SEPTEMBER / OCTOBER 2010 | Volume 16 | Number 5

ALSO INSIDE: UPDATE ON HEALTH INFORMATION TECHNOLOGY

Not only can a disability slow your pace... it could also stop your income. Studies show that 43% of people age 40 will suffer a long-term disability before they are 651 and one in seven workers are disabled for five years before retirement.2 If you suffer a disabling injury or illness and can’t continue working, do you have a reliable financial source to replace your income?

IMPROVED! PROGRAM

Santa Clara County Medical Association and Monterey County Medical Society/CMA members can turn to the Sponsored Group Disability Income Insurance Plan. This plan is designed to provide a monthly benefit up to $10,000 if you were to become Totally Disabled. Learn more about this valuable plan today. Call Marsh for free information, including features, costs, eligibility, renewability, limitations and exclusions at 800-842-3761.

• C AL

IF O R N I A

Administered by:

Endorsed by:

Y MEDIC UNT A CO

IAT SSOC ION • LA

TA CLARA SAN

Sponsored by:

Underwritten by: New York Life Insurance Company New York, NY 10010 on Policy Form GMR

1 Statistic attributed to Insurance Information Institute, for Loeb, Marshall. “Excessive or Necessity: Is Disability Insurance Worth the Price?” MarketWatch, Viewed 4/20/2010 National Association of Insurance Commissioners (NAIC). Article found at http://articles.moneycentral.msn.com/Insurance/InsureYourHealth/DisabilityInsuranceCanSaveYourLife.aspx. “Disability Insurance Can Save Your Life” Viewed 4/20/2010.

47139 (9/10) ©Seabury & Smith Insurance Program Management 2010 • CA Ins. Lic. #0633005 • AR Ins. Lic. #245544

d/b/a in CA Seabury & Smith Insurance Program Management • 777 S. Figueroa St., Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com Marsh is part of the family of MMC companies, including Kroll, Guy Carpenter, Mercer, and the Oliver Wyman Group (including Lippincott and NERA Economic Consulting).

BULLETIN THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

700 Empey Way • San Jose, CA 95128 • 408/998-8850 • www.sccma-mcms.org

MEMBER BENEFITS Legal Services/On-Call Library Reimbursement Advocacy/ Coding Services Billing/Collections

From the Editor’s Desk.................................................................................6 Joseph Andresen, MD

Creating a Healthier and Greener Medical Office: Saving Green By Going Green...............................................................................................8 Cindy Russell, MD

Medical Waste, the Truth Be Told..............................................................12 Ben Ottmar

Discounted Insurance

Keep the Oil in the Soil: Climate Change Update...................................14

Referral Services With Membership Directory/ Website

Update on Health Information Technology............................................18

Legislative Advocacy/MICRA

Cindy Russell, MD

The 4 Ts: Assessing Exposure to Multiple Chemicals..............................22 Joel Kreisberg, DC, MA

House of Delegates Representation

Green Pharmacy: Preventing Pollution...................................................26

Practice Management Resources and Education

In Memoriam..............................................................................................31

Financial Services Professional Development

Joel Kreisberg, DC, MA

Solar Energy: Easy, Affordable and Quick...............................................32 Cindy Russell, MD

Why Fi?: Is Wireless Communication Hazardous to Your Health?........34 Cindy Russell, MD

Health Information Technology Resources

Classified Ads..............................................................................................42

Publications

The Navigation Guide: An Evidence-Based Tool to Bridge the Gap

CME Tracking Physicians’ Confidential Line

Between Clinical Practice and Environmental Health Science...........44 Patrice Sutton, MPH; Jeanne Conry, MD, PhD; Pablo Rodriguez, MD; Tracey Woodruff, PhD, MPH

Verizon Discount Human Resources Services PAGE 3 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

The Santa Clara County Medical Association Officers

AMA Trustee - SCCMA

Councilors

President Thomas Dailey, MD President-Elect William Lewis, MD Past President Howard Sutkin, MD VP-Community Health Cindy Russell, MD VP-External Affairs Rives Chalmers, MD VP-Member Services Scott Benninghoven, MD VP-Professional Conduct Eleanor Martinez, MD Secretary Sameer Awsare, MD Treasurer James Crotty, MD

James G. Hinsdale, MD

El Camino Hospital of Los Gatos: Art Basham, MD El Camino Hospital: Lynn Gretkowski, MD Good Samaritan Hospital: Jeff Kaplan, MD Kaiser Foundation Hospital - San Jose: Efren Rosas, MD Kaiser Permanente Hospital: Allison Schwanda, MD O’Connor Hospital: Jay Raju, MD Regional Med. Center of San Jose: Emiro Burbano, MD Saint Louise Regional Hospital: John Huang, MD Stanford Hospital & Clinics: Peter Cassini, MD Santa Clara Valley Medical Center: John Siegel, MD

Tanya W. Spirtos, MD (Alternate)

SCCMA/CMA Delegation Chair James Crotty, MD (District VII)

CMA Trustees - SCCMA Martin L. Fishman, MD (District VII) Susan R. Hansen, MD (Solo/Small Group Physician) James G. Hinsdale, MD (President) Randal Pham, MD (Ethnic Member Organization Societies) James Crotty, MD (District VII)

Chief Executive Officer William C. Parrish, Jr.

BULLETIN THE

Official magazine of the Santa Clara County Medical Association and the Monterey County Medical Society

Printed in U.S.A.

Editor

Joseph S. Andresen, MD

Managing Editor Pam Jensen

Opinions expressed by authors are their own, and not necessarily those of The Bulletin or the Santa Clara County Medical Association and the Monterey County Medical Society. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by the Santa Clara County Medical Association or the Monterey County Medical Society of products or services advertised. Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 pjensen@sccma.org © Copyright 2009 by the Santa Clara County Medical Association.

THE MONTEREY COUNTY MEDICAL SOCIETY OFFICERS President John Jameson, MD President-Elect James Ramseur, MD Past President William Khieu, MD, MBA Secretary Eliot Light, MD Treasurer John Clark, MD

CHIEF EXECUTIVE OFFICER William C. Parrish, Jr.

DIRECTORS Paul Anderson, MD

Patricia Ruckle, MD

Valerie Barnes, MD

Scott Schneiderman, DO

Ronald Fuerstner, MD

Kurt Sliger, MD

David Holley, MD

Steven Vetter, MD

R. Kurt Lofgren, MD

CMA TRUSTEE – MCMS Valerie Barnes, MD

PAGE 4 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

For Physicians Only

In every medical community, there are those rare physicians, who after many years of practice, have been singled out to exist in a class of their own. These physicians often take care of the most distinguished and high profile people in their communities. These are the doctors whom MD2 will pursue as we open new offices in select cities.

Chicago

—

San Francisco

—

Seattle

—

Portland

—

Bellevue

If you are such a physician, with a primary care practice in the community surrounding Stanford, we would like to hear from you.

Palo Alto

FROM THE EDITOR’S DESK

ENVIRONMENTAL ISSUE By Joseph Andresen, MD It’s hard to believe. It seems that summer has come and gone in the blink of an eye. Those long sun-soaked days, family vacations, and pleasant memories now recede as the cool and crisp mornings of fall are upon us. I would like to take this opportunity to give special recognition to Dr. Cindy Russell. I’ve known Dr. Russell for the past two decades. She is a caring and dedicated surgeon. Her commitment to her patients, family, and our community is boundless. I will never forget the evening that our three-year-old son fell in the bathtub and had a deep cut over his eye, just before my wife and I planned to leave for the theater. Within minutes of my phone call, Dr. Russell was at our front door, then reassuring David as she put a stitch in his wound while he lay quietly on our family room couch. I still can’t believe that he didn’t protest a bit, but as I said, Dr. Russell is a pretty special doctor. Dr. Russell has had a longstanding interest in the environment and giving back in any way that she can. She is currently the Vice-President of Community Health, Chair of the Environmental Health Committee, and a CMA Delegate with the Santa Clara County Medical Association. This month’s issue highlights her contributions in a series of articles that we all will find informative, concerning, and, hopefully, moved to take action. What sustains you? How can we best motivate ourselves and others to improve our community and environment? Where is the largest incidence of workrelated asthma in the United States? If you guessed hospitals, you are correct!

How best to handle and reduce red bag waste? What are the consequences of pharmaceutical waste? Why shop with EPEAT? What are some of the new cleaning strategies that are effective and less toxic? Dr. Russell’s article “Creating a Healthier and Greener Medical Office: Saving Green by Going Green,” presents a cogent and convincing discussion of these topics. Joel Kreisberg, DC, MA, founder of the Teleosis Institute, is a wellrespected authority on the environment and medicine. In his articles, “The 4 Ts: Assessing Exposure to Multiple Chemicals” and “Green Pharmacy: Preventing Pollution,” we recognize the importance of production, proper handling, and disposal of medications to reduce undesired consequences in our environment. Any discussion of our changing environment and health issues would not be complete without the topic of cell phones and Wi-Fi. Of course, we must understand the current RF-EMF (Radio FrequencyElectromagnetic Frequency) standards and what they do not measure. Sunlight is something to which we all can relate. It is a natural form of electromagnetic radiation observed since the beginning of human existence. Humans produced microwaves and radio waves for the first time in 1886. What have we learned from the Bioinitiative Report? What is the latest on the safety of cell phone use, especially for those under the age of 20? What do we know about cellular function, risk of tumors, the immune system, the bloodbrain barrier, DNA, memory effects, neurological symptoms, and EMF?

Joseph Andresen, MD is the editor of The Bulletin. He is board certified in anesthesiology and is currently practicing in the Santa Clara valley area. Do you know your cell phone’s SAR (Specific Absorption Rate) level? What do Switzerland, Italy, and Russia have in common? All have imposed much lower RF limits than the U.S. The EU has adopted the “Precautionary Principle:” “When there are indications of possible adverse effects, though they remain uncertain, the risks from doing nothing may be far greater than the risks of taking action to control these exposures.” Should we do the same? How do we advise our patients? These are all important questions. Thanks to Dr. Russell’s very comprehensive article, “Why Fi: Is Wireless Communication Hazardous to Your Health?” we can discuss and answer many of the questions raised above. We now have a much better understanding of the potential risks of the electronic conveniences of our daily lives and a strategy to live with them. As I sit here with my laptop, typing this column, sitting a few feet from my Internet router with my cell phone in my pocket, I now realize that we all should have a renewed respect and awareness for our modern electronic environment. I hope you find these topics and discussions as informative and important as I have. Please share your thoughts and join us in this important dialog.

PAGE 6 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

When patients and families are coping with serious, life-limiting illness,

When someone in your family gets sick, it feels like you are going walking by yourself. But when hospice comes, you feel like somebody is guiding you and you are not alone. Thank God there’s a program like this that picks you up and helps prepare you for the journey you and your loved ones are going to take. Hospice of the Valley helps everyone prepare for that. — Carmen V. Gary Bertuccelli, social worker Pam Nates, chaplain

they require expert care, compassion and personal attention. Whether it is spending time with loved ones, fulfilling dreams, or simply remaining comfortable and independent for as long as possible, Hospice of the Valley guides patients and their families to meet their goals. • The hallmark of hospice care is that it serves patients wherever they live—be it in their home, nursing home, hospital or assisted-living facility • Hospice of the Valley team members consist of physicians, nurses, social workers, chaplains, hospice aides, volunteers, and grief counselors who are experts in palliative and hospice care and are available to assist in the management of your patient’s needs Margarita Vizcaya, hospice aide

Jeanne Fabricius, RN, case manager

• For those dealing with grief and loss, the Community Grief and Counseling Center at Hospice of the Valley provides families and individuals with one-on-one counseling and loss-specific support groups to adults, teens and children • Since 1979, Hospice of the Valley‘s legacy of compassionate palliative and hospice care, community education, advocacy and outreach has set the standard for quality hospice care state wide and nationally, and our organization is a locally-based, operated, and supported non-profit organization Monique Kuo, MD, medical director

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SPECIAL: ENVIRONMENT AND MEDICINE

Creating a Healthier and Greener Medical Office: Saving Green by Going Green By Cindy Russell, MD VP of Community Health, SCCMA

Think Global and Green Local: Graceful Greening

Below is a summary of the valuable information and resources gleaned from the recent “Greening Your Medical Office” June 2010 seminar, co-sponsored by Stanford, SCCMA, and Palo Alto’s Community Environmental Action Partnership. You will find out where to recycle electronics, how to have a free energy audit, how to get a free low flush toilet in your office or home, and much more! Visit the Going Green section of the SCCMA website for continued updates.

Gracefully greening your medical office may not seem easy, but Dr. Joel Kreisberg, founder of Teleosis Institute in Berkeley, is a local and national leader in this field. Motivation is what he feels is the primary element. Beyond that, his leadership seminars have you use checklists to glide through the options of energy conservation, environmentallypreferable purchasing, green pharmacy program, and waste minimization. The Institute produces a beautiful quarterly journal packed with useful information and inspiring articles.

What Sustains You? Trick question. What’s the first step to greening your office? Answer— Knowing why you are doing it. In a presentation at the “How to Green Your Medical Practice” seminar, on June 1, Dr. Kreisberg, founder of the Teleosis Institute, had us pair up and ask each other four times “What sustains you?” We found out it was the same things—our family, our community, a fulfilling job, and nature. Creating a shared vision of caring and stewardship in your office, by sitting in a circle and bringing each of your staff into this, is the foundation. Bring yourselves into the process. Your Green Team will sprout and grow, as you foster this connection by a common concern for all that you care about. The interesting thing is that you can actually save money doing it. Conservation pays!!!

Dr. Kreisberg’s approach is holistic and effective. Any physician can join his organization and take advantage of the courses and resources he has to offer locally. They even have an online leadership course in sustainable medicine, which is approved for 40 units of CME! Check out their excellent website at www. Teleosis.org. The Florida Medical Association recently launched its My Green Doctor Office Program as well, that can help guide any doctor’s office to improve its energy and environmental practices (www. mygreendoctor.org).

