Send a voice message to LivingPlanet
Subscribe to the podcast here: Living Planet Podlink
TRANSCRIPT:
Vanessa: There was a car that overtook us on the wrong side of the road and our car went into a violent spin and hit into a concrete wall.
Vannessa Carter was in the passenger seat. Twenty-five years old. Driving through Johannesburg. She says that moment changed everything.
Vanessa: I had multiple injuries. I broke all the bones in the right side of my face. I had a traumatic brain injury. I ruptured my intestines, I fractured my pelvis, I hurt my neck and my back. And so it was a very long recovery from there.
She lost her right eye, and went through surgery after surgery to reconstruct her face, working with a string of different doctors and specialists...
Vanessa: … maxillofacial surgeon, plastic surgeon, ENT surgeon and so on, to work with me to implement different types of prosthetics… And so it was a very long recovery from there.
Six years after the crash, she received a prosthetic implant to reconstruct her cheekbone.
But then, while out shopping one day, something alarming happened.
Vanessa: When I got into my car, there was a whole lot of moisture on my face and I pulled down the rearview mirror and there was pus seeping out everywhere, and so I panicked.
She hurriedly dialed the number of her plastic surgeon.
It was an infection.
She needed another surgery to clean the prosthetic and prevent the infection spreading.
Vanessa: The infection had eaten away a little bit of the lower eyelid at that point in time.
The surgery seemed to work. At least at first.
Vanessa: But two weeks later I was readmitted again for an emergency surgery because the infection had come back again. And this kind of went on for 11 months…
Eleven months - with an infection that kept returning again and again.
Vanessa: I was taking antibiotics, I was seeing my doctors, but nobody could give me answers. And all this time this bacterial infection was basically eating away at the tissue on my face.
Eventually they had to remove the prosthetic. And they sent it off for testing to find out what the problem was.
Vanessa: And so this kind of rang alarm bells because I was like: Why is this infection so special? You know, why do they need to send it for testing? I mean we know it's an infection, why are these antibiotics not working?
She soon got her answer - when the pathology office sent her the test results.
Vanessa: And at the very top it said MRSA -- methicillin resistant Staphylococcus aureus. I could not pronounce that at that point in time. But I got onto the Internet like most patients do, and up came this term: antibiotic resistance.
MRSA – the culprit behind Vanessa’s infection – is just one of a growing number of superbugs that have evolved to be resistant to certain antibiotics.
That means these drugs stop working, and even minor infections can become difficult to treat - or deadly.
The World Health Organization has called antibiotic resistance one of the most “complex and frightening health challenges of our time.”
And it says without urgent action, drug-resistant infections could claim 10 million lives annually by 2050.
So why is this happening?
One reason is the overuse and misuse of antibiotics – in our healthcare systems and also in animal agriculture.
Another driver is pharmaceuticals ending up in the environment, creating the right conditions for superbugs to develop and spread.
You might think this pollution is a problem for places near drug manufacturers, or hospitals, or factory farms. But pharmaceuticals have been detected in rivers and soils just about everywhere in the world.
The rise of drug-resistant superbugs is just one part of the story.
Pharmaceutical residues leaching into the environment are also affecting wildlife – changing the way they behave and grow.
So how do we fix this?
That’s what we’ll be looking at in this episode of Living Planet. I’m Neil King.
We’re in a national park in central England. It’s idyllic here – a clear stream winds through rolling green hills. There’s moss near the water’s edge, and trees stretch overhead, casting dappled shade over the soft ground… This is the Peak District.
Alistair: Which is a really beautiful area... You know, it's in a sort of treed area flowing through the trees, there’s footpaths along it where the public go for a stroll.
That’s Alistair Boxall, a professor of environmental science at the University of York in the UK. He hasn’t come here to take a stroll, though … he’s here on business, as part of a project testing the water in national parks across the country.
Alistair: That water looks very, very clear. Very, very clean, very inviting. If you're a kid, you could go for a paddle in it.
But when he takes a sample from this idyllic stream back to the lab, the results surprise. him.
Alistair: That stream had levels of pharmaceuticals higher than we've measured anywhere in London.
Here’s what they found: high levels of metformin – used to treat type 2 diabetes, as well as paracetamol, caffeine, antihistamines and the antiepileptic drug carbamazepine.
For some drugs, the concentrations were at levels considered harmful for fish, invertebrates and algae.
Alistair: So you can have effects cascading up the food chain.
They also found antibiotics – in amounts high enough to promote the development of drug-resistant superbugs.
The cocktail of drugs in that small stream in the English Peak District isn’t particularly unique.
It also chimes with a much larger study Alistair was involved in – this time looking at pharmaceuticals in rivers around the world. They tested more than 1,000 sites in 104 countries.
