THE ENVIRONMENTTHE ENVIRONMENTAND AND

MEDICINEMEDICINE’’S 1ST COMMANDMENTS 1ST COMMANDMENT““Do No HarmDo No Harm””

I SEMINARIO ESTADUAL HOSPITAIS I SEMINARIO ESTADUAL HOSPITAIS SAUDAVEISSAUDAVEIS

Sao Paulo

September 12, 2008

PeterPeter OrrisOrris, MD, MPH, FACP, FACOEM , MD, MPH, FACP, FACOEM Professor of Internal and Preventive MedicineProfessor of Internal and Preventive Medicine

Past President, Medical StaffPast President, Medical StaffCook County HospitalCook County Hospital

(The John H.(The John H. StrogerStroger Jr. Hospital of Cook County)Jr. Hospital of Cook County)

Chicago, IllinoisChicago, Illinois

Roles and Responsibilities of the Health Care Roles and Responsibilities of the Health Care Sector in the Protection of the EnvironmentSector in the Protection of the Environment

Health Care IndustryHealth Care Industry

World Wide:World Wide:–– 59,220,000 Full Time Health Care Workers59,220,000 Full Time Health Care Workers–– 3% of Gross Domestic Product in 19483% of Gross Domestic Product in 1948–– 10.2% of GDP in 200310.2% of GDP in 2003–– Range 2% to >14% Range 2% to >14%

WHO, World Health Report, 2006

Most Hospital Waste Is Most Hospital Waste Is Simply Simply ““TrashTrash””

Hospital Waste (Trash)

Includes 2%pathologicalwaste

Reg. Med. WasteHazardous Waste

Hospital WasteHospital WasteLike Household TrashLike Household TrashIs Largely RecyclableIs Largely Recyclable

10%

10%3%

7%10%15%

45%

Food Waste MetalsWood GlassOther PlasticsPaper and Paperboard

Problems with Hospital WasteProblems with Hospital WasteToxicity Toxicity -- Dioxin (from PVC and other chlorinated items)Dioxin (from PVC and other chlorinated items)-- Mercury and other heavy metalsMercury and other heavy metals

Increasing VolumeIncreasing Volume-- Large amounts of singleLarge amounts of single--use, disposable itemsuse, disposable items-- Recycling not being utilized in many casesRecycling not being utilized in many cases

MERCURYMERCURY

Global Mercury EmissionsGlobal Mercury Emissions5,000 tons per year5,000 tons per year

20%

40%

40%

Natural

Re-emissions of PastAnthropogenicCurrentAntropogenic

Global Mercury EmissionsGlobal Mercury Emissions

Sources of Environmental Mercury Sources of Environmental Mercury from Human Activityfrom Human Activity

Medical waste incinerators account Medical waste incinerators account for for 10%10% of the total from of the total from

combustion sources. combustion sources.

Health Care Products Containing Health Care Products Containing Mercury and Their AlternativesMercury and Their Alternatives

ProductProductHg batteriesHg batteriesEsophageal devices, Esophageal devices, Cantor & MillerCantor & Miller--Abbott Abbott tubestubesHg thermometersHg thermometersHgHg--based blood pressure based blood pressure monitoring devicesmonitoring devicesLamps & lighting devicesLamps & lighting devicesHg switchesHg switchesHg dental amalgamsHg dental amalgams

AlternativesAlternativesLithium, zinc air, alkalineLithium, zinc air, alkalineProducts w/ tungsten Products w/ tungsten tubing Anderson ANtubing Anderson AN--2020Digital, expansion or Digital, expansion or aneroidaneroidElectronic vacuum gauge, Electronic vacuum gauge, expansion or aneroidexpansion or aneroidNonNon--Hg basedHg based--sodium sodium vapor,glow lights, opticalvapor,glow lights, opticalNonNon--Hg switchesHg switchesGold, ceramic, porcelain Gold, ceramic, porcelain

ACUTE INORGANIC MERCURY VAPOR ACUTE INORGANIC MERCURY VAPOR INHALATION POISONINGINHALATION POISONING

11--2 mg/m3 of elemental mercury vapor causes acute chemical2 mg/m3 of elemental mercury vapor causes acute chemicalbronchiolitisbronchiolitis andand pneumonitispneumonitis, with extensive pulmonary fibrosis. , with extensive pulmonary fibrosis.

