September - December 2007
Power and poisons

There’s something about mercury

IT’S A shimmery, shiny substance that seems to have a mind of its own when held between one’s fingers. In the Philippines, it is commonly found in thermometers that are widely used in hospitals to check on patients’ temperatures or are sold over the counter for household use. Other medical devices, in fact, still use elemental or metallic mercury — even if this is a known toxic substance that can be absorbed by the skin and can easily penetrate biological membranes, including the blood-brain barrier. When inhaled, mercury vapors can cause neurological and behavioral disorders, and sometimes can lead to death. Even at low doses, these vapors can have harmful effects on the kidneys, and the digestive, respiratory, and immune systems.

SPILLS from broken thermometers were stored in this bin prior to the Philippine Heart Center’s switch to non-mercury devices. [photo by Mira Mendoza]

The Philippine healthcare system has been slow to respond to the concerns raised over the continued use of mercury in medical equipment, including the lowly thermometer. Yet even foreign observers say the country has finally stirred into action regarding the use of the toxic substance in health devices.

Indeed, in its latest report on global mercury reduction, the international organization Health Care Without Harm (HCWH) cites the Philippine experience as a model in switching to alternatives and creating policy solutions. This is even though the Department of Health (DOH) has yet to release a much awaited administrative order (AO) that outlines what needs to be done to reduce the presence — and use — of mercury in the healthcare system.

The United Nations Environment Programme (UNEP) has already identified mercury pollution as a major environmental and human health problem. In a 2002 report, it also tagged the healthcare sector as a significant source of mercury releases. It added that Asia accounted for over half the global emission of 5,000 metric tons a year.

The Philippines has no available statistics on the country’s own mercury releases. Nevertheless, the health department’s draft AO, which was crafted earlier this year and cited by the HCWH as a major plus in the country’s mercury-reduction efforts, mandates the phaseout of mercury-containing thermometers and blood pressure devices along with other products that make use of mercury (dental amalgam and some laboratory chemicals). The AO also orders the substitution, where possible, of safer alternatives for batteries and certain vaccines that use mercury. Emphasis on mercury-waste management, fluorescent lamp recycling, and safe disposal are among the other high points in the proposed AO.

But if DOH seems to be taking its time releasing the AO, at least it’s not because it suddenly lost its political will, as is often the case with many government agencies on the verge of a big switch. It’s because, explains Ana Rivera, supervising health program officer of the DOH-Environmental and Occupational Health Office, the health department belatedly realized that it cannot implement the change by itself.

“After our initial meeting on the proposed AO,” says Rivera, “we realized that we had to coordinate with partner agencies. Given the scope of the proposed AO, the health department will need the assistance of the Department of Trade and Industry (DTI) in giving accreditation for alternative products based on the criteria that the Bureau of Health Facilities Development will provide.”

Meanwhile, last February, the DOH issued a memorandum containing guidelines for handling accidents involving mercury at home, school, and medical facilities. The memo, which is similar to a previous HCWH fact sheet released four months earlier, includes first-aid/pre-hospital treatment for mercury victims. But Faye Ferrer, HCWH Southeast Asia’s program coordinator for mercury says the memo’s real highlight is when it says that “the best way to prevent mercury spills is to not store mercury at home, in schools, and in the workplace.”

IN ITS 2002 report, UNEP said that 10 percent of the mercury releases generated by the healthcare sector came primarily from the incineration of medical waste that contains significant concentrations of the substance. Fortunately, the Philippines has banned the incineration of hospital waste, with the law on this taking full effect in 2003. But hospital facilities have since been left wondering how best to dispose of the various products and devices that use mercury.

In truth, this is among the problem points in the draft AO. Rivera says that issues regarding a centralized storage facility for the phased-out products would first have to be discussed with the Department of Environment and Natural Resources (DENR). An engineer, she mulls aloud, “Do we store the mercury-containing products in the hospital, or in the DOH? Where will the temporary storage be set up until a final disposal area is established?”

Aside from the ubiquitous thermometer, medical devices containing mercury include blood-pressure monitors, gastrointestinal tubes, and dental amalgam and other laboratory chemicals. Mercury is present as well in some pharmaceutical supplies like vaccines, nasal sprays, and diuretics. Fluorescent lamps, batteries, switches, thermostats also use mercury.

