Strategies to Promote Strategies to Promote Mercury Free Health CareMercury Free Health Care

Joshua Karliner, International Team Coordinator, Health Joshua Karliner, International Team Coordinator, Health Care Without HarmCare Without Harm

www.noharm.orgwww.noharm.orgwww.mercuryfreehealthcare.orgwww.mercuryfreehealthcare.org

UNEP Mercury Products WorkshopUNEP Mercury Products WorkshopBangkok, May 18, 2007Bangkok, May 18, 2007

What is HCWH?What is HCWH?HCWH’s work sits at the HCWH’s work sits at the intersection of two core intersection of two core principles—principles—

the right to health care andthe right to health care and the right to a healthy the right to a healthy environmentenvironment

We take the Hippocratic Oath: “First We take the Hippocratic Oath: “First Do No Harm,” as our point of Do No Harm,” as our point of departure.departure.

We address the paradox inherent in We address the paradox inherent in health care systems that pollute and health care systems that pollute and therefore undermine human health. therefore undermine human health.

We transcend that paradox by We transcend that paradox by advocating for a healthier, more advocating for a healthier, more ecologically sustainable health care ecologically sustainable health care sector and positive alternatives to sector and positive alternatives to polluting technologies, products and polluting technologies, products and practices.practices.

Who Is Health Care Without Harm?Who Is Health Care Without Harm?

““the Campaign for Environmentally Responsible Health Care”the Campaign for Environmentally Responsible Health Care”

Health Care Without Harm is an international coalition of 443 organizations in Health Care Without Harm is an international coalition of 443 organizations in 52 countries working to transform the health care sector so it is no longer a 52 countries working to transform the health care sector so it is no longer a source of harm to people and the environment.source of harm to people and the environment.

Issues:Issues: Alternatives to medical waste incineration, mercury, PVC in the health Alternatives to medical waste incineration, mercury, PVC in the health care sector. Green buildings. And more.care sector. Green buildings. And more.

Offices in:Offices in: USA, Prague, Buenos Aires, and Manila. Partners in South Africa USA, Prague, Buenos Aires, and Manila. Partners in South Africa and India.and India.

www.noharm.orgwww.noharm.org

HCWH Global Mercury GoalsHCWH Global Mercury Goals

1. Phase mercury out of the health care industry, globally1. Phase mercury out of the health care industry, globally..

2. Replace mercury in health care with viable, cost-effective 2. Replace mercury in health care with viable, cost-effective alternatives and safely dispose of mercury as it is alternatives and safely dispose of mercury as it is phased out of the health care system.phased out of the health care system.

3. Contribute to broader coalition, governmental and inter-3. Contribute to broader coalition, governmental and inter-governmental efforts to eliminate environmental governmental efforts to eliminate environmental contamination from mercury.contamination from mercury.

Mercury in Health Care As Mercury in Health Care As MessengerMessenger

Addressing mercury in Addressing mercury in health care raises the health care raises the public and policy makers’ public and policy makers’ awareness of the issue.awareness of the issue.

Eliminating mercury in Eliminating mercury in health care can be a key health care can be a key part of a national, part of a national, regional and global regional and global strategy.strategy.

The HCWH Mercury Experience in The HCWH Mercury Experience in the USthe US

Convinced all the top pharmacy chains in the Convinced all the top pharmacy chains in the nation to stop selling mercury thermometers.nation to stop selling mercury thermometers. 11 of the top 15 national retailers 11 of the top 15 national retailers 20,429 of 31,844 retail stores or 64% no longer sell 20,429 of 31,844 retail stores or 64% no longer sell

mercury thermometersmercury thermometers

With allies, passed mercury thermometer bans in With allies, passed mercury thermometer bans in 11 states.11 states.

Worked through H2E to convince more than 5,000 Worked through H2E to convince more than 5,000 hospitals, to sign a pledge to eliminate the use of hospitals, to sign a pledge to eliminate the use of mercury by 2005mercury by 2005

Convinced the largest Group Purchasing Organizations Convinced the largest Group Purchasing Organizations (GPOs) to take mercury "off contract," including (GPOs) to take mercury "off contract," including Consorta (buys for 480 hosptials), and Premier and Consorta (buys for 480 hosptials), and Premier and Novation (3,100 hospitals).Novation (3,100 hospitals).