Alistair: It covered every continent. And basically what we did was we searched for 61 different pharmaceuticals and apart from a very small number of sites, we found pharmaceuticals everywhere. And I think that's really a reflection on the fact that we as a society use a large number of pharmaceuticals, both as human medicines but also as veterinary medicines.
The only sites where no drug residues were found were Iceland…. and a remote village in the Venezuelan rainforest where the indigenous people don’t use modern medicines.
Alistair: ...very upstream in the Amazon. So it's a place that was pretty much unaffected by Western society.
Almost everywhere else, they found high levels of the diabetes medicat ion metformin, as well as antibiotics, and drugs used to treat depression, epilepsy, pain, inflammation and allergies. A quarter of the sites had active pharmaceutical ingredients at levels considered harmful for wildlife.
So how are drugs ending up in the environment?
When we take medication, whether it’s an antidepressant, a painkiller or antibiotic, our bodies only absorb part of the drug. The rest is excreted in our urine or feces and ends up in sewage systems.
That’s where most pharmaceutical pollution from humans begins.
Because many wastewater treatment plants aren’t designed to fully remove these substances, traces of drugs can pass through - and end up in rivers, lakes, and other parts of the environment.
Globally, just over half of all wastewater is treated before it’s released.
And in many lower-income countries, treatment systems are limited or lacking altogether.
Alistair says that’s why contamination from drugs is much worse in parts of sub-Saharan Africa, in South Asia and Latin America.
Alistair: It’s where you have poor wastewater treatment systems if you have it, or no wastewater connectivity. So you've basically got raw sewage going straight out into the river.
The global population is growing – and it’s aging. That means the amount of drugs being taken around the world is only going to go up. Growing access to cheaper medicines has also led to more pharmaceuticals entering the sewage system.
Discharges from pharmaceutical manufacturing plants are another source of pollution. And then there’s agriculture and livestock farming. Large amounts of drugs, including antibiotics, are also used to treat farm animals. And if their manure gets spread over fields as fertilizer... soils, crops and nearby waterways can become contaminated.
Drug residues in the environment may be invisible, but they can wreak havoc on wildlife.
Even small doses can be enough to mess with how animals behave, reproduce and grow.
One well documented case in the 90s caused the decimation of vulture populations in India.
Alistair: A lot of environmental forensic work was done to try and find out what that was, you know, was it climate change? Was it a bacterial infection? But the conclusion at the end of the day was it was down to a chemical called diclofenac
Diclofenac – an anti-inflammatory drug that was being used to treat cattle.
Alistair: And when the cattle were dying, the vultures were coming in, they were consuming the carcass and they were exposed to the diclofenac.
India used to have tens of millions of vultures. But in the space of just a few years, the population plummeted by over 95%. It’s believed to be the fastest decline of a bird species in recorded history. They’ve since banned the use of diclofenac in cattle. They’re also trying to reintroduce the vultures.
Alistair: I think it sort of shows how careful we need to be in terms of chemicals in the environment and how much more observant we need to be to try and understand, you know, when we use a chemical, what it might be doing to the environment.
There are other examples. Research out of North America showed that the synthetic hormones in the contraceptive pill found in one waterway caused what’s known as the feminization of male fish - resulting in reproductive failure and population collapse. Another study, this time from the UK, showed that the antidepressant Prozac caused starlings to lose their appetite and libido.
But when drugs end up in the environment, it’s not just a problem for local plants and animals. It also affects us.
A study looking at the Indian vultures estimated that the near extinction of these crucial scavengers allowed deadly bacteria and infections to spread, leading to the deaths of about half a million additional people over five years.
And then there’s the rise of drug-resistant superbugs.
Alistair: We are detecting antibiotics, you know, quite widely in the environment around the world. So that includes rivers. It's also been detected in soils.
And, just to recap, bacteria exposed to this drug pollution in the environment can then develop defenses to it.
Alistair: The big worry is if that resistance then finds its way back into the human population. So I don't know, perhaps you irrigate a crop with water that contains these bacteria. And then we consume the crop or perhaps we drink some water that contains these genes. That resistance will be getting back into our bodies. And then if we get sick and we need to use antibiotics, you know, potentially it will make the use of those antibiotics less effective…So the antimicrobial resistance crisis.
The antimicrobial resistance crisis.
It’s been singled out as a major global health challenge by the UN.
Not only could it cause millions more deaths. It also comes with a hefty economic burden. The UN says that, if left unchecked, drug-resistant infections could cost us 412 billion-dollars annually by 2050 and shave 3.4 trillion dollars off GDP per year in the next decade.
One important factor here is the overuse of antibiotics. That boosts the risk of bacteria in our bodies developing resistance to these life-saving drugs.
Humans consume more than 30,000 tons of antibiotics a year. Around a third of that ends up in rivers. And that’s just us. Some estimates suggest at least more than double that amount of antibiotics are used on farm animals.
