Foreword
If you have to be hospitalized in the United States it’s going to run you (or your insurance company) about 930 bucks a day, on average. Would you be willing to pay 93 cents more—that’s right, 93 cents, not much more than you’d pay for a candy bar down at the gift shop––so that the hospital you’re in could “afford” to stop polluting the air with one of the most potent toxic substances known to science? Would you pay those pennies so that your hospital could avoid fouling the environment with an astonishingly toxic chemical that already taints virtually all of the milk and meat you and your children eat––a toxic substance that, once in the environment or the human body, stays indefinitely and can’t be cleaned up?
Of course you would. Who wouldn’t? Especially since that 93-cent per patient investment would all but halt the burning of the hospital’s wastes and pay for itself within a few short years at most. After that, your hospital will save money on waste disposal. Even more compelling, for a tiny fraction of your hospital bill you’d help eliminate one of the nation’s top sources of the pollutant in question: Dioxin. It has been drifting out of smokestacks for decades, wherever medical waste was burned, along with mercury, cadmium, lead and other pollutants.
No responsible health care professional could be comfortable with the irony that prevailing methods of handling hospital waste are in effect increasing the risk of diseases like cancer. Indeed, doctors, nurses and other health care providers around the country are working even now to reduce the impacts of medical waste on the environment and human health. They’re doing it out of concern for their community, their patients and their bottom lines.
Which brings us to the curious position that the American Hospital Association has been pursuing so aggressively for the past few years. The AHA, the leading trade association for the hospital industry, has pushed extremely hard to weaken pending air pollution rules from the Environmental Protection Agency for medwaste incinerators. Properly devised rules would eliminate emissions of dioxins and other pollutants from hundreds of medwaste incinerators around
the country. For example, the EPA has full authority to eliminate from the medwaste stream materials that lead to the formation of dioxins and cause pollution from mercury and other toxins in the first place. Tough new rules would also lend encouragement to a wide range of anti-pollution efforts underway within and outside the health care industry, and as documented in this study, make hospitals and other institutions more environmentally responsible.
The Clinton Administration, sorry to say, appears poised to capitulate to the AHA. After initially proposing some fairly tough standards the Administration now seems to be beating a fast and full scale retreat. Under its revised rules the Clinton EPA would allow hundreds of medwaste incinerators to continue operation with no pollution control equipment whatsoever. Incinerators would be monitored for pollutants less thoroughly and less often, and the people who run the incinerators would need only the most meager training. The AHA’s lead expert on medical waste, seeming pleased with all this, has dubbed the Administration’s proposed rules “painless” for hospitals.
Clearly the American Hospital Association is badly out of step with the American public when it defends retrograde trash burners and continued dioxin contamination. We can’t help wondering if the AHA isn’t also out of step with its own membership. It ‘s hard to conclude otherwise, based on the anti-pollution efforts underway at hospitals described in this report, and from the many doctors, nurses and other health care experts who have joined Health Care Without Harm: The Campaign for Environmentally Responsible Health Care.
While this report, First, Do No Harm, is intended as the campaign’s debut, it is in equal measure a testimonial to a great many community organizers, nurses, doctors, and public interest advocates whose work has made this report possible. Their research has elucidated the many facets of the medwaste threat. Their powers of persuasion have moved the American Public Health Association, among other prestigious bodies, to join in efforts to solve the problem. And their passion and activism have snuffed out thousands of incinerators over the years. We hope we’ve done justice to their case and cause with this study.
Kenneth A. Cook President Environmental Working Group
Executive Summary
“First, do no harm” is the credo of every health care professional. But for decades that vow has been insidiously violated through the emission of toxic pollution from thousands of incinerators operating at hospitals and other health care institutions throughout the United States. Medical waste incinerators recently have been identified as a top source of the notorious environmental contaminant dioxin, one of the most potent toxic chemicals known to humankind. In mid-February, 1997, a group of 25 scientists from 11 countries, convened by the prestigious International Agency for Research on Cancer (IARC), classified dioxin (2,3,7,8 TCDD) as a proven human carcinogen. In animal studies, dioxin is 300,000 times more potent a carcinogen than the pesticide DDT (NRC 1996), which was banned in 1972.
