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Time and ways to lighten the chemical load in health care

Introduction by Croakey: A global push to reduce the carbon footprint of the health sector is set to gain momentum next month with the release of a ‘Global Road Map for Health Care Decarbonization: A navigational tool for achieving zero emissions with climate resilience and health equity’.

The Global Road Map, to be launched on 14 April by Health Care Without Harm, will set a course for zero emissions in health care, aligning it with the Paris Agreement’s goal to keep global warming below 1.5 degrees Celsius, the organisation said.

“The road map models how the sector can decarbonise by taking seven high impact actions to reduce the sector’s global emissions, and provides a set of recommendations for health sector leaders to respond rapidly to help prevent and prepare for the inextricably linked climate and health crises while also contributing to broad-based health equity,” the organisation said.

Meanwhile, Health Care Without Harm, in conjunction with the United Nations Development Programme, recently released a report on international efforts to reduce the use of harmful chemicals in the healthcare sector.

Croakey journalist Nicole MacKee reports below on the Chemicals of Concern for the Health Sector report and local expert calls to reduce health sector waste.


Nicole MacKee writes:

Chemicals abound in the healthcare setting, and many chemical agents are required to ensure safe, high-quality health care.

But an international body is calling on the sector to review its use of some potentially harmful chemical agents and, where possible, opt for alternative strategies.

A report released recently by Health Care Without Harm, Chemicals of Concern for the Health Sector, identified a wide-ranging list of chemicals used in the health care setting internationally that have been associated with harm.

“Chemicals … have a unique importance in the health sector, where they are used as disinfectants, cleaning agents, laboratory reagents, sterilants, pesticides, pharmaceuticals, medical devices and equipment, furnishings and building materials and are unintended chemical by-products, like dioxins, produced during medical waste incineration,” the report said.

However, it noted the hazards of the chemicals were not well understood by health professionals nor adequately incorporated into procurement decisions.

New report

“To minimise the hazards, the health sector has been taking steps to promote and implement sustainable health care within their institutions and to collaborate externally with suppliers and manufacturers to advance sustainable procurement within the health sector.”

The report includes chemicals that may impact upon human health or the environment in the following ways: toxicity (eg, carcinogen, mutagens, reproductive hazards); endocrine disrupting chemicals; neurotoxicity, developmental toxicity, and immune-toxicity; allergenic; skin and eye irritants; and environmental determinants linked to persistent bioaccumulative toxicants in the products, and acute and chronic aquatic toxicity.

Among a long list of chemicals, the report points to potential harms associated with sterilising agents such as ethylene oxide and to polyvinyl chloride (PVC), which is used in medical devices.

The report pointed to the Sustainable Development Goals and the 2030 agenda to promote sustainable health systems. The Goals seek to promote good health and wellbeing (SDG3) and sustainable consumption and production (SDG12).

No surprises

Associate Professor Nick Osborne, epidemiologist and toxicologist at the University of Queensland’s School of Public Health, said there were no surprises in the Chemicals of Concern for the Health Sector report.

“All the usual suspects are there,” he said, noting that the report highlighted both newer chemicals and those that had been around for hundreds of years.

“Hippocrates complained long and hard about lead mines and how the people who lived around them were unhealthy a couple thousand years ago.”

He said it was important to consider both the potential for acute toxicity, as well as low-level chronic exposure.

But while the report highlighted sources of toxicity that would be mostly well known to the health sector, Osborne said it would be helpful in guiding procurement and in addressing the healthcare sector’s large carbon footprint.

“The carbon footprint of the health care is high compared with a lot of industries,” he said. “Pharmaceuticals are a large driver of that, but there are other products contributing too, so a range of hospitals are looking for alternatives to lower their carbon footprint.’

Climate change is one of the biggest threats to health this century and it needs to be addressed. Obviously, the people providing health need to resist being part of that problem.”

In Australia, some local health services are already moving to reduce their environmental impact. Last month, the Hunter New England Local Health District (HNELHD) announced an “ambitious” initiative to be carbon and waste neutral by 2030.

The HNELHD’s ‘Sustainable Healthcare: Together Towards Zero 2030’ plan encompasses efforts to convert to clean energy sources – with Newcastle’s John Hunter Hospital soon to boast the largest solar panel installation in Australia – address water sustainability, and reduce general and health-specific waste.