It’s not yet clear how big the link is between human health and antimicrobial resistance in nature. It’s an area that needs more research. But the UN says there is growing evidence that the environment “plays a key role in the development, transmission and spread” of superbugs.
Vanessa: Before I had this resistant infection, I was like everybody else and I always thought that antibiotics cured everything. And I think this is a huge problem in society.
Vanessa, who we heard from at the start of the episode, spent three years fighting a drug-resistant infection of Staphylococcos aureus – MRSA. In the end she was given multiple last resort antibiotics in two-week rotations until one finally worked.
Vanessa: I was very lucky that they did end up resolving it, but not a lot of patients have those same opportunities, and in fact, many of them die.
For Vanessa, that experience was a turning point.
Until then, she says, she had never even heard of antibiotic resistance. But after everything she’d been through, she couldn’t stop thinking about it - and about how little people seemed to know.
Vanessa: This really frustrates me that this thing called antibiotic resistance was not common knowledge. I decided to start small – I got into social media and I started advocating. I was one of the first patient advocates posting saying ‘ We don’t know what this thing called antibiotic resistance is!’
That was in 2013.
Today, she’s the chair of the World Health Organization’s Task Force of antimicrobial resistance survivors. She also founded a charity in the UK, where she lives now, to share the stories of other patients.
Vanessa: I've heard so many stories, so many patient stories where their life changed in a second. And not just, not just from somebody lying in a hospital bed, but I mean, I've heard stories where somebody'd been infected from a farm.
It's something that you can get from animals, livestock, the community and in human health. If it ends up in the waterways, if it ends up in the soil, if it ends up all over the place, you know, umm, this is where we're going to end up with an antibiotic... I mean, I don't know like to use word apocalypse…
So what can we do about it?
If most of our pharmaceuticals are entering the environment through sewage, then improving wastewater treatment is a key part of the solution.
In lower- and middle-income countries - where treatment systems may be limited or even non-existent - Alistair says the focus should be on simple, decentralised approaches: systems that are low-cost, low-maintenance, and practical to run.
Alistair: They might not perform quite as well as a nice shiny wastewater treatment works, but they'll probably perform enough to bring the concentrations down.
In many Western countries, capturing pharmaceuticals in wastewater would require adding an extra level of treatment – and using chemicals or activated carbon filters, for example, to get these compounds out.
But this kind of advanced treatment uses a lot of energy, potentially adding to greenhouse gas emissions. It could also create other toxic compounds in the process. And there is another major stumbling block…
Alistair: Financial cost. So it does cost a lot of money.
But this is something the EU is trying to roll out nonetheless. Under its Urban Wastewater Treatment Directive, member states will be required to upgrade wastewater treatment plants in the next few years… and 80% of the cost is to be covered by the pharmaceutical and cosmetics industry. That last detail has hit a lot of resistance – not least from the pharmaceutical lobby.
The EU also has new rules for monitoring and reducing pharmaceuticals in surface and groundwater. And member countries will be required to monitor antimicrobial resistance in wastewater.
Over the pond, the US Environmental Protection Agency has moved to include pharmaceuticals on a list of contaminants in drinking water for the first time, which could lead to new limits on those substances for water utilities.
But Alistair says change isn’t happening fast enough.
Alistair: I really think we need to think more globally. And you know, work with these other regions to help fix the problem because, with antibiotics, if we don't do that, we're never going to solve the problem of antimicrobial resistance. We need to be protecting the whole planet and not the just the bits where we live.
He’d also like to see better monitoring of waterways around the world so that we can keep track of how drug concentrations fluctuate and affect the environment over time.
Alistair: It's just, it's hidden. That's part of the problem because, you know, people don't realise what's there and I think because they can't see it, they're less concerned about it and because they're less concerned about it, you know, the decision makers are under less pressure to actually fix the problem...
I think the danger is if we just let this carry on, then the quality of the environment will degrade. You know, we're already seeing species decline and it could be that pharmaceuticals are contributing to that.
Stopping the flow of drugs into the environment is going to mean expensive changes to the way we treat wastewater. And advanced filtering is something that’s probably not realistic for poorer countries that often have the worst pharmaceutical contamination.
But what if, instead of trying to capture these pollutants, we designed them differently? What if they were biodegradable?
Klaus: We started this about 20 years ago and everyone laughed about us…
Klaus Kümmerer is a professor of sustainable chemistry at Leuphana University in Luneburg, in northern Germany.
Klaus: … especially the pharmaceutical industry said, ‘that will never work.’ And I said, ‘do you have data? Please send them over. Then there is no need to investigate.’ They said, ‘we don't have data, but we know.’ And I said, ‘I'm a scientist, I will try.’ And we also could have failed.
Klaus and his team have been working for years to develop more environmentally friendly drugs. This is a concept known in the sustainable chemistry field as “Benign by Design.”
