Journal of Human Security | 2017 | Volume 13 | Issue 1 | Pages 5–15

DOI: 10.12924/johs2017.13010005

ISSN: 1835–3800

Journal of

Human Security

Research Article

Emerging Security Challenges to Africa: The Case of

Haphazard Disposal of Pharmaceuticals in Ghana

Ken Emmanuel Ahorsu

* and Yvonne Esseku

Legon Centre for International Affairs and Diplomacy (LECIAD), University of Ghana, Legon, Ghana

African Collaborating Centre for Pharmacovigilance, Accra, Ghana. E-Mail: esseku@yahoo.com

* Corresponding author: E-Mail: [email protected]; k[email protected], Tel.: +233 208142882

Submitted: 13 July 2016 | In revised form: 28 November 2016 | Accepted: 3 January 2017 |

Published: 27 March 2017

Abstract:

The study of the Disposal of Unused/Unwanted Medicines Project examines ways in which

medicines are disposed of in Ghana and assesses how disposal methods can impact water resources.

The study showed a number of challenges: gaps in the legislative framework for the disposal of medicines;

environmentally-unfriendly methods of disposal of medicines; and large quantities of medicines potentially

disposed of indiscriminately with major impact on the environment. It recommends a review of the legal

framework to ensure the proper disposal of all unused medicines; policies to mop up excess medicines with

members of the public; review of prescribing and dispensing practices to reduce excess medicines; and

further research into the types of pharmaceuticals that are present and persist in the environment, their

effects and how they affect quality of life.

Keywords:

disposal of unused medicines Project (DUMP); environmental security; eco-pharmacovigilance;

Ghana; human security

1. Introduction

The concept of security, today, has become more inclusive,

holistic, and often conceptualised in global terms rather than

the hitherto realpolitik notion of national security. Issues

bordering on economics, socio-culture, migration, public

health, and the environment, among others, have become

integral parts of the security calculus with the view to safe-

guarding the welfare of citizens within nation-states and the

environment [

]. The 1992 Rio de Janeiro United Nations

Conference on Environment and Development (UNCED),

in particular, raised concerns about unsustainable develop-

ment and its inimical impact on the environment, people,

and society [

]. The expanded notion of security under the

banner of human security has increasingly been conceived

as a universal, interdependent, and people-centred norm

that focuses jointly on protecting people from fear and want

[

]. Direct and indirect causal links have been established

between human activities, environmental degradation and

climate change; and the transnational dangers therein to a

sustainable world [4–6].

Human beings and other living organisms interact ac-

tively with, and depend on the environment for their suste-

nance and survival. While the environment ecologically

recycles waste products, the disequilibrium caused by

human exploitation and dependence on the environment

undermines sustainable ecosystems. This, in turn, in-

creasingly inhibits the environment’s continued ability to

optimally support human life [

]. Human enterprises of-

ten introduce pollutants into the environment, either pur-

 2017 by the authors; licensee Librello, Switzerland. This open access article was published

under a Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/).

librello

posely or by accident, that affect the quality and quantity

of available natural resources such as water, arable land,

pasture, food, and air for breathing. Even seemingly pos-

itive practices such as the use of pharmaceuticals and

other chemicals for the treatment and improvement of the

quality of human life can result in pollution and seriously

threaten the environment and the quality of human life in

unforeseen ways [3].

This article is concerned with the disposal of pharmaceu-

ticals, the probable environmental degradation they cause,

and the real dangers they pose to the well-being of indi-

viduals, communities, and societies. Pharmaceuticals are

useful in the effective delivery of health care both for hu-

mans and for veterinary use. However, pharmaceuticals

enter the environment through consumption, metabolism,

and elimination through faeces and urine or through direct

disposal of excess or expired supplies [

]. While usage

of pharmaceuticals always comes with certain outcomes

in mind, there are often latent effects other than those en-

visaged by the consumer, dispenser, and prescriber. The

science and activities related to the detection, assessment,

and understanding of these unintended effects is known

as pharmacovigilance. In view of the frequency with which

these effects occur in the environment after elimination of

the product by the consumer, eco-pharmacovigilance has

emerged as a branch of pharmacovigilance in the study of

the unintended consequences of pharmaceuticals on the

environment.

The study of the impact of the presence and persis-

tence of pharmaceuticals on environmental security is

an emerging one. This article argues that while eco-

pharmacovigilance manifestations are ubiquitous, popu-

lations and environmental interdependence speciﬁcs cul-

turally bound in the maelstrom of social change, in turn

inﬂuence the former’s dynamics and adaptive responses.

People-environment interdependence differs from culture to

culture; so too does the nature of degradation and pollution

differ from one culture to the other. Africa and, for that

matter, Ghana, traditionally has a rich environment and bio-

diversity; however, with heightened social change, Africa’s

conservation movement does not incorporate the pressures

posed by the use and disposal of orthodox medicine. The

article, therefore, makes the case that the study of the

presence and persistence of pharmaceuticals in the envi-

ronment, as well as the potential human security threats

they pose to Africa is topical, and urgent.

The study investigates how unused pharmaceuticals

are disposed of, the state in which they enter the environ-

ment, and the potential effects they might have on water

resources and ecosystems, and subsequently on environ-

mental and human security. The article is organised into

the following sections: introduction, methodological consid-

erations, literature review, legal framework for disposal of

pharmaceuticals in Ghana, overview of the practice and

culture of pharmaceutical disposal in Ghana, hazards and

challenges of pharmaceutical disposal, case study of the

Disposal of Unused Medicines Project (DUMP), ﬁndings,

and the conclusion. The article looks at the ways in which

these pharmaceuticals are introduced into the Ghanaian

environment by conducting a case study of the Disposal of

Unused Medicines Project (DUMP) of the Cocoa Clinic in

Accra-Ghana that is run under the supervision of the Food

and Drugs Authority (FDA). Based on this case study, it

assesses the impact of both regulated and unregulated dis-

posal on the environment, examining how the presence and

persistence of pharmaceuticals in the environment affects

ecosystems and water resources. The article investigates

the various ways in which these effects impact environmen-

tal security.

2. Methodological Considerations

There is a dearth of studies on the subject in the Ghanaian

context. As such, the study reviews research conducted in

other parts of the world to project potential and probable

effects of pharmaceuticals on water resources and ecosys-

tems in Ghana. The paper adopts a qualitative case study

approach. We consider the case study method the most

appropriate, because, as stated earlier, while the manifesta-

tions of eco-pharmacovigilance are ubiquitous, populations

and environmental interdependence bordering speciﬁcs dif-

fer largely from culture to culture. The phenomenon of

regulated pharmaceutical disposal in Ghana is new and

quite technical, making the knowledge of its practice and

concepts not widespread. Given these conditions and limita-

tions, this study uses a small technical speciﬁc sample that

affords deep investigations in order to achieve an in-depth

understanding of the legal framework, concepts, practices,

beneﬁts, limitations, and challenges associated with the

disposal of unused medicines in Ghana. The Cocoa Clinic

in Accra, the Food and Drugs Authority (FDA), and the En-

vironmental Protection Agency (EPA), all of Ghana, are the

institutions engaged in the DUMP project. Semi-structured

interviews held in January 2014 with the clinical pharmacist

in charge of DUMP at the Cocoa Clinic, two ofﬁcials of the

FDA directly involved in DUMP, and an ofﬁcial of the EPA

responsible for the disposal of medical and industrial waste

provided primary data for the study.