Are You Creating Asthma in Your Office? Dr. George Tingwald is a rare professional who is both an architect and

Cindy Russell, MD is the Vice-President of Community Health, Chair of the Environmental Health Committee, and a CMA Delegate with the Santa Clara County Medical Association. She is board certified in Plastic Surgery and is currently practicing with the Palo Alto Medical Foundation Group. physician. He planned the California Pacific Medical Center’s five-campus master plan in San Francisco and is director of medical planning for Stanford Medical Center’s Renewal Project. He is also chief consultant for the upcoming PBS documentary “The Greening of Medicine and Healthcare.” He pointed out that hospitals are not healthy places to work. He stated that health care is responsible for the largest incidence of work-related asthma in the United States. Hospitals alone account for 63% of work-related asthma in the health care industry. Unbelievable, but true. This is due to exposure to latex, cleaning products with sensitizing chemicals, air fresheners, formaldehyde in carpet and furniture, as well as other chemicals causing poor indoor air quality. Displacement ventilation is the new mantra for healthy indoor air in hospitals and he plans to use it in the new Stanford Hospital. For the PBS documentary, Dr. Tingwald has gathered an “A list” group of “Green Action” health care professionals,

PAGE 8 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

including Gary Cohen of Health Care Without Harm, Debra Levin from the Center for Health Design, Robin Guenther of Sustainable Healthcare Architecture, Mary Pittman from the Public Health Institute, Kathy Gerwig from Kaiser Permanente’s Workplace Safety and Environmental Stewardship Program, and Dr. Richard Jackson, formerly with the CDC and now at UCLA’s School of Public Health. Dr. Tingwald concluded his excellent presentation saying “Trying to save the planet, while poisoning the environment, doesn’t make any sense!” Look for the upcoming special on PBS next year.

Medical Waste Reduction: Waste Not, Want Not Hospitals are the third largest source of waste in the nation and discard about two million tons of medical waste per year, according to Health Care Without Harm. About half are now recycling at least some medical waste. Some hospitals are using reprocessed surgical instruments that are, in many cases, better than new and save money. Reprocessing and remanufacturing programs from Ascent Healthcare Solutions have saved its hospitals more than $82 million in supply chain costs during the first half of 2009. In a throw away economy, we are not fully aware that our common trash can is part of our environment (air, soil, and water) that we depend upon for our own health and well-being. As you know, with many synthetic products, there is no such thing as “throwing it away.” Many of these synthetic chemicals enter a cycle of pollution. Products that are manufactured with toxic chemicals are then disposed of in a landfill with a toxic legacy of groundwater pollution and soil contamination. The oceans are filled with plastic waste (mostly from land-based trash), which eventually breaks down into small particles that

“feed” the bottom of the food chain. Pollution prevention is the key! Jack McGurk, former long-term chief of the Environmental Management Branch of the California Department of Health Services, is a hero of waste reduction for health care. He played a key role in the California Waste Management Act and developed and led a pollution prevention project with California hospitals to reduce solid waste. The mercury reduction program was overwhelmingly successful with a 95% reduction in mercury products in hospitals. The new concern is Red Bag Waste, which costs hospitals and private physicians a lot of money for disposal. The problem is two-fold. One, there have been violations where needles, liquid body fluids in tubing, and bloodsoaked gauze were found in the municipal trash and cost the hospitals thousands of dollars in fines and also limited options for disposal for the violator. The second is an overinterpretation of the Medical Waste Reduction Act that causes much more regular trash to be put in the red bags, thus costing more.

What Is Red Bag Waste? Stanford Hospital has solved the problem of red bag waste by sterilizing and treating all hospital garbage other than recycled items and compost, thus rendering it safe for municipal garbage. Needles are placed in Daniels reusable needle containers, which are dumped, then returned, saving thousands of pounds of waste. Biohazard red bag waste includes fluid blood, heavily blood-saturated items, bags and IV tubing containing blood products, suction canisters, hemovacs, chest drainage units, and hemodialysis products. What doesn’t go in the red bag is garbage, sharps, pathology specimens, hazardous waste, and medication. A tip to reduce waste is to put the red bag container in a location away from regular trash to

How to Reduce Pharmaceutical Waste •

Prescribe less

•

Decline pharmaceutical samples

•

Encourage companies to give patients drug vouchers instead of samples

•

Encourage pharmacy take-back programs to patients

•

Put pharmaceuticals in hazardous waste for incineration

discourage regular garbage from going in it. Lightly saturated gauze and other dressings can go in the regular trash.

What We Pour Down the Sink, We Eventually Drink Pharmaceutical waste has become a huge issue, Mr. McGurk states, as we are now finding hundreds of pharmaceuticals in our drinking water, including antidepressants, birth control pills, antibiotics, and chemotherapy agents. They find their way into the water by inappropriate disposal of unused medications in landfills or flushed down the toilet. Another pathway is municipal sewage placed on agricultural fields, which contains unmetabolized medications excreted in the urine and feces of people. The sludge also contains personal care products and antimicrobials we commonly use containing endocrine disrupting chemicals, which have been found to adversely affect aquatic animals. The solution is multifold and includes: 1) prescribing less medication to patients; 2) removing or reducing pharmaceutical samples in our offices; 3) having widespread pharmacy take-back programs in which hopefully all pharmacies would

PAGE 9 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

Continued on page 10

Creating a Healthier and Greener Medical Office, from page 9 eventually participate; and 4) incinerate pharmaceuticals as hazardous waste.

Greenwaste Recycling Instead of throwing away your recyclables at the office, some doctors are taking the small amount of bottles and cans from the office and bringing them to their house once a week, putting them in their own recycle bins. Marc Green of Greenwaste, the waste collection for many cities in the area, agrees that is a good idea. Greenwaste has a successful model to sort and divert about 90% of the waste from the landfill. They use a covered compost program for food and yard waste as well. They are working hard in Palo Alto with the Zero Waste Program and are now taking blue wrap around sterilized instruments.

Water Water Everywhere: Save Water and Get a Rebate! Water is the 21st century gold and it won’t get any cheaper. Karen Morvay, from the Santa Clara Valley Water District (SCVWD), encourages every business and resident to get a free water audit from them. Water conservation is just one of many programs the SCVWD has to offer. They provide great ideas to cut back on water usage and have rebate programs for energy efficient washers and also have free high efficiency toilets! Worth looking into! For information, call 408/4966965 and talk to the folks at Water Wise Consulting, who contracts for them. You can also visit www.valleywater.org.

Right Lights Program: Don’t Kilowatt—Save a Watt! New lighting upgrades for your business can save money and energy for

years to come. Jay Melena, from the Right Lights Program, highlighted options including new thinner tubular fluorescents that are more energy efficient, but fit in the same older fixtures. They pay for themselves in two years. Occupancy sensors are another great way to save money in areas of low use. They now offer “daylighting” sensors to turn lights on or off in response to natural lighting in high use areas. The Right Lights Program offers free audits! They serve all businesses, regardless of size, and will walk through your office with you to help you customize your program. Stanford Medical Center saved about 40,000 kilowatts and $5,000 per year after the audit. Skinspirit, a smaller venture in Palo Alto, saved about 11,000 kilowatts per year. For information, contact Ecology Action, a nonprofit group that sponsors the program, at www. RightLights.org.

E-Waste: The Fastest Growing Waste Stream

are heavily exposed to the toxins, while poisoning the air, land, and water. It is piling up fast! Of the three million tons of E-Waste discarded in 2007, only 13% was recycled. Reputable recyclers are hard to find, and Judy Levin of the Center for Health and the Environment www. ceh.org made us aware of several places to properly recycle your E-Waste. They have an E-Steward Program that certifies recyclers who do not export overseas, do not send E-Waste to prisons, and who do not release private information and data from computers. Beware, not all recyclers recycle—they may just be collectors!

Where to Recycle Your E-Waste If we gathered all the E-Waste in the U.S., it would form a 22-story pile that covers an area the size of Los Angeles (470 square miles)! In our area, there are several companies that are E-Steward certified. •

Green Citizen is one and they have three locations: San Francisco, Palo Alto (next to Whole Foods), and Burlingame (www.GreenCitizen.com).

Did you know that it takes a rhinoceros’s weight of raw materials (1.8 tons) to make your computer? That means each time you buy another computer, another 1.8 tons of materials are mined from the earth. The average computer is junked after just two years. The average cell phone lasts only 18 months. When the cell phone, computer, television, or other electronic equipment is put in the landfill, lots of harmful chemicals leach out into the landfill and into our water. Computers are especially toxic, containing cadmium, lead, and mercury.

•

ECS Refining, LLC/United Data Tech Distributors in Santa Clara (www.UnitedDatatech.com).

•

For others, visit the E-Steward website at http://www. electronicstakeback.com/recycling/ find_a_responsible_recycler.htm.

These electronic devices are not designed with recycling in mind and most find their way to India, Africa, and China, where low-wage earners, including children, break apart the devices and

It is always more sustainable to upgrade and add memory to your old computer, but when you must buy a new computer, EPEAT can help you evaluate a product with high environmental standards

Buying Greener Electronic Gadgets: Shop With EPEAT

PAGE 10 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

in mind. EPEAT is a program of the Green Electronics Council and they look at a variety of criteria including: •

Intentional elimination of lead, mercury and cadmium, and other

•

harmful materials

•

Use of post-consumer plastic

•

Design for end-of-life recycling

•

Longevity and upgrade ability (instead of planned obsolescence)

•

Energy conservation

•

Packaging

•

Corporate environmental responsibility

You can visit their website at www.EPEAT.net.

Greener Cleaning Products Unfortunately, green cleaning is a difficult problem for medical offices. Products that disinfect have toxic properties and contribute to asthma, chemical sensitivities, and other health problems. Quaternary compounds are one such common chemical used as an antimicrobial, but it does do the job of cleaning. We do need to remove harmful bacteria, such as MRSA, and viruses with surface cleaning. Research is now being focused on greener cleaners including just very dilute bleach. Krisanne Hanson, project director in the General Services Division at Stanford University Medical Center, says hospitals such as Stanford have an Environmentally Preferable Purchasing Program (EPP). Safer products can be used that are fragrance free. Metal-free floor products are important (high gloss has its environmental price). The best option is no floor wax! If you are buying cleaning products for your medical office, look for the GREEN SEAL or ECO LOGO certification. They are “greener” than others.

Microfiber cloth is an extremely effective cleaning material. It holds up to seven times its weight in water, absorbs oils, is non-abrasive, and does not leave lint or dust. According to tests, the microfibers remove 99% of bacteria, whereby normal cloth reduces bacteria by 33%. Microfiber cannot be used on high-tech coated surfaces as it does accumulate dust that can be transferred. Microfiber must be washed in regular washing detergent without fabric softeners or oils, as these clog the fibers. They are a synthetic material and are not biodegradable, but they are reusable. The most common use in offices is for mops and cleaning rags. Ms. Hanson pointed out it is important to know your cleaning contractors, so you can help them choose safer products. A good janitor is your primary method of choice to incorporate Integrated Pest Management to reduce or eliminate pesticides in your office. Your office staff can help with good housekeeping. Keeping food in the refrigerator, and sealing cracks and crevices or other openings for bugs is key. Stanford has an excellent environmental program led by Ms. Hanson. They recently won an Environmental Excellence Award at the Clean Med Conference in Baltimore. The Clean Med Conference brings together hospitals, nonprofits, and businesses interested in greening medicine. Next year, it will be in Phoenix, Arizona on April 6-8. If you are interested, visit http://www.cleanmed.org/. It is inspiring to know that there is a growing effort in many areas to transform medicine toward a more sustainable path. We can all be part of the change.

References/Greening Resources 1. Work Related Asthma Among Healthcare Workers, Pechter et al. http://www.cdph.ca.gov/programs/ ohsep/Documents/hcw.pdf 2.

Kaiser Greening Efforts. http://xnet. kp.org/newscenter/opexcellence/2009/0 22609kathygerwig.html

3. Teleosis: Health Professionals in Service of the Global Environment WWW.Teleosis.org 4.

Medical Waste regulation

Red Bag information- http://www. calrecycle.ca.gov/ReduceWaste/ Business/posters/redbag.htm

6. www.Greenwaste.com 7. www.RightLights.org 8. To find a reputable E-Waste Recycler http://www.electronicstakeback.com/ recycling/find_a_responsible_recycler. htm 9.

More sustainably manufactured electronics WWW.EPEAT.net

10. WWW.CleanMed.org 11. City of Los AngelesDept of public works, Bureau of Sanitation http:// www.ci.la.ca.us/san/solid_resources/ pdfs/medicalwastereduction.pdf 12. http://www.cleanmed.org Annual Conference 13. http://www.noharm.org Health Care Without Harm 14. http://www.healthandenvironment. org Collaborative on Health and Environment 15. http://green.harvard.edu/green-office Harvard’s Green Office Program 16. www.mygreendoctor.org Florida Medical Association Green Doctor Program

PAGE 11 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

SPECIAL: ENVIRONMENT AND MEDICINE

Medical Waste, the Truth Be Told By Ben Ottmar Monterey Sanitary Supply Certified Medical Waste Hauler What is the definition of medical waste? What are the rules and regulations in regards to medical waste? Who can pick up medical waste and how is it treated? Good questions of which some physicians are just unclear. In 1988, the federal government passed the Medical Waste Tracking Act, which set the standards for governmental regulation of medical waste. After the Act was repealed in 1991, states were given the responsibility to regulate and pass laws concerning the disposal of medical waste. All 52 states vary in their regulations, from no regulations to very strict. How is medical waste defined? Interestingly enough, according to the Health Care Environmental Resource Center, the federal government does not require a standard definition for regulated medical waste. However, according to the California Medical Waste Management Act (CMWMA) of 1991, medical waste is defined as “solid waste generated or produced in the diagnosis, treatment, or immunization of human beings or animals. It also includes waste generated in any associated research, in the production or testing of biologicals (medicinal preparations made from living organisms and their products), any trauma scene waste (including waste removed from the actual scene), or any accumulation of home-generated sharps waste. Additionally, the definition of medical waste includes materials such as discarded surgical gloves, discarded surgical instruments, blood-

soaked bandages, culture dishes, used glassware, discarded needles used to give immunizations or draw blood (medical sharps), and removed body organs.” Regulated medical waste breaks down into six categories. Liquid medical waste includes blood and blood products. Organs and body parts fall under pathological and anatomical waste tissues. Microbial waste comes from laboratories and mainly includes cultures and stocks of infectious agents. Contaminated animal carcasses, body parts, and bedding is the category for biological materials that originate from test animals. The sharps category includes syringes, broken glass, and needles. The broadest category is isolation waste—biological waste and materials contaminated with viruses or other pathogens. Such waste is isolated to protect others from highly communicable diseases. This category makes up the majority of medical waste discarded at small quantity generator facilities. Additionally, medical facilities produce a variety of waste hazardous chemicals, including radioactive materials. While such wastes are normally not infectious, they may be classified as hazardous wastes, and require proper disposal. Some physicians in California are unclear of the rules and regulations regarding the waste they generate. The CMWMA states in Chapter 9, Section 118280, that any generator of medical waste that produces 20 pounds or more of biohazardous (red bag) waste in a month is required to be serviced (picked up for treatment) by a certified hazardous waste hauler every seven days. For a doctor who generates 20 pounds or less of red bag

waste in a month, service is required every 30 days by a certified hazardous waste hauler. For sharps waste, the law can be misinterpreted. All sharps should be placed in a certified sharps container. Once that container is three-quarters full, or to the fill line, the lid should be properly closed and the container should then be labeled “sharps” or “biohazard.” The generator has thirty days, once the lid is shut, to have that container properly disposed. There are a few different methods for treating medical waste. The most common method of sterilization is an autoclave. The autoclave uses steam and pressure to sterilize the waste. The preferred method for body parts is incineration. In California, incineration of hazardous waste is against the law. Therefore, all incinerable waste in California needs to be transported to other states, like Utah or Texas, where incineration is legal. Only certified hazardous waste haulers can pick up medical waste. These haulers must have valid hauler registration licenses/permits with the state in which they are transporting. A list of hazardous waste haulers in California can be found by contacting the California Department of Public Health at www.cdph.ca.gov. A physician or health care facility may significantly reduce its environmental strain and economic costs by reducing the amount of regulated medical waste it produces. This is mainly achieved through proper identification of regulated medical waste and by keeping solid waste from entering the regulated waste stream. Training medical staff to clearly

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identify and consciously be aware of what is entering the regulated waste stream seems to be the most effective way to reduce the amount of regulated waste produced by hospitals, physicians, and veterinarians.

educating staff, administrators, and the local community about the dangers of contaminated medical waste and by instituting lowcost, safe medical waste disposal practices, all health facilities can minimize the risks associated with waste disposal.

