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May 22, 2008

Jeremy A. Lazarus, MD
Member, Board of Trustees
American Medical Association

CleanMed 2008
Hilton Pittsburgh
Pittsburgh, Pennsylvania

Good morning. What an amazing conference to get to participate in.

I'm proud to be here to represent the President of the American Medical Association, Dr. Ron Davis. And I need to tell you that the only reason he's not here himself is, just a few months ago, Ron was diagnosed with pancreatic cancer.

Many of you know how slim the odds of beating that particular cancer are. The survival rate five years after diagnosis is less than five percent. It's what took Vince Edwards, who played Ben Casey, MD. It killed New York's Mayor LaGuardia, the actor Michael Landon, the dancer Juliet Prowse, songwriter Henry Mancini, the psychiatrist and author M. Scott Peck, and the hard-boiled detective story writer Mickey Spillane. You've probably heard that actor Patrick Swayze has it right now.

Ironically, Dr. Davis is a preventive medicine physician. He's only in his 50's. He's stayed in terrific shape — slim and trim. And Ron's waged a personal war - there's no better word for it — against tobacco, against alcohol abuse, and against unhealthy eating for his entire professional life.

Many of you are familiar with Randy Pausch, the computer science professor at Carnegie Mellon who was diagnosed with pancreatic cancer. Over six million people have watched what he called his "Last Lecture" online. It's just come out as a book as well, and it's nothing short of inspirational.

Well, in the AMA, we feel the same way about Ron Davis.

Because of his treatments in his native Michigan and also in Houston, he's had to turn down most of his speaking events, especially those outside the Great Lakes region. He felt so strongly about this conference, though, that this was going to be a rare exception. Unfortunately, he had a bad reaction to his most recent round of chemotherapy.

His plan is to remain active writing articles, and to still speak at the venues closer to him. He's also set up a Care Page, a personal medical blog telling how he's doing every couple of weeks or so. Thousands of people are checking it out online, just to check in on him now.

So if anybody here's interested, he's said it's fine to let you know it's at www.carepages.com. Just sign up, then search for his name, Ron Davis, with no space between the two names.

The bottom line is, though: He's continuing to lead the AMA, and he's inspired us all.

Ron's still got a wonderful sense of humor, so he even provided me with a joke to start thing off. I'm not really sure about it, though.

You see, Ron's a public health physician, and I'm a psychiatrist. Guess who comes out on the butt end?

Well, anyway, he thought I should tell you about my patient who thinks he's a tree, since that at least has something to do with the environment.

This man couldn't come into the office because, of course, he was supposedly "rooted" into the ground at his home. So his wife came to visit and complain.

Of course, I asked her the obvious question. What kind of a tree was he?

She said it actually varied by season. In the spring, he was a cherry tree. In the summer, it was peach. And in the fall, he was an apple tree.

I told her he clearly needed help, and that I'd be happy to make a house call. But depending on the severity of his delusions, it was certainly a possibility I could cure him.

She said, "Well, Doc, that's actually what has me worried. You see, I'd like to have my husband back. But right now, the whole family really appreciates the fruit."

Hey, it's not my fault, blame Ron Davis.

Anyway, it's true that as a psychiatrist, my experiences with environmental issues do tend to be significantly different from those in the public health arena.

For example, I have quite a few patients who are obsessed about global climate change.

I try to be reassuring to them. But truth be told, I'm probably more worried about my patients who aren't worried about climate change.

I'm a marathoner and a triathlete, so it's important to me to eat right. The continental breakfast served here this morning was excellent.

One of my pet peeves is going to a medical conference where the breakfast is bacon and eggs. Or bagels and cream cheese. Or Danish pastries with that sugary stuff drizzled on top.

And for lunch, when we go around speaking medical students and residents, sometimes it's too hot dogs or pizza. Doughnuts are always popular at fund-raising events. And medical society dinners tend to have enormous pieces of prime rib.

But besides being bad for us, it's hypocritical to then turn around and tell our patients to improve their nutrition.

What's even more embarrassing is hospital cafeterias with unhealthy food. Especially if they include a fast-food restaurant.

We know there's an obesity epidemic in this country, and what that does to diabetes, hypertension, heart disease, arthritis, and several other conditions. The question is: Why don't we practice what we preach?

Well, at the AMA Board of Trustees meetings now don't just talk the talk. We walk the walk. We know that we are what we eat.

At our breakfasts, we now have fresh fruit, oatmeal, cold cereals, juices, skim milk, turkey sausage, and scrambled eggs made from a cholesterol-free egg substitute. That's not my favorite, but the taste can be spiced up with salsa and chopped tomatoes and green peppers, instead of ham and cheese.

