Taking on Toxics II: Health Care Without Harm

by Charlie Cray

Environmental and public health activists were astonished to discover in the mid-1990s that U.S. Environmental Protection Agency (EPA) analysis showed that medical waste incinerators were the biggest source of dioxin in the United States.

"The irony that the health care industry should be the leading source of one of the most toxic substances around seemed extremely compelling," says Charlotte Brody, a registered nurse and organizer with the Center for Health, Environment and Justice. "It was an extraordinary organizing opportunity because we knew that most health care professionals who knew about the issue would want to do something about it."

Soon Brody and others from 28 organizations - a core of environmental activists, nurses, doctors and public health advocates - formed Health Care Without Harm (HCWH), a broad-based campaign designed to reform the environmental practices of the health care industry.

"Health Care Without Harm is driven by the fundamental notion that the health care industry has a particular ethical responsibility to minimize adverse impacts on public health and the environment," says Dr. Ted Schettler, science director of the Science and Environmental Health Network. "The health care industry can play a leadership role by looking beyond regulatory compliance and doing what's necessary to prevent illness rather than working only to treat it after it occurs."

The organization has developed quickly. In just five years, HCWH has grown to represent nearly 300 organizations in over 25 countries, including more than 88 health care institutions, health-affected constituencies (groups representing people afflicted with cancer, endometriosis and other diseases, as well as children's health advocates), associations of health professionals, religious organizations and many local and national environmental organizations.

Organized into various work groups, the campaign has deployed a flexible matrix of strategies to force the health care industry to apply its ethical commitment to "First, Do No Harm" to the environmental and occupational impacts of the technologies and materials used in health care. The result has been a holistic and sophisticated pollution prevention campaign that has forced the closure of hundreds of medical waste incinerators, motivated countless hospitals to conduct waste audits and establish recycling programs, and catalyzed the use of replacements for toxic materials used in medical devices, such as mercury and polyvinyl chloride plastics (PVC).

Campaign Origins

Incinerators were HCWH's first target. In addition to supporting local community-based campaigns that have shut down over 20 medical waste incinerators since the campaign began, HCWH has stigmatized incineration in general and moved hospitals and clinics towards waste segregation, recycling and the selection of safer infectious waste treatment methods.

"Working with nurses and others who knew health care institutions from the inside, we often did for the health care industry what EPA wasn't doing through their new incinerator regulations," says Tracey Easthope of the Ecology Center of Ann Arbor, Michigan. "We even provided information demonstrating how waste reduction and alternative treatment technologies could save them money."

While learning to use such carrots, the campaign also wielded a big stick, working to strengthen U.S. EPA's new medical waste incinerator regulations. The stricter emissions standards forced hundreds of additional hospitals to choose between paying to upgrade their facilities with expensive new emissions control equipment or stop burning their waste and seek viable alternatives.

With the help of Essential Action, a project of Essential Information, the publisher of Multinational Monitor, the anti-incineration effort has also expanded abroad, to India and other countries where incinerator manufacturers migrated after the U.S. market declined.

In 2001, HCWH will release a report that evaluates non-incineration waste treatment technologies appropriate for less industrialized nations.

Medical Pollution Prevention

Another flank of HCWH's work has been to reduce the use of toxic substances.

"Mercury is a good issue to lead with because there are readily available alternatives for common uses like fever thermometers and because, unlike with PVC, there isn't a huge lobby behind mercury that would bring in a group of people in three-piece suits to harass the agency people when they tried to do something," says Jamie Harvie, a coordinator of the mercury strategy for HCWH.

Soon after HCWH took up the issue, the U.S. EPA and the American Hospital Association entered into a memo of understanding that calls upon hospitals to phase out their use of mercury by 2005. HCWH campaign materials were reported to be key documents in the development of the memo of understanding.

At the same time, to gain real community engagement of the issue, local HCWH members organized thermometer "swaps" and "round-ups" at hospitals, schools and homes.

Thus far, HCWH has gathered mercury-free facility pledges from more than 600 clinics and hospitals.

At first, the pledges were not enough to affect the major retailers of thermometers - including K-Mart, Albertson's, CVS, Wal-Mart and Walgreens - who continued selling mercury thermometers in the face of a growing demand for alternatives.

But HCWH organizers ratcheted up the pressure on the local level in several towns and cities, beginning with Duluth, Minnesota in March 2000, followed by San Francisco, Ann Arbor and Boston, where laws were passed banning the sale of mercury fever thermometers.

The ordinances had an extraordinary effect. The governor of Massachusetts, for instance, called upon other communities to follow Boston's example the day after its ordinance passed, and the administrator of EPA's New England region recommended that other states follow suit.

