Symbiosis Vol 2, No 3

The recently coined phrase Ecologically Sustainable Medicine reflects a growing awareness of the interdependence of human health, environmental health, and health care practices. Professionals learning about ESM often ask about the meaning of the word sustainability. The term has many layers of meaning. This article considers modern definitions of sustainability in the context of medical ethics.

The term sustainability found its way into our vocabulary in 1980 with the publication of World Conservation Strategy (1), and Building a Sustainable Society (2) by Lester Brown, founder and former president of Earthwatch Institute. A simple definition is “achievement of a balance between human impacts and the capacity of the natural world that can be sustained indefinitely, taking into account three interdependent elements: the environ¬ment, the economy and the social system.” (3)

In 1987, the Brundtland Report (4), as it is now called, was published by the United Nations Commission on Environment and Development. This report is one of the first to use the term sustainable development to describe the potential for humanity to “meet the needs of the present without compromising the ability of future generations to meet their own needs.” The report noted that sustainable development has different meanings and implications in affluent nations than it does in poor nations. Affluent nations must adopt “life-styles within the planet’s ecological means,” to move towards sustainable development. This places a “limit on the present state of technology and social organization on environmental resources.” For poor nations, sustainable development requires “meeting the basic needs of all and extending to all the opportunity to fulfill their aspirations for a better life.” Poverty, due to its instability and the potential it poses for catastrophic degradation of local environments, threatens sustainability. Thus, different socioeconomic issues imply two very different goals for sustainable development. The underlying theme requires “population size and growth in harmony with the changing productive potential of the ecosystem.”

Key to the theory of sustainability is the ability of the ecosystem to maintain functional equilibrium for human populations. Only during the last 40 years have human beings have seriously threatened the stability of the earth’s ecosystems. In his article, A General Statement of the Tragedy of the Commons, (5) Herschel Elliott sets forth four premises that lead to the breakdown of ecosystems.
These are:

1. The Earth is finite: it has a limited stock of renewable fuels, minerals, and biological resources, a limited throughput of energy from the sun, and a finite sink for processing wastes.

2. Although human activity very often does occur on privately owned lands which are not a commons, that and all other human activities take place in some larger natural commons. And that larger commons is a limited biosystem, which is in a dynamic, competitive, and constantly evolving equilibrium. The equilibrium of an ecosystem can usually accommodate any activity on the part of its members as long as that activity is limited in amount and/or is practiced only by a small population. But continuous growth in the numbers of any organism or in its exploitation of land and resources will eventually exceed the capacity of the ecosystem to sustain that organism.

3. Now, for the first time on a global scale, human beings are exceeding the land and resource use that the Earth’s biosystem can sustain.

4. Individuals who seek to maximize their material consumption contribute to the ever-increasing exploitation of the world’s commons. But it is also true that all who follow the rarely questioned principles of humanitarian ethics—to save all human lives, to relieve all human misery, to prevent and cure disease, to foster universal human rights, and to assure equal justice and equal opportunity for everyone— do so also.

1. Brown L. Building a Sustainable Society. New York: W. W. Norton; 1980.
2. International Union for the Conservation of Nature and Natural Resources. World Conservation Strategy. Author; 1980.
3. Towards sustainability: learning for change—a report to the citizens of British Columbia. March, 1993.
4. United Nations Commission on Environment and Development. Brundtland Report [Our Common Future]; 1987.
5. Elliott, H. A general statement of the tragedy of the commons.
   Available at www.dieoff.com/page121.htm. Accessed May 30, 2005.

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Mercury: The Case of the Deadly
‘Fugitive Emission’

The Alice in Wonderland reference to the Mad Hatter alludes to the fact that chemicals, including mercurous nitrate—formerly used in hat-making to cure felt—could cause symptoms of mental illness. During the 1800s hatters working in poorly ventilated workshops would breathe in mercury vapor, and prolonged exposure to the mercury vapors caused mercury poisoning. Victims developed severe and uncontrollable muscular tremors and twitching limbs, called “hatter’s shakes”; other symptoms included distorted vision, confused speech, irritability, loss of memory, depression, anxiety, and other personality changes. This was called mad hatter syndrome.

