Industrial societies are experiencing an increase in diseases and conditions, such as asthma, birth defects, cancers, and infertility that have been linked, to varying degrees, with chemical environmental exposures. Chemical contamination threatens human health and puts the ecosystems that sustain us in jeopardy. Even though these hazards and their associated effects warn of a future public health calamity, citizens and governments are hindered from taking precautionary action, often because of their ignorance. Currently, 80,000

Chemical contamination threatens human health and puts the ecosystems that sustain us in jeopardy

chemicals are registered in the United States (U.S.). Of these 3,000 chemicals are used in major quantities. However, safety information is exceedingly limited for the majority of chemicals produced and used within the U.S. and abroad. This data gap impedes pollution controls necessary to protect vulnerable populations, such as children and pregnant women, from disease and disability.

The purpose of this article is to inform nurses and other health care professionals about the nexus between the environment and health and present approaches in which they can be involved to support comprehensive reform of chemicals management in the U.S. It will discuss the health impact of hazardous chemicals and the environmental regulatory failures within the U.S. to protect the public. It will also report on international chemical management initiatives and key elements of chemical policy reform that can guide the U.S. regulatory, market-based, and institutional-based approaches to a comprehensive, chemical policy reform. The role of nursing in advocating for these reforms will be presented.

The Problems with Hazardous Chemicals

Increasing attention has been focused on the potential ill effects to human health resulting from exposure to man-made chemicals that find their way into the environment. Due to their particularly hazardous characteristics, one group of chemicals that has raised particular concern is the Persistent Bioaccumulative Toxins (PBT). A PBT may be a chemical 'parent compound,' or a secondary chemical that is the result of metabolism or environmental degradation. PBTs tend to have long half-lives (the amount of time it takes for 50% of a substance to break down, or be excreted) in organisms (including the human organism) and in the environment (Easthope & Valeriano, 2005).

When absorbed into organisms these chemicals, due to their lipophilic nature, may be stored in the organism's fat tissue. In this way PBTs build up in the food chain, i.e., they bioaccumulate. When a given PBT is absorbed by very small organisms, which in turn are consumed by larger and progressively larger organisms, the stored chemicals are passed along to the increasingly larger organisms, becoming more concentrated as

…citizens and governments are hindered from taking precautionary action, often because of their ignorance.

they move up the food chain. Humans, said to be at the top of this chain, consume fish or other animals below them on the food chain thereby receiving the most concentrated doses, which are more concentrated than in the surrounding environment. The amount of a chemical that bioaccumulates depends on several variables including the mode and rate of uptake, the amount of fat tissue in the organism, and the speed with which the chemical is metabolized, as well as other biological and physiological factors (Easthope & Valeriano, 2005; US Geological Survey, 2006).

PBTs can transfer between the environmental media of air, water, and land, and cross geographical boundaries to travel long distances. Hence, humans can be exposed to PBTs in a variety of ways. They can be exposed to PBTs and all environmental chemicals, through oral ingestion, inhalation, and dermal contact which can occur in their work places, homes, schools, and communities (Ott, Steineman, & Wallace, 2007).

While nurses usually do not have a background in toxicology, their familiarity with pharmacological principles provides a frame of reference to understand the toxic effects of hazardous chemicals. Both the science of pharmacology and that of toxicology deal with the introduction of chemicals into the human system and the effects these chemicals have on that system. There are many parallels between human exposure to both pharmaceuticals and to environmental chemicals (ECs). The effects of both drugs and hazardous chemicals can be seen immediately (acute), long-term (chronic), or become apparent after a latency period (Sattler, 2006). Both chemicals and pharmaceuticals are delivered in doses, though the dosing of pharmaceuticals is carefully controlled, while the dose of an EC the human receives is largely uncontrolled, unknown, and taken unknowingly (Sattler). There can be either therapeutic or 'side- effects' of pharmaceuticals, while in most cases exposure to ECs is harmful. We know many drugs can have drug-to-drug interaction; therefore patients are advised against taking these medications in combination. However, since ECs are ubiquitous and exist in mixtures, the effects that these ECs have on the human system (when they are consumed/absorbed at unknown levels and in varying mixtures) is unknown and largely unstudied (Sattler).

Toxic effects from ECs might be seen in the environment, animals, or in humans. In animals and humans these fall into broad categories including carcinogens, mutagens/genotoxins, teratogens, endocrine disruptors, neurotoxicants, reproductive toxicants, or developmental toxicants. Toxic endpoints may be to a particular organ or organ system, such as the blood, cardiovascular, kidney, liver, and others (Easthope & Valeriano, 2005).

Chemical toxicity can be determined directly through in vitro and animal lab tests, and less directly through epidemiological studies of humans. Determination of the toxic effect of chemicals in humans can be quite complicated for the following reasons:

• It is difficult to determine effects from one specific chemical when there are many, since we are not exposed to single chemicals, but to mixtures of chemicals that may have additive effects.
• Potential synergistic effects of these chemical combinations are difficult to study.
• The exposure may be one time and acute or else chronic and for extended periods of time, so different dosages must be considered.
• Some health effects may manifest long after the initial exposure. 
• We may not have methods sensitive enough to measure some of the more subtle effects.
• Extrapolating from animal studies to humans is complicated, and direct human studies of toxic chemicals are unethical.

Although many of the toxic effects of ECs are unknown, some effects are known. One example of chemicals with known effects are the endocrine disrupting chemicals (EDCs), a group of chemicals (primarily PBTs) which have received considerable scientific attention and concern. It is known that these chemicals have the potential to alter the normal functioning of the endocrine system in animals and humans (The International Program on Chemical Safety, n.d.).

Although the exact mechanisms and links are often unclear, due to the complicating reasons cited above, general studies indicate that EDCs in humans may be responsible for certain reproductive effects, including lowered sperm quality, impaired fertility, declining sex ratios (fewer males born), and abnormal development of male reproductive organs. Other associations between EDC exposure and human health include endometriosis; precocious puberty; disruptions in neural function; disruptions in immune function; and cancers of the breast, testes, endometrium, prostate, and thyroid. The biological plausibility that these effects may be due to the EDCs is given added weight by the observations that the effects are also seen in wildlife and in lab animals (The International Program on Chemical Safety, n.d.).

Since PBTs are hazardous by definition, they have received a lot of attention and are a good starting point in a discussion of hazardous chemicals. However, it is important to keep in mind that PBTs are not the only group of hazardous chemicals to which humans are exposed. Toxic, non-PBTs found in environmental substances, such as organic solvent. Trichloroethylene (TCE), for example, is an industrial solvent used in dry cleaning that has been found in water supplies and may be encountered from exposure to contaminated air or soil. The International Agency for Research on Cancer has determined that TCE is a probable carcinogen, associated with several forms of cancer (World Health Association International for Research on Cancer, 1997). In addition, TCE exposure has been associated with a wide array of other adverse health effects, including neurotoxicity, immunotoxicity, developmental toxicity, and endocrine toxicity (Caldwell & Keshaya, 2006).

Failures in Federal U.S. Regulation

In this section, the authors will discuss various federal, environmental regulations promulgated with the intent of protecting the public from the deleterious effects of exposure to hazardous chemicals. The considerable regulation of pharmaceutical chemicals, described above, compared to that of ECs provides an instructive framework for highlighting many of the major limitations in the environmental regulation within the U.S. Consider the following:

• Pharmaceuticals undergo rigorous pre-market testing and U.S. Food and Drug Administration (USFDA) oversight; ECs do not. 
• There is full disclosure of pre-market testing results for pharmaceuticals; there is none for ECs.
• There is comprehensive labeling for pharmaceuticals regarding efficacy, interactions, and specific side effects; only limited information is available for most ECs.
• There is a system for reporting unexpected side effects for pharmaceuticals; there is none for ECs.
• There is a formal mechanism for recall for pharmaceuticals; again no such mechanism exists for ECs (Sattler, n.d.).

