Eliminate Discarded Pharmaceuticals in Drinking Water:
The Public Health Awareness Campaign.
By Don Mitchell
April 1, 2013
University of Memphis
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Eliminate Discarded Pharmaceuticals in Drinking Water:
The Public Health Awareness Campaign.
EXECUTIVE SUMMARY
The quality of drinking water is diminishing. The unsafe practice of disposing unwanted
pharmaceuticals and personal care products (PPCPs) into the sewer system is one of the leading causes of
tainted water quality. Waste water treatment plant effluents allow PPCPs into ground waters that
eventually sieves into drinking water aquifers. The lack of better filtration technology and stricter
detection limits compounds the waste water effluent problem. Literature reviews and data collected by
Murray and colleagues, (2010) found that, “Trace pollutants referred to as, emerging contaminants (ECs)
have recently been detected in the freshwater environment and may have adverse human health effects.”
Most state Public Health Departments list primary prevention tenets according to Kovner and Knickman,
(2011) as those of, “Helping people avoid the onset of a health condition and injuries” when it comes to
protecting the public. This public health department policy is not confined to just the clinical definition
but also The U.S. Department of Health and Human Services definition where “policies, programs,
services, and research… conditions in which the population can be healthy” (p. 739). At the federal level,
policies regarding research on PPCPs have been implemented but few policies on prevention or curbing
the improper disposal of PPCPs at state levels have been realized. Policy guidelines appear to be mixed
at best and state public health directors lack program initiatives regarding PPCP contamination. A cost
effective means of delivering a public health message would be through a public service campaign. Its
message is specifically designed to help eliminate PPCPs from being flushed Down the Drain and further
burdening the waste water treatment facilities. Campaigns to increase public awareness about PPCP
contamination would work very well with populations in urban, rural areas and will help kindle a dialog
between state and federal stakeholders on permanent remediation efforts.
The subsequent analysis will examine three policy alternatives: (1) the status quo policy, (2) other state
policies, and (3) the Down the Drain policy. Policies are evaluated by: effectiveness, efficiency, equity
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and political feasibility. This assessment determines that The Tennessee Public Health Director should
adopt the “Down the Drain” public awareness campaign and closely work with the Governor for
remediation of the PPCP problem. The Down the Drain public awareness campaign would be cost
effective because it eliminates start-up costs by utilizing existing U.S. Environmental Protection Agency
approved literature. Services can be equitably distributed throughout urban and rural populations
whereby everyone receives intervention equally. Positive political feasibility would be met with
enthusiasm because the health risk associated with PPCPs affects all stakeholders including residents, law
makers and elected officials equally. “Organized community efforts aimed at the prevention of disease
and promotion of health that focus on society” according to researchers Kovner and Knickman, (2011)
defines—public health. The “Down the Drain” public health message will accomplish The State of
Tennessee’s Public Health Department defined and stated goals of disease prevention and health
promotion.
INTRODUCTION
Disposal of unused or unwanted pharmaceuticals and personal care products (PPCP) is an emerging
and complex environmental issue for preserving citizen’s safety and the quality of drinking water.
HISTORY
The research of PPCPs has dated back to 1970s and has included health risks to humans, plant life and
animals. Recent research by Koplin (2002) confirmed “contaminants being found in 80% of the streams
sampled” (p. 1) and Seiler, Zaugg, Thomas and Howcroft (1999) indicated that “aspirin, nicotine and
caffeine have long been found in sewage treatment facilities effluents”, (p. 405). Data from researcher,
Barnes, et al. (2008) has shown the most frequently detected compounds in U.S. groundwater include
“insect repellant, plasticizer, phosphate, fire retardant, veterinary and human antibiotics” (p. 193).
McLachlan, Simpson and Martin (2006) studies “have shown that male fish in detergent-contaminated
water express female characteristics, turtles are sex-reversed by polychlorinated biphenyls (PCBs), male
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frogs exposed to a common herbicide form multiple ovaries” (p. 1). Testimony provided before U.S.
