AsiaHgConference Report 15March11

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CONFERENCE

REPORTMarch 15, 2011, Manila, Philippines



This report has been documented and prepared by Desiree M. Lopez for Health Care

Without Harm (HCWH), World Health Organization (WHO) and the United Nations

Development Programme- Global Environment Facility (UNDP-GEF) Global Health Care

Waste Project.

Health Care Without Harm would like to acknowledge f inancial support for the confer-

ence and this document from the Swedish International Development Agency (SIDA)

with the assistance provided by the Swedish Chemicals Agency (KemI). The document

does not necessarily reflect the official positions of Sida or KemI.



CONTENTs

I. ExECuTIvE summaRy

II. ThE CONFERENCE

III. CONFERENCE ORgaNIzERs

Iv. CONFERENCE PROgRam

v. CONFERENCE OuTCOmE

St U t th 7 Sts f Mcu-F Hath Ca

vI. IssuEs aNd ChallENgEs

vII. ThE way ahEad

aPPENdIx



The Asia Regional Conference on Mercury-Free

Health Care: Phasing-out mercury-containing fe-

ver thermometers and sphygmomanometers, was

organized by Health Care Without Harm (HCWH),

the World Health Organizaon (WHO), and the

United Naons Development Programme-Global

Environment Facilit (UNDP-GEF) Global Health

Care Waste project.

In 2006, the Southeast Asia Conference on

Mercury in Health Care held in the Philippines

prompted acon in the Philippines on the use of

mercury devices in the health care sector and its

subsequent consequences to global health and

environment condions. In 2008, the WHO and

HCWH launched the Global Iniave to Substute

Mercur-Based Medical Devices with safer, af -

fordable and accurate alternaves.

The Asia Regional Conference came several years

aer the rst Mercur-Free Conference iniaveand was designed to learn from the success that

the Philippine health sector has had in substut-

ing mercury-based medical measuring devices

with safe, accurate and aordable alternaves,

while also looking into challenges such as man-

agement of mercury waste and guidelines for

procurement of sustainable alternaves.

Parcipants included more than 100 representa-

ves of ministries of health and environment,

health professional organizaons, hospitals and

other health sector organizaons from 10 Asiancountries.

It focused on various iniaves from around the

world to phase-out mercury measuring devices in

health care, the progress made among ten Asian

countries and experiences toward mercury-free

health care from several Philippine health care

facilies. It delved into the accurac of mercur-

free thermometers and sphygmomanometers

and the guidelines on on-site storage for phased-

out mercury-containing measuring devices.

Countr presentaons from China, India, Indo-

nesia, Mongolia, Nepal, Philippines, South Korea,

Thailand and Vietnam gave a picture of how

mercur substuon has evolved in the dierent

countries and how the connuing challenges will

shape the course of the iniave in the long run.

An ehibit featuring alternaves to mercur

thermometers and sphygmomanometers was

mounted along with special demonstraons on

the maintenance and calibraon of thesealternave equipments.

The Manila Declaraon on Mercur-Free Health

Care 2011 is a signicant conference output

encouraging mul-sectoral involvement in the

mercur-free health care iniave. It outlines

recommendaons on local and internaonal

government polic-making, acve civil societ

involvement and business and private sector sup-

port in the mercury-free campaign.

ExECuTIvE summaRy




Health Care: Phasing-out mercury-containing

fever thermometers and sphygmomanometers

gathered ocials from Ministries of Health and

Environment, hospital managers and repre-

sentaves of naonal health care professional

associaons from across Asia including China,

India, Indonesia, Korea, Mongolia, Nepal, Philip-

pines, Thailand, Vietnam and Saudi Arabia to

discuss eorts made at substung mercur-

based medical measuring devices with safe,

accurate, aordable alternaves throughout the

region. Technical and policy experts from other

countries including South Africa and the United

States were also present.

Over 100 delegates aended the conference,

including Nepal’s Secretar of Health Dr. Praveen

Mishra and Director Rebecca Peñael of the

Philippine Department of Health-- Naonal

Center for Health Facilies Development.