The heavy metal mercury has a long history of use in human activities. In very small quantities, mercury conducts electri¬city, measures temperature and pressure, and forms alloys with almost all other metals. With these and other unique properties, mercury plays an important role as a process or product ingredient in a number of industrial sectors worldwide, including health care.

Metallic mercury is a thick, shiny, silver-white, odorless liquid; when heated, it is a colorless, odorless gas. Mercury can combine with nitrogen and carbon compounds, which metals typically won’t touch, as well as forming the usual metal salts. Mercury may occur naturally in the environment as elemental mercury (Hg or quicksilver); it may be dissolved in rainwater as (Hg +2); it may appear in a solid mineral form as cinnabar (HgS); and as methylmercury (HgCH3), an organometal. Thus, mercury pollution is found in air, water, and earth. Complicated organometallic mercury compounds catalyze the synthesis of a range of pharmaceutical and other man-made products.

Mercury released into the air from the burning of fossil fuels falls down directly onto waterways or is deposited on land where it can be washed into the water. Methylmercury demonstrates the most characteristic chemical trait of mercury—association. Bacteria in the water cause chemical changes that transform mercury into methylmercury, which then enters the food chain. The methylmercury that accumulates in the tissue of fish and other aquatic animals, which are used as human food sources, is the most toxic form of mercury to animals and humans. Over forty states have fish consumption advisories because of widespread mercury contamination.

HEALTH ISSUES
NEUROLOGICAL EFFECTS OF METHYLMERCURY
Mercury has been linked to numerous health effects in people and wildlife. It can cause early death, weight loss, and reproductive problems in wildlife. In fish, methyl¬mercury can concentrate to levels one million times higher than those in the surrounding water.

The most common ways that people are exposed to mercury are inhalation of inorganic mercury vapor after a spill or during a manufacturing process, or ingestion of methylmercury from contaminated fish. Mercury can pose a significant health threat when spilled in a small, poorly ventilated room. As a neurotoxin, mercury attacks the brain and the central nervous system, which is extremely sensitive to mercury and methylmercury. Children and fetuses are harmed by lower concentrations of mercury than it takes to hurt adults. In utero, mercury passed from the mother can cause brain damage, mental retardation, coordination problems, blindness, seizures, and the inability to speak in children; it can also pass to a nursing infant through breast milk. Infants and children exposed to toxic doses of mercury may have problems with attention span, visual-spatial skills, memory, and coordination (for example, delayed onset of walking), problems with language development; they may develop cerebral palsy, altered muscle tone and deep tendon reflexes, mental retardation, blindness, and seizures, and can have reduced neurological test scores. Exposure also appears to weaken the heartbeat and the developing immune system and can damage the kidneys. In March, 2001 a study from the Centers for Disease Control and Prevention sampled the mercury levels in the blood, hair and urine of women and children and found that one in 10 women have mercury levels high enough to cause their children neurological damage—putting about 395,000 babies a year in danger. Although fetuses and young children are especially sensitive to methylmercury, mercury poisoning can affect adults as well, and the effects may be subtle and not recognized immediately. Nervous system problems can include impaired coordination, tremors, irritability, memory loss, depression, blurred vision, and a tingling sensation in the skin. Other symptoms include fatigue, headache, decreased concentration and muscle or joint pain.

CARDIOVASCULAR EFFECTS OF METHYLMERCURY
More recent data show that mercury can also have negative cardiac effects in adults at levels well below those associated with neurological and developmental problems (>5.8 ?/L). It may be linked to increased blood pressure, irregular and increased heart rate, and increased rates of death from heart attacks in at least 12 scientific studies. There are inadequate human cancer data available for all forms of mercury, but methylmercury has been shown to cause kidney tumors in male mice. The EPA has determined that methylmercury is a possible human carcinogen.