Klaus: We need pharmaceuticals. They are the basis of our high living standard and health and these then we need to design from the very beginning for that day after they have fulfilled their service and function in our human body that they are degrading in the environment - fully degrading. That would be the gold standard: mineralizing to carbon dioxide and water.
Drugs that decompose. Klaus says it goes against the pretty dominant idea that pharmaceuticals should be stable at any cost - a feature that allows them to stick around in the environment for a long time. But, Klaus says it doesn’t have to be that way.
His team has developed anti-cancer drugs that biodegrade completely in wastewater treatment plants. They also developed and patented two biodegradable alternatives to the antibiotic Ciprofloxacin, which is considered particularly difficult to break down.
Klaus: So in the human body it should not be stable for years. A few days, sometimes a few hours is sufficient and then it should be excreted and then it could already start in the bladder.
That’s how it works: Once their antibiotic has performed its job, and reaches the bladder, the different pH or acidity there triggers the degradation process … allowing it to partially break down into carbon dioxide and water.
Klaus: And the activity with antibiotics is very important because if we excrete active antibiotics, which we normally do, we can foster resistant bacteria everywhere, and these come back to us in terms of resistance.
So if more antibiotics were biodegradable, that could curb antibiotic resistance in the environment.
The research team’s antibiotic never made it to market.
Klaus: We as a small university working group, we cannot develop a compound and bring it on the market. Now industry has to step in. But we have shown it's feasible, it's possible and now we see also within the last two or three years that pharmacists associations, and pharmacists, pharmacy professors at universities are very much interested in the topic.
He says there is a gradual transition happening towards greener drugs. And there’s also interest from patients.
Klaus: I think it's, it's now going nicely forward - after 20 years... I'm quite optimistic. The pressure increases, increases, and someday, and maybe in 20-30 years, it will be the new normal.
He says he’d like to see stronger incentives for companies developing more sustainable drugs - things like fast-tracked approval processes, or longer patent protections that could boost returns.
In his view, that’s the real long-term solution to pharmaceutical pollution - designing cleaner drugs from the outset, rather than relying on costly upgrades to wastewater treatment systems.
Klaus: We have learned that with this advanced treatment stage we are approaching a limit that cannot solve the problem. It creates problem, postpones problem into the future, needs a lot of energy and resources.
...You can also think about, what does upgrading of sewage treatment cost compared to what we could do with this money in the development of new compounds? Which would be a much more elegant solution. It would be not a smart solution. It would be a wise solution. As Albert Einstein said: a smart person solves a problem, a wise person avoids it. I have the age now to be a little bit more wise.
And one more thing that could make a big difference: using fewer pharmaceuticals in the first place.
Klaus: We have to start at the beginning of the pipe, I call it.
That means using medicines more carefully, and doctors only prescribing what is absolutely necessary.
Klaus: So if you have caught a cold, a lot of people think I need an antibiotic. Antibiotics do not kill viruses and viruses are responsible for a cold . And so this needs to be understood better and also applied better in education of medical doctors, but also with patients. We have to inform them. And my grandma used to say: If you are sick with a cold or something like this, it takes about a week if you take pharmaceuticals and it takes about 7 days if you don't.
It’s obvious, but drugs that aren’t consumed in the first place are drugs that don’t end up in the environment. That also saves energy and resources across the healthcare system - which matters, given that healthcare, including pharmaceuticals, accounts for around four and a half percent of global greenhouse gas emissions.
And of course, the best way to avoid using pharmaceuticals is to do what we can to stay healthy. Wash hands regularly to reduce the risk of infection and make sure vaccinations are up to date.
Vanessa: Today even, I mean, I'm 47 now. Any signs of infection… And I still have that ... I don't want to, I don't know if I should label it as PTSD, but I mean, I still have that fear… of what if? You know, umm, because it's not just a case of the three years. You live with that trauma for the rest of your life.
Vanessa says her experience with antibiotic resistance has made her more vigilant. She’s careful about washing hands and keeping surfaces clean. And if she’s prescribed antibiotics, she makes a point of discussing with her doctor whether they’re really necessary, and what the risks of resistance might be.
Vanessa: Antibiotics are a miracle cure because at the end of the day, at the end of my story, it was antibiotics that saved me and saved my life and got me through those surgeries. However, you know, we take them for granted….
I mean, we've got hotels that just, for example, say we clean your room every second day. We actually consider the environment. We consider climate change.
Why are we doing that for, for this kind of topic, because this is about human health… they always talk about, you know, ‘we've gone green.’ I was booking a hotel this morning. It was like ‘we've gone green.’ Would you like a green hotel? (laughs)
Yeah, okay, well, you know, where do we get to in terms of that with antibiotic use, not just in humans, but in animals?
So, you know, let's use them wisely to make sure that we can cure the illnesses that we need to at the time that we need to.