In 1989, Noel Brown, director of the New York office of the United Nations Environment Programme said that unless the global warming trend was reversed by 2000, rising sea levels could wipe entire nations from the face of the earth (Spielman, 1989); in 2005, ‘experts’ at the United Nations University claimed that there would be up to 50 million environmental refugees by 2010 (BBC News, 2005); in 2009, British prime minister Gordon Brown disclosed that negotiators had 50 days to save the world from global warming (BBC News, 2009); and in 2011 Prince Charles warned that there were 96 months to save the world (Verkaik, 2011). These predictions invite the inference that while there is a healthy debate to be had around the science concerning the environment, resorting to futurology contributes little.
An evidence-based approach to how human activity is endangering the environment suggests that in the context of the pharmaceutical industry much remains to be done. For example, Bartolo et al (2021) cite research showing that in 2015 the pharmaceutical industry's aggregate global emission was an estimated 52 million metric tons of carbon dioxide equivalent (MMTCO2Eq), while the automotive industry generated 46 MMTCO2Eq. And Bartolo et al (2021) anticipate that climate change will place extra demands on healthcare systems and the pharmaceutical industry, with, for example, raised temperatures fuelling increased pollen concentrations, more cases of asthma and greater demand for asthma medication.
In this respect it is interesting to consider Janson et al (2020), who note that in the 1990s, metered dose inhalers (MDIs) that contain chlorofluorocarbons were replaced with dry-powder inhalers (DPIs) and MDIs containing hydrofluorocarbons (HFCs). Although HFCs are not ozone-depleting, they are potent greenhouse gases, and Janson et al (2020) indicate that in 2017, 70% of all inhalers sold in England were MDI, compared to 13% in Sweden. Applying the Swedish DPI and MDI distribution to England, say Janson et al (2020) ‘would result in an annual reduction of 550 kt CO2e. The lower carbon footprint of DPIs should be considered alongside other factors when choosing inhalation devices.’
And according to Wilkinson et al (2019), MDIs contribute around 3.9% of the carbon footprint of the UK National Health Service (NHS), and they evaluated the impact of switching from MDIs to DPIs on greenhouse gas emissions and drug costs after analysing NHS prescription data from England in 2017. They found that if MDIs using hydrofluoroalkane (HFA) propellant were replaced with the cheapest equivalent DPI, for every 10% of MDIs changed to DPIs, drug costs would fall by £8.2M annually. But ‘if the brands of DPIs stay the same as 2017 prescribing patterns, for every 10% of MDIs changed to DPIs, drug costs increase by £12.7M annually’ (Wilkinson et al, 2019), and they conclude that most potential savings are due to less expensive long-acting beta-agonist (LABA)/inhaled corticosteroids (ICS) inhalers. Significantly, Wilkinson et al (2019) indicate that ‘detailed information about the carbon footprint of all inhalers is not publicly available.’
Despite the apparent extravagant environmental cost of MDIs, Panigone et al (2020) make clear not only that the certified carbon footprint of specific MDI products may differ significantly, but that MDIs may remain an essential option for many patients. Panigone et al (2020) aimed to both quantify the carbon footprint of 5 MDI and 2 DPI products and estimate the carbon footprint of the same products when manufactured with a new low global warming potential (GWP) propellant HFA152a. They not only found that the carbon footprint of ‘a specific series of MDI products is in the lower range or lower compared with what has been reported, underlining the need for proper quantification’, but that using innovative, low GWP propellants may confer environmental benefits rather than switching to DPI, and they speculate that with ‘the model used in the present study, an 85%–90% reduction in the carbon footprint of existing MDIs if transitioned to new propellants is envisaged’ (Panigone et al, 2020). Citing the announcement of environmentally friendly MDIs using low GWP propellants by 2025, Panigone et al (2020) underline the importance of how imaginative ‘green’ thinking can allow patients to access appropriate medications they need for the optimal continuity of their care.
It is rational approaches to climate change rather than alarmist conjecture that will help determine how we address environmental challenges.