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Medical waste is one of the country's biggest sources of dioxin. When will hospitals clean up their act?

Health Problem at the Health Care Industry

The Amicus Journal - Winter, 2000

BY DICK RUSSELL

The twin smokestacks are set well back from High Street, barely visible to drivers passing through this industrialized sector of East Oakland, California. A sign at the front gate reads: "INTEGRATED ENVIRONMENTAL SYSTEMS ... People, Service and Environment." Within the confines of this compound, two kilns burn continuously five days a week, incinerating some 20 tons of waste pen day. The white vapor that streams from the smokestacks looks innocuous enough. But before its $5 million remodeling in 1996, Integrated Environmental Systems (IES) was cited for almost 200 violations of clean air standards. And what's in the vapor today is a matter of much local concern and controversy. Although IES's emissions currently fall below the pollution limits mandated under the Clean Air Act, test burns it has conducted show that the smokestacks nonetheless continue to spew forth some dioxin – the most carcinogenic chemical compound known to science.

photo Peter DaSilva
Michael Green of San Francisco's Center for Environmental Health is on of several activists pushing Integrated Environmental Systems – the last commercial medical waste incinerator in California – to reduce its emissions of dioxins.

Standing on the sidewalk outside the incinerator, Michael Green tells me, "About three-quarters of the time, the wind blows east, right oven a low-income, people-of-color neighborhood nearby. Today, whatever's coming out of the stacks is moving west, right toward the bay oven there." Green, who left his work as a contractor with the Department of Energy four years ago to found the nonprofit Center for Environmental Health in San Francisco, points to a bridge a few hundred yards away. Beneath it stands a small group of fishermen, casting their lines.

IES has been operating here in the San Francisco Bay area since 1981. Because it burns waste from all over California and releases the byproducts mainly into an African-American and Latino community, it is a serious environmental justice problem. Moreover, this is the last commercial medical waste incinerator in California. Ninety percent of the waste burned here is trucked in from hospitals and clinics. Most of the dioxin in the vapor is created by burning polyvinyl chloride (PVC plastics, which are pervasive in hospitals – used in IV bags, tubing, specimen containers, oxygen tents, packaging, and other items. Every year, some 500 million IV bags are sold in this country, and 80 percent of them are made of PVC. Overall, the plastic content of hospital waste is between 15 and 30 percent, about twice the level found in typical household waste.

In 1994, the Environmental Protection Agency (EPA) labeled medical waste incinerators the largest source of dioxin emissions in the country. By 1998, after tougher restrictions created by EPA had forced most of the oldest and dirtiest on-site hospital burners to close, medical waste incinerators still ranked just behind municipal waste burners, tied with copper smelters as the second-worst dioxin polluter. Moreover, because many hospitals continue to use mercury in chemical solutions, thermometers, and blood pressure gauges, a new federal survey has found that medical waste incineration is also the country's worst source of air emissions of this highly toxic metal.

 
Surely the health care industry, of all industries, has no business sending dangerous poisons into the air. Susan Forsyth, vice-chair of the government relations committee for the California Nurses Association, was chilled when she came to the frightening realization that, as she puts it, "The trash that I throw away on my unit is actually causing people to get the cancer and reproductive problems which I'm then treating." (See box on dioxin and mercury below.)

In effect, the medical industry has unwittingly created a vicious cycle that violates Hippocrates' famous principle for treatment of disease: "At least, do no harm." NRDC's Gina Solomon, an M.D. and assistant clinical professor of medicine with the University of California at San Francisco, explains the paradox this way: "Having spent years of my life working in hospitals, I can testify that there's very much of a mindset that doesn't look to the future. The attitude is, 'What can be done for this patient right now?' – without any kind of social conscience or awareness of broader issues." That attitude says Solomon, "is antithetical to a public health approach."

Due in large part to a new international coalition caller Health Care Without Harm (HCWH), the public health approach is finally starting to gain a foothold. The coalition arose in 1996 out of a conference at Commonweal, a California health research institute whose founder, Michael Lerner, is renowned for his pioneering work with terminal cancer patients. Today, HCWH boasts 178 members, ranging from organizations such as the American Nurses Association, Breast Cancer Fund, and Endometriosis Association to scientists, physicians, religious groups, hospital administrators, and environmental activists.