The interview with the Cocoa Clinic ofﬁcial seeks to

discover the aim, concepts, processes, practices, and chal-

lenges of the DUMP project. It enquires about how, what,

which, when, and how much medicines were received, han-

dled, and disposed off from both the public and the Cocoa

Clinic. It ascertains if the unused, unwanted or expired

medicines collected were categorised before disposal; and

if the disposal facility is open to all segments of the pub-

lic or only to clients of the Cocoa Clinic. It also seeks to

know if banned narcotics and native drugs were sought

and collected in addition to the orthodox medicines, and if

they were, how they were handled. The interview further

seeks information on how unexpired medicines are handled

upon collection, how long the medicines collected are kept

before disposal, and whether or not the clinic was directly

involved in the actual disposal of the drugs. It also enquires

if ofﬁcials of the Cocoa Clinic visit the disposal sites and

attempts to discern any other challenges encountered by

the clinic in the running of the DUMP project.

The FDA is responsible for the regulation and practice of

the disposal of medicines and other chemicals in Ghana; it

administers the activities of DUMP in collaboration with the

Cocoa Clinic. The interview with the FDA seeks to ascer-

tain the efﬁciency of national guidelines on the disposal of

expired and unused medicines in Ghana; to know the differ-

ent sources from which unused and expired medicines are

received for disposal; and to assess the challenges the FDA

faces with respect to the effective disposal of medicines and

the environment’s safety. The interview also enquires as to

whether current disposal methods were at par with interna-

tional best practices. Questions were also asked pertaining

to costs associated with DUMP, collaboration with other

national agencies with respect to the disposal of medicines,

the general effects of indiscriminate and unregulated dis-

posal of medicines on the environment and society, and the

measures put in place to tackle these adverse effects.

The study also seeks to know the regulations relating to

the disposal of unused and expired medicines; the EPA’s

perspectives with respect to the disposal of medicines; and,

its roles in the DUMP Project. Questions in the interview

also focus on whether or not the medicines disposed of by

the EPA are categorised in any way before disposal. This

is important since different types of medicines often have

varied effects on the environment; and if the EPA has any

contingency plans for the mitigation of negative fallouts that

may arise as a result of the methods used for the disposal

of medicines. The EPA is also quizzed on the main dangers

that indiscriminate and unregulated disposal of medicines

poses generally to Ghana, and if there are any strategic

measures in place to counter such effects alone or in col-

laboration with other public agencies.

3. Literature Review

Earlier studies on the environment and security after the

two World Wars and the inception of the nuclear arms race

have focused on the promotion of positive peace through

sustainable development and living in harmony with nature.

As the Cold War realpolitik tapered away from the 1970s

into the mid-to-late 1980s, the ﬁeld emerged as ‘environ-

mental’ security, while acknowledging that environmental

factors play roles in violent conﬂicts[

]. Barnett deﬁnes

environmental degradation as “the process by which the

life-sustaining functions of the biosphere are disturbed.” [

]

The 1994 UNDP Report called for sustainable development

strategies to curb pollution, and to preserve and regenerate

the environment for future generations. Harmful chemicals

and other toxins are increasingly being introduced into water

systems by human activities [

]. Increased scarcity

and pollution of water sources, cost of water provision,

water-borne diseases, worm infestations, and dwindling

ﬁsh stocks have all been attributed to man-made pollution

[

]. Of late, pharmaceuticals have been increasingly found

in, and perceived as, major pollutants of the environment,

especially in water bodies making ‘pharmaceuticals in the

environment’ (PIEs) an integral part of environmental and

human security [8,14,15].

Holm, et al deﬁne eco-pharmacovigilance as the sci-

ence and actions related to the detection, assessment,

comprehension, and avoidance of adverse effects of phar-

maceuticals in the environment [

]. Pharmaceuticals enter

the environment through human, institutional and animal

consumption, excreta or disposal; they are disposed of as

unaffected compounds or active metabolites into sewer-

age systems or straight into the drainage system without

puriﬁcation. The mode of disposal notwithstanding, phar-

maceuticals have a probability of entering the human food

cycle and into surface and underground water bodies often

escaping puriﬁcation [17].

Once in the environmental media, pharmaceuticals

go through varied diminishing processes such as photo-

degradation, dilution, uptake by soil, and physiological and

anaerobic breakdown [

]. Nilsen et al, however, ﬁnd

the presence of pharmaceuticals in residue tests on the

Columbia, Willamette, and Tualatin rivers, numerous small

urban coves and the sewage of waste water treatment

plants (WWTPs) [

]. Presence of veterinary pharmaceu-

ticals were found in lagoons, underground water, soil, and

the run-off from farms and lands treated with mixtures of

pharmaceuticals [

]; showing that pharmaceuticals reg-

ularly endure in their original form or as metabolites in the

environment [

]. Kinney et al, ﬁnd the presence of phar-

maceuticals in both upstream and downstream WWTPs

with discharge samples studied showing that WWTPs are

not able to completely remove pharmaceuticals from waste

water [

]. Glassmeyer et al ﬁnd WWTPs as an important

origin of pharmaceuticals in the environmental media. In

circumstances where there are no WWTPs to treat chemi-

cals and pharmaceuticals, pharmaceuticals in their active

forms or as metabolites are openly discharged into the en-

vironmental media; and may affect all organisms they come

into contact with [24].

Watanabe et al find veterinary pharmaceutical antimi-

crobial Monesin, introduced to the environment by lactating

cows from flush lanes to lagoons and nearby underground

water sources [

]. This shows that Monesin persists in

water bodies and nearby soils. The impact of antibiotics

used in dairy production and their introduction in water

bodies, Boxall finds, may be responsible for producing

resistance in some microorganisms [

]. Monesin was, how-

ever, absent from dairy farm fields treated with manure,

suggesting absorption of monesin by soil particles and at-

tenuation under anaerobic circumstances. Davis et al in a

worst case scenario study, collected runoff water from soil

treated with pharmaceuticals before any attenuation could

take place and found all the pharmaceuticals present [21].

It demonstrates that soils treated with pharmaceuticals can

become a source of pollution of nearby surface water. It is

not clear what the long-term exposure and effects of such

non-therapeutic doses found in drinking water are.

Wu et al study the uptake of pharmaceuticals by agricul-

turally relevant plants that were grown in pharmaceutical-

treated hydroponic and soil systems and ﬁnd the presence

of pharmaceuticals in different concentrations in the plants

that were harvested [

]. Different components of plants,

and even entire plants, were examined. They ﬁnd that the

absorption of pharmaceuticals in the cases of some plants

or certain pharmaceuticals is extremely quick, attaining

equilibrium within four hours while some pharmaceuticals

took as many as 51 days. The traces and concentration of

the pharmaceuticals in the different parts of the plants were

signiﬁcantly different. It was less in scale along the contin-

uum of the roots, stems, leaves and seeds. The absorption

of pharmaceuticals from soil systems was not as decisive as

was the case in hydroponic systems; and that the presence

and concentration of pharmaceuticals in plants depend on

the frequency with which soils are spiked. Younger plants

exhibit higher chemical presence than the older ones when

the soil is spiked only once, but the presence and concen-

tration of chemicals are similar in both younger and older

plants when the soil is spiked repeatedly and the scale of

presence and concentration of chemicals in the different

parts are similar in both hydroponic and soil systems.

