by Ms. S. Patton

The unnecessary incineration of medical waste is a leading source of dioxin and mercury pollution. Dioxin is a known human carcinogen and has been linked to birth defects, decreased fertility, immune system suppression and other hormonal dysfunction. Mercury can interfere with the development of the fetal brain and is directly toxic to the central nervous system, kidneys and liver.

The campaign, Health Care Without Harm, was created to provide a remedy for the pollution from health care practices. In September, 1996, representatives of 28 organizations met together at Commonweal in Bolinas, California to create this new effort. Thus far, 75 organizations are working together at eliminate the pollution in health care practices without compromising safety or care. We invite you to join us.

To transform the health care industry so it is no longer a source of environmental harm by eliminating pollution in health care practices without compromising safety or care. We will accomplish the mission by:

1.Promoting comprehensive pollution prevention practices.

4.To phase out the use of mercury in the health care industry;

For more information or to join the campaign, contact one of the campaign's three coordinators: Charlotte Brody at CCHW Center for Health, Environment, and Justice at 703-237-2249 or cbrody@essential.org; Jackie Hunt Christensen at the Institute for Agriculture and Trade Policy at 612-870-3424 or jchristensen@iatp.org, or Gary Cohen at 617-524-6018. Gcohen@igc.apc.org. You can visit our website at http://www.sustain.org/hcwh.

The amount of medical waste generated per hospital patient has more than doubled since 1955. Changing medical technology clearly has played a role in the rise of the medical waste mountain, due, in part, to the use of more plastic and more disposable products. Experts also point to other factors such as unnecessary red bag disposal of waste, inefficiencies in hospital waste management, excessive use of disposables, and the scarcity of storage space in hospitals.

The concept of "universal precautions" requires that all body fluids be regarded as potentially infectious. This broad definition encourages the generation of massive amounts of what is believed to be "infectious waste", which is unjustified on closer examination of real data. "Red-bagging" is the practice of discarding "contaminated" waste in red bags earmarked for disposal as regulated medical waste, most often in medical waste incinerators. Without a clear understanding of what truly belongs in that category, "red-bagging" has been overused in most institutions, as is demonstrated by detailed analyses of bag contents. Surveys of hospitals show that some actually encourage the disposal of all waste from patient care areas in red bags while others attempt to be more selective but with little monitoring or education.

About 10 to 15 percent of hospital waste is properly described as "infectious waste". The rest is solid waste made up of paper and paper board, plastics, food waste, metal, glass, wood and other materials. According to the Society for Hospital Epidemiology of America, "Household waste contains more microorganisms with pathogenic potential for humans on average than medical waste." Thus, despite many unique characteristics of health care facilities and enormous variability among those facilities, most medical waste can be reduced using the same waste minimization techniques used in homes and offices.

According to the Centers for Disease Control, 2% or less of a typical hospital's waste stream -- pathological waste (body parts) -- must be incinerated to protect public health and safety. But hospitals routinely burn 75 to l00% of their waste. The unnecessary burning of polyvinyl chloride plastic, paper, batteries, discarded equipment and other noninfectious materials leads to emissions of dioxins and mercury as well as furans, arsenic, lead, cadmium, and the generation of toxic ash.

The US EPA has identified medical waste incinerators as a leading source of both dioxin and mercury pollution of our environment and our food supply.

Dioxin is the common name for a class of 75 chemicals. Dioxin has no commercial use. It is a toxic waste product formed when waste containing chlorine is burned or when products containing chlorine are manufactured. PVC (polyvinyl chloride) plastic is a major source of the chlorine in medical waste.

Dioxin is atmospherically transported and enters the food chain long distances from its point of origin. Dietary sources of dioxin, which account for 90% of human exposure, are meat, dairy products, eggs, and fish. Dioxin builds up in fatty tissue. Because of the high fat content of breast milk, nursing infants are exposed to about 50 times the adult dose and may receive more than l0% of their total lifetime exposure during the nursing period, a time when they are most vulnerable to the toxic effects of dioxin.