We're trying to get our own house in order, or at least our kitchen. Most of us are now eating right, and we get more physical activity and exercise. We're even making sure our meetings are held in cities with smoke-free workplaces. It's just part of trying to set a good example.

Well, now it's time for us physicians to do the same with the environment.

Last year, the Health Care industry as a whole comprised about 16 percent of our nation's Gross Domestic Product. That amounts to a huge footprint on our environment, no matter what - 2.3 trillion dollars worth. And that number is projected to rise to 20 percent of the GDP by 2016. Can you say 4.2 trillion dollars?

So not only what we do as far as caring for our population, but how large we are, allows our industry to take leadership. I'm talking about calling for new ways of making materials, new ways of growing and distributing food, and new ways of building buildings.

We in this room should try to use our clout to get products to be less toxic, to improve more sustainable agriculture, and to show some real leadership in developing energy efficiency.

Hospitals can use their purchasing power to help change the way we as a society make products, and build buildings, and grow food. For example, healthy food is more than improving nutrition. Working to improve food production helps with related issues like antibiotic resistance, and with the general pollution that comes from the waste from the industrial food system.

Doctors are opinion leaders in American society. In every society, really. And poll after poll shows we're still greatly trusted by the American people.

Well, a doctor's first promise is to "do no harm".

We're supposed to educate people on how to avoid disease through healthy living. An ounce of prevention, and all that.

But more and more, we're discovering how closely the health of the individual is connected to the health of our ecosystem.

As physicians, we get to play a vital role in bridging the scope of prevention from the individual to the environment. Because just like with individuals, a preventive approach with environmental issues makes more sense.

When we think about healthy food nowadays, we need to think beyond individual nutrition. We need to think how food is produced. And then, how does that production affects both individual health and global health?

We have to worry about some critical issues now:

  • Worker health and safety
  • Socio-economic health
  • Air and water quality
  • Hormones
  • Pesticides
  • Non-therapeutic antibiotics
  • Climate change

Seven out of every ten Americans die each year of a chronic disease. Three in particular — asthma, non-Hodgkin's lymphoma, and breast cancer — are on the rise. And what's especially troubling about those three is that they've been linked to toxic pollutants.

As have several other chronic diseases. In fact, it's now become a public health necessity to pay more attention to air and water quality, global climate change, the general degradation of the environment, and toxic chemical exposure. The CDC issued a report three years ago about exposure to 148 potentially toxic chemicals found in our environment.

Our health care system does a pretty good job in diagnosing and treating illness, and in alleviating pain and suffering. But our actions in regards to the environment have a ways to go.

One big problem area is medical waste incinerators. They're used by many hospitals to burn garbage. That can mean trash in the reception area to waste material in the O.R.'s.

But when those incinerators burn it, they're a major producer of dioxin, which you all know is a particularly potent carcinogen. In the mid-1990s, the E.P.A. found that medical waste incinerators were the #1 source of dioxin in the U.S. And we won't even talk about them also being responsible for 10 percent of mercury emissions in our country.

Dioxin can form when polyvinyl chloride plastic, which we all know as PVC, or the "poison plastic," is burned. PVC plastic is the most widely used plastic in medical devices like I.V. bags and tubing. There's also PVC in many health care facilities' furnishings — in the flooring, the carpet backing, the wall coverings, the doors and the windows.

If that wasn't bad enough, PVC plastic exposes patients to the phthalate DEHP, which is used to soften the medical devices that are made of PVC plastic. In animal studies, researchers have found that phthalates cause damage to the liver, kidneys, lungs, and reproductive systems.

Medical devices made of PVC plastic can leak DEHP, and several government reports have found that many patients have been exposed to potentially unsafe amounts of DEHP while receiving medical care.

And researchers at the Harvard School of Public Health found that babies in neonatal intensive care units experience a high exposure to DEHP.

The good news is that a number of health care institutions are working toward eliminating the use of medical and building materials that include PVC and DEHP, and several already have stopped using them.

So one way for hospitals and health care facilities to become "greener" is to use alternatives to PVC and DEHP.

What else can we do?

  • We can stop using mercury.
  • We can stop using hazardous flame retardants, and harmful pesticides.
  • We can be more careful whenever we do have to use problematic chemicals.
  • I bet almost all of us can recycle more efficiently and more thoroughly.
  • We can use bio-based flatware that's biodegradable.
  • Native plants around our buildings improve the water quality and save water.
  • Composting operations improve the soil around the area.
  • And we can make sure new buildings are green from the earliest planning stages.

The list goes on and on.

Some of these great ideas that I've mentioned and that come from across the spectrum in this room, are more difficult and costlier than others.