The remainder of this section will build upon these concerns by detailing the limitations of U.S. environmental regulation for industrial chemicals. Environmental regulation will be discussed in terms of

There is full disclosure of pre-market testing results for pharmaceuticals; there is none for environmental chemicals.

secondary prevention, primary prevention, and worker's right-to-know, as well as regulatory limitations impacting U.S. Environmental Protection Agency (EPA), the Occupational Safety and Health Administration (OSHA), an agency of the U.S Department of Labor, and state-level activities to regulate the chemical environment.

Secondary Prevention Regulation

In the US there are several federal environmental laws that operate in concert to limit the hazards of exposure to chemicals present within the ambient environment. A few of these chemical management laws, such as the Clean Air Act, Clean Water Act, Safe Drinking Water Act, and Food Quality Protection Act, regulate the release of chemicals and set permissible limits to these chemicals in our air, drinking water, or food. Still other laws, such as Resource Conservation and Recovery Act (RCRA), and the Comprehensive Environmental Response, Compensation and Liability Act were promulgated to manage chemicals that are found at toxic levels in the environment and that present a risk to health. The purpose of these laws is to establish rules for the proper handling/disposal of solid and hazardous waste (RCRA) as well as provide the federal government the authority to respond to releases of hazardous substances and fund clean-up of abandoned hazardous waste sites. In addition, the Emergency Planning and Community Right-to-Know Act (EPCRA) requires industrial reporting of toxic releases and encourages the development of local plans to respond to chemical emergencies. To learn more about the environmental laws regulated by the USEPA visit the USEPA website at www.epa.gov.

While all of these laws are critical to limiting the deleterious affect of exposures to hazardous chemicals and in identifying parties potentially exposed, these laws actually constitute a secondary, and even tertiary level of prevention for environmental pollution. Traditionally, these levels of prevention are used in public health to discuss activities aimed at early detection and early intervention to minimize the deterioration of health from a disease. By applying these concepts to laws that regulate chemicals in the U.S. it is clear that laws operating at these levels only serve to detect hazards and to limit their impact and are generally characterized as pollution management laws. Unfortunately, this approach to protecting human health from dangerous chemicals is comparable to 'closing the barn door after the horse has escaped.' These actions come too late and place vulnerable populations at risk given the limited resources the USEPA has for enforcement.

Primary Prevention Regulation

As in other arenas of public health, primary prevention is clearly the preferable and most effective method for controlling the incidence of diseases caused by environmental chemical contamination. Primary prevention for chemical regulation involves those laws that control chemicals before they are marketed and become downstream contributors to the chemical mixtures found in the global environment. There are two federal U.S. environmental laws promulgated to serve this purpose. These laws are the Toxic Substances Control Act (TSCA) and the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA). The USEPA is responsible for administering these laws.

TSCA (signed into law in 1976) authorizes the USEPA to screen existing and new industrial chemicals used in U.S. manufacturing and commerce and to identify potentially dangerous products or uses that should be subject

…primary prevention is clearly the preferable and most effective method for controlling the incidence of diseases caused by environmental chemical contamination.

to federal control. This law was enacted as the USEPA was to begin making test rules; 62,000 chemicals were in commerce at that time. These chemicals were the start of the TSCA Chemical Substances Inventory (TSCA Inventory) and still constitute the vast majority of the chemicals in use today (Guth, Denison, & Sass, 2005). The chemicals on this original list of 'existing' chemicals were allowed to continue to be used commercially without requiring product safety information. However, the USEPA has the authority to require the development by producers of test data on existing chemicals if the agency can prove that these chemicals: (a) may present an unreasonable risk of injury to health or the environment' during their manufacture, processing, distribution, use, or disposal; or (b) are produced in high volume and there is potential for a substantial quantity to be released into the environment or for a substantial or significant human exposure (Fletcher et al., 2005).

While it appears at first glance that TSCA contains the necessary tools to require chemical safety information, its regulatory potency is softened by the need for the USEPA to prove and defend decisions to require more information regarding chemicals of concern. Existing chemicals can only be regulated if the chemical presents an 'unreasonable risk,' if the benefits of regulation outweigh the industry cost and lost economic and social value, and if the USEPA has chosen the least burdensome way to eliminate only the unreasonable risk (Fletcher et al., 2005). This policy creates a cost-benefit standard that favors industry over a health-based, decision-making standard that would protect public health. This point is demonstrated in the U.S. Government Accountability Office report to Congress noting that since TSCA was enacted, the USEPA has required testing on fewer that 200 of the 62,000 chemicals on the original inventory and has only banned five substances. No chemicals have been banned under this statute since 1990 (Government Accountability Office, 2005). Under TSCA, chemicals new to the market after the passage of TSCA are to be filed with the USEPA through a pre-manufacture notice before they can be manufactured or imported into the US. The USEPA has 90 days to act or the chemical may be introduced to market. TSCA does not require toxicity data for these new chemicals, and the USEPA can only require safety test data if they can prove an 'unreasonable risk'  to human health. In the absence of test data the EPA uses computer modeling called Structure Activity Relationship analysis to compare its chemical structure with other existing chemicals and to negotiate some restriction and withdrawals. Although this process provides preliminary screening, it is less effective in detecting toxicity of chemicals than actual testing (Fletcher et al., 2005; Guth, et al., 2005; USEPA, 1993). Once chemicals are marketed they are added to the TSCA Inventory and subject to the same rules for regulation as those 62,000 original 'existing' chemicals on the initial inventory list.

Another important limitation to TSCA is that chemical manufacturers registering their products on the TSCA Inventory are able to withhold critical ingredient information under a confidential business clause. The manufacturer can claim that certain ingredients are trade secrets and that they are withholding information to stay competitive. The stipulation in TSCA that allows for confidential business information (CBI) withholding interferes with community and worker right-to-know laws. Thus, the ability of the public and workers to adopt preventative behaviors that would limit exposures to hazardous chemicals is thwarted.

The second federal U.S. law controlling chemicals that enter into market is FIFRA. FIFRA governs the sale and use of pesticides in the U.S. and directs the USEPA to restrict use of pesticides to prevent unreasonable adverse health effects for humans and the environment. The process by which USEPA regulates the sale and use of pesticides is through registration and labeling. Manufactures must submit data that documents how the pesticide behaves in the environment along with toxicity information. Unlike TSCA, the USEPA may require a battery of up to 100 tests of active and inert ingredients in the pesticide depending on the potential for exposure. Based on the data submitted, the EPA determines if, and under what conditions, the pesticide might exhibit an unreasonable risk to human health or the environment. Pesticides that are to be used on food crops must also employ a series of tests on their active, as well as some of the inert ingredients, to determine the amount of residue that could remain on crops and subsequently find its way into food products (Fletcher et al., 2005).

The Federal Food Drug and Cosmetic Act (FFDCA), sets the conditions for 'safe' levels of pesticide residues on food and in end-product, processed foods by setting tolerance levels. If tolerance levels cannot be set because no 'safe' level for the residue can be established for human consumption, the pesticide cannot be registered for use on food crops. Any pesticide that is granted registration has specific, approved uses and conditions for use that include directions for handling, storage, and disposal. The manufacturer must then place this information on their product label before this product goes to market (Fletcher et al., 2005).

It is clear that FIFRA does a better job at assisting the USEPA to protect the environment and public health than does TSCA by requiring safety testing from manufactures before a product can be registered. However, shortcomings of this law do exist, particularly because the USEPA is required to consider the cost-benefit of not registering or banning a pesticide. This decision's impact can restrict the economic health of an industry.

