Health without harm
We all need medicine. But it’s one of the most damaging things for our planet. Giles Crosse investigates how saving lives isn’t all it seems.
It’s a bit surprising when you realise healthcare is among the more resource heavy things we do to the planet. It’s also tied all with all kinds of fundamental aspects of sustainability too. Rising populations need more healthcare, using more resources and more energy.Increasing need for healthcare in developing countries will have the same effect. And then there are the innate burdens placed on the environment by production processes for medicines. What about the annual energy footprint of your local hospital? The recyclability of your weekly medication?And what effects are global pharmaceuticals having on the marine environment, or the air that we breathe? The more you look at the equation, the more you realise how truly complex, and how truly difficult to solve it may actually be.
For the global good
All of these questions require answers, and they are needed soon. Luckily there are places where some serious good work is taking place. ‘Making e-health solutions sustainable is a real challenge – especially in low resource settings,’ explains Sweden’s Karolinska Institutet, in its document ‘e-health in Low Resource Settings: the Path to Sustainability.’
‘A sustainable e-health solution is the one that uses ICT resources to meet healthcare needs of the present without compromising the ability of future generations to meet their own needs.’
Other work is happening in Sweden to turn hospitals into some of the most sustainable buildings around. The New Karolinska Solna University Hospital, planned for opening in 2015, illustrates some of these goals.
‘The New Karolinska Solna will be designed to meet three main environmental certifications, ISO 14001, LEED and GreenBuilding,’ explains Solna’s website. ‘ Each of these rating systems establish an environmentally related certification criteria to minimize a building's negative environmental impact.’ And there’s more.
‘With the human factor as the focal pivotal point, The New Karolinska Solna will be built and operated with the lowest environmental impact to date in new hospital construction. At its core, all environmental efforts emanate from the model of keeping the patient and staff in an optimal indoor environment. This will be achieved by fastidiously conserving natural resources and planning in the full circuit of nature’s cycle into every decision.
‘The new hospital’s structural design will make use of insulation and a compact design concept to considerably reduce energy input for heating and cooling. Health care facilities electricity consumption traditionally takes up half the hospital's total energy requirement. As a result, energy-efficient equipment and lighting is a priority.
‘The aspiration of the NKS is to have as near a zero-impact rating regarding greenhouse gas pollution as reasonably possible. The goods and shipments to and from the new hospital expect to be largely fuelled with renewable resources. Public transportation servicing the New Karolinska Solna is also primarily supplied by renewable fuels.’
If this can be achieved, it will be a remarkable illustration of what the future might hold.
Here and now
“Often sustainability falls foul of public procurement,” explains Paul Wayley, who works with the Campaign for Greener Healthcare on evidence-based sustainability policy. “Agencies like the NHS in the UK need cultural permission to put these agendas in place. Estates managers in general are bound by the fact that often sustainability is just not a priority.
“There is also a rising incidence of sustainability related illness.” This is another point few of us consider. By eating too much meat, not only do we add to a resource intensive process, we then require care when we develop cardiac or weight related issues. It’s a true illustration of how real sustainability is an inherently holistic issue.
“Green pharmaceuticals is going to be one of the interesting areas in the future,” Wayley continues. “Agencies in Europe are becoming increasingly interested in things like water discharge, and minimising the toxicity of how pharmaceuticals relate with the environment.
“We could design drugs to be more environmentally benign. But then there is a difficulty, because you are looking at a drug that you want to persist, and to work, while it’s in the body. But then you want that same drug to breakdown very quickly and harmlessly in the environment as soon as it’s released and has done its job. That’s potentially tough to do.
“Another thing which is important in this context is that if you look back over the years the discovery rate of new drugs has slowed down. There’s also the risk from how these things are produced. Some of the water in Hyderabad is practically sludge.”
Sadly, it seems he’s right. Back in January 2009, The Huffington Post described the situation in the area thus; ‘When researchers analyzed vials of treated wastewater taken from a plant where about 90 Indian drug factories dump their residues, they were shocked.
‘Enough of a single, powerful antibiotic was being spewed into one stream each day to treat every person in a city of 90,000. And it wasn't just ciprofloxacin being detected. The supposedly cleaned water was a floating medicine cabinet a soup of 21 different active pharmaceutical ingredients, used in generics for treatment of hypertension, heart disease, chronic liver ailments, depression, gonorrhoea, ulcers and other ailments. ‘
The implications of all this are worrying. Dr Joakim Larsson works at The University of Gothenburg. His pages on the University website explain past work to, ‘assess risks (including resistance development) associated with the extraordinary large releases of antibiotics and other pharmaceuticals from bulk drug producers in India.’
‘Pharmaceuticals are thought to reach the aquatic environment primarily via sewage effluents, where for example estrogens can feminize fish. Antibiotics in normal treated sewage effluents are not believed to cause resistance or affect microbial diversity.
‘However, we recently showed that treated effluent from 90 production sites in India contains extremely high, toxic levels of antibiotics, with ciprofloxacin up to 1 million times the levels normally found in sewage effluents. We will start to address the environmental impact of the release of pharmaceuticals at this centre for the global bulk-drug market.’ continue the details.
Greener chemistry may be the solution to all of this. Plainly, money speaks when it comes to producing drugs cheaply, and the potential problems this may cause. There are more fundamental issues. A personal visit to my GP the other week resulted in an offer of antibiotics, despite the fact I’d only just taken a test, and was awaiting results confirming the need for them. Anja Leetz is Executive Director for Health Care Without Harm Europe. She thinks changing procurement to address issues of CO2 emission, waste, pharmaceuticals and chemicals use in healthcare could be a way forward.
“Governments face rising cost for healthcare, so naturally there needs to be a dialogue in how to fulfil the need, for aging populations, changes in weather patterns, heat waves, floods, air conditions in big cities. Intervention is required in terms of legislation, to drive change within the systems on chemicals, or on renewable energy.
“Technology is only a small part, far more attention should be given to questioning structures of workflow and innovative solutions. Human potential for identifying solutions will have a bigger impact.
“Sustainability has not really arrived yet, it is a change of thinking, away from compartment structures of dealing with patients, it requires a holistic approach. For example, even though the EU Commission is stating there is a link between environment and health, in practical terms it is not addressed in policy development yet, this is also reflected through the fact that at EU national level environment and health ministries do not collaborate enough on health policies.
“At hospital level, if they have an environmental officer this person often deals with end of pipe solutions, how to handle the waste, instead of starting at the beginning (procurement) and being part of the decision making level in a hospital.
“There are good examples in Sweden, Stockholm City Council, Karolinska Hospital and Austria, Vienna Hospital Association, City of Vienna and their procurement policy,”
Leetz explains that green and sustainable pharmacy looks at the whole life cycle, aiming to minimise effects on health and environment, and examining how biodegradable medicine works with no exposition, no effects and no risk.
“The key here is the degradability after use is part of the functionality. We have not reached this yet and there is huge potential for research and opportunities for the future. If we don’t change the way we work now we will have an even higher demand on the system and less people who can afford care, even in Europe.”
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