MERCURY IN FISH
While fish is an excellent, low-fat source of protein, rich in Omega 3 fatty acids— which are important for fetal and child brain development and protective of cardiovascular health in adults—in recent years there has been increasing concern about the alarming amounts of methylmercury in some species. Larger and older fish tend to have the highest levels of mercury as mercury bio-accumulates. Short-lived, small fish tend to have the least. The EPA and the FDA published new and joint guidelines in 2004. The guidelines recommend that women of childbearing age as well as pregnant, or breast-feeding women and young children avoid four types of fish: king mackerel, shark, swordfish and tilefish because they contain high levels of mercury. The recommendations also suggest that these individuals eat no more than 12 ounces of fish a week and that they eat fish that are lower in mercury. The guidelines list shrimp, light tuna (skipjack), salmon, pollack and catfish as popular fish that are low in mercury. Especially at issue is albacore tuna, which children and others may eat frequently because it is easy to prepare, inexpensive, and a good source of protein; it has three times the level of methylmercury found in light tuna and represents about a third of the tuna sold in this country. It appears that much of this problem could be simply avoided if light canned tuna, rather than albacore or fresh tuna, were eaten. In California under Proposition 65, restaurants, supermarkets and canners are required to post a warning to consumers that fish contains mercury. See sidebar for a list of fish that are low in mercury. For more information on fish and mercury, you can call 1-888-SAFEFOOD or visit the U.S. Food and Drug Administration website at www.cfsan.fda.gov/seafood1.html

MERCURY USES AND ALTERNATIVES IN HEALTH CARE
Although other industries produce larger amounts of mercury waste than do hospitals and other health care facilities, mercury is so toxic that is important for the health care sector to eliminate it whenever possible; further, there are additional toxins produced by the industries that make equipment, devices, and chemicals for health care facilities. Hospitals contribute 4-5% of the total wastewater mercury load. Mercury-containing devices improperly disposed of in a landfill are also a potential source of harm. In 2000, the mercury from fever thermometers accounted for 17 tons or 10% of mercury in the municipal solid waste stream (see page 15 for our article on setting up a thermometer exchange program). Medical waste incinerators, as well as municipal waste incinerators, emit mercury when they burn wastes that contain mercury. Medical waste incineration is a leading source of dioxin, mercury, and other pollutants linked to cancer, learning disabilities, and other illnesses. The U.S. Environmental Protection Agency (EPA) states that medical waste incinerators are the fourth largest source of mercury in the environment. The good news in California, however, is that as a result of stringent air emission standards enacted in 1990 by the California Air Resources Board (ARB) for controlling dioxin production, only a few medical waste incinerators remain in operation in the state. In 1991 the ARB identified 146 medical waste incinerators in California, including 9 off-site treatment facilities. Today, there are fewer than a dozen medical waste incinerators. Although many facilities are now using alternative products that do not contain mercury, it is still often found in products such as thermometers, sphygmomanometers (blood pressure cuffs), batteries, dilation and feeding tubes, thermostats, and fluorescent lamps. Mercury from these products can be released to the environment during various stages of the product life cycle including production, transportation, manufacturing, use, and disposal. If the products are spilled, broken, or disposed of improperly, there is a potential for significant harm to human health and the environment. Elimination of methylmercury occurs very slowly with various half-lives of months to years. Teleosis partner Health Care Without Harm (HCWH) has developed a List of Mercury-Containing Items in a Hospital Setting, available at www.noharm.org/mercury/issue.

MERCURY REDUCTION IN HEALTH CARE: LONG TERM ECONOMICS
Typically, the cost of using mercury has been focused on the purchase price of the device. However, the true cost includes the potential for costly spills, adverse health effects, liability, regulatory compliance costs, and maintaining equipment and trained personnel to handle mercury releases. The Tellus Institute’s report “Healthy Hospitals: Environmental Improvements Through Better Environmental Accounting” proposes that environmental costs and benefit information can be incorporated into accounting practices to attain a more meaningful cost. Among these costs are setting up— permitting, installation; back-end—site closure, disposal of inventory, post-closure care; regulatory—training, monitoring, recordkeeping; liability—Superfund, personal injury, property damage; future regulatory compliance costs; employee safety and health compensation; organizational image. Cost-effective alternatives exist for virtually every mercury-containing product used in the health care setting. There are a number of websites that offer information on recycling and on alternatives to mercury containing products. In September 2001, Health Care without Harm and the Hospitals for a Healthy Environment (H2E) partnership merged their pledge programs for mercury elimination into one national pledge initiative. H2E is a partnership between HCWH, the American Hospital Association (AHA), the American Nurses Association (ANA) and the U.S. Environmental Protection Agency (EPA). Another resource is the Sustainable Hospitals Project—a clearinghouse for selecting products and work practices that eliminate or reduce occupational and environmental hazards (including a list of alternative health care products and practices), maintain quality patient care, and contain costs. The website for this project, which was developed by the University of Massachusetts at Lowell, may be found at www.Sustainablehospitals.org.