Health Care: Phasing-out mercury-containing

fever thermometers and sphygmomanometers,

was organized by Health Care Without Harm,

the World Health Organizaon, and the UNDP-

GEF Global Health Care Waste project.

Countr presentaons gave a picture of how

mercur substuon has evolved in the dier-

ent countries and how the connuing challenges

will shape the course of the iniave in the longrun.

The Philippines shared it experience at various

levels of advocac-- from a naonal polic on

mercury thermometer and sphygmomanometer

phase out to actual eperiences of 1st Do No

Harm awardees for mercury phase-out in health

care.

The St. Paul Hospital of Tuguegarao (Philippines)

shared its experience of total phase out of mer-

cury thermometers and sphygmomanometers

while the whole St. Paul network of hospitals

shared their praccal soluons toward achiev-

ing greener hospitals all over the country. The

San Lazaro Hospital (Philippines) presented

its Mercury Management Team’s advances in

the phase-out of mercury thermometers and

sphgmomanometers and best pracces for

on-site management and storage of phased-out

mercury measuring devices.

An ehibit on digital alternaves was mountedto give the parcipants an overview of the wide

range of opons in the market toda. Dr. Jorge

Emmanuel of the UNDP GEF conducted etra

sessions on calibrang digital thermometers and

sphygmomanometers.

A visit to the San Lazaro Hospital was part of the

second da’s inerar to allow the delegates

an eperience of how mercur-free pracces

both in the medical secons of the hospital are

operaonal.

ThE CONFERENCE



Health Care Without Harm (www.noharm.org) is an internaonal coalion with over

483 member organizaons in 53 countries, working to transform the health care sec-

tor worldwide, without compromising paent safet or care, so that it is ecologicall

sustainable and no longer a source of harm to public and the environment. HCWH’s

campaign is supporng the health care industr to beer appl its ethical commitment

to “First, Do No Harm” to the environmental and occupaonal impacts of the technolo -

gies and materials used in health care.

The UNDP-GEF Project (hp://www.gefmedwaste.org) is a global demonstraon pro-

ject on healthcare waste. Its goal is to protect public health and the global environment

from the impacts of dioin and mercur releases. It accomplishes this b demonstrang

pracces and technologies that limit the amount of healthcare waste generated, elimi-

nate the burning of healthcare waste, and reduce the quant of broken mercur-con-

taining devices that are improperly handled, discarded or burned. The project involves

seven strategicall selected countries: Argenna, India, Latvia, Lebanon, the Philip-

pines, Senegal and Vietnam. An addional component aimed at developing aordable,

non-burn healthcare waste treatment technologies is taking place in Tanzania. The pro-

ject is implemented b the United Naons Development Programme (UNDP) funded

b the Global Environment Facilit (GEF) in keeping with the Stockholm Convenon on

reducing persistent organic pollutants (POPs).

The World Health Organizaon (www.who.int) is the direcng and coordinang author-

it for health within the United Naons sstem. It is responsible for providing leader-

ship on global health maers, shaping the health research agenda, seng norms and

standards, arculang evidence-based polic opons, providing technical support to

countries and monitoring and assessing health trends.

WHO believes that in the 21st centur, health is a shared responsibilit, involving equi-

table access to essenal care and collecve defence against transnaonal threats.

CONFERENCE ORgaNIzERs



WelCoMe AddreSS

Arch. Rebecca Peñael

Director III, Naonal Center for Health Facilies

Development, Department of Health (Philippines)

Dr. Praveen Mishra

Secretary of Health,

Ministr of Health and Populaon (Nepal)

opening reMArkS

Dr. Jorge Emmanuel

Chief Technical Advisor,

UNDP-GEF Global Healthcare Waste Project

Dr. Hisashi Ogawa

Regional Adviser,

World Health Organizaon Western

Pacic Region (WPRO)