HNELHD Chief Executive Mr Michael DiRienzo said in a media release that the organisation would be investigating innovative ways to approach the everyday disposal of food scraps, general waste and recycling.

He said:

We’ll also be taking a closer look to see what health-specific waste normally thrown in the rubbish, like oxygen masks, PVC tubing, and clean, single-use plastics used every day in our operating theatres, are appropriate and safe for recycling.”

Osborne said when chemicals were needed, selecting those with a short half-life would reduce their environmental impact.

“If you can choose chemicals that have short half-lives, they degrade back to simplistic chemicals that are unharmful,” he said.

Reusable masks

The Chemicals of Concern for the Health Sector report highlighted several case studies for reducing chemical use, including an initiative in a Colombian hospital to replace single-use PVC anaesthesia masks to a reusable silicon alternatives.

Fundación Valle del Lili in Cali gradually replaced disposable masks in surgery and respiratory therapy with reusable silicone face masks. “The substitution resulted in cost savings and use of a product made with less toxic material,” the report said.

“The silicone mask is made from less toxic materials with reusable potential and end-of-life recyclability. These silicone masks are used to anesthetise both adults and children for surgery.”

The hospital sterilises and disinfects them before and after each use.

Commenting on this program, Osborne cautioned though about the risks of change.

“Whenever you have change from one product to another, there is a change in risk. The risk doesn’t just go away,” he said. “By introducing something new you might introduce something worse.”

In another case study, Bongani Regional Hospital in South Africa introduced an Integrated Pest Management system to substitute the use of hazardous pesticides with more sustainable methods.

The system was implemented in three phases: introducing pest repellents; sterilisation of natural predators using insect light traps; and bird control.

“Prior to the implementation of [Integrated Pest Management], the hospital’s pest control program was centred on the use of pesticides which were harmful to the employees and patients and also the environment. The use of pesticides was not only expensive but also ineffective as it only lasts for a few weeks,” the report said.

The system resulted in cost savings (50 percent) and reduced use of pesticides (80 percent).

‘Dose is the toxin’

When chemicals were needed, Osborne said using the recommended dose was crucial.

“’Dose is the toxin’ is the saying we use in toxicology,” he said. “Everything can be toxic, it’s just the dose that you are exposed to that makes the difference.”

He said, however, there was no point in using chemicals at such low levels that they were ineffective.

“That just pollutes the environment without actually doing the job, so it’s about getting the job done but not using chemicals excessively,” he said.

“Some chemicals are very useful, we do have to use them, but maybe we can limit their use to extreme cases when they are really needed, as we are now doing with antimicrobials,” said Osborne who has has recently written a chapter for a World Health Organization book on cyanobacteria in waterways.

Waste not

Efforts to reduce the large amounts of hospital waste are also critical to curbing the health care sector’s substantial environmental impact.

The global COVID pandemic has resulted in a massive increase in the amount of medical waste.

“Hospital waste, indeed any health service waste (including dentists, vets, pathology services and so forth) is a huge problem for the world,” said Professor Linda Shields who is the Centaur Fellow and Honorary Professor at the University of Queensland’s Faculty of Medicine.

“In most places it goes into landfill after being treated and compacted, or incinerated under strict requirements. In the poorer countries of the world, it can be seen lying in waste tips.”

Shields said surgical procedures required a vast array of disposable items.

“Driven by various epidemics around the world including AIDS, and other blood-borne diseases, the use of disposable items across health care has caused a waste problem of magnificent proportions,” she said.

“It has been shown much of the residual effects of disposal of this waste ends up in water tables, soil, and places like the Great Barrier Reef. This includes not just residues from plastics (of which the waste is largely comprised), but heavy metals and cytotoxic drugs, as well as antibiotics, various gases, and a plethora of chemicals.”

Shields applauded the efforts of health services that were looking to ways to recycle waste.

“This work is vitally important, and at present, is mostly by aware health services trying to do something about on the service or individual level,” she said.

“Much more research is needed to see how much, and what, can be safely recycled in hospitals, and for my particular field of interest, in operating theatres.”

In years past, Shields said, medical equipment was cleaned, sterilised, and reused.

“This system worked well, until the blood-borne diseases came along,” she said. “The world went crazy trying to prevent contaminating anything used in health services, with the desired effect of reducing the incidence and prevalence of these diseases.

However, she said, it was now time to review the use of disposables, and look for a way to protect both human health and the environment.

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