HIDDEN SOURCES OF MERCURY
In addition to medical equipment, devices, and chemicals, there are other, less visible products used in health care whose production involves mercury. Almost half of U.S. hospital waste is office paper and cardboard, and most of the paper products have been bleached with chlorine during the paper production process. Along with coal-fired power plants and automobile scrap yards as the largest emitters of mercury pollution are factories that produce chlorine, many of which use “mercury-cells.” In 1894, a process was devised to produce chlorine by pumping a saltwater solution (brine) through a vat of mercury, or “mercury-cell,” that catalyzes an electrolytic chemical reaction. While the majority of plants have replaced these with newer technologies that do not use mercury, a number of plants around the world have continued to use this outdated technology. There are currently nine mercury-based chlorine facilities in the United States. Releases from chlorine plants may in fact top power plants as the greatest source of mercury releases to air, because a certain amount of mercury that evaporates during routine operations escapes through unmonitored ventilation systems and other leaks and are lost—these are referred to as “fugitive emissions.” According to the industry reports, chlorine plants’ fugitive emissions are nine times greater than monitored mercury releases. Yet this is just an estimate, and such emissions may be even greater than the industry suggests. The lost mercury could be in the air, in the water, in the soil, or in the chlorine facility itself. By purchasing chlorine-free paper, health care facilities will contribute significantly to a healthier and safer environment.

ACTION URGENTLY NEEDED
As indicated above, the EPA and FDA published new and joint guidelines on mercury emissions in 2004. Unfortunately, one of these guidelines retracts a prior EPA commitment to protect public health by requiring, within three years, “maximum achievable control technology” for toxic pollution from power plants (the ‘rescission rule’). The other purports to require significant reductions in power plant mercury emissions; however, this “pollution trading rule” has such a delayed compliance time frame that the promised reductions will not actually occur for more than two decades. Further, what few people know is that an EPA-funded, peer-reviewed study by the Harvard Center for Risk Analysis working on behalf of the Northeast States for Coordinated Air Use Management (Harvard/NESCAUM) estimated health benefits of decreasing mercury emissions 100 times greater than EPA’s figures. The study also found that controlling power plant mercury pollution could save up to nearly $5 billion by reducing neurological and cardiovascular harm. In the past, the United States has led the international community on environmental issues—for example, when the EPA removed lead from gasoline. Now is the ideal time for us to again lead the way, using our technological ingenuity, by taking responsibility for the mercury pollution that originates here.

SOURCES

• Health Care Without Harm, www.noharm.org/mercury/issue.
• National Research Council 2000, Sustainable Hospitals Project, www.Sustainablehospitals.org.
• Tellus Institute’s 2001 report “Healthy Hospitals: Environmental Improvements Through Better Environmental Accounting”
• U.S. Environmental Protection Agency
• National Resources Defense Council, www.nrdc.org/media/pressreleases/ 050324.asp.
• Salonen JT, Seppanen K, Lakka TA, et al. Mercury accumulation and accelerated progression of carotid atherosclerosis: a population-based prospective 4-year follow-up study in men in eastern Finland. Atherosclerosis. 2000; 148: 265ˆ273. Available at circ.ahajournals.org/cgi/ content/full/106/21/2747#R20-118058.

