29 avril, 2022

Primum Non Nocere

WHO estimates that more than 13 million deaths around the world each year are due to avoidable environmental causes. The climate crisis, which is also a health crisis. There is an urgent need for actions to keep humans and the planet healthy.
Being an ER doctor and having worked during the COVID-19 Pandemic in France and in Tunisia, I was concerned about the enormous quantities of products used by the patients and the health professionals and the management of the medical waste.
It seems to be an emergency to address this issue with the health professionals in order to expose the challenges and advocate for a more environment friendly clinical practice.


The Latin phrase Primum non nocere (First, not to harm) have been introduced into medical ethics in 1864 by the medical ethicist Worthington Hooker.
It gives a maximum and exclusive priority to the negative injunction.
Yet, medical activities are causing an unintended harm.


Health systems are a massive component of the economy and have an important environmental footprint. It is part of the different steps of the materials economy[1].
The health sector consumes enormous quantities of materials, energy and water.
It is also making a major contribution to climate change through the use of the chemicals.


Some very dangerous intoxications of humans and other living beings can directly be caused by medical activities like the mercury pollution. 
Every year, 2,000 tons of mercury end up in the human environment. Mercury is a highly toxic heavy metal. It is impossible to destroy.
Spilled mercury circulates in the environment and gets into the food chain via water, where it concentrates particularly in the bodies of fish[2].
It attacks the heart and the circulatory system and, if it is ingested regularly, can lead to kidney failure, respiratory arrest and death[2].



Direct contact of humans with mercury can result in neurological and behavioral disorders: children exposed to methylmercury while they are in the womb can have impacts to their cognitive thinking, memory, attention, language, fine motor skills, and visual spatial skills[3].
Ingestion of fish and shellfish that contain methylmercury by pregnant women affect unborn infants' growing brains and nervous systems[3]. 




In addition, the health care system produces large amounts of waste, much of which are toxic and is a large source of dioxin emission from medical incinerators.
For example, The Poly Vinyl Chloride or PVC is the utmost used plastic in medical products like IV bags. When it’s burned, it produces a highly toxic dioxin. 



Air pollution plays a role in many of the major health challenges and has been linked to cancer, asthma, stroke and heart disease, diabetes, obesity, and changes linked to dementia[4].
Neither the concentration limits set by governments, nor the World Health Organization’s air quality guidelines, define levels of exposure that are safe for the population[3].


The health care system contributes to at least 4 to 10% of the CO2 footprint.


During the COVID-19 pandemic, there has been an unprecedented increase in health care demand.


(Source FR News)

According to the WHO:
- approximately 87,000 tons[6] of personal protective equipment (PPE) were procured between March 2020- November 2021 and shipped to support countries. This estimate is only about PPE from the UN system and does not include commodities procured outside of the UN initiative, nor waste generated by the public, like disposable medical masks.
-140 million test kits, with a potential to generate 2,600 tons of non-infectious waste (mainly plastic) and 731,000 liters of chemical waste (equivalent to one-third of an Olympic-size swimming pool) have been shipped,
-over 8 billion doses of vaccine have been administered globally producing 144,000 tons of additional waste in the form of syringes, needles, and safety boxes. 
Most of this equipment ended up as waste.


(Source: Inkyfada)

These tens of thousands of tons of extra medical waste weren’t managed adequately because attention and resources were devoted to the COVID-19 pandemic and much less to the safe and sustainable management of COVID-19 related health care waste.
Today, 60% of the health facilities in the least developed countries, are not equipped to handle existing waste loads, let alone the additional COVID-19 load[6].
Underfunded healthcare systems, poor training and lack of awareness of policies and legislations on handling medical waste have led to increased improper handling of waste within hospitals, healthcare facilities and transportation and storage of medical waste. [7]
Many countries do not have national guidelines in place to adhere to the correct disposal of such wastage. In some contexts, hazardous waste is left unprotected under severe weather influences; it can absorb the UV and re-emit it as heat and/or create free radicals[4].



Free radicals cause damage to cells, proteins and DNA and are associated with human diseases, including cancer, atherosclerosis, Alzheimer's disease, Parkinson's disease and many others[8].


