Attachment D:
April 6, 1998 Richard Ackermann
Manager
Dear Mr Ackermann: At a meeting with you and a World Bank team on March 2nd we
discussed my experiences observing medical waste management practices in India
in October and November 1997 in Delhi, Mumbai and Calcutta, and what value these
observations might have for the further development of that aspect of the State
Health Systems Development Project which is supposed to address the management
of medical waste. I was asked at that time to provide further background on my
eleven basic recommendations which I presented at that meeting, which I will do
in an attachment to this letter. In being able to continue to advise NGO’s, state and municipal
governments and hospitals in India, which I am asked to do on a regular basis,
it would be helpful for me to have more information as well. So I would like to
pose three questions to your and your staff and would appreciate a timely
response. (1) You indicate that you are awaiting the results of studies being done by
each state government on the approach they would like to see adopted for the
management of medical waste. What I have not received is any indication of how
the question is being asked (which of course will have a great deal to do with
the answer), what the qualifications of those who are conducting the study, and
what you will do with the answer. I know that it is Bank policy to try and
empower the people who will be affected by a project to help direct it. However,
I also know that the Bank does not give blanket approval to any request,
particularly if it is environmentally questionable, or if such a response is
contrary to public health goals. So the final part of this question is what will
your response be if any of the studies call for the mass incineration of waste
from hospitals? If incinerators are at all involved in the solutions will the
bank impose USA air pollution standards on any equipment that it authorizes fund
expenditures for? What about assurances for maintenance and worker training? (2) It would appear that the Bank needs to have a fully developed policy on
medical waste incineration, since a review of health projects on the
Bank’s agenda indicate that in many cases where the Bank finances health
system improvement they also cite a need for management of wastes. In January
1996, the World Bank’s South Asia Office published a report on
environmental projects in India. The report, titled, "India’s
Environment - Taking Stock of Plans, Programs and Priorities" correctly
calls for medical waste to be segregated and decontaminated at source, rather
than relying on incineration: "Long- term environmental policies,
guidelines and statutes should be linked with immediate requirements to
segregate and decontaminate medical waste at its source. This linkage should
include appropriate technology for sustainable environmental and public health
protection, rather than imported high-technology incinerators that are expensive
to purchase and difficult to maintain." Can we take it that this is
official bank policy? Does it apply outside of projects in South Asia? (3) It is important to note that waste is a by-product of a process. If you
do not put something into that process it will not become waste. If the process
is providing health care services and you use instruments which are mercury
based technology, disinfectants that are regulated as pesticides in the US, or
supplies which are packaged in PVC plastic, the waste outputs affect the quality
of air, water and land, as well as pose worker safety problems. Are any of the
Bank’s guidelines or programs set up to promote and practice pollution
prevention. As you know this is the mainstay of environmental management in
Europe and the US, and I am assuming that the Bank is involved in promoting best
practices. Your responses to these questions will be very useful, so that I can work
with groups and health care facilities and governmental departments to move
ahead with planning and implementation of programs fully understanding the
implications of their decisions. Attached you will find some additional notes which further explain my
reasoning for my eleven recommendations. Marleen Dykman, HDNHE was particularly
interested in this, but please distribute them to everyone who attended. It
might be more helpful if people went through the recommendations and asked
specific questions. I appreciated the opportunity to meet with all of you, and
hope that this is a helpful exercise. I am willing to continue to be in
conversation with you and your staff concerning these issues and hope that we
can have a fruitful exchange which will lead to improving programs that I
present, that the World Bank funds, and to improving the health and environment
of people in India and elsewhere who look to those programs as an integral part
of their development. I am looking forward to your response. Sincerely, Glenn McRae Enclosure NOTES – What follows are some additional notes on the original paper,
"11 Recommendations" but he complete text of the original paper is not
included. The notes are best read in conjunction with the original
paper. Eleven Recommendations for Improving Medical Waste Management in
India The original paper of this title was written in December 1997 by Glenn McRae
and Hollie Shaner of CGH Environmental Strategies, Inc. at the request of
NGO’s municipal and state officials and hospital administrators and
physicians in India who met with Shaner and McRae in 1997 to develop an approach
to medical waste management which made sense for India. At the request of a team
from the World Bank brought together by the Manager of the Bank’s South