Guillette Jr. et al study the effects of endocrine disrupt-

ing contaminants (EDCs) such as pesticides on various

physiological characteristics and other features of alligators

in Lake Apopka (that witnessed a huge pesticide leak 40

years prior) and Lake Woodruff (unexposed to pesticides),

both fresh water bodies located in Florida, USA [

]. The

studies show alligators in Lake Apopka laying fewer eggs

and showing lower survival rates for both hatchlings and

juvenile alligators over the years, relative to those of Lake

Woodruff. The results also demonstrate that some EDCs

are capable of changing both endocrine and physiological

characteristics of alligators; affecting certain organs and pro-

ducing stunted hormones essential for survival and repro-

duction; thus reducing male alligator genital sizes [

]. A

chemical such as trans-Nonachlor, by itself may reverse sex

whereby male alligators becomes female [

]. When alliga-

tors are exposed to a combination of chemicals such as p,p-

DDE and trans-Nonachlor, there is no sex change despite

the high presence of the latter. The effects of chemicals on

reptiles depend on the level of the chemical’s concentration

and other environmental conditions such as changes in

temperature. As such, the presence, concentration, and

effects of pharmaceuticals can only be accurately predicted

when their entry into the environment is scrutinized and

regulated. Other studies have found that exposure of ﬁsh

to female human hormones in bodies of water, often results

in feminisation of male ﬁsh [

]. The near annihilation

of Southeast Asian vultures has been traced to their con-

sumption of dead cattle that had earlier been treated with

the pain killer, Diclofenac [31,32].

UNEP identiﬁes the oil industry in the Niger Delta Region

of Nigeria as the main source of extensive contamination

of the region with severe ramiﬁcations for the people of

Ogoni [

]. Aworawo observes that “drill cuttings, drilling

mud, the ﬂuids used to stimulate production, the chemicals

injected into the earth to control corrosion or to separate oil

from water and the production of general waste” gas ﬂares

and hazardous efﬂuents are responsible for the constant

pollution of land and water bodies in the Niger Delta region

[

]. Uneasily degradable chemicals, construction of ﬂow

lines and trunk networks, oil terminals, creation of waste

pits and barrow pits, oil spillage as a result of old corrosive

pipes, human error and sabotage, equipment failure, and

unceasing ﬂaring of natural gas have resulted in surface

and underground water pollution, other ecological damage

and violence [

–

]. The net effect of oil production and

petroleum wastes has resulted in the presence and con-

centration of organic chemicals such as phenol, cyanide,

sulphide-suspended solids, chromium, and biological oxy-

gen that degrade water bodies, soil and air, thereby posing

countless health challenges to the people of the region [

In Ghana, the mining of gold and other precious minerals

takes place across the country but is mainly concentrated

in the greenstone and alluvial regions of Birim, Tarkwa and

the Ofﬁn, Pra, Ankobra, and Tano rivers and their tribu-

taries: the main locales for food and cash crop farming. The

culture of mining is inherently, intensively, and irreversibly

destructive to the environment, poisoning the environment

with enormous quantities of hazardous chemicals such as

mercury and cyanide, degrading arable land through inap-

propriate and wasteful working practices, depleting forest

and eroding soil cover, poisoning underground and surface

water bodies, and undermining livelihoods and the health

and safety of communities [

]. The use of Mercury and

cyanide and their presence in the mining environs are ad-

versely affecting biodiversity, ﬁshing, and farming [

–

Farming and ﬁshing communities in mining areas are ex-

posed to neurological disorders as a result of consuming

food and ﬁsh produced from soils and water bodies polluted

by mercury use in mining [42].

On the occurrence and persistence of pharmaceuticals

in the environmental media and the quality of water bodies

in Ghana, Abruquah, et al, carried out a pioneering study on

how the residents of Konongo-Odumasi in the Ashanti Re-

gion dispose of their unwanted medications and the probable

effects these medications and their disposal practices have

on the environment [

]. They employed judgement sampling

and interviewed 500 residents and found that 38% of those

interviewed disposed of their discarded medication by bury-

ing; 29% put them in their domestic garbage and disposed of

them; 7% burnt them; 4% flushed them down the toilet; and,

only 1% returned their unwanted medications to the pharma-

cies [

]. The findings of the study imply that a high 71% of

the respondents disposed of their redundant medicines by

dumping them straight into the environmental media.

As stated earlier, environmental security has risen to

the fore as the concept of security has shifted to a more

human-centred approach. The exigencies of ecological

degradation may be felt locally and globally, and often in-

tersects with other components of human security such

as public health and food security. Pharmaceuticals in the

environment, over sometime, pose potential risk to human

and other consumers higher up the food chain [

]. These

effects impact on the health of ecosystems, and pollution

of this nature often leads to environmental insecurity and

unsustainable development [3,17].

4. Legal Framework for the Disposal of Medicines in

Ghana

The disposal of medicines in Ghana is regulated by the

Public Health Act, 2012 (Act 851) [

]. Under Act 851,

the disposal of pharmaceuticals falls within the remit of the

Food and Drugs Authority as provided for under Section

132, Closure of Premises and Safe Disposal of Unwhole-

some Regulated Products:

The Authority shall, order the closure of any premises

where articles regulated by this Part are manufac-

tured, stored, prepared or sold, if the Authority has

reason to believe that the articles are exposed to the

risk of contamination or deterioration, and the Au-

thority may make a further order appropriate in the

circumstances.

The Authority shall supervise the safe disposal of an

unwholesome regulated product at a fee determined

by the Authority.

A person shall not dispose of an unwholesome regu-

lated product without the supervision of the Authority.

A person who contravenes subsection 3 shall pay a

ﬁne of not more than ﬁve thousand penalty units to

the Authority.

Section 148 of the Act empowers the FDA to provide guide-

lines “for the destruction of an adulterated food or drug”

and “for the seizure and disposal of products regulated

under this Part.” The Act does not, however, insist on ad-

herence to disposal methods and procedures that protect

the quality of the environment in general or that of water

resources. The choice of appropriate methods and proce-

dures for the preservation of the environment and water

bodies are therefore left to the environmental conscious-

ness and judgement of the ofﬁcials of the FDA. Prior to the

passage of the 2012 Public Health Act, the EPA was, by de-

fault, responsible for the eco-friendly disposal of medicines,

chemicals and industrial waste. The establishment, func-

tions, and responsibilities of the EPA are enumerated under

the 1994 Environmental Protection Agency Act, (Act 490).