Improper medical waste disposal is one of the greatest threats to members of the community. For example, contaminated medical waste can be found by children who are playing and cause them injury and infection. In many low-resource settings, scavenging of medical waste is a significant problem. Not only are scavengers at risk of injury and infection themselves, but this practice can also put clients and the local community at risk when scavenged waste, such as syringes and needles, is reused. By

Monterey Sanitary Supply Inc. was founded in 1952 and was purchased by the current owners in 1973. The company specializes in sanitary, facility, and stationary supplies. They have also recently been granted certification to haul medical waste as another service to offer tricounty area clientele. With the continued delivery of genuine service and quality products, Monterey Sanitary Supply offers a business relationship that is simple and amiable. For more information, visit their website at www.montereysanitary.com or call Ben Ottmar at 831/601-1370.

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PAGE 13 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

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SPECIAL: ENVIRONMENT AND MEDICINE

Keep the Oil in the Soil Climate Change Update a lower CO2 with a new goal of 350ppm. Converting to a renewable sustainable energy system would improve the economy and provide national security.

By Cindy Russell, MD VP Community Health, SCCMA Chair, SCCMA Environmental Health Committee Is global warming a hoax? Increasing numbers of the public think so, due to a few who have put welcomed doubt into the minds of many. All legitimate climate scientists, however, agree that climate change is real and is caused by humans burning fossil fuel. In addition, it is happening faster than the models predicted. The earth has warmed dramatically in the last 30 years. This will not only have economic, agricultural, and weather impacts, but there will also be threats to public health due to increasing heat-related illnesses and spreading of infectious diseases. We are forcing changes in the system that we don’t fully understand. This makes some of the large-scale geotechnical solutions difficult to support as there is even less understanding of the serious and rapid planetary changes they could create. Geoengineering proposals, such as iron fertilization of the ocean, cloud seeding, space mirrors, and artificial trees, are energy intensive, expensive, untested, and a distraction from quicker and safer means to combat this issue. When there is a glitch with these massive experiments on nature, unlike a computer, there is no reboot option. The careful and prudent thing to do is to reduce emissions by reducing fossil fuel consumption, keeping the oil in the soil, the coal in the hole, and the tar sands in the land. This would give the atmosphere a chance to equilibrate to

Economy and Environment Governments have stopped denying global warming, and are now talking about how to adapt to it as sea levels rise and the weather is changing. Businesses are even beginning to change policy to reduce their CO2 footprint, understanding that if there is no planet, there is no economy in which to have a business. According to Nobel laureate Chris Fields, an expert on global warming, “a number of government, business, and independent organizations have analyzed the projected costs of these proposals, using widely accepted economic forecasting tools and techniques. The results indicate strongly that such costs are well within manageable bounds, both from a macroeconomic perspective and in terms of impacts on individual consumers. Substantial greenhouse gas emissions can be achieved in the immediate or near term using technology that is here today.” (Climate Change for Policymakers and Business Leaders) This is an update on global climate change. It is the biggest environmental challenge we face. There is no silver bullet to solve this problem. It is up to each of us.

Six Degrees: Our Future on a Hotter Planet The Intergovernmental Panel on Climate Change (IPCC ) and other independent researchers predict, by the year 2100, we will have anywhere from 1.1 to 6.4 Celsius degrees of warming. This is based on solid atmospheric physics and an immense data base. Mark Lynes, in his well researched and referenced book “Six Degrees: Our Future on a Hotter Planet,” graphically describes how we will be impacted by seemingly small changes in global temperature. The earth truly is a fragile planet. At one degree Celsius, we will begin to see droughts. At two degrees Celsius, Greenland’s ice sheet will melt and this will raise sea levels about seven meters. Three degrees is the “tipping point” where global warming negative feedback loops operate and humans have little control. At four degrees, the Western Antarctic ice sheet will melt and polar bears and all ice dependent species will be extinct. At five degrees, the water temperature will be such

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that there will be no ice on either pole and there will be mass extinction in the oceans. At six Celsius degrees, the planet will be uninhabitable. The goal for governments and scientists is to stay below two degrees Celsius increase or we will lose our options.

We Have Already Warmed One Degree According to NASA data and the 2008 IPCC report, over time, the average global temperature is up about 0.74 degrees Celsius. Human activity appears to be the culprit. In the carbon cycle, modern volcanic activity releases only 130 to 230 megatonnes of carbon dioxide each year, which is less than 1% of the amount released by human activities.

800,000 Years Beyond Our CO2 Limit Latest figures show that our atmosphere currently has about 392ppm CO2, well above our 350ppm goal. This is the highest it has been for at least 800,000 years according to recent carbon dated ice core samples. Atmospheric carbon dioxide concentration has varied between 180-to210ppm during ice ages, increasing to 280 to 300 ppm during warmer intergalatial periods. Humans have enjoyed modern agriculture due to this approximately 280ppm CO2 level for the last 12,000 years. It was warm enough to allow us to grow grain in melted fertile valleys, yet cold enough to keep the glaciers frozen, but trickling out water for farms and forests. 280ppm has been good to us humans, but since the industrial revolution 200 years ago, we are now beyond our limit. Levels of CO2, however, continue to rise 2ppm annually, according to the NOAA, and largely due to human activity.

Natural CO2 Sinks Filling Up Natural CO2 sources in the past were balanced by natural sinks such as the ocean or plant growth. Burning fossil fuels, such as coal and petroleum, puts 22 million tons of CO2 in the oceans every day. Fuel combustion is the leading cause of increased anthropogenic CO2 and deforestation is the second major cause, according to the experts. Population expansion and increasing consumption drive this. Humans are filling up, cutting down, and burning down our CO2 sinks fairly quickly.

350ppm CO2 in the Atmosphere Is the Number Rajendra Pachauri, the U.N.â€™s top climate scientist for the International Intergovernmental Panel on Climate Change, in 2009 stated, after extensive research, that 350ppm CO2 was the upper limit and the bottom line for the stability of the planet. Prior to that in 2007, scientists said that 450ppm would be the number we should aim towards. Then the Arctic melted and new evidence, including ice core CO2 samples, demonstrated that indeed 350ppm is our goal. Doing so will require the United States to cut its greenhouse gas emissions to 40% to 80% below 1990 levels by 2020. Above that level, average global temperatures are likely to increase by more than two degrees Celsius (3.6 degrees Fahrenheit) by the end of the century. This is a threshold that more than 100 leaders in Copenhagen, including the G8 leading industrialized nations, agree must not be reached.

Copenhagen or Bust: A Lot of Heat, But No Light Worldwide efforts have been attempted to curb CO2 emissions. What did they accomplish in the latest international effort to curb global warming at the Climate Conference in Copenhagen December 2009? Unfortunately, not much. The United Nations called for this meeting to form an agreement about how much reduction countries should aim toward and develop systems to make that happen. A weak non-binding Copenhagen Accord was drafted by the U.S., China, India, Brazil, and South Africa, but not adopted. Countries varied wildly in their ambition to reduce climate change. Pledges were made by many. The best was Costa Rica, which pledged to become climate neutral by 2021. The European Union was strong on its pledge to reduce emissions 20% to 30% of 1990 levels by 2020, while the United States pledged a 4% reduction. Canada was a little less ambitious than the U.S. at 3% and Brazil pledged that they may range from a 1.8% reduction to a 5% gain in CO2. Significantly more reductions in CO2 are needed. There are sadly still political and economic realities of climate change that make discord more likely than accord. Human reality, however, differs significantly from planetary reality. Letâ€™s look at the numbers. Continued on page 16

Keep the Oil in the Soil, from page 15 What Does the World Look Like With the Current Copenhagen Pledges? Well… 3.9 degrees Celsius hotter by 2100. A group of scientists at MIT and other universities have developed a Climate Interactive Scorecard to determine CO2 levels in the future. Inputting the pledges at the Copenhagen Climate Conference, they predict a 3.9C rise in temperature. If they base this on “potential commitments,” this would be 2.9C degrees. This of course would be above the two degrees Celsius limit increase and bad news for our food supply, weather patterns, and species extinction.

Evidence of Climate Change in Nature We don’t need climate modeling anymore to tell us something is amiss. The evidence is right in front of us. Changes have been seen, from dying coral reefs to shifting species habitats to our new Arctic Passage. The effects of global warming are “accelerating at a pace that goes beyond the scenarios and models we’ve been using.” — Achim Steiner, UNEP Executive Director, October 2007

endangering the entire ocean food chain. In April 2010, long-time oyster farmers from the Pacific Northwest experienced death of all their oyster larvae. With help from scientists at the University of Oregon, they found the problem was due to the acidified seawater pumped into their hatchery in Tilamook, Oregon, preventing calcification of the shells. Oceans are already suffering a 90% decline in fish from the sea due to overfishing.

Spring Has Sprung An extensive review article in Nature January 2003 demonstrated that seasons are shifting due to climate change. “These analyses reveal a consistent temperature-related shift, or ‘fingerprint,’ in species ranging from molluscs to mammals, and from grasses to trees. Indeed, more than 80% of the species that show changes are shifting in the direction expected on the basis of known physiological constraints of species. Consequently, the balance of evidence from these studies strongly suggests that a significant impact of global warming is already discernable in animal and plant populations.” This is evident in the Bark Beetle invasion in pines, in North America, which is decimating forests.

Oceans Away! Oceans have absorbed large amounts of CO2, creating acidification of the seawater. Since the industrial revolution, the ocean’s acidity has increased by 30%. The increased acidity destroys coral reefs, dissolves shells, and prevents reproduction. The entire food chain is disrupted. There is growing alarm that harm has already been done and that in 20 years or less at the current rate of emissions, we will profoundly affect everything from crabs to coral,

Are You Having a Meltdown? The massive ice sheets in Greenland and Antarctica are shrinking. The almost complete disappearance of the Canadian ice shelves on Ellesmere Island are well-documented changes. As the frozen tundra melts, methane, a potent greenhouse gas, which was trapped below, is now escaping into the atmosphere. Glaciers are rapidly retreating. The most dramatic example of glacier retreat is the

loss of large sections of the Larsen Ice Shelf on the Antarctic Peninsula. In a 35-day period beginning on January 31, 2002, about 3,250 km2 (1,250 sq mi) of shelf area disintegrated. 80% of Bolivia’s glaciers will be gone by 2015. Unfortunately, this means no water for the inhabitants below.

Rapid CO2 Emissions Reductions Needed Although the urgency of climate change is not as obvious to us as a fire or a cardiac arrest, if we don’t leap into action, the changes soon will be irreversible. The rate of increase in CO2 has gone up exponentially in the last 30 years. Carbon dioxide has an atmospheric lifetime of 50 to 200 years before it is absorbed by a sink or is involved in another chemical reaction. The carbon we emit today will continue to accumulate for a long time. Scientists are now saying we need more stringent commitments on the order of 80% reduction in CO2. The National Academy of Sciences released on May 19, 2010 a series of reports that emphasized the urgency of climate change and why the U.S. should act now to reduce emissions of heat-trapping gases. One central point was this: “The longer the nation waits to begin reducing emissions, the harder and more expensive it will likely be to reach any given emissions target.”

Be Part of the Solution Global warming is upon us. We are all in this boat together. We have a common destiny. To get back down to 350ppm and keep the oil in the soil, it will take working together to change our behavior, habits, and ultimately our culture. We have to get smaller, more local,

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and less centralized. As Bill McKibben writes in his book “Eaarth: Making a life on a tough new planet,” we need to “focus not on growth, but on maintenance, on a controlled decline from the perilous heights to which we have climbed.” We have to stop accumulating and expanding, and begin communicating and creating sustainable communities on a walk in our neighborhoods or through the Internet. Bill McKibben, who wrote the first book for general audiences on climate change, did the latter when he formed the 350.org organization. It is a global work party and call to action inspiring others to work together in their communities, taking steps large and small for the planet. This year’s timeline is October 10, 2010. Prepare to take action if you like. I find his website hopeful. You really can make a difference.

