Green Health - or how to get pharmaceutical pollution on the agenda?
To agenda the issue of pollution by pharmaceuticals and multi-resistant bacteria in The Netherlands Huize Aarde has been involving different actors of the water and medicine chain, as well as students from a number of universities. See below for a summary of the initiatives taken and the results achieved.
Main conclusion: after detection of the complexibility of the issue, the different sectors involved will discover that each sector is not in the position to solve the problem by itself.
Recommendations: as a fragmented approach is a major bottleneck to solve social dilemmas such as micro-pollution, a shared vision and more integration of policies is needed.
Summary of activities & results - 2003 to date

2016   The MEDUWA coalition has been extended to small companies and research institutes to co-develop innovative solutions in the whole medicine chain to prevent the emission of pharmaceuticals and multi-resistant micro-organisms to air, water, soil and food.
The MEDUWA-innovations include:
- a watershed information system to simulate the effect of measures on water quality;
- a
tool that express the level of contamination per treatment, animal, kilo of meat or liter of milk;
- herbal
and algal alternatives for antibiotics;
- treatment technologies for point sources;
- animal
monitoring to avoid medication;
- the
development of a bio-medicine for animals and humans.

2015   This year the University Medical Centre Utrecht UMCU) focuses in their project Green Pharmacy on awareness raising; the avoidance of wastage of medicinal products; and support to pilots for technical solitions, see their annual report (in Dutch). Huize Aarde is responsible for the awareness sessions.

At the UMC Groningen a seminar has been organised with the aim to get the subject of pharmapollution on the agenda of this hospital and its regional partners. Central topics include the influence of hospital wastewater on water quality; risks of medicines in the environment; contribution of health care institutions to the spread of antibiotic resistance; and the role of hospitals in order to prevent these contaminations. Huize Aarde contributed to this seminar.

2014   To increase risk perception by the health care sector, Huize Aarde has been presenting the issue of pharmaceutical pollution to laboratory staff, officials of environmental and social responsible management, pharmacists and physicians at several Dutch and Colombian Hospitals.
The University Medical Centre Utrecht (UMC-U) started the icon project Green Pharmacy to limit the spread of medicines and medicin resistant micro-organisms in the environment.

2013   The RUG-students organised two national meetings for surface water authorities and drinking water companies to discuss their recommendations. The result of which was that the water authorities and drinking water companies agreed to pay more attention to source oriented measures.
Korienke Smit, Judith Muis and Johanna Heeringa present their analysis of the roles to be played in the medicine chain (photo SHA).

2012/2013   Master students Biomedical Science of Groningen University (RUG) Gijs Bijl; Korienke Smit; Judith Muis; and Johanna Heeringa, did research for the UvW; waterschap Vechtstromen; waterschap Friesland (Wetterskip Fryslân); and Huize Aarde on the new role of the water authorities in the product or medicine chain: to take an active role by communicating to all actors to assume their responsibility to lower pharmaceutical emissions at the source.
Partly on the basis of the research by the students, a monitor (in Dutch) was developed in order to follow the attitude and policy of various actors towards pharmaceutical pollution.

On November 19th 2012 SHA gave a presentation about MEDUWA at the Third International Conference on Sustainable Pharmacy in Osnabrück, Germany. SHA also co-ordinated the contributions from the Netherlands (two presentations and three posters).

2010   Huize Aarde started to participate in the project PACMem of Norit Process Technology and X-Flow BV (now Pentair BV). Other partners were Saxion University, waterschap Vechtstromen, and GMB Bioenergy. The project aimed at developing a small and integrated device for the treatment of sewage. Huize Aarde developed the concepts of Green Pharmacy (in Dutch)  and Green Chemistry (in Dutch), and persuaded the companies to pursue an integrated vision on micro-pollution and to develop source oriented solutions.

