Nepals Decision “Regarding Mercury based Equipments and Dental Amalgam”
Decision ‘Regarding Mercury based Equipments and Dental Amalgam’, August 21st 2019
Amalgam dental fillings consist of approximately 50% mercury, a highly neurotoxic heavy metal. Growing scientific consensus raises concerns about this substance being released from the tooth filling into the patients’ organisms. This is dangerous, particularly for children and unborn foetuses in their physical and mental development. Furthermore, handling dental amalgam puts at risk dental health care workers, and release into the environment can pollute rivers and other water bodies, and thus fish and drinking water.
After detecting high contamination levels in dental care staff, and after signing the Minamata convention on Mercury, the Nepali government decided to ban the use of amalgam fillings for children under 15 and pregnant and breastfeeding women. Furthermore, it works on a phase-down, and eventually complete phase-out for all patients, supported by broad information campaigns in collaboration with NGOs.
- Ban of amalgam fillings for children under 15 and pregnant and breastfeeding women.
- Plan of a complete phase-out
- Drastic cut of use led to some areas to be declared mercury free.
- Ban on import, purchase, and use in healthcare of mercury-based equipment (2013)
- Constitution of Nepal (2015) (https://lawcommission.gov.np/en/?cat=87), according to which “every citizen shall have the right to live in a clean and healthy environment.”
- The Public Health service act, 2075 (2018): https://www.lawcommission.gov.np/en/wp-content/uploads/2019/07/The-Public-Health-Service-Act-2075-2018.pdf
The regulation is a very positive step towards protecting public health and the environment from the harmful effects of mercury. It aligns with international efforts to phase out mercury use, such as the Minamata Convention on Mercury, which Nepal has signed but not yet ratified. The 2019 Law, along with the 2013 Law on import of mercury-based equipment present measured, but ambitious responses to the scientific research conducted primarily by the Centre for Public Health and Environmental Development (CEPHED) in 2013. The legislation seeks to protect vulnerable groups (children and pregnant and nursing mothers) from mercury pollution with a complete ban, and the wider population with a phase-down of dental amalgam, aiming at a complete phase-out in coming years. And to this end, the comprehensive compliance monitoring indicates significant success, with 94% of monitored Dental Healthcare Facilities found to shifted to mercury-free alternatives.
The Nepali government’s response to emerging scientific evidence on the dangers of mercury pollution in Nepal was fast, considered and effective. The exemplary policy sets a high standard in the global move away from mercury-based dentistry. The Future Policy Award would set the example for neighbouring countries like India, Bangladesh and maybe even China, revealing the benefits of taking similarly ambitious steps to protect citizens’ health and environment.
Our “Best Policies” are those that meet the Future Just Lawmaking Principles and recognise the interconnected challenges we face today. The goal of principled policy work is to ensure that important universal standards of sustainability and equity, human rights and freedoms, and respect for the environment are taken into account. It also helps to increase policy coherence between different sectors.
Sustainable use of natural resources
- Attempt to eliminate unsustainable resource.
- Protection of fragile environment (such as Chitwan National Park).
Equity and poverty eradication
- Reduced future healthcare expenses, and measures taken to lighten the load of initial increased expenses.
- Nuanced phase-out of dental amalgam, until alternatives are considered suitable.
- Measures taken partially because of mercury’s bio accumulative properties – present in 100% of dentists tested.
- Complete ban on children and pregnant and nursing mothers.
Public participation, access to information and justice
- Consultation of Nepal Dental Association, Nepal Medical Association and Universities.
- Awareness raising using various media.
Good governance and human security
- Multisector engagement from stakeholders.
- Stakeholders also included and consulted throughout the implementation process.
- Compliance monitoring tracking implementation.
Integration and interrelationship
- Implementation alongside UN MDGs and UN SDGs.
- Compliance monitoring revealed that 94% of Dental Healthcare Facilities had switched to mercury-free alternatives.
Common but differentiated responsibilities
- 70% of dentists did not express any problems with using mercury-free alternatives.
- Long term cost-benefit analysis of using alternatives.
In the early 2000s, there was a high import, purchase, and use rate of mercury-based equipment such as mercury-based thermometers and sphygmomanometers and dental amalgam in the Nepali health sector. Biomonitoring conducted by the Centre for Public Health and Environmental Development (CEPHED) in 2013 revealed that all the health worker participants (dental doctors and nurses), were found to have 0.097-0.547 ppm of mercury in their bodies. Considering that a level of 0.085 ppm is associated with neurodevelopmental effects, this finding was highly alarming. As a result of this research, the Ministry of Health banned import, purchase and use of all mercury-based equipment in July 2013. A study conducted in 2019, just months before the new law was passed, on the attitudes and practices in a dental institution in Kathmandu suggested that 73.44% did not use amalgam frequently for restoration due to concerns about mercury toxicity. Dental amalgam was no longer the main filling used, at least in the capital. Yet, according to the Minamata Initial Assessment report, conducted in the same year, the annual release of mercury from use and disposal of mercury-based products was estimated at 2590 Kg from the health sector, 13.2% of the total 19,615 Kg in Nepal. This report also highlighted the significance of dental amalgam filling use and disposal as being the main source of mercury release in water. Further action was necessary.