Currently working to convince hospitals to only donate Currently working to convince hospitals to only donate mercury-based medical devices based on prior-informed mercury-based medical devices based on prior-informed consent and donor responsibility, or to curtail the consent and donor responsibility, or to curtail the practice.practice.

Mercury Free Medicine in the Mercury Free Medicine in the European UnionEuropean Union

Many countries phasing out Many countries phasing out mercury.mercury.

EU about to ban mercury EU about to ban mercury thermometers; considering thermometers; considering sphygmomanometers.sphygmomanometers.

Sweden has eliminated mercury Sweden has eliminated mercury from health care almost entirely. from health care almost entirely.

European Commission has European Commission has approved a mercury export ban. approved a mercury export ban. Products may be next.Products may be next.

HCWH working in coalition on HCWH working in coalition on these issues.these issues.

New WHO Policy on Mercury in New WHO Policy on Mercury in Health CareHealth Care

Short Term: Short Term: Develop and implement plans to Develop and implement plans to reduce the use of mercury equipment and reduce the use of mercury equipment and replace with mercury-free alternatives. Address replace with mercury-free alternatives. Address clean-up, storage, disposal.clean-up, storage, disposal.

Medium Term: Medium Term: Increase efforts to reduce use of Increase efforts to reduce use of unnecessary mercury equipmentunnecessary mercury equipment

Long Term: Long Term: Support a ban of mercury containing Support a ban of mercury containing devices and promote alternatives.devices and promote alternatives.

Four Challenges for Mercury Four Challenges for Mercury Substitution in Health CareSubstitution in Health Care

three “A’s” and the Big “D”three “A’s” and the Big “D”

We must replace mercury with We must replace mercury with devices that are: devices that are:

AccurateAccurate AAffordableffordable AAvailablevailable

The fourth challenge: The fourth challenge: DDISPOSALISPOSAL

HCWH Mercury Campaign in Asia, HCWH Mercury Campaign in Asia, Africa and Latin AmericaAfrica and Latin America

1.1. EducationEducation

2.2. Demonstration on the groundDemonstration on the ground

3.3. Policy Development and ImplementationPolicy Development and Implementation

4.4. Moving Markets– fostering supply and Moving Markets– fostering supply and demand.demand.

1. Education:1. Education:HCWH/UNEP PartnershipHCWH/UNEP Partnership

www.mercuryfreehealthcare.orgwww.mercuryfreehealthcare.org Phase 1: 2006Phase 1: 2006

SE Asia– Manila—January 25-26,SE Asia– Manila—January 25-26, 2006. 2006. 200 Health care leaders from 7 countries in 200 Health care leaders from 7 countries in the regionthe region

Latin America–Buenos Aires August 3-4.Latin America–Buenos Aires August 3-4. 150 Health care leaders from 11 countries in 150 Health care leaders from 11 countries in the region.the region.

Phase 2: 2007Phase 2: 2007

Southern Africa – DurbanSouthern Africa – Durban, November 14-16, , November 14-16, 20072007

Country workshops in Country workshops in Brazil, Mexico, Brazil, Mexico, Malaysia, VietnamMalaysia, Vietnam

Phase 3– Contemplated for 2008Phase 3– Contemplated for 2008

South Asia, IndiaSouth Asia, India – 2008 – 2008

More country workshops and policy initiatives.More country workshops and policy initiatives.

2. Demonstration:2. Demonstration:Toward Mercury Free Health CareToward Mercury Free Health Care

Change on the GroundChange on the GroundAsiaAsia More than 30 hospitals already moving toward mercury-More than 30 hospitals already moving toward mercury-

free health care in Philippines.  free health care in Philippines. 

India– 5 hospitals have piloted mercury free health care. India– 5 hospitals have piloted mercury free health care. Toxics Link expanding this work.Toxics Link expanding this work.

China– SEPA, US EPA and HCWH piloting mercury China– SEPA, US EPA and HCWH piloting mercury free health care in Beijing.free health care in Beijing.