Congress by Soloman (2010) indicated that the “source of hormonal contaminants in water is steroids
used in livestock operations which contribute to widespread environmental contamination” (p. 8). Subtle
consequences on marine life are bothersome as well, Daughton and Ternes, (1999) issued the following
warning, “effects on aquatic organisms is particularly worrisome because effects could accumulate so
slowly that major change goes undetected until the cumulative level of these effects finally cascades to
irreversible change” (p. 907). Middleton and Ambrose (2008) research indicated, “Migratory waterfowl
are increasingly becoming immune to antibiotics from tainted surface waters” (p. 338). Farm workers
and U.S. food supplies are also potentially affected by PPCPs as shown by Graham, et at. (2009) report,
"The carriage of antibiotic resistant enteric bacteria by flies in the poultry production
environment increases the potential for human exposure to drug resistant bacteria.
Management implications include the need to work toward removing more of these
compounds during wastewater treatment processes, possibly by increasing solids retention
times or implementing reverse osmosis” (p. 2701).
Other studies of wastewater treatment plants have shown that “phthalates, estrogens and steroids may
pass through treatment facilities without degrading” (Drewes & Hemming 2008) & (Alatriste-Mondragon
2003). The Tennessee Division of Water Resources report in 2012 has indicated, “The most common
mechanism for their [PPCPs] entry into the environment is through wastewater discharges” (TN Division
of Water Resources, 2012). Waste water treatment by itself is not enough for safe discharges with the
subsequent discharging of PPCPs into U.S. waterways. Wastewater treatment plants and septic systems
are generally not designed to treat discarded pharmaceutical waste, new nano-products or micro pollutants
because of the extra fine particulate matter. This PPCP water contamination phenomenon is a worldwide
event which affects drinking water globally and poses a health hazard for our citizens and the state.
THE CURRENT STATUS QUO FOR REMEDIATION
National Level of Preparedness
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The U.S. Environmental Protection Agency has known of the PPCP problem since the 80s and has
authorized further analysis. The U.S. Food and Drug Administration has also recognized the problem but
has inadvertently sent mixed messages on the solutions; one of which was disposal of pharmaceuticals by
flushing.
State of Tennessee Preparedness
In 2012, the State of Tennessee recognized the potential hazards to drinking water caused by PPCPs.
There are no permanent policies locally or statewide for the recognition or remediation of PPCPs. The
State of Tennessee has ordered testing on effluent discharges of waste water treatment plants at various
locations which will be conducted by the University of Tennessee and federal grant money. The report is
expected to be released by June 2013. In absence of any concrete findings by University of Tennessee
and with the plethora of existing reports and data suggesting the dangers associated with PPCP
contaminations, it seems reasonable to make assumptions that the Tennessee water quality is also
diminishing.
Organizational Issues
The Tennessee Department of Public Health must be willing to take the lead on problem solving with
the absence of any federal policy because of the expressed concern for its Tennessee citizens. With the
absence of any meaningful state policy an awareness campaign can start with public utilities mailing
brochures to citizens notifying them of the associated dangers of flushing PPCPs into the sewer system.
Coordinating all stakeholders for state wide coverage of campaign mailers is crucial. Program
implementation must be statewide, with local jurisdictions and private business as partners. Most cities
and counties have either public or private water distributors as well as solid waste disposal infrastructure
in place. Mailers will accompany billing statements. Sparsely populated rural areas may require
additional mailers because they do not use public or private services. The U.S. EPA has a website:
http://www.epa.gov/ppcp/ dedicated for informational means on best practices.
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POLICY GOALS

The policy goal of “least cost” method of efficiency of state resources.

Policy goal should be one of social justice in equitable distribution and meet basic needs.

Policy goal should be a better health outcome for all state populations.

Policy goal should meet with political feasibility.