Eco-Dentistry™

Creators of Transcendentist®,
A Model of Mercury-Free Dentistry

Walking along a jasmine-scented brick path and listening to the enchanting chimes of a Tibetan bell, you approach a building. Upon entering, you are offered a warm cup of tea and given a pair of slippers. As you remove your shoes and put on the slippers, you rest your feet on carpets of untreated wool, which are placed on floors composed of marmoleum, a vinyl alternative made from flax, wood flour, and rosin. Sitting in furniture made from recycled woods and upholstered with cotton, silk, and wool, and listening to the soothing sound of water flowing onto smooth rocks in a fountain, you are surrounded by wallpaper made from reclaimed paper pulp and bark.

You might have to pinch yourself to remember that you are sitting in a dental office—namely, Transcendentist®, on Ashby Avenue in Berkeley, California. The comfortable surroundings here were built primarily with renewable, reusable, and recyclable materials by the husband-wife team Fred Pockrass, DDS, and Ina Pockrass, pioneers who created the first fully eco-friendly practice in the country in 2002. Transcendentist® is certified by the Bay Area Green Business Program (www.greenbiz.ca.gov) and the East Bay Sustainable Business Alliance (www.sustainablebiz.org). By combining elements of a wellness spa with pain-free, environmentally sound dentistry, Transcendentist® transforms smiles with state-of-the-art techniques, biocompatible materials, and handmade restorations. Providing care that is good for both people and the environment, this model of eco-dentistry is a powerful example of Ecologically Sustainable Medicine.

This sustainable approach to dentistry incorporates ecologically sustainablematerials and practices that reduce the impact of medical procedures on the environment as well as protecting clients from toxic materials. Lighting and electricity is provided by renewable energy resources such as wind power, made possible by 3 Phases Energy Center (www.3phases.com). The Pockrasses utilize only recycled paper and environmentally safe cleaning products and service provided by Tibby Janitorial. They have reduced the amount of paper they use by implementing a digital patient charting system and using washable, reusable pure cotton terry bibs, which are washed on location. In eco-dentistry, the dental procedures involve a filtration system that ensures an environmentally sound disposal of extracted mercury fillings; this prevents contamination of waterways. Eco-dentistry utilizes digital imaging as an alternative to x-rays. This change reduces exposure to radiation by 75-90%. In addition, they use steam-based instrument sterilization,eliminating the use of harmful and toxic chemicals.

Since graduating from McGill University in Montreal, Canada, Fred Pockrass has been practicing general and restorative dentistry for over 23 years. After eight years in practice, he fulfilled a lifelong dream of studying with a meditation master in India. While in the Himalayas, he created a Western-style dental clinic where he served as personal dentist to a renowned Indian guru and provided dental care to clients from around the world until late 2000. Dr. Pockrass has a degree in meditation and is a certified Tai-Chi teacher, and lifelong yoga practitioner. Ina Pockrass, J.D., has a background in intellectual property law and has been a partner in several prestigious law firms; she is also chair of the board of directors of Circle of Life, the nonprofit founded by Julia Butterfly Hill. She is a lifelong meditator and a practitioner of yoga and NIA™ movement techniques. The staff at Transcendentist® integrates exceptional ecologically-sustainable dental care and such spa-type services as tea, slippers, and foot rubs in the dentist’s chair—a fulfillment of Ina’s dream to “create a model where the consciousness of the environment and the human beings we were serving came first.”

In the true ecological spirit of interdependence, the Pockrasses give back to the community that supports them. When someone refers a client to Transcendentist®, they make a donation to a non-profit in honor of the referer. They have donated toothbrushes for children in El Salvador and hosted community programs on topics ranging from Chinese herbs to women’s wellness and meditation.

To learn more about the principles and practices of eco-dentistry, Teleosis executive director Joel Kreisberg spoke with them in their Berkeley office.

JK: Would you share with the readers of Symbiosis the inspiration and vision that led to the creation of Transcendentist®?

IP: I was very inspired by Julia Butterfly Hill. I am the chair of the board of Circle of Life, the organization she founded. One saying that she often uses resonated with me profoundly—Mahatma Gandhi’s, “be the change you want to see in the world.” Don’t just talk about it, but actually be that.