In a dramatic retreat from an initial 1995 proposal––which had been issued under court order–– the Clinton Administration in June, 1996 proposed exceedingly weak air pollution safeguards for medical waste incinerators. In contrast to the Administration’s recent high profile rules for tougher new standards on particulate air pollution and ground level ozone, the proposed medical waste incinerator rule will do next to nothing to halt emissions of dioxin, mercury and other pollutants into the environment. Moreover, by failing to restrain medwaste incineration the Administration’s regulations are almost certain to discourage fledgling efforts at many healthcare institutions to reduce the impact of medical waste on public health while saving money on waste disposal.
First, Do No Harm, a series of state-level reports with a national overview, is the product of a collaborative public education effort by members of Health Care without Harm: The Campaign for Environmentally Responsible Health Care. The campaign is a nationwide coalition of more than three dozen organizations, including community groups, environmental justice organizations, scientists, physicians, nurses and nursing organizations, other health care professionals, national labor unions, religious organizations, and environmentalists.
Major Findings
Medwaste and Dioxin. Dioxin is created as a by-product in many industrial processes including waste incineration. EPA has determined that medical waste incinerators are among the top two or three sources of dioxin contamination. Peer-reviewed research has documented that dioxin causes cancer, affects the immune system, causes birth defects––including fetal death–– decreases fertility, causes female and male reproductive dysfunction, and adversely affects a variety of hormonal processes involving insulin, thyroid hormones, and steroid hormones. Few chemicals cause such a wide variety of effects, and none exhibit dioxin’s astonishing toxicity—the ability to cause damage at doses almost too low to measure. There is no safe level of exposure to dioxin.
Dioxin is highly persistent in the environment and concentrates in animal fat, with meat, milk products and fish being primary sources of human intake. EPA’s current draft assessment of dioxin shows that while about 1 trillionth of a gram of dioxin may be a “virtually safe” daily dose, humans routinely and inadvertently consume 300 to 600 times that amount every day. Nursing infants take in 50 times the amount of dioxins that adults consume daily, and can accumulate the “safe” maximum lifetime dose in just 6 months of breast feeding. Because the average person in the United States consumes hundreds of times the “safe” level every day, our bodies already are contaminated with levels of dioxin that are at or near levels that have been observed to cause health effects in humans and laboratory animals.
Once the environment or a human body has been contaminated by dioxin, it cannot be “cleaned up.” The only solution to dioxin pollution is to prevent it from being formed and dispersed in the first place.
Waste generation. This study estimates that the nation’s 6,000 hospitals generate about 4 billion pounds (2 million tons) of waste per year. The hospital waste stream contains twice as much plastic as household waste, making it a disproportionate contributor to environmental dioxin contamination. The vast majority of this waste can and should be managed and reduced with the same techniques as households use––sorting, recycling, and environmentally sound purchasing. Only a small portion of hospital waste, an estimated 295,000 tons (15 percent), is infectious waste that requires special treatment, and according to the Centers for Disease Control, very little of this infectious waste needs to be burned. Our case studies profile hospitals that have used waste management programs to dramatically reduce their waste stream and slash their disposal costs. With waste minimization programs most hospitals could eliminate all but a fraction of the waste they now burn on-site or haul off for burning elsewhere, allowing many to shut down their incinerators. Hospitals can shift to more benign materials, eliminating supplies made from polyvinyl chloride for example, and to alternative waste treatment methods like autoclaving. The American Public Health Association recently adopted a resolution (Appendix A) to encourage the reduction of dioxin releases from medical facilities through reduced use of items made of poly vinyl chloride (PVC), one of the main materials that creates dioxin when incinerated.
Medical Waste Incinerators.
