These 10 lifesaving medical products are contributing to climate change

Dolutegravir is a key HIV medicine used by over 22 million people in 110 low- and middle-income countries. But this lifesaving drug is also contributing to climate change. By 2030, Unitaid estimates dolutegravir-based treatment regimens will contribute 2.7 megatons of greenhouse gas emissions annually. This is based on the manufacturing, amount of chemicals used, and energy required to produce these medicines, multiplied by the number of people — 30 million — expected to be receiving this treatment on a daily basis by 2030. According to Unitaid Director of Results Vincent Bretin, producing 1 kilogram of this treatment’s active pharmaceutical ingredient releases 314 kg of carbon dioxide in the atmosphere. But it’s not the only one. In its report released on Tuesday ahead of the 28th U.N. Climate Change Conference, or COP 28, Unitaid identified that the supply chain for dolutegravir-based treatment and nine other lifesaving products — medications for HIV, tuberculosis, or malaria; diagnostics; long-lasting insecticide-treated bednets; and medical oxygen — are contributing huge amounts of emissions in the atmosphere, at over 3.5 million tons. This is larger than the emissions of the city of Geneva, which was 2.6 million tons in 2019, Bretin said in a statement sent to Devex. “The irony here is that a sector that strives to keep people well is also contributing to the problem,” Unitaid spokesperson Herve Verhoosel said in a statement. Why is this important The report provides additional insights into how health supply chains are contributing to the planet’s carbon emissions, which are harmful to people’s health and are the main drivers of climate change. According to Unitaid, these health aspects are “often overlooked” and the study aims to fill the gaps in research. But it also offers solutions to reduce these emissions, such as improving manufacturing processes. One example is solvent recycling. Each kilogram of dolutegravir requires almost 400 kg of solvents. Bretin said recycling and reusing them would significantly reduce emissions. This, combined with other solutions such as heat integration and continuous manufacturing to improve the creation of active pharmaceutical ingredients, could abate up to 15% of carbon emissions at no additional cost to manufacturers, he said. Other solutions include switching to renewable energy, and redesigning packaging, such as using bulk packaging for long-lasting insecticide-treated nets to reduce single-use plastics. According to Bretin, there are efforts now from both manufacturers and buyers to move away from single-use plastic packaging, but not yet on the new generation of bed nets studied in the report. “Bulk packaging is not yet a possibility due to a lack of evidence on product stability,” he wrote to Devex. He said these solutions could reduce emissions generated by the 10 products by 70%. The report also identifies waste treatment at manufacturing sites to prevent the leakage of toxic materials into the environment, as well as recycling to reduce plastic waste. Long-lasting insecticide-treated nets generate over 57,000 tons of plastic waste yearly, according to Bretin. “Plastic waste is damaging to the environment, and can also create breeding sites for mosquitos, fueling the very issue that bed nets are meant to address,” he said. Plastics continue to be used in the production of bed nets, but he said, “There are very early-stage efforts to explore using recycled plastics and bio-based alternatives.” What requires further attention While the report identifies the emissions in the production of 10 lifesaving products, it also sheds light on the risks climate change poses on the availability and efficacy of some of them. Artemisinin-based combination therapies are first-line treatments for malaria in most malaria-endemic countries. One of the main ingredients of this treatment, artemether, comes from a plant cultivated in China. But the plant is sensitive to climate conditions and may contain less active ingredients when exposed to heat and dry weather. The drug also faces supply chain risks in India, where most of it is manufactured. About 75% of the manufacturing sites for the drug in India that have received WHO prequalification — which means they have been assessed for quality and safety — are located in two specific regions in the country where there’s elevated flood risk. Additionally, when it’s transported to countries, the drug can lose efficacy when exposed to heat. This can pose problems as the planet gets hotter. For example, heat waves in Nigeria, a country that accounts for nearly 27% of the global malaria burden, are expected to increase 2.5 times by 2050. According to the latest Lancet Countdown report, the world is on track to reach 2.7 degrees Celsius of heating by 2100. “The conditions of storage of ACT are a major risk in a country like this,” Bretin said. However, efforts are being made to address the risks of heat waves on the supply chain. One example is Unitaid investing in heat-stable carbetocin, which is used for the prevention of postpartum hemorrhage — severe bleeding after childbirth, which is a leading cause of maternal deaths worldwide. While oxytocin is considered the gold standard medication to prevent and treat postpartum hemorrhage, it requires cold storage, which isn’t ideal in many low-resource settings. “Heat-stable carbetocin can be used in areas where the quality of oxytocin cannot be guaranteed due to insufficient or unreliable cold chain systems, making it both a critical health intervention and more resilient to climate change,” Bretin wrote. Update, Nov. 30, 2023: This article has been updated to clarify that heat-stable carbetocin is used for the prevention of postpartum hemorrhage.