Asia Department’s Environment Unit, the following is offered as an
addendum to that original paper to provide further information, a rationale for
the recommendations and further resources to support the recommendations. Credentials: CGH Environmental Strategies, Inc. has established itself as one
of the foremost authorities on waste management systems for the health care
industry. The American Hospital Association has published two manuals and two
monographs on managing wastes at Health Care facilities, (all of which were peer
reviewed), which are now cited as standards in waste management. CGH staff
provide a unique combination of 20 years of experience as a health care
practitioner in a wide variety of clinical settings, and 20 years experience in
community environmental issues and organization development. Since its inception
in 1991 CGH has worked with all levels of the health industry, from the
production of packaging and supplies for health care, to the use of these
materials, to the final disposal, providing a total life cycle understanding of
medical waste. CGH has worked with institutions throughout the United States as
well as in Canada, the Virgin Islands, New Zealand and India. CGH emphasizes
public health, worker safety and pollution prevention as primary goals of
managing wastes. A list of specific references are available upon
request. The Recommendations: (1) CLEARLY DEFINE THE PROBLEM - Before any clear improvement can be made in medical waste management,
consistent and scientifically based definitions must be established as to what
is meant by medical waste and its components, and what the goals are for how it
is managed. If the primary goal of "managing" waste from medical
facilities is to prevent the accidental spread of disease, then it must first be
acknowledged that there is only a small percentage of the waste stream that is
contaminated in a manner that renders it capable of transmitting disease, and
that the only documented transmission of disease from medical waste has been
from contaminated sharps (syringes, etc.). It was not until the late 1980's that consistent and serious attention was
turned to the composition of medical waste in the United States. As waste was
evaluated, it became evident that only a small portion was truly
"potentially infectious," and posed a hazard to workers or the
community. It is this portion that requires special treatment. In addition, the
nature and diversity of hazardous chemicals used was also revealed, and the need
to develop programs and processes to segregate these materials became
evident. As in the U.S., hospitals in India only produce a small quantity of material
that is potentially infectious. As in the U.S., hospitals need to establish
segregation programs at point of generation to keep that small quantity
isolated. As in the U.S., practitioners in India need additional training on
understanding personal protection from blood borne pathogens, infection control,
and waste segregation. Waste segregation is the first step - but to get to that
first step you need everyone to understand the problem and be using a similar
language. There is a great opportunity to do this in India through a
professional organization, the Hospital Infection Society of India, which is
based in Mumbai, but which is interested in establishing national standards
along these lines. Any definition of the problem should also remain consistent with
recommendations from the World Health Organization and the Centers for Disease
Control. The two basic studies on medical waste composition were conducted
independently by two U.S. practitioners: Leach, Connie and Hollie Shaner, RN. "Medcycle Offers opportunities for
Nurses as Front Line Recyclers. In Regulatory Analyst, Vol. 1, #2, November
1992. Tieszen, Myles E., MD and James C. Gruenberg, MD. "A Quantitative,
Qualitative, and Critical Assessment of Surgical Waste." In Journal of the
American Medical Association, Vo. 267. No. 20, May 27, 1992. Both of these studies indicated that the amount of waste which needed to be
treated as potentially infectious was much less than was actually being
segregated into that category. Much of the wastes being collected for special
treatment did not need to be. These two studies which shared very similar
findings were also validated by another independent study in
Australia. The specific issues related to the impact of different waste management
choices made by health care on the environment and public health were documented
in a national video conference: The Health Care Industry’s Impact on the Environment: Strategies for
Global Change. Produced by the University of Vermont with discussants: Eric Chivian, MD
(Director, Center for Health and the Global Environment, Harvard Medical
School); Jean Richardson, PhD, (Associate Professor of Environmental Studies at
the University of Vermont); Ted Schettler, MD, MPH (Physicians for Social
Responsibility); Jan Schultz, RN, MS, (Consultant and member of the American
Association of Operating Room Nurses); Hollie Shaner, RN, MSA (Environmental
Health Coordinator at Fletcher Allen Health Care, Burlington, VT); Susan
Wilburn, RN, MPH (Occupational Health and Safety Specialist, American Nurses
Association). January, 1998 The web site for the program can be found at: http://uvmce.uvm.edu:443/profprog.htm
Letter from Glenn McRae, CGH Environmental Strageties to
Richard Ackerman of the World Bank
Environmental Unit South Asia Region
The World Bank1818 H Street, NW
Washington, DC 20433
Vice President
You can also contact Ellen Ceppetelli at UVM for more information: 1-800-639-3188.