Merci Ferrer

Eecuve Director, Health Care Without Harm-

Southeast Asia

SeSSion 1

GLOBAL INITIATIVES TO PHASEOUT MERCURy

MEASURING DEVICES IN HEALTH CARE

Joshua Karliner

HCWH Internaonal Team Coordinator

SeSSion 2

MERCURy IN HEALTH CARE PHASEOUT OF

MEASURING DEVICES: THE PHILIPPINE ExPERIENCE

Faye V. Ferrer

Program Ocer, HCWH-SEA

SeSSion 3COUNTRy PRESENTATIONS ON MERCURy PHASEOUT

OF MERCURyCONTAINING FEVER THERMOMETERS AND

SPHyGMOMANOMETERS

CONFERENCE

PROgRamCHinA -- Th uct, us, a atats

f mcu thmmts a

shmmamts ChaDr. Z. Cao, Instute for Environmental Health

and Relave Products Safet, Chinese Center

for Disease Control and Prevenon

indiA -- Mcu-F Hath Ca iaDr. S. Kulshresta

Directorate General of Health Services

Ministry of Health & Family Welfare

indoneSiA -- Mcu-F Hath Cayuun Ismawa, Balifokus, Denpasar

MongoliA -- Mcu-F Hath Ca

itats MaDr. B. Tsetsegsaikhan, Ministr of Health

nepAl -- Mcu-F Hath Ca itats na

Dr. Praveen Mishra, Secretar of Health,Ministr of Health and Populaon

Mr. Mahesh Nakarmi

Director, Health Care Foundaon

Dr. Pramita Suwal

Asst. Prof., BP Koirala Instute of Health Sciences



SeSSion 4

ToWArdS MerCUry-Free HeAlTH CAreRichael T. Batang, Housekeeping Supervisor,

Saint Paul Hospital, Tuguegarao City, Cagayan, Philippines

ACCUrACy oF MerCUry-Free deviCeS

in HeAlTH CAreDr. Peter Orris

Chief of Occupaonal and Environmental Medicine,

University of Illinois

SeSSion 5

STorAge oF pHASed-oUT MerCUry

ConTAining deviCeSDr. Karen Abejar-Arago

Program Manager, Health Care Waste Management,

Mercury Management Team, San Lazaro Hospital, Philippines

gUidelineS For inTeriM on-SiTe STorAge oF

pHASed-oUT MerCUry ConTAining deviCeS

FroM HeAlTH CAreDr. Jorge Emmanuel

Chief Technical Advisor,

UNDP-GEF Global Healthcare Waste Project

CloSing reMArkS

A. Juan Miguel Cuna

Director, Environmental Management Bureau,

Department of Environment and Natural Resources

(Philippines)

SoUTH koreADr. Dong Chun Shin

Chair, Internaonal Commiee,

Korean Medical Associaon

As of the present, there has yet been no organ-

ized eort in South Korea on mercur-free

health care. Most health professionals believe

that at some level, there already has been a

stop to the use of mercury-containing measur-

ing devices in the country, except for cardio-

vascular equipment. However, beyond the

consequences of broken thermometers, South

Korea would tend to put more pressure on the

queson of the environmental impact of mer-

cury use. On the average, Koreans are exposed

to 4 mcg of mercury; however, this becomes

signicant when such accumulate in the envi-

ronment and impacts on the net generaons.

South Korea tends to move toward the

advocac for green hospitals. Since 2008, it has

eplored possibilies of working with the World

Medical Associaon for some acon on naonal

networking for green hospitals.

THAilAnd -- phas-ut f Mcu-Cta

F Thmmt a

ShmmamtDr. Twisuk Punpeng

Department of Health

vieTnAM -- Stuat f mcu-f

hath ca vtamDr. Nguen Thi Lien Huong

Deput Director, Vietnam Health

Environment Management Agency



CONFERENCE OuTCOmE

St U t th 7 Sts f Mcu-F Hath CaTh s sts t mcu f hath ca was ut th WHo-HCWH ga itat Mcu-F

Hath Ca as a ss f actts, t cssa a s sc squc, twa th mcu

f cama th hath ca sct. patcat cuts th Asa ra Cfc ha ma

ss th fw was:

edUCATion And TrAining

All countries in the region have embarked on a multude of educaon and training acvies on

the health impact of mercur for healthcare professionals, paents and the general public. Train-

ing programs and print materials and guidelines on proper clean-up, storage and disposal of mer-

cury measuring devices are being made and disseminated to a wide variety of audiences.