Another weakness is that even with the community's right-to-know law (EPRCA) the average citizen will find it difficult to access information about pesticides that are registered. It will be difficult because the USEPA does not need to make the toxicity information available, and pesticide producers can claim that certain

The stipulation…that allows for confidential business information withholding interferes with community and worker right-to-know laws [and thwarts] ability of the public and workers to adopt preventative behaviors that would limit exposures to hazardous chemicals.

ingredients are confidential under a trade secret clause. Although coordination of pesticides through FIFRA and FFDCA has been successful in controlling exposure to these chemicals in food, the potential for exposure through other media, such as water or air, are not considered when the USEPA is determining whether or not to register a pesticide.

Worker's Right-to-Know

Another piece in the patchwork quilt of chemical policy in the US is the federal Hazard Communications Standard or the 'worker's right-to-know' rule (Hazard Communications Standard 29 CFR 1910.1200) enacted in 1983. This regulation aims at providing workers the right to know about exposure to toxic chemicals in the workplace; however, it doesn't really give workers the right not to be exposed to hazardous chemicals. OSHA enforces the Standard (U.S. Department of Labor, OSHA, n.d.).

Key elements of this right to know rule include the following:

• Chemical manufacturers must determine whether or not their chemicals pose a hazard to human health and/or physical safety.
• If a chemical is determined to be a threat, its manufacturer must produce a material safety data sheet (MSDS) for the chemical and distribute it.
• In the workplace all hazardous chemicals must be labeled and there must be a corresponding MSDS with all workers having access to the data sheet.
• All workers must be trained about the hazardous chemicals in the workplace
• When new chemicals are being used, the employers must be trained in using them.
• The MSDS and a written Hazard Communication Standard Plan must be accessible to all employees (Sattler & Lipscomb, 2003).

A worker's right-to-know is repeatedly limited because the MSDSs are often (a) incomplete or contain inaccurate or conflicting information, (b) are not required to contain information on environmental effects and chemical reactions, (c) have no 'plain language' requirements, and (d) are not required to undergo certification or a third party review so that the manufacturer may underestimate the hazard and its health effects to workers.

In general, it takes OSHA ten years to promulgate a new standard.

OSHA has standards for only a handful of workplace chemical exposures, such as arsenic, asbestos, benzene, cadmium, carcinogens, compressed air, ethylene oxide, formaldehyde, hazardous waste operations, lead, methylene chloride, and vinyl chloride (Sattler & Lipscomb, 2003). In general, it takes OSHA ten years to promulgate a new standard. Despite over 15 years of work on glutaraldehyde (Cidex), there is no exposure limit established for this asthmagen and potent sensitizer commonly used as a high level disinfectant in hospitals. The U.S. National Institute for Occupational Safety and Health (NIOSH) has only a recommended exposure limit; while the European standards for this chemical are already set at one tenth the limit recommended by NIOSH.

Regulatory Limitations Impacting EPA and OSHA

An important limitation to promulgating protective environmental or occupational regulations has been placed on the USEPA and OSHA by both executive and legislative mandates. These mandates have obligated all federal agencies, including the USEPA and OSHA, to address both the cost and the benefits when considering imposing new regulations. This obligation was set forth by President Clinton through Executive Order 12866 on Regulatory Planning and Review (58 Federal Register 51735, October 4, 1993). This order requires agencies to perform cost-benefit analyses of proposed and final regulations. Under Executive Order 12866, federal agencies should promulgate only such regulations as are required by law, or are made necessary or compelling by public need. Either agency must assess all costs and benefits of available regulatory alternatives, including the alternative of not regulating. Further, in choosing among alternative regulatory approaches, agencies should select those approaches that maximize net benefits (Croote, 1999).

In addition, federal agencies were mandated by the legislative branch through the Unfunded Mandates Reform Act (P.L. 104-4), Title II, to perform cost-benefit analyses when considering any promulgation. The Unfunded Mandates Reform Act (UMRA) requires that federal agencies perform cost-benefit analyses of their regulations, including the effects of the regulation on health and the environment (Croote, 1999). The outcome of both the Executive Order 12866 and UMRA is that federal agencies often adopt regulations that will have the least cost impact. Therefore it is cost of protection that is the driver in U.S. regulation not

…federal agencies often adopt regulations that will have the least cost impact…not the principle of choosing the regulatory option that is most health-protective.

the principle of choosing the regulatory option that is most health-protective.

States Lead the Charge for Reform

Due to the long history of TSCA's ineffectiveness in blocking dangerous chemicals from entering into market, several states have enacted state-level legislation that is more stringent in its requirements than federal legislation. One important example is California's Safe Drinking Water and Toxic Enforcement Act of 1998, also known as Proposition 65. An important feature of this state law is that it prohibits the discharge of certain listed chemicals into drinking water unless the discharger can demonstrate 'no significant risk.' This law maintains a list of 750 chemicals known to cause cancer, birth defects, or other reproductive disorders. It requires manufactures to place labels alerting the public if chemicals on the list are contained in their product. The important outcome of this law is that many manufactures have opted to change their products to substitute safer chemicals in place of toxic chemical which they would have been required to report on their label under Proposition 65.

Other state level activities have involved states passing pollution-prevention legislation. These laws vary across the states; however, a common model is for states to require annual pollution-prevention planning and reporting by industry. A Massachusetts law is an example of this pollution prevention legislation. The Massachusetts Toxic Use Reduction Act requires facilities that use certain listed toxic compounds to submit annual reports on the amounts used, to pay annual fees based on usage levels, and to prepare toxics-use-reduction plans with specific details on in-plant changes to reduce, avoid, or eliminate use of these materials. This act also allows the state authority to ban or limit certain chemicals.

Overview of Changes in International Policy

Major legislative efforts to improve chemical regulation are occurring around the world. The European Union (EU) recently passed a regulation titled, "Registration, Evaluation and Authorization of Chemicals" (REACH) which regulates chemicals requiring manufacturers to provide health and safety data on chemicals, thereby moving the market towards safer alternatives. The Stockholm Convention on Persistent Organic Pollutants (POPs) is a treaty that has been adopted by over 150 countries to ban the 12 worst chemicals (often referred to as the 'dirty dozen') from production, use, and transport. The International Chemical Control Toolkit offers a system for identifying potential chemical hazards in the occupational setting to assist in protecting workers. These international movements are likely to have global repercussions because the European market is large, and many U.S. companies sell products in Europe. With Europe's lead, other countries are now struggling with the issue of reforming outdated and ineffective chemical policy laws. These international efforts are attempts to establish broad-based chemical policies. In order to understand what such a policy might look like, we present two international approaches to chemical usage, the Stockholm Convention for Persistent Organic Pollutants and the EU REACH, along with a description of the International Chemical Control Toolkit.

Stockholm Convention

The Stockholm Convention on Persistent Organic Pollutants (POPs) (sometimes referred to as the POPs Treaty) was adopted at a conference held in 2001 in Stockholm, Sweden. Over 150 countries had signed onto the Convention before it entered into force on May 17, 2004. POPs are environmental chemicals that have many of the same characteristics as PBTs (i.e. persist for extended periods of time, bioaccumulate in organisms and the environment, have toxic effects, and can be transported over long distances) except that POPs are a subclass including only organic chemicals (Orris, Chary, Perry, & Asbury, 2000). The Convention seeks to protect human health and the environment from these chemicals. Signers to the Convention agree to prohibit the production and use of certain 'intentionally' produced POPs (industrial chemicals and pesticides), restrict the use of Dichloro-Diphenyl-Trichloroethane (DDT), which has been retained for its use against malaria vectors until substitutes for it are available, and reduce or eliminate unintentionally produced POPs (dioxins and furans).

The Convention provides a process by which additional chemicals with POP characteristics may be added to the original 'dirty dozen' list so that they will be similarly controlled. Further articles of the Convention state that the Convention's participants agree to: (a) develop a plan to implement conditions of the Convention, (b) educate policy and decision makers and the public about the health hazards of POPs chemicals, (c) encourage development and use of safer alternatives, and (d) identify and appropriately manage old stockpiles and waste containing POPs (United Nation's Environment Program, n.d.).