(2) FOCUS ON SEGREGATION FIRST -
The current waste management practice observed at many Indian hospitals is that all wastes, potentially infectious, office, general, food, construction debris, and hazardous chemical materials are all mixed together as they are generated, collected, transported and finally disposed of. As a result of this failure to establish and follow segregation protocols and infrastructure, the waste leaving hospitals in India, as a whole is both potentially infectious and potentially hazardous (chemical). At greatest risk are the workers who handle the wastes (hospital workers, municipal workers and rag pickers). The risk to the general public is secondary and occurs in three ways: (1) accidental exposure from contact with wastes at municipal disposal bins; (2) exposure to chemical or biological contaminants in water; (3) exposure to chemical pollutants (e.g., mercury, dioxin) from incineration of the wastes.
No matter what final strategy for treatment and disposal of wastes is selected, it is critical that wastes are segregated (preferably at the point of generation) prior to treatment and disposal. This most important step must be taken to safeguard the occupational health of health care workers. Hospitals are currently burning wastes or dumping wastes in municipal bins which are transported to unsecured dumps. The wastes contain mercury and other heavy metals, chemical solvents and preservatives (e.g., formaldehyde) which are known carcinogens, and plastics (e.g., PVC) which when combusted produce dioxin and other pollutants which pose serious human health risks not only to workers but to the general public as it migrates into food supplies.
If proper segregation is achieved through training, standards, and tough enforcement, then resources can be turned to the management of the small portion of the waste stream needing special treatment. This is not to minimize the need for resources to be allocated to assisting with segregation. Training, proper containers, signs, and protective gear for workers and ongoing periodic audits are all necessary components of this process to assure that segregation takes place and is maintained.
This assessment of the waste composition in hospitals in India was based on two surveys conducted in Mumbai in October and November of 1997, and in Delhi and Calcutta in November1997 by CGH at a total of nine hospitals (both government and private), as well as a prior survey conducted at a private Mumbai hospital in 1996, and subsequent surveys by teams trained by CGH in Delhi. These assessments involve an analysis of materials purchased and used, a visual inspection of waste receptacles throughout a facility, and an inspection of the bins where waste is aggregated for pick-up by public services, or at an incinerator where waste is stored prior to burning. After conducting both visual assessments and complete waste sorts at several hundred hospitals in the United States, the Virgin Islands and New Zealand, CGH has
determined that the results of the visual survey can be quite adequate for purposes assessing proportions of types of waste and for planning a management system.
It should also be acknowledged that waste segregation is being practiced at some hospitals in India as thoroughly as in many U.S. hospitals, so this management technique can work here.
- Waste segregation, particularly of sharps, does result in a reduction in needle sticks and other worker related injuries.
- Waste segregation reduces the volume of waste needing special treatment. This in turn provides multiple options for safe waste treatment and disposal.
- Waste segregation lowers the capital cost involved in purchasing and operating a treatment facility because it reduces the requirements for waste processing capacity.