References 1. Chemical & Engineering News: Latest News - Ice Core Record Extended http://pubs.acs.org/cen/news/83/ i48/8348notw1.html 2. Gerlach, T.M., 1992, Present-day CO2 emissions from volcanoes: Eos, Transactions, American Geophysical Union, Vol. 72, No. 23, June 4, 1991, pp. 249, and 254 – 255 3. Oregon Oyster farm affected by acidification http://abcnews.go.com/ GMA/Eco/ocean-acidificationhits-northwest-oyster-farms/ story?id=10425738 4. 2007 IPCC Report Summary http:// www.ipcc.ch/pdf/assessmentreport/ar4/syr/ar4_syr_spm.pdf 5. http://www.ncdc.noaa.gov/oa/ climate/globalwarming.html#q3 6. http://www.letsactnow.org/HowUrgent/

7. http://www.ace.mmu.ac.uk/Resources/ Teaching_Packs/Key_Stage_4/ Climate_Change/02p.html 8. http://www.ucsusa.org/global_ warming/science_and_impacts/ science/global-thermometer-stillclimbing.html 9. http://www.theecologist.org/ News/news_round_up/312138/ geoengineering_climate_solution_ or_dangerous_distraction.html 10. Climate change for Policymakers and Business Leaders - by Nobel Laureate, Christopher Field and Peter Darbee, CEO and President of PG&E Corporation http://www.pgecorp.com/ corp_responsibility/pdf/climatepaper_ final.pdf 11. Annual increase in CO2 http://www. esrl.noaa.gov/gmd/aggi/ 12. 10 Personal Solutions to Climate Change, Union of Concerned Scientists http://www.ucsusa.org/ global_warming/what_you_can_do/ ten-personal-solutions-to.html

10 Personal Solutions to Climate Change Union of Concerned Scientists 1. The car you drive is the most important personal climate decision:  When you buy your next car, look for the one with the best fuel economy in its class. Each gallon of gas you use is responsible for 25 pounds of heattrapping gases in the atmosphere. 2. Choose clean power: More than half the electricity in the United States comes from polluting coal-fired power plants. Switch to a renewable electricity company or buy a solar or wind system for your home, especially if it has a heated pool. 3. Look for Energy Star appliances. 4. Unplug an unused freezer. 5. Get a home energy audit. Acterra in Palo Alto, through their Green at Home Program, offers free inhome audits in many cities. (www.acterra.org/programs/ greenathome) 6. Lightbulbs matter: If every U.S. household changed one light bulb to compact fluorescent, it is estimated that 90 billion pounds of CO2 could be saved. 7. Think before you drive: Use a carpool or mass transit when you can. 8. Buy good wood from forests that are managed in a sustainable fashion. 9. Plant a tree. They store carbon and provide shade. 10. Let policymakers know you are concerned about global warming.

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LEGISLATIVE NEWS

Health Information Technology (HIT) Update Reprinted with permission by Alameda-Contra Costa Medical Association This is an update to help SCCMA/MCMS members navigate the process of adopting health information technology (HIT) and optimize their opportunity to obtain federal subsidies, should you choose to seek those funds:

Overall Timeline Beginning in 2011, qualifying physicians (see below) may start receiving federal subsidies for HIT usage, and have up until the end of 2012 to qualify to receive the full subsidy that is available. As described below, final rules defining the eligibility requirements have finally been promulgated and should be fully implemented in the next few months so that physicians can begin to adopt them, if desired. Physicians who adopt qualifying HIT in 2013 and beyond would have smaller amounts of federal subsidies available to them. Starting in 2015, physicians participating in the Medicare program face penalties if they have not yet implemented a qualifying EMR system. Details regarding these incentives and penalties are discussed below.

Resources/Activities From Organized Medicine •

In the next few months, we will be announcing the availability of federally-funded services designed to assist physicians with the purchase and adoption of qualified EMR systems. Included among the services that will be offered are: general education on EMR adoption and federal programs available to assist with such adoption; pre-negotiated deals with a small number of EMR vendors that include standardized purchase and support agreements; assistance with medical practice analysis to identify suitable EMR systems and develop implementation plans for the practice, and; assistance meeting federal “meaningful use” requirements (discussed below) to qualify for the federal subsidies that are offered. These services are made available as a result of CMA efforts to form an organization – the California Health Information Partnership & Services Organization (CALHIPSO) – that obtained approximately $32 million in federal stimulus funds to assist physicians with HIT adoption in California. CALHIPSO’s services are designed to assist physicians in any specialty and medical practice setting, and subsidies are specifically provided to fund these services for primary care physicians in groups of 10 or less.

•

The CMA will soon be announcing its completion of a yearlong vetting process of approximately 10 EMR systems, some of which may offer preferred pricing rates to CMA members. CMA will also offer a tool to assist physicians with EMR system selection.

•

Information on HIT adoption is available on both the SCCMA/ MCMS and CMA websites (www.sccma-mcms.org; www. cmanet.org), and educational programs will continue to be provided in the near future.

Status of Federal Activities and Subsidies to Promote HIT Adoption As previously reported, the federal stimulus legislation allocates funds to help promote HIT adoption both through programs to assist physicians with the adoption process and direct subsidies for HIT usage to physicians participating in the Medicare and/or Medicaid programs. The program to assist physicians with the adoption process will be announced in the next few months, as discussed above under “Resources From Organized Medicine.” Following is a summary of how to qualify for the subsidy for using EMR system.

Federal Financial Incentives for HIT Adoption The stimulus legislation takes a carrot and stick approach to encouraging physicians to adopt HIT. The carrot is direct subsidies for demonstrating qualified use of HIT (discussed below) as follows: of up to $44,000 to physicians who are not hospitalbased who participate in the Medicare program, and; up to $63,750 to physicians who are not hospital-based, and whose practice is comprised of at least 30% (by patient volume) of Medicaid patients (20% if they are pediatricians). If physicians qualify under both the Medicare and Medicaid programs, they will select which one to access. Physicians cannot receive incentives from both programs. “Hospital-based” physicians, for whom these incentive payments are not intended because they are expected to utilize HIT within the hospital where they practice, are defined as physicians for whom 90% of their patient encounters occur in inpatient and emergency department settings. The bonus payments may be paid out beginning in 2011 if physicians meet qualifications for IT usage at that time, and can continue up to 2016. To ensure that physicians

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receive the full amount of the subsidy available, they must qualify no later than the end of 2012, but would still be eligible for a portion of the subsidy if they qualify in 2013. The “stick” offered by this federal legislation is a 1% cut in Medicare payments starting in 2015 that increases to 3% by 2017 if physicians do not engage in qualifying HIT. There will be no financial penalties for physicians in the Medicaid program. There are two key requirements to qualify for the above described subsidies: 1) purchase an EMR system that meets federal certification requirements, and; 2) demonstrate compliance with the federal definition of “meaningful use” of the electronic medical record system (EMR). Following is the status of these requirements: EMR System Certification – In June, the federal government issued the final rule that establishes the criteria for EMR systems to qualify for federal certification and also the criteria for organizations desiring to be authorized to certify qualifying EMR systems. Over the next few months, as these certifying organizations are approved by the federal government and qualifying EMR systems receive that designation, those systems will be identified in a list maintained on the federal HIT website, located at: http://healthit.hhs.gov. Meaningful Use Requirement – The final rule defining “meaningful use” was issued on July 13. It requires physicians to meet specified measures pertaining to EMR usage and quality of care practices. An overview of the “Meaningful Use” requirement is provided below.

Meaningful Use Final Rule (Note: This summarizes a detailed description of this rule prepared by the CMA that is available in the members-only section of www.cmanet.org.) The “Meaningful Use” requirements, as they apply in varying ways to both the Medicare and Medicaid incentive programs, are implemented in stages. The rule, just recently adopted, only defines Stage 1, which physicians must meet in the first year they receive an incentive payment. A subsequent rule will define Stage 2, to take effect in 2013. The status of a Stage 3 rule is uncertain at this time. The dates by which a physician must demonstrate Stage 2 of meaningful use will depend on when they achieve Stage 1. CMA’s detailed summary of this rule lays out graphically how the stages of meaningful use correspond to provider incentive payments. Also, in both the Medi-Cal and Medicare programs, physicians can begin demonstrating meaningful use as early as January 1, 2011, and it is expected that the first incentive payments will be made in May 2011 (assuming the physician has also purchased a qualifying EMR system as discussed above). In the first year that a physician expects to achieve meaningful use, he or she must demonstrate meaningful use for any 90-day period that falls completely within that calendar year. For example, a physician

could begin demonstrating meaningful use on January 1, 2011, and finish at the beginning of April. After that first year, physicians will need to report meaningful use for the entire calendar year to qualify. For both programs, physicians will initially use self-attestation to report meaningful use, a much improved process over the initially proposed process requiring a “PQRI” type reporting process on Medicare claims. The details of the attestation process should be announced in the next few months. After the first year, the federal government expects to have an internet-based system in place for Medicare physicians to report compliance. States will have to develop similar systems for the Medi-Cal incentive program.

Medicare Incentive Program For physicians participating in the Medicare program and desiring to qualify for the Medicare subsidy (up to $44,000), the Medicare incentive program specifies the measures that physicians must report to demonstrate “meaningful use.” Compared to the proposed initial rule governing these requirements, the final rule is greatly simplified. Physicians will now have to report on fewer measures, and it offers greater flexibility in selecting measures to report. In addition, for almost all measures that are based on percentages (i.e., “50% of prescriptions transmitted electronically”), the required percentages have been reduced. Overall, a physician will have to report on 15 “objectives” to achieve meaningful use, which is broken down into reporting six quality measures and 14 other medical practice/EMR usage measures. Importantly, the final rule now allows physicians who practice in communities where health information technology infrastructure is not sufficiently developed to report compliance if they are capable to meet the measure, but cannot do so because the infrastructure is nonexistent.

Overview of Required Objectives and Measures The main set of items physicians will report are known as “objectives” and “measures.” The objectives are broad policy goals that the federal government hopes to achieve through meaningful use – such as encouraging electronic prescribing. The measures are the actual criteria that physicians will have to meet to realize that objective. The objectives and measures are broken into two parts, known as “core” objectives and “menu” objectives. The core objectives and measures are a list of 15 items on which all physicians will have to report. In addition, physicians will select five of the 10 menu items that are most relevant to their clinical specialty. The core set of objectives includes: •

Record patient demographics.

•

Record vital signs and chart changes (height, weight, blood pressure, body-mass index, growth charts for children).

PAGE 19 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

Continued on page 20

Health Information Technology Update, from page 19 •

Maintain up-to-date problem list of current and active diagnoses.

•

Maintain active medication list.

•

Maintain active medication allergy list.

•

Record smoking status for patients 13 years of age or older.

•

Provide patients with clinical summaries for each office visit.

•

On request, provide patients with an electronic copy of their health information.

•

Generate and transmit permissible prescriptions electronically.

•

Computer provider order entry (CPOE) for medication orders.

•

Implement drug-drug and drug-allergy interaction checks.

•

Implement capability to electronically exchange key clinical information among providers and patient-authorized entities.

•

Implement one clinical decision support rule and ability to track compliance with the rule.

•

Implement systems to protect privacy and security of patient data in the EHR.

•

Report clinical quality measures to CMS or states.

A complete list of the objectives and measures is available in the detailed CMA summary at the members-only section of www.cmanet.org.

Clinical Quality Measure Reporting Within the clinical quality measure objective, three of the quality measures will be “core” measures on which all physicians will have to report – adult weight screening and follow-up, hypertension: blood pressure management, and tobacco screening and cessation. If a physician feels that one of these core measures does not apply to his or her specialty, then that physician may report on one of three “alternate core” quality measures – influenza screening for patients over the age of 50, weight assessment and counseling for children and adolescents, and childhood immunization status. In addition, physicians will select three clinical quality measures from a list of 41 options. For example, physicians may choose to report on the percentage of their female patients who receive breast cancer screening or the percentage of their patients who receive proper asthma treatments. This will give physicians the flexibility to select measures that are most applicable to their practice specialty. Note that physicians who believe that a core objective or core quality measure is inapplicable to their specialty (for example, radiologists who do not see patients) will be allowed to report that and will not be held responsible for that objective. A chart of both the mandatory and optional clinical quality measures is in the CMA summary in the members-only section at www. cmanet.org.

Medi-Cal Incentive Program While the final determination of meaningful use to qualify for the Medi-Cal (Medicaid) incentive payment program will be left to the State of California, the federal rule lays out the broad guidelines for how it will work. The incentive payments for MediCal physicians will be calculated using a different methodology than the one used in Medicare. Unlike in Medicare, where the incentives are not based on cost of implementing an EHR, MediCal incentives are based on incurred cost. In the first year of the program, Medi-Cal physicians have the option to receive incentive payments for “adoption, implementation, or upgrade” of a system without having to report compliance with “meaningful use” measures. In any given year, the maximum incentive for a Medi-Cal physician will be 85% of the “net allowable average cost” (NAAC). NAAC is set at $25,000 for the first year, and $10,000 for each of the next five years. Thus, the maximum allowed incentive is 85% of $75,000, or $63,750. Physicians will be responsible for the other 15%, but can obtain that from outside sources. Also, responding to CMA-expressed concerns about making minimizing the complexity of complying with “meaningful use” requirements, the final federal rule severely limits the ability of states to implement their own definitions of “meaningful use” so that it will largely follow the definition applicable to the Medicare incentive program described above.

Assigning Incentive Payments to a Medical Practice or Clinic Any physician is allowed, at his or her own discretion, to assign their incentive payments to a medical group or clinic where they may be employed and use the group/facility’s EMR system. Note that if the physician practices in multiple locations or only on a part-time basis with a group or clinic, their incentive payment may only be designated to one location. The physician is still responsible for demonstrating meaningful use, but is allowed to qualify based on the practice/clinic’s overall patient volume rather than their individual volume. Thus, for example, if more than 30% of a clinic’s patient volume is Medi-Cal, every physician in the clinic can qualify for the Medi-Cal incentive program, regardless of their individual volume. Similarly, if a capitated medical group had 30% of its patient panel assigned by a Medi-Cal managed care plan, every physician in the group would then qualify for Medi-Cal incentives. For a full description of the “meaningful use” requirements, including a listing of all the reportable measures, go to the members-only section of www.cmanet.org. Additional updates and educational opportunities will be announced from SCCMA/MCMS and CMA in upcoming months.

PAGE 20 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

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The 4 Ts: Assessing Exposure to Multiple Chemicals BY J O E L K R E I S B E R G , D C , M A

Humans, like most life forms on Earth, are bombarded daily with multiple chemicals. Rarely are we exposed to a single, isolated chemical stressor. In analyzing the effects chemicals have on organisms, toxicologists traditionally have focused on a select number of pollutants regarded as “high volume” chemicals; but these represent only a small sample of the substances most organisms are exposed to on a regular basis. Although this type of research is valid and relevant, investigating the effects of one chemical on organisms or ecological systems may not be the best way to understand the toxic effects of multiple chemicals. Due to the large number of chemicals introduced into the environment in the 20th century, this approach does not account for many biologically transformed metabolites and other naturally occurring toxicants.

