In an effort to shift attitudes away from the use of hazardous chemicals in the health care sector, Health Care Without Harm’s regional offices in Asia and Latin America started the Chemicals Substitution and Management in the Health Care Sector: A Four-Hospital, Multi-Country Project in the Philippines and Argentina. Initiated in 2012, the activity is being conducted, in part, with support from the Strategic Approach to International Chemicals Management’s (SAICM) Quick Start Program.
The project’s goal is to get the ball rolling on the adoption of national policies and procedures substituting hazardous chemicals in health care. Health Care Without Harm-Asia (HCWH-Asia) and Health Care Without Harm Latin-America (HCWH-LA), is also working with the HCWH global network of experts and partners.
The project is being tested in four pilot hospitals in the Philippines and Argentina.
It’s a sad paradox: while the health care sector works to improve the condition of patients, it often uses chemicals that can harm the health of these patients and the environment. These chemicals remain harmful through its lifecycle of production, use, and disposal.
Patients and health care workers are the most vulnerable, since they work closely with these substances on a daily basis. Factory workers who manufacture these products are also at risk, as are waste disposal workers.
While toxic chemicals harm people living near the health care facilities and factories, the harm can spread beyond adjacent areas. Toxic chemicals entering the environment – especially water systems – can harm populations far removed from their place of origin and use.
This contradiction – that chemicals used in health care are harming the people it strives to help – has spurred many hospitals to design new strategies to phase out or substitute hazardous chemicals with safer alternatives.
It’s time for a global shift in the attitudes people have towards the use of harmful chemicals in health care. HCWH-Asia will spearhead a multi-sectoral strategy to promote chemical safety and achieve SAICM’s goals. HCWH-Asia is also receptive to feedback from other health care stakeholders to provide practical advice and perspectives.
The project was built on HCWH-Asia and LA’s established networks, strategies, experience, and its understanding of mercury elimination.
Why the Philippines and Argentina?
The Philippines and Argentina have track records for implementing mercury-elimination policies on a national level. Both countries have served as catalysts for mercury elimination campaigns in surrounding regions. It’s a source of credibility that proves even developing countries can have positive global impacts.
The problem of chemical exposure is intertwined with deep development issues. Most developing countries, including the Philippines and Argentina, do not have comprehensive chemical policies. For much of the population in developing countries, exposure to toxic chemicals is compounded by poor basic living conditions. There is also a lack of clear regulations on the proper manufacture, use, and disposal of dangerous chemicals. HCWH-Asia sought to educate health care workers and common people on these issues.
Getting stuff done: Project components
I. The Health Care Priority Chemicals Matrix
Identify chemicals to be given highest priority, based on international conventions and initiatives (SAICM; the Basel, Rotterdam, and Stockholm Conventions; WHO; GHS). Cross-reference these substances with the known hazardous chemicals used in health care facilities in participating countries. Create a matrix identifying dangerous chemicals for substitution and/or management, including the highest priority chemicals identified in SAICM.
II. Test chemical substitution/management in pilot hospitals
Two hospitals in each country will test a model for substitution and management of dangerous chemicals. Relevant experts will be consulted on the selection of appropriate hospitals. Based on a consultation process, the project will also select specific chemicals from the matrix for control in each hospital.
III. Educate health care workers and other stakeholders
Organize training workshops and develop then distribute materials on the safe uses of hazardous chemicals and their alternative.
IV. Secure the “legacy” of the project
Enable the replication and continuation of the project past the end of the activity. By establishing pilot hospitals and providing education, a roster of experts will be established. These experts will lead by example, continue the project, and disseminate results, laying the groundwork for:
•Replication of pilot hospital programs throughout the health sector nationally and regionally.
•Development of pilot chemical policies at the hospital level for potential replication by health authorities and hospital systems at the provincial and national levels.
•Support for local, regional, and global moves toward safe chemicals in health care.
•Ensuring that all replication activities are in alignment with SAICM/international protocols.
V. Effectively document and disseminate the project:
A final report will be drafted for broad distribution in both countries, and around the world. This report will document the experiences of the four pilot hospitals, and draw on positive examples from around the world on the substitution of dangerous chemicals, in alignment with SAICM and other international standards.
Project benefits and results
Social benefits: Benefits of a redefined approach to chemicals use and management in health care are likely to be very broad and preventive in nature. It is difficult to quantify financial benefits but it is very clear that social benefits would be significant and may include:
•Less exposure to hazardous chemicals in hospitals and factories that manufacture these substances. Less exposure means less health impact, less health care costs, and less liability and worker compensation.
•Fewer public health threats and diseases, lowered exposures in communities that host manufacturing and disposal facilities, thus reducing health care costs and building better community relations.
