Back in 2021, when as the chair of the COP26 UN climate talks, the UK could plausibly claim to be providing leadership in tackling the climate emergency, for the first time in the discussions the emissions and other environmental impacts of the health sector were given spotlight.
That was a real step forward, given healthcare is estimated to account for 4.4% of climate emissions globally (4% in England), and the other environmental impacts – particularly the use of plastics and the impact of human pharmaceuticals – were coming into focus.
Then came the Covid-19 pandemic and, understandably, the sector was forced to focus on trying to cope with immediate medical and social care needs.
But the environmental impacts of the health sector have not gone away, and indeed the issue has only become more pressing. As we are witnessing daily demonstrations, desperate to highlight the urgency of cutting emissions in this climate emergency, scientists are exposing huge threats to human and environmental health stemming from antimicrobial resistance and the effect of endocrine-disrupting chemicals – including pharmaceuticals, and other general medicines.
It is in that light that I was delighted to work with my interns from the British Society for Antimicrobial Chemotherapy, Julze Alejandre and Emily Stevenson to produce a policy paper on ‘eco-directed and sustainable pharmaceutical prescribing’ in the UK. That covers both what is happening, and what should be happening.
Taking the lead in sustainable prescribing
In terms of action, it is clear that the nations of the UK are taking distinct paths.
Scotland has taken the lead on sustainable prescribing in healthcare and is working to tackle the impacts of pharmaceuticals on the environment. NHS Scotland is working with organisations such as the One Health Breakthrough Partnership to tackle the issue of pharmaceutical pollution and making concerted efforts on ‘realistic medicine’; principles which are deeply ingrained in NHS Scotland’s climate emergency and sustainability strategy.
In England, the aims of Greener NHS and NHS England’s delivering net zero strategy have tended to narrowly focus on carbon emissions.
As an immediate point of departure, the policy paper insists that all issues of waste should be ‘reduced’. Alternatives to pharmaceuticals – often labelled ‘green and blue prescribing’ or ‘social prescribing’ are areas of growing activity as the associated medical benefits are recognised. But, as I commented in the debate in the Health and Social Care Act, all too often they are seen as an add-on, a ‘nice to have’, rather than a solution in their own right. The environmental benefits of such a choice have received little attention but deserve to.
The importance of a systemic approach
There’s also a need to act at the other end of the medical chain, the research and design of medicines. In consultations with the pharmaceutical industry, we learnt about an innovative European programme, PREMIER, which is looking to both assess the environmental impacts of existing general medicines, and to build in consideration of those impacts from the start of the drug development process.
In between, it is crucial that medicines are prescribed according to the best possible evidence, and only when needed. The most effective and appropriate medicine should mean that return visits, and further prescriptions, are in many cases unnecessary, and that patients get all the advice and support they need to take medicines to their best effect.
Associated with that is patient-centred and shared decision making between medical providers and patients. If patients understand why they are taking medicines, how they are best used, and disposed of where necessary, not only will they be better off, so too will the environment.
Environmental health and human health: one and the same
It’s a big step, but clearly an essential one. To ensure that medicines operate effectively, dosage levels mean that much is expelled from the body into the environment. And those are compounds designed to have effects on living things – effects that continue in rivers and streams, in soil and on the breeze.
I’ve no doubt that at this point, some readers are thinking that surely patient health must be paramount – that medicines should do whatever it takes to ideally cure patients, or at least ameliorate their symptoms. But that’s taking a 20th-century, reductionist view of health; one that’s delivered for us the deeply unhealthy, struggling society that is only now, given the number of people of apparent working age who are not fit to work, getting attention from the government.
Instead, what we need is a One Health, or Planetary Health paradigm, one that acknowledges we are living beings (humans are holobionts, made up of many thousands of species in our microbiomes) in a complex web of life, and the health of the animals, plants, soils and waters around us have an immediate impact on our health.