Incineration is often the favored disposal method due to the rapid diminishment of up to 90% of waste, as well as production of heat for boilers or for energy production. This type of method – if not applying the right technologies – potentially creates hazardous risks of its own, such as harmful emissions and residuals.


The other used methods are:
-Open dumping Landfill
-Chemical disinfecting
-Indiscriminate waste


These methods also have risks like:
-Airborne contamination
-Land contamination
-Risk of contact in the surrounding communities
-overflow into seas and oceans
-Lasting waste in the environment
-Expenses for electrical usage
-Risk of contact with chemicals,
-possibility of not treating all pathogenic substances leading to contamination after treatment

The lack of effective waste management system, potentially exposes health workers to needle stick injuries, burns and pathogenic microorganisms, while also impacting communities.[9]


There is an urgent need for a climate-smart health care systems.


“We don’t want to be poisoning people in the name of healing them”. 
(Gary Cohen- Health without Harm)


(Source: ALAMY)


Health professionals must rise up to ensure their safety and that of patients:
There are many actions that can be organized either on the institutional, medical levels or on the individual level that can improve the quality and sustainability of health care:


On the institutional level:
-Working with the stakeholders in order to have the objective to reduce Health care system footprint, which also means big savings from transport, building energy use, water, and purchased goods and services[10]. This can be through strong national policies and regulations, regular monitoring and reporting and increased accountability, behavior change support and workforce development, and increased budgets and financing[6].
-Advocating for the countries to integrate the ongoing negotiations to ban the use of mercury in all kinds of industry and to sign and implement the Minamata convention[11]: Mercury should be forbidden. In Health structures, all products containing mercury need to be replaced with existing safer alternatives.
-Working with accreditation institutions and Advocating to transform the supply chain in order to purchase reusable recyclable or biodegradable devices that are safer for the patients like IV bags without PVC, safer gloves, products used in cleaning and even safer electronics and healthier food, including using eco-friendly packaging and shipping.
-Pressuring The ministry of Health and hospitals to invest in non-burn waste treatment technologies like having more autoclaves and less incinerators and adopting triage and recycling of the Hospitals waste.
-Health professionals can even act in order to transform the design of hospitals to reduce their impact on our environment, advocating for using renewable energies.


On the medical level:
Since 20% of the carbon footprint is made up of energy use in the facilities, some changes in the individual clinical practice will be useful: recognizing which elements of our activity in the health service are adding value to that patient and doing our best to try and strip out wasteful activities.
-Implementing Primary preventive intervention[12] aiming to reduce the need to visit hospitals  which will reduce the aspect of the carbon footprint, through reducing risks or threats to health, reducing demand and consumption of health services[10].
-Implementing secondary and tertiary prevention intervention in all the specialties in medicine across the hole health system, will reduce the demand on health services, making huge savings in the expenses of the health system in a very rapid fashion, it will also contribute to keeping people happy and to saving the environment.
-The implication of patients in their own care management in order to spot dysfunctions earlier, avoiding complications and evitable diseases and expenses.  
There are great examples like the Green nephrology in the UK[10] and the cataract surgery in Aravind Eye Hospital in India[13] that show how some simple interventions can improve quality of care, save money and reduce the health care system footprint.
Clinical leadership[14] in needed to undertake actions, like shifting away from propellant inhalers, changing anesthetic practice, moving to less intensive models of care and working with tools like LCA (Life Cycle Assessment) regulated by the International Organization of Sterilization which enables us to reuse safely medical material and avoid single use disposable items… Many actions can be done within each medical specialty to fight the overmedicalization of health and to rationalize the use of the services.


On the personal level[10]:
-Turning off the computers at night.
-Apply the TLC operation principals: Turn equipment off, lights out and close doors, which diminish energy consumption, improves patients comfort and saves money.
-Putting the waste in the right bin helps manage the medical waste correctly.
-Safe and rational use of PPE and every other medical equipment reduces environmental harm from waste, saves money and reduces potential supply shortages.
- Refuse the prescription of unsafe medical devices like those using mercury in order to completely eliminate its use and supply.
-Whenever possible avoiding prescriptions of drugs in favor of social prescriptions like dietary advices which might reduce the use of pharmaceutical products which production also causes a big part of pollution.


