COMMENTARY

A Reader and Author Respond to "Green Healthcare"

Shaheen E. Lakhan, MS, MEd, AFACB, MICR, PhD, MD (c.); Peter Yellowlees, MD

Disclosures

August 15, 2008

To the Editor:

I read Dr. Peter Yellowlees' editorials with much interest.[1,2,3] It is very heartening to know that America is waking up to such a revolution, and much is being done in the way of achieving a "greener" America.

Green healthcare can primarily be achieved by practicing environmentally friendly healthcare building designs, using solar energy to replace fossil fuel-driven heating-cooling systems, rainwater harvesting in places where it is feasible, recycling of chemicals and solvents used in the facility, etc. For example, the histopathology lab at the University of Texas at Galveston uses a very modern distillation unit to reuse solvents from waste.[4] This helps save about 7 tons of chemicals for reuse. The result: a savings of $19,000 for the University and sparing the ecosystem from the possible damage that these chemicals could have caused if conventional disposal methods were used.

Apart from these initiatives, clinicians per se have a greater responsibility toward the environment because the link between human healthcare and environmental healthcare is inseparable. As Dr. Yellowlees has mentioned in his article, we always tend to think "I already do enough." For most ailing patients, clinicians are considered only next to God because they make life so much better for them. Being held in such an esteemed position, it becomes the clinicians' responsibility to go that extra mile to make sure that their modi operandi of medical practice is not only healing humanity but also the environment.

The statistics revealing the amount of pharmaceutical drug waste going into the soil and water bodies of our planet is mind-boggling. From numerous surveys, drugs, such as acetaminophen, verapamil, and hormones, have been found most commonly in water bodies throughout the United States.[5] These and many more chemicals from pharmaceutical drugs have been found to adversely affect a variety of aquatic life-forms. Humans are also adversely affected because water treatment plants do not completely remove these medications.

Most of the time, such instances of drugs polluting the environment have been found as a result of the ignorance of the consumers. A survey was carried out on 301 patients in the outpatient pharmacy setting.[6] Out of these, more than half of the patients flushed the unused medications down their toilets. Of note, less than 20% of the patients were given advice about proper disposal of unused medications by their healthcare providers. It is here that the clinicians play a very major role. Apart from the routine examinations and treatments, it is essential that clinicians take some time out during each appointment to inform patients about the proper disposal of the prescribed medications in case of expiry, or return any unused medication to the collection centers. In fact, the problem of pharmaceutical pollution could be nipped in the butt itself. This can be done by prescribing only the required amounts of medications, prescribing starter packs first and then going on to refills, periodically checking the compliance of the patient to the prescribed drug, and prescribing environmentally friendly medications. Clinicians could volunteer to organize and maintain medication collection points to collect unused medications from the patients and direct them to the proper sources for disposal, or recycling.

Making healthcare greener is not just the sole responsibility of clinicians. Pharmaceutical companies also need to work hand in hand in order to achieve this. Who would know more about the product than the manufacturers themselves? Pharmaceutical companies definitely need to pay their dues to the environment, too. They go to great lengths advertising their products, and spend thousands of dollars getting the product literature printed and colorful product labels made. They also hold product launching ceremonies and parties, and have endless presentations to educate clinicians and consumers about how effective the drug is going to be, or how much better the drug is compared with that of a competitor company. However, it is very sad that little is done in the way of educating consumers and clinicians as to how the unused or expired drug should be disposed.

The controlling bodies of the pharmaceutical industries in all countries should make it mandatory to print on the product label, instructions with regard to appropriate methods of disposal of the medication. In places where pharmacies/clinics dispense the medications with an additional recommended dosage/dose label, a list of collection centers for returning unused drugs could also be included.

However, despite making healthcare green being an age-old, burning environmental issue, it is still in its infancy in the healthcare realms of some developing and third-world countries. Apart from primarily making healthcare accessible in such places, it becomes the responsibility of the governments to embrace good "greening" policies at the outset itself to prevent further damage to the environment.

Taking initiatives like these and standing up in support for such a cause could go a long way in caring for our Mother Earth and preserving a pristine environment for our own children and grandchildren.

I thank Dr. Yellowlees for initiating such a thought-provoking topic in this medical forum.