Alternate Policy (PPCP Public Awareness Campaign)
Mailers should use the EPA’s designed awareness policy. See appendices 1. Participation by all utility
companies offering water services, sewage treatment or solid waste pick up should be mandatory. In rural
areas where residents use “self-sufficient” services; those residents can be notified by county tax records.
COMPARISON OF THE ALTERNATIVES DISCUSSION
Currently, there are no listed permanent policies for the State of Tennessee in correctly disposing of
unwanted pharmaceuticals and personal care products. The following dialog compares the status quo
policy (or no policy) with a proposed public awareness campaign known as Down the Drain. Down the
Drain public awareness will be effective, efficient, equitably distributed and generate better health
outcomes with the state wide populations as well as stimulate positive political feasibility for the
program. The objective of PPCP remediation will be to create a proactive program approach versus a
reactive approach. The short term objective is to have a permanent program in place rather than a
planned one day National event for collections. The short term program of Down the Drain would lead to
a permanent policy and a longer term approach of strengthening waste water treatment plants ability to
detect and eliminate PPCPs at nano levels.
GOALS
Effectiveness is to maximize population health from PPCP tainted drink water. Efficiency is a mix of
public programs that maximize health outcomes at the least cost. Equity will be equal for all state
residents because the current system has left the entire population exposed to the growing dangers of
PPCPs and the potential threat of drinking contaminated water. Improved Public Health in state
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populations would exist under the Down the Drain campaign. The current status quo policy is not
acceptable in terms of better health outcomes in populations which mandated under the Tennessee Public
Health Departments creed. Political Feasibility would materialize under the Down the Drain public
awareness campaign because of its low cost and politically attractive nature and a need for state law for
remediation and subsequent strengthening of waste water treatment plants. See Table 1.
EVALUATION AND RECOMMENDATION
It is recommended that the State of Tennessee proceed with the Down the Drain PPCP remediation
program. The Tennessee Department of Public Health will be held responsible for its content and
direction. Public Service announcements will be instituted statewide at minimal cost through TV / Radio
and media website public service messages. Mailers to citizens would be cost effective because larger
metropolitan cities in Tennessee have public utilities and send out monthly billing statement. Many of the
state utility companies are profitable and are one of the few generating revenue on a permanent basis.
These companies can afford to endure the cost of Down the Drain campaign without any specific state
funding. Those cities would include a “message statement” within their customer’s utility bill. Rural
areas have private water wells that have been drilled by private well drillers; those businesses would be
made responsible for mailers and incur the cost to be considered as the cost of doing business. Most state
residents would be informed and all state residents’ public health would be better served with higher
quality drinking water.
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Table 1.
Alternative policy Recommendation
Effectiveness
Efficiency
Equity
Political Feasibility
* a few states have an ad hoc PPCP policy in this region;
Arkansas & Georgia have ad hoc and not very informative
(no state policy); Kentucky, Alabama and Mississippi have
no policy.
1
Current TN
status quo
policy
no policy
no policy
no policy
no policy
2
3
Other state
policies*
Down the
Drain' policy
yes*
yes*
yes*
yes
yes
yes
yes*
yes
Definitions: Population perspective
Effectiveness: extent to which healthcare improves
the health of patients and populations
Efficiency: evaluates these improvements in relationship
to the resources required to produce them
Equity: health disparities and the fairness and
effectiveness of the procedures for addressing them.
Political Feasibility: policies favored by constituents
Table by Don Mitchell, Definitions provided by:
Aday, Lu Ann, et al. Evaluating the healthcare system:
effectiveness, efficiency, and equity. Chicago: Health
Administration Press, 2004.
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Appendix 1
US EPA Website Poster
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References
Aday, Lu Ann, et al. Evaluating the healthcare system: Effectiveness, efficiency, and equity.
Chicago: Health Administration Press, 2004.
Alatriste-Mondragon, F., Gavala, H., Iranpour, R., Stenstrom, M. K., & Ahring, B. K. (2001).