Nepal’s educaon program targets a wide range of audiences and does not limit educaon to

the health care workers onl. Educaon and training directed to the health care sector includes

mercur waste handling and disposal as well as general informaon about mercur toicit. The

program also targeted students and the general public with basic mercur safet informaon to

ensure that the health care sector’s precauonar pracces are beer understood and supported

by the populace. It also tries to maximize the use of posters and signage to educate people who

are not health workers but who frequent health care facilies.

1



repliCATion in oTHer HoSpiTAlS

Properl documented eperiences of mercur-free pracces allow for replicaon b other health care facilies.

In China, the experience of two general hospitals in Beijing inspired two other hospitals in the Northern and

Eastern parts of the countr to start their own mercur-free wards and health care facilies.

MegA-CiTy/provinCiAl poliCieS

Municipal and provincial policies on mercur-free health care serve as eamples for replicaon in other regions.

A polic issued b the Delhi Department of Health and Famil Welfare in 2007 has urged all 73 government-run

hospitals in the cit to stop new purchases of mercur thermometers. Over 2,200 health care facilies in the Na-onal Capital Territor of Delhi have since graduall been replacing mercur measuring devices with alternaves.

4

3

piloT HoSpiTAlS

Whether mandatory or voluntary, pilot hospitals carrying the mercury-free line had been launched in the

region and are serving as models of sound environmental and toxic-wastes management to others.In the Philippines, inial pilot hospitals were on a voluntar basis. The eventual release of a naonal polic of

a two-year phase-out of mercury thermometers and sphygmomanometers turned in high rates of success for

the campaign.

In Thailand, voluntar pilot facilies are beginning to inuence and inspire other hospitals and health care

units to opt for mercur-free alternaves to thermometers and sphgmomanometers.

Nepal’s dnamic pilot at the Naonal Kidne Center drew a lot of interest for its zealous and broad-based

acvies, as well as its “out-of the-bo“approach to the mercur issue.

2



ModelS For repliCATion in regionS

Documented eperiences in various scales and proporons serve as models to be emulated b health

care facilies operang at dierent levels in a localit, province, region or countr.

Vietnam’s involvement in a UNDP GEF -WHO-HCWH project allowed for the idencaon of an urban

hospital, a provincial hospital and a cluster of rural health facilies who shall begin with the substuon

of mercur-based measuring devices as part of a broad sustainable health care waste management eort.

In Indonesia, seven pilot hospitals were engaged for the mercur-free campaign in Despansar.

Models in Bali, Jakarta and Bandung have followed suit.

ConTribUTing To globAl poliCy

Experiences and movements in various parts of the world all lead toward an intensifying campaign on

mercury-free health care among various sectors of society around the world.

The conference parcipants came out with the Manila Declaraon of 2011 which gives out recommenda -

ons for governments, civil sociees, WHO and United Naons and private sector towards the realizaon

of mercury-free healthcare. (Appendix)

6

7

nATionAl poliCieS

Country policies help speed-up the process of the campaign and facilitate compliance on a large-scale.

The Philippines came out with Administrave Order 2008-021 calling for a two-ear phase of out of

mercur thermometers and sphgmomanometers in Jul 2008. Similar policies are underwa in India.

In Mongolia, the Joint Order #07/27 of the Minister of Health and Director General of the Naonal

Emergenc Management Agenc was promulgated prohibing the purchase of the mercur-containing

thermometers and sphygmomanometers and dental amalgam.

5



What follows are issues and realizaons discussed in the course of the presentaons, fora and conference sessions.

knoWledge, edUCATion, popUlArizATion-

THe TASk oF CHAnging Mind SeTS

Eecng change in the mindsets of health care professionals and the public remains a big task in the mercur

-free health care campaign. The shi to alternaves becomes a dicult choice where there is running be-

lief about the superior accurac of mercur measuring devices as well as the prohibive cost of alternaves.

