As Founder and President of Health Care Without Harm and Practice Greenhealth, Gary Cohen works with health care companies to promote the health of people and the environment. He spoke with us about why environmental issues are relevant to health care companies, how this sector can address these issues (and learn from other industries that have done the same), and why it's important to reframe climate change as a health challenge.

"Do no harm" has long been used to guide the ethics of medical practitioners, but your organizations, Practice Greenhealth and Health Care Without Harm, have given that phrase new meaning. What are you hoping to accomplish through your work?

We believe that in order to address the epidemic of chronic disease in our society, we need to move upstream and address the environmental and social determinants that contribute to these diseases. Ultimately, we need to move toward a prevention model of health care, and the environmental health lens is the most powerful way to get there. Health care should be a role model for the transition away from toxic chemicals, fossil fuels, and junk food. Our sense is that health care needs to reposition itself to be an anchor for community health and resilience.

Given the number of important CSR issues for the pharmaceutical industry, including access to medicine, why should pharmaceutical and medical device companies focus on their environmental impact?

Given their mission to provide life-saving drugs to people on the planet, it's inconsistent for them to be polluting the environment and contributing to chemical exposure in the name of that healing mission.

What are the most serious environmental issues for health care companies?

The first issue is the enormous amount of toxic materials that are produced for every pound of drug. The waste-to-product ratio for pharmaceuticals is quite high. That contributes in the places of production to significant environmental pollution, and places that are part of the global supply chain show dramatic public health and environmental impacts. The second problem, which is even more ubiquitous, is that there are active pharmaceuticals in the drinking water for tens of millions of people. This reality is a largely uncontrolled drug experiment whose impacts we have yet to fully understand. For example, we're only just learning that low doses of toxic chemicals can have a profound impact on a developing child in the womb and in early years of life. The third one is related to the supply chain all around. Pharmaceutical companies need to understand the worker and public health and environmental consequences of pharmaceutical production, use, and disposal.

What actions do you recommend that companies take to address these issues?

In the short term, pharmaceutical companies need to understand how they render their current pharmaceutical use biologically inactive so that it doesn't raise risks of contaminating our drinking water. In the long term, they should be thinking about "designing in" from the get go. They should bring chemistry principles into the design process so that it's another indicator for how you make drugs.

When you discuss these issues with companies, how do you describe the business case for action?

There are a few pieces of the business case. The first is that reducing the amount of chemicals and water used in the production process saves them money and mitigates environmental compliance and liability issues. In the use of the drugs, it shows greater responsibility to their mission and their customers. In the disposal, it mitigates the risk of [potential] low-dose exposures and synergistic impacts of drugs and chemicals. Lastly, supply chain buyers will be increasingly requiring a higher level of environmental accountability. For example, last November, we were able to get the largest group-purchasing organizations in the United States together to have them ask the same set of questions of their supply chain. They are helping to create a consistent message to suppliers that there are chemicals they don't want in their products.

e spoke earlier about the potential threats the industry poses to the environment. On the flip side, what are some environmental challenges that might affect the operations of pharmaceutical and medical device companies?

First, water scarcity and the enormous amount of water that is used to make drugs. How do you deal with that in a water-scarce environment in the future? Second, understanding the disease patterns that will be related to climate change. Certain kinds of diseases will migrate to higher latitudes because of warmer climates, including dengue fever, Lyme disease, and malaria. In places like India, that could mean 100 million more people affected. The pharmaceutical industry is going to be challenged to show what it is doing to help.

What are the greatest opportunities for the pharmaceutical and medical device industries in the environmental space?

One of the [biggest opportunities] over the next five to 10 years is reframing climate change as a health issue. Mostly, it's been seen as an environmental and a national security issue, but the "externalities" of climate change as it relates to health have been left out. The imagery we have around climate change has a lot to do with polar bears on melting ice caps, and that's not really the way most people will experience it. They'll experience the spread of different kinds of chronic diseases and novel diseases as a result of climate and ecosystem disruption. The pharmaceutical industry has enormous global reach, [and they have the opportunity to] become champions for helping us understand the global public health dimension of climate change and become part of the solution in terms of adaptation and mitigation.

What can the health care industry learn from other industries' approaches to environmental challenges?

What we are seeing in a number of sectors is different learning curves. Some industries such as apparel and forestry are ahead of the curve due to pressures from environmentalists and labor unions. The learning from those industries is the power of coming together to find collective solutions. We're doing that now with all the hospitals who are saying, "We might compete for the same clients and patients in a city, but let's collaborate on how to support each other's efforts to detoxify our supply chain and reduce our carbon footprint." I think that's a meaningful way to collaborate.