Health Care Without Harm:
A Model of Collaboration

The burning of chlorinated plastics in medical waste, according to a report of the Environmental Protection Agency (EPA), is one of the major sources of dioxin poisoning in humans and animals, and, in particular, in developing fetuses. Dioxin forms in medical waste incineration when PVC and other chlorinated plastics are burned. The dioxin goes up the chimney, lands on pastures, livestock eat the grass, and the dioxin comes back to people in meat and dairy products, and also in fish. The higher a creature eats on the food chain, the more rapidly dioxin accumulates in body fat as a "persistent organic pollutant."

Dioxin is one of an increasingly recognized class of "endocrine disrupting" chemicals. These chemicals can do damage when they accumulate in a person or animal through exposures in the air, water and food, but their greatest damage comes during pregnancy, when they mimic or block the miraculously delicate signals that the mother's hormonal system sends the developing fetus to guide its development. According to some recent scientific studies by Colborn (1996), DeVito (1995), Jacobson, and the EPA (1994), as the child develops, dioxin exposure in the womb and through breast milk may result in cancer, endometriosis, learning disorders, behavioral disorders, immune and neurological disorders, and a wide range of other problematic conditions.

The more scientists learn about endocrine disrupting chemicals, the more troubled they have become. First, according to recent studies by Colborn (1996) and the EPA (1997), there appears to be no minimum dose at which they are safe for a developing fetus. Since the whole governmental mechanism of "risk assessment," which gives industry the right to expose people to toxic chemicals like dioxin, assumes that there are no safe doses, this new finding of no safe minimum dose may mean, as one scientist put it, "the end of risk assessment as we know it."

Second, many of these endocrine disrupting chemicals have different effects on the developing fetus at different "developmental windows" and at different dosages. A smaller dose at one window may have a completely different effect than a larger dose at another window.

Third, the impact of many of these endocrine disrupting chemicals appears in many instances to be additive or even synergistic. To do a decent job of evaluating their full health effects, scientists would have to test for all the mixtures that developing fetuses are actually exposed to at all the different times they may be exposed. Scientists have only begun to undertake this complex task.

Fourth and finally, people are already carrying loads of many of these chemicals -- and specifically dioxin -- at levels at which there are known health effects in either animals or humans. People don not have "room" for additional exposure to dioxin. Yet, medical waste incineration and other sources of dioxin creation such as municipal waste incinerators continue to pump dioxin into the atmosphere and into animal and human bodies.

Exposure to mercury -- also used in numerous health care products found in medical facilities such as dental amalgams, hearing aids, pacemakers, defibrillators, thermometers, and esophageal devices -- also has been found, in recent scientific studies by the EPA and the New Jersey Department of Health, to cause significant health problems, such as brain, kidney, and nervous system damage. Like the plastics that turn into dioxin when burned, mercury-containing products are most often incinerated and leak mercury into the atmosphere. A 1995 EPA study found that of the estimated 243 tons of mercury emitted annually into the atmosphere by human sources, approximately 85 percent is from combustion by incineration, including medical waste incinerators, which account for 27 percent.

THE HEALTH CARE WITHOUT HARM CAMPAIGN

It is ironic that America's health care system, whose physicians take the Hippocratic Oath, "above all, I will do no harm" is inadvertently hurting today's children, through its use of chlorinated plastics and mercury that are later incinerated. In response, a wide range of constituencies have been motivated to develop the Health Care Without Harm (HCWH) campaign with support from the Jenifer Altman Foundation, the StarFire Fund, the W. Alton Jones Foundation, the Turner Foundation, the Walter S. Johnson Foundation, and the Merck Family Fund.

HCWH grew out of two meetings held in the spring of 1996 at Commonweal, a health and environmental research institute in Bolinas, CA, which convened approximately 35 people from a variety of professions concerned with the growing evidence of health problems related to endocrine disrupting chemicals. After the second meeting, the group decided to convene a third time to strategize about building a nationwide campaign to address these concerns. At the third meeting, the decision was made to focus on medical waste incineration as the best way to draw attention to these environmental health problems because, in 1995, the EPA had stated that the medical system was one of the top two industries generating the greatest amount of dioxin in the United States. The paradox that the U.S. health care facilities are poisoning people through poor medical waste practices seemed to be an important piece of information that the public should know.

Started just over a year ago, HCWH now has signed up over 60 groups nationwide such as the American Nurses Association, the Mt. Sinai School of Medicine, the Center for Health, Environment and Justice, the National Environmental Law Center, the Indigenous Environmental Network, the Institute for Agriculture and Trade Policy, the Oil, Chemical and Atomic Workers International Union, Breast Cancer Action, the Learning Disabilities Association, and the Endometriosis Society, as well as concerned physicians, nurses, hospital administrators, various citizen and environmental justice activists, policy and legal analysts, scientists, and labor representatives. By signing on with HCWH, these organizations and individuals have made a commitment to help eliminate dioxin and mercury from the medical waste stream in a variety of ways.

• HCWH has focused its efforts on ensuring that the EPA regulates the pollution standards of medical waste incinerators at the same levels as municipal waste incinerators, if not even more tightly. This campaign has resulted in significant tightening of EPA standards, though the levels of permitted pollution remain far higher than HCWH hoped. Even though the new standards are inadequate, they seem likely to compel the closure of some of the worst offending medical waste incinerators across the country.
  
  
• The "Adopt-A-Hospital" initiative of the campaign has begun to educate health care administrators about how they can dispose of their toxic waste in a less harmful manner, and save money, by switching from incineration to alternative medical waste disposal technologies, improving their "reduce, reuse, and recycle" programs, and using alternative products that do not contain chlorinated plastics and mercury.
  
  
• HCWH has brought in a number of physicians and nurses to serve as spokespeople about environmentally sound public health practices in health care facilities regionally and nationally. They include Eric Chivian, MD, Harvard Medical School; Robert Lawrence, MD, John Hopkins School of Public Health; Michael McCally, Mount Sinai School of Medicine, John Constable, MD, Massachusetts General Hospital; Ted Shettler, MD, Physicians for Social Responsibility; Barry Levy, MD, American Public Health Association; Gina Solomon, MD, MPH, University of California, San Francisco, Medical Center.
  
  
• The campaign is working with labor unions to ensure a just transition for workers who might be affected by changes in industry practices and product lines.
  
  
• HCWH has begun to work with colleagues internationally to help create similar standards for health care facilities around the world, particularly in developing countries.

COLLABORATION AROUND SHARED VALUES

Perhaps one of the most interesting facets of the campaign is the spirit of collaboration among very diverse constituencies. Grassroots activists, Washington policy advocates, environmental groups, health care professionals, patient groups, unions, and environmental justice advocates are working effectively together. They acknowledge differences yet value shared goals and the opportunity to not only make important changes in our health care system's treatment of the environment -- and therefore people's health -- but to educate related industries and the general public about what the health care system is doing to undermine people's health and well-being as well as serving to protect and heal.

In addition, because there are so many different aspects to this initiative, the foundations involved have been able to provide support to HCWH either from their health or their environmental program areas, and a few, including the Jenifer Altman Foundation, have combined their interests in health and the environment and created a new environmental health program.