Clinical findings correlate with the duration of exposure, the Clinical findings correlate with the duration of exposure, the concentration of mercury, and the survival time after exposureconcentration of mercury, and the survival time after exposure.

Asano S et. al. Pathol Int.2000 Mar;50(3):169-74

Therefore Breakage is a significant ProblemTherefore Breakage is a significant Problem&&

Proper Cleaning of spills is importantProper Cleaning of spills is important

Elemental Mercury PoisoningElemental Mercury Poisoning

Classic triad of Classic triad of ““Mad HatterMad Hatter””syndromesyndrome

ErethismErethismTremorTremorGingivitisGingivitis

Renal impairmentRenal impairment

Chemical Forms of MercuryChemical Forms of Mercury

OrganicOrganic–– Methyl, ethyl,Methyl, ethyl, dimethyldimethyl–– Phenyl organic groupsPhenyl organic groups

Health Effects of Methyl Health Effects of Methyl Mercury on HumansMercury on Humans

InhalationOralDermal

Death

Acute

Intermed

iate

ChronicSystemic

Immunologic

Neuro

logicRep

roducti

veDev

elopmen

tal

Genotoxic

Cance

r

Existing Studies (ATSDR 1998)

MinamataMinamata DiseaseDisease

Constriction of visual fieldsConstriction of visual fieldsIrregular gaitIrregular gaitLoss of muscular coordinationLoss of muscular coordinationLoss of speech, hearing, and tasteLoss of speech, hearing, and tasteEmotional disturbanceEmotional disturbance““Living wooden dollsLiving wooden dolls””

MercuryMercuryEffects of Low Dose Prenatal ExposureEffects of Low Dose Prenatal Exposure

Grandjean, et. al., Neurotoxicology & Teratology, 19:6, 1997

Per c

ent o

f chi

ldre

n w

ith lo

w te

stsc

ores

at a

ge 7

yea

rs

40

30

20

10

0

MOTORATTENTION

VISUOSPATIAL

LANGUAGEMEMORY

> 50 μg/l30-50 μg/l15-300 μg/l< 15 μg/l

Children with low prenatalmercuryexposure < 15 >5030-5015-30

Children with high prenatalmercury

exposure

% F

aroe

Isla

nd C

hild

ren

with

lo

wes

t sco

res

at a

ge 7

yea

rsµg/l

A Quantitative Analysis of Prenatal Methyl A Quantitative Analysis of Prenatal Methyl Mercury Exposure and Cognitive DevelopmentMercury Exposure and Cognitive Development

Joshua T. Cohen PhD, et. Al.Joshua T. Cohen PhD, et. Al.Harvard Center for Risk Analysis, Harvard School of Public HealtHarvard Center for Risk Analysis, Harvard School of Public Health, Boston, h, Boston,

Prenatal MeHg exposure sufficient to Prenatal MeHg exposure sufficient to increase increase

Mercury in maternal hair at birth by 1 Mercury in maternal hair at birth by 1 μμg/g g/g

Decreases IQ by 0.7 points. Decreases IQ by 0.7 points. American Journal of Preventive Medicine Volume 29, Issue 4 , NovAmerican Journal of Preventive Medicine Volume 29, Issue 4 , November 2005ember 2005

$1.3 billion$1.3 billioneach year is attributable each year is attributable

totomercury emissions mercury emissions

fromfromAmerican power plants. American power plants.

Leonardo Trasande, Philip J. Landrigan, and Clyde Leonardo Trasande, Philip J. Landrigan, and Clyde SchechterSchechterMount Sinai School of Medicine, New York, New York, USA

Public Health and Economic Public Health and Economic Consequences of Methyl Mercury Toxicity Consequences of Methyl Mercury Toxicity

to the Developing Brainto the Developing Brain

Environ Health Perspect 113:590Environ Health Perspect 113:590––596 (2005).596 (2005).