"Most retailers order their thermometers in one big batch," Jamie Harvie explains. "I think they were scared that they'd be stuck with what was essentially an illegal product in a few local places, so they decided to switch company-wide. This demonstrates once again the power of local organizing."

The strategy also demonstrated the power of HCWH's holistic approach, which allows the campaign to emphasize either the environmental or human health angle, depending upon the audience and circumstance.

By carefully integrating both environmental and occupational health concerns, HCWH also ensures that what are considered acceptable alternatives to existing practices "doesn't shift the risk between occupational exposures and the environment," says Susan Wilburn of the American Nurses Association.

By September 2000, HCWH had commitments from a dozen major retail stores, including Rite-Aid, Brooks, Albertson's, Wal-Mart, K-Mart, Walgreens, CVS, Toys R Us and Drugstore.com. Collectively, the retailers sell millions of thermometers a year.

That kind of market power was enough to get Becton, Dickinson and Co., one of the largest makers of private label thermometers, to announce at the same time that it would stop making glass mercury-based thermometers at its plant in Brazil and stop purchasing them from a Chinese factory.

The Vinyl Solution

Another HCWH goal has been to reduce the use of PVC plastic in medical supplies, and "to build momentum for a broader PVC phase-out campaign."

"In the late 1950s and early 1960s, when it became apparent that cigarette smoking was the main cause of lung cancer, physicians and nurses who were convinced to stop smoking had an important influence on the general population," says Peter Orris, a professor of internal and preventive medicine at the University of Illinois. "In the same way, as the health care industry begins to act on the connection between dioxin and PVC it will have an important affect on the general public's perception of the issue."

"Mercury was the wedge issue," says Bill Ravanesi, HCWH's Boston coordinator. "Now we're using the credibility built around that to create awareness about PVC and other issues."

Armed with reports on the toxic effects of PVC, HCWH gathered resolutions from a variety of professional associations and state and local medical societies. At the same time, the campaign approached hospital supply purchasing groups such as Kaiser, Tenet Healthcare and Universal Health Services, which have since either stopped buying some PVC products or developed a purchasing preference for non-PVC products.

Meanwhile, HCWH began working with shareholder activists to convince Baxter International, the largest maker of IV equipment and other medical products, to develop timetables to phase out use of PVC.

From the start, the Chlorine Chemistry Council/Vinyl Institute (CCC-VI) lobbied against virtually every HCWH initiative against the use of PVC, often bogging the campaign down in arcane scientific debates which HCWH activists say distracted from the search for safer, cost-effective substitutes.

Some of the industry's efforts seemed to backfire. At the end of 1998, after a number of European countries had enacted restrictions on the use of PVC in toys because of toxic additives that leached out during their use, the CCC-VI, forseeing an affect on U.S. markets, initiated a $1 million ad campaign highlighting the use of PVC in medicine. The pro-PVC ads, which ran in the Washington Post and other influential papers, depicted a group of doctors and nurses in an operating room along with PVC equipment. "People who save lives for a living depend on vinyl," the ads crowed.

The ads motivated HCWH members to investigate the hazards of toxic additives (e.g. DEHP softeners) which leach out of PVC medical devices. What they found was startling and added compelling justification a PVC phase-out.

Although DEHP had been voluntarily removed from use in toys, it had not been removed from vinyl medical products, some of which (e.g. IV bags) leached the chemicals out in much greater amounts. Evidence from the manufacturers' product labels as well as the scientific literature revealed that some drugs accelerated the leaching process.

"When you add it all up," says Schettler, who conveyed the science to a variety of regulatory fora, "you find that certain kinds of medical care result in patients being exposed to DEHP at or near levels that cause damage in animal tests ... for example, testicular, liver and kidney damage. Laboratory tests show that the immature, developing animal is most susceptible, and it turns out that some of the highest human exposures to DEHP occur during hospital care of sick newborn infants."

In mid-July, after a two-year study, a National Toxicology Program (NTP) panel expressed serious concern that DEHP may harm the reproductive organs of critically ill and premature male infants exposed during medical treatment.

The NTP finding is bound to further pressure manufacturers of equipment used in neonatal intensive care units, where high levels of phthalate additives may leach and off-gas from vinyl products used in feeding and respiratory therapy.

A breakthrough came in May 1999, when Baxter announced it would "commit to exploring and developing alternatives to PVC products and to developing and implementing proposed timetables for substituting its current containers for intravenous (IV) solutions with a container that does not contain PVC."

As icing on the cake, Baxter also requested that the CCC-VI refrain from using Baxter products in advertising campaigns.

Meanwhile, HCWH campaigners are seeking change from other manufacturers. Plans are being laid for CleanMed: An International Conference on Environmentally Preferable Medical Products, which will bring hospitals, purchasing groups, manufacturers and academics together in Boston in May.