(3) INSTITUTE A SHARPS MANAGEMENT SYSTEM -
Of the 10 percent or less portion of the waste stream that is potentially infectious or hazardous, the most immediate threat to human health (patients, workers, public) is the indiscriminate disposal of sharps. Proper segregation of these materials is the highest priority for any health care institution. If proper sharps management were instituted in all health care facilities throughout India much of the risk of disease transmission from medical waste would be solved. This would include proper equipment and containers distributed everywhere that sharps are generated (needle cutters and needle boxes), a secure accounting and collection system for transporting the contaminated sharps for treatment and final disposal, and proper training of all hospital personnel on handling and management of sharps and personal protection.
This recommendation would seem to be self-explanatory. All studies of disease transmission from medical waste in Europe and the U.S. (The only places where such studies have been conducted) have shown the connection between sharps and disease transmission. The concern over other wastes is often more aesthetic than scientific.
(4) KEEP FOCUSED ON REDUCTION -
Indian hospitals generate significantly less waste than U.S. hospitals. In part this is a result of a decision to maintain a system that relies on reprocessing and reuse of materials. Establishing precise guidelines for product purchasing that emphasize waste reduction will keep waste generation rates from escalating. A single product choice can result in the generation of tons of additional waste. New emphasis needs to be put on reduction of hazardous materials used. For example, hospital waste management would benefit from a policy of a phase out of mercury-based products and technologies. Digital and electronic technology is available to replace mercury-based diagnostic tools. This is a purchasing and investment decision. Since there is no capacity in India to safely manage mercury wastes, this reduction policy will make a major contribution to cleaning up the hospital waste stream. This is an example of a reduction strategy which could be identified and implemented in India. Practicing pollution prevention is the most cost effective way of securing public health.
Hospitals in India reprocess much more in the way of supplies and equipment than is done in the United States. They both invest in reusable permanent equipment that can be sterilized and reused numerous times safely in the treatment of patients, and they fabricate kits and supply packets on site as needed. Additional training and investment in reprocessing equipment would be a beneficial and more sustainable objective for hospitals in India than the current push to move to more disposable supplies and equipment as is current practice in the U.S., if keeping the costs of the delivery of health care in India under control is an objective. In interviewing the heads of reprocessing departments at several hospitals we reached the conclusion that this approach can be safely carried out, and would benefit from more investment in training and updated equipment.
In addition, there is a real need to reorient practices away from using some traditional equipment such as mercury based diagnostic equipment. Wastes from medical facilities in the U.S. and Europe are a major source of mercury pollution. Even in these countries where there are adequate services and equipment available to clean up and reclaim mercury waste they are not adequately used. Our recommendation is to move toward a mercury free health care setting, a goal which has been embraced by a growing number of hospitals in the U.S. If mercury is absent from the health care setting, one does not have to establish ways to manage it before it gets into waste water, ground water, autoclaves or incinerators.
(5) ENSURE WORKER SAFETY THROUGH EDUCATION, TRAINING AND PROPER PERSONAL PROTECTIVE EQUIPMENT -
Workers who handle hospital wastes are at greatest risk from exposure to the potentially infectious wastes and chemical hazardous wastes. This process starts with the clinical workers who generate the wastes without proper knowledge of the exposure risks or access to necessary protective gear, and includes the workers who collect and transport the wastes through the hospital, the staff who operates a hospital incinerator or who take the waste to municipal bins, the municipal workers who collect wastes at the municipal bins and transport it to city dumping sites, and the rag pickers, who represent the informal waste management sector, but play an important role in reducing the amount of waste destined for ultimate disposal.
This recommendation arises from visitations and audits at a series of hospitals in Delhi, Calcutta and Mumbai. In all of the hospitals visited we interviewed and observed workers and they generated and managed the waste stream. This included clinicians generating waste, ward boys and cleaners collecting and transporting it, and sanitation workers dumping it in municipal bins or at an incinerator. We observed several incinerators in operation and in multiple cases we observed municipal workers collecting mixed wastes from the bins where hospitals disposed of their wastes.
