Growth,Gaps,and Emerging Priorities in Environmentally Sustainable Medical Imaging

The Exponential Rise of Sustainable Imaging

We congratulate the authors of Environmental Sustainability in Radiology: A Global Bibliometric Analysis of Growth, Structure and Emerging Research Priorities for an important and timely contribution to our understanding of this rapidly evolving field. ¹

Once a niche interest, environmentally sustainable medical imaging has transformed into a mainstream academic domain. The literature on “Green Radiology” has seen a staggering acceleration. While historical output prior to 2015 was minimal, annual publication volumes surged after 2019, culminating in an explosive period over the last 2 years; 54% of all papers on the topic were published in 2024 and 2025 alone. ¹ This bibliometric boom reflects a growing recognition within the healthcare sector of its own carbon and environmental footprint, as well as the profound risk the climate crisis poses to human health.

This rapid academic expansion mirrors global efforts to decarbonize healthcare delivery. As healthcare contributes 5% of global greenhouse gas emissions, healthcare systems, including radiology, have a moral duty and ethical responsibility to act. Furthermore, as imaging resources are increasingly strained by demand that outpaces capacity, the value equation in radiology must evolve. True resource stewardship now requires a framework that integrates economic efficiency, equitable allocation, and environmental sustainability.

Mapping the Structural Consolidation of Knowledge

Bibliometric analysis, a quantitative research method, uses metadata, statistics, and mathematical techniques to analyze large volumes of academic literature to map research trends, identify collaborative networks, and discover knowledge gaps. ² At this point in time for the new and rapidly expanding field of “Green Radiology,” this bibliometric review provides a critical structure to assess the present and plan the future.

O’Dwyer et al identified 2720 unique authors distributed across 252 different journals with publication output dominated by high-income countries. ¹ A median of 6 authors per publication indicates the development of a deeply collaborative team science rather than isolated opinions. ¹ The science mapping shows that a “core group” of journals and international collaborative networks is developing, indicating coordinated research efforts. ¹

The Heterogeneity of Evidentiary Maturity

Evidentiary maturity in sustainable healthcare refers to the levels of scientific validation and evidence supporting different “green” interventions. ³ While evidence-based healthcare relies on rigorous randomized trial data, environmental sustainability strategies are often built on a mix of quality improvement metrics, supply-chain carbon accounting, and consensus guidelines.

The authors’ bibliometric data reveals a broad disconnect in the range of papers that cover the main themes of environmentally sustainable healthcare: mitigation, adaptation, and resilience. The related but distinct domains of adaptation and resilience are considered separately – a newer approach in sustainable radiology publications – as they require different approaches and timelines. ⁴ Adaptation describes the use of imaging to understand climate and environmentally sensitive disease processes, and to prepare for the new climate realities of extreme weather events, heat, and poor air quality. ¹ Resilience describes anticipating, surviving, and recovering from extreme climate events. ¹

Mitigation to reduce emissions and waste accounted for over half (60%) of all papers; however, of those only 39% were original research. ¹ The remainder were calls to action, guidelines, and statements. In comparison, publications on adaptation accounted for 41% of the total, with a much larger trend toward original research (83%), which the authors felt may be due to inclusion within broader health system literature. ¹ Resilience in medical imaging was significantly underrepresented at 2%. ¹

The implementation gap revealed by this bibliometric analysis is that, although we are publishing on mitigation with guidelines, toolkits, and statements, we are not conducting enough data-driven primary research to demonstrate that the strategies are effective in reducing emissions. ¹ Utilizing tools of implementation science will provide structure to translate research findings into practice. ⁵ Conversely, adaptation has more robust data and metrics, yet has not been front and center in environmentally sustainable radiology discussions.

The Resilience 2% Blind Spot

The bibliometric analysis uncovered a gap of urgent concern: research and publications on resilience account for only 2% of the total. This work is essential to ensure that radiology departments have stable infrastructure, staffing plans, and supply chains to withstand climate shocks that will intensify and become more frequent in the coming years.

While environmentally sustainable radiology has hyper-focused on reducing the environmental impact of diagnostic and interventional radiology, far too little attention has been paid to ensuring that medical imaging equipment is protected from floods and overheating, that robust data access is maintained, and that medical imaging staff are safe and able to attend work. A recent paper measured the increase in imaging utilization on days with increased heat and poor air quality; more of this research will be essential to ensure that medical imaging departments continue to function and recover quickly after an extreme weather event. ⁶

Beyond the Bibliometric Mirror: A Call for Data

In this bibliometric analysis, the authors have provided us a mirror to view our strengths and current gaps. The early literature on “Green Radiology” – calls-to-action, toolkits, and narrative reviews- served well to sound the alarm and generate interest in and engagement with environmentally sustainable radiology. As the field matures, the low-carbon, high-quality, climate-resilient radiology future to which we must transition will be driven by primary research, the development and standardization of metrics and implementation science, with an increased emphasis on system resilience and global equity. ¹ The call to such action is at hand.