Mercury Out Of The FishMercury Out Of The FishNot Fish Out Of The MotherNot Fish Out Of The Mother

Comparison of Mercury (ppm) and OmegaComparison of Mercury (ppm) and Omega--3 Fatty 3 Fatty Acid (g/100g) in Fish SpeciesAcid (g/100g) in Fish Species

High Mercury SpeciesHigh Mercury Species

TilefishTilefish: 1.6 Hg, 0.17 O: 1.6 Hg, 0.17 O--3s3sSharkShark: 1.3 Hg, 0.07 O: 1.3 Hg, 0.07 O--3s3sKing MackerelKing Mackerel: 0.97Hg, : 0.97Hg,

0.18 O0.18 O--3s3sSwordfishSwordfish: 0.95 Hg, 0.58 O: 0.95 Hg, 0.58 O--

3s3s

High OmegaHigh Omega--3 Species3 Species

MackerelMackerel: 0.08 Hg, 3.61 O: 0.08 Hg, 3.61 O--3s3s

SalmonSalmon--sockeye:sockeye: 0.03 Hg, 0.03 Hg, 3.00 O3.00 O--3s3s

HerringHerring: 0.01 Hg, 2.34 O: 0.01 Hg, 2.34 O--3s3sTuna, albacore:Tuna, albacore: 0.26 Hg, 0.26 Hg,

2.33 O2.33 O--3s3s

PVC in Medical ProductsPVC in Medical Products

IV bagsIV bags

Blood bagsBlood bagsIV and respiratory IV and respiratory therapy tubingtherapy tubing

Venodyne sleevesVenodyne sleeves

Patient ID cardsPatient ID cards

Water bed linersWater bed liners

Rigid packaging traysRigid packaging trays

Mattress coversMattress covers

XX--Ray folder holdersRay folder holders

Shower curtainsShower curtains

Dialysis bagsDialysis bags

Thermal blanketsThermal blankets

DioxinDioxin

No commercial useNo commercial useProduced during Produced during production or production or destruction of destruction of chlorinated chlorinated organic organic compoundscompounds75 separate dioxin75 separate dioxin--like compoundslike compounds

2,3,7,8 tetrachlorodibenzo-para-dioxin (TCDD)

Most research is performed on TCDD because it has the greatest

potencyPSR, 1998

TCDDTCDD

Viktor YushchenkoViktor Yushchenko

Human Health Effects of DioxinHuman Health Effects of Dioxin

CancerCancerKnown human carcinogenKnown human carcinogen

Neonatal AbnormalitiesNeonatal AbnormalitiesChange in sex ratioChange in sex ratioAltered level of thyroid Altered level of thyroid hormonehormone

Skin DisordersSkin DisordersPorphyria cutanea tardaPorphyria cutanea tardaChloracneChloracne

Neurologic DisordersNeurologic DisordersPeripheral (animal)Peripheral (animal)Central (PCB?)Central (PCB?)

Immune SystemImmune System•• Change in immune system Change in immune system

parameters / modulationparameters / modulation

Endocrine System EffectsEndocrine System EffectsLow levels of testosteroneLow levels of testosteroneIncrease glucose intolerance Increase glucose intolerance or diabetesor diabetesDecreased estrogen & Decreased estrogen & estrogenestrogen--receptor levels after receptor levels after fetal exposurefetal exposure

Physicians Physicians are theare the

Gate KeepersGate Keepers

Physicians in Hospitals Physicians in Hospitals WorkWork

in front of the Presidiumin front of the Presidium

Nurses are the KeyNurses are the Key

Within Health CareWithin Health CareThere Is No ArgumentThere Is No Argument

About About The Need To Avoid PoisoningThe Need To Avoid Poisoning

The EnvironmentThe Environment

Obstacles To Seeing The Obstacles To Seeing The Problem Problem

Clinical ParadigmClinical Paradigm

DoseDose

Other ways to be Other ways to be ‘‘toxictoxic’’

There is the same old ways: hurt, kill, or mutant There is the same old ways: hurt, kill, or mutant and individual (whether it is a cell, organ or and individual (whether it is a cell, organ or being).being).OthersOthers–– Immune system dysfunction.Immune system dysfunction.–– Endocrine disruption.Endocrine disruption.

Alter reproductive capability, maleness, femaleness, etc...Alter reproductive capability, maleness, femaleness, etc...

–– Alteration of systemAlteration of system’’s patterns.s patterns.Pattern change can impact the system drastically.Pattern change can impact the system drastically.

–– Lose of diversity.Lose of diversity.

Human development is disrupted at vulnerable stages by fetal and infant exposure to endocrine disruptors.