REACH

Another European initiative is the European Union's REACH Regulation. The REACH Regulation was formally adopted on December 18, 2006, and will enter into force in June of 2007. REACH was initiated in 1998 because of the growing recognition of the need to reform chemical policy worldwide. REACH is intended to ensure that meaningful chemical safety information will be available to the users and puts the responsibility for providing this information on the chemical producers. It covers both existing chemicals (which will be phased-in) and new chemicals. This is different from TSCA which grandfathered in 'existing' chemicals when the law was enacted and has not required an assessment or an evaluation process for these grandfathered chemicals.

Under REACH, manufacturers and importers of chemicals will be responsible for 'registering' their chemicals. In the registration process they will provide safety data for chemicals produced or imported in quantities of one or more tons per year. Manufacturers and importers of chemicals of ten tons or more per year must, in addition, submit a chemical safety report in which they provide detailed hazard and risk assessment information which will describe how the chemicals can be "adequately controlled." The information will be evaluated, and further information may be requested if needed.

There is another process for chemicals of very high concern (carcinogens, mutagens, reproductive toxins, PBTs, and chemicals that have "probable serious effects to humans or the environment"). Manufacturers of these chemicals will be required to seek 'authorization' for their use, a step that will help ensure that they are analyzed, assessed, and regulated for each specific use. The analysis must show that risk from use of the chemical can be adequately controlled. An important part of this authorization process is providing information regarding alternatives to the chemical, and when available, a plan for substitution with a safer chemical (European Commission, 2006; Lowell Center for Sustainable Production, n.d., a ). Although compromises were made before this regulation was signed, REACH can serve as a model of an up-dated chemical policy.

International Chemical Control Toolkit

Persons who are exposed to chemicals in the work place experience some of the highest, most concentrated exposures. Only about 1,000 chemicals in use globally have Occupational Exposure Limits (Papp, Eijkemans, & Vickers, 2004). For this reason, safety measures have been developed to protect the health of workers, which may also be applicable to EC exposures. The World Health Organization, together with

Control Banding helps avoid the need to assess each chemical separately.

the International Labor Organization and the International Occupational Hygiene Association developed a system for classifying chemicals by hazard and risk to determine the appropriate control measures. This system, known as "Control Banding" was initiated in the United Kingdom. It was adapted for a global audience in response to the need for occupational safety expertise in developing countries and in small and medium-sized businesses, where resources may be scarce, and professional advice is at a premium. This regulation helps avoid the need to assess each chemical separately.

Potentially harmful chemicals are assigned what are called 'Risk (R) Phrases' which are categories that describe the chemicals' most harmful effects. These R Phrases are listed on the chemical label or MSDS which comes from the chemical suppliers. The R Phrases are then put into "Hazard Bands"or groupings according to their hazardous characteristics.

When a chemical's Hazard Band is known, the level of exposure to that chemical for a given task is determined. Parameters that are considered for this are the quantity of a chemical to be used, the likelihood that the chemical will become airborne, and its level of volatility. When the user has ascertained the Hazard Band and the level of exposure, or 'Exposure Band,' the appropriate control measures can be determined with the help of control guidance documents. These measures, determined by industrial hygienists, include general ventilation, engineering controls, and containment (enclosure of the process). At times the user may be advised to seek the advice of a specialist. This system has its limitations, but allows employees in areas with limited resources to protect their health (Jackson, 2004; Papp et al., 2004; Vickers, 2004)

Key Elements of Regulatory Chemical Policy Reform

Chemical policy reform encompasses a large number of elements, such as regulatory and voluntary measures, internal business policies determining chemicals to be used and how they will be used, fiscal policies (such as taxes), education initiatives (labeling programs), and investment in 'Green Chemistry.'Several other policy areas, such as occupational health, facility pollution, and emergency planning, are closely linked to chemical policy because of the needed information regarding the hazardous properties of chemicals (Lowell Center for Sustainable Production, n.d., b). Therefore, the adoption of a comprehensive, chemical-management reform would have a far-reaching impact on protecting worker, community, and consumer health. Comprehensive chemical policy reform is predicated on the Precautionary Principle. The Louisville Charter for Safer Chemicals builds on the Precautionary Principle to describe desirable outcomes for making the planet safe from hazardous chemicals. In the section that follows, we will discuss the Precautionary Principle, The Louisville Charter for Safer Chemicals, and the necessary elements for establishing a broad, chemical policy reform.

Precautionary Principle

As outlined in the section on health effects, one encounters a great deal of scientific uncertainty when trying to link a specific toxic chemical with human health effects. In the latter part of the 20^th century a principle of precaution began to take form to address a variety of potential health and environmental dangers that were not yet fully understood. This principle advocates for a preventive approach to disease, a concept familiar to nursing. The Rio Declaration on Environment and Development, developed at

The Precautionary Principle advocates for a preventive approach to disease, a concept familiar to nursing.

the Rio Earth Summit in 1992, defined this principle by stating: "Where there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used as a reason for postponing cost-effective measures to prevent environmental degradation" (Martuzzi & Tickner, 2004, p. 27).

Using similar language, The Wingspread Statement on the Precautionary Principle, developed at a 1998 conference in Racine, Wisconsin, stated, "Where an activity raises threats of harm to the environment or human health, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically" (Wingspread Statement on the Precautionary Principle, 1998, p. ). Precautionary action can be justified where inaction has the potential for harm to present and future generations.

The American Nurses Association (ANA) adopted the Precautionary Principle as Association policy in 2003. The ANA's Issue Statement noted that this principle allows action to be taken in the face of uncertainty; shifts the burden of proof to those who create the risks; includes analysis of alternatives to potentially harmful activities; uses participatory, decision-making methods; takes the life cycle of products or chemicals into account; and adds the proactive step of pre-market analysis of environmental harm (ANA, 2003).

Louisville Charter

The Precautionary Principle provides the philosophical base for the development of the Louisville Charter. The Louisville Charter for Safer Chemicals is a set of principles formulated in May of 2004 by groups and individuals. This Charter communicates a broad vision of the elements of comprehensive, chemical policy for protecting human health and the environment. It offers a description of the desired changes required in the chemical-management system so that it protects workers, communities, and most vulnerable populations from the deleterious effects of exposure to dangerous chemicals.

Six principles make up the Louisville Charter for Safer Chemicals. Table 1 lists the Charter's six principles and rational for their adoption. This table was developed by the authors of this paper to help communicate to the reader these principles formulated in 2004. These principles have the potential for broad application including guiding state legislative policy development that incorporates the phase-out of PBTs and other chemicals of concern, a development that could eventually lead to national chemical policy reform. The principles can also stimulate industrial innovations that would swing chemical production towards safer alternatives, processes, and solutions. Additional information about the Louisville Charter for Safer Chemicals can be found at the web site www.louisvillecharter.org.

Critical priorities of the Louisville Charter are to phase out the most dangerous chemicals, invest in research and development of safer alternatives, and promote the adoption of these alternatives. Implicit in these priorities is the desire that the high-risk communities that bear the greatest burden of environmental exposures are protected and that those responsible for creating hazardous chemicals bear the full cost of correcting damages to human health and the environment. The Louisville Charter strives for changes that would improve availability of comprehensive, safety information to workers as part of MSDS.