HCWH workshops in 2007 in Malaysia, and possibly HCWH workshops in 2007 in Malaysia, and possibly Vietnam.Vietnam.

Latin America Latin America More than 40 hospitals moving toward mercury-free More than 40 hospitals moving toward mercury-free

health care in Argentina. health care in Argentina.

42 hospitals in Sao Paulo Brazil have switched to 42 hospitals in Sao Paulo Brazil have switched to mercury free health care. More than 50 more are mercury free health care. More than 50 more are committed to doing so. HCWH supporting these efforts.committed to doing so. HCWH supporting these efforts.

Mexico, HCWH is working with Mexican government and Mexico, HCWH is working with Mexican government and CEC to pilot mercury free health care in two hospitals in CEC to pilot mercury free health care in two hospitals in 2007.2007.

3. Policy Initiatives3. Policy Initiatives

National Policy ModelNational Policy Model Philippine Ministry of Health developing national policy in Philippine Ministry of Health developing national policy in

the form of Administrative Order to phase out mercury the form of Administrative Order to phase out mercury from health care across the country.from health care across the country.

Philippine Department of Environment and Natural Philippine Department of Environment and Natural Resources has required regional offices to set up Resources has required regional offices to set up storage facilities for mercury containing devices and storage facilities for mercury containing devices and supplies.supplies.

Municipal Policy ModelMunicipal Policy Model City of Buenos Aires, Argentina has issued policy to City of Buenos Aires, Argentina has issued policy to

phase out mercury from 33 public hospitals and 38 phase out mercury from 33 public hospitals and 38 health care centers– largest public health system in health care centers– largest public health system in Argentina. HCWH/US EPA/UNEP engaged in a Argentina. HCWH/US EPA/UNEP engaged in a partnership to support this effort in 12 hospitals). This partnership to support this effort in 12 hospitals). This could be a model for large cities in developing countries.could be a model for large cities in developing countries.

Policy Development: Policy Development: HCWH/UNDP/WHO HCWH/UNDP/WHO Global Environment Facility project to pilot mercury free Global Environment Facility project to pilot mercury free

health care in 7 countries: Senegal, Lebanon, Latvia, health care in 7 countries: Senegal, Lebanon, Latvia, India, Vietnam, Philippines, Argentina. Policy India, Vietnam, Philippines, Argentina. Policy component.component.

Global Policy…..Global Policy…..

Health Care Leaders Call for a Health Care Leaders Call for a Binding Treaty Binding Treaty

““We will advocate through our health care We will advocate through our health care institutions, national governments and institutions, national governments and professional associations for national professional associations for national legislation and a binding international legislation and a binding international instrument to substantially reduce global instrument to substantially reduce global supply and demand of mercury.” supply and demand of mercury.”

--Manila Declaration on Mercury Free Health Manila Declaration on Mercury Free Health Care, January 26, 2006Care, January 26, 2006

““We…agree to…advocate for a legally binding We…agree to…advocate for a legally binding international instrument, or the inclusion of international instrument, or the inclusion of organic mercury in the Stockholm organic mercury in the Stockholm Convention, so as to substantially reduce Convention, so as to substantially reduce the global mercury supply and demand.” the global mercury supply and demand.”

----Buenos Aires Declaration, August 4, 2006Buenos Aires Declaration, August 4, 2006

4. Moving Markets: Mercury-based 4. Moving Markets: Mercury-based Medical Device Industry Medical Device Industry

Total Global Medical Device Industry Market more Total Global Medical Device Industry Market more than $100 billion.than $100 billion.

Production is growing in Asia. China and India are Production is growing in Asia. China and India are key producers. key producers.

