What does climate change and global warming mean to you? Perhaps you are looking forward to warmer summers, especially after the weather earlier this year. Or perhaps, as a result of this year’s summer, you have been made aware that the effects of climate change may not be as agreeable as we might think.
Evidence suggests that recent events, such as the location of the jet stream and the extreme wet weather, may be linked to climate change and global warming. Globally, the weather is becoming more extreme and incidents more common. This year we have seen typhoons and accompanying floods in the Philippines, China, Thailand, Russia and Australia, and extreme heat in parts of the US. Such extreme weather events have tripled in frequency since the 1980s, linked to global warming.
Global health threat
Climate change has been said to be the biggest global health threat in the 21st century. There are obvious health effects related to extreme weather events owing to the direct mortality or morbidity of those affected. But there are also less direct ones such as an increase in stress-related mental health disorders, and malnutrition as a result of crop failure. Vector-and water-borne diseases will also be more prevalent in flood areas. Poor countries are likely to fair the worst from these effects, which will lead to an increase in the inequalities of the world. Temperature-related health effects primarily cause a problem for the cardiorespiratory system. The “heat island effect” that occurs in cities leads to an increase in ozone smog with consequent exacerbation of asthma and chronic obstructive pulmonary disorder. Build-up of nitric oxide and sulphur dioxide also worsen cardiac conditions.
In England, the Department of Health produces a heat wave plan, which we no doubt receive and file away; in recent years it has usually been a sign that the fine spring weather is changing to a cold, wet summer! But what are we doing as a profession, either to help mitigate climate change or prepare for the consequent health-related effects?
Keith Ridge, DoH chief pharmaceutical officer, has given us the lead and has been reported as saying: “My vision of a clinical profession includes pharmacy taking responsibility for the local community helping to improve health and reduce health inequalities. Arguably the biggest threat to our society is from climate change and we must minimise our carbon emissions in our everyday lives.” But are you living up to, and according to, that vision?
Pharmacy has been good at adapting to the public health needs of societal change. We have embraced the challenges of smoking, obesity, alcohol and sexual health. But they are all much more visible than the challenge of climate change. However, we need to recognise that climate change affects us all. We need to embrace the challenges of climate change and accept our social responsibility to help others in this respect. We need to be aware of, and prepare for, the consequences on health and play our part in minimising and mitigating climate change.
The medical profession has an active sector already addressing this but, as yet, there seems to have been little movement within pharmacy. There have been some useful articles here in The Pharmaceutical Journal outlining how ecological issues were included in the teaching at Bradford School of Pharmacy (PJ 2010; 284:55) and there was a call to action from Gul Root, England’s principal pharmaceutical officer (PJ 2008;281:596).
The Co-operative pharmacy group seems to be the furthest forward, having published an ethical strategy that includes a section on climate change. It has reduced its carbon footprint by bringing in a once-daily delivery policy, and having an extensive recycling policy and a commitment to renewable energy sources. All branches source their electricity from renewable sources.
Within the pharmaceutical industry, GlaxoSmithKline has teamed up with Accenture Sustainability Services and produced a guide to how the industry can and should respond to climate change. The recent project on recycling inhalers (PJ 2011;287: 564) is one example of a commitment to sustainability. Pfizer also has a policy framework that promotes implementation of low carbon and renewable energy projects.
Sustainability high on NHS agenda
Within the NHS the sustainability agenda is high, not only because of the potential cost savings but also in response to the global threat of climate change.
The largest contributor to the carbon footprint of the NHS is pharmaceuticals manufacture and use. “International carbon footprinting guidance for pharmaceuticals and medical devices” has been proposed that will support consistent quantification of the carbon footprint of pharmaceuticals. The purpose will be to support internal product appraisals. Although it is not intended to support claims of favourable environmental performance of one product over another, one wonders if in the future in addition to considering the clinical and pharmacoeconomic evidence, we will be required to consider the carbon footprint of drugs.
As pharmacists we are familiar with thinking about wastage and how to minimise it from a cost perspective. Campaigns to encourage return of unwanted medicines and attempt to reduce unnecessary reordering of medicine have made us aware of the cost implications of wastage, but we also need to promote these campaigns as supporting sustainability and the mitigation of climate change. There has been much debate recently in the pharmacy and medical press about whether, in order to ensure a sustainable NHS, these drugs could be recycled. We need to develop a simple algorithm to ascertain their storage conditions to enable an informed decision to be made about their potential for reuse.
We also need to reconsider the current practice of twice daily deliveries to pharmacies. As part of the Co-op’s ethical strategy it has moved to once-daily deliveries. How acceptable would fewer deliveries be to you and your patients? We seem to have developed a culture where patients expect to have their new medicines on the same day as they receive their prescription. And yet they may have lived with the condition undiagnosed for months or years, so what is the sudden urgency?
Aside from a few medicines for acute conditions, many could wait. Perhaps we should be developing a formulary of the top 50 medicines that will always be kept in sufficient quantities in the pharmacy to ensure immediate access and another list of those that will be available within five days. Use of such lists, together with more efficient repeat prescribing and dispensing processes should enable us to reduce the number of deliveries and thus reduce our carbon footprint.
In addition to the sustainability angle to the mitigation of climate change, we also need to prepare for the impact on health that climate change will bring. One of the main immediate risks of heat is dehydration. We could identify those patients who have conditions or take drugs that put them at greater risk of heat stroke and counsel them on measures to minimise the risk. We could counsel patients on diuretics and antihypertensives to adjust their dosage in heatwaves.
What can we do as individuals? We can reduce our personal carbon footprint. How many journeys currently taken by car could we change to public transport and cycling or walking? Not only would we reduce fuel usage we would contribute to addressing the obesity problem. We could campaign for changes, such as prohibiting cars from major city centres, where public transport and cycling are available as alternatives.
We also need to think about our diets. Currently half of the cereals grown are fed to animals. How more efficient it would be if we radically changed our diets, reducing our consumption of meat and dairy produce and increasing our consumption of cereals and vegetables. We could feed the world and help avert the health related problems of malnutrition.
Reduce use of energy
We need to reduce our use of energy both at home and the workplace. Can non-essential lighting be turned off, could we eco-boil the kettle with just enough water for our needs. Although these are little things, if we all made an effort it could be significant. We should also be promoting these changes to others. We need to promote our pharmacies as “green” and sustainable to encourage others to adopt the message.
Carbon dioxide emissions attributable to the NHS in England are greater than the total emissions from all aircraft departing from Heathrow airport. Two-thirds of these emissions are related to goods and services that the NHS procures, notably pharmaceuticals and medical equipment. The NHS is therefore pushing ahead to be environmentally sustainable, in a way that also produces financial sustainability. An NHS Sustainability Unit has been set up, which says that sustainability means more than merely lasting or surviving; it means designing and delivering health care that uses resources in ways that do not prejudice future health and wellbeing.
Five per cent of transport emissions in the United Kingdom are estimated to be accounted for by health care-related journeys. We need to minimise these “care miles”. Delivering care closer to people’s homes is one area where pharmacy could provide services and thus contribute to the sustainability agenda. Promoting prevention and self-management of illness without the need to visit a doctor or hospital is another area. Just as we promote other health campaigns we should, as a profession, be promoting the sustainability agenda and linking this with the mitigation of climate change. We have a lot to offer. Meeting the NHS sustainability agenda is one area where we could be successful in getting new services commissioned.