Table 1. Principles of the Louisville Charter for Safer Chemicals
Principles (P)	Description
P1-Require Safer Substitutes and Solutions	Hazardous chemicals and emissions can be eliminated by altering production processes, substituting safer chemicals, redesigning products and systems, and supporting innovative research and development for sustainable chemicals.
P2-Phase Out Persistent, Bioaccumulative, or Highly Toxic Chemicals	This principle is based on the idea that chemicals belonging to the Persistent Bioaccumulative Toxins (PBTs) category and other chemicals of equal concern are hazardous to human health and the environment. By virtue of their characteristics, they are very difficult to manage, having unacceptable threats to workers, the environment and/or ecosystems. Therefore, these chemicals should not be used and should be banned from manufacture, importation, and exportation.
P3-Give the Public and Workers the Full Right-to-Know and Participate	Due to barriers in access of information and insufficient data, the public and workers rarely receive adequate information about potential hazards associated with chemicals found in their workplaces or communities. Community members and workers must have the "right-to-participate" in decisions about chemicals that are manufactured and used by local industries, planned clean-up initiatives, and activities for about chemicals that are manufactured and used by local industries, planned clean-up initiatives, and activities for protecting those exposed to chemical hazards.
P4-Act on Early Warnings	The premise of this principle is precautionary. Therefore, if credible evidence resulting from new or existing chemicals is noted action should be swiftly taken to prevent, mitigate, and eliminate exposures so that human health and the environment are protected.
P5-Require Comprehensive Safety Data for All Chemicals	U.S. laws do not systematically require chemical producers to research or report on the human health effects or environmental fate of chemicals currently existing in commerce. Without this information the market is unable to stimulate innovation of safer alternatives, and the public can not make full use of environmental statutes or the liability system when harmed by chemical hazards. This principle states that only chemicals that provide adequate safety information should be allowed to stay in the market. This is the principle of 'No Data, No Market.'
P6-Take Immediate Action to Protect Communities	When communities and workers are exposed to levels of chemicals that pose a health hazard, immediate action is necessary to eliminate these hazards so that no population bears a disproportionate burden of risk.

Model Chemical Policy: Looking into the Future

While the Louisville Charter and Precautionary Principle offer a broad sweep of the changes that are necessary for chemical management in the US and abroad, the steps towards achieving these outcomes are more nebulous. A model chemical policy would correct fundamental problems that exist in the current system. Wilson (2006) referred to these fundamental problems in the U.S. as the Chemical Data Gap, Safety Gap, and Technology Gap.

Briefly, the Data Gap refers to the limited availability of comprehensive and standardized toxicity information regarding most of the chemicals in production and use. Wilson (2006) suggested that this lack of chemical information weakens the deterrent function of product liability, prevents markets from functioning properly, and weakens worker protection and worker compensation systems. The USEPA is impeded from protecting the public from dangerous chemicals because before it takes action, it must first prove that a chemical exhibits an 'unreasonable risk of injury to health or the environment' which is a difficult risk to prove. Then it must mandate controls that are the least onerous to industry. The Safety Gap is fueled by lack of data on toxicity for most chemicals. At the heart of the Safety Gap is the inability of the USEPA to take action. Without adequate information, government agencies are unable to identify and prioritize chemical hazards. The Technology Gap exists because inadequate toxicity information and a weak chemical regulatory system dampen the motivation of chemical producers to invest in new, green (environmentally safe), chemistry technologies. Compounding this lack of market drivers is inadequate government investment in the research and development of green chemistry and in the training of scientists in this discipline.

Denison (2007) presents six policy activities that are likely to be important for closing these Chemical Data, Safety, and Technology Gaps. These activities involve: (a) identifying and prioritizing chemicals for action, (b) tracking chemicals through production and use, (c) requiring industry to research and report risk-relevant information, (d) government reviewing and assessing information to identify hazards, (e) imposing regulatory controls, and (f) sharing and disclosing risk-relevant information. Table 2 was developed by the authors of this paper to list Denison's six policy activities, highlight the gap(s) addressed by the activity, and describe the process by which the activity could be implemented to effect change. These activities apply to both the production and use of existing as well as new chemicals (Denison).

Table 2. Activities for Closing the Chemicals Data (D), Safety (S), & Technology (T) Gap
Activity	Gap Addressed	Process
Identifying & prioritizing chemicals of concern	Safety	S- Require the EPA to prioritize chemicals of concern that will lead to mandated reduction in use, substitution with a safer alternative, or immediate phase-out based on a chemical’s persistence, bioaccumulative nature, and toxicity to human and ecosystem health.
Tracking chemical production/use	Data Safety Technology	D-Require a nationwide searchable web-based chemicals database inventory that contains information from producers about chemical production, use, and comprehensive safety information, S- Require TSCA regulation regarding Confidential Business Information (CBI) be changed so that chemical inventories reflect actual exposure risks, require labeling of products (using barcodes) that contain highly hazardous or hazardous chemicals (see Figure 1-chemical action pyramid) (Rationale: 65% of chemical information disclosed to the U.S. EPA under TSCA regarding production and use is classified as CBI; downstream users are not fully aware of the potential hazards linked with the chemicals they are using.) T-Require full disclosure through production and use inventories in order to stimulate the development of new production processes or substitutions of safer alternatives,
Facilitating or requiring the reporting and generation of risk-relevant information	Data Safety Technology	D- Require the chemical industry to generate and distribute chemical toxicity information based on test criteria set by regulatory agency, S-Mandate industry to provide toxicity information on all new chemicals and for those existing ‘chemicals of concern’ that are in high production volume, T-Link chemicals to their toxicity to allow the market to function properly. Stimulates safer chemical alternatives,
Assessing information to determine hazards, exposures and risks	Safety	S-Require regulatory agencies to screen/ assess all new chemicals and existing chemicals of concern using health-based standard not an economic standard.
Imposing controls to mitigate risk	Safety	S-Change TSCA regulation so that regulatory agencies can impose controls on new and existing chemicals to address potential as well as documented risks without having to prove “unreasonable risk to health” or selecting a control that is least onerous to industry
Sharing & Disclosing information	Data Safety	D-Change TSCA and FIFRA so that chemical producers are mandated to share and disclose risk-relevant information along the supply chain connecting producers, processors, distributors and downstream chemicals users as well as disclose information to other countries. S-International controls on chemicals of concern should trigger assessment and decisions for imposing risk reducing controls within the U.S.

A critical activity for closing all three of these gaps in chemical management involves identifying and prioritizing chemicals of concern. Belliveau, Rossi, and Valeriano (2006) have

A critical activity for closing the Data, Safety, and Technology Gaps in chemical management involves identifying and prioritizing chemicals of concern.

created a useful framework, called the Chemical Action Pyramid (See Figure) for identifying chemicals of concern. The Figure is reprinted in this paper with the permission of its original authors (Belliveau et al.). This framework proposes a method for prioritizing actions to be taken based on a chemical's toxicity attributes. In this pyramid, chemicals are stratified into four hazard categories or tiers. The top of the pyramid represents those chemicals that are the most hazardous to human health and the environment. These chemicals are unacceptable and need to be removed from the market (phased-out). The bottom of the pyramid consists of preferred chemicals that have little or no toxicity, degrade into safe substances, and should be used in substitution of other, more hazardous, chemicals when applicable.

The Chemical Action Pyramid has a similar interpretation to the familiar food pyramid where the base constitutes the healthiest foods (fruits, vegetables, whole grains) recommended as the mainstay of our diet and the pyramid top constitutes the least healthy foods (fats, sweets) that should be consumed with marked moderation. Likewise, the chemical action pyramid follows this use gradient where highly hazardous (very persistent, very bioaccumulative) chemicals on the top should have limited use and the preferred (safe) chemicals at the base should comprise the majority of chemicals used in the market. Along the left side of the pyramid are text boxes that describe policy actions suitable for the chemicals found in each tier. Along the right side of the pyramid are text boxes that describe the rational for categorizing a chemical into a specific tier. The Chemical Action Pyramid is a valuable framework that assists in identifying and prioritizing chemicals that require more stringent controls to mitigate risk. Thus, this framework assists with policy efforts to close the Chemical Data, Safety, and Technology Gaps.

Figure 1. Chemical Action Pyramid-based on the inherent hazard of industrial chemicals and their breakdown products.