•Reduced cost of cleaning up accidents involving chemicals used for health care.
•Reduced product liability and the legal costs associated with it.
•Reduced need for regulatory requirements and the costs associated with them.
•Reduced impact on wildlife and the environment.
Common Dangerous Chemicals in Health Care
I. Disinfectants and Sterilants
Chemicals of concern: Glutaraldehyde, ethylene oxide, chlorine buckets, pesticides, quaternary ammonium compounds
Affected individuals: Health care workers, disposal workers
•Glutaraldehyde is a potent occupational skin irritant and causes asthma.
•Ethylene oxide is flammable and explosive, a probable human carcinogen, a toxic air contaminant, and an ozone depleter.
•Chemicals designed to kill biological organisms like pesticidal cleaners can be very toxic to humans and ecosytems.
•Chlorine bleach (sodium hypochlorite), can in some circumstances liberate chlorine gas, a respiratory irritant and sensitizer.
•Quaternary ammonium compounds are respiratory sensitizers.
•Redesign of cleaning processes.
•Alternative safer chemicals such as peracetic acid and hydrogen peroxide solutions.
•Integrated Pest Management (IPM) for pest control.
•Less toxic disinfectants that are adequate for many purposes.
II. Pesticides for Control of Pests Onsite
Chemicals of concern: Various pesticides
Affected individuals: Pesticide applicators, community members living in production, use and disposal sites.
•Nausea, headaches, rashes and dizziness with sufficiently large exposures.
•Link to cancer, birth defects, neurological and reproductive disorders, and the development of chemical sensitivities.
•Some pesticides contaminate food webs.
•Integrated pest management
III. Cleaning Agents
Chemicals of concern: Ingredients may include surfactants, chemicals that enhance the effects of other compounds, alter acid-base balance, bind minerals and metals like mercury, fragrances, and disinfectants.
Affected individuals: Health care workers, community members living in production and disposal sites.
•Solvents may include glycol ethers, some of which cause birth defects, toxicity to testes, and damage to red blood cell.
•Some solvents are toxic to the nervous system.
•Surfactants such as alkylphenol ethoxylates degrade into nonylphenol, which is toxic to aquatic wildlife; ethanolamines can cause asthma.
•May contain chemicals that cause cancer, reproductive disorders, respiratory ailments, eye and skin irritation, central nervous system impairment, etc.
Alternatives: Less-toxic cleaning agents are widely available and used. GreenSeal, for instance, certifies cleaners with lower environmental and human health toxicity.
IV. Medical Devices such as IVs
Chemicals of concern: Mercury, bisphenol A (BPA), DEHP, PVC
Affected individuals: Patients (DEHP), production workers, disposal workers (mercury), community members living in production, use and disposal sites.
•Mercury is a potent neurotoxin that can harm the brain, spinal cord, kidneys and liver.
•Mercury can contaminate the food web.
•PVC manufacture and incineration generates dioxins, chlorinated organochlorines.
•DEHP, an additive to PVC, can damage the liver, kidneys, lungs and reproductive system, particularly developing testes, according to animal studies.
•In animal studies, BPA is associated with alteration in breast, prostate, and brain development, changes in behavior, and susceptibility to breast and prostate cancer.
•Human studies find a direct association with risk of diabetes and heart disease.
Alternatives: Alternatives are available for all mercury products used in the health care setting. PVC-free and DEHP-free alternatives are available for many uses, with some geographic restrictions.
V. Building Materials and Indoor Furnishings
Chemicals of concern:
•Carcinogens, mutagens and reproductive toxicants
Affected individuals: Health care workers, production workers, community members living in production, and disposal sites
•The construction and use of buildings consumes billions of tons of raw materials, including many toxic chemicals, generates significant waste, consumes a tremendous amount of energy and contributes toxic emissions to the air.
•Materials and furniture used indoors can degrade indoor air quality contributing to disease.
Alternatives: There are significant opportunities to improve environmental quality and human health through green planning, design and construction of health care facilities
Chemicals of concern: Metals like lead and mercury, brominated flame retardants, chlorinated plastics
Affected individuals: Hospitals workers who utilize electronic equipment, production workers, community members living in production and disposal sites
•Improper disposal of electronic equipment poses a significant threat to public health and the global environment. When electronic products are incinerated or dumped in a landfill, they can release heavy metals and other hazardous substances that contaminate groundwater and pollute air.
•Brominated flame-retardants result in toxic polybrominated dibenzodioxins and –furans when recycled. Markedly elevated levels of these are measured in recyclers and in communities hosting recycling operations. Health effects include cancer, immune and reproductive system toxicity. Electronic use may contribute to elevated levels of flame retardants in indoor dust.