The mission of HCWH is twofold. First, it spreads the word about the hazards of medical waste incineration. It was at an HCWH meeting, for instance, that Susan Forsyth had her eye-opening realization. Second, HCWH educates medical personnel about the fact that most of the waste they now send for incineration simply does not need it. Nationwide, hospitals annually generate some two million tons of waste, a total that has more than doubled since 1955. By long-standing custom, most of this waste is "red-bagged," that is, discarded into red bags marked with a biohazard symbol and destined for burning. Yet if hospitals changed their purchasing and disposal practices, as much as 85 percent of the waste being labeled "infectious" today could be treated as ordinary trash. As Forsyth explains it, all that plastic – from IV bags to plastic gloves and eating utensils – just doesn't need to be burned. "There's certainly a place for waste segregation;" she says, "but just because something's been near a patient doesn't mean it's pathological. As things stand, one simple nursing procedure might fill several large trash cans a day per room." For instance, blood, tissues, and cultures of infections agents are biohazardous; but non-bloody gloves, IV bags, and IV tubing, all of which are commonly red-bagged, are not.
photo Peter DaSilva
Sister Susan Vickers of Catholic Healthcare West: maintaining hospital safety while reduicing medical waste incineration.

Adds Sister Susan Vickers, advocacy director for a nonprofit hospital chain called Catholic Healthcare West: "In the wake of the AIDS epidemic came the advent of 'universal precautions,' an effort to protect both patients and health care workers from any possibility of infection. So there's been a real switch to disposable, single-use items across the board. Now we need to ask, in a very deliberate fashion, where does it make sense to have multiple-use?" A number of hospitals are beginning to answer that question, some of them by hiring full-time waste management coordinators. Since haulage fees for red-bag waste are at least five times higher than for unregulated trash, rethinking garbage is proving to be extremely cost-effective.

The model for Catholic Healthcare West – which, with forty-seven acute-care facilities in California, Arizona, and Nevada, is the largest consortium of hospitals in HCWH – is its own Dominican Santa Cruz Hospital. Dominican Santa Cruz saved $35,000 in 1997 alone by rewriting its waste protocols. The hospital also opened a store in which, says Sister Mary Ellen Leciejewski, ecology program coordinator at Catholic Healthcare West, "any item that could conceivably have another life became stock for the shelves." Residents of Santa Cruz now visit the store (named Dominagain) to reclaim plastics, paint, scrub brushes, pitchers, trays, cups, and other perfectly usable items that were once simply discarded. Another innovator, New York's Beth Israel Medical Center, is saving more than $600,000 per year on medical waste disposal costs. (See sidebar below.)

Other examples are proliferating. When the Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, had to close its old incinerator, it hired coordinators for both recycling and infectious materials in each hospital department. The Butterworth Hospital in Grand Rapids, Michigan, has eliminated 280 pounds of mercury from its waste over the past four years, and become 99 percent mercury-free, by using such alternatives to traditional equipment as digital thermometers and lithium and zinc batteries.

"Traditionally, environmental activists have targeted government regulators and the chemical industry," notes Gina Solomon. "I think Health Care Without Harm has started a trend in looking at sectors that don't manufacture the toxics but use them. After all, the health care industry has a reputation to protect and no stake in the future of PVC plastic or mercury-containing instruments."

Or, as nurse Susan Forsyth summarizes: "It's a win-win situation. Management saves money and the environment, and looks good to the community."

 
Sitting in his fifth-floor office in Oakland's TransPacific Building, beneath a wall poster that reads "Health Care is Not For Profit," Dr. Arthur Chen speaks of having been "essentially tutored on all the impacts of medical waste" at an HCWH conference. Chen evidently learned the lessons well: "We need zero dioxin in this county," he insists. As health officer for the Alameda County Health Department, Chen is charged with enforcing health and safety codes affecting 1.4 million people and thirteen hospitals – and his mandate includes oversight of IES. Says Chen, "We're working hard to convince the company that it behooves them to think of alternatives as a reasonable investment, given that their days with incineration may be numbered just because of sheer public opinion."

IES, notes Chen, does have the capacity to microwave medical waste. Microwaving boils infectious microbes, leaving most of them harmless, and is more than effective for most hospital waste. (Only 2 percent of hospital waste, such as tissues and organs, is categorically pathological and must be incinerated.) Another option is autoclaving, which uses super-heated, pressurized steam to sanitize trash and which renders between 85 and 90 percent of the waste inert. While precautions must be taken during autoclaving to ensure that wastewater from the condensed steam doesn't carry mercury into any nearby water bodies, many hospitals are starting to turn to onsite autoclaves as a means of reducing dioxin formation.

"We're not calling for a shutdown of IES but a change in their technologies," says Bradley Angel of Greenaction, a Southwestern network that assists community activist groups. One of these groups is PUEBLO (People United for a Better Oakland), a ten-year-old grassroots organization that spent eight months fighting the renewal of IES's operating permit – but lost, despite the fact that IES had never submitted an environmental impact report. Karleen Lloyd, an African-American woman who lives less than a mile from the incinerator, says, "Our neighborhood is disproportionately impacted by various industries, and the regulatory agencies have never looked at the synergistic effect of these pollutants."

