CONFERENCE REPORT

March 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 financial support for the conference 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. II. III. Iv. v. ExECuTIvE summaRy ThE CONFERENCE CONFERENCE ORgaNIzERs CONFERENCE PROgRam CONFERENCE OuTCOmE
Stepping Up to the 7 Steps of Mercury-Free Health Care

vI.

IssuEs aNd ChallENgEs

vII. ThE way ahEad aPPENdIx

ExECuTIvE summaRy
The Asia Regional Conference on Mercury-Free Health Care: Phasing-out mercury-containing fever thermometers and sphygmomanometers, was organized by Health Care Without Harm (HCWH), the World Health Organization (WHO), and the United Nations Development Programme-Global Environment Facility (UNDP-GEF) Global Health Care Waste project. In 2006, the Southeast Asia Conference on Mercury in Health Care held in the Philippines prompted action in the Philippines on the use of mercury devices in the health care sector and its subsequent consequences to global health and environment conditions. In 2008, the WHO and HCWH launched the Global Initiative to Substitute Mercury-Based Medical Devices with safer, affordable and accurate alternatives. The Asia Regional Conference came several years after the first Mercury-Free Conference initiative and was designed to learn from the success that the Philippine health sector has had in substituting mercury-based medical measuring devices with safe, accurate and affordable alternatives, while also looking into challenges such as management of mercury waste and guidelines for procurement of sustainable alternatives. Participants included more than 100 representatives of ministries of health and environment, health professional organizations, hospitals and other health sector organizations from 10 Asian countries. It focused on various initiatives 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 facilities. It delved into the accuracy of mercuryfree thermometers and sphygmomanometers and the guidelines on on-site storage for phasedout mercury-containing measuring devices. Country presentations from China, India, Indonesia, Mongolia, Nepal, Philippines, South Korea, Thailand and Vietnam gave a picture of how mercury substitution has evolved in the different countries and how the continuing challenges will shape the course of the initiative in the long run. An exhibit featuring alternatives to mercury thermometers and sphygmomanometers was mounted along with special demonstrations on the maintenance and calibration of these alternative equipments. The Manila Declaration on Mercury-Free Health Care 2011 is a significant conference output encouraging multi-sectoral involvement in the mercury-free health care initiative. It outlines recommendations on local and international government policy-making, active civil society involvement and business and private sector support in the mercury-free campaign.

ThE CONFERENCE
The Asia Regional Conference on Mercury-Free Health Care: Phasing-out mercury-containing fever thermometers and sphygmomanometers gathered officials from Ministries of Health and Environment, hospital managers and representatives of national health care professional associations from across Asia including China, India, Indonesia, Korea, Mongolia, Nepal, Philippines, Thailand, Vietnam and Saudi Arabia to discuss efforts made at substituting mercurybased medical measuring devices with safe, accurate, affordable alternatives throughout the region. Technical and policy experts from other countries including South Africa and the United States were also present. Over 100 delegates attended the conference, including Nepals Secretary of Health Dr. Praveen Mishra and Director Rebecca Peafiel of the Philippine Department of Health-- National Center for Health Facilities Development. The Asia Regional Conference on Mercury-Free Health Care: Phasing-out mercury-containing fever thermometers and sphygmomanometers, was organized by Health Care Without Harm, the World Health Organization, and the UNDPGEF Global Health Care Waste project. Country presentations gave a picture of how mercury substitution has evolved in the different countries and how the continuing challenges will shape the course of the initiative in the long run. The Philippines shared it experience at various levels of advocacy-- from a national policy on mercury thermometer and sphygmomanometer phase out to actual experiences 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 mercury thermometers and sphygmomanometers while the whole St. Paul network of hospitals shared their practical solutions toward achieving greener hospitals all over the country. The San Lazaro Hospital (Philippines) presented its Mercury Management Teams advances in the phase-out of mercury thermometers and sphygmomanometers and best practices for on-site management and storage of phased-out mercury measuring devices. An exhibit on digital alternatives was mounted to give the participants an overview of the wide range of options in the market today. Dr. Jorge Emmanuel of the UNDP GEF conducted extra sessions on calibrating digital thermometers and sphygmomanometers. A visit to the San Lazaro Hospital was part of the second days itinerary to allow the delegates an experience of how mercury-free practices both in the medical sections of the hospital are operational.