Eperiences across the region point to the need for connuing research and advocac and the producon and

popularizaon of knowledge and educaon products that shall make audiences see beond tradion and simplecost accounng in the mercur issue. There was also menon of how perspecves ought to be directed toward

environmental cost accounng, that is, the bigger picture.

AlTernATiveS

AccurAcy- The main issue posed to advocates of substuon is whether alternaves to mercur measuring

devices will be at par with mercur devices. Mercur has alwas been the tradional “Gold Standard” for meas-

urement of fever and blood pressure and digital alternaves are deemed less reliable especiall in cardiologi-

cal condions that rel on the supposed accurac of mercur sphgmomanometer readings. Half the work is in

breaking the mth of mercur’s unquesoned accurac and reliabilit among medical praconers.

AffordAbility-The issue of cost-eecveness of alternaves was also put to the fore. In China, Thailand,

India, Mongolia, and Vietnam and most other countries, the cost of non-mercur thermometer substutes run

as high as 600% compared to mercury thermometers.

China also epressed that technologies for the manufacture of alternaves are oen not available locall. This

signicantl causes a dent into the China econom where manufacturers of mercur measuring devices number

at least 16,000 and earn from eporng 40% of their produce.

Price also determines, to a great etent, the accessibilit of the alternaves.

Thus, the logic of swinging the demand for alternaves. The good news is that most local suppliers of mercur

measuring devices in the presenng countries also carr digital alternaves in their product lines. A swing inthe demand for alternaves eventuall causes an increase in their suppl and a relave lowering of prices.

IssuEs aNd ChallENgEs



WASTe MAnAgeMenT And diSpoSAl

CleAnUp, STorAge

Much of the technology for the proper cleanup, storage and disposal of mercury waste in health care facili-es has et to be promoted and popularized. The Philippines’ San Lazaro Hospital under its Mercur Man-

agement Team shared its experiences in the handling and on-site storage of phase-out devices and health

care waste while Dr. Jorge Emmanuel of the UNDP underscored “double-packaging ” or “packaging redun-

dancy “as a salient feature of proper handling and storage of mercury and toxic wastes.

FinAl diSpoSAl

Soluons toward the nal disposal of mercur waste remain elusive but not hopeless. It was pointed out

that no countr successfull addressed nal disposal of mercur waste without some form of adverse eect

on the environment. Incineraon contributes to toic waste in the atmosphere and in both land and

water bodies.

In the Philippines as well as in India, knowledge about and pracces pertaining to mercur waste storage

and disposal sll need to be properl shared and popularized.



The mercury-free campaign may be escalated by

working with what has been gained in the region

and in the countries involved so far-- local and

naonal policies calling for phase out and a shi

to alternaves, replicang and popularizing best

pracces, connuing educaon and populariza-

on of knowledge products, consciousl shiing

demand for alternaves b developing informed

audiences.

Polic and legislaon help facilitate the campaign

at all levels. Naonal policies fast-track imple-mentaon but local legislaons ensure proper

operaon at manageable levels. Regional polic

shall ensure cooperaon and mutual benet

among partner countries. Global polic and legis-

laon however, paves the greatest wa toward a

mercury-free future.

There is an expressed need to develop knowledge

products such as researches on the health impact

of mercury on health care professionals and

other vulnerable sectors, other mercury sources

in the health care facilit, materials on praccal/household handling of mercury waste.

There is also a need for basic informaon sources on

standards for alternaves to mercur measuring devices

and the storage and disposal of health care waste.

ThE way ahEad

Th Maa dcaat f 2011 s a fft twa

ffct a c-ma a uts

cmmats fm th cfc atcats

ass t th fw scts:

governMenT And regionAl bodieS to formulate

policies and direcves toward the phase out of mercur

measuring devices in the health care sector, to promote

regional cooperaon along these lines, to promote alter-

naves and provide informaon to peoples, to idenf

alternaves and best pracces for storage and disposal

and to work towards the forging of an internaonall

binding legal instrument on Mercury-Free Health Care.

