Implications for Public Policy, Environmental Justice, and Public Health Education -By Mark Mitchell M.D., MPH

1. Minamata Treaty Goal 2. Why is Mercury Exposure a Problem? 3. Minamata Treaty Requirements 4. Sources of Mercury in the U.S. 5. Why Focus on Mercury Products? 6. Exposures in Vulnerable Populations 7. Policies Needed to Reduce Mercury Exposure

Mercury Treaty Negotiations Objective: “…to protect the human health and the environmental from anthropogenic emissions and releases of mercury and mercury compounds.”

 Mercury is an element ◦ Cannot be created or destroyed by humans ◦ Can change in form to become more or less  Toxic  Biologically available  Mercury is persistent, bioaccumulative and toxic

 Fish consumption is largest source ◦ Fish consumption advisories in all 50 states ◦ Mercury in commercial fish varies considerably ◦ High mercury commercial fish:  Swordfish  King Mackerel (not canned, Atlantic, or Pacific Mackerel)  Shark  Tilefish  Tuna (especially albacore [white] tuna)  Mercury amalgam tooth fillings ◦ Have not been shown to cause direct harm in adults  Some medications and multi-dose vaccines ◦ Particularly eye, ear, and nose antibiotics ◦ Have not been shown to cause direct harm to humans

 To protect public health we must reverse the bioaccumulation in fish  To reverse bioaccumulation of mercury in fish, we must eliminate as much mercury released into air and water as possible on a global scale  The Minamata Convention on Mercury attempts to do this

 Reduce or eliminate mercury from artisanal and small-scale gold mining.artisanal and small-scale gold mining  Control mercury air emissions from ◦ coal-fired power plants, ◦ coal-fired industrial boilers, ◦ certain non-ferrous metals production operations, ◦ waste incineration and ◦ cement production.  Phase out or reduce mercury in manufacturing processes ◦ chlor-alkali production, ◦ vinyl chloride monomer production, and ◦ acetaldehyde production. Source:

 Phase-out or reduce mercury use in mercury containing products ◦ batteries, switches, lights, ◦ cosmetics, ◦ pesticides and ◦ measuring devices, ◦ reduce the use of (phase down) mercury in dental amalgam In addition, the Convention addresses the supply and trade of mercury; safer storage and disposal, and strategies to address contaminated sites.

(tons)* Releases to Air Releases to Water Releases to Land Intentional Use in Products Combustion of Coal and Other Fuels Mining (mercury in ore) Other Total * Source: Cain, et al, Substance Flow Analysis of Mercury Intentionally Used in Products in the United States. Journal of Industrial Ecology 2007 Vol: 11(3): DOI: /jiec

 Mercury in products is (arguable) easiest source to eliminate in the U.S.  Mercury in non-dental products has dropped 97% since 1980 (Source: EPA Strategy to Address Mercury Containing Products, Sept. 2014)

Eleven Low Amalgam Countries  Use of mercury in dentistry is declining more slowly than in other products in U.S.  There are safe substitutes  Even though only about 48-68% of dentists in the U.S. use dental amalgam,[1] dental amalgam still represents one of the leading uses of mercury in the United States at about 18 to 30 tons annually (35 to 57% of use in products).[2][3]  Many other countries have virtually eliminated dental amalgam

 Pregnant women and developing fetus  Women who might become pregnant  Nursing mothers  Young children  Subsistence fishers who fish from local waters  People who engage in cultural practices using azogue  Those who eat more than one or two tuna meals per week  Those from developing countries who live near mining or mercury storage or disposal sites

 People of Color are more likely to have high mercury levels (Source: Schober, S et al: JAMA. 2003;289(13): ) ◦ From subsistence fishing or eating more local fish ◦ From eating more canned tuna ◦ From cultural practices using azogue  Low Income people get amalgam fillings placed more often ◦ Amalgam is more likely to be used for American Indians, Alaska Native, Asians, and Pacific Islander patients while composite is more likely to be used in other patients.[4] ◦ Medicaid often only covers cost of amalgam fillings ◦ Patients often are not given a choice of fillings ◦ Dental students are often required to place amalgam fillings in dental clinics

 INCREASE fish consumption in pregnant women and children while REDUCING canned tuna and other higher mercury fish  Eliminate added mercury from products, as much as possible  Increase public awareness of mercury in foods and products, and the availability of low mercury alternatives  Research alternatives to mercury in products where no good alternative currently exists  Modify insurance to cover non-mercury dental products

 [1]Haj-Ali R, Walker MP, Williams K., Survey of general dentists regarding posterior restorations, selection criteria, and associated clinical problems, Gen Dent Sep-Oct;53(5): (“A total of 714 dentists (26.3%) responded. Direct composite was the material used most commonly for posterior intracoronal restorations. Dentists in amalgam-free practices (31.6%) were significantly more likely (p = 0.001) to use direct composite than dentists whose practices used amalgam.”); U.S. EPA, Health services industry detailed study (August 2008), 304m_2008_hsi-dental pdf, p.3-1 (“The survey found that 52 percent of dentists do not place amalgam fillings”).Haj-Ali RWalker MPWilliams KGen Dent m_2008_hsi-dental pdf  [2] U.S. Geological Survey, Changing Patterns in the Use, Recycling, and Material Substitution of Mercury in the United States(2013), p.26 (“Dental amalgam represents one of the leading uses of mercury in the United States at about 18 to 30 t annually and constitutes the largest amount of mercury in use in the United States.”)  [3]U.S. Geological Survey, Changing Patterns in the Use, Recycling, and Material Substitution of Mercury in the United States(2013), p.1http://pubs.usgs.gov/sir/2013/5137/pdf/sir pdf  [4] Sonia K. Makhija, Valeria V. Gordan, Gregg H. Gilbert, Mark S. Litaker, D. Brad Rindal, Daniel J. Pihlstrom and Vibeke Qvist,Practitioner, patient and carious lesion characteristics associated with type ofrestorative material : Findings from The Dental Practice-Based Research Network, J A M D ENT A SSOC 2011;142; ,

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