CONFERENCE ORgaNIzERs
Health Care Without Harm (www.noharm.org) is an international coalition with over 483 member organizations in 53 countries, working to transform the health care sector worldwide, without compromising patient safety or care, so that it is ecologically sustainable and no longer a source of harm to public and the environment. HCWHs campaign is supporting the health care industry to better apply its ethical commitment to First, Do No Harm to the environmental and occupational impacts of the technologies and materials used in health care. The UNDP-GEF Project (http://www.gefmedwaste.org) is a global demonstration project on healthcare waste. Its goal is to protect public health and the global environment from the impacts of dioxin and mercury releases. It accomplishes this by demonstrating practices and technologies that limit the amount of healthcare waste generated, eliminate the burning of healthcare waste, and reduce the quantity of broken mercury-containing devices that are improperly handled, discarded or burned. The project involves seven strategically selected countries: Argentina, India, Latvia, Lebanon, the Philippines, Senegal and Vietnam. An additional component aimed at developing affordable, non-burn healthcare waste treatment technologies is taking place in Tanzania. The project is implemented by the United Nations Development Programme (UNDP) funded by the Global Environment Facility (GEF) in keeping with the Stockholm Convention on reducing persistent organic pollutants (POPs). The World Health Organization (www.who.int) is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends. WHO believes that in the 21st century, health is a shared responsibility, involving equitable access to essential care and collective defence against transnational threats.

CONFERENCE PROgRam

WelCoMe AddreSS
Arch. Rebecca Peafiel Director III, National Center for Health Facilities Development, Department of Health (Philippines) Dr. Praveen Mishra Secretary of Health, Ministry of Health and Population (Nepal)

SeSSion 3

COUNTRy PRESENTATIONS ON MERCURy PHASE-OUT OF MERCURy-CONTAINING FEVER THERMOMETERS AND SPHyGMOMANOMETERS

CHinA -- The production, use, and alternatives

of mercury thermometers and sphygmomanometers in China
Dr. Z. Cao, Institute for Environmental Health and Relative Products Safety, Chinese Center for Disease Control and Prevention

opening reMArkS
Dr. Jorge Emmanuel Chief Technical Advisor, UNDP-GEF Global Healthcare Waste Project Dr. Hisashi Ogawa Regional Adviser, World Health Organization Western Pacific Region (WPRO) Merci Ferrer Executive Director, Health Care Without HarmSoutheast Asia

indiA -- Mercury-Free Health Care india

Dr. S. Kulshresta Directorate General of Health Services Ministry of Health & Family Welfare

indoneSiA -- Mercury-Free Health Care MongoliA -- Mercury-Free Health Care

initiatives in Mongolia

yuyun Ismawati, Balifokus, Denpasar

Dr. B. Tsetsegsaikhan, Ministry of Health

SeSSion 1
GLOBAL INITIATIVES TO PHASE-OUT MERCURy MEASURING DEVICES IN HEALTH CARE Joshua Karliner HCWH International Team Coordinator

nepAl -- Mercury-Free Health Care initiatives in nepal

Dr. Praveen Mishra, Secretary of Health, Ministry of Health and Population Mr. Mahesh Nakarmi Director, Health Care Foundation Dr. Pramita Suwal Asst. Prof., BP Koirala Institute of Health Sciences

SeSSion 2
MERCURy IN HEALTH CARE PHASE-OUT OF MEASURING DEVICES: THE PHILIPPINE ExPERIENCE Faye V. Ferrer Program Officer, HCWH-SEA

SoUTH koreA

Dr. Dong Chun Shin Chair, International Committee, Korean Medical Association As of the present, there has yet been no organized effort in South Korea on mercury-free health care. Most health professionals believe that at some level, there already has been a stop to the use of mercury-containing measuring devices in the country, except for cardiovascular equipment. However, beyond the consequences of broken thermometers, South Korea would tend to put more pressure on the question of the environmental impact of mercury use. On the average, Koreans are exposed to 4 mcg of mercury; however, this becomes significant when such accumulate in the environment and impacts on the next generations. South Korea tends to move toward the advocacy for green hospitals. Since 2008, it has explored possibilities of working with the World Medical Association for some action on national networking for green hospitals.