Shaheen E. Lakhan, MS, MEd, AFACB, MICR, PhD, MD (c.)
Executive Director
Global Neuroscience Initiative Foundation (GNIF)
Los Angeles, California
slakhan@gnif.org
http://slakhan.gnif.org

References

  1. Yellowlees P. Green healthcare: what does the future hold. Medscape J Med. 2008;10:157. Available at: http://www.medscape.com/viewarticle/576903 Accessed August 4, 2008.

  2. Yellowlees P. Green healthcare: what is happening now. Medscape J Med. 2008;10:157. Available at: http://www.medscape.com/viewarticle/576710 Accessed August 4, 2008.

  3. Yellowlees P. Green healthcare -- why not. Medscape J Med. 2008;10:157. Available at: http://www.medscape.com/viewarticle/576543 Accessed August 4, 2008.

  4. Harris S. Going green. AAMC Reporter. October 2007. Available at: http://www.aamc.org/newsroom/reporter/oct07/green.htm Accessed August 4, 2008.

  5. Boehringer SK. What's the best way to dispose of medications? Pharmacist's Letter. 2004;20. Available at: http://www.epa.gov/esd/chemistry/ppcp/images/pharmacist/pdf Accessed August 4, 2008.

  6. Seehusen DA, Edwards J. Patient practices and beliefs concerning disposal of medications. J Am Board Fam Med. 2006;19:542-547. Abstract

Author's Reply:

I am in complete agreement with all of the excellent comments and suggestions made by Dr. Lakhan. There is an increasing body of evidence suggesting that pharmaceuticals and personal care products are significant pollutants of our water systems.[1] I agree that correct disposal of unused medications is essential, and that as a profession we do not do nearly enough to ensure that this happens. My own clinical practice for a number of years has been asked to tell patients to bring any unused drugs in when they consult me, and I then send them to the pharmacy for destruction, but like most doctors, I have not in the past routinely asked about this issue and am sure I could have done a lot more. There are actually federal guidelines,[2] which were published in 2007 by the Office of National Drug Control Policy, that are a useful start, although my personal view of these guidelines is that they need significant revision as they promote pharmacy take-back programs only after suggesting that drugs either be taken out of their containers and thrown in the trash, put in impermeable bags and discarded, or -- if the label instructs -- flushed down the toilet. Surely this is the wrong order because the evidence suggests[3] that pharmacy take-back programs should be the primary approach taken in this matter, as they are the only way of completely preventing aquatic pollution. Relevant professional organizations should also promote their own guidelines and policies on this matter.

California has taken an important lead in this issue, acknowledging that "currently there are few safe and convenient ways for consumers to dispose of unused prescription drugs. Nearly all unused pharmaceuticals enter either our solid waste system or our sewage system. Neither disposal methods are environmentally sound.[3]" In November 2007, Governor Schwarzenegger signed SB 966 (Simitian), which is designed "to begin the process of establishing a state-wide solution for the growing problem of improper disposal of unused and expired pharmaceutical drugs by creating model disposal programs and requiring the California Integrated Waste Management Board to report back to the legislature on their potential.[3]" Other states should follow this approach, and physicians should promote these legislative initiatives.

Dr. Lakhan makes a number of useful comments about the responsibility of the pharmaceutical industry in this area, with which I fully agree. It would seem a straightforward matter to have "disposal guidelines" routinely inserted in product information. I would be interested in comments from any readers on this, particularly those involved in the industry.

Peter Yellowlees, MD
Professor of Psychiatry
University of California, Davis
peter.yellowlees@ucdmc.ucdavis.edu

References

  1. Green pharmacy: preventing pharmaceutical pollution. J Ecologically Sustainable Med. Spring/Summer 2007. Available at: http://www.teleosis.org/pdf/symbiosis/Intro_EcoTox4.2.pdf Accessed August 5, 2008.

  2. Office of National Drug Control Policy Web site. Available at: http://www.whitehousedrugpolicy.gov/drugfact/factsht/proper_disposal.html Accessed August 5, 2008.

  3. Pharmaceutical waste in focus. Californians Against Waste Web site. Available at: http://www.cawrecycles.org/issues/pharmaceutical Accessed August 5, 2008.


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