Dioxin can cause:

a. Cancer. Dioxin is a proven human carcinogen according to the prestigious International Agency for Research on Cancer (IARC). Liver, lung, stomach, soft and connective tissue cancers as well as Non-Hodgkin’s lymphoma have all been associated with dioxin.

b. Immune System Effects. Low exposures to dioxin result in increased susceptibility to bacterial, viral and parasitic diseases.

c. Reprodutive and Developmental Effects. In animals, dioxin exposure causes decreased fertility, decreased litter size, and inability to carry. pregnancies to term. Maternal exposure results in offspring with lowered testosterone levels, decreased sperm counts, birth defects and learning disabilities. Human studies report lowered testosterone levels in exposed workers and birth defects in children of Viet-nam veterans exposed to dioxin in Agent Orange. Nursing human infants exposed to high dioxin concentrations in breat milk had significantly lower levels of the thyroid hormone necessary for normal development of the brain.

d. Hormone Disruption. Dioxin behaves like a hormone by way of attaching to a receptor and altering the genetic activity in cells. Since human hormones can exert effects at levels of parts per trillion, small amounts of dioxin could cause a chain reaction in the body.

Mercury is a natural heavy metal found in the earth's crust. It is used for a variety of industrial purposes and is found in many items that we use everyday, such as batteries and paints. In the medical field, mercury is used in thermometers, blood pressure devices (sphygmomanometers), and dilation and feeding tubes, as well as batteries, and fluorescent lamps. Because of the significant use of these items medical waste may account for 20 percent of the mercury in the solid waste stream.

Mercury cannot be destroyed through incineration. Following release through a smokestack, mercury is deposited back to land or to surface waters where it will essentially remain indefinitely. It exists in both an in organic form (elemental mercury) and in an organic form called methyl mercury. Elemental mercury can be converted to methyl mercury by microorganisms like bacteria. Methyl mercury is more biologically available, meaning that it can interact with human cells and damage them.

Mercury pollution exists widely in the environment and concentrates in animals and ultimately in the human body. According to the US EPA's 1997 Report to Congress, 37 states have determined that all or some of their lakes, streams and rivers are too contaminated with mercury to allow people to eat the fish and seafood from dose bodies of water.

Mercury causes neurological toxicity. It attacks the body's central nervous system; it can also harm the brain, kidneys and lungs. It can cross the blood-brain barrier as well as the placenta. Methyl mercury from contaminated fish easily crosses the placenta and enters the brain of the developing fetus. The critical effect from prenatal exposure to methyl mercury is psychomotor retardation.

In August 1997, the US LPA released the first federal standards and guidelines regulating hospital and medical waste incinerators. The standards and guidelines also establish requirements for Medical Waste incinerator (MWI) operator training and qualifications, and testing and monitoring of pollutants. Additionally, the guidelines for existing MWIs contain equipment inspection requirements and the standards for new MWIs include siting requirements. New facilities will have approximately six months after startup to comply with the rule; while existing facilities will have three to five years to comply.

EPA decided not to define infectious waste in this regulation. Instead, EPA used definitions of hospital waste and medical and infectious waste only to designate which incinerators are subject to the regulations. Crematoria and incinerators that burn only pathological waste (animal body parts), expired pharmaceuticals, or radioactive medical waste are not covered by this new rule.

Health Care Without Harm advocated for stricter, more protective emission limits than were issued in the final rule. The campaign also worked to focus the EPA’s attention on waste reduction and waste segregation in health care facilities instead of on more expensive and less protective scrubbers and filters States now have until September 1998 to create rules that are at least as protective as the federal standard. Health Care Without Harm will work with states to adopt regulations that provide more protection for people and wildlife than the new US EPA rules.

EPA's new medical waste incinerator rule suggests that advanced and expensive technology is the solution to the problem of pollution from medical waste incinerators. The installation of wet and dry scrubbers and emission control monitoring equipment will reduce the toxicity of emissions. But such "end-of-the-pipeline" solutions are more expensive and less protective than a "preventive medicine" approach that integrates medical product purchasing and disposal decisions and which emphasize the use of non-toxic, recyclable, and reusable materials.