EPA is proceeding with weak medwaste incineration regulations in the absence of a comprehensive inventory of medical waste incinerators. The agency also has neglected to incorporate “right to know” measures that will inform the public of the location and characteristics of the facilities that burn medical waste. Our analysis of EPA data on recently permitted medwaste incinerators found:
• A total of 2,036 facilities held incinerator permits in recent years, with a combined incinerating capacity of nearly 900,000 pounds per hour nationwide. Thousands of hospitals and other facilities have shut down incinerators in recent years, but much of this waste is being burned elsewhere, in cement kilns, regional incinerators or other facilities. Even so, EPA data identify permitted medwaste incinerators in 1,032 counties in 42 states.
• About 69 percent of the permitted medwaste incinerators had no pollution control technologies whatsoever. These facilities account for 56 percent of total incineration capacity. Many of these uncontrolled incinerators are in rural areas, where emissions may more readily contaminate the food supply (meat and dairy products.)
• Only about 1 percent of permitted medical waste incinerators operate with state-of-the-art air pollution control technologies (dry scrubbers with carbon injection or fabric filter/packed bed controls). These “high tech” incinerators, capable of reducing dioxin emissions by more than 90 percent (but not eliminating dioxin emissions) account for a minute fraction (2 percent) of total U.S. medwaste incinerator capacity.
Implications for Children, Poor People, People of Color.
Pollutants emitted by medwaste incinerators have been shown to contaminate the environment at great distances from the source. Less is known about health risks that incinerator pollutants like mercury and cadmium may pose to populations living in close proximity to medwaste incinerators. EPA has not determined if children, people of color or low income Americans may be at special risk by virtue of living near medwaste incinerators. We were able to develop a precise geographic location for 1,348 health care institutions that have recently been issued incineration permits according to the EPA. When we analyzed these locations against 1990 U.S. Census data we found:
• Over 5.6 million American children under the age of 16 live within 2 miles of a permitted medical waste incinerator.
• Over 7.1 million people of color––15 percent of the minority population–– live within 2 miles of a permitted medical waste incinerator. By comparison, 9 percent of white Americans live within 2 miles of medwaste burners.
• Nearly one American in seven (14%) who is living below the poverty line also lives within 2 miles of a medical waste incinerator.
Alternatives to Incineration Cost Pennies Per Day.
By segregating out ordinary waste and treating the infectious portion that remains through autoclaving or other methods, health care institutions can almost eliminate the need to incinerate—and in the process eliminate emissions of dioxin and other pollutants. Based on EPA’s own cost analysis, our study found that the near term cost for the average U.S. hospital to make this switch would be just 93 cents per patient per day, compared to $930 per day for the average hospital stay.
The Clinton Administration’s Weak Medwaste Rules.
Pollution control standards now being proposed by the Clinton Administration have been described as “painless” by the American Hospital Association’s top expert on the issue. But these rules will mean continued, unacceptable pollution of the environment with dioxin, mercury and other toxins.
• Weaker standards. The Administration’s initial rule contained a single, fairly stringent standard for all medwaste incinerators; the new rule will likely make standards contingent on size. The new rules may drop requirements for any air pollution control devices whatsoever on hundreds of small incinerators, which are often the dirtiest and account for a substantial amount of total dioxin generated by medwaste incinerators. The most stringent Administration proposal for dioxin emissions, which applies only to the largest medwaste incinerators, is still ten times weaker than the dioxin emission standards being proposed for hazardous waste incinerators, cement kilns and other waste burners.
• Weaker monitoring. Under the Administration’s proposal, EPA will require “initial testing” for regulated pollutants at incinerator start up with no subsequent testing for facilities that rely only on good combustion practices to control emissions. The original rule called for initial and annual testing for at least three years. For facilities with scrubbers the EPA will require initial testing and skip testing for the first three years. This means that the facilities with no pollution controls will have to test their emissions less than those with scrubbers. EPA’s initial rule required that tests would consist of three test runs of four hours each. Now EPA will require only three test runs of one hour each, reducing the reliability of the monitoring data.
• Less training for operators, less accountability for incinerators. EPA significantly weakens requirements for operator training and eliminates the requirement for a trained and qualified operator to be on duty when the incinerator is burning, despite the reliance on “good combustion practices” as the sole pollution control measure for hundreds of smaller incinerators.