Assessing exposure

Assessing exposure to risk for multiple chemicals requires an all-inclusive systems perspective, and EPA senior scientist Christian Daughton has developed such a

to multiple

model: it outlines a way to conduct a holistic assessment of chemical exposure as it

chemicals requires an

gories are Toxicant, Totality, Tolerance, and Trajectory.1 Daughton says, “The paradigm

actually occurs in the real world. Dubbed “The 4Ts,” the model’s four primary cate-

all-inclusive systems

of the 4T’s sets the stage for the overall true risk as reflected by the sum total of

perspective.

throughout the historical multidimensional space and trajectory of all other exposure

exposure of all toxicants (anthropogenic [or created by humans] and naturally occurring) variables.”2 The categories encompass not only individual offending substances (toxicants), but the entire world of stressors (totality), the vulnerability of an organism (tolerance), and combined history of an organism's exposure (trajectory) in assessing risk.

Holistic Exposure Assessment: Toxicant, Totality, Tolerance, Trajectory In addition to exposure to chemicals, multiple nonchemical stressors—physical, biological, and psychological—effect organisms and react in complex, often synergistic, ways. An individual organism’s vulnerability varies depending upon a variety of condi-

Continued on page 24 PAGE 22 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

View the original image (PDF) here: Biological Systems and Stressors – http://www.teleosis.org/pdf/4Ts_4.2

PAGE 23 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

SYMBIOSIS

Continued from page 22 tions; for humans, our developmental stages are one particularly important variable. For example, gestation and early childhood are more vulnerable stages of the human life cycle. Different toxicant dose concentrations and exposure duration—for example, lower doses for longer periods of exposure—may increase risk during these periods. The macro-environment continues to accumulate “toxicants”—both naturally occurring and anthropogenic toxic chemicals. Chemicals may enter biological organisms in 4 ways: respiration, ingestion, dermal exposure, or parenteral (direct entry into the organism, e.g. through intravenous injection, such as a vaccine). Rather than considering a one-time exposure to a single toxicant, it is impor-

Holistic Exposure Assessment

tant to take account for total number of past and present exposures, which occur in temporal patterns along a trajectory—long term, intermittent, episodic, and acute. This gives a more accurate picture of the organism’s exposure by looking at the duration and concentration of individual toxicants as well as all previous toxic exposures.

Toxicants Naturally occurring and human-made toxicants that enter organisms through respiration, ingestion, dermal exposure, or parenteral (intravenously)

Totality All stressors including exposure to chemicals

Tolerance

This “totality” may be synergistically enhanced or resisted by nonchemical stressors— such as pathogens, electromagnetic radiation, physical stressors, temperature/ humidity, emotional stress and noise—that affect the organism. An organism’s “tolerance,” which accounts for its ability to resist change at the organismic level, is determined by its general fitness and genetic disposition. Various chemical and nonchemical stressors challenge the individual’s capacity for maintaining homeostasis, i.e., the tendency to return to a healthy physiological equilibrium. The “trajectory” encompasses not only past cumulative exposures but also future exposure; this is a more accurate picture of overall exposure and resulting risk over time. Key to the 4Ts model is the critical state, which is defined as the “state at which an additional single exposure event can result in irreversible adverse effect, one that pushes the organism beyond its ability to maintain homeostasis.”2 In humans, we call this state disease. The 4Ts model offers a more sophisticated and systemic approach than previously available for addressing the complex distribution and effects of multiple

Ability to resist change

chemical exposure on living organisms. The significance of this model will emerge as

at organismic level—

toxicologists and physicians begin to utilize this valuable resource.

determined by fitness and genetics REFERENCES

Trajectory Long term, intermittent, episodic, and acute— past and potential future cumulative exposures to toxins

1 Daughton CG. Cradle-to-cradle stewardship of drugs for minimizing their environmental disposition while promoting human health. I: Rational for and avenues toward a green pharmacy. Environmental Health Perspectives 2003;111:757-774. [full text PDF also available at: http://www. pubmedcentral.nih.gov/articlerender.fcgi?artid=1241488 2 Daughton, CG. Emerging chemicals as pollutants in the environment: A 21st century perspective. Renewable Resources Journal. 2005; 23(4):6-23. [full text PDF also available at: epa.gov/esd/ chemistry/ppcp/images/iom-2003.pdf]U.S.Environmental Protection Agency: National Exposure Research Laboratory 3 Environmental Sciences. Biological Systems and Stressors. Available at: http://www.epa.gov/ nerlesd1/chemistry/ppcp/stressors.htm. Accessed April 16, 2007. [Pictorial representation of model available at: http://www.epa.gov/esd/chemistry/ppcp/images/stressor.pdf]

DR. JOEL KREISBERG is founder and executive director for the Teleosis Institute in Berkeley, California . The institute was founded in 2004 as a non profit organization with a mission to develop effective, sustainable health care inspiring professionals to serve as environmental stewards as a daily practice. Their goal is to reduce the footprint of the healthcare system through education, advocacy and example. www.teleosis.org 2

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PAGE 24 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

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Green Pharmacy: Preventing Pollution A Cross Sector Approach BY J O E L K R E I S B E R G , D C , M A

The recent increase in awareness of environmental issues is creating an opportunity for all constituencies involved with PPCPs to take action and reduce potential harm. A “cross-sector” approach offers a systems perspective that includes all individuals and organizations involved with the production, distribution, consumption, and disposal of pharmaceutical medicine. For pharmaceutical pollution, the solution calls upon all sectors involved in health care—pharmaceutical developers and manufacturers, hospitals, individual physicians and all those involved in the health care system, law enforcement agencies, pharmacies, waste management agencies, consumers, environmental protection organizations, and governmental agencies—to participate in

Dispose Medicines Wisely

preventing pharmaceutical pollution. This powerful approach provides a comprehensive solution to an issue that has the potential to affect much of life on Earth.

www.teleosis.org/ greenpharmacy

The Manufacturing Sector The manufacturing of medicine is ripe for leadership. In the past decade “green chemistry,” which minimizes the use of toxic chemicals in design and production, has emerged as a technological advancement in the research and development of new pharmaceutical

treatments.

As manufacturers become more responsive

concerns about environmental hazards and sustainability, production techniques that

lower the overall impact on the environment are becoming increasingly

important. From a product standpoint, this sector is developing a new model of “product stewardship”—a “cradle-to-cradle” strategy for developing a new product. While all those involved in the production, distribution, sale, and use of any drug should be involved with product stewardship, the manufacturing sector is in the best position to reduce the environmental impact of medicines, because a product begins with development and manufacturing. If the process begins with cradle-to-cradle stewardship, it is more cost-effective and environmentally sensitive. One way manufacturers can exercise healthy product stewardship is to design drugs that are more ecologically sensitive and medicines that biodegrade more

Green Pharmacy

PAGE 26 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

SYMBIOSIS quickly and yield end products that are less harmful. Innovative drug design can improve delivery systems to require lower doses for efficacy; shifting from the current system of averaging, the practice of refining a medication’s expiration date can bring shelf life into closer alignment with real time; recyclable materials can be used for packaging, or package size can be reduced to minimize the unused portion of prescriptions; and more complete and direct information about proper disposal techniques can be added to packaging. The pharmaceutical industry is in an excellent position to provide more information directly to physicians. The European pharmaceutical industry is currently

Pharmaceutical

implementing a system in which medicines are graded for persistence, bioaccumula-

developers and

who will be in a position to make healthier environmental choices. As is already hap-

tion, and toxicity (PBT). This information will be available to prescribing physicians,

manufacturers,

pening in Canada, Australia, and New Zealand, our pharmaceutical industry could pro-

hospitals, individual

ives might promote advanced recycling strategies, which would require changes in

physicians, law enforcement agencies,

vide funding for the proper disposal of unused or expired medicines. the current laws for drug handling in America.

The pharmaceutical industry could

also devote a portion of its huge advertising campaign to educate both physicians and consumers about the environmental and health issues associated with PPCPs.

pharmacies, waste

Health Care Systems

management agencies, consumers,

Such initiat-

Hospitals

environmental

Model solutions already exist for the medical industry. Those involved in hospital

protection

Environment (H2E) (http://www.h2e-online.org/) is collaborating with many major

organizations, and

medicine are already developing methods for proper disposal. Hospitals for a Healthy hospitals in the United States, initiating proper disposal of hospital wastes. In May 2007, H2E’s Environmental Excellence Summit focused on pharmaceutical waste

governmental

management. Since much of medicinal waste is generated by hospital medicine itself,

agencies—all can

where patients and consumers can easily return unwanted and expired medicines.

help prevent pharmaceutical pollution.

there is no reason why hospitals cannot be regional centers for “take-back” programs, With a high concentration of physicians and nurses, hospitals also offer an opportunity to expand the educational content required of the medical profession.

Physicians, Veterinarians, and Dentists Individual physicians must also participate in the solution. Any medical office can offer a take-back program. Physicians, as the first line in any health care strategy, can inform patients about healthy product stewardship. The time when a doctor is prescribing a medication is an ideal moment to educate patients about proper disposal habits. Imagine receiving a phone call from your medical office reminding you not only about your next appointment but also to bring your expired and unused medicines with you. Veterinarians and dentists can take these steps as well. Domestic

www.teleosis.org/ greenpharmacy

animals are the object of increasing amounts of PPCPs in medicine. These offices, too, can participate in proper disposal programs.

Green Pharmacy

PAGE 27 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

SYMBIOSIS Pharmacies and Law Enforcement Agencies To date, many of the proposed solutions for proper disposal of PPCPs are focused on two sectors, pharmacies and law enforcement. Pharmacies seem a natural fit for proper disposal of medication, and in fact some pharmacies serve as take-back sites for proper pharmaceutical disposal. In British Columbia, 95% of all pharmacies have recycle bins, which allow consumers to bring their unused/expired medicines back whenever they shop. Because certain medications find their way into an illicit drug market, law enforcement agencies sometimes participate in take-back programs to ensure that these substances are handled only by a pharmacist, physician, or police officer. Take-back events and selected programs at police stations are helpful, but are less accessible.

Hospice One sector of the health care system that relies most heavily on medication is hospice. Researchers estimated in 2003 that at least $1 billion worth of unused drugs are flushed down the toilet each year.1 Senior centers and home hospice care should consider several types of disposal systems. Current hospice protocol is to have families dispose of medicine; unfortunately, it is often disposed of improperly. These medicines are typically good quality medicines that could easily be reused for others in need. While regulations prevent hospice workers from reverse handling of medicine, families could return unused medicines to proper disposal facilities, or investigate if long term care facilities in your area accept unused dispensed medications. Senior centers, too, can offer educational outreach and take-back services.

At least $1 billion worth of unused drugs are flushed down the toilet each year.

Waste Management Agencies and Environmental Organizations Waste management agencies have an interest in seeing that PPCPs are disposed of properly. Municipal water agencies in particular are developing policies that maintain proper water quality. Some agencies are proposing regulations that would prevent hospitals from disposing medicines directly into the municipal water system. Solid waste organizations too, have a similar interest, though unused medicines make up a relatively small percentage of solid waste. Most solid waste systems in the U.S. request that unwanted medicines be returned to hazardous waste facilities. However, only a very small percentage of household medicines are hazardous wastes

and pound for pound, hazardous waste is much more expensive to handle. Since many medications are not hazardous, significant money can be saved by separating most drugs out of the hazardous waste stream. Other approaches to drug recycling do exist. For manufacturers, “reversedistribution,” which allows pharmacists to return unsold drugs back to the manufacturer, could be enlarged to include unused medication and expired medication. While human health is very important, water quality needs to be preserved for nonhuman life as well. Many environmental organizations that support wildlife and aquatic ecosystems are supporting take-back programs. In Oakland, California, for example, Save the Bay is actively involved in preventing PPCP pollution.

Green Pharmacy

PAGE 28 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

SYMBIOSIS

Consumers Finally, consumers need to participate in keeping our environment clean. Each of us has a responsibility for healthy product stewardship of all consumer goods. Rather than throwing medicine down the toilet or in the garbage, bring non-controlled drugs to a take-back site or hazardous waste facility. Buy smaller containers of medicines. Buy products with recyclable packaging. Ask your doctor about environmental impacts of your medication and whether a more sustainable alternative exists. Always choose the smallest prescription amount or refill option unless the medication is for a chronic condition. Encourage your physician or primary care provider to take back unused/expired, non-controlled medicines. Most importantly, commit to health promotion strategies that reduce your need for medication in the first place. When given

What you can do • Dispose of unused or unwanted medications at take-back sites or events only • Do NOT dispose of any

a choice, always choose sustainable medical treatments first, reserving more problematic choices for more difficult situations. Unused medications may be donated to nonprofit organizations that redistribute medicines to charitable organizations in non-industrial countries that need basic medications. Green funeral practices are emerging as an alternative to traditional practices that release significant chemicals into the environment.

medication down the toilet or in the trash • Purchase drugs in small amounts, limiting expired medications • Ask for medications with low environmental impact • Encourage your provider to take-back non-controlled unused/expired drugs. • Commit to health prevention strategies to reduce your reliance on medications

www.teleosis.org/ greenpharmacy

Green Pharmacy

PAGE 29 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

SYMBIOSIS Who Pays? Perhaps the most contentious aspect of proper disposal of PPCPs is cost: Who should pay? No one wants to pay the additional cost for proper product disposal. In many sectors of durable goods or consumer goods, particularly electronics, the cost of disposal is beginning to be included in the cost of the product. For consumers, this is the preferred method, although a fee added at time of purchase, called an “advanced recycling fee” (such as the system for beverage bottles and cans), allows users to pay as they go. When this is mandatory, however, it feels like a tax. Many of us remember the struggle to get “bottle bills”—an added fee on bottles—passed in state legislatures. Perhaps medications can be handled that way, although experience shows that the public is not easily persuaded to mandate such fees. The product stewardship model suggests that the cost be spread throughout the life cycle of the product and that the proportion of cost be distributed by the ability of the party to have a significant impact.2 Applying this model, pharmaceutical companies would provide the largest proportion of investment. To date, this is how Europe and other industrialized countries are building capacity. But healthy product stewardship requires everyone’s participation. In addition to manufacturer involvement, we need to shift our focus to actions and processes that reduce the need for disposal, thereby reducing household accumulation of unwanted drugs. Currently our focus is on prudent disposal options, but we need to address this problem at the source rather than further downstream at the consumer/patient level. We need to aim for a healthcare-consumer system that results in fewer medications needing disposal. Each one of us can contribute to a healthier home for all of us on planet Earth—just by making the better choice.