1From “A Framework for Chemicals Policy Reform: Issues in Model Policy Development” by M. Belliveau, M. Rossi, and L. Valeriano, 2006. Copyright 2006 by the authors. Unpublished manuscript. Reprinted with permissionauthors.

Prioritizing chemicals that are to be the first controlled or eliminated, based on the chemicals classification system, is just one option for framing reform. The benefit is that it focuses attention to the obvious, dangerous chemicals, such as PBTs, and strives to remove them from the market. However, the majority of the chemicals in production and use fall into the "chemicals of unknown concern" (Tier III) category. Caution is needed to be sure that Tier I and Tier II chemicals are not substituted with Tier III chemicals because of the risk of replacing known dangers with potentially greater dangers. Perhaps another way to think about prioritizing chemicals is to consider the six activities proposed by Denison (2007). Using these activities, prioritization might focus on which chemicals ought to be assessed first (activity 4). In this way, Tier III chemicals that are in high production volume (high risk of exposure) may float up to the top of the "to do" list for assessment because of the burning need for more information to close this data gap. This is one of the approaches adopted by REACH whereby high volume chemicals (1000 tons/year or more) are being addressed before chemicals of lesser volume (100 tons/year or less).

Another approach to chemicals prioritization might be to remove barriers for disclosure of information (activity 6). Comprehensive safety information that lists all of the contents in a product is frequently withheld by producers under the guise of confidential business information (CBI). In order to close the Data Safety and Technology Gaps, prioritizing the removal of CBI would provide the ability to detect potentially hazardous exposures to consumers and workers. It would also act as a market driver for developing safer/preferred chemicals (Tier IV). The combination of all these approaches must be utilized if comprehensive chemical policy reform is to take root and grow quickly enough to make a difference.

Market-Based Approaches

A critical vehicle towards achieving reform in chemical production and use within the US or abroad is through market-centered initiatives. This approach is powerful because it suggests a 'win-win' situation in which corporations involved in chemical production and use can become part of the 'new chemical economy. The goal for this 'new chemical economy' is that corporations can remain economically viable while at the same time minimize their negative impact on human health and the environment. Market-based approaches regarding chemical management are frequently framed in the context of a pollution-tax versus a cap-and-trade system. In

The goal for this 'new chemical economy' is that corporations can remain economically viable while at the same time minimize their negative impact on human health and the environment.

the cap-and- trade system, environmental regulatory agencies establishes a 'cap' that limits total emissions from a designated group of polluters, such as a specific industry, to a level lower than their current emissions. The emissions allowed under the new cap are then divided up into individual permits for individual companies representing the right of that company to emit a specific amount of pollution. These permits take on a monetary value, and companies are free to buy and sell permits depending on their technological ability to reduce their own emissions. Although some companies are able to pollute more by buying permits, the goal of decreased emissions is still met by the industry as a whole.

Recently the market-based approach has taken on a broader meaning to encompass market-based alternatives that are aimed at pollution prevention not just pollution management. Market-based alternatives, like Green Chemistry and safer substitution, and green purchasing, will be discussed below to illustrate how these market drivers foster comprehensive chemical policy reform.

Green Chemistry

Industries producing and using chemicals contribute to the U.S. and European economies as they provide jobs, produce profits, and contribute to state and local tax revenues. Global chemical production is expected to double every 25 years for the near future (Wilson, 2006). It is clear that products created through chemicals abound and have positive purposes such as pest control, disease treatment, and

…chemicals have carved out a significant niche in modern society and are unlikely to disappear.

packaging of materials. In fact, a popular advertising slogan is "Better Living through Chemistry." As this slogan suggests, chemicals have carved out a significant niche in modern society and are unlikely to disappear.

However, it is critical to keep in mind that there is generally little relationship between a chemical's usefulness and its toxicity. Often the risk that a chemical poses to human or ecological health is unrelated to what it accomplishes. Additionally, pollution does not add to the profitability of the corporation producing it. Thus, a chemical's toxicity and resultant environmental and health impacts are really byproducts of its development. If a chemical or its production process can be designed so that its toxicity is reduced or eliminated, both industry and the public will benefit.

This decrease in environmental toxicity is the goal of a new scientific movement known as Green Chemistry, and aimed at preventing pollution through the environmentally safe design of chemical products and processes. Anastas and Warner have developed the 12 Principles of Green Chemistry which highlight for chemists principles for reducing or eliminating the use or generation of hazardous substances in the design, manufacture, and application of chemical products. Examples of these principles include preventing waste, designing safer chemicals and products, designing less hazardous chemical syntheses, and using safer solvents and reaction conditions. The 12 Principles for Green Chemistry can be viewed in its entirety on the EPA's website www.epa.gov/greenchemistry.

Green Chemistry offers a heady, market-based approach for driving innovations in chemical policy. In fact, experts have reported that alternative technologies, such as Green Chemistry, are less damaging, economically

If a chemical or its production process can be designed so that its toxicity is reduced or eliminated, both industry and the public will benefit.

superior, and function as well, if not better, than more traditional (toxic) options (Lowell Center for Sustainable Production, n.d., c). An important industry and regulatory gain achieved through Green Chemistry is that costs attributed to adverse health effects from handling, transporting, and disposing of hazardous materials are largely eliminated through this technological advancement. Currently, this alternative to chemical design and production is largely underutilized because little funding has been directed either to scientists or to businesses to create 'cleaner/safe' chemicals.

It should be noted that the industry push to 'greenwash' nanotechnology remains of questionable value. As with many of the chemicals currently on the market, little is known about the hazards attributed to this technology. Some scientists have found that there may be significant cardiopulmonary effects of exposure to nanotubes (Lam, James, McCluskey, & Hunter, 2004; Li et al., 2007). Therefore, caution should be used in supporting nanotechnology as a Green Chemistry method until more is discovered about its health impacts.

Safer Substitution and Green Purchasing

A common recommendation for limiting the production and use of the Chemical Action Pyramid Tier I and Tier II chemicals involves substituting hazardous substances with preferred (Tier IV) chemicals. Since substitution and green purchasing practices are closely linked they will be discussed together in this paper.

The adoption of safer chemical alternatives is one of the key principles supported by the Louisville Charter. The Charter states that substitution policies must be mandatory to achieve a world safe from hazardous chemicals. Regulatory imperatives are needed to provide enough of a competitive advantage for safer product adoption (Thorp & Rossi, 2005). Substitution and green purchasing policies are needed to provide strong incentives for the market to change and for industry to adopt safer processes. These policies can act as effective market drivers which motivate chemical producers to adopt safer processes, substitute safer (preferred) chemicals, and invest in research on green technologies to attain/maintain a competitive edge in the marketplace.

Grass roots organizations have employed this market-based approach to make safer, personal care products available. An example of this is the Campaign for Safe Cosmetics. This Campaign, described on its website www.safecosmetics.org, was launched because most chemical ingredients in cosmetics are not subject to pre-market approval by a regulatory body (USFDA, 2005) and many contain hazardous chemicals. This situation is changing in Europe where a new EU law forbids the use of over 1,000 cosmetic ingredients that are known carcinogens, mutagens, and reproductive toxins, such as DBP discussed above, (The Commission on European Communities, 2004).

The Campaign for Safe Cosmetic asks cosmetic companies to sign a pledge to remove toxic chemicals from their products and replace them with safer alternatives. This request, along with pressure from the E.U. law to formulate safer products that can meet European specifications, and be sold there, provides a two-pronged force to cosmetic companies to adopt safer practices. The campaign and the public attention it has brought to the topic is asource of market-based pressure. So far, more than 400 companies, mostly smaller and natural food store companies, but also larger companies such as Estee Lauder, L'Oreal, and Revlon, have signed the pledge (Brody, 2006).