SeSSion 4 ToWArdS MerCUry-Free HeAlTH CAre

Richael T. Batang, Housekeeping Supervisor, Saint Paul Hospital, Tuguegarao City, Cagayan, Philippines

ACCUrACy oF MerCUry-Free deviCeS in HeAlTH CAre

Dr. Peter Orris Chief of Occupational and Environmental Medicine, University of Illinois

SeSSion 5 STorAge oF pHASed-oUT MerCUry ConTAining deviCeS

Dr. Karen Abejar-Arago Program Manager, Health Care Waste Management, Mercury Management Team, San Lazaro Hospital, Philippines

THAilAnd -- phase-out of Mercury-Containing

Fever Thermometer and Sphygmomanometer
Dr. Twisuk Punpeng Department of Health

gUidelineS For inTeriM on-SiTe STorAge oF pHASed-oUT MerCUry ConTAining deviCeS FroM HeAlTH CAre
Dr. Jorge Emmanuel Chief Technical Advisor, UNDP-GEF Global Healthcare Waste Project

CloSing reMArkS
Atty. Juan Miguel Cuna Director, Environmental Management Bureau, Department of Environment and Natural Resources (Philippines)

vieTnAM -- Situation of mercury-free

health care in vietnam
Dr. Nguyen Thi Lien Huong Deputy Director, Vietnam Health Environment Management Agency

CONFERENCE OuTCOmE
Stepping Up to the 7 Steps of Mercury-Free Health Care
The seven steps to mercury free health care was outlined by the WHo-HCWH global initiative on Mercury-Free Health Care as a series of activities, not necessarily done in a single prescribed sequence, toward the mercury free campaign in the health care sector. participating countries in the Asian regional Conference have made progress in the following ways:

edUCATion And TrAining

All countries in the region have embarked on a multitude of education and training activities on the health impact of mercury for healthcare professionals, patients and the general public. Training programs and print materials and guidelines on proper clean-up, storage and disposal of mercury measuring devices are being made and disseminated to a wide variety of audiences. Nepals education program targets a wide range of audiences and does not limit education to the health care workers only. Education and training directed to the health care sector includes mercury waste handling and disposal as well as general information about mercury toxicity. The program also targeted students and the general public with basic mercury safety information to ensure that the health care sectors precautionary practices are better 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 facilities.

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, initial pilot hospitals were on a voluntary basis. The eventual release of a national policy of a two-year phase-out of mercury thermometers and sphygmomanometers turned in high rates of success for the campaign. In Thailand, voluntary pilot facilities are beginning to influence and inspire other hospitals and health care units to opt for mercury-free alternatives to thermometers and sphygmomanometers. Nepals dynamic pilot at the National Kidney Center drew a lot of interest for its zealous and broad-based activities, as well as its out-of the-boxapproach to the mercury issue.

3 4

repliCATion in oTHer HoSpiTAlS

Properly documented experiences of mercury-free practices allow for replication by other health care facilities. In China, the experience of two general hospitals in Beijing inspired two other hospitals in the Northern and Eastern parts of the country to start their own mercury-free wards and health care facilities.

MegA-CiTy/provinCiAl poliCieS
Municipal and provincial policies on mercury-free health care serve as examples for replication in other regions. A policy issued by the Delhi Department of Health and Family Welfare in 2007 has urged all 73 government-run hospitals in the city to stop new purchases of mercury thermometers. Over 2,200 health care facilities in the National Capital Territory of Delhi have since gradually been replacing mercury measuring devices with alternatives.

nATionAl poliCieS
Country policies help speed-up the process of the campaign and facilitate compliance on a large-scale. The Philippines came out with Administrative Order 2008-021 calling for a two-year phase of out of mercury thermometers and sphygmomanometers in July 2008. Similar policies are underway in India. In Mongolia, the Joint Order #07/27 of the Minister of Health and Director General of the National Emergency Management Agency was promulgated prohibiting the purchase of the mercury-containing thermometers and sphygmomanometers and dental amalgam.

