Guest Editorial
Environmental public health: Issues for the new millennium
Ian Stewart
Prince of Wales Children's Hospital, Sydney NSW
PP: 051 - 052
Article Text
Environmental health. What images come to mind when we think of the relationship between the environment and human health? The big issues, perhaps. Ozone layer damage leading to increased incidence of melanoma and cataracts. Climate change resulting in more heat-stress related illness and vector-born diseases; or diarrhoeal diseases caused by contaminated water supplies. These problems are certainly worrying and the potential costs of treating such diseases are alarming. But look at our local environment, our smaller-scale habitats. Environmental health issues are all around us; some are apparent, many are hidden from day-today scrutiny. Children with high blood lead levels have been getting an airing in the press lately, as have those of us who are trying to give up passive smoking.
Now look closer still, to our homes and workplaces-our niches. Environmental issues surround us, envelop us even, so that we often fail to recognize them as environmental problems, and so it follows that we don't spend much energy seeking solutions. Ask people what they think of hospitals (ie the hospital environment) and the most common response is a negative one: 'I hate that hospital smell', 'All those sick people coughing and moaning', 'So depressing'. Look around the average ward, and negative images of health are not hard to spot. Nurses scurrying outside for a cigarette; cockroach infestations, nosocomial infections, meals made from unhealthy ingredients. What enormous potential for influencing health outcomes if hospitals were perceived by the patients, staff, and wider community as institutions that exemplify good health.
Hospitals are highly disproportionate contributors to our cities' waste disposal problems. Most clinical wastes in Australia are disposed of by landfill or incineration. Solid waste incinerators produce several hundred stable and toxic compounds including dioxins and furans; these compounds are known carcinogens and mutagens. A study in Denmark comparing the stack output of hospital and general municipal waste found that hospital waste contributed 30% of the dioxins and furans produced, yet it comprised only 1 % of the total waste. Why? The answer is obviously to be found in the ever-increasing volumes of disposables used in the wards, operating theatres and pathology laboratories. A lot of these disposables are plastic, and a lot of this plastic is polyvinyl chloride (PVC) which forms dioxins and furans when burned in old, inefficient incinerators. Most hospital incinerators are substandard.
So is the answer to throw more money at the problem; build modern, efficient incinerators so that the hospitals can stop polluting the air with carcinogenic compounds? Cast your net still wider to look for environmental links. Most medical disposables, and the associated packaging, are made of hydrocarbons, paper and cotton, with small quantities of cheap metals. When these materials undergo complete combustion in an efficient incinerator, the end products released to the atmosphere are mainly oxides of carbon, nitrogen, and sulfur. The latter two are atmospheric pollutants, and carbon dioxide is the major player in greenhouse climate change.
So looking at disposables from the perspectives of health promotion and health protection, we see that we must find ways of reducing our demand for these products. Convenience and cost must be more critically examined. Disposables are expensive enough already, but there are more costs not accounted for and not reflected in the purchase price. Chemical and plastics manufacturers are notorious environmental vandals; mercury discharged into sewers and oceans, intractable wastes such as hexachlorobenzene stored in thousands of drums because no suitable method of disposal is available, toxic vinyl chloride monomer discharged into the air and waste water. The community is left to bear the costs of polluted air and water: pollution abatement, monitoring, and treatment of pollution-related illness.
The current policy guidelines for reuse of disposables are unclear; the most recent NSW Department of Health circular is from 1983, which notes that medical devices marked 'single use only' are routinely resterilized in Australia and overseas, primarily to restrain costs. But some medico-legal problems exist, and the Department adopted the US Food and Drug Administration Guidelines as an interim measure (now, of course, a decade-long interim). The FDA Guidelines state that single use medical devices are not to be re-used unless the user can demonstrate that the device can be safely reprocessed. This state of affairs is welcomed by the disposables industry, which is not at all keen to see its products re-used. The medical products industry wins again as there is no reciprocal obligation for manufacturers to demonstrate their product to be unsafe after one use, so the words 'single use only' can be seen stamped on many products for no better reason than to maintain sales.
Yet there is light at the end of the tunnel. The American Society for Hospital Service Personnel has published guidelines for developing re-use testing protocols to help individual hospitals develop their own policies and satisfy medico-legal requirements. Some Australian hospitals have established waste management committees to look at ways of reducing their consumption of disposables.
Nurses have established a national organization, Nursing The Environment, which will examine and report on a wide range of environmental and public health issues. NTE held a much-lauded conference, Health and Ecology: a Nursing Perspective, in Melbourne early this year. This conference illuminated nurses' commitment to holistic health care, with presentations ranging from hands-on topics such as disposables, education packages, and local environmental hazards, to broader issues like empowerment, global ecology, eco-feminism and Aboriginal spirituality.
If we keep on destroying the environment in which we live, then eventually we won't be able to live in it. The risks to our health imposed by environmental despoliation must lead us to question the current strategy of encouraging healthy individual behaviour and more spending on curative medicine.
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