Miranda Law, PharmD, MPH, BCPS
Malaika R. Turner, PharmD, MPH
At the end of this case, students will be able to:
- Recognize the impact of the SDGs on patient care
- Discuss the relationship between the SDGs and the role of the pharmacists in patient care and achieving public health goals
- Examine the role of SDGs and their targets in specific patient case scenarios
In 2015, the Sustainable Development Goals (SDGs) were established and adopted by all United Nations (UN) Member States as part of the 2030 Agenda for Sustainable Development.1 The SDGs consist of 17 main goals, each with multiple specified targets, were developed based on decades of previous global health work by individual countries and the UN, including the Millennium Development Goals.2 They serve as a blueprint for global health, recognizing that tackling problems in climate change, education, inequality, and economic growth are important and go hand in hand with directly tackling problems in improving health.
The 17 goals consist of: (1) no poverty, (2) zero hunger, (3) good health and well-being, (4) quality education, (5) gender equality, (6) clean water and sanitation, (7) affordable and clean energy, (8) decent work and economic growth, (9) industry, innovation and infrastructure, (10) reduced inequalities, (11) sustainable cities and communities, (12) responsible consumption and production, (13) climate action, (14) life below water, (15) life on land, (16) peace, justice and strong institutions, and (17) partnerships to achieve the goals.2 Together, the 17 SDGs have 169 targets to achieve by 2030.2
The SDGs cover a broad range of topic areas, and in many instances, the goals and their targets may seem unrelated to what a pharmacist does on a daily basis. Despite this, a closer look at the relationships between the SDGs and the role of pharmacists in patient care will show that achieving public health goals do impact the patients that pharmacists interact with and are more intricately related than it may have first seemed. For example, SDG 6 focuses on clean water and sanitation, which from a bird’s eye view does not seem like it has to do with pharmacist direct patient care. However, understanding that lack of access to drinking water may prevent patients from being able to take their pills, and poor sanitation may result in infectious diseases that pharmacists will then have to work with physicians to treat. Additionally, SDG goals focused on economic growth such as SDG 8 (decent work and economic growth) can also be relevant to direct patient care because without employment and a means to make an income, patients often cannot afford medications that they need, resulting in uncontrolled disease states. Although only one of the SDGs directly addressed good health and well-being, many of the SDGs can influence how our patients present and what we can do to help them with their care.
CC: “She says she’s here to begin medication services.”
Patient: DS is a 42-year-old Indian female (65 in, 82 kg) who was referred to you for MTM services. Her T2DM and asthma have been uncontrolled for many years, and the physicians are concerned about her worsening microvascular complications from persistently high sugars. Since her physicians were educated about pharmacist services, they have asked the pharmacist at the clinic to try and help manage her medications to better control her chronic diseases.
HPI: DS does not speak English and you are provided with a student translator to be able to understand the discussion during the visit. She does not have insurance and pays for everything out of pocket, with permission from her husband.
PMH: T2DM (for eight years); asthma (since age 10); PTSD (unknown duration)
FH: Unknown; she left her family at a young age in an arranged marriage and has not spoken to her parents since age eight.
- Denies alcohol or tobacco use
- Denies illicit drug use
- Metformin 1000 mg BID
- Glipizide 10 mg daily
- Insulin glargine 25 units subcutaneously nightly
- Albuterol HFA 90 mcg inhaler 1-2 puffs every 4-6 hours as needed
Vitals: POC glucose at today’s visit 342 mg/dL
- HgbA1c from 15 months ago 10.2%
- No other labs available due to limited resources for lab work in the clinic
ROS: Not performed at this visit
Surgical history: C-section delivery of 3rd child (five years ago)
SDH: DS has been married since the age of eight and lives in a rural village with limited clean water and electricity. Her family is very poor. She is a pescatarian with a diet that consists mainly of bread, beans, and any fish available, but since good fish from the market is expensive, she pays less for fish that locals catch from nearby streams and lakes, sometimes eating it without fully knowing what kind of fish it is. Her village is highly polluted mainly because there is no running water, no proper sanitation system for bathroom use, and air pollution from the main city reaches their small village leaving little clean air for breathing.
Additional context: Before the visit, you are informed by her physician that DS lives in an abusive marriage but since she has no means to provide for herself or her children, she continues to live at home with no intention of leaving her husband. Her husband has tight control over everything she does, and also keeps a close eye on what medications she is taking on a daily basis. She is not able to do much without being watched and if she is caught doing something her husband does not agree with, she is often physically and verbally abused.