FP: We were also inspired by our own personal experiences. As we were designing our space we were fortunate to be invited into many offices in the Bay Area, and a number of them were newly created. Brand new, fresh dental offices. There was one in particular where I had an incredible allergic reaction. We knew that there must be off-gassing coming from the paint and the carpets. I had never experienced that before, so it really caught me by surprise. We realized that we are the human beings who live in this kind of environment eight hours a day. Our clients come in for about an hour at a time. We wanted to create a space where everyone would feel comfortable.

JK: So it began by creating a space for yourselves, as the primary occupants?

FP: Sustainability—ecological sustainability —really begins with the first person, and that’s you. It’s the old adage, “Physician heal thy self.” First you heal yourself on an emotional level, on a physical level, on a spiritual level. Once that healing takes place, then as a doctor you will be much more effective in being able to offer guidance and healing to your clients. When you open yourself up to transformation, the mirror reflects both ways.

JK: Is Transcendentist® a holistic dental practice?

FP: We don’t call ourselves holistic, but rather we are whole-person oriented. We are whole-person centered, so we relate to each person as a whole person. Meditation is a big part of that. First and foremost, the dentist needs to meditate, then encourage the staff to meditate, because when the dentist is peaceful, that peacefulness will radiate. We use various types of meditation and other ancient methods that guide your brain to go into deeper and deeper states of relaxation.

JK: How do you manifest and maintain your vision through your office space?

FP:We set out intentionally to create a healing environment. First and foremost, we wanted it to be an environment where we could help people transform their previous experience of what it meant to go to the dentist. So, Transcendentist® is about transformation of your experience. It’s about health, beauty, and wellness; it’s also about discovering your inner smile. It’s really about transforming your whole experience. We took a client-centered approach rather than a doctor-centered approach. We wanted our space to feel more like a spa, or like you were walking into your best friend’s living room. A place where you would be warmly welcomed with beautiful music in the background, beautiful plants, organic teas, comfortable furniture to sit on, pleasing sounds of music, and attractive sights and smells that didn’t have the typical dental office sounds and smells.

JK: So the built environment is sustainable. What are some of the techniques you implemented that qualify as ecologically sustainable?

FP: We have a healthy gum program, which is a nonsurgical approach to healthy gums. It’s now known that gum disease affects your cardiovascular system. There are linked effects to your immune system. There are normally over 200 species of microorganisms in your mouth, but when you have gum disease bacteria are able to permeate your gum tissue and get into your bloodstream. This affects so many other areas, not just the gum tissues. Very typically our clients tell us they don’t feel any pain during our nonsurgical gum therapy approach.

JK: In addition to a reduction in pain, are there other benefits of this nonsurgical approach?

FP: The day after treatment, clients say they feel a sense of lightness and well-being and an overall sense of greater vitality. This makes sense, because you’re clearing the bacteria out of the mouth. The mouth feels fresher, the breath feels fresher, and digestion improves. Everything feels so much lighter, because you are getting rid of all those toxins that would otherwise just be sitting in your mouth as the focal point of infection.

JK: It sounds as though there is an immediate relief from the removal of toxins. How do you ensure that the treatment room itself is not being contaminated by these procedures?

FP: We run negative ion generators in all of our rooms. We have special hi-tech filter systems that both clean and purify the air. These hi-tech filter systems run a UV light plus a HEPA filter, plus the negative ion generator. The air in the rooms is constantly being cleansed. We are trying to protect ourselves as well as our clients. I think we’re at more risk to exposure than our clients are. So for myself and for my staff, we put those systems in place. When we built the office we also put in a mercury separator system on our suction systems. We worked with an OSHA consultant because we wanted to make sure that everything we were doing was up to standard and even beyond that. We wanted to set up a very new type of a practice, but we wanted to do it in such a way that we were really dotting our i’s and crossing our t’s, so we sought guidance from an OSHA expert.

JK: I’m impressed with your efforts. What are some of the alternatives to chemically based, toxic solutions and processes that came out of this consultation?