The most important part of waste management is waste minimization. Waste reduction begins with the initial process of procurement of hospital supplies. Purchasing professionals working with vendors can considerably increase the amount of reusable items and decrease the amount of waste generated. Minimizing packaging and buying products that are durable rather than disposable, when feasible, all lead to reduced waste disposal. Materials sent to waste disposal systems need to be true "waste" and not materials that could or should be reused or recycled. Finally, the waste treatment method should not create toxic compounds or release pollution into the environment.

Waste segregation, essential for successful recycling and widely practiced with household waste, is perhaps the most important step in reducing the volume and toxicity of the medical waste steam. Paper and cardboard products, glass, some plastics, and metals can readily be recycled in existing markets.

Found throughout a hospital facility is a mix of solid waste similar to that found in any other institution, as well as waste generated specifically as a result of patient care. To design the best system for the hospital it is necessary to conduct a waste assessment to become familiar with the waste types and generation patterns in all areas of the hospital.

There are several ways to conduct a waste assessment. There is the quick and dirty method of just wandering around looking in trash receptacles and compactors. A trip to the landfill with the hospital's hauler might also be a quick and revealing method. And there is a more comprehensive waste assessment procedure, which hospital personnel can conduct in-house or do in concert with an outside consultant or agency. Whether using an outside consultant or in-house staff, a comprehensive waste assessment is preferable. However, this is not always possible. Both in-house and external resources must he evaluated to determine which route should be taken.

Recycling (and buying products made with recycled materials) reduces the pollution from resource extraction (mining, forestry) and manufacturing products, and reduces the pollution associated with incineration, landfills and other waste disposal methods. Recycling in health care facilities presents many challenges since the recycling world does not understand hospital waste composition. The average person tends to think that health care waste is laden with needles, body parts, blood and bandages. However, when sorting through health care waste, the dominant materials ate paper and cardboard, followed by plastics, metals, glass and other materials which are commonly recycled by other entities such as hotels, restaurants and office buildings. Recycling can save organizations thousands of dollars.

Autoclaves are the most commonly used medical waste treatment alternative in the United States. Like most waste disinfection techniques, an autoclave destroys infectious agents through the use of steam heat, like a high technology dishwasher. Unlike incineration, however, the material is not burned, reducing the risk of dioxin production. Frequently, wastes are shredded prior to autoclaving, in order to facilitate the process.

Microwaves use radiant energy to heat water that is sprayed onto waste. Once the water reaches its boiling point, it boils the microbes, rendering most of them harmless.

Microwaves, autoclaves and other alternative waste treatment technologies must be independently evaluated for safety and effectiveness. Any medical waste treatment technology approved by a state or federal agency should be subject to stringent regulations which have been developed with worker safety, public health and environmental considerations in mind.

Polyvinyl chloride (PVC) is one of today's most popular plastics. Commonly used PVC items in health care include IV bags, tubing, endotracheal tubes, oxygen tents, mattress covers, packaging and office supplies such as binders.

PVC production involves many toxic chemicals as feed-stocks, as additives or as by-products. Dioxin is released when PVC is made, producing a plastic that is about 57% chlorine. When PVC is incinerated, the chlorine is released and combines with organic matter to produce dioxin.

Incineration of PVC produces at least 75 other hazardous chemicals as by-products. Many of these by-products are known to or suspected of causing cancer. Additives such as lead, cadmium and phthalates are also released into the environment. Lead can cause brain damage and birth defects. Cadmium is a carcinogen and can cause kidney damage, emphysema, birth defects and reproductive damage. Burning PVC also produces hydrochloric acid, or HCL. In addition to being a dioxin precursor, and a contributor to acid rain, HCL wreaks havoc on the pollution control equipment and the incinerator itself, where it can "eat" the chrome plating off the machinery.

Safe alternatives exist for many of the uses of PVC in medical settings. Easily replaced PVC items include patient identification bracelets and cards, IV bags, compression stockings and fluid collection devices. Rigid PVC products often have alternatives made of metal or non-chlorinated plastics such as polypropylene and polycarbonate. New non-chlorinated plastic polymers are being developed that will provide even more alternatives for current manufacturers of PVC products.

