https://orcid.org/0009-0008-5195-0037
Abstract
Metals and metalloids including cobalt, gadolinium, lutetium, and germanium are used in numerous medical applications spanning diverse specialities including orthopedics, radiology, oncology, and healthcare artificial intelligence. These medical advances include cobalt containing orthopedic implants, gadolinium-based contrast agents, lutetium-containing cancer drugs, and germanium-based semiconductors. While these metal and metalloid-based solutions do improve patient care, there is a heavy side to how the elements needed for these solutions are mined, extracted, and discarded. These practices often exploit and harm vulnerable populations and environments. As healthcare professionals, we should be aware of the entire mineral to medicine lifecycle. As providers and consumers of these metal and metalloid-based solutions, we must advocate for more responsible and ethical extraction and recycling practices. As researchers and educators, we must promote and support continued research and development into less resource-intense medical solutions that can both improve patient care and sustainability.
We are living at a time where there is immense innovation pertaining to diagnostics, therapeutics, and healthcare artificial intelligence (AI). This includes improved orthopedic implants and diagnostic imaging agents, theranostic agents for difficult to treat cancers, and AI algorithms that can improve the diagnostic capabilities of laboratory tests and imaging modalities. What these innovations have in common are often clinically described as metals, but more appropriately are metals and metalloids. While many of these metal and metalloid-based solutions do improve patient care, there is a heavy side to how these elements are mined, extracted, and disposed of, that results in the exploitation and harm of vulnerable populations and environments. While exploitation and harm of populations and environments is certainly not distinct to the acquisition and disposal of metals and metalloid-based healthcare solutions, specific metals, and metalloids will be discussed below to highlight how advancements in healthcare and technology can not only heal but also harm.
Heavy–of great physical weight or density
“Heavy metals” have previously been defined as elements that have a high atomic weight and a density at least five times greater than that of water [1]. Clinically, arsenic, lead, cadmium, and mercury are a few metals/metalloids that are often considered as “heavy metals” [1]. While chemically speaking, this definition of “heavy metals” may not be appropriate, the term “heavy metals” is widely used in the clinical setting to describe numerous metals and metalloids. Numerous other “heavy” metals or metalloids that are essential in modern healthcare include cobalt, gadolinium, lutetium, and germanium. Cobalt provides strength to alloys and gadolinium, in the Gd3+ form, makes it suitable as a central ion in chelates used in magnetic resonance imaging [2]. Lutetium can be a clinically suitable beta emitter, and the properties of germanium allow it to be a fast signal transmitter.
Heavy–complex
The diverse chemical properties of these metals and metalloids make them useful in complex medical specialties. Cobalt has been an essential component of orthopedic implants and currently as many as 20 million North Americans have cobalt containing arthroprosthetic components [3]. Gadolinium, a rare earth element, is an essential component of modern radiology imaging contrast agents. Since their introduction, more than 450 million gadolinium-based contrast agents (GBCAs) have been administered worldwide [4]. Lutetium, specifically 177Lu, is another rare earth element that is used to treat prostate cancer that has spread to other parts of the body and is resistant to other treatments [5]. Due to its promising theranostic capabilities, 177Lu usage has rapidly increased in recent years [6]. Germanium, a metalloid, can be used as a substitute for silicon in semiconductors and provides superior thermal resistance, making germanium-based microchips suitable for high-performance electronics including those used in AI applications [7]. As AI techniques such as machine vision, natural language processing, and machine learning become more adopted in medicine, high performance computing will become more in-demand throughout healthcare and healthcare-adjacent industries.
Heavy–oppressive
These metal and metalloid-based medical advances however come at a steep price. That price is the exploitation and oppression of vulnerable populations and environments throughout the world. The oppressive conditions of cobalt mining in the Democratic Republic of Congo have been vividly described by Siddharth Kara in Cobalt Red: How the Blood of the Congo Powers Our Lives. Child labor, violence, extortion, and widespread ecologic contamination are systemic problems surrounding cobalt mining in the region [8]. Importantly, germanium is also extracted from the waste material of some of these same cobalt mining operations, thus questions surrounding the ethical extraction of germanium should also be investigated. The mining and extraction of rare earth elements including gadolinium and lutetium also pose significant risk to both human health and the environment. For every ton of rare earth element produced, about 2000 tons of toxic waste are also produced [9]. This is especially concerning in China because as of 2016, China accounts for 85% of the global supply of rare earth elements [9]. The mining and extraction of these medically relevant elements are not the only potentially destructive steps from mineral to medicine. Environmental contamination caused by the medical use of rare earth elements including gadolinium is also of concern. Since GBCAs are predominantly excreted renally, gadolinium has contaminated numerous waterways and ecosystems surrounding large medical practices since its widespread adoption in healthcare [10].
Heavy–of significant importance or seriousness
Metal and metalloid-based medicine does improve the health of countless people. However, the practice of medicine should not only consider the direct impact on patients, but also consider the human and ecological impact associated with the acquisition, medical use, and disposal of these elements. There are various ways that healthcare professionals can promote ethical stewardship of metal and metalloid-based medicines and technologies.
Awareness: We must educate each other on the upstream and downstream costs associated with providing metal and metalloid-based solutions in the practice of medicine.
Advocacy: As consumers, we must encourage vendors of metal and metalloid-based medicines and technologies to participate in organizations such as the Global Battery Alliance or the Responsible Minerals Initiative. These organizations work to ensure that mineral acquisition, processing, and recycling are responsible and sustainable.
Test utilization: We must ensure proper stewardship of tests, procedures, and pharmaceuticals that we provide to patients. By ensuring that only the right patients receive the right treatment at the right time, we can reduce waste surrounding metal and metalloid-based medicine.
Computing stewardship: We must consider if AI approaches, and the technology required to support AI are medically necessary or appropriate to address certain healthcare needs. We must consider if specific healthcare problems can be answered with less resource-intensive processes or products.
Innovative recycling: We must support and participate in innovative recycling processes to attenuate the risk of metal and metalloid-based pollution of the environment
Continuous improvement. We must continuously research and develop less resource-intense healthcare solutions. One example of this is the appropriate use of AI in radiology imaging to reduce the dosage of GBCAs administered to patients [10]. This is a great example of how one element-based solution can reduce the reliance of an element-based diagnostic agent.
As a profession, we must not rob Peter to treat Paul. Metal and metalloid-based medicines and technologies have a diverse range of useful applications in medicine. However, some of these solutions currently come at a heavy cost to both humans and the environment. As healthcare professionals, we should be aware of the mineral to medicine lifecycle and advocate that these metals and metalloids, as well as other elements, used in healthcare are ethically and responsibly mined, extracted, and recycled. We must be ardent stewards of these medicines and technologies, and we must promote continued research and development into less resource intense and more ethically attained medical solutions for patients.
Conflict of interest
None declared.
Funding
None declared.
Data availability
No new data were generated or analyzed in support of this article.
