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.