Mercury ThermometersMercury ThermometersChina:China: Annual Production (2003): 120 million (40 million for domestic Annual Production (2003): 120 million (40 million for domestic

consumption, and 80 million for export. consumption, and 80 million for export. India: India: Exports 570,000Exports 570,000

Mercury SphymomanometersMercury SphymomanometersChina: China: Annual Production: More than 1 millionAnnual Production: More than 1 millionIndia: India: Exports 60.000.Exports 60.000.((SourcesSources: Global Village of Beijing; Toxics Link): Global Village of Beijing; Toxics Link)

Alternative Devices: HCWH is investigatingAlternative Devices: HCWH is investigatingAnecdotal evidence shows that India and China are increasing Anecdotal evidence shows that India and China are increasing

production and export of mercury-free devices. production and export of mercury-free devices.

ASIA HAS THE POTENTIAL TO PRODUCE THE ALTERNATIVES ASIA HAS THE POTENTIAL TO PRODUCE THE ALTERNATIVES AND SELL THEM GLOBALLYAND SELL THEM GLOBALLY

4. Moving Markets:4. Moving Markets:Toward Mercury Free Health CareToward Mercury Free Health Care

Fostering Alternative IndustryFostering Alternative Industry

Must change both demand and supply at the same time.Must change both demand and supply at the same time.

Identify existing suppliers of alternatives. HCWH South East Asia Identify existing suppliers of alternatives. HCWH South East Asia has produced a guidebookhas produced a guidebook

Support the development of affordable, accurate non-mercury Support the development of affordable, accurate non-mercury thermometer industry in India, China and elsewhere.thermometer industry in India, China and elsewhere.

Philippines Moving ForwardPhilippines Moving ForwardDemonstrating ChangeDemonstrating Change

• South Cotabato Hospital (150 beds) procuring South Cotabato Hospital (150 beds) procuring alternative thermometers and blood pressure alternative thermometers and blood pressure devicesdevices

• National Children’s Hospital (250 beds) and National Children’s Hospital (250 beds) and Philippine Heart Center (300 beds) training Philippine Heart Center (300 beds) training doctors, nurses, staff, waste handlers.doctors, nurses, staff, waste handlers.

• Manila Adventist Medical Center, 150 beds, has switched to alternative thermometers and blood pressure devices.

• Central Luzon Doctor’s hospital 200 beds, conducting comprehensive mercury audit.

• Davao is conducting region-wide inventory.

Philippines Moving ForwardPhilippines Moving Forward

2. Shifting Policy– Administrative OrderMercury Waste Management

3. Moving Markets– Identifying suppliers, increasing demand.

4. Working Regionally in SE Asia.

Mercury in Vaccines a Precautionary ApproachMercury in Vaccines a Precautionary Approach

Despite the lack of conclusive scientific evidence of harm from thimerosal, enough plausible Despite the lack of conclusive scientific evidence of harm from thimerosal, enough plausible concern has been raised to justify reformulating vaccine preparations so that they do not require concern has been raised to justify reformulating vaccine preparations so that they do not require thimerosal. thimerosal.

This conclusion is justified because organic mercury is a neurodevelopmental toxicant and This conclusion is justified because organic mercury is a neurodevelopmental toxicant and

there are viable alternatives to vaccine formulation without sacrificing safety or efficacy. there are viable alternatives to vaccine formulation without sacrificing safety or efficacy.

Regulators, public health officials and pharmaceutical companies have recognized this and Regulators, public health officials and pharmaceutical companies have recognized this and moved to phase-out thimerosal use in the US and in several European countries. moved to phase-out thimerosal use in the US and in several European countries.

Such phase-outs, by switching to single-dose vaccines that do not require thimerosal as a Such phase-outs, by switching to single-dose vaccines that do not require thimerosal as a preservative, are positive steps, but do not address the broader problem of multi-dose vaccine preservative, are positive steps, but do not address the broader problem of multi-dose vaccine preparations in developing countries, where thimerosal use continues. preparations in developing countries, where thimerosal use continues.

In this regard, viable options for the delivery of multi-dose vaccines in developing countries In this regard, viable options for the delivery of multi-dose vaccines in developing countries should be developed as a matter of priority. This effort should be led by the World Health should be developed as a matter of priority. This effort should be led by the World Health Organization, with participation from other intergovernmental agencies, national governments, Organization, with participation from other intergovernmental agencies, national governments, pharmaceutical companies, international NGOs and foundations. pharmaceutical companies, international NGOs and foundations.