Under Section 2, the EPA is:

“to secure by itself or in collaboration w ith any other

person or body the control and prevention of discharge

of waste into the e nvironment and the protection and im-

provement of the q uality of the environment” and “to pre-

scribe standards and guidelines relating to the pollution

of air, water, land and any other forms of environmental

pollution including the discharge of waste and the control

of toxic substances”.

By virtue of these provisions and in the absence of

clearer provisions, the EPA became responsible for advis-

ing other institutions including the FDA on the judicious

disposal of medicines to better protect the environment.

The provisions of Act 851 specifically provide for the dis-

posal of unused, expired or unwanted medicines held by

commercial facilities and supply points but not for those held

by members of the public. This lacuna poses a number of

dilemmas to individuals as to what to do with their unwanted

medications. Moreover, since the eco-friendly disposal of

such unwanted drugs comes at a cost, the cost may most

probably serve as a disincentive for eco-friendly disposal.

5. The Practice and Culture of the Disposal of

Pharmaceuticals in Ghana

The process for regulated disposal of medicines is triggered

by the receipt of an ofﬁcial letter by the FDA from an or-

ganisation that has some medicines to be disposed of. It

can also be initiated by an order of a court of competent

jurisdiction which requires that a particular quantity or batch

of medicines be disposed of. Before the institution of Act

851, such entities would have had to notify the EPA by letter

with pictures of such intents. Beyond expired or unwanted

medicines, these products might also include active phar-

maceutical ingredients that are no longer required by the

manufacturing concerns that own them. Next, the FDA car-

ries out an onsite inspection and audit of the medicines

marked for disposal in order to conﬁrm the types and quan-

tity as well as determine the necessary fees to be paid

by the holding organisation. This fee is not charged if the

holding organisation is run by the state. The products to be

disposed of are held in storage by the holding organisation

till the date set for disposal, since the FDA does not own

storage facilities. Again, there are no speciﬁc guidelines

on the storage conditions of medicines marked for disposal.

The FDA supervises the packing of the medicines, leads

the vehicle to the chosen disposal site, and carries out the

disposal of the medicines using a predetermined method

of disposal in the presence of an ofﬁcial of the organisation

that initiated the entire process. Prior to Act 851, an EPA

ofﬁcial would be present during the period of disposal.

The FDA undertakes disposal of these medicines in four

ways; these are crushing and burying, burning, incinera-

tion, and emptying liquid formulations into municipal drains.

Crushing and burying involves placing the products into

an identiﬁed excavated spot, crushing them in the pit and

covering it over with earth afterwards. With burning, the

medicines are doused with fuel and set on ﬁre at the dis-

posal site. Incineration is mostly used for the disposal of vac-

cines, oncogenic medicines and steroids, and involves the

use of incinerators owned by other organisations as the FDA

does not own any incinerators. All solid medicines besides

those that fall into the category for incineration are disposed

of either by crushing and burying or by burning, while liq-

uid products are poured down municipal drainage systems.

Medicines are not sorted out according to their pharmaco-

logical action during the process of disposal, which means

medicines with augmenting effects might end up together

and possibly produce enhanced effects beyond that which

they might individually produce.

Disposal sites are not owned by the FDA, and as a result,

the organisation initiating the disposal, whether public or pri-

vate, pays a site fee for the use of the site. The FDA’s lack

of control over the management of disposal sites means

it is unable to ensure that any other activities at the sites

are carried out in a manner that does not prove detrimental

to the surrounding environments and the people. Current

dump sites used by the FDA for disposal of medicines are

located in Kpong, Abokobi, and Nsawam. All three sites

are used for disposal processes that require crushing and

burying while the latter site at Nsawam, which is signiﬁ-

cantly removed from the human population, is also used for

disposal that involves burning. The distance of the Nsawam

site from the closest human settlement (the Nsawam Town-

ship), is meant to prevent residents from being exposed to

the possibly toxic fumes that the burning process generates.

The crushing and burying sites are chosen based on the

level of the water table in order to reduce the possibility of

contaminating the ground water with the pharmaceuticals

that have been buried on the site.

Prior to the passage of Act 851, the EPA was largely

responsible for all the processes referred to above. It is still,

however, responsible for the management of the disposal

of industrial and medical waste. Its Chemicals Control and

Management Centre (CCMC) collaborates with the FDA

and District Assemblies on the disposal of medical waste.

The CCMC’s objectives are to protect human health and the

environment from the indiscriminate, inappropriate use and

improper management of chemicals while ensuring safe

use of chemicals for people and the environment, among

others (Information on the CCMC is on its page at the EPA

Ghana website. http://www.epa.gov.gh/epa/-).

6. The Disposal of Unwanted/Unused Medicines

Project (DUMP)

The DUMP project pioneered by the Cocoa Clinic’s phar-

macy in 2009, was in response to a need identiﬁed during

dispensing of medicines. A counselling session with a hy-

pertensive diabetic revealed the patient had large quantities

of prescribed medications from previous visits that had not

been used. This led to the realization that there was a

need to provide support services to clients to handle un-

used medicines in their possession. The project initially

focused on the clientele of the Cocoa Clinic, providing edu-

cational programmes to encourage patients to return their

unwanted, unused, and expired medications to avoid the

attendant risks of accidental poisoning of children or the

abuse of medication by other parties with access to these

medications. Disposal of drugs by ﬂushing them down the

toilet or throwing them in the trash which have been iden-

tiﬁed by another study as among the major methods of

disposal by individuals in Ghana is also discouraged. [9]

The clinic also encouraged its clientele to stick to and

complete dosage regimens to avoid having left over quanti-

ties of medicines at their disposal. They were also warned

about the potential dangers of sharing medications with

other parties who have neither been diagnosed nor advised

by qualiﬁed personnel to take such medication. Any un-

used drugs are to be placed by clients of the clinic into bins

placed at vantage points around the facility. Posters are

strategically placed to serve as a helpful reminder, ﬂiers

and stickers are periodically distributed, while a magazine

published with the project in mind, Safe Medicines, is also

made available to clients and members of the public. The

DUMP project has not been limited to the clients of the Co-

coa Clinic. Through periodic public outreach programmes,

some identiﬁable groups have participated in the project and

also deliver their unused and unwanted medicines to the

Cocoa Clinic for onward disposal by the FDA. Currently, the

Calvary Baptist Church and different groups in the Kaneshie

Central Market collect unused medicines for regulated dis-

posal under the DUMP project. The project also involves

the Cocoa Clinic’s mother organisation, Ghana Cocobod,

and provides collection bins on all ﬂoors of the Cocobod

Head Ofﬁce for the convenience of staff members who want

to dispose of medicines. All the bins (at the Cocoa Clinic

facility and Cocobod Ofﬁces) are regularly emptied and

the contents sorted out into their various pharmacological

classes.

The bins provided for disposal are labelled as follows:

A) Tablets and Capsules

B) Suspensions and Syrups

C) Injections and Injectables

Eye preparations, skin preparations and other topical

preparations

Clients are free to dispose any quantity or type of

medicines without any questioning or interference by clinic

ofﬁcials, and the bins are available throughout the week

to clients who wish to dispose of medicines. Medicines

collected under the DUMP project after being grouped into

their pharmacological classes are then weighed to assess

the quantities and percentages of the medicines collected.