6 7

ModelS For repliCATion in regionS

Documented experiences in various scales and proportions serve as models to be emulated by health care facilities operating at different levels in a locality, province, region or country. Vietnams involvement in a UNDP GEF -WHO-HCWH project allowed for the identification of an urban hospital, a provincial hospital and a cluster of rural health facilities who shall begin with the substitution of mercury-based measuring devices as part of a broad sustainable health care waste management effort. In Indonesia, seven pilot hospitals were engaged for the mercury-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 participants came out with the Manila Declaration of 2011 which gives out recommendations for governments, civil societies, WHO and United Nations and private sector towards the realization of mercury-free healthcare. (Appendix)

IssuEs aNd ChallENgEs

What follows are issues and realizations discussed in the course of the presentations, fora and conference sessions.

knoWledge, edUCATion, popUlArizATionTHe TASk oF CHAnging Mind SeTS

Effecting change in the mindsets of health care professionals and the public remains a big task in the mercury -free health care campaign. The shift to alternatives becomes a difficult choice where there is running belief about the superior accuracy of mercury measuring devices as well as the prohibitive cost of alternatives. Experiences across the region point to the need for continuing research and advocacy and the production and popularization of knowledge and education products that shall make audiences see beyond tradition and simple cost accounting in the mercury issue. There was also mention of how perspectives ought to be directed toward environmental cost accounting, that is, the bigger picture.

AlTernATiveS
AccurAcy- The main issue posed to advocates of substitution is whether alternatives to mercury measuring devices will be at par with mercury devices. Mercury has always been the traditional Gold Standard for measurement of fever and blood pressure and digital alternatives are deemed less reliable especially in cardiological conditions that rely on the supposed accuracy of mercury sphygmomanometer readings. Half the work is in breaking the myth of mercurys unquestioned accuracy and reliability among medical practitioners. AffordAbility-The issue of cost-effectiveness of alternatives was also put to the fore. In China, Thailand, India, Mongolia, and Vietnam and most other countries, the cost of non-mercury thermometer substitutes run as high as 600% compared to mercury thermometers.
China also expressed that technologies for the manufacture of alternatives are often not available locally. This significantly causes a dent into the China economy where manufacturers of mercury measuring devices number at least 16,000 and earn from exporting 40% of their produce. Price also determines, to a great extent, the accessibility of the alternatives. Thus, the logic of swinging the demand for alternatives. The good news is that most local suppliers of mercury measuring devices in the presenting countries also carry digital alternatives in their product lines. A swing in the demand for alternatives eventually causes an increase in their supply and a relative lowering of prices.

WASTe MAnAgeMenT And diSpoSAl CleAnUp STorAge ,

Much of the technology for the proper cleanup, storage and disposal of mercury waste in health care facilities has yet to be promoted and popularized. The Philippines San Lazaro Hospital under its Mercury Management 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 redundancy as a salient feature of proper handling and storage of mercury and toxic wastes.

FinAl diSpoSAl
Solutions toward the final disposal of mercury waste remain elusive but not hopeless. It was pointed out that no country successfully addressed final disposal of mercury waste without some form of adverse effect on the environment. Incineration contributes to toxic waste in the atmosphere and in both land and water bodies. In the Philippines as well as in India, knowledge about and practices pertaining to mercury waste storage and disposal still need to be properly shared and popularized.

ThE way ahEad

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 national policies calling for phase out and a shift to alternatives, replicating and popularizing best practices, continuing education and popularization of knowledge products, consciously shifting demand for alternatives by developing informed audiences. There is also a need for basic information sources on standards for alternatives to mercury measuring devices and the storage and disposal of health care waste.

The Manila declaration of 2011 is an effort toward effecting global policy-making and outlines recommendations from the conference participants addressed to the following sectors:
governMenT And regionAl bodieS to formulate
policies and directives toward the phase out of mercury measuring devices in the health care sector, to promote regional cooperation along these lines, to promote alternatives and provide information to peoples, to identify alternatives and best practices for storage and disposal and to work towards the forging of an internationally binding legal instrument on Mercury-Free Health Care.

