—for example T2T RA care and biomarker-guided stratification in systemic autoimmune rheumatic diseases—can be aligned with greener delivery models to reduce emissions from high-intensity services such as emergency care and inpatient stays. Low-carbon incentives should focus on how care is delivered—by reducing low-value care, optimizing dosing and monitoring, and improving supply-chain efficiency—rather than restricting access to high-efficacy therapies. As rheumatology enters an era of carbon pricing and tighter fiscal constraints, departments need governance tools that can align clinical quality, costs, and emissions. Our proposed Rheumatology Balanced Scorecard builds on prior work integrating environmental indicators into hospital performance frameworks and sustainability-balanced scorecards in public healthcare systems, as well as emerging models that link HTA with the Balanced Scorecard for technology management 19-21. In this framework, an Environmental & Sustainability perspective tracks total annual emissions, transparency of supplier LCA data, and reductions in medical waste, incorporating environmental impact alongside safety, efficacy, and cost in therapeutic decisions. A Patient & Community perspective monitors telemedicine uptake, patient travel-related emissions, flare rates, and rural–urban differences in access, allowing services to see whether low-carbon interventions are narrowing rather than widening inequities. An Internal Processes perspective follows the proportion of new technologies evaluated using Green HTA, and metrics such as first-time-right and Treat-to-Target biologic prescribing, which capture how often patients receive effective therapy early in the disease course and are expected to reduce preventable flares, hospitalizations, and their associated carbon emissions. A Learning & Growth perspective measures staff training in sustainable care, cross-departmental projects between clinicians and supply-chain teams, and research output in low-carbon rheumatology, embedding decarbonization into organizational culture. Importantly, environmental metrics in this Balanced Scorecard are not intended to justify restricting access to high-efficacy therapies such as biologic disease-modifying drugs, but to identify and eliminate low-value and wasteful care—for example, redundant investigations, unnecessary routine visits, or avoidable supply-chain inefficiencies. By linking environmental data (LCA) and evidence-based appraisal (HTA) to strategic goals through the Rheumatology Balanced Scorecard, rheumatology services can move from rhetoric to accountable implementation in a carbon-priced world 19-21 (Table 2). Annual reduction in total carbon emissions (kg CO2e) Supply chain LCA data transparency (%) Medical waste reduction rate (%) Telemedicine adoption rate (%) Reduction in patient travel carbon emissions (kg CO2e) Disease flare rate (Flare Rate) Proportion of Green HTA incorporated into new technology assessments (%) Precision prescribing (T2T) rate (%) (avoiding ineffective test and treatments) Medication Stewardship program rate (%) (promote appropriate use of medications and reduce medication-related waste) Operating Room BSC (Adopt Sustainable Operating Room Scorecard to reduce footprint) Reusable & Streamlined Supplies (%) (Replace single-use textiles with reusables and optimize supply management) Improvement in cold chain logistics energy efficiency (%) Inpatient low carbon food service rate (%) (Implement plant-forward menus and person-centered food services to minimizing food waste and including low carbon food items) HTA 2, 3 Sustainable Operating Room Scorecard 24 Staff sustainable healthcare training hours Number of cross-departmental (clinical/community/supply chain) collaboration projects Number of publications on low-carbon rheumatology The fight against climate change is fundamentally a fight for our patients' health. By embracing a data-driven strategy that combines precision medicine, supply-chain accountability, Green HTA, and the intelligent integration of telemedicine within a Rheumatology Balanced Scorecard, our community can lead rather than follow. A low-carbon future for rheumatology is not only an environmental imperative—it is a clinical obligation to protect both our patients and the planet on which they depend. G.-N.K. conceived the study idea, All authors designed the research framework, and led the overall project administration. G.-N.K. collected and curated the data, conducted the formal analysis, and interpreted the results. G.-N.K. drafted the original manuscript and revised it critically for important intellectual content. All authors reviewed and approved the final version of the manuscript and agree to be accountable for all aspects of the work. The authors declare no conflicts of interest. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
Kuo et al. (Wed,) studied this question.