Table 1 shows a typical distribution, in percentages, of the

medicines received for disposal according to their pharma-

cological activity.

The quality of medicines that are neither expired nor

damaged cannot be guaranteed because veriﬁcation of

the conditions under which they were stored is next to im-

possible. As a result of this, all medicines received under

the project are disposed of even if they are not expired or

undamaged. Since 2009, no banned narcotic drugs have

been collected. The clinical pharmacist at the Cocoa Clinic,

however, judged that there may be some individuals who

may wish to dispose of these kind of drug (Interviewed by

Y.Y. Esseku, 22

January 2012). He suggested there was

a need to either extend the DUMP project or create a new

project to encourage the disposal of banned narcotics with-

out risk of being prosecuted. The project has also collected

both complementary and unorthodox medicines which are

all handled in the same manner. The Cocoa Clinic in line

with FDA procedure for the disposal of pharmaceuticals

stores the collected medicines on its premises until they are

ﬁnally disposed of once every year under the auspices of

the FDA. The procedure for the disposal of medicines col-

lected under the DUMP project follows the exact procedure

laid down by the FDA described in an earlier paragraph of

this paper. The Cocoa Clinic is classiﬁed as a government

facility and so does not pay the disposal fee but does pay

the site fee as required. Figure 1 shows the scheme of

movement of unused and unwanted medicines from collec-

tion to disposal.

Table 1.

Categories and Quantities of Medicines Received for

Disposal under DUMP (Culled from Safe Medicines, 2011).

Class Total collected (%)

Antihypertensive agents 21

Antibiotics 18

NSAIDs and Analgesics 18

Steroids 8

Anti-Malarial agents 6

Haematinics 6

Anti-diabetic agents 5

Antiulcer agents 3

Antacids 3

Cough preparations 3

Spasmolytic agents 3

Antihistamines 2

Anti-asthmatic agents 2

Anti-gout agents 1

Muscle Relaxants 1

Figure 1.

Movement of Unused Medicines – DUMP (dis-

tilled from interviews by authors).

7. DUMP and Environmental Security

The DUMP project, despite its obvious limitations and nar-

row coverage, provides an outlet for the regulated disposal

of pharmaceuticals. It helps to reduce incidences of acci-

dental poisoning or abuse of unused, unwanted or expired

medicines and ensures that the potential effects of these

drugs on the environment can be controlled through their

regulated disposal. Thus, in its own limited manner, it con-

tributes to the environmental security of the population and

by extension the sustainable development of the country.

Interviews with Mr. Amedzro of the FDA and Dr Coomson

of the EPA showed both men agreed that unregulated and

improper disposal of pharmaceuticals poses negative con-

sequences for the environment and its inhabitants. This is

perhaps the main motivation behind the FDA siting disposal

sites at locations signiﬁcantly removed from human settle-

ments. To avoid the possible contamination of ground water,

sites chosen for crushing and burying are located in areas

that have very low water tables. The study ﬁnds that there

is no policy in place to evaluate or deal with potential long-

term effects that might result from the current regulated

methods of disposal. The methods, for instance, ignore the

possibility of the noxious fumes from disposal sites where

the pharmaceuticals are burned travelling great distances

by wind to neighbouring communities. While the concentra-

tion of chemicals in these fumes might be low by the time

they reach such settlements, long-term exposure to even

the small quantities of chemicals in the air might be harmful

to the health of inhabitants and the natural environment.

It is interesting to note that Mr Amedzro and Mr

Abubakari, both ofﬁcials of the FDA, considered the meth-

ods currently in use as inadequate in protecting the environ-

ment from long-term exposure that is potentially detrimental

to the environment and public health. They were of the

belief that more sophisticated methods and facilities such

as incinerators might be better options and may signiﬁcantly

lower the risks to the environment posed by the disposal

of these medicines. Mr Amporful, an ofﬁcial of the Cocoa

Clinic who had visited the disposal sites used for the DUMP

project, believes that the current methods in use were not

adequate to protect the environment. He felt that the lack of

facilities which would ameliorate the environmental effects,

was a result of challenges faced by government agencies

in securing funds for facilities whose immediate use will not

be appreciated.

The possibility of polluting surface water sources be-

cause of burning of medicines is a concern. Chemicals

present in the fumes from the burning of several pharma-

ceuticals have the potential to dissolve into nearby water

bodies that might serve local communities. They may be

dissolved in rain or fog and enter these water sources. Tak-

ing into consideration the fact that medicines of various

chemical compositions are often burnt together, there is

the signiﬁcant risk of chemical reactions that produce com-

pounds with unknown effects. Davis et al also indicate that

surface water is exposed to pharmaceuticals found in the

runoff from soil that washes into them [

]. Despite these

chemical residues being small in quantity, their long-term

exposure to aquatic life and animals that are dependent on

these water sources might be detrimental.

The current disposal method of choice for liquid

medicines, according to Mr Amedzro of the FDA, involves

their discharge into municipal drains. This makes the receiv-

ing waters that these drains flow into the ultimate recipients

of these waste products which are often introduced in active

forms into the drains. These drains empty into streams and

rivers, reducing the quality of the water supply and directly

exposing the aquatic habitat to these pharmaceuticals. Again

while the concentrations of these liquid medicines in these wa-

ter bodies might be low, aquatic organisms such as fish have

been known to accumulate some of these medicines in vari-

ous body tissues with other studies noting male fish experi-

encing feminisation on exposure to human female hormones

[

]. Alligators have also been found to suffer lower survival

rates, reduced phalanges, shrinking genitalia (males), and

sex reversal on exposure to certain chemicals [

]. There is

of course the yet to be investigated potential risk to human

health as a result of long-term exposure to these doses of

medicines present in water sources being consumed. Such

contamination could, over time, lead to the non-availability

of that water body as a source of water for domestic con-

sumption. It could also result in the removal of a source of

livelihood and survival particularly in communities that rely

on such water bodies. The current methods of disposal also

do not address the likelihood of plants absorbing these chem-

icals, particularly plants that grow in swamps. According to

Wu et al, these plants pose the danger of reintroducing these

pharmaceuticals into the terrestrial environment. Some hu-

man pharmaceuticals are also known to be toxic to plants

and when absorbed in this manner might lead to the destruc-

tion of the plant itself or be stored in parts of the plant which

might be consumed by other organisms higher up the food

chain including humans [26].

As earlier stated, the sites for crushing and burying are

selected with the water table in mind to avoid contaminating

ground water sources. Thus, the sites chosen are usually

areas that have a very low water table. This was conﬁrmed

by Mr Abubakari and Dr Coomson of the FDA and EPA

respectively. Despite the presumption that carrying out

this disposal method high above the water table will pre-

vent contamination of groundwater by pharmaceuticals so

dumped, Shield reports the presence of pharmaceuticals in

groundwater samples 300 metres away from a landﬁll site

which had been abandoned for over 20 years [

]. Phar-

maceuticals are thus shown to persist for long periods in

soil and are, in time, able to reach the water table. Dump-

ing in un-engineered landﬁlls, no matter how high above

the water table only postpones the inevitable pollution of

groundwater resources nearby. Dr Coomson of the EPA

points out though that sites marked for burying hazardous

waste are noted to prevent burying chemicals that have

the potential of reacting with the waste previously buried

at the site. This measure is to prevent the creation of toxic

compounds that might be damaging to the environment and

nearby populations.