For WHo And Un AgenCieS to provide technical as-

sistance and informaon, to encourage polic-making

among governments and help mobilize resources toward

Mercury-Free Health Care.

For Civil SoCieTy groUpS to advocate for policies,

act as watchdogs to the implementaon of the

iniave, and help in networking and inuencing

public percepon.

For the privATe SeCTor to oer and produce alterna-

ves to mercur measuring devices, phase-out

producon of mercur-based instruments, eercise

extended producer responsibility and support the goals

of Mercury-Free Health Care.



Maa 2011 dcaat Mcu F Hath Ca

gath Maa, phs th ccas f th Asa ra Cfc Mcu-F Hath Ca, m tha 100

stats f msts f hath a mt, hath fssa aats, hstas, a th hath sct

aats fm Asa cuts cam tth t ass c a tchca ssus a th susttut f

mcu-as mca cs. Th u ma th fw caat:

aPPENdIx

Recognizing,

- the important role the health sector plas in protecng and promong public health;

- the negave consequences of mercur polluon on human health

- the negave impacts of mercur polluon on the environment

- and mercur’s toic, persistent and bioaccumulave nature;

Recognizing that,

- alternaves to mercur-based medical devices are available, aordable and at least as accurate as mercur devices in their use;

- health sstems in man countries in Asia have switched or are in the process of switching to the available alternaves;

- the WHO-HCWH Global Iniave for Mercur-Free Health Care aims to substute 70 percent of mercur thermometers

and blood pressure devices globall b 2017;

- the substuon of mercur-based medical devices will contribute to health sstem strengthening b improving the qualit of health care and the occupaonal health and safet of health care workers;

- the world’s governments are negoang a legall binding treat to phase-out most uses of mercur;

We, the parcipants in the Asia Regional Conference on Mercur-Free Health Care recommend the following plan of acon:

FOR GOVERNMENTS AND REGIONAL BODIES:

- Formulate the polic and direcves to phase-out the use of mercur devices in the health sector’s da-to-da pracce.

- Promote mul-sectoral collaboraon for beer implementaon of polic-based plans, including collaboraon between

Ministries of Health, Environment and Industry.

- Provide informaon to the people including health professionals regarding the harmful eects of mercur, thereb educang

and communicang with a diversit of stakeholders.



- Replace mercur devices with alternaves that are at least as accurate and well-calibrated as mercur devices in public health facilies.

- Idenf not onl alternaves to mercur-based medical devices, but also provide for the safe storage and disposal of these mercur

devices including potenall mandang etended producer responsibilit.

- Encourage the development of an appropriate plan for the phase-out of mercury thermometers and sphygmomanometers in the

Internaonal Negoang Commiee to Prepare a Global Legall Binding Instrument on Mercur.

FOR WHO AND OTHER UN AGENCIES:

- Make technical assistance and eperse available to the Government and other health sector organizaons for mercur

substuon and safe disposal.

- Produce informaon, educaonal and technical guidance materials.

- Mobilize resources for the iniaon of Mercur-Free Health Care.

- Encourage policy makers to work towards Mercury-Free Health Care.

FOR CIVIL SOCIETy ORGANIZATIONS:

- Advocate for policies and pracces that substute mercur-based medical devices with safe, accurate, aordable alternaves.- Change the public percepon of the issue through educaonal acvies.

- Work as a watchdog for the implementaon of government acvies and policies.

- Network with dierent stakeholders, government organizaons and civil societ organizaons to see the eecve implementaon.

- Promote iniaves in the private sector health instuons, as well as with manufacturers for Mercur-Free Health Care.

FOR THE PRIVATE SECTOR:

- Phase-out the producon, sale and markeng of mercur-based medical devices.

- Epand producon and distribuon of non-mercur devices, making qualit, aordable and validated alternaves available

at aordable prices.

- Provide for Extended Producer Responsibility by taking back phased-out mercury equipment and managing the mercury waste.

SUPPORT THE GOALS OF MERCURyFREE HEALTH CARE.

Manila, the Philippines, March 15, 2011



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