Acknowledgments
EWG analyst Jackie Savitz is the principal author of First, Do No Harm. EWG information technology director Chris Campbell conducted the database analyses for both the national overview and state editions of the study, and built the initial website for Health Care Without Harm <www.ewg.org/medwaste.html>. Ken Cook of EWG wrote sections of the report and provided overall editorial and analytical direction.
Molly Evans of EWG designed the report and coordinated all production. Thanks to Ron Blalock for his cover art. For their work in the nationwide release of the study we are grateful to Allison Daly, EWG grassroots coordinator; Charlotte Brody of the Citizens Clearinghouse for Hazardous Waste; Laurie Valeriano of the Washington Toxics Coalition; Jackie Hunt Christensen of the Institute for Agriculture and Trade Policy; Susan Claymon of the Breast Cancer Coalition; Karen Perry of Physicians for Social Responsibility; and Margie Alt of U.S. PIRG. We also want to thank the steering committee for Health Care Without Harm and other assorted friends of the order for their sup- port throughout the preparation of this publication.
EWG would like to thank the following people who provided facts, data, articles, advice and other information or gave us helpful comments on the report: Charlotte Brody, Jackie Hunt Christensen, Susan Claymon, Gary Cohen, Paul Connett, Peter DeFur, Michael Drescher, Robert Eleff, Lois Gibbs, Catherine Hill, Rick Hind, Michael Lerner, Steven Lester, Michael McCally, Mark Muff, Karen Perry, Hollie Shaner, Bill Walker, Richard Wiles, Laurie Valeriano and Jane Williams. Needless to say, any errors of fact or interpretation in this report are the sole responsibility of EWG.
Finally, we would like to thank all of the hard working activists and organizations who participate in the HCWH campaign and who helped in the release of this report. Most of all we are grateful to Michael Lerner for the vision and support that made the report and the Campaign itself possible.
First, Do No Harm was made possible by grants from the StarFire Fund, the Jenifer Altman Foundation, W. Alton Jones Foundation (through support of CCHW) and the Joyce Foundation. The opinions expressed in this report are those of the authors and do not necessarily reflect the views of the supporters listed above.
Health care without harm participating organizations
Action for Women’s Health, Albuquerque NM
AFL-CIO, Washington DC
Breast Cancer Action, San Francisco CA
Breast Cancer Fund, San Francisco CA
California Communities Against Toxics, Rosamond CA
Center for the Biology of Natural Systems, Flushing NY
CGH Environmental Strategies, Burlington VT
Citizens for a Better Environment, Madison WI
CCHW Center for Health, Environment and Justice, Falls Church VA
Chemical Impact Project, Kentfield CA
Clean North, Sault Ste. Marie ON
Commonweal, Bolinas CA
EarthSave, Santa Cruz CA
Ecology Center, Ann Arbor MI
Endometriosis Association, Milwaukee WI
Environmental Working Group, Washington DC
Environmental Stewardship Concepts, Richmond VA
Greenpeace, Washington DC, Chicago IL, and San Francisco CA
Human Action Community Organization, Harvey IL
Indigenous Environmental Network, Hackensack MN
Institute for Agriculture and Trade Policy, Minneapolis MN
Jenifer Altman Foundation, Bolinas CA
Learning Alliance, New York NY
Learning Disabilities Association, Pittsburgh PA
Minnesota Center for Environmental Advocacy, St. Paul MN
Mt. Sinai School of Medicine, New York NY
Multinational and Development Clearinghouse, Washington DC
National Environmental Law Center, Boston MA and Davis CA
1199, the National Health & Human Service Employees Union, New York, NY
National Women’s Health Network, Washington DC
Pollution Probe, Toronto ON
Physicians for Social Responsibility, Washington DC, Boston MA, and San Francisco CA Science and Environmental Health Network, Windsor ND
South Bronx Clean Air Coalition, Bronx NY
Toxics Action Center, Boston MA
United Citizens and Neighbors, Urbana IL
Washington Toxics Coalition, Seattle WA
Work on Waste, Canton NY