A few days ago, while listening to a radio programme, I learned that the composer and conductor Gustav Mahler died of sepsis, aged only 51. He died in 1911, before antibiotics were available for treatment, in the pre-antibiotic days, a direction in which we are we are heading again unless we consider changing when and how we use them. It always amazes me how slow society is to avert crisis situations such as antimicrobial resistance (AMR), although we have evidence about the pollution and impact of pharmaceuticals in the environment and the growing threat of AMR. We need to act to protect not only ourselves, but also our environment and other species.

^{HCWH Exec. Director Anja Leetz at Politico's recent AMR:Averting Tomorrow's Nightmare Event}

We know that pharmaceuticals in the environment are a global pollution problem - over 631 different pharmaceutical agents or their metabolites have been detected in at least 71 countries on all continents.[1] It is with reason that the Strategic Approach to International Chemicals Management (SAICM), a UN Environment Programme, in October 2015 adopted environmentally persistent pharmaceutical pollutants as an emerging issue that should be addressed under this UN programme.

So what can be done to avert the threat of AMR?

1. First, we need to understand that APIs (active pharmaceutical ingredients) in medication are designed to be biologically active, therefore they will have an impact in the environment by design – as they pass through the system of humans and animals with these pharmaceutical ingredients unchanged. The best we can do is to move towards green pharmaceuticals and to create new products that are benign by design. This will have to be the goal and gold standard for the pharmaceutical industry in the future. Until we get there we need to apply risk mitigation strategies and minimise pharmaceuticals entering into the environment throughout the life cycle (in their production, use, and disposal phases).
2. Pharmaceutical companies need to take full responsibility for their supply chains and clean up the production side of the industry to end this type of pollution. This is a particular problem for companies in China (who produce 80-90% of antibiotic APIs) and India, as highlighted in a report by SumofUs[2].
3. Our regulatory system is dysfunctional. We need to strive for coherence of legislation – for both human & veterinary medicine, within the Water Framework Directive (only 3 pharmaceuticals on the watch list, but not on the priority list and no thresholds have been set), and in soil protection and animal husbandry. A good starting point for this work would be to apply the 10 policy recommendations suggested by Mistrapharma[3] in Sweden.
4. We need a systematic monitoring of the occurrence and effects of pharmaceuticals in the environment and transparent publishing of data (currently there is no public access to environmental risk data, but also national authorities have no exchange of data [for example between the European Medicines Agency (EMA), the European Commission (EC), and national authorities] and any data that does exist often sits in authorities drawers and is not used).
5. We need to harmonise legislation and regulations relating to human and veterinary medicine. For example, a risk-benefit-analyses for human medicine is needed, as it exists already for veterinary medicine.
6. Last resort antibiotics (drugs given when all others have failed to create a response in the patient) should not be given for veterinary use, but only for humans, as defined by the WHO  - we know that 2/3 of all the antibiotics used in Europe are used in livestock farming, not for human treatment. This needs to change. People need to know that this use impacts on the potential increase the threat of AMR for humans.
7. Finally, we need to majorly raise awareness at all levels, so that we, as citizens, can make choices during treatment and disposal. We may not always need drugs for an illness (we should adapt the rational use concept) and we should all be made aware of how to dispose of unused and out-of-date drugs safely. This may vary from country to country, but one thing that rings true for everybody in all regions is that you should never ever flush unused drugs down the sink or toilet. What seems like common sense needs to be taught to children and adults alike.

The One Health approach (which recognises that health of humans, animals and ecosystems are interconnected) offers many opportunities to address the challenges of AMR, but it needs all stakeholders to take action and go beyond statements. The recent vote on veterinary legislation in the EU Parliament was the first test to see if policy-makers are prepared to take bold actions. In the end we will be judged by our deeds. Only if society at large truly understands the cost and health implications of AMR, and challenges both the industry and legislators to act, will we see any real change. Gustav Mahler could have lived and finished his 10^th symphony if antibiotics had been available when he was alive. Lets make sure we avert future catashrophies so that we do not end up in a pre-antibiotic age again.

 - Anja Leetz, Executive Director, HCWH Europe

Read More:

• Check out our Pharmaceuticals in the Environment Infographic here.
• Search our Pharmaceuticals in the Environment project website to understand the pollution challenge.
• Read more about the SumOfUs report ‘Bad Medicine’ here.
• Look at the WHO factsheet on AMR
• Read the paper: Improving Environmental Risk Assessment for Human Pharmaceuticals
• Watch the TEDx Talk: The Coming Crisis in Antibiotics
• Watch the TEDx talk: Our Drugs in Their Water

Preview Image: Global Panorama via Flickr CC