Everyone Participates

Commit to health promotion strategies

Green Pharmacy offers an opportunity for social action that will greatly benefit our

that reduce your need

environment at all levels of our society. With relatively simple yet firm commitments

for medication in the

icine we effectively become part of the solution. Ideally, there would be no drugs to

to change our habits, becoming stewards of medicine rather then consumers of med-

first place—if there is

return. Until that time, all prescribed medicines would be brought back in subsequent

a choice, always

tributors would facilitate medical, dental and veterinarian offices in disposing of

choose sustainable

visits to a physician, veterinarian and dentist. Manufacturers and pharmaceutical disthese medicines wisely. Consumers willingly participate by returning unused medication. Green Pharmacy is a commitment we undertake today. Our vision is zero

medical treatments

waste. Our simple actions have a positive effect of the health and vitality of our world.

first, reserving more

a sustainable healthy future.

problematic choices for more difficult situations.

It requires a commitment to restore that each of us carries in our hearts a vision of

REFERENCES

1 Van Eijken M, Tsang S, Wensing M, De Smet PAGM, Grol RPTM. Interventions to improve medication compliance in older patients living in the community: A systematic review of the literature. Drugs & Aging. 2003;20(3); 229-240. 2 Product Stewardship Institute. Available at http://www.productstewardship.us/. Accessed April 16, 2007.

PAGE 30 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

MEMBER NEWS AND HAPPENINGS

In Memoriam David Druker, MD 8/16/41 – 7/23/10 Dr. David Druker, chief executive officer of the Palo Alto Medical Foundation and a mentor to many in the medical field, died on July 23, 2010, at the age of 68, after a three-year battle with lung cancer. Dr. Druker served as the foundation’s CEO since 1999 and worked there for 35 years. Colleagues remembered

him as an innovative and successful leader, and a kind doctor who was beloved by patients. His colleagues said, “He listened. That’s what made him such a great leader—he listened.” Also said, “David was a healer, a teacher, a visionary, and a mentor to all of us. He had an ability to engage the people’s hearts and minds around a singular purpose of creating the very best medical care possible for the community.”

Dr. Druker completed his residency at the University of Oregon School of Medicine and was a boardcertified dermatologist. After a year of private practice in Portland, he moved to Palo Alto in 1975 and he got a job in the Department of Dermatology at the Palo Alto Medical Clinic, which would become the Palo Alto Medical Foundation. He was named executive director of the Palo Alto Medical Clinic in 1989, chief operating officer of the medical foundation in 1994, and CEO in 1999. A great loss for all of us.

William J. Siegel, MD 6/19/30 – 8/3/10 Dr. William Siegel passed away on August 3, 2010 at the age of 80. He was president of the Santa Clara County Medical Association in 1983-84 and a member of SCCMA since 1968. He was a boardcertified pathologist, retired in 1998.

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PAGE 31 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

SPECIAL: MEDICINE AND THE ENVIRONMENT

SOLAR ENERGY: Easy, Affordable, and Quick By Cindy Russell, MD VP Community Health, SCCMA Solar systems for your home or business are becoming easier to install and more affordable. Unlike complex and problematic solutions, such as nuclear power or global geoengineering proposals, these systems are ready to install and save you money and CO2 emissions right away. Solar panels have improved and offer increased efficiency of up to 18% in some panels. Companies are offering discounts on systems you buy yourself and now they are even leasing your roof, so you pay no up-front costs and lower or eliminate your electricity bill. There are both state and federal tax incentives to reduce the costs substantially. Another advantage is that when you place your photovoltaics on your roof, you become very aware of how much and where you use energy. This, in turn, makes you focus more on conservation, which is the key to reducing CO2 emissions.

Federal and State Tax Incentives Enhanced federal tax credits for solar systems were signed into law on February 17, 2009. The American Recovery and Reinvestment Act of 2009 removed the maximum credit amount for all eligible technologies (except fuel cells) placed in service after 2008 for a residence in the U.S. It allows for a credit equal to 30% of the cost of qualified alternative energy equipment, such as solar electric (PV) systems, solar hot water heaters, geothermal heat pumps, and wind turbines, through 2016. The California state program now offers a 7.5% state income tax credit on the purchase and installation costs of gridconnected solar or wind energy systems.

Some cities, such as San Francisco, also have additional incentives, which are higher for low-income families. A good website to review this is www.dsireusa.org. Most solar or wind installers should be aware of these rebates and help you with them. Overall, you get about a 40% cost reduction for your solar system.

Santa Clara Valley Medical Center Goes Solar In celebration of Earth Day 2009, Santa Clara Valley Medical Center activated a newly-installed solar power system as part of SCVMC’s Green Building Project. It generates approximately 10% of the SCVMC campus energy needs. A 720-kilowatt SunPower ® Tracker system is being used to track the sun during the day, increasing sunlight capture by up to 25% over fixed tilt systems. There are many qualified installers and a variety of solar panels from which to choose. Some installers will even give you an estimate after looking at your property on Google Earth. A few are listed here or search the Web for a local company that suits you and your price range. Note that Solar Technologies, who installs panels, along with SunPower (which manufactures the panels), will offer a discount

to SCCMA members. Enjoy the feeling of energy independence!!!!! •

Solar Technologies – www. solartechnologies.com

•

Solar Panel Installers in Santa Cruz – http://www.findsolar.com/Directory/ CA/santa-cruz-solar-panel-installers. aspx

•

SunPower – www.sunpowercorp.com/ asp/sccmamcms

•

Solar City – www.solarcity.com

PAGE 32 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

SPECIAL: MEDICINE AND THE ENVIRONMENT

Why Fi? Is Wireless Communication Hazardous to Your Health? By Cindy Russell, MD VP Community Health, SCCMA We are exposed to increasing levels of microwave electromagnetic radiation from many devices which offer convenience and speed. We are not only addicted to it, we depend on it. But what do we know of the health and environmental effects of this enlarging wireless web we are in? What should you tell your patients? For sure, there has been a good deal of controversy about health effects of cell phones, cordless phones, smart meters, cell towers, and any number of wireless devices constantly and silently sending information through the air. Because of the escalating microwave radiofrequency exposure from many sources throughout the world, there is a broad concern that wireless communication is or will be a significant public health issue.

Biologic and Human Health Studies Show Reason for Concern While three decades of literature have shown biologic effects on a cellular level, until recently, there were no longterm studies that indicated an increase in cancer in humans. A sufficient amount of research now exists to suggest there is reason for concern about longterm, and probably short-term, adverse health effects from this technology, although some conflict still exists. Many scientists throughout the world have been calling for a reevaluation of the international standards for EMF, as

they are not protective of human health. The current RF-EMF standards are based solely on heat effects of the microwave radiation on tissue and not the biological effects seen in the laboratory at levels more than a hundred times lower than what is allowed. Although more studies are underway, recent research on the microwave frequencies from cell phones and cell phone towers has demonstrated biological non-thermal effects, including leakage of the blood brain barrier, genetic damage with single- and doublestranded DNA breaks, disruption of intracellular communication, abnormal protein synthesis, and alternation of DNA expression. Epidemiological studies have demonstrated an increase in brain tumors, with long-term use. Neurobehavioral effects from EMF have been reported to include memory loss, tinnitus, headaches, hearing loss, and insomnia.

The Electromagnetic Spectrum Electromagnetic Waves   Electromagnetic waves are a form of energy that consists of vibrating electric and magnetic fields. Electric fields are produced by forces of electric charges and magnetic fields are produced when electric charges are in motion. When an appliance is plugged in, an electric field is produced around the appliance; when the appliance is turned on and the electrical current is flowing, a magnetic field is added. When the appliance is unplugged the  electric

Cindy Russell, MD is the Vice-President of Community Health, Chair of the Environmental Health Committee, and a CMA Delegate with the Santa Clara County Medical Association. She is board certified in Plastic Surgery and is currently practicing with the Palo Alto Medical Foundation Group. field remains at the outlet and there is no electric or magnetic field around the wiring or appliance. Common Sources of Electromagnetic Radiation   The main natural source of electromagnetic radiation is the sun. Natural electromagnetic energy (i.e., sunlight) is necessary for photosynthesis in plants. Man-made sources, however, account for most of the electromagnetic radiation in our environment. With the proliferation of new technological devices in our home and workplace, we are all exposed to electromagnetic radiation daily. Everyday household electrical devices such as hairdryers, electrical ovens, fluorescent lights, microwave ovens, stereos, mobile phones, and computers and the transmitters that support these items emit electrical and magnetic fields of varying intensities. ELF, RF, and Microwaves The electromagnetic spectrum extends from non-ionizing, extremely low frequencies ELF (long wavelength) used

PAGE 34 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

for electrical power line distribution with 50-60 HZ (oscillations of 50-60 times/ second) and found in home appliances and electrical wiring; to radio and communication frequencies RF for radio, TV, cell phones, microwave ovens, satellite TV, and wireless networks (1 KHz through 2500 MHz and now to 300 GHz which produce wave oscillations billions of times per second); to short wavelength ionizing high gamma radiation at the opposite end of the frequency spectrum (UV light, X-rays, and radioactive sources). Radio frequency waves (RF) are usually defined as those in the range 30 kHz to 300 GHz. Microwaves are a subset of radio waves typically between 300 MHz to 300 GHz. The electromagnetic spectrum is also divided into ionizing and non-ionizing bands based on how the wave interacts with biological tissue. Ionization involves removal of electrons from their normal positions in atoms and molecules, damaging tissues including DNA. Although ELF is a non-ionizing form of radiation, the International Agency for Research on Cancer (IARC) has classified the extremely low-frequency (ELF) electromagnetic fields (EMF) as “possible carcinogenic” based on the reported effects. There is, of yet, no such classification with non-ionizing radiofrequency (RF), although some research supports this. Evolution in a Low RF World We evolved in an environment largely of a magnetic nature and a low radiofrequency (RF) world with little ELF-EMF. The sun’s rays provide us with visible light and UV light, but our fragile ozone layer protected us from most of its lethal ionizing rays. Microwaves were for the first time produced by humans in 1886, when radio waves were broadcasted and received. Until then, microwaves had only existed as a part of the cosmic background radiation. By utilizing microwaves in telegraph communication, radars,

television, and, above all, in the modern mobile phone technology, mankind is today exposed to microwaves at magnitudes far greater than the original background radiation since the birth of universe. (Nittby 2009)

What Frequencies Are We Exposed To With Cell Phones? GSM stands for Global System for Mobile communication, which is the most widely used in Europe and many parts of the world. GSM operates at either the 900 MHz or 1,800 MHz frequency band. The Universal Global Telecommunications System (UMTS) is a newer third generation system and emits

wideband microwave (MW) signals with multiple frequencies. It is also known as Broadband. UMTS requires new base stations and new frequency allocations. It is called 3G. UMTS may result in higher biological effects compared to GSM signal because of eventual “effective” frequencies within the wideband.

The Bioinitiative Report In 2007, a group of international scientists, researchers, and public health policy professionals completed a comprehensive public policy initiative to document what is known of the biological effects that occur at low intensity EMF exposures. This Bioinitiative Report looked at all the data, both positive and negative, regarding EMFs. After reviewing this extensive body of research, there was a clear consensus that existing public safety limits are outdated and new standards were needed that are based on biological effects, rather than the current thermal effects of microwave radiation to which we are exposed. They also point out that many new wireless devices are exempt from wireless standards. The report also discusses the fact that while there is not 100% certainty with regards to some EMF effects, there is sufficient evidence in order to take action to prevent public harm. The Bioinitiative Report seems at first daunting, however, the chapters are well referenced, detailed, balanced, and readable. See www.bioinitiative.org. Much more research has been done since that report.

Cell Phones and Brain Cancer Brain cancer, like other cancers, typically takes many years to develop and cell phones have only been used for 15-20 years. It is logical that earlier studies did not show any increase in brain tumors

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Continued on page 36

Why Fi?, from page 35 due to this latency period, however, newer studies indicate otherwise. Dr. Hardell, a well-respected Swedish researcher, has looked at the long-term human effects of the use of cell phones and cordless phones, and their associated risk for acoustic neuromas, gliomas, and astrocytomas. He has published many articles on this subject and has found a consistent pattern with increased risk in acoustic neuromas on the ipsilateral side with more than 10 years of use (Hardell 2007). A newer study, published in Neuroepidemiology (Hardell 2010), showed an increase in malignant tumors as well. The highest risk was again for the same side the phone was used and for those using cell phones for more than 10 years. The risk increased with over 2,000 hours of cumulative use. In other research, the highest risk was found in those using cell phones before the age of 20. “We conclude that current standard for exposure to microwaves during mobile phone use is not safe for long-term exposure and needs to be revised.” (Hardell 2009)

Industry Versus Independent Research A review of the literature on cell phones and brain cancer demonstrated that the older industry-funded Interphone research found no increase in brain tumors. All of the independent Swedish studies found a significant increase in brain tumors from cell phones and cordless phones. Morgan evaluated the flaws in the Interphone and Swedish studies. He found 11 flaws in the Interphone studies and 3 flaws in the Swedish study (Pathophysiology, Aug 2009). The industry studies had selection bias, insufficient latency time, exclusion of young adults and children, rural areas with

higher power levels not investigated, other sources of transmission excluded, exclusion of brain tumor types, and funding bias. Both had flaws of exclusion of brain tumor cases due to death, tumors outside radiation plume considered exposed, and recall accuracy of phone use. The latest Interphone update (May 2010) did show a small increase in some types of brain cancers. No definite conclusions could be reached, however, and there was a range of opinions on the panel with regards to the safety limits of cell phones.

Belyaev, in 2006, exposed rat brain to 915 MHz microwaves of global system for mobile communication (GSM) and found up regulation in 11 genes producing proteins, including those affecting neurotransmitter regulation. Dozens of studies show similar effects. Not all genes are affected and the effects depend on biologic and EMF variables as well as research protocols. The evidence, however, indicates that clinically relevant EMF radiation from wireless devices affects biologic systems.

