Ontario families are required to provide up-to-date vaccination records as children begin schooling. Exemptions are allowed on both medical and nonmedical (religious or philosophical) grounds. In a recent report, Toronto Public Health (2019) called for an end to nonmedical exemptions – a proposal some allege infringes the Canadian Charter of Rights and Freedoms right to freedom of religion and conscience. This paper explores whether and to what extent vaccine refusal is protected under the Charter and argues that the elimination of nonmedical exemptions can be justified under Section 1 of the Charter. The issue of mandatory vaccination may take on special urgency in the coming months and years, if and when a vaccine is found for COVID-19.Excluding capital projects, spending on hospitals, physicians and drugs makes up more than two thirds of provincial and territorial governments’ healthcare spending (CIHI 2019). One expects that health services and policy research would be aligned with where the money flows and yet, there is a misalignment. For example, research as published by Healthcare Policy, is not so neatly aligned with provincial and territorial governments’ healthcare spending patterns. In this issue, for instance, there are only two such articles – one related to medication adherence and cost, and another related to payment policy associated with a hospital’s alternative level of care utilization. The previous issue of Healthcare Policy was similarly focused, with only two articles the study settings of which were primary care.We are fortunate to have the reflections and wisdom of experts from multiple disciplines in this issue’s discussion of healthcare sustainability. In the lead paper of this issue of Healthcare Papers, we issued a call to action drawing on the capacity of the Canadian health sector to address climate change (Miller and Xie 2020). Our colleagues agree on the need to deliver sustainable care and raise important questions about how such an aim can be achieved. In this response, we consider and revisit three themes feasibility of a sustainable healthcare system, theories of change that support our recommendations and capacities that enable change.The health system is a major contributor to Canada’s greenhouse gas emissions, largely arising from the ways that care is organized and delivered. Nurses, representing the largest group of regulated healthcare professionals, are experts in the organization and delivery of care, and are uniquely and critically positioned to witness and address the harmful effects of climate crisis. Thus, sustainable health systems cannot be achieved without nurses. check details Yet, nurses’ capacity to lead on issues of climate crisis and sustainability remains underdeveloped. We argue that the nursing profession needs to widely embrace climate crisis as a priority nursing problem and to take visible leadership on this issue. To enable the transformation of the health system toward sustainable and equitable delivery of care, health systems should incorporate a sustainability lens into strategic decision making, and implement and scale up nurse-led models of care. It is time to move beyond “engaging” or even “empowering” nurses to participate in sustainability initiatives. It is time for nurses to lead.The impacts of climate change can already be seen among many of the patients in our clinics and emergency rooms, and as with all disasters, the most impoverished and marginalized members of society are the hardest hit. The health system has a social accountability role to anticipate and respond to the evolving health needs of our society. We are the stewards of this planet, steering the course through current and future challenges. What we do now will determine what the world will be like for our children and grandchildren. At times like this, more than ever before, health workers around the world must unite and engage in contributing to shaping future policy directions and monitoring progress to create a post-COVID world where social accountability and sustainable development go hand in hand.Building on the article by Miller and Xie (2020) that raises a call to action for environmentally sustainable healthcare in Canada, this commentary posits that there is a responsibility to place that action in light of health equity. It also identifies an opportunity to build on an existing approach to health system improvement, that is spreading across Canada, by adding an additional aim around environmental sustainability and placing the outcomes for health systems firmly in health equity. By doing this in a clear, anti-racist and anti-colonial setting, sustainability can build on Canada’s Indigenous knowledge and principles of sustainability to align health system sustainability with reconciliation and equity.The current pandemic is a stark reminder that crises bring to light society’s vulnerabilities. In the lead paper of this issue of Healthcare Papers, Miller and Xie (2020) argue that the same is – and will be – true for climate change. They make a compelling and urgent case for its importance to health and healthcare in Canada and around the world. Opportunities to advance the multiple interrelated dimensions of sustainability in the health sector include understanding and mitigating the health implications of climate change; preparing the health sector for climate change; and accelerating the health sector’s contribution to society-wide net-zero targets. High-performing, resilient health systems with their capacity to deeply engage with communities, and to respond dynamically to changing circumstances, will be key to proactively addressing climate change, just as they are proving to be in pandemic preparedness and response.Miller and Xie (2020) raise a call to action on creating a sustainable Canadian healthcare system as part of a more just and sustainable economic model. This commentary explores the economic dimensions of this call to action. It provides a brief overview of relevant concepts and insights from emerging schools of economic thinking, and contemplates challenges and opportunities for health system sustainability as the economic consequences of COVID-19 play out in coming years.