Alternatives: Electronics manufacturers need to develop less toxic alternatives to the most hazardous components in response to international regulation and consumer expectations.
Chemicals of concern: Biologically active agents that can be active at low doses.
Affected individuals: Those consuming tainted drinking water, those in production use and disposal sites.
Harmful effects: Pharmaceuticals are biologically active with specific disease target endpoints. There are potential health and ecological impacts when many pharmaceuticals are mixed together, when people who are not ill are exposed inadvertently, or when populations are exposed to widely used pharmaceuticals.
•Pharmaceutical collection programs
•Redesign of pharmaceuticals
•Preferable product selection
•Changes to water treatment system
VIII. Lab Chemicals
Chemicals of concern: Toluene and xylene (used to fix tissue specimens and rinse stains), formaldehyde, mercury
Affected individuals: Health care workers, community members living in production, and disposal sites
•Eye and respiratory irritation, abdominal problems
•Chronic exposure: laryngitis, bronchitis or bronchial pneumonia, conjunctivitis Formaldehyde is a carcinogen
•Substitution with safer alternatives is preferable to process controls, and/or personal protective devices
•Less toxic alternatives to some lab chemicals are available
IX. Waste disposal (Incineration, trash dumps)
Chemicals of concern:
Brominated and chlorinated organic toxicants including:
Affected individuals: Waste disposal workers, members of the community.
•Dioxins are a known human carcinogen, and can cause birth defects, learning disabilities, endometriosis, infertility, suppressed immune function, reduced IQ and hyperactive behavior in children. It bioaccumulates in people and wildlife.
•Incinerator emissions can include carcinogenic, mutagenic and reproductive toxicants, asthmagens and respiratory irritants.
Alternatives: There are readily available and widely used alternatives to incineration throughout the world. Some chemotherapeutic waste may be an exception.
To further intensify its campaign against the use of mercury in health care settings, Health Care Without Harm – Asia (HCWH-Asia) once again partnered with KemI. KemI is a Swedish governmental authority working to control the use of chemicals, and prevent its spread into the environment.
The new project was dubbed Creating Pilot Hospitals for Mercury Substitution in Indonesia and Hazardous Chemical Substitution in the Philippines. The activity was a two-part project that expanded work in the mercury phase-out arena.
HCWH-Asia and KemI have a history of successfully implementing mercury substitution campaigns. In 2010, KemI supported the group in its campaign for mercury substitution in Philippine pilot hospitals. In 2011, an Asia Regional conference on mercury highlighted the success of that pilot campaign. The conference also attracted support for piloting in more hospitals in Denpasar City in Bali, Indonesia.
The latest project, Creating Pilot Hospitals for Mercury Substitution in Indonesia and Hazardous Chemical Substitution in the Philippines, continues the groundwork laid in HCWH-Asia’s previous KemI projects.
The health care sector uses large amounts of medical devices such as thermometers and sphygmomanometers that contain mercury and other hazardous chemicals. The effects of these substances on the environment have been well-documented.
It’s a paradox that while the health care sector is committed to helping people, the tools it uses can negate the care it provides. Many hospitals have become more informed on the negative effects of using mercury. This knowledge has spurred them to seek alternatives to mercury.
Due, in part, to the efforts of HCWH-Asia, attitudes are shifting away from mercury on a national scale. Policies are also being implemented that promote more environmentally sound options. This shift is is in line with Administrative Order 21, which mandated the phase-out of all mercury-containing devices by 2010.
A Combined Effort
Under the project, HCWH-Asia worked with hospitals and other stakeholders to pave the way for safe chemical policies. The list below also illustrate available methods and alternatives of rendering health care workplaces safe:
Cleaning products: Replace with non-toxic products, use microfiber mops, refine cleaning processes. (Often, it is possible to clean rooms better without chemical cleansers by targeting high use sites, like telephone handles and doorknobs)
Equipment sterilizers: Replace or isolate chemicals, improve and enforce industrial hygiene control measures
Acrylic resins (in automate systems, ventilation systems medical polymers): Replace or isolate chemicals, improve and enforce industrial hygiene control measures
Phthalates: Use phthalate-free products
Pharmaceuticals: Install Hoppers, ventilation hoods, personal protective equipment, respirators; institute clinical substitutions if these are equally effective in treating patients; improve and enforce industrial hygiene control measures
Latex gloves: Use non-latex or powder-free latex gloves
Pesticides: Implement non-toxic Integrated Pest Management programs
Perfumes and fragrances in scented cleaners and products: Use fragrance-free products