Time to act: pharmacists must be prepared for environmental changes

As climate change begins to alter environmental conditions, global patterns of human disease are shifting with inevitable impacts on the pharmacy profession and our practice. How readily would you be able to recognise the symptoms of malaria? Would you be able to select an appropriate antiprotozoal for leishmaniasis treatment? What will you do to support vulnerable patients through extended heat waves? 

The European Centre for Environment and Human Health (part of the University of Exeter Medical School) in Truro researches these types of questions. A recently published article¹ gives some examples of the challenges ahead and of the types of diseases and drugs we may soon need to familiarise ourselves with.

Green pharmacy

Not only is it important to consider how changes to the climate will affect the health of the population, it is also necessary to evaluate the impact of the pharmaceutical industry on the environment.

There are going to be more of us and we will be living longer. If current modelling proves accurate more of us are going to be elderly, obese, diabetic and depressed, among other things.^{2, 3} Add to this the increasing availability of cheaper generic medicines; it seems the population will be taking more medicines than ever before. In fact, the UK’s Royal Commission on Environmental Pollution predicts that pharmaceutical usage in the UK alone will double by 2052 due to the ageing demographic.⁴

Concern is growing about the damaging environmental consequences that medicines currently exert on the environment, or may in the future. This has been highlighted already by the deaths of millions of vultures on the Indian subcontinent following exposure to diclofenac,⁵ the on-going ‘feminisation’ of male fish associated with the excreted components of the contraceptive pill⁶ and the global spread of antibiotic resistance.^{7, 8}

Additionally, the carbon footprint of pharmaceuticals is huge, with 20% of the NHS carbon footprint relating to pharmaceutical products (NHS Sustainable Development Unit, August 2013), while the risk to the environment of pharmaceutically active by-products excreted by patients is largely unknown.⁹

Surely then the combination of growing drug use and its potential environmental impact, both directly and indirectly via energy use, suggests that it would be pertinent to apply the precautionary principle and encourage medicines’ stewardship, implementing “green pharmacy”. Pharmacists have a duty as a profession to ensure responsible medicines’ stewardship: that medicines’ wastage is minimised and disposal is safe. We also have a greater responsibility to begin to consider the broader environmental impacts of the drugs we provide to our patients and the associated policy over coming years.

Green pharmacy is certainly an area drug companies are aware of. August 2013 saw the Association of the British Pharmaceutical Industry launch a tool to calculate the carbon footprint of pharmaceutical products. The ABPI collaborated with the Carbon Trust to help pharmaceutical companies quickly estimate the carbon footprint of tablet medicines distributed in blister packs.¹⁰ It is hoped the tool will be used by manufacturers, commissioners and healthcare providers to start highlighting carbon hotspots and to target work to reduce emissions. On the legislative side, the EU has, for the first time, listed three pharmaceuticals (diclofenac, 17-a-ethinylestradiol, 17-ß-estradiol) in legislation (Water Framework Directive, 2013/39/EU11) as substances on a “watch list” which requires member states to undertake monitoring programmes and consider reduction in discharges to the environment where appropriate. The cost of compliance for the UK water industry to meet initial proposed Environmental Quality Standards for 17-a-ethinylestradiol alone were recently estimated at over £20bn.¹²

There comes a point where one has to question the ethics of further drug development in certain disease areas. Should the National Institute for Health and Care Excellence start to consider the environmental impact when appraising drugs, recommending those with the lower environmental impact where the therapeutic differential is minimal? Perhaps drug prices should reflect the cost of removing pharmaceutical active products to subsidise the water companies’ sewerage costs.

Climate change brings many challenges

Changes in temperature and weather

Global warming has seen the mean surface temperature increase by 0.74C between 1906 and 2005, and projections of future greenhouse gas emissions indicate a further increase of 1.1 to 6.4C by the end of the 21st century.^{13, 14}

The frequency, duration and intensity of heat waves are expected to increase and vulnerable individuals are already suffering. Official figures showed that the European heat wave of 2003 killed 4,800 people in France alone and an estimated 70,000 people across Europe.¹⁵

These climatic changes will not just apply to summers. Although overall winter temperatures may be higher, more frequent intense winter storms are predicted, as we have experienced with the most recent winter in the UK. One of the challenges for public health will be getting people to change routines to adapt to these new conditions.