Policy and legislation help facilitate the campaign at all levels. National policies fast-track implementation but local legislations ensure proper operation at manageable levels. Regional policy shall ensure cooperation and mutual benefit among partner countries. Global policy and legislation however, paves the greatest way 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 facility, materials on practical/ household handling of mercury waste.

For WHo And Un AgenCieS to provide technical assistance and information, to encourage policy-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 implementation of the initiative, and help in networking and influencing public perception. For the privATe SeCTor to offer and produce alternatives to mercury measuring devices, phase-out production of mercury-based instruments, exercise extended producer responsibility and support the goals of Mercury-Free Health Care.

aPPENdIx
Manila 2011 declaration on Mercury Free Health Care
gathered in Manila, philippines on the occasion of the Asia regional Conference on Mercury-Free Health Care, more than 100 representatives of ministries of health and environment, health professional organizations, hospitals, and other health sector organizations from nine Asian countries came together to address policy and technical issues regarding the substitution of mercury-based medical devices. The group made the following declaration:
Recognizing, the important role the health sector plays in protecting and promoting public health; the negative consequences of mercury pollution on human health the negative impacts of mercury pollution on the environment and mercurys toxic, persistent and bioaccumulative nature;

Recognizing that, - alternatives to mercury-based medical devices are available, affordable and at least as accurate as mercury devices in their use; - health systems in many countries in Asia have switched or are in the process of switching to the available alternatives; - the WHO-HCWH Global Initiative for Mercury-Free Health Care aims to substitute 70 percent of mercury thermometers and blood pressure devices globally by 2017; - the substitution of mercury-based medical devices will contribute to health system strengthening by improving the quality of health care and the occupational health and safety of health care workers; - the worlds governments are negotiating a legally binding treaty to phase-out most uses of mercury; We, the participants in the Asia Regional Conference on Mercury-Free Health Care recommend the following plan of action: FOR GOVERNMENTS AND REGIONAL BODIES: - Formulate the policy and directives to phase-out the use of mercury devices in the health sectors day-to-day practice. - Promote multi-sectoral collaboration for better implementation of policy-based plans, including collaboration between Ministries of Health, Environment and Industry. - Provide information to the people including health professionals regarding the harmful effects of mercury, thereby educating and communicating with a diversity of stakeholders.

- Replace mercury devices with alternatives that are at least as accurate and well-calibrated as mercury devices in public health facilities. - Identify not only alternatives to mercury-based medical devices, but also provide for the safe storage and disposal of these mercury devices including potentially mandating extended producer responsibility. - Encourage the development of an appropriate plan for the phase-out of mercury thermometers and sphygmomanometers in the International Negotiating Committee to Prepare a Global Legally Binding Instrument on Mercury. FOR WHO AND OTHER UN AGENCIES: - Make technical assistance and expertise available to the Government and other health sector organizations for mercury substitution and safe disposal. - Produce information, educational and technical guidance materials. - Mobilize resources for the initiation of Mercury-Free Health Care. - Encourage policy makers to work towards Mercury-Free Health Care. FOR CIVIL SOCIETy ORGANIZATIONS: Advocate for policies and practices that substitute mercury-based medical devices with safe, accurate, affordable alternatives. Change the public perception of the issue through educational activities. Work as a watchdog for the implementation of government activities and policies. Network with different stakeholders, government organizations and civil society organizations to see the effective implementation. Promote initiatives in the private sector health institutions, as well as with manufacturers for Mercury-Free Health Care.

FOR THE PRIVATE SECTOR: - Phase-out the production, sale and marketing of mercury-based medical devices. - Expand production and distribution of non-mercury devices, making quality, affordable and validated alternatives available at affordable prices. - Provide for Extended Producer Responsibility by taking back phased-out mercury equipment and managing the mercury waste. SUPPORT THE GOALS OF MERCURy-FREE HEALTH CARE. Manila, the Philippines, March 15, 2011