Biodegradation and Toxicity of Phthalate Esters during the Anaerobic Digestion of
Wastewater Sludge. Proceedings of the Water Environment Federation, 2001(13), 902920.
Barnes, K. K., Kolpin, D. W., Furlong, E. T., Zaugg, S. D., Meyer, M. T., & Barber, L. B.
(2008). A national reconnaissance of pharmaceuticals and other organic wastewater
contaminants in the United States--I) groundwater. Science of the Total Environment,
402(2), 192-200.
Daughton, C. G., & Ternes, T. A. (1999). Pharmaceuticals and personal care products in the
environment: agents of subtle change?. Environmental Health Perspectives, 107(Suppl
6), 907.
Drewes, J. E., Hemming, J., Ladenburger, S. J., Schauer, J., & Sonzogni, W. (2005). An
assessment of endocrine disrupting activity changes during wastewater treatment through
the use of bioassays and chemical measurements. Water Environment Research, 12-23.
Graham, J. P., Price, L. B., Evans, S. L., Graczyk, T. K., & Silbergeld, E. K. (2009). Antibiotic
resistant enterococci and staphylococci isolated from flies collected near confined poultry
feeding operations. Science of the Total Environment, 407(8), 2701-2710.
Honoré, P. A., Wright, D., Berwick, D. M., Clancy, C. M., Lee, P., Nowinski, J., & Koh, H. K.
(2011). Creating a framework for getting quality into the public health system. Health
Affairs, 30(4), 737-745.
Kovner, A. R., & Knickman, J. R. (2011). The current US health care system. Jonas and
Kovner's Health Care Delivery in the United States, New York: Springer Publishing.
Kolpin, D. W., Furlong, E. T., Meyer, M. T., Thurman, E. M., Zaugg, S. D., Barber, L. B., &
Buxton, H. T. (2002). Pharmaceuticals, hormones, and other organic wastewater
contaminants in US streams, 1999-2000: A national reconnaissance. Environmental
science & technology, 36(6), 1202-1211.
McLachlan, J. A., Simpson, E., & Martin, M. (2006). Endocrine disrupters and female
reproductive health. Best Practice & Research Clinical Endocrinology & Metabolism,
20(1), 63-75.
Middleton, J. H., & Ambrose, A. (2005). Enumeration and antibiotic resistance patterns of fecal
indicator organisms isolated from migratory Canada geese (Branta canadensis). Journal
of wildlife diseases, 41(2), 334-341.
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Murray, K. E., Thomas, S. M., & Bodour, A. A. (2010). Prioritizing research for trace pollutants
and emerging contaminants in the freshwater environment. Environmental pollution,
158(12), 3462-3471. Abstract retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/20828905
Planning and Standards Section, Division of Water Resources, Tennessee Department of
Environment and Conservation (TDEC).2012 305(b) Report; Status of Water Quality in
Tennessee. Retrieved from
http://www.tn.gov/environment/wpc/publications/docs/2012_305b.pdf
Seiler, R. L., Zaugg, S. D., Thomas, J. M., & Howcroft, D. L. (1999). Caffeine and
pharmaceuticals as indicators of waste water contamination in wells. Ground Water,
37(3), 405-410.
Soloman, G. M. (2010, February). Endocrine disrupting chemicals in drinking water: risks to
human health and the environment. In Testimony on Behalf of the Natural Resources
Defense Council before the US Congress, Committee on Energy and Commerce,
Subcommittee on Energy and the Environment. Retreived from
http://www.nrdc.org/health/files/hea_10022501a.pdf
U.S. EPA resource page. EPA website. Retrieved from
http://www.epa.gov/ppcp/
USGS resource page. USGS web site. Pharmaceuticals, Hormones, and Other Organic
Wastewater Contaminants in U.S. Streams. USGS Fact Sheet FS-027-02. June 2002.
Retrieved from http://toxics.usgs.gov/pubs/FS-027-02/
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