The Significance of Small Effects: The Significance of Small Effects: EFFECTS OF A SMALL SHIFTEFFECTS OF A SMALL SHIFT

IN IQ DISTRIBUTION IN A IN IQ DISTRIBUTION IN A POPULATION OF 260 MILLIONPOPULATION OF 260 MILLION

160140120100806040

70 130I.Q.

mean 100

6.0 million "gifted"

6.0 million"mentally retarded"

5 Point Decrease in Mean IQ5 Point Decrease in Mean IQ

160140120100806040

Mean 95

70 130

2.4 million"gifted"

9.4 million"mentally retarded"

57% INCREASEIN

"MentallyRetarded”Population

I.Q.

Key concepts Key concepts -- EcotoxicologyEcotoxicology

Population effectsPopulation effectsCommunity effectsCommunity effectsEcosystem effectsEcosystem effects

Clinicians and PatientsClinicians and PatientsEnvironmental Disease

SOCIAL DISEASES SOCIAL DISEASES

REQUIRINGREQUIRING

SOCIAL SOLUTIONSSOCIAL SOLUTIONS

Clinicians and PatientsClinicians and PatientsEnvironmental Disease

Who is The Patient?Who is The Patient?THE COMMUNITYTHE COMMUNITY

Clinicians and PatientsClinicians and PatientsEnvironmental DiseaseEnvironmental Disease

Unbiased Review of the ScienceUnbiased Review of the ScienceApply Toxic Therapeutic Balance for Apply Toxic Therapeutic Balance for Community PatientCommunity PatientTransparent Precautionary ConclusionsTransparent Precautionary ConclusionsProfessional Organization ConsensusProfessional Organization Consensus

Health Care Professionals are Influential Opinion SettersHealth Care Professionals are Influential Opinion Setters

Health Care Products Containing Health Care Products Containing Mercury and Their AlternativesMercury and Their Alternatives

ProductProduct–– Hg batteriesHg batteries–– Esophageal devices, Esophageal devices,

Cantor & MillerCantor & Miller--Abbott Abbott tubestubes

–– Hg thermometersHg thermometers–– HgHg--based blood based blood

pressure monitoring pressure monitoring devicesdevices

–– Lamps & lighting Lamps & lighting devicesdevices

–– Hg switchesHg switches–– Hg dental amalgamsHg dental amalgams

AlternativesAlternatives–– Lithium, zinc air, Lithium, zinc air,

alkalinealkaline–– Products w/ tungsten Products w/ tungsten

tubing Anderson ANtubing Anderson AN--2020–– Digital, expansion or Digital, expansion or

aneroidaneroid–– Electronic vacuum Electronic vacuum

gauge, expansion or gauge, expansion or aneroidaneroid

–– NonNon--Hg basedHg based--sodium sodium vapor,glow lights, vapor,glow lights, opticaloptical

–– NonNon--Hg switchesHg switches–– Gold, ceramic, Gold, ceramic,

porcelain porcelain HCWH, www.noharm.orgHCWH, www.noharm.org

operations

Support organic and

locally produced food

products

environmental purchasing

1.1 Organic & Local Food1.2 No Antibiotics in meat

Saving $$ and the Saving $$ and the EnvironmentEnvironment

Jacobi Medical Center cut annual waste Jacobi Medical Center cut annual waste management costs by 30%management costs by 30%Working with WasteWorks, St. Barnabas Working with WasteWorks, St. Barnabas Hospital reduced waste volume by 65% and Hospital reduced waste volume by 65% and costs by 50%costs by 50%P2 efforts by Staten Island University P2 efforts by Staten Island University Hospital reduced waste management costs Hospital reduced waste management costs by $500,000 per yearby $500,000 per year

Lead in GasolineLead in Gasoline

Health Care Without HarmHealth Care Without Harm

The Campaign for The Campaign for Environmentally Environmentally

Responsible Health CareResponsible Health Care

Web site: www.noharm.org

AcknowledgementsAcknowledgementsThanks to my Colleagues at University of IllinoisThanks to my Colleagues at University of IllinoisAnne Krantz, MD, MPHAnne Krantz, MD, MPHDan Hryhorczuk, MD, MPHDan Hryhorczuk, MD, MPHAnd And Postings on the Internet Postings on the Internet

For providing me many excellent slides for editing