Implementing a sustainable health care system is easy, it saves money, improves health and reduces the CO2 footprint.
The COVID-19 waste challenge and increasing urgency to address environmental sustainability offer an opportunity to strengthen systems to safely and sustainably reduce and manage health care waste.
Health professionals are unwillingly contributing to the environmental problem.
All forms of environmental activism are important: personal commitments, reflection and collective actions, research, collaboration and advocacy, but also disobedience.
Many health professionals around the world chose to be part of resistance movements like the Extinction Rebellion which is a global environmental movement using nonviolent civil disobedience to compel government action to avoid tipping points in the climate system, biodiversity loss, and the risk of social and ecological collapse.


When our patients are exposed to such a clear and avoidable cause of death, illness and disability, it is our duty as health professionals to speak out.


[1] Youtube.com. 2007. The story of stuff. [online] Available at: <https://www.youtube.com/watch?v=9GorqroigqM&t=1276s> [Accessed 6 April 2022].
[2] (www.dw.com), D., 2022. Mercury to be banned | DW | 14.01.2013. [online] DW.COM. Available at: <https://www.dw.com/en/mercury-to-be-banned/a-16519002> [Accessed 27 April 2022].
[3] US EPA. 2022. Health Effects of Exposures to Mercury | US EPA. [online] Available at: <https://www.epa.gov/mercury/health-effects-exposures-mercury> [Accessed 27 April 2022].
[4] Essentracomponents.com. 2019. UV and its effect on plastics: an overview | Global Manufacturer & Distributor of Component Solutions — Essentra Components. [online] Available at: <https://www.essentracomponents.com/en-gb/news/product-resources/uv-and-its-effect-on-plastics-an-overview> [Accessed 27 April 2022].
[5] Holgate, S., 2017. ‘Every breath we take: the lifelong impact of air pollution’ – a call for action. Clinical Medicine, 17(1), pp.8-12.
[6] Who.int. 2022. Tonnes of COVID-19 health care waste expose urgent need to improve waste management systems. [online] Available at: <https://www.who.int/news/item/01-02-2022-tonnes-of-covid-19-health-care-waste-expose-urgent-need-to-improve-waste-management-systems> [Accessed 27 April 2022].
[7] Chisholm, J., Zamani, R., Negm, A., Said, N., Abdel daiem, M., Dibaj, M. and Akrami, M., 2021. Sustainable waste management of medical waste in African developing countries: A narrative review. Waste Management &amp; Research: The Journal for a Sustainable Circular Economy, 39(9), pp.1149-1163.
[8]  livescience.com. 2016. What Are Free Radicals?. [online] Available at: <https://www.livescience.com/54901-free-radicals.html> [Accessed 27 April 2022].
[9] Youtube.com. 2013. Health Care Without Harm. [online] Available at: <https://www.youtube.com/watch?v=iPzoskTpiwQ&t=105s> [Accessed 27 April 2022].
[10]Youtube.com. 2013. Sustainable Specialties. [online] Available at: <https://www.youtube.com/watch?time_continue=95&v=KlT4kP8WSms&feature=emb_logo> [Accessed 27 April 2022].
[11] Mercuryconvention.org. 2021. Convention de Minamata sur le mercure – Texte et Annexes | Minamata Convention on Mercury. [online] Available at: <https://www.mercuryconvention.org/fr/resources/convention-de-minamata-sur-le-mercure-texte-et-annexes> [Accessed 27 April 2022].
[12] Iwh.on.ca. 2022. Primary, secondary and tertiary prevention. [online] Available at: <https://www.iwh.on.ca/what-researchers-mean-by/primary-secondary-and-tertiary-prevention> [Accessed 27 April 2022].
[13] Youtube.com. 2018. Carbon Footprint of Cataract Surgery at Aravind Eye Hospitals High quality and size. [online] Available at: <https://www.youtube.com/watch?v=sdDwu1NEg1I> [Accessed 27 April 2022].
[14] Carevoyance. 2018. Identifying & Understanding Clinical Leadership. [online] Available at: <https://www.carevoyance.com/blog/clinical-leadership> [Accessed 27 April 2022].

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