Dumping waste with mercury in landfills enables the toxic substance to enter and accumulate in bodies of water where it can transform into the more dangerous methylmercury. This inorganic form of mercury is absorbed by fish tissue and increases in predator fish that are on top of the aquatic food chain. In recent years, several warnings have been issued by both international and local environment agencies to avoid eating mercury-contaminated fish.

Methyl mercury affects a person’s neurological functions. Even low doses can have dire consequences on children, who can have their cognitive thinking, memory, and language and motor skills seriously affected. Even a developing fetus is not spared as methylmercury can pass through the placenta, targeting the unborn child’s brain where it causes permanent harm.

FOR SURE local healthcare professionals have long been aware — however vaguely — of the risks posed by materials and products that use mercury. But concerns about these dangers were apparently put in the backburner by most; it took a groundbreaking conference on mercury last year and a particularly nasty incident involving the substance at a Parañaque school for members of the healthcare community to finally take a more careful look at the dangers in their midst.

Ironically, officials at the Philippine Heart Center — where the mercury conference was held in January 2006 — took even longer than that. Four months after the conference (organized by HCWH in association with UNEP, and with the support of DOH, DENR, and the Heart Center itself), the hospital’s Waste Management Committee invited Rivera as a resource person for one of its regular meetings. Admits Ester Borja, head of the committee and chief of the Heart Center’s Auxiliary Services Department: “It was through Engineer Rivera’s account of her personal experience that we learned about the gravity of the St. Andrew’s School mercury spill. This made me and the rest of the committee to seriously consider a phaseout of all mercury devices.”

A PHC staff shows beads of mercury from broken thermometers collected using a tongue depressor. [photo by Mira Mendoza]

St. Andrew’s was the Parañaque school where early last year at least 24 students, mostly aged 13, wound up in the hospital as confirmed cases of mercury poisoning. Investigation showed that the students were poisoned after they were allowed to play with 50 grams of mercury intended for a science experiment. The school had to remain closed for months while local and international experts cleaned up and decontaminated it.

Rivera herself notes an increase in reports of mercury spills in healthcare facilities following the release of the DOH memorandum on how to clean up after mercury accidents, indicating a rise in awareness and concern about the substance’s possible effects. On average, the health department receives at least two calls per month requesting for assistance on handling mercury spills. But Rivera says that in a monitoring exercise conducted by the DOH last May on four government hospitals, the results were ominously “significant.”

She explains that this can only mean a history of spills that have not been cleaned up properly in these facilities (which she declines to name). Rivera points out that mercury is a persistent element — and becomes even more so in an airconditioned enclosure. She says that simple cleaning using a broom or worse, a vacuum cleaner, could only aid in spreading the contamination.

Absorbed by carpet, or trapped in floor cracks and crevices, elemental mercury can easily volatilize into mercury vapor, contaminating indoor air. Inhalation of mercury vapor in the short term will not readily manifest symptoms. Generally, a month or more is needed to produce symptoms.

The hospitals that were monitored have since been advised on how to reduce their indoor mercury levels to safe standards (0.2 micrograms per cubic meter). Rivera also reports that the raised awareness regarding mercury’s dangers has led to hospital workers themselves clamoring for the release of the health department’s AO on mercury.

PRESSED TO issue a memo banning the purchase of mercury thermometers by all hospitals by 2008 while the AO remains in limbo, the DOH has instead offered to have all government-regulated hospitals in Metro Manila put any mercury thermometer bought for 2008 on hold while those that have yet to place an order for such would be told not to proceed.

Many hospitals, however, are already taking it upon themselves to move toward mercury-free healthcare — with or without an AO, memo or no memo. HCWH even says there are more than 50 such hospitals. Ferrer also says these are currently developing policies or guidelines on evaluating safe alternatives to devices containing mercury and even testing some of options to the mercury thermometer and sphygmomanometer (the more formal name for the blood-pressure monitoring contraption). Some have also gone on to purchasing digital thermometers, albeit only for select wards.