This could be particularly challenging in the dementia population where a change of routine can be confusing and disorientating. As front-line healthcare workers, what strategies can community pharmacists put in place to help educate and support these vulnerable patients — and their carers — to change their behaviour to help them stay safe during such extremes of temperature and weather conditions?

Climate and air quality

Climatic change could also exacerbate the health impacts of aero-allergens, such as pollen and mould spores, and increase the prevalence of algal toxins, some of which can become airborne. Changing weather patterns and rising temperatures are likely to cause changes in plant ranges, which in turn may cause changes in pollen production, shifts in, or even lengthening of the pollen production season and the introduction and disappearance of different pollen types.¹⁶ For our patients this could extend the hay fever season, and people who have not previously suffered from hay fever may develop symptoms in reaction to new pollens.

Climate change is also expected to affect the production of mould spores, particularly indoors. Studies have shown rises in temperature and CO2 levels increase spore concentrations and the spore season starts earlier and lasts longer. This may be especially relevant in developed countries where adults and children spend more than 90 per cent of their time indoors.¹⁷ Coastal communities may see an increased exposure to algal toxins in aerosols.¹⁸

All of these factors have the potential to exacerbate asthma and other existing respiratory conditions with a resultant increase in their pharmaceutical treatment.

Vector-borne diseases

Changes in climate can also prompt changes at the ecosystem level, affecting vector-borne diseases through impacts on the pathogens, their vectors and hosts. Various models have predicted the spread of mosquito species in the northern hemisphere,¹⁹ and there are already areas in Eastern Europe that are now suitable for mosquito species that transmit diseases such as dengue and yellow fever.²⁰ Thus, as temperatures increase so will the potential for transmission of Plasmodium vivax and P. falciparum, which produce malaria.

We can also expect an increase in the incidence of tick vectors such as Lyme disease,²¹ flea vectors which carry diseases such as the plague,²² and fly vectors which can transmit leishmaniasis.²³ As a profession, how knowledgeable and prepared are we for the pharmaceutical treatment and prophylaxis of these diseases and recognising their symptoms? Do we know enough about interactions of these drugs with more commonly used “Western drugs”?

World in flux

Climate change is happening and, therefore, our healthcare needs will be affected. Exactly how climate change will affect health remains uncertain and subject to controversy. However, a global increase in pharmaceuticals is almost certain.¹

So, faced with this, what will be the role of the next generation of pharmacists and technicians in the context of climate change and the protection of our environment? What training and education do we need to be planning for today? Pharmacists are the experts in medicines. They should become experts in reducing their wider environmental impacts, too. They have a key role in delivering the public health agenda; they should become experts in helping the public deal with the day-to-day challenges that climate change will bring. Lastly, they should lobby hard to ensure that the design and manufacture of the pharmaceuticals with which they ply their trade is done with the smallest carbon footprint and minimal environmental impact.

The future poses many questions. The “Pharma town” visualisation, recently published in Science,²⁴ highlights the multitude of potential intervention points, from educational and behaviour-change mechanisms to technological interventions. Is it time that we consider our own place, roles and responsibilities within this system? Should we be developing our own definition of “green pharmacy” and implementing it? Should we take it on ourselves to educate drug consumers about proper disposal of unused medicines, or make it an easier process? Should we lobby those with power to allow the use of medicines donation programmes to dispose of unused medicines or develop our own system of reuse, or advocate the use of more expensive, but potentially less environmentally damaging medicines? Is it our responsibility to educate prescribers or do we need prescribers to take on environmentally informed prescribing practices such as those seen in Sweden?