IP: We wanted to be sure that our infection control procedures were sound. The consultant recommended that rather than using toxic disinfectants in our treatment rooms, we use something called CaviCide®. It’s used in neonatal care units, so it’s hospital grade, extremely low in toxicity, and it’s extremely effective. Another decision was whether to use traditional x-rays or digital imaging. Digital imaging was 75-90% less radiation and did not involve any toxic x-ray development chemicals. It cost more, but we decided to buy the digital. And we wanted to have our patient bibs be reusable, not something that you would throw away, so we bought cotton ones that we wash onsite in our energy efficient machines. We had our OSHA consultant work with us on what constellation of detergents and disinfectants we could use that weren’t chlorine-based and weren’t polluting the environment. So when we were deciding what kind of sterilizer to buy, we chose a steam rather than a chemical sterilizer. Instead of using a lot of paper pouches for instruments, we have cut way back on that and now sterilize instruments in reusable towels.

FP: It’s actually a surgical drape that you wrap the instruments in and they go through the ultrasonic to sterilize. Everything gets wrapped up in these surgical drapes and that passes through the whole disinfection system, so when you open them up, you have a sterile tray and the instruments in there. There is nothing disposed and it’s all reusable.

JK: I know that you have a mercury amalgam separator. Is there a standard protocol for this type of extraction?

FP: We follow the safety protocols that were set out by the IAOMT, which is the International Association of Oral Medicine and Toxicology. The safety protocol includes providing an independent air supply through a nose piece. Some clients decline, but some choose to use that process.

IP: And we provide a cloth to cover the face while the procedure is going on.

FP: We only remove mercury amalgam in the presence of a mercury dam. This is a little latex sheet that sits over your teeth and protects your mouth so that none of the little chunks or bits of the old filling can fall into your mouth, so you don’t have to worry about swallowing them. That’s a big concern. People say, “Well, I heard it’s more dangerous to get my fillings out than to leave them in.” We always put on a rubber dam, which helps to isolate the mouth, and it allows us to just see the tooth we’re working on.

JK: What other practices do you use to make this experience more ecologically sound?

FP: In terms of ecological dentistry, or eco-dentistry™, as we’ve coined it, we use a combination of guided mediations. For example, take the process of numbing or freezing. We guide our clients through a type of hypnosis approach as they are getting the numbing. So, we pre-numb the area first with a topical cream. Then we’ll do a guided breathing exercise with our clients, and very often they report that they didn’t feel anything at all; or if they felt something, it wasn’t painful. It’s something that all dentists can do. What we believe makes the difference is truly honoring each person who walks through the door. It’s not a tooth that walks in the door; it’s a whole person.

JK: How do you ensure patient buy-in with these treatments?

FP: We spend a lot of time educating our clients, so the very first contact with the clients is not done in a treatment room. Our first contact with clients is done in the consult room. Here, we sit knee-to-knee, eye-to-eye, and we talk. We like to find out what the client’s expectations are. Why are they here and what are they looking for? What have their previous experiences been in dental work? We want to find out who our clients are. Then, when we get into the more clinical phase, we want to find out what’s going on with their mouth, how healthy are their mouths? Is there disease present? How could we help to resolve the problems and help people to stay healthy?

JK: How are your clients responding to this shift in dental care?

IP: It is profound. I’ll just give you an example of a person who had not been to the dentist in more than seven years. A highly educated man with plenty of financial resources; it wasn’t money that had been stopping him from seeing a dentist. He found out he had some health problems and needed to see a dentist. Part of the problem related to the health of his gums, which were infected and in extremely poor condition. This man was literally trembling; he had to bring his wife with him. He sat in here, he was pouring with sweat, nervous. But he had an incredible experience. We give everyone a foot massage when they get their teeth cleaned. He had his wife with him the whole time. He comes back here now, every three months. He walks in and says, “Hey, how you doing? Oh, I’m good. I’m glad my time has come again. Can I just hang out here for half an hour? My wife can’t pick me up till then.” So what has happened is that what used to be a horrible ordeal to be avoided at all costs has been transformed. He now looks forward to his dental visits as a way to take care of himself, and he doesn’t have to be afraid anymore.