Here's one that isn't. Concentrate on serving fresh, local, and organic foods. Hospitals ought to buy meat and poultry that were raised with no non-therapeutic antibiotics. They should use milk produced with no recombinant bovine growth hormone. They need to replace the unhealthy snacks found in vending machines with some healthy choices.

Another option is to host farmers markets, either on hospital grounds or nearby. Admittedly, that would be harder, but just imagine the positive message that would send.

We now finally have some health care systems professionals who understand the need for more eco-friendly hospital settings. You all know about the Global Health and Safety Initiative. Many of you are leaders in it, "greening" the health care industry, and improving patient safety.

But health care systems aren't the only part of the health care sector that can better support the environment. All stakeholders, including physicians, should work toward making health care greener.

We American doctors can find some inspiration from the Canadian Medical Association. Last month, they announced they'll add environmentally preferable practices to all aspects of their meetings. Whenever possible, they're going to donate leftovers to food banks. They'll reduce and eliminate waste, including a stop to serving bottled water. They'll turn off lights and escalators during off hours. And they're replacing paper reports and agendas with Web-based directories.

Last year, our president attended their first green annual meeting in Vancouver, and was really impressed. The meeting produced significantly less trash, partly because a number of delegates used laptops instead of paper reports.

All the attendees also received a ball-point pen with a biodegradable encasing made from Mater-Bi. That's a cornstarch-based "bioplastic" material that breaks down into carbon dioxide, water, and organic humus when discarded into soil. And the cap on each pen contained a tomato seed that will sprout once it's "planted" — so to speak.

The AMA's policy is for physicians to be spokespersons for environmental stewardship, and to urge the medical community to cooperate in reducing or recycling waste. We also partner with publishing vendors who are environmentally sensitive. We ask them to use a combination of recycled material, recyclable paper, and reusable material whenever possible.

Earlier this month, the building that houses our Chicago headquarters launched a new recycling program that includes specific containers on each floor for bottles, cans, and plastics. We're making it easier for people to do the right thing.

And there's always more we can do. JAMA, the Journal of the American Medical Association, recently published an article by Dr. Paul Auerbach of the Stanford University School of Medicine. He listed several other ways that physicians can become more aware and involved in environmental issues.

One suggestion that I think deserves to be highlighted is for medical schools to offer an elective course on the connection between environmental issues and human health. Taking that a step further, environmental awareness could also be part of physicians' professional development, probably with a continuing medical education tie-in.

We recently heard from a homeopathic doctor in a small private practice who found out we were interested in improving our green factor. She wrote: "For the first time in years, I am proud to say that I am a member of the American Medical Association."

Her office is in a condominium complex in Scottsdale, Arizona, and she specifically chose materials with no outgassing, including wall board, insulation, paints, furniture and carpeting. It cost her about 25 percent more to build it that way. But she's convinced it was worth it, both for her patients and her staff.

Many of those patients not only can't work in a normal office building because of all the chemicals, they couldn't see their regular physicians with any degree of comfort, because of all the chemicals and odors in the standard office. They don't have that problem with her. She and her staff got rid of all the artificial and toxic petrochemicals. They use vinegar and alcohol for cleaning. And they avoid artificial scents like the plague.

And physicians can be good citizens as well. As community leaders, we can and should look into joining various environmental organizations, and supporting them with our medical expertise. From smaller local ones to the amazing organizations that are co-sponsoring this incredible conference.

Preventive medicine for the globe. We have to be realistic, because that's a hard sell. It's a hard sell just to the individuals who want to smoke, engage in risky behavior when it comes to drugs, alcohol and sex. Or to those who can't stay out of fast food restaurants, and who don't want to get up off the couch and exercise.

Well, it's even harder when it's a problem for everybody. So we definitely have our work cut out for us. All of us.

It comes down to dollars as well, and perhaps that will motivate some. If we're successful focusing on prevention, we should also be able to show we can reduce the need for some health care services. That would in turn bring down health care costs. And that ought to decrease the environmental footprint, just as a by-product.

Thinking about prevention would not only help us examine excessive or unnecessary diagnostic or therapeutic interventions. It would help us look twice at the added costs and risks with impacts on the environment, too.

My last point is this: We physicians have pledged to "do no harm." When we broaden our approach to health care, and we include environmental factors, the bottom line is that we practice better medicine. We promote good patient care. And we make good on our promise to do no harm.

Thank you all for your leadership in health care, and working with physicians so we can jointly demand what's best for our patients, our colleagues, and health care in general. It's truly been my honor to be here with you this morning. The AMA applauds you all.

You're the forward-thinkers dedicated to the movement to make the world a healthy place. And all I ask of you, is that you continue on with the passion that this agenda so clearly deserves.

Thank you very much.

I believe we have until the end of the hour. I'd be happy to take your questions, and hear your thoughts about what physicians could perhaps do better.