During the lengthy hearing process on the IES permit, it was revealed that medical waste was soon to start arriving from the Hawaiian island of Oahu, where local protests had forced an incinerator to close. It also came out that two of the four members of the hearing board convened by the agency issuing the permit (the Bay Area Air Quality Management District) had contractual consulting relationships with a subsidiary of IES's parent company, Norcal. "Even though these members received a legal opinion that seemed to vindicate them, you have to say that's a bit suspicious," comments Dr. Chen.

In April of 1998, PUEBLO's appeal was denied on the grounds that IES had revamped its facility. Then, last February, came a grassroots victory of potentially far greater import. Oakland became the first city in the country to pass a resolution calling for immediate steps to protect public health from dioxin emissions. Despite heavy lobbying against this measure by the Washington, D.C.-based Chlorine Chemistry Council, the city council voted unanimously to, among other things, urge "Oakland health care institutions to reduce PVC use and eventually become PVC-free."

Throughout California, the pressure on IES is mounting. In March, San Francisco's Board of Supervisors voted unanimously for a resolution intended to eliminate dioxin wherever possible. The California Medical Association, as well as the American Public Health Association, has issued a statement calling for minimization or phase-out of PVCs. The Oakland-based Kaiser Permanente hospital chain has embarked on a nationwide effort to implement waste reduction and go mercury-free.

Not surprisingly, the plastics industry is mounting its own advocacy program – a multimillion-dollar advertising campaign. One recent ad in a San Francisco newspaper depicted emergency-room doctors standing in front of a sign reading "Vinyl Saves Lives." Still, even within the ranks, momentum against PVCs appears to be building. Chemical and Engineering News, essentially a house organ for the industry, recently came out in favor of "a prudent switch to non-PVC, DEHP-free alternatives" for medical supplies. (DEHP, an ingredient added to vinyl to provide flexibility and transparency, is listed by EPA as a probable human carcinogen.)

As for IES, it has not committed to any changes in its own practices beyond upgrading its emissions control. "We incinerate medical waste because it provides 100 percent destruction of anything that's potentially infectious," says spokesperson Robert Reed. IES does autoclave about 15 percent of its waste at the request of customers, and it has called on its hospital clients to try to cut back on what they ship for incineration. Public health activists in the area view this as a small step on a long road. Karleen Lloyd points to a chart indicating a 65.5 percent increase in asthma in her area over the past decade, most of it in children – including her two daughters. "What kind of future are we building for our children, especially kids of color?" she wonders.

 
The message is also spreading beyond individual hospitals. In the summer of 1998, the American Hospital Association signed an agreement with EPA calling for the elimination of mercury from the waste stream by 2005. Browning-Ferries Industries, the nation's second-biggest waste-hauler, has credited HCWH for its public commitment in June 1998 to close a significant number of its sixteen remaining medical waste incinerators and replace them with autoclaves.

And last April saw a startling breakthrough at Baxter Healthcare Corporation, one of the two leading manufacturers of medical supplies. In October 1998, Susan Vickers had written Baxter about the commitment by Catholic Healthcare West to phase out chlorinated plastics and urged the company to start selling a non-PVC IV bag known as Clear-Flex. Then, in the spring, three groups of Roman Catholic and labor union shareholders threatened to introduce a resolution for a phase-out of all vinyl products. The company announced in April that it will develop and enforce a timetable for introducing non-PVC medical supplies.

There is still a long way to go. "Greening" Hospitals, a 1998 HCWH report, surveyed fifty major U.S. hospitals and found that only a fifth have programs to reduce purchases of PVC plastic. The average hospital recycles only about a third of readily reusable items. Even among hospitals with mercury-reduction programs in place, 37 percent still buy mercury thermometers, and nearly half purchase mercury blood pressure devices.

But HCWH's inroads are clearly having an effect. "Two years ago, the chemical industry regarded us as fringe lunatics trying to undermine their market," says HCWH national coordinator Gary Cohen. "Today, hopefully, we represent the early stages of an environmental health movement." Envisioning a future in which children are born free of toxic chemicals and mothers can breast-feed their infants without passing on dioxin to them, he adds, "At its deepest level, this is a human rights campaign."


WEBSITES
American Public Health Association
California Medical Association
Catholic Healthcare West (CHW) - (*www.chwsocialregion.org)
Center for Environmental Health
Environmental Protection Agency
Health Care Without Harm (HCWH) - (*www.sustain.org/hcwh)
National Institute of Environmental Health Science

 
PUBLICATIONS

Our Stolen Future, by Theo Colborn, Dianne Dumanoski, and John Peterson Myers, Dutton, 1996
"Dissolving Medical Waste," by Brandy E. Fisher, Environmental Health Perspectives, Vol. 104, No. 7, July 1996
Dying from Dioxin, by Lois Marie Gibbs and the Citizens Clearinghouse for Hazardous Waste, South End Press, 1994
Chemical Contamination and Its Victims, edited by David W. Schnare and Marlin T. Katzman, Quorum Books, 1989

Dioxin and Mercury: The Health Hazards

Dioxin is actually a class of seventy-five chemicals, formed when waste containing a chlorine source such as polyvinyl chloride (PVC) plastic is burned and during the manufacture of certain organic chemicals containing chlorine. At least seven of dioxin's chemical forms are highly toxic, and one – 2,3,7,8-tetrachlorodibenzodioxin – is believed to be the single most carcinogenic compound in existence. Scientists have documented that, even at very low levels of exposure, dioxin can also cause birth defects and affect the immune system, reproductive organs, and a variety of hormonal processes in ways whose ultimate effects are unknown.