Anti-microbial resistance (AMR) has over the years been

a major cause of concern for the health care delivery indus-

try with the WHO identifying it as one of the causes of the

escalating costs of treatment. AMR develops as a result of

infection causing microorganisms developing resistance to

existing medication, creating the need for stronger medica-

tion to be developed and often resulting in the unchecked

spread of difﬁcult to treat conditions [

]. Although this

research has not uncovered any ﬁndings on the subject

conﬁrming resistance as a result of exposure of microorgan-

isms to medications in the environment, there is a realistic

possibility for instance that exposure to antibiotics will de-

velop resistant capabilities in microorganisms so exposed

[

]. This possibility is enhanced by the fact that

the doses that might be released through various disposal

methods are smaller and thus unlikely to result in the de-

struction of such organisms as is the case with therapeutic

doses. Messrs Amedzro and Abubakari of the FDA and

Dr Coomson of the EPA all share the opinion that unregu-

lated and indiscriminate disposal of medicines holds dire

implications for the environment and the population. They

point to possible contamination of ground water sources

when such drugs are buried without regard for the depth

of the water table, the inhalation of toxic fumes from open

burning of such medicines, and ﬁnally the risk of polluting

water bodies and harming aquatic life through unchecked

dumping of medicines into drains.

The Cocoa Clinic serves a very tiny segment of the

Ghanaian population. In its home region, the Greater Ac-

cra Region, there are 384 health institutions with several of

them being much larger than the Cocoa Clinic and therefore

serving larger segments of the population [

]. No other

health facility in the region or in any other part of the country

is on record for collecting unused medicines from clients or

the general public besides the Cocoa Clinic. Two hundred

and ﬁfty-two of these health institutions are classiﬁed as

clinics. For the purposes of this paper, attendances at the

Cocoa Clinic will be used to represent average attendance

ﬁgures at clinics in the Greater Accra Region.

The research thus assumes that the average quantities

of drugs collected by the Cocoa Clinic would be represen-

tative of the average that could be collected by clinics in

the Greater Accra Region if they all ran a program simi-

lar to DUMP. The Table 2 shows an extrapolation of the

potential quantities of drugs that are unused, unwanted or

expired and are possibly being disposed of with unregulated

and unsafe methods. The estimated ﬁgures here are only

based on possible clients of clinics in the region and do

not include those of other larger health facilities like district,

regional, and referral hospitals or much smaller facilities like

community health posts or low level health centres.

These figures indicate quantities of medicines that are

potentially available from clients of these clinics but are not

being collected for regulated disposal under the auspices of

the FDA. These medicines are likely being indiscriminately

disposed of into the environment with little or no documenta-

tion as to what possible effects they might be having on the

environment. There is the possibility that sources polluted by

this potential unregulated disposal are consumed by unsus-

pecting humans and other organisms, negatively impacting

their life and engendering environmental insecurity.

Table 2.

Projected Quantities of Medicines Disposed of

in an Unregulated Manner by Attendants to Clinics (Cal-

culated by authors using ﬁgures Cocoa Clinic and Ghana

Health Service).

Class Quantities (kg)

Antihypertensive agents 3916

Antibiotics 3357

NSAIDs and Analgesics 3357

Steroids 1492

Anti-Malarial agents 1119

Haematinics 1119

Anti-diabetic agents 932

Antiulcer agents 559

Antacids 559

Cough preparations 559

Spasmolytic agents 559

Antihistamines 373

Anti-asthmatic agents 373

Anti-gout agents 186

Muscle Relaxants 186

8. Effects of the Presence and Persistence of

Pharmaceuticals on Water Resources and

Ecosystems

As indicated above, even the most cautious disposal meth-

ods are not fool proof at preventing pharmaceuticals in the

environment from entering either surface or ground water

sources. They contaminate these sources, often becoming

toxic to the aquatic life forms and other living organisms

higher up the food chain that either consume these animals

or depend on these sources of water for drinking. Some

human hormones and certain pesticides affect the reproduc-

tive health of ﬁsh, alligators, and other aquatic organisms

that might be sensitive to them. Plants may also be affected

through drawing on water that contains pharmaceuticals.

This might be toxic to the plants, or may be absorbed and

concentrated into certain parts of the plant, to be later rein-

troduced into the terrestrial environment after consumption

by animals. Such contaminated water sources are unwhole-

some for human and animal consumption. The exposure of

essential body organs such as the liver to non-therapeutic

doses over long periods of time is likely to induce severe

health complications.

Pharmaceuticals can also produce major unintended

effects that affect ecosystems. Evidence for this comes

from drawing on the example of the near collapse of the

Southeast Asian vulture population where large numbers

of vultures died after consuming the ﬂesh of cattle that

had earlier been treated with Diclofenac. These doses of

Diclofenac, though not harmful to the cattle, had become

stored in their tissues and proved poisonous to the vul-

tures who consumed their ﬂesh after the cattle had died

[

]. This proves that the consumption of body tissues that

have signiﬁcant concentrations of pharmaceuticals might be

detrimental to the health of organisms further up the food

chain. Animals such as ﬁsh and other aquatic organisms

that serve as food for humans and other animals, when

exposed to pharmaceuticals in their habitat, might store

them in their tissues in similar fashion and prove toxic to the

humans and other organisms that feed on them.

Another effect on the ecosystem as a result of dis-

posal of pharmaceuticals has to do with the feminisation

of male fish after exposure to female human hormones

[

]. This holds dire repercussions for the maintenance

of a healthy fish stock in the affected water body. This

might have knock-on effects for human populations that

are dependent on these fish stocks for their survival and

even other organisms living within that ecological system

which feed on the fish. The exposure of producers (plants)

and primary consumers to these pharmaceuticals has the

potential to put all other consumers in that particular eco-

logical food chain at risk.

9. Conclusion

In conclusion, the study ﬁnds that while quite a few leg-

islative provisions exist for the disposal of pharmaceutical

waste and general preservation of the environment, they do

not speciﬁcally cover unwanted, unused or expired pharma-

ceuticals that are held by members of the general public.

The DUMP project instituted by the Cocoa Clinic in Accra

has managed, with the help of the FDA and EPA, to provide

an outlet for the regulated disposal of unwanted pharma-

ceuticals held by the public. The study ﬁnds that these

regulated disposal methods, despite taking health and envi-

ronmental precautions in their execution, are not sufﬁcient

to protect the environment from the possibilities of damage

and long-term health effects.

The quantities of medicines collected annually under the

DUMP project points to the possibility of very large quan-

tities of unused, unwanted or expired medicines held by

members of the general public and disposed of in ways that

are unregulated and essentially indiscriminate in nature.

The study ﬁnds that such unregulated and indiscriminate

disposal has the potential of leading to pharmaceuticals

ﬁnding their way into environmental media and generating

all sorts of ill-effects for both plants and animals.