Green purchasing practices include buying, selling, and utilizing environmentally preferable products. Environmentally preferable products are defined as "products and services that have a lesser or reduced effect on human health and the environment when compared with competing products or services that serve the same purpose" (Office of the Federal Environmental Executive, 1998). Environmentally

Green purchasing practices include buying, selling, and utilizing environmentally preferable products.

Preferable Purchasing (EPP), a term interchangeable with green purchasing, is the practice of purchasing such materials. EPP takes into consideration the effects of the products on the environment through the whole life cycle of that product. Tracking the life cycle includes following raw materials acquisition, production, manufacturing, packaging, distribution, reuse, operation, maintenance, and disposal of the product.

EPP uses the concept of substitution to replace hazardous chemicals with safer alternatives. The first chemical policy reform principle of the Louisville Charter requires safer substitutes and solutions. According to the Charter it is not enough to merely replace one chemical with another. Rather this principle requests an analysis of the function the chemical serves. Analyzing a chemical's function in a given task may lead to the discovery that changing the way the task is performed is environmentally preferable to simply replacing one chemical with another. This may lead to changes in systems, materials, processes, or chemicals; it encourages policy makers and manufacturers to support research and development of more creative, safer solutions (Thorp & Rossi, 2005).

EPP and substitution policies, when adopted by large organizations, can result in a market-based approach to chemical policy change. For example, supplies and equipment that come into the hospital may do so through Group Purchasing Organizations (GPO). A GPO brings together many purchasers in order to keep prices low, and leverage the buying power of all organization members. Vendors compete to meet the requirements set by institutions or GPOs in order to win contracts. When businesses demand products with environmentally preferable characteristics, strong incentives are created for the market to produce these products so as to meet the need and remain competitive. This results in the manufacturing, selling, and availability of safer, less hazardous products.

Institutional Approaches

A critical and exciting approach to achieving comprehensive chemicals reform involves the health care industry serving as a vehicle for inspiring greener innovation in chemicals use. The health care industry encompasses health care institutions and providers, such as nurses, physicians, and public health practitioners, as well as health professional associations. As a collective, the health care industry is a vital agent for addressing chemicals as a whole because it can use its significant purchasing power to transform the design and manufacture of products towards greater sustainability. This is a fitting role for the health care industry, which has a natural stake in reducing the use of chemicals that are linked to

The health care industry has a responsibility to learn about the hazards it creates and to lead by example through its purchasing and safe chemical substitutes priorities and to support comprehensive, chemical policy reform.

disease and an ethical responsibility to do so as the leader and advocate for the health of the communities that they serve. It is especially important that the industry lead the way in promoting safer chemicals policy, given the numerous chemicals or toxic substances still in use in health care settings which have been linked to adverse health effects, such as glutaraldehyde (linked with occupational asthma) and mercury (linked with neurotoxicity). The health care industry has a responsibility to learn about the hazards it creates and to lead by example through its purchasing and safe chemical substitutes priorities and to support comprehensive, chemical policy reform.

The steps in a comprehensive, chemical policy reform will be presented below. Examples of how health care organizations and health professionals have contributed to promoting comprehensive, chemical policy programs will be included to offer the reader ideas for greener innovations within their own workplace.

The first step of a comprehensive, chemical policy reform is for an organization to establish a written policy regarding chemicals reform. This policy should state that the company's vision, values, principles, and organizational objectives are consistent with the adoption of a safer chemicals program.

The next step of this reform is to develop a plan of action for a pilot project for implementation of a new chemical policy (HCWH, 2007). For example an organization could target individual suppliers, product areas, or specific departments. This would necessitate development of a pilot team. The team would need to identify the specific chemical that will be removed, reduced, or replaced based on the chemical's hazardous characteristics. The Chemical Action Pyramid's tiered approach to classifying chemicals could serve as a guide for prioritizing chemicals for removal from a health care institution. An action plan indicating tasks to be done, the person responsible for each task, and due dates for task completion would also be needed. Nurses should play a leadership role in the team that implements the pilot project. Nurses can use their professional education to help establish the health basis for identifying chemicals of concern, draft the organization's written policy towards toxic chemicals, develop staff education regarding the chemical hazards, and assist in identifying alternative chemicals and products that will ensure patient and worker safety and clinical efficacy.

The final step is to evaluate the results of the program, assessing the project's success in meeting its goals, the overall acceptance of the program, and barriers encountered during the project. The program can be expanded to other areas of the facility, incorporating what was learned during the pilot project (HCWH, 2007). Hospitals that implement chemical policy reform will need to work with their GPO, teaching their GPO how to ask questions about chemical components of products and materials and how to request substitutes in their proposals or purchasing bids. In this way, institutions and corporations can have an impact on the market beyond their individual place of work by signaling the market that organizations will be requiring full disclosure of chemical components and data on health testing prior to purchasing. A hospital's establishing a purchasing policy to exclude products containing certain chemicals, for example, brominated flame retardants, a class of chemicals found in computer and textile products, will necessitate manufacturers' providing safer alternatives if they want to maintain the hospital's business. This has already been done successfully in replacing mercury-containing products with mercury-free products. As more institutions and companies make the same requests for specific types of chemical-free products, more alternatives and innovations will become available to all.

Moving Beyond Individual Institutions: Nursing Initiatives

Health care's mission to prevent illness and heal disease makes the industry a potentially powerful advocate for safer chemical laws. Several professional, health-related organizations are already working to build an advocacy movement in the health care sector. Some of these efforts are aimed at creating market drivers through purchasing policies adopted by health care institutions as described above. Yet the current

…the current state of ineffective chemical regulation in the US is a situation that cannot be entirely remedied by voluntary initiatives or institutional purchasing policies, no matter how large. Laws requiring the development of safer alternatives will be necessary.

state of ineffective chemical regulation in the US is a situation that cannot be entirely remedied by voluntary initiatives or institutional purchasing policies, no matter how large. Laws requiring the development of safer alternatives will be necessary. This will necessitate recruiting health leaders who can voice the need to support state and federal chemical reform legislation. This next section will describe a variety of such efforts by nurses and the nursing profession.

The HCWH coalition has advanced environmental safety in health care organizations through the search for safer substitution of chemicals and alternatives to medical waste incineration, one of the leading causes of dioxin production. HCWH has developed a model chemical policy to assist health care institutions in using their purchasing power to advocate for safer chemicals. The HCWH model seeks to eliminate data gaps in the knowledge of the toxicity, environmental attributes, and use of the chemicals used to manufacture products; to support the substitution of toxic chemicals with chemicals or processes of lesser environmental impact; and to support an economy where manufacturers, suppliers, and consumers are provided with sufficient information to compare toxicity options and environmental impacts of the chemicals and products they use.

The ANA participated in the negotiation of the 1998 Memorandum of Understanding (MOU) between the USEPA and the American Hospital Association (AHA) to create the Hospitals for a Healthy Environment (H2E) program. The H2E program called for hospitals to eliminate mercury from use by 2005 and to reduce the use of PBTs. In 2001, ANA and HCWH joined as partners in H2E to assist in mobilizing hospitals and nurses to achieve the goals of the MOU. As hospitals joined the H2E 'Making Medical Mercury Free' campaign, nurses assisted by conducting inventories of mercury-containing products and developing databases of appropriate alternatives. H2E developed a model, mercury-free policy for hospitals, tools for conducting mercury inventories, information about alternatives to mercury-containing products in clinical measuring devices, and recognition awards to hospitals for successfully achieving the goal of mercury elimination. As hospitals began to demand the mercury-free alternatives, such products became available to meet the demand. By 2005 an H2E and AHA survey found that 54% of hospitals had already eliminated virtually all mercury from their institutions (HCWH, 2005). In 2005, ANA joined the Physicians for Social Responsibility, the American Academy of Pediatrics, the American Public Health Association, and 13 state Attorneys General in suing the USEPA over clean air standards for coal-fired power plants that were causing mercury pollution (ANA, 2005).