Having signed the Minamata Convention, affirming its commitment to the global impetus for mercury-free dentistry, the Government of Nepal seeks to implement the recommendations of the Minamata Initial Assessment report. It legislates a complete ban on the use of mercury dental amalgam in pregnant and nursing mothers, as well as on children below 15 years. Recognising the developmental dangers of mercury contamination, it evidences a clear aim to protect these especially vulnerable groups. Continuing its focus on future generations, the law seeks to ensure that education of future Nepali dentists is conducted in accordance with recent scientific knowledge on the risks of dental amalgam. It commits to amending the curriculum in dental academies and universities and to ban the use of mercury dental amalgam in practical exercises. Beyond this, the law represents the government’s concentrated effort to significantly phase-down dental amalgam use. With the long-term aim of phasing out completely, it sets the condition of a complete ban: “five years of available alternatives”.
A key priority in ensuring proper implementation was ensuring that all dentists were aware of the new law. To this end, the government primarily made use of existing hospital and dental clinic internal circulation systems. The cooperation of the Nepal Dental Association (NDA) certainly facilitated this process; the umbrella organization had already adopted mercury-free dentistry months before the law came into effect. In 2023, the NDA consisted of around 2,000 dentists, a hugely comprehensive number considering that in 2015, the total number of registered Nepali dentists was 1,803. As such, interviewed parties were confident that every dentist practicing in Nepal would be aware of the new restrictions. Their compliance is being monitored by health inspectors, the government’s “eyes and ears”, who use a mix of observational visits, inspections of the store and procurement sections, questionnaire surveys, and consultative meetings with relevant stakeholders at national and sub-national levels. Efforts to raise public awareness, including radio, tv, newspapers and social media campaigns, have specifically focussed on spreading information about the dangers of dental amalgam, and the benefits of mercury-free healthcare. CEPHED even organised a Mercury-Free Dentistry and Mercury-Free Health Care Week of Action campaign in 2018 in Bharatpur, Chitwan, with the slogan “Say Ahh, Think Mouth Think Health” During this campaign, demonstrations of mercury-free alternatives were conducted, attempting to not only inform patients about the dangers of mercury, but also about the benefits of alternatives.
The primary vehicle to assess the results of the measures taken against mercury is recent compliance monitoring conducted by the Ministry of Health and Population and supported by CEPHED. This revealed generally effective implementation of laws regarding mercury-based equipment (2013), and dental amalgam (2019). Of a total 47 Dental Healthcare Facilities (DHCF) monitored – randomly selected from at least one major city and surrounding areas in all seven provinces of Nepal – 44 were aware of the government’s decision on Mercury Free Dentistry. Of these, 93.62% were found to be shifted to mercury-free alternative dental fillings like Glass Ionomer Cement, and only 6.38% were found to be still using dental amalgam in capsule form. 34 of the 47 had not encountered any problems using non-mercury alternatives, while the remaining 13 mentioned that these had lower strength with ensuing cost and time burdens. Regarding the increased cost of alternatives, interviewed parties mentioned long-term reduced mercury-related healthcare expenses and decreased cost due to larger supply and more established supply chains. Increased health insurance coverage to 24% of all families across all regions, and the widening of procedures covered also lightened the initial load of these costs.
Certain areas of Nepal, such as the Chitwan District, were even declared “mercury free”, and evidenced reduced environmental mercury pollution. This includes the Chitwan National Park and Narayani River, a UNESCO World heritage site and home to several endangered species. Because of its efforts in the area, CEPHED was awarded the WWF Conservation Award 2020.
The law must be understood within the framework of the global Minamata Convention, which has committed to phasing-down mercury use. Already a signatory to the convention, Nepal is preparing to ratify it. The World Alliance for Mercury-Free Dentistry aims even higher, wanting to phase out global use of dental amalgam completely. Tis NGO has given Ram Charitra Sah of CEPHED its “First in Asia” Award, recognising recognises the important steps taken by the Nepalese government and highlights the policy’s uniqueness in Asia. There might be a chance of setting an example for neighbouring countries like India and Bangladesh or even China. In all three, implementation of such a law would perhaps be a more onerous process due to their enormous populations. In India, dental care is less available, with only 58% visiting a dentist regularly. Certainly, Nepal’s positioning next to the two “giants of the world”: India and China, provides it with the unique challenge of influencing their policies. Nevertheless, the policy does seem to have received recognition from its Bangladeshi neighbours.
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