The study finds that water resources are at extreme

risk from both regulated and unregulated forms of dis-

posal of pharmaceuticals. These reduce the quality of

water resources and may prove toxic to the aquatic habi-

tat therein and other organisms that inhabit the same

ecological food chain.

The study recommends, among other things, that to en-

sure sustainable development, there is the need to improve

the current legal framework to adequately address the effects

of pharmaceuticals on the environment as a result of their

disposal by members of the public. This study further shows

that there are large quantities of pharmaceuticals held by

members of the general population, that can be described

as unwanted, unused or expired. In order to prevent their

indiscriminate disposal into the environment, it would be

important to introduce new policies or amend existing ones.

10. Recommendations

Given the ﬁndings of the study, there is the need to increase

public education through the Food and Drugs Authority

on the potential dangers of improper disposal of unused

and unwanted pharmaceuticals. One of the main factors

enabling improper disposal appears to be the complete

absence or lack of any comprehensive program/avenue to

receive unused/expired pharmaceuticals. An increased pub-

lic education on safe disposal of unwanted pharmaceuticals

will only be meaningful when unwanted pharmaceuticals

Collection Centers are established at health facilities nation-

wide to receive unused/expired pharmaceuticals from the

public for proper disposal by the authority.

FDA regulation of pharmaceuticals in terms of safety

and marketing should be extended to include a database

for all drugs to enable the authority to track these drugs

even while they are in circulation. This should aid in locating

expired drugs still in stock or on the market so they can

be immediately and safely disposed of. To make this even

more feasible, Ghana’s relatively high ‘mobile phone’ pen-

etration rate can prove useful as has been the case in the

implementation of other policies that have needed to reach

both urban and rural areas. The FDA already has a system

in place for the public to verify the authenticity of drugs via

a ‘mobile phone’ platform. This paper recommends an ex-

tension of the current FDA ‘mobile phone’ platform to allow

registered pharmaceutical points of sale, and other health

institutions around the country, to be included in a database

that would track and collect unused and expired medicines

while serving as collection points for such medicines held

by members of the public.

These recommendations would require extra ﬁnancing

to be feasible. As stated above, the FDA and the EPA

in Ghana are both severely underfunded and have to bill

private holders of unused/expired drugs for disposal while

not being able to reach out to members of the general

public in this respect. This paper recommends that govern-

ment should consider increasing budgetary support to these

agencies through allocating a bit of the National Health In-

surance Levy charged as part of Value Added Tax (VAT) on

goods and services to support effective disposal of pharma-

ceuticals. In addition, they could levy importers and local

manufacturers of medicines to raise funds to support proper

disposal of their merchandise. Government can also seek

to encourage donor organisations and corporate entities,

particularly those in the health sector, to emulate the Cocoa

Clinic by supporting similar initiatives across the country as

part of their aid activities or corporate social responsibilities

respectively. Increased funds should enable the FDA to

remove cost barriers that are presently a signiﬁcant contrib-

utory factor to unapproved disposal of drugs outside FDA

involvement or supervision.

As research in this area continues to grow, it would

be helpful if state agencies such as the FDA and the EPA

increased collaboration with both local and international

scholars in the ﬁeld through workshops and conferences

towards developing new and improved strategies to dispose

of pharmaceuticals without harming the environment any

further than is already the case. Seeing as this poses a

key environmental security concern, it would be necessary

for the National Human Security Ofﬁce to play a key role in

this proposed development by securitizing the problem thus

emphasizing its seriousness and drawing signiﬁcant public

and state attention to addressing it.

References and Notes

[1]

Sachs SE. The Changing Deﬁnition of Security; 2003. Available from:

www.stevesachs.com/papers/paper security.html.

[2]

Rio Declaration on Environment and Development. Environmental

Conservation. 1992;19(04):366. doi:10.1017/s037689290003157x.

[3]

New Dimensions of Human Security. United Nations Development

Programme; 1994. Human Development Report.

[4]

Biswas NR. Is the environment a security threat? Environmental secu-

rity beyond securitization. International Affairs Review. 2011;20(1):1–

22. Available from: http://ndc.gov.bd/lib mgmt/webroot/earticle/2180/

Niloy Biswas - Is the Environment a Security Threat.pdf.

[5]

Mathews JT. Redeﬁning security. Foreign Affairs. 1989;68(2):162–

177.

[6] Myers N. Environmental Security. Foreign Policy. 1989;74:23–41.

[7]

Greenwood F, Webster F. Sustainable Water: Chemical Science

Priorities; 2008.

[8]

Boxall ABA, Fogg LA, Blackwell PA, Blackwell P, Kay P, Pemberton

EJ, et al. In: Veterinary Medicines in the Environment. Springer

Nature; 2004. pp. 1–91. doi:10.1007/0-387-21729-0 1.

[9]

Abruquah AA, Addai-Agyei JA, Ampratwum FT. Unwanted Medication

in Rural Ghanaian Households: Disposal Practices and Environmen-

tal Impact. Ghana Pharmaceutical Journal. 2013;pp. 73–82.

[10]

Barnett J. The Meaning of Environmental Security: Ecological politics

and policy in the new security era. London, UK; 2001.

[11]

Water Pollution Control—A Guide to the Use of Water Quality Man-

agement Principles. United Nations Development Programme, Water

Supply & Sanitation Collaborative Council, WHO; 1997.

[12]

Spencer T, Altman P. Climate Change, Water, and Risk: Current

Water Demands Are Not Sustainable. Natural Resources Defense

Council, United States. 2010;.

[13]

The World Bank. Development and the Environment World Develop-

ment Report 1992. Oxford University Press; 1992.

[14]

Boxall ABA. The environmental side effects of medication. EMBO

Reports. 2004;5(12):1110–1116. doi:10.1038/sj.embor.7400307.

[15]

Kummerer K, Velo G. Ecopharmacology: A new topic of importance

in pharmacovigilance. Drug Safety. 2006;.

[16]

Holm G, Snape JR, Murray-Smith R, Talbot J, Taylor D, S

orme

P. Implementing Ecopharmacovigilance in Practice: Challenges

and Potential Opportunities. Drug Safety. 2013;36(7):533–546.

doi:10.1007/s40264-013-0049-3.

[17] WCED. Our Common Future. Oxford University Press; 1987.

[18]

Snyder S, Lue-Hing C, Cotruvo J, Drewes JE, Eaton A, Pleus RC,

et al. Pharmaceuticals in the Water Environment. National Asso-

ciation of Clean Water Environment (NACWA) and Association of

Metropolitan Water Agencies (AMWA). 2009;pp. 38.

[19]

Nilsen E, Furlong ET, Rosenbauer R. Reconnaissance of pharma-

ceuticals and wastewater indicators in streambed sediments of the

Lower Columbia River Basin, Oregon and Washington. Journal of

the American Water Resources Association. 2014;50(2):291–301.

[20]

Watanabe N, Harter TH, Bergamaschi BA. Environmental occur-

rence and shallow ground water detection of the antibiotic monensin

from dairy farms. J Environ Qual. 2008;37(5 Suppl):S78–85.

[21]

Davis JG, Truman CC, Kim SC, Ascough II JC, Carlson K. Antibiotic

Transport via Runoff and Soil Loss. Journal of Environmental Quality.