Although HCWH has yet to name the hospitals that it says are bent on becoming mercury-free, two facilities are already recognized as pioneers in effectively accomplishing a complete phaseout of mercury thermometers and blood-pressure monitors. Both hospitals have removed these devices even in their respective purchasing policies.

The Manila Adventist Medical Center, a 150-bed private hospital, decided to switch to mercury-free alternatives after the January 2006 mercury conference. By mid-2006, it had successfully replaced all its mercury thermometers and sphygmomanometers.

The other hospital is actually the Heart Center, where the board approved Borja’s recommendation for a phaseout of mercury devices soon after Rivera’s talk. The Center’s Products Standards Committee was then assigned to evaluate and present criteria for non-mercury alternatives.

Meanwhile, the hospital’s Waste Management Committee started its mercury spill management training for its staff. Mercury spill kits were distributed to each nursing unit. Spills were no longer ignored, but were reported. According to Borja, this was how they found out that between February to June 2007, there were 32 thermometer breakages in the hospital.

A thermometer contains about a gram of mercury. The HCWH says, “Thermometer breakages on a case-to-case basis pose some harm to patients, nurses, and other healthcare providers when mercury is absorbed through the skin or mercury vapor is inhaled.”

Borja relates how the Waste Management Committee’s insistence for the nurses to personally do the cleanup (within a five-minute deadline) eliminated any resistance to the use of digital alternatives. By last July, the Heart Center had purchased its first batch of digital thermometers — partially financing the transition by passing on the cost to patients. This has led to some resentment from patients who rue the huge leap in price (almost P200). But Borja says the nurses have been very successful in convincing patients that the added cost would go a long way in ensuring a healthier environment for all.

Similar efforts are being undertaken in other DOH-retained hospitals, such as the National Kidney and Transplant Institute and the Philippine Children’s Medical Center, both in Quezon City. Rivera is also proud to say that although the San Lazaro Hospital in the DOH compound in Manila has not completely gone mercury-free yet, its staff have “a strong awareness and knowledge of healthcare waste management.” One proof of this, she says, is its own initiative to phase out dental amalgam.

THE HCWH identifies three fundamental challenges that implementing a transition to mercury-free healthcare faces: accuracy, affordability, and disposal.

During the 2006 mercury conference, Dr. Esperanza Icasas-Cabral, now the social welfare and development secretary and former president of the Philippine Hypertension Society, added another hindrance: sheer habit. She pointed out that doctors who were trained in mercury-containing devices showed resistance to switching to alternatives. The mercury manometer, for instance, has occupied an eminent position in blood pressure measurement since 1926. “It’s a long tradition that is not easily forsaken,” Cabral said.

But Cabral added that mercury-free sphygmomanometers like the aneroid type are more economical in the long run as they eliminate the risk of spills and associated training costs. In addition, non-mercury blood-pressure monitoring devices have passed various studies in the United States and the United Kingdom that were conducted to test their accuracy. It has been established as well that as with any blood pressure monitoring device (mercury, aneroid, or digital), calibration is essential in ensuring accurate readings.

On the issue of affordability, the HCWH recognizes that replacing mercury-based medical devices is seen as an expensive proposition for cash-strapped healthcare sectors in the developing world. Rivera cannot help but agree, saying, “There really is a resistance with the initial capital outlay.”

“But,” she says, “we explain that in the long term, training healthcare workers on how to handle mercury spills and the cost of cleanup and decontamination do balance out.”

As for disposal issues, the problem lies with what will be done with the retired mercury-containing devices once healthcare facilities make the switch. There is still no single solution to the long-term retirement of mercury wastes, although there are short-term options being done in North America and many European countries like storing mercury waste on-site, extended product responsibility, national regulations, and collection programs.

Last July, DOH formed a technical working group (TWG) to address the local healthcare system’s problem with mercury, including disposal. The TWG is composed of representatives from its concerned bureaus, the DTI, DENR, hospital administrators, health sector representatives, technical experts, and environment groups such as HCWH and the Basel Action Network.

HCWH knows there are many obstacles in the path toward a mercury-free healthcare system. But it would rather emphasize the positive, citing the initiatives — however simple and slow-moving — from both government and private facilities as evidence that this is not impossible to achieve.

Mira S. Mendoza is a freelance writer-researcher and graphics artist.