The JanusInfo database (www.janusinfo.se/environment), set up in 2009, allows doctors to check whether medicines are “green” before prescribing them. The database rates pharmaceutical substances in terms of their toxicity, persistence, and bioaccumulation potential based on data given by pharmaceutical manufacturers. It was part of Stockholm’s larger effort to reduce levels of the most environmentally hazardous medicines in waste water effluent and in surface water by 2011. It was so well received that it was soon extended to all of Sweden.

Regardless of the actions “green pharmacists” choose to take, the continuing pollution of our environments by pharmaceuticals must be addressed and, for prevention and mitigation strategies to be truly effective, multiple interventions from all the players involved in this system must be implemented with the same goal in mind.

None of the challenges facing the current and future generations of leaders are greater than those posed in protection of the environment. The pharmacy profession should take a lead in developing the “green pharmacy” concept and develop the skills to be a valued resource in helping our patients deal with the link between the changing environment and their own health.

References

1. Redshaw CH, Stahl-Timmins W, Fleming LE et al. Potential changes in disease patterns and pharmaceutical use in response to climate change. Journal of Toxicology and Environmental Health 2013;16:285–320.
2. Depledge M. Reduce drug waste in the environment. Nature 2011;478:36.
3. Depledge M. Does the pharmaceutical industry need a new prescription? Science in Parliment 2011;68:44–5.
4. The Royal Commission on Environmental Pollution Twenty-ninth Report: demographic change and the environment; The Royal Commission on Environmental Pollution: United Kingdom, 2011.
5. Taggart MA; Senacha KR, Green RE et al. Diclofenac residues in carcasses of domestic ungulates available to vultures in India. Environment International 2007;33:759–65.
6. Gilbert N. Drug waste harms fish. Nature 2011;476:265.
7. Taylor NG, Verner-Jeffreys DW, Baker-Austin C. Aquatic systems: maintaining, mixing and mobilising antimicrobial resistance? Trends in ecology and evolution 2011;26:278–84.
8. Wright GD. Antibiotic resistance in the environment: a link to the clinic? Current Opinion in Microbiology 2010;13:589–94.
9. Kümmerer K. Pharmaceuticals in the environment. Annual Review of Environment and Resources 2010;35:57–75.
10. Association of the British Pharmaceutical Industry. New carbon footprint tool launched to calculate the carbon footprint of pharmaceutical products. Available at: http://www.abpi.org.uk/media-centre/newsreleases/2013/Pages/220813.aspx (Accessed 31 October 2013).
11. The European Parliament and the Council of the European Union, Directive 2013/39/EU of 12 August 2013 amending Directives 2000/60/EC and 2008/105/EC as regards priority substances in the field of water policy. In DIRECTIVE 2013/39/EU, Union, E, Ed. Brussels, 2013;56.
12. House of Commons Science and Technology Committee Water quality: written evidence; 2013.
13. Intergovernmental Panel on Climate Change Climate Change 2007: the physical science basis. Contribution of Working Group I to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change 2007; p996.
14. Intergovernmental Panel on Climate Change Climate Change 2007: impacts, adaptation and vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change; Cambridge University Press, Cambridge, UK, 2007; p976.
15. D’Ippoliti D, Michelozzi P, Marino C et al. The impact of heat waves on mortality in 9 European cities: results from the EuroHEAT project. Environmental Health 2010;9:37.
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21. Gage KL, Burkot TR, Eisen RJ et al. Climate and vectorborne diseases. American Journal of Preventive Medicine 2008;35:436–50.
22. Enscore RE, Biggerstaff BJ, Brown TL et al. Modeling relationships between climate and the frequency of human plague cases in the southwestern United States, 1960–1997. The American Journal of Tropical Medicine and Hygiene 2002;66:186–96.
23. Ready PD. Leishmaniasis emergence in Europe. Eurosurveillance 2010;15:19505.
24. Stahl-Timmins W, Redshaw C, White M et al. The Pharma Transport Town: understanding the routes to sustainable pharmaceutical use. Science 2013;339:514–15.