2006;35(6):2250–2260. doi:10.2134/jeq2005.0348.

[22]

Kinney CA, Furlong ET, Werner SL, Cahill JD. Presence and dis-

tribution of wastewater-derived pharmaceuticals in soil irrigated

with reclaimed water. Environmental Toxicology and Chemistry.

2006;25(2):317–326.

[23]

Kinney C, Furlong E, Zaugg S, Burkhardt M, Werner S, Cahill J,

et al. Survey of Organic Wastewater Contaminants in Biosolids Des-

tined for Land Application. Environmental Science & Technology.

2006;40(23):7207–7215.

[24]

Glassmeyer S, Koplin D, Furlong E, Focazio M. Fate of Pharmaceu-

ticals in the Environment and in Water Treatment Systems. Aga D,

editor. Informa UK Limited; 2007. doi:10.1201/9781420052336.

[25]

Wu C, Spongberg AL, Witter JD. The uptake of pharmaceuticals

and personal care products by agriculturally relevant plant species;

2011. Available from: www.teknoscienze.com/Articles/Chimica-Oggi-

Chemistry-Today-The-uptake-of-pharmaceuticals-and-personal-

care-products-by.aspx.

[26]

Guillette LJ, Crain DA, Gunderson MP, Kools SAE, Milnes MR, Or-

lando EF, et al. Alligators and endocrine disrupting contaminants

: A current perspective. In: Annual Meeting of the Society for

Integrative and Comparative Biology. vol. 40; 2000. pp. 438–452.

10.1093/icb/40.3.438.

[27]

Guillette LJ, Pickford DB, Crain Da, Rooney aa, Percival HF.

Reduction in penis size and plasma testosterone concentra-

tions in juvenile alligators living in a contaminated environ-

ment. General and Comparative Endocrinology. 1996;101(1):32–42.

doi:10.1006/gcen.1996.0005.

[28]

Crain DA, Guillette LJ, Rooney AA, Pickford DB. Alterations

in steroidogenesis in alligators (Alligator mississippiensis) ex-

posed naturally and experimentally to environmental contami-

nants. Environmental Health Perspectives. 1997;105(5):528–533.

doi:10.2307/3433582.

[29]

Christiansen LB, Winther-Nielsen M, Helweg C. Feminisation of ﬁsh

The effect of estrogenic compounds and their fate in sewage treat-

ment plants and nature. Danish Environmental Protection Agency;

2002. No. 729. Available from: http://www2.mst.dk/udgiv/publications/

2002/87-7972-305-5/pdf/87-7972-306-3.pdf.

[30]

Briggs H. ’Gender-Bender’ ﬁsh problem widens. In Depth: Festival of

Science. BBC; 2000.

[31]

Roach J. Has Mysterious Killer of India’s Vultures Been Found?; 2004.

Available from: http://news.nationalgeographic.com/news/2004/01/

0128 040128 indiavultures.html.

[32]

Randolph E. Vultures in India close to extinction because of cattle

drug; 2011. Available from: http://www.thenational.ae/news/world/

south-asia/vultures-in-india-close-to-extinction-because-of-cattle-

drug.

[33]

Environmental Assessment of Ogoniland. United Nations Develop-

ment Programme; 2011.

[34]

Aworawo D. Deprivation and resistance: environmental crisis, politi-

cal action, and conﬂict resolution in the Niger Delta since the 1980s.

Journal of International and Global Studies. 2013;4:52–70. Available

from: library.lindenwood.edu/archives/LindenwoodPublications

DigitalFormat/JournalofInternationalandGlobalStudies/2012-

2013/5.2013JournalofInternationalandGlobalStudies.pdf#page=59.

[35]

Ile, C Akukwe C. Niger delta, Nigeria, Issues, Challenges and oppor-

tunities for equitable development. Nigeria World Feature. 2001;Avail-

able from: http://nigeriaworld.com/articles/2000-2001/niger-delta.

html.

[36]

Okaba B. Petroleum industry and the paradox of rural poverty in the

Niger Delta. Ethiope Pub. Corp; 2005.

[37]

Azaiki S. Inequities in Nigerian politics: the Niger Delta, resource

control, underdevelopment and youth restiveness. Ibadan, Nigeria:

Y-Books; 2003.

[38]

Owabukeruyele WS. Hydrocarbon exploitation, environmental degra-

dation and poverty in the Niger Delta Region of Nigeria; 2000.

[39]

Akabzaa T, Darimani A. Impact of Mining Sector Investment in

Ghana: A Study of the Tarkwa Mining Region. Third World Network.

2001;Available from: http://commdev.org/userﬁles/ﬁles/1466 ﬁle

Impact 20of 20Mining 20Sector 20Investment 20in 20Ghana.pdf.

[40]

Kessey KD, Arko B. Small Scale Gold Mining and Environmental

Degradation , in Ghana : Issues of Mining Policy Implementation and

Challenges. Journal of Studies in Social Sciences. 2013;5(1):12–30.

[41]

Donkor A, Nartey V, Bonzongo J, Adotey D. Artisanal mining of gold

with mercury in Ghana. West African Journal of Applied Ecology.

2009;9(1). doi:10.4314/wajae.v9i1.45666.

[42]

Yelpaala K. Mining, Sustainable Development, and Health in Ghana:

The Akwatia Case-Study. Brown University, USA; 2004. Avail-

able from: www.ddiglobal.org/login/resources/mining-sustainable-

development-and-health-in-ghanakaakpema-yelpaala2004.pdf.

[43]

Republic of Ghana. Public Health Act 2012 (Act 851); 2012. Available

from: faolex.fao.org/docs/pdf/gha136559.pdf.

[44]

Barnes KK, Christenson SC, Kolpin DW, Focazio MJ, Furlong ET,

Zaugg SD, et al. Pharmaceuticals and Other Organic Waste Water

Contaminants Within a Leachate Plume Downgradient of a Municipal

Landﬁll. Ground Water Monitoring & Remediation. 2004;24(2):119–

126. doi:10.1111/j.1745-6592.2004.tb00720.x.

[45]

World Health Organization WHO. WHO on Anti-Microbial Resistance;

2013. Available from: http://www.who.int/mediacentre/factsheets/

fs194/en/.

[46]

Szczepanowski R, Linke B, Krahn I, Gartemann KH, G

utzkow T, Eich-

ler W, et al. Detection of 140 clinically relevant antibiotic-resistance

genes in the plasmid metagenome of wastewater treatment plant

bacteria showing reduced susceptibility to selected antibiotics. Mi-

crobiology. 2009;155(7):2306–2319. doi:10.1099/mic.0.028233-0.

[47]

orjesson S, Melin S, Matussek A, Lindgren PE. A seasonal study

of the mecA gene and Staphylococcus aureus including methicillin-

resistant S. aureus in a municipal wastewater treatment plant. Water

Research. 2009;43(4):925–932. doi:10.1016/j.watres.2008.11.036.

[48]

Ghana Health Service. Health Facilities; 2014. Available

from: http://www.ghanahealthservice.org/healthstats.php?dd=4&

region=GreaterAccraRegion.