Use the following website to assist in answer the following case questions: https://sdgs.un.org/
1. The pharmacist begins by asking DS questions about her diabetes medications. She reports compliance on all her oral medications, but states she only takes her insulin sometimes. Upon further questioning, it is revealed that her home does not have running electricity, and she was taught that if it gets hot in her home, she must throw her insulin out. Her husband only gives her money to buy insulin once every three months, so after she disposes of it, she does not get another one for a while. What SDG(s) is/are related to this problem and achieving which SDG targets within this goal could help prevent this problem in the future?
2. The pharmacist finds some pamphlets on lifestyle changes that can be helpful in controlling diabetes and provide them to DS to help her learn about diet and exercise recommendations. Upon receiving them, she states she never learned to read or write and hands the pamphlets back. What SDG(s) is/are related to this problem and achieving which SDG targets within this goal could help prevent this problem in the future?
3. The pharmacist asks about DS’s PTSD and if she has ever taken anything for it. She states she has had it for a while and thinks it is because of the violence in her marriage. However, her husband does not believe there is anything wrong and will not allow her to take medications for a problem that “does not exist”. What SDG(s) is/are related to this problem and achieving which SDG targets within this goal could help prevent this problem in the future?
4. At the end of the visit, the pharmacist asks DS if she has any questions about her medications. She states that all three of her children seem to have some learning deficits and is not sure why. She wants to know if there was any medication that they can be given. The pharmacist proceeds to discuss this with the physician since this is out of her scope of practice. The physician states that she has asked this question many times, but the answer is always no, there aren’t any medications that can be given. He proceeds to say that although there could be multiple causes, he thinks one main problem is that she is eating fish from bodies of water that are highly polluted with toxins such as Polychlorinated biphenyls (PCB), which could be causing harm to her children when she is pregnant. What SDG(s) is/are related to this problem and achieving which SDG targets within this goal could help prevent this problem in the future?
5. What barriers now exist for managing this patient’s health conditions because above mentioned SDG goals have not been met?
6. Which targets in SDG3 relate directly to the care you are trying to provide for DS?
7. Recognizing the important role that SDG’s can play on patient care, what solutions (policies, programs, etc.) can you think of that may help to achieve any one or multiple of the SDG’s? Brainstorm a list and think about the applicability of these solutions to different countries around the world.
8. In many instances, the best way to find solutions is to engage directly with the community you are trying to help. In what ways would you want to do this? Describe community engagement initiatives you would want to initiate to help advance an SDG or SDG target.
9. Although it is important to understand how public health problems that are being tackled in the SDGs can directly impact patient care, there is also an ethical component that is important to recognize. What ethical problems do you note in this case and what do you think is the best way to tackle these issues?
The SDGs represent a unified, worldwide front on tackling some of the world’s greatest public health challenges. As pharmacists, our direct patient care interactions in high-income countries may seem to have little to do with many of the SDGs and their targets, but it is imperative to realize that many of these goals are related to social determinants of health and impact how patients present to us as well as what barriers they have managing their own health.
Pharmacists and student pharmacists can and should be a part of the larger initiative to improve public health, particularly in reaching targets in SDG 3 (Good health and well-being: Ensure healthy lives and promote well-being for all at all ages), through patient education and being part of policy development in our country. Even though the SDGs and their targets are applicable across the world (and often may seem to be more important for developing countries), it is vital to recognize that public health efforts are needed everywhere, including the US, and particularly for populations who live in socioeconomically disadvantaged areas. The concept of local is global is very applicable as we aim and work to be part of the solution in attaining the targets set out in the SDGs.
Patient Approaches and Opportunities
SDGs should play a critical role in our approach to the provision of patient care across cultures and locations. It is imperative that pharmacists are aware of the various aspects of a patient’s life including social determinants of health that play a pivotal role in patient care, treatment, and ultimately health outcomes. Pharmacists have a duty to provide culturally respectful care, free from bias and saviorism. Pharmacists and pharmacy students should engage in cultural competency training and personal reflection to ensure they are not projecting unrecognized biases onto patients. Pharmacists should take advantage of opportunities to better understand the impact of culture and community on patient treatment through direct patient communication as well as immersion in the community wherever possible.
Finding ways to combat barriers to care – including cultural and socioeconomic barriers – is critical to improving health outcomes. For instance, when working with patients in which you are not able to communicate due to language barriers, you should consider the use of medical translation services to ensure both you and the patient are able to express and receive information adequately. Being inclusive of dietary restrictions and access to food, among many other considerations, impacts the recommendations pharmacists may provide to our patients. However, it is important to remember, we may not be able to ascertain all the information we may deem necessary, so it is important to make the most informed decision (shared between patient and healthcare professional) possible given the information provided.
Related chapters of interest:
- Ethical decision-making in global health: when cultures clash
- More than just diet and exercise: social determinants of health and well-being
- Sex education: counseling patients from various cultural backgrounds