EMF and Oxidative Stress Biological Effects From the Basic Science Literature Many studies of microwave radiation have shown alteration of cellular processes with up regulation or down regulation of genes which encode proteins with diverse functions including neurotransmitter regulation, blood-brain barrier (BBB), and melatonin production (Belyaev et al., 2006; Leszczynski et al., 2002, 2004, 2006). Zhao, in 2007, evaluated changes of gene expression in rat neurons after exposure to the pulsed RF-EMF at a frequency of 1800 MHz and SAR 2W/Kg. He found alterations in 34 genes that are associated with multiple cellular functions. RF fields have been shown to activate a cellular stress response, which is a protective mechanism characterized by stress protein synthesis. Stress proteins help damaged proteins refold to regain their conformations, and also act as “chaperones” for transporting cellular proteins to their destinations in cells. The stress response, by its very nature, shows that cells react to EMFs as potentially harmful. (Kültz 2005) (Shallom 2002) ( Leszczynski 2002) (Weisbrot 2003)

Oxidative stress has been shown in the myocardium of rats exposed to cell phone radiation. (Ozguner 2005) A review of immunologic effects revealed EMFs to disturb immune function through stimulation of various allergic and inflammatory responses, as well as effects on tissue repair processes. Johannson, in 2009, summarizes; “These and the EMF effects on other biological processes (e.g., DNA damage, neurological effects, etc.) are now widely reported to occur at exposure levels significantly below most current national and international safety limits. Obviously, biologically based exposure standards are needed to prevent disruption of normal body processes and potential adverse health effects of chronic exposure.” This topic has become so important that a special issue of Pathophysiology August 2009 was published on Electromagnetic Fields (EMF), available online at www.sciencedirect.com.

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Cell Phones and the BloodBrain Barrier The blood-brain barrier helps maintain a highly stable extracellular environment necessary for accurate synaptic transmission and protects nervous tissue from injury. A number of studies on blood-brain barrier effects do show leakage can occur with certain frequencies and power of EMF. Salford, in 1994, studied the biological effects of electromagnetic fields on the blood-brain barrier (BBB) and found albumin leakage in animals exposed to 915 MHz microwaves versus controls. Schirmacher (2000) reported that an in vitro model demonstrated increased permeability of the blood-brain barrier to sucrose with exposure to 1.8 GHz conforming to GSM standards compared to controls. Studies by Nittby, in 2009, confirmed this effect and found albumin extravasation from the brain, even after seven days with a SAR as low as 0.12W/kg.

Brain Effects: Electrical Activity Marino, in 2009, analyzed the reports in which human brain electrical activity was compared between the presence and absence of radio-frequency and low-frequency electromagnetic fields (EMFs) from mobile phones, or between pre- and post-exposure to the EMFs. Of 55 reports, 37 claimed and 18 denied an EMF-induced effect on either the baseline electroencephalogram (EEG), or on cognitive processing of visual or auditory stimuli as reflected in changes in eventrelated potentials. He states, “Overall, the doubt regarding the existence of reproducible mobile-phone EMFs on brain activity created by the reports appeared to legitimate the knowledge claims of the mobile-phone industry. However, it funded, partly or wholly, at least 87% of the reports. From an analysis of their

cognitive framework, the common use of disclaimers, the absence of information concerning conflicts of interest, and the industry’s donations to the principal EMF journal, we inferred that the doubt was manufactured by the industry.”

DNA and Genotoxic Effects A major concern of the adverse effect of EMF is as a carcinogen. As the majority of cancers are initiated by damage to a cell’s DNA, many studies have looked at the potential for DNA breaks with EMF. Microwave frequencies used in wireless communications are not in the ionizing radiation segment of the EMF spectrum that we know to cause rapid and predictable DNA damage. Nevertheless, there are numerous studies that demonstrate singleand even double-stranded DNA damage. The mechanism is not yet completely understood, but a likely explanation is oxidative damage through the free radical pathway. Free radicals kill cells by damaging macromolecules, such as DNA, protein, and membranes. This leads to changes in cell function and death. Chemical toxins have a similar pathway of damage. In this way, microwave frequencies could act as a co-inductor of DNA damage, rather than as a direct genotoxic agent. (Phillips 2009) Several reports have indicated that electromagnetic fields (EMF) enhance free radical activity in cells (Lai and Singh, 1997, 2004; Oral et al., 2006; Simko, 2007). Another mechanism of harm is to DNA repair. Belyaev, in 2009, found intracellular DNA repair mechanisms were inhibited by Broadband (UMTS) and stated the effects “persisted up to 72 hours following exposure of cells, even longer than the stress response following heat shock.” (Belyaev 2009 Bioelectromagnetics)

Senior Moments: Memory Effects of RF-EMF Considering the frequent use of mobile phones, studies have looked at their possible implications on cognitive functions. Nittby et al., in 2008, exposed rats to two hours per week for 55 weeks of 900 MHz GSM cell phone RF-EMF. They then evaluated cognitive function and found GSM-exposed rats had impaired memory for objects and their temporal order of presentation, compared to sham exposed controls. They concluded “Our results suggest significantly reduced memory functions in rats after GSM microwave exposure.” An analysis of neurobehavioral affects of GSM mobile phones, by Barth in 2008, showed a small impact on human attention and memory.

Acute and Chronic Neurologic Symptoms From EMF In Egypt, a study of inhabitants near the first cell phone tower in the district showed a significant increase in reported headaches, memory changes, dizziness, tremors, and sleep disturbance. They conclude “inhabitants living nearby mobile phone base stations are at risk for developing neuropsychiatric problems and some changes in the performance of neurobehavioral functions” (Abdel-Rassoul G 2007). Bortkiewicz, in 2004, found people living in the vicinity of base stations reported similar complaints in addition to irritability, depression, blurred vision, concentration difficulties, nausea, and lack of appetite. The interesting thing was that this association was observed in both those who linked their complaints with the presence of the base station and those who did not notice such a relation. Hutter, in 2009, studied the association between tinnitus and mobile phone use. While tinnitus can be Continued on page 38

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Why Fi?, from page 37 associated with loud noise, earphones, diseases and disorders of the ear, and vascular pathologies, there are few known risk factors for tinnitus apart from these conditions. There has been anecdotal evidence of a link between mobile phone use and tinnitus, but so far there have been no systematic investigations into this possible association. Hutter looked at 100 consecutive patients presenting with tinnitus in an individually matched case-control study. The risk estimate was significantly elevated for prolonged use (≥4 years) of a mobile phone. Children and adults are already at risk of hearing loss and tinnitus from high noise levels and earphones and headphones, which are on the rise as well. (Vogel 2009)

Affects on Sperm Have Implications for Infertility Scientists looking at the effects of mobile phone microwave frequencies on sperm have found that the morphometry and sperm binding is affected. Flazone used 900 MHz and a SAR of 2.0 to examine these effects and concluded “These results could indicate a significant effect of RF-EMF on sperm fertilization potential.” (Falzone, 2010). Agarwal reported in Sterility and Fertility journal, in 2009, the effects of one hour of cell phone RF-EMF on sperm. He found a significant decrease in sperm motility and viability. He concluded that radiofrequency electromagnetic waves emitted from cell phones may lead to oxidative stress in human semen and cautioned against men putting their cell phones in trouser pockets.

SAR Levels on Cell Phones Remember how older cell phones used to make your ear warm if you were on the phone a while? Well, newer phones are less likely to do that due to Specific Absorption Rate (SAR) limits. Cell phones and some other wireless communication devices are regulated by the FCC according to their emissions, which depend on the amount of power absorbed into the body. SAR is a way of measuring the quantity of radio frequency (RF) energy that is absorbed by the body. For a phone to pass FCC certification and be sold in the United States, its maximum SAR level must be less than 1.6 watts per kilogram within one gram of tissue for the head. The limit for absorption of radiofrequency radiation is limited to 0.08W/kg for whole body exposure, set by the American National Standards Institute (ANSI), National Council on Radiation Protection and Measurements (NCRP), and the Institute of Electrical and Electronics Engineers (IEEE), the world’s largest technical organization.

Children’s Brains Are More Vulnerable: SAR Level Children’s brains are immature and continue to develop important learning connections until their early twenties. In addition, children’s skulls are thinner, absorb more radiation, and, studies suggest, are more prone to radiation damage (Wiart 2005, 2008) (Ghandi 1996). Because of this, some scientists argue that, for children, there needs to be a margin of safety for SAR levels. According to the Pew Internet and American Life Project in 2008, 71% of American children between 12 and 17 years old owned cell phones. More than half use the device daily.

Health Ministers and authorities in France, India, Israel, Russia, and the U.K. recommend limiting use of the cell phone in teenagers and children to emergency use only. In June 2010, San Francisco became the first U.S. jurisdiction to respond to increased concerns over possible links between cell phone use and cancer, adopting a city ordinance requiring retailers to post the radiation levels of mobile phones (Washington Post June 22, 2010). This was adopted as a consumer disclosure policy. In June 2008, India banned advertisements of pregnant women and children in mobile phone ads, as a precaution.

Switzerland, Italy, and Russia With More Stringent SAR Limits Although the NCRP, ANSI, and the IEEE recommend levels set by thermal standards, some countries in the world have established new, low-intensitybased exposure standards that do not rely on heating. Emerging scientific evidence on the biologic effects of RF has encouraged some countries to reduce the RF limits to levels that are hundreds of times lower than U.S. standards. In the cell phone frequency range of 800 MHz to 900 MHz, the levels range from 10 microwatts per centimeter squared in Italy and Russia to 4.2 microwatts per centimeter squared in Switzerland. The United States and Canada limit such exposures to only 580 microwatts per centimeter squared. According to Belyaev 2007, “Numerous data on the NT (non thermal) MW (microwave) effects clearly indicate that the SAR-concept alone cannot underlie the safety guidelines for chronic exposures to MW from mobile

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communication and other approaches are needed.”

Cell Phone Towers In 1973, the first call was made from a cell phone. In 1982, the FCC authorized the first commercial cellular service in the U.S. In 1987, there were one million subscribers, and in 2008, there were about 270 million. At last count, there are an estimated 245,000 registered cell towers in the United States (CTIAWireless Association data). It is expected to double in the next five years. Each cell company (T-Mobile, Verizon, Nextel, Sprint) owns these towers. There is no publicly available database of all individual cell site locations. The FCC does not require cell phone towers to be registered. Cell towers are only a small subset of wireless towers, as many more towers are unregistered. The towers may be listed with the private owner and not listed with a specific carrier. In addition, there are smaller “micro-cell” towers which are located in cities, every other block and 10 to 20 feet above ground, that are used to improve coverage where buildings exist that may interfere with transmission, although the microwave frequencies can pass through most structures easily. These micro-cells transmit similar radiofrequencies and are no less risky. Of particular concern is the cumulative radiation exposure from this wide variety of sources. Several studies have shown an increased risk of cancer, as well as other neurobehavioral effects, on those living near cell phone towers. (Abdel-Rassoul G 2007) (Bortkiewicz 2004) ( Khurana 2005) It appears the most hazardous is within 1,300 feet of the tower. This may be dependent on how many carriers are on the tower and other factors. Many jurisdictions are so concerned they

are beginning to limit cell phone tower placements. Knesset, a city in Israel, banned placing towers on residential buildings in 2007. Taiwan, in 2007, removed 1,500 cell towers from residential areas and schools, as the NCC had been urged by lawmakers to “strongly intervene” in efforts to cut the number of base stations by at least half, since the coverage rate of existing MPBSs is more than five times the amount that Taiwan actually needs. They stated, “residential neighborhoods and schools must not be exposed to the risk of radiation emitted by the MPBSs that could cause cancer, miscarriages, and diseases of the nervous system.”

Proof or the Precautionary Principle? European Union policy requires that the Precautionary Principle be the basis for environmental protection for the public. “When there are indications of possible adverse effects, though they remain uncertain, the risks from doing nothing may be far greater than the risks of taking action to control these exposures. The Precautionary Principle shifts the burden of proof from those suspecting a risk to those who discount it.” Their perspective is that it is important to protect public health and take preventative action before certainty of harm is proven. If governments wait until there is absolute certainty and proof of harm, then much damage to human health, the environment, and the economy could occur. This has been seen with many environmental toxicants such as mercury, lead, tobacco, and chemical pollution. The International Commission on Non-Ionizing Radiation Protection (ICNIRP), Institute of Electrical and Electronics Engineers, Inc. (IEEE), and National Council on Radiation Protection and Measurements (NCRP), in developing their recommendations for exposure

standards, require proof of adverse effect and risk before amending the exposure standards. The Precautionary Principle Treaty requires action to protect the public when a reasonable suspicion of risk exists.

Precautionary Principle Proponents European Environment Agency: “There are many examples of the failure to use the precautionary principle in the past, which have resulted in serious and often irreversible damage to health and environments. Appropriate, precautionary, and proportionate actions taken now to avoid plausible and potentially serious threats to health from EMF are likely to be seen as prudent and wise from future perspectives. We must remember that precaution is one of the principles of EU environmental policy,” says Professor Jacqueline McGlade, executive director of the EEA. (EEA Report 2007) The Austrian Medical Association recommended to the public, in 2005, to use wired internet connections instead of Wi-Fi. Vienna Resolution: “The currently used national and international practiced strategy to determine limit values is extremely conservative, it urgently demands replacement by the precautionary principle, similar to strategies in many other sciences. The ‘Salzburg-model’ showed that neighbor involvement and a precautionary limit value of 1 mW/m2 EMF-flux-density can be achieved even for the sum of all GSM frequencies without technically compromising the quality of the GSM net.” Salzburg Resolution (Austria): In 2000, the Salzburg, Austria Resolution was passed with regards to telecommunications base stations. They stated, “Presently, the assessment of biological effects of exposures from Continued on page 40

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Why Fi?, from page 39 base stations in the low-dose range is difficult, but indispensable for protection of public health.” There is, at present, evidence of no threshold for adverse health effects. It is recommended for existing and new base stations to exploit all technical possibilities to ensure exposure is as low as achievable (ALATA-principle). In addition, the protocol should include considerations on existing sources of HFEMF exposure. Benevento Resolution 2002 (Italy): “More evidence has accumulated suggesting that there are adverse health effects from occupational and public exposures to electric, magnetic and electromagnetic fields, or EMF, at current exposure levels. What is needed, but not yet realized, is a comprehensive, independent, and transparent examination of the evidence pointing to this emerging, potential public health issue. Resources for such an assessment are grossly inadequate, despite the explosive growth of technologies for wireless communications as well as the huge ongoing investment in power transmission. There is evidence that present sources of funding bias the analysis and interpretation of research findings towards rejection of evidence of possible public health risks.”

The Porto Alegre Resolution 2009: Co-sponsored by the Brazilian Health Ministry and the International Commission for Electromagnetic Safety, May 18, 2009. “We agreed that the protection of health, well-being, and the environment require immediate adoption of the Precautionary Principle… for the establishment or modification of nonionizing radiation exposure standards.

