Pharmaceuticals have been detected in water systems across the globe, contributing to the rise of antibiotic-resistant superbugs that are no longer treatable. Is there a solution?
At age 25, Vanessa Carter was involved in a severe car crash in Johannesburg. The accident fractured every bone on the right side of her face, launching her into a multi-year ordeal involving numerous reconstructive surgeries.
Six years later, Carter received a prosthetic implant to rebuild her cheekbone. She thought the worst was behind her. However, one day, she noticed pus leaking from her face. It turned out to be an infection that persisted for nearly a year.
"I was taking antibiotics, I was seeing my doctors, but nobody could give me answers," she told DW. "And all this time this bacterial infection was basically eating away at the tissue on my face."
The cause, it emerged, was MRSA — methicillin-resistant Staphylococcus aureus — one of a growing number of superbugs that antibiotics can no longer combat.
A looming global crisis with 10 million deaths per year
Antimicrobial resistance — the process by which bacteria, viruses, fungi, and parasites evolve to resist the drugs intended to kill them — has been classified by the UN as a major global health threat.
By 2050, drug-resistant superbugs could cause 10 million deaths annually. If not addressed, they could result in costs of $412 billion (€352 billion) per year by 2050 and reduce global GDP by $3.4 trillion annually over the next decade.
One factor driving their spread is the misuse or overuse of antibiotics in healthcare. Another is antibiotic pollution in the environment.
"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," said Alistair Boxall, an environmental science professor at the UK's University of York. "That resistance will be getting back into our bodies."
Drugs have been found all over the world
Pharmaceuticals have been identified in rivers and soils globally. A recent study, in which Boxall participated, tested river water at over 1,000 locations across 104 countries.
"We searched for 61 different pharmaceuticals and apart from a very small number of sites, we found pharmaceuticals everywhere," he said.
The only sites free of drug residues were Iceland and a remote village in the Venezuelan rainforest, where Indigenous residents do not use modern medicines.
Everywhere else, researchers discovered high levels of the diabetes drug metformin, along with antibiotics and medications for depression, epilepsy, pain, and allergies. A quarter of the sites had pharmaceutical levels deemed harmful to wildlife.
How are drugs ending up in the environment?
When we take medication, our bodies absorb only part of it. The remainder is excreted and enters sewage systems. Antibiotics are also frequently overprescribed and overused. Humans consume over 30,000 tons of these drugs annually, with about a third ending up in rivers.
Many wastewater treatment plants are not designed to fully eliminate these substances, so traces pass through into rivers, lakes, and soils.
Globally, just over half of all wastewater is treated before release.
In many lower-income countries, treatment systems are limited or nonexistent, meaning contamination is often worse in parts of sub-Saharan Africa, South Asia, and Latin America.
Pharmaceutical manufacturing plants are another pollution source, as is agriculture. Large quantities of drugs are given to farm animals. Some estimates suggest that at least double the amount given to humans is used for livestock. When their manure is spread as fertilizer, nearby waterways can become contaminated.
One village's win might clean up waterways across Europe
To view this video please enable JavaScript, and consider upgrading to a web browser that supports HTML5 video
The effects on wildlife can be severe.
Research from North America found that synthetic hormones in the contraceptive pill caused the "feminization" of male fish in one waterway, leading to reproductive failure and population collapse. Another UK study found that the antidepressant Prozac caused starlings to lose their appetite and libido.
What are solutions to counter antimicrobial resistance?
Upgrading wastewater treatment is a key part of the solution.
In many Western countries, this would require an additional treatment level — using chemicals or activated carbon filters, for example, to capture those pharmaceutical compounds.
But advanced treatment consumes a lot of energy, potentially increasing greenhouse gas emissions. It could also create other toxic compounds in the process.
Coronavirus: traces in wastewater
To view this video please enable JavaScript, and consider upgrading to a web browser that supports HTML5 video
And "it does cost a lot of money," Boxall added.
Still, the European Union is moving forward. Under its Urban Wastewater Treatment Directive, member states will be required to upgrade treatment plants in the coming years, with 80% of the cost covered by the pharmaceutical and cosmetics industry — a provision that has faced strong opposition from the pharmaceutical lobby.
The EU has also introduced rules to reduce pharmaceuticals in surface and groundwater and will require member states to monitor antimicrobial resistance in wastewater.
In the US, the Environmental Protection Agency has for the first time moved to include pharmaceuticals on a list of drinking water contaminants.
But Boxall says change is not happening quickly enough and that advanced filtering is not realistic for poorer countries, which often face the worst pharmaceutical contamination.
Does biodegradable medication exist?
Klaus Kümmerer, a professor of sustainable chemistry at Leuphana University of Lüneburg in northern Germany, believes the answer lies in designing drugs that fully degrade after serving their function in the human body.
"That would be the gold standard: mineralizing to carbon dioxide and water," he said.
His team has developed anti-cancer drugs that biodegrade completely in wastewater treatment plants. They have also patented two biodegradable alternatives to the antibiotic Ciprofloxacin, which is considered particularly difficult to break down.
Once their antibiotic has done its job and reaches the bladder, the change in pH or acidity triggers the degradation process.
But the antibiotic never reached the market.
"We as a small university working group, we cannot develop a compound and bring it on the market. Now industry has to step in," said Kümmerer.
Designing cleaner drugs and not relying on costly wastewater treatment upgrades is the real long-term solution to pharmaceutical pollution, he believes. But using fewer pharmaceuticals in the first place — meaning using medicines more carefully and doctors prescribing only what is strictly necessary — is also important.
"Antibiotics do not kill viruses and viruses are responsible for a cold," said Kümmerer.
"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 seven days if you don't."
This article was based on an episode of Living Planet produced by Natalie Muller. Listen to the full episode here.
Edited by: Jennifer Collins