2011   Waterschap Regge en Dinkel (now waterschap Vechtstromen), together with the regional Pharmacists’ umbrella KNMP-Twente, made an inventory of the most frequently prescribed medicines in their region and measured these molecules in the local surface waters. High concentrations (more than 1 microgram/liter) were found of some pharmaceuticals (metoprolol, metformine and ibesartan) and one metformine-metabolite (guanylurea) up to 50 microgram/L. These activities were performed as a pre-pilot of MEDUWA.
As a result the pharmacists involved started thinking about replacing of some persistent pharmaceuticals (Oosterhuis M et al 2011, H2O nr 9 (in Dutch)). In addition to this more co-operation between water managers and health care staff is recommended. Moreover, an international publication on the prediction of pharmaceuticals in surface water using local sales data appeared, see Oosterhuis M et al 2013.
This was the first time that a close co-operation between a water authority and pharmacists took place in the Netherlands, setting a new level of problem analysis and problem solution in the field of pharmacautical pollution.
From the year 2010 members of the board of the Dutch Union of Water Authorities (Unie van Waterschappen, UvW) and officials of regional water authorities involved communicated about the MEDUWA-project on management level. This close cooperation of Huize Aarde with water authorities at regional and national level helped formulate their policy. UVW, in their "Statement on pharmaceuticals in water" in 2011 pointed out the importance of a source oriented approach of pharmaceutical pollution (such as rational use of medicines, and collection of unused medicines). Consequently the pharmaceutical industry and health care sector are expected to play an active role in this dossier.
This year Huize Aarde starts preparing an action research project “Source Oriented Separation of Pharmaceuticals in Hospitals”, SOSPharmaH. A broad group of actors is involved: Utrecht University, Utrecht Medical Centre, Delft Technical University and Kiwa Water Research, Nieuwegein. Also other academic medical centres are considering to participate. SOSPharmaH focuses on promotion (developing and testing) measures at the source (“before-the-pipe-measures”) that prevent and reduce discharge of, in particular halogenated X-ray contrast media, anti-cancer agents, antibiotics and antibiotic resistant organisms, in the sewer system by in- and outpatients of the participating hospitals.

2009   To stimulate awareness and discussion, various papers were published in Dutch journals of the water sector and 
the environmental sector. Also this website was started to provide information on various aspects of micro-pollution, and to disseminate reports of the research done by the trainees.
Saxion student Wouter Rademakers published a review about the effects of pharmaceutical contamination on water ecology in H2O nr 5 (in Dutch, download English translation); this review attracted national attention and was quoted on tens of websites, amongst them two websites of associations of pharmacists. The review was also submitted to the Directorates General for Research and Environment (Unit Protection of Water & Marine Environment) of the European Commission.
The Dutch Technical Commission on Soils, Ministry of Agriculture formulated a recommendation on new contaminants in the soil, inter alia on the basis of formentioned publication and an other publication from 2008 on cytostatics in surface water by Eri van Heijnsbergen, Utrecht University student (H2O nr 18, in Dutch, download English translation).
Meanwhile Huize Aarde started developing the MEDUWA (“MEDicines Unwanted in WAter”) methodology in close cooperation with water authority waterschap Regge en Dinkel (now waterschap Vechtstromen) and the Dutch Institute for Rational Use of Medicine. Later, also other Rhine East water authorities waterschap Reest & Wieden and waterschap Rijn & IJssel were involved in MEDUWA. The aim is to lower micro-pollution in soil, water, air and food through a joint effort by the health care, agricultural and water sector together. This approach requires a different role of the Water Authority at the regional and (inter)national scale. Water managers are required to share the problems with the other actors of the product chain.
The MEDUWA team is making a model of the medicine chain (photo: SHA)
As a result of this collaboration the Dutch Institute for Rational Use of Medicine has expressed its wish for an active role in the management of human and veterinary pharmaceutical contamination on a national and international scale.
2008   By Huize Aarde a national workshop was organised for a group of key researchers, policy makers and policy implementers, to formulate a strategy for an integrated approach to deal with the problem of pharmaceutical contamination, download its report (in Dutch). One of the results of this workshop was the formation of a coalition between the water sector and health care sector, leading to an action plan on a regional scale, see MEDUWA (2009).

2006   A symposium about pharmaceuticals in the environment was organised by Huize Aarde and Saxion University. Many of the participants were confronted with this issue for the first time.
In the same year the Ministry of the Environment invited Huize Aarde to discuss the issue of pharmaceutical contamination with all parties involved.

2005   Students of Saxion University of Applied Sciences, Enschede and Deventer have organised various workshops and meetings, for which different officials of the water chain and medicine chain were invited. During these workshops for the first time employees of water authorities (waterschappen) waterschap Groot Salland and waterschap Regge & Dinkel (now waterschap Vechtstromen) were acquainted for the first time with the issue of pharmaceutical pollution. Students also interviewed various officials in the field.
As a result, Saxion University meanwhile joined by Twente University, Enschede make this issue part of their courses on water quality management on a regular basis.
And as a consequence of the traineeships, in 2005 Huize Aarde was invited by the Rector of the Saxion University to investigate the feasibility for a lecturer in the field of micro-pollution. In 2009 this resulted in a lectureship Water Technology whith a focus on monitoring and elimination of pharmaceuticals.

2004   Student reports have been finished on:
- Health effects of antibiotics in the environment, by Nadine Dumke, Nils Jong, Jorne Troost;
- The impact of phthalates on the organism, by Dave Keunekamp, Niek Leus, Anouk Regeling, Remi Tibben;
- Indicators for psychosocial, economic and legal implications of health damage caused by man-made chemicals.

2003   Huize Aarde has offered students in various disciplines from a number of Dutch universities traineeships in the areas of micro-pollution and pharmaceutical pollution.