A barrier to eliminating toxic chemicals, such as mercury, is the current environmental regulatory process which bans one highly hazardous chemical at a time. This process requires a massive effort by agencies and activists who are trying to protect human health by gathering safety data on more than 80,000 chemicals now in use. Recognizing that reform can not effectively happen one chemical at a time, the ANA passed a resolution calling for broad chemical policy reform. This resolution also encouraged focusing on categories of chemicals such at PBTs rather than on single chemicals. This resolution titled "Nursing Practice, Chemical Exposure and Right-To-Know Action Report" (ANA, 2006) identified the need to ensure that the nursing profession supports a fundamental reform of the nation's current chemical laws, regulations, rules, standards, and policies in order to protect nurses and other health care workers, patients and their families, communities, and the environment. Further, it advocates for increased research to better understand the relationship between health and the environment, and supports the integration of environmental health policy into nursing education, practice, research, advocacy, and policy development. Finally, the resolution resolves to ensure that nurses and the communities that they serve have full access to information and the right-to-know about the potentially harmful chemicals, pollutants, and hazards to which they are exposed regardless of the setting.

State nurses associations have also engaged in advocating for chemical policy reform. State nurses associations, which are constituent member associations of ANA, met in July of 2006 with environmental health activists to determine a unified policy and strategy to address the need to reform chemical policy at the state level in concert with national reform goals. One state association, the Washington State Nurses Association (WSNA), is taking leadership in advocating for chemical policy reform at the state level and educating the public to make the connection between health and the environment. The WSNA is working with nurses who are elected officials in the Washington state legislature.

WSNA has had a strong and effective legislative program for almost 100 years (WSNA, 2007). This program now includes an annual nurse-lobby day in the legislature which attracts over 500 nurses who meet with their elected officials to educate them about nursing issues. The nurses learn how the legislature works and the importance of nurse involvement in policy making. As a result, the state of Washington has elected eight nurses to the legislature, more than any other state in the US. Nurses in the legislature have risen to leadership roles that include chairing the Health Committee and the Ways and Means Committee. In 2002, WSNA established a committee on occupational and environmental health to lead policy development within the organization and make recommendations for policy action.

One action WSNA took was to join the Toxic Free Legacy Coalition, whose organizational members work together to promote policy protecting people from toxic chemicals. WSNA, now a member of the Board of this Coalition, has promoted nurse involvement in this Coalition to the extent that, as of this writing, nurses are members of most of the Coalition committees. Another effective advocacy activity involved the coauthoring of a letter by the Executive Director of WSNA, along with the President of the Washington State Academy of Pediatrics, to the editor of a large local newspaper advocating for safer chemical policy for health. (Lawson & Huntington, 2005).

Nurses in the Washington State legislature have also taken leadership in advocating for chemical reform. These nurse legislators drafted a 'dear colleague' letter to educate their fellow elected officials about the connections between the environment and health and to urge them to support the proposed legislation banning the persistent and bioaccumulative class of chemicals found in such chemicals as the brominated flame retardants. One of the nurse legislators, Dawn Morrell, presented the work of WSNA work regarding chemical policy at the National Council of State Legislatures meeting in August of 2006. Although the legislation lost by one vote in the 2006 session, the nurses used the remainder of 2006 to educate the public about the severity of health problems resulting from these chemicals. The legislation to ban BFRs, reintroduced early in 2007, was supported by over 500 nurses attending the WSNA nurse-lobby day. In April, 2007 the Washington State Legislature passed the first-in-the nation ban on Toxic Flame Retardants. The ban passed in both the House of Representatives and in the Senate. Washington's Governor Gregoire signed the bill into law on April 17, 2007.

Conclusion

Although the 1970s was the decade that birthed the environmental movement, Earth Day, and the Environmental Protection Agency in the US, it is only, now, in the first decade of the 21^st century, that the human health effects of the chemicals formulated in the past century are publically recognized. Nurses, as health care leaders, need to know the hazards of these, currently, poorly regulated and toxic chemicals, and

Nurses, as health care leaders, need to know the hazards of these, currently, poorly regulated and toxic chemicals, and be involved in developing public policy to protect human health

be involved in developing public policy to protect human health. The voices of nurses and organized nursing must be heard in these policy debates.

The purpose of this article has been to inform nurses and other health care professionals about the nexus between the environment and health and present approaches in which they can support comprehensive reform of chemicals management in the U.S. In order to slow the increasing rates of asthma, cancer, developmental disabilities, and infertility, this article has described the way forward to safer chemical policy and highlighting opportunities for nurses to join with other organizations committed to enhancing environmental health.

Authors

Kristen Welker-Hood, DSc, MSN, RN

Kristen Welker-Hood, holds a Bachelor of Science in Nursing degree from Binghamton University (SUNY) and a Master’s of Science degree in community health nursing from Johns Hopkins University. Kristen also holds a science doctorate in environmental health from Boston University School of Public Health. She has worked in various areas of environmental health including indoor air pollution, pediatric lead poisoning, environmental asthma, and chemical policy. She presently is a Senior Policy Fellow in the Center for Occupational and Environmental Health at the American Nurses Association (ANA). In her current position she continues to work on environmental and occupational health issues, with a focus on framing a broad chemicals policy reform within the Unites States. She is also the program manager for ANA’s subcontract grant for the First Receiver education program, designed to educate nurses regarding personal protection strategies to prevent exposure to hazardous substances in the workplace. This education has been made available to ANA members as part of a grant awarded through the International Chemical Workers Union Council Consortium funded by the National Institute of Environmental Health Sciences. She has authored articles on an array of occupational and environmental health-related subjects.

Marian Condon, MSN, RN

Marian Condon, holds a Master’s degree in community and public health nursing. She has worked on environmental and occupational health issues with Health Care Without Harm and Hospitals for a Healthy Environment, and presently serves as a Senior Staff Specialist in the Center for Occupational and Environmental Health at the American Nurses Association. In her current position she continues to work on environmental and occupational health issues, especially as they pertain to nurses. She has authored articles on an array of occupational and environmental health-related subjects. Marian is a nurse luminary and volunteers on the Environmental Health Task Force for the Maryland Nurses Association.

Susan Wilburn, MPH, BSN, RN
E-mail: susan.wilburn@att.net

Susan Wilburn, an international, occupational and environmental health specialist, serves as the Coordinator of the American Nurses Association’s (ANA’s) RN No Harm program and as a technical consultant with the World Health Organization’s (WHO’s) Occupational Health Programme and the Making Medical Injections Safer health care worker study at John Snow, International. Ms. Wilburn has worked as a nursing consultant to the International Council of Nursing (ICN), coordinating the joint WHO/ICN Needlestick Prevention Project in Tanzania, South Africa, and Vietnam. Prior to that, Susan worked for ten years at the ANA, founding the Center for Occupational and Environmental Health. Under her leadership, ANA joined Hospitals for a Healthy Environment as one of the four partners along with the American Hospital Association, the Environmental Protection Agency, and Health Care Without Harm; and initiated ANA’s Safe Needles Save Lives campaign of education, capacity building, and advocacy she led the effort nationally to pass the 2000 Needlestick Safety and Prevention Act. Susan received her undergraduate degree from the Kent State (Ohio) University School of Nursing and her Master’s of Public Health from the University of Washington.

Lowell Center for Sustainable Production, University of Massachusetts Lowell (n.d., b). What is chemicals policy? Retrieved February 10, 2007 from www.chemicalspolicy.org/aboutchemicalspolicy.shtml

U.S. Environmental Protection Agency (2007).12 Principles of green chemistry. Retrieved February 22, 2007 from www.epa.gov/greenchemistry/pubs/principles.html

Wingspread Statement on the Precautionary Principle. (1998). Retrieved April 19, 2007 from www.gdrc.org/u-gov/precaution-3.html

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