We recognize that, in Brazil as well as all over the world, where there has been an unprecedented explosion in the availability and use of non-ionizing electromagnetic fields for electrical and wireless communications technologies (mobile and cordless phones, Wi-Fi and WIMAX networks, RFID, etc,), as well as major electrical grid and wireless broadband infrastructure changes, this assessment should inform risk management to take proper steps to protect the public from long-term, low-level exposure to extremely-low frequency, as well as radio frequency electromagnetic fields, that have substantially increased in the ambient environment in recent years. The exposure levels at which these effects have been observed are many times lower than the standards promulgated by the International Commission for NonIonizing Radiation Protection (ICNIRP) and the IEEE’s International Committee on Electromagnetic Safety (ICES). These standards are obsolete and were derived from biological effects of short-term high intensity exposures that cause health effects by temperature elevation and nerve excitation discovered decades ago. We are deeply concerned that current uses of non-ionizing radiation for mobile phones, wireless computers, and other technologies place at-risk the health of children and teens, pregnant women, seniors, and others who are most vulnerable due to age or disability, including a health condition known as electromagnetic hypersensitivity. We strongly recommend these precautionary practices: 1. Children under the age of 16 should not use mobile phones and cordless phones, except for emergency calls;

2. The licensing and/or use of Wi-Fi, WIMAX, or any other forms of wireless communications technology, indoors or outdoor, shall preferably not include siting or signal transmission in residences, schools, day-care centers, senior centers, hospitals, or any other buildings where people spend considerable time; 3. The licensing for siting and installation of infrastructure related to electrical power and wireless broadband telecommunications, particularly, cellular telephony, Wi-Fi and WIMAX, should only be approved after open public hearings are held and approval granted with full consideration given to the need to apply the Precautionary Principle. Sensitive areas should be avoided to protect vulnerable populations; 4. Mankind shall be encouraged to continue to discover new means of harnessing non-ionizing electromagnetic energy, aiming at bringing benefits to society, through definition of new standards of human exposure, which are based on the biological realities of nature and not solely on the consideration of economic and technological needs.”

Who Is Opting Out of Wi-Fi? Those opting out of Wi-Fi are doing so for a variety of reasons, including public health protection, data security, and better data retrieval with a wired connection. The France National Library in Paris, July 2008, placed a moratorium on Wi-Fi in their four tower buildings for reasons of improved research quality with cabled connection as well as applying the

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Precautionary Principle, due to evidence of harm from Wi-Fi. Herouville St. Clair, Normandy France Schools: In April 2009, all Wi-Fi from primary schools was removed and the city may, after study, limit emissions from cell towers or remove the antennas.

Recommendations

Reviews:

•

Children under 16 should not use cell phones or cordless phones, except in an emergency.

•

Use cables wherever possible. Advantages of cabled networks are speed (Wi-Fi is slower than wired networks), security (Wi-Fi is insecure – even with WEP or WPA encryption), and reliability (Wi-Fi is often known to drop connections).

1. Pathophysiology 16: Special Issue Volumes 1 and 2, including Sage C. Carpenter DO. 2009. Public Health Implications of Wireless Technologies. Volume 16, August 2009, Pages 67250. http://www.sciencedirect.com/ science/journal/09284680. Scroll through previous or next volume tab.

Salzburg, Austria Schools: In 2005, the Public Health Department of Salzburg, Austria region adopted a policy of no Wi-Fi or DECT phones in schools, based on reports of sensitive people who develop symptoms of difficulty with concentration, memory problems, headaches, restlessness, etc.

•

Frankfurt Local Education Authority and the German Teachers Union banned Wi-Fi in schools.

If it is not possible to remove your wireless connections, it is advised that you take other precautions and do not sit in close proximity to a wireless router (keep it in an unoccupied room, if possible).

2. BioInitiative Working Group, Cindy Sage and David O. Carpenter, Editors. BioInitiative Report: A Rationale for a Biologicallybased Public Exposure Standard for Electromagnetic Fields (ELF and RF) at www.bioinitiative.org, August 31, 2007. http://www.bioinitiative.org/

•

Turn off any wireless devices at night time while you sleep, as these devices emit microwaves at all times, not just when the device is transmitting data. Plugging electrical cords into a surge protector works well with an easy onoff switch.

3. European Environmental Agency (EEA) Report 2000. Late Lessons from Early Warnings. The Precautionary Principle 1896-2000. Environmental issue report No 22. http://www.eea.europa.eu/publications/ environmental_issue_report_2001_2

•

Avoid using a wireless laptop on your lap for extended periods of time, as it radiates cell phone levels of RF. Put it on a table.

•

Avoid cordless phones, as the EMF is almost as strong as the cell phones. Land lines work very well.

4. European Environmental Agency (EEA) Report 2007. McGlade. Radiation from everyday devices assessed. http://www.eea.europa. eu/highlights/radiation-risk-fromeveryday-devices-assessed.

•

Use speaker phone option for your cell phone as much as possible.

•

Avoid wireless devices.

Lakehead University, Ontario, Canada: November 2009 policy states “there will be no Wi-Fi connectivity provided in those areas of the University already served by hard wire connectivity until such time as the potential health effects have been scientifically rebutted or there are adequate protective measures that can be taken.” Lawrence Livermore National Laboratory in California banned all wireless networks in 2002, including the most prevalent, Wi-Fi, from its grounds due to “security vulnerabilities,” according to USA Today, 1/28/02.

What to Tell Patients to Reduce EMF Exposure? Because of the uncertainty in science regarding the minimum nonionizing radiation level below which no adverse health effects can occur, and the long latency for low-dose exposure, the Precautionary Approach is suggested and it is recommended that EMF human exposure be kept to a minimum. Here are a few suggestions.

REFERENCES: Reviews, Scientific Articles, and Other Article Sections For a full report of all references, visit www.sccma-mcms.org and click on the “Going Green” tab.

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CLASSIFIED ADS VOLUNTEER OPPORTUNITies MAKING A DIFFERENCE AT ROTACARE Rotacare in Mtn View is one of nine clinics in the Bay Area serving uninsured patients. We have urgent need for more physicians and mid-level providers to provide care for adults and children. The clinic is held in the basement of YMCA building adjacent to El Camino Hospital in Mtn View. It is fully staffed with nurses, educators, translators, pharmacists, and other support staff. Malpractice insurance is covered by Rotacare. Hours of operation are Mon, Wed, Thurs evenings. Providers usually work 2.5 hours monthly, or according to availability. Specialists can see patients at Rotacare or arrange to have patients referred to their office. Our volunteers have found this a rewarding experience and a way to make a difference in our own community. For further information, please call Lila Steiner at 650/988-7948 or email Lila_Steiner@ elcaminohospital.org.

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MEDICAL/DENTAL CONDOMINIUMS FOR SALE OR LEASE

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OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage. We are currently looking for several knowledgeable and progressive primary care and specialty physicians Continued on page 46

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PRACTICE MANAGEMENT

THE NAVIGATION GUIDE An Evidence-Based Tool to Bridge the Gap Between Clinical Practice and Environmental Health Science By Patrice Sutton, MPH; Jeanne Conry, MD, PhD; Pablo Rodriguez, MD; Tracey Woodruff, PhD, MPH This article originally appeared in San Francisco Medicine, the journal of the San Francisco Medical Society, www.sfms.org. Rapidly accumulating evidence indicates that ubiquitous exposure to “everyday” levels of environmental chemicals can manifest in a wide range of adverse health outcomes across the human lifespan and generations.1,2 Approximately 87,000 chemical substances were registered for use in U.S. commerce as of 2006, with about 3,000 chemicals manufactured or imported in excess of 1 million pounds each,3 and 700 new industrial chemicals are introduced into commerce each year. Today, these chemicals are distributed throughout patients’ homes, workplaces, and communities, contaminating food, water, air, and consumer products. Everyone in the U.S. has measurable levels of multiple environmental contaminants.4 While many scientific questions remain, the strength of the evidence is sufficiently high that leading health care professionals and scientists have called for timely action to prevent harm.5-7 How have these calls to action reverberated in the trenches of clinical practice? The scientific evidence linking environmental contaminants and adverse human health impacts is voluminous and largely unfamiliar to practicing clinicians. There is no trusted, ready reference, or compendium to consult in order to provide patients with timely, evidencebased advice about their exposure to environmental contaminants (unlike the situation with pharmaceuticals). Hence,

providing evidence-based anticipatory guidance about environmental exposures is far outside the comfort zone and time constraints of most clinicians. Yet patients armed with Internet printouts are clamoring for advice about topics as wideranging as the potential for harm from the chemicals in their babies’ bottles to whether their workplace exposure to toxic chemicals will have an adverse impact on their pregnancies. Many more patients may be unaware of the preventable harms they and their families face from toxic substances in their homes, workplaces, and community environments. Health care providers have a professional and ethical responsibility

In an effort to speed the translation of environmental health science into improved patient outcomes, the University of San Francisco’s Program on Reproductive Health and the Environment undertook an interdisciplinary collaborative effort to develop the Navigation Guide, a systematic and transparent road map for evaluating the relevant scientific evidence. The Navigation Guide is based on contemporary methods of evidence-based medicine (EBM). The purpose of the Navigation Guide is to build a foundation that can be used to provide the practicing clinician with an easy, transparent, and quick way to incorporate the state of the science, patient values and preferences, and other factors into clinical care decisions.

Perhaps the most unfamiliar aspect of environmental health for the practicing physician is the need to advise patients about their exposures in the absence of human experimental data

Perhaps the most unfamiliar aspect of environmental health for the practicing physician is the need to advise patients about their exposures in the absence of human experimental data (i.e., randomized-controlled trials [RCTs]) linking the exposure to a health outcome. When it comes to advising patients regarding their exposure to environmental contaminants, a clinician should not wait for human experimental evidence—it will almost never be available. In the context of preventing adverse exposure to environmental contaminants, clinicians need to take timely action based primarily on scientific evidence from animal (in vivo) and in vitro studies. This can seem counterintuitive, because the use of in vivo and in vitro studies are not routinely part of daily clinical practice and are often misunderstood by clinicians as “weak” evidence.

to provide prevention-oriented guidance in all of these situations. By proactively intervening to protect patients from harmful environmental exposures linked to a myriad of chronic diseases and disabilities, health professionals can improve patient health outcomes more broadly.

However, in vivo and in vitro data are integral to regulatory scrutiny

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of compounds used every day in clinical practice. Pharmaceuticals are tested for toxicity and to ensure benefits outweigh harms before a physician can decide whether or not to prescribe the drug. Before a drug can even be tested in humans, the company or sponsor is required to perform in vitro and in vivo laboratory tests to discover how the drug works and whether it’s likely to be safe and work well in humans. Only after the substance has undergone toxicity testing can humans be exposed in RCTs. Finally, before a drug is approved for sale, an independent and unbiased review must establish that a drug’s health benefits outweigh its known risks. Therefore, in vivo, in vitro, and human experimental evidence—plus an analysis of risks and benefits—have all informed human exposure decisions prior to the substance’s entry into the marketplace. Once a drug is on the market, post-market RCTs are also possible (such as testing the comparative efficacy of two different drugs). In stark contrast, clinical practice decisions about patient exposure to exogenous substances in the environment must typically be made prior to regulatory scrutiny of a compound and in the absence of risk-benefit analysis, because of our current regulatory and legal structure for governing manufactured chemicals. Unlike the case with pharmaceuticals, the presence of a product on the shelf at the local chain store does not mean the product has been tested for toxicity and does not mean its benefits and harms have been compared. Advising patients about substances that lack regulatory oversight presents a very different decision context to the practicing clinician. Indeed, the vast majority of chemicals in commercial circulation have entered the marketplace without comprehensive and standardized information on their reproductive or other chronic toxicities.8 Ethical considerations also virtually preclude experimental human data from the evidence stream—one cannot experiment by exposing some

people to polluted water and others to clean water and then see what happens. Instead, human evidence in environmental health sciences is collected by observing how exposures are differentially distributed in the real world and measuring health outcomes among populations more (often occupationally) or less exposed. While of scientific import, studies that link workplace and/or community exposures to adverse health outcomes represent a failure of prevention. For example, animal data on the carcinogenicity of a variety of chemicals have preceded, as well as predicted, later epidemiological observations in humans, and strong evidence exists that experimental results can be extrapolated qualitatively to human subjects.9 Whereas an experimental animal carcinogenic study typically lasts two years, it can take twenty years to get a result from a comparable human study.9 Moreover, the benefits of environmental chemicals are mostly not health related, exposures are unintentional, and they vary and may or may not be significant, depending on the toxicity of the agent.

Guide by professional organizations will result in evidence profiles that provide uniform, simple, and transparent practice guidelines.

For all of these reasons, to protect their patients from harm related to environmental contaminants, clinicians must take timely action based on the same “upstream” in vivo and in vitro indicators of potential harm that keep (or should keep) toxic drugs with no patient or population benefits off the market. The Navigation Guide is a systematic way to compile, rate, and sort the evidence stream to make it easy and quick for clinicians to confidently do just that.

Patrice Sutton, MPH, is a research scientist in the Program on Reproductive Health and the Environment at UCSF. Jeanne Conry, MD, PhD, is chair of the American College of Obstetricians and Gynecologists, District IX, assistant physician in chief of Obstetrics and Gynecology at Kaiser Permanente North Valley. Pablo Rodriguez, MD, is associate chair of obstetrics and gynecology and clinical associate professor in the Department of Obstetrics and Gynecology at Brown Medical School and Women and Infants Hospital of Rhode Island. Tracey Woodruff, PhD, MPH, is associate professor and director of the Program on Reproductive Health and the Environment. Visit http://prhe. ucsf.edu.

The Navigation Guide is a systematic, transparent EBM methodology that is a key step in moving the emerging science in environmental health directly, rapidly, and easily into the exam room— where it can make a difference to the health of patients and their families. The urgent need to address the role of the environment on patient health is increasingly gaining traction in state and national professional societies of physicians and other clinical care providers. Uptake of the Navigation

To this end, the American College of Obstetricians and Gynecologists’ District IX, which represents more than 5,000 California physicians, is actively engaged in the development of the Navigation Guide to support the clinical practice of its state and national fellows. Likewise, Planned Parenthood Federation of America, whose affiliates serve more than three million women and men per year throughout the U.S., is a key partner in developing the Navigation Guide. The Navigation Guide is currently in the final stages of development. We anticipate its publication in late 2010 in a peer-reviewed journal. We hope that by 2011 it will begin to provide these and other professional organizations with a currently missing tool in a much larger effort to address the health impacts of widespread patient exposure to toxic substances in the environment.

References A full list of references is available online at www.sccma-mcms.org (click on the “Going Green” tab).

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PAGE 46 | THE BULLETIN | JULY / AUGUST 2010

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www.cpmc.org/services/heart PAGE 47 | THE BULLETIN | SEPTEMBER / OCTOBER 2010

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