Mercury is a potent neurotoxin, which means it attacks the body’s central nervous system. Neurotoxic risks to developing fetuses and young children are primary reasons for fish-consumption advisories, aimed at discouraging pregnant women, women of child-bearing age, and young children from eating too much fish. Studies done on women who ate methyl mercury-contaminated fish or grain showed that even when the mothers showed few effects of exposure, their infants demonstrated nervous-system damage.

Mercury has been widely used in many industrial processes because of its diverse properties: it responds to temperature and pressure changes (making it useful for thermometers and blood pressure devices), conducts electricity, and forms alloys with other metals. However, alternative products are available for most commonly used mercury containing medical equipment. Mercury thermometers and blood pressure gauges can be replaced with electronic devices. Tungsten can replace mercury in feeding tubes and dilators. Instead of mercury batteries, rechargeable batteries can be used.

This health care problem can be cured. Every health care facility can take steps over the next nine to 12 months to dramatically reduce the environmental harm it produces. In doing so, every facility can benefit financially, improve staff morale, increase worker safety, avoid liability cost, improve regulatory compliance and strengthen its relationship with the community.

Step one: Establish a "green team" Convene a task force of administrators, housekeepers engineers and others who are currently responsible for waste handling. Authorize this team to:

a. identify the percentage and content of your facility's waste stream that is currently being incinerated and what is currently being recycled, and

b. assign in-house staff or contract with an outside consultant to conduct a waste audit to identify wasteful practices and to design a waste management strategy that incorporates waste reduction, reuse, and recycling measures.

Step two: Put someone in charge. Assign or hire staff full time responsibility of developing and implementing a program that integrates materials purchasing with waste segregation and recycling to reduce the waste stream volume and toxicity through environmentally sensitive work practices.

Step three: Train staff about the environmental consequences of medical waste incineration. Waste handlers, nurses, purchasing staff, boards of directors, medical ethicists, physicians, medical assistants, administrative staff and food service personnel all need to be aware of the problems and costs of unnecessary red-bagging and the availability of less expensive and more protective alternatives.

Step four: Don't incinerate what you can recycle. Implement or expand your recycling program. Cardboard, glass, office paper, drink cans, newspapers and magazines, and PETE. (#1) and HDPE(#2) plastic have nationwide recycling markets. Implement a purchasing program that favours products made of recycled products including recycled paper that has not been bleached with chlorine. Communicate with suppliers about the need for totally recyclable or reusable packaging materials.

Step five: Don 't incinerate what you can reuse. Create a plan to assess, on an ongoing basis, the availability of reusable products, and substitute, when feasible, for disposable items.

Step six: Don't incinerate what you can safely dispose of by other methods. The small percentage of hospital waste that is infectious can be made harmless and unidentifiable by autoclaving, microwaving or other alternatives to incineration.

Step seven: Begin a program to eliminate the use of mercury-containing products within the institution and set a goal to becoming a mercury-free facility by the year 2003. Mercury is present in batteries, thermometers, Miller-Abbot tubes, Cantor tubes, sphygmomanometers, electrical equipment, fluorescent lamps, laboratory reagents and disinfectants. Alternatives already exist for most of these, but where they do not, such as energy efficient, but mercury-containing fluorescent light bulbs, engage in recycling to avoid releasing mercury into the environment.

Step eight: Create a plan to reduce the use of chlorinated plastics, such as polyvinyl chloride (PCV), with the five year goal of its near-complete phase-out from your institution. PVC may be present in ventilator and oxygen therapy tubing, endotracheal tubes, ambu bags, facemasks and oral airways, IV bags and tubing, dialysis equipment, patient ID bracelets, gloves, protective covers, record binders and mattress covers.

Step nine: Assign materials management staff to research and communicate with suppliers concerning the substitution of materials (sterilizing solution, floor cleaners, cooling unit biocides) from the point of view of reducing toxic chemical inputs, providing safety to health care employees and reducing environmental pollution emissions and impacts.

Health Care Without Harm strives to help hospitals achieve these nine steps. We can provide educational materials, refer experts, suggest speakers, and identify health care facilities willing to share their experience in becoming environmentally responsible. Our web site is http://www.sustam.org/hcwh.