JK: So Transcendentist® takes the fear of out dentistry. Is that the main incentive?

FP: I had a patient the other day who came in and said, “You know, I was really looking forward to coming to the appointment today, because I know I’m so busy and so stressed out in my life. I know that at least for the next hour, I can relax. Do whatever you need to do, fix my teeth, take care of everything.” This is not the exception; it’s more often the rule.

JK: That’s encouraging. How has your leadership in this arena helped to shift the dental industry as a whole?

IP: I don’t know if we’re the leaders, but we’re doing it. It’s important to show that it can be done. And it’s not that hard. Yes, it is a little more expensive, but what is the true cost of putting mercury into our water systems so that all of us drink it for the next 30 years? We are really encouraged, for example, that Alameda County is now requiring dental offices to install amalgam separators. I think that’s a good example of things changing. These are simple things; they’re not complicated.

JK: Where do you see this shift in health care coming from?

IP: Once the human beings who encounter health care practitioners and wellness practitioners begin to raise the awareness of the practitioners, that is when we will begin to see profound change. It is not going to be top down; rather it’s going to be a consumer saying, “This is what I want.”

FP: Part of that will happen with privatization, which is a trend in health care delivery. The insurance industry is overwhelmed, to say the least. That’s a separate topic! But what happens is that consumers are beginning to take more responsibility for and control of their own health decisions. As consumers, they recognize that they are in a position to make their own decisions; they are starting to vote with their dollars. This means that people will be consuming in such a way that consumer choices will drive the marketplace. In terms of health care as a marketplace, consumer choices will in effect change how health care is delivered. As people realize the power of making health care decisions for themselves, they will want to be treated a whole person, rather than as just a wisdom tooth.

JK: How do you see this as part of the larger picture of greening health care?

FP: I think it’s huge. In terms of the dental community itself, there is certainly a lot of room for growth. And it doesn’t mean that every dental practice will therefore need to be green-certified. Even small steps, such as using 100% recycled paper for printers, can help. If every single medical office did just that, it would reduce medical waste dramatically. There are so many different areas in which you can apply energy efficiency. Any professional office—whether it’s a dentist, a doctor, a lawyer, an architect, or a chiropractor—can apply some of the recommendations of the green certification program.

JK: I can only imagine the positive outcome if every office implemented this approach. How does one help people justify the cost of making the steps towards sustainable care?

FP: Ina brought up the question of the real cost of having a non-green business. Well, it’s more expensive to use no-VOC paint, but look more closely at the true costs involved, down the road, for the health of our children and the health of the environment. Looked at that way, not greening health care actually has a much bigger price tag. First and foremost, I think once you create that internal change in the head and the heart of each medical practitioner, awareness grows and deepens. You start looking for the ways in which you can provide healing in a truly healing environment.

JK: How does this work extend beyond the self into the community?

FP: The term eco really means that we are interdependent. Every action you take is interrelated with every other action, so we’re not trying to be all things to all people. Rather, we are integrated with the greater community at large. It’s in everyone’s best interest to be eco-minded and sustainable. In terms of the whole community— the business community, the medical community, and the community at large—part of the definition of eco-interdependence is that the rising tide raises all boats. This is our planet, it’s our home, we all have to interdependently interact with each other. If we are destroying the rainforest in the Amazon, we’re affected by it up here. So if the choice to use recycled paper and paying a few pennies more can make a difference, that is the contribution that I am choosing to make because I am looking at it as a long-term investment in our collective future.

JK: It is interesting to see that the way dental health is done has a profound effect on the global environment. How do you maintain a positive outlook when it comes to creating a shift in the way we treat our planet?

IP: Well, you could say we live in a world that has been clear-cut, where there is just rank destruction. Yet there are some healthy, vibrant forests, where there is clean air and a real diversity of wildlife. Fred and I have chosen to surround ourselves with people who are living in the forest—that’s our community. It is a community of likeminded health care professionals, businesses, clients, and friends.

Book Review

The Ethics of Environmentally Responsible Health Care

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