Because the chlorine bonds in the dioxin molecule are extremely resistant to chemical or physical breakdown, dioxin is highly persistent in the environment. It can be airborne for long distances and subsequently enter the food chain through plants and water, ending up in meat, dairy products, eggs, and fish. The human body processes dioxin very slowly once it is consumed, creating a buildup of the chemical in fatty tissue – such as the female breast. Thus, nursing infants are particularly likely to receive doses of dioxin.

Combustion-related sources, such as incinerators, account for the majority of known dioxin emissions. A large proportion of dioxin emissions, from a multiplicity of sources, can be traced to a handful of individual chlorine related products and processes: PVC plastic, chlorine-based pulp bleaches, pesticides, and chlorinated solvents. PVC is the most abundant product of chlorine chemistry, consuming more than 30 percent of all the chlorine produced annually in the United States. It is widely used in pipes, many other building materials, furniture, packaging, and more. And dioxins are formed both when PVC is manufactured and when it is incinerated.

Mercury, a naturally occurring element, is a neurological toxin. It attacks the body's central nervous system and is also capable of harming the kidneys and lungs. Coal-powered utility plants are the biggest producers of airborne mercury emissions, which are released when coal containing mercury is burned. Once freed from the minerals in which it had been locked up and effectively rendered harmless, mercury does not disappear or break down. Falling back onto land or surface waters, mercury remains there indefinitely, concentrating in animals and ultimately in human beings.

Residents of forty-one states have been warned not to eat certain types of freshwater fish because of mercury contamination. In May, a new sampling released by the Environmental Working Group and HCWH found high enough levels of mercury in canned tuna to warn about potentially detrimental effects, particularly in pregnant women and preschool children.

D.R.

One Hospital's Prescription for Success

photo Klaus Schoenwiese
Janet Brown of Beth Israel Medical Center

In the summer of 1988, syringes washing up on eastern seaboard beaches were big news. In 1989, Congress passed the Medical Waste Tracking Act – and Janet Brown, then working for the Waste Tech consulting firm on New York City's medical waste plan, watched as most hospitals overreacted, "red-bagging everything in sight." The amount of medical waste discarded every day at one campus of the Beth Israel Medical Center, for instance, surged from 2,300 pounds to more than 11,000 pounds, with associated costs of packaging and shipping rising from $30,000 a month to $130,000 a month.

In 1991, Brown was hired by Beth Israel as its first waste manager. She began with employee education: stickers on the bins, signs defining what needed to be red-bagged and what could be clear-bagged, one-on-one meetings with staff. She added strategic placement of waste cans and a rigorous monitoring system. Since Brown arrived, her programs have saved the hospital complex more than $600,000 every year on medical waste disposal costs and more than $900,000 on trash in general.

"We reduced our red bags by a million pounds a year," Brown is saying, leading a visitor on a tour of the facility. "But that doesn't reduce the volume of your waste. It just shifts it from one [waste] stream to another. So then we needed to emphasize recycling. We switched, for example, to a reusable 'sharps' system for collecting needles – and eliminated the incineration or landfilling of 2,700 plastic containers a month. Luckily, this too saved money."

Walking through a fenced-off area outside where the hospital collects its waste for disposal, Brown points first to a large red container where the red bags are placed, bound for an off-site autoclave. "For recycling, over there is where we bale our corrugated boxes," she continues, "and that's where we store our plastics, and the blue bin is for paper." Brown concedes there's a long way to go. "We don't even know, half the time, what these medical devices are made of. Some are composed of multiple kinds of plastics, and that makes them pretty much impossible to recycle, unless there's a market I haven't found. But I'm trying to get into looking 'upstream'-things like setting up delivery systems so that all supplies in the operating room will arrive in reusable totes instead of cardboard boxes."

Adds Brown, "For years, I've pretty much just been cleaning things up at the back door. As for my label of 'garbage woman' – well, I don't mind that one bit."

D.R.

Dick Russell (dickrusl@aol.com) is currently working on a book about the Pacific gray whale. Support for this article was provided by the Center for the Study of Public Policy. Research assistance was provided by Alyssa Webb.


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