(6) PROVIDE SECURE COLLECTION AND TRANSPORTATION -
If the benefits of segregation are to be realized then there must be secure internal and external collection and transportation systems for waste. If waste is segregated at the point of generation only to be mixed together by laborers as they collect it, or if a hospital has segregated its waste and secured it in separate containers for ultimate disposal only to have municipal workers mix it together upon a single collection, then the ultimate value is lost. While worker safety may have been enhanced, the ultimate cost to the environment and the general public is still the same.
In addition the very real concern of hospital administrators and municipal officials to prevent the reuse of medical devices, containers and equipment after disposal should be taken into account in any management scheme. One has only to walk by street vendors selling latex gloves, or using cidex (a disinfectant regulated as a pesticide in the US) containers to hold water for making tea, to understand the risk that unsecured waste disposal systems have.
In addition, the practice of cleaning and reselling, syringes, needles, medicine vials and bottles, is not well documented but appears to have enough informal evidence to indicate that it is a serious concern. Items that could potentially be reused illegitimately must be either rendered unusable after their use (cutting needles, puncturing IV bags, etc.) or secured for legitimate recycling by a vendor or system that can be monitored for compliance.
Repeated conversations with government officials, hospital administrators and department heads all raised this concern. Most of the "systems" that were observed to be in place were designed to prevent items such as syringes and gloves from being reused through an elaborate accounting, collection and destruction process. The nature of most of these "systems" increased handling which put workers at greater risk, especially from needle sticks. Interviews with physicians, and an independent investigation in Delhi following waste destined to be "recycled" from a hospital has documented that the resale for reuse of syringes, tubing, gloves, and other medical supplies occurs. Based on discussions with purchasing personnel at hospitals there is a small risk that these materials find their way back into a hospital system. It is more likely that they are sold at small shops to individuals who go to clinics and other individual medical practitioners and have to supply their own supplies. Proper management of materials within a hospital facility is possible, and systems could be implemented to prevent most of this type of reuse. The opinion of many clinicians interviewed indicated that much of the "reuse" market was actually supplied by theft of clean new supplies, taken from the hospital supply prior to use. Tighter inventory control, coupled with a more formal recycling system and set of agreements organized and supported by city government could decrease the improper reuse of other items, especially items harmful to public health such as empty chemical containers.
(7) REQUIRE PLANS AND POLICIES
To ensure continuity and clarity in these management practices, health care institutions should develop precise plans and policies for the proper management and disposal of wastes. They need to be integrated into routine employee training, continuing education, and hospital management evaluation processes for systems and personnel. In the U.S. the Joint Commission for the Accreditation of Health Care Organizations (JCAHO) has been developing a set of standards on the "Environment of Care" which includes plans and policies for the proper management of hazardous materials and worker safety. Compliance with the JCAHO standards is a prerequisite to hospital accreditation. The US Environmental Protection Agency’s new MACT rule (Summer 1997) stipulates that hospitals, with medical waste incinerators, develop waste minimization and pollution prevention plans. Municipal governments or state governments in India could require waste management plans and implementation of those plans from all hospitals as a condition for operating.
Self-explanatory.
(8) INVEST IN TRAINING AND EQUIPMENT FOR REPROCESSING OF SUPPLIES-
The practice of the reprocessing of equipment and medical materials for reuse in health care facilities is well established in India and should continue to be supported and enhanced. The Hospital Infection Society of India firmly supports judicious reuse of materials, and should begin to set infection control standards for reprocessing. Maintenance of this effort within hospitals will provide quality products and thwart efforts to increase reliance on disposables. In general disposable products are costly, increase waste generation, and do not necessarily guarantee decreases in infection rates in hospitals. Reprocessing of supplies must however be supported with investment in proper equipment, supplies and training so that it is carried on in a safe and efficient manner.
Covered in Number 4.
(9) INVEST IN ENVIRONMENTALLY SOUND & COST EFFECTIVE MEDICAL WASTE TREATMENT AND DISPOSAL TECHNOLOGIES -
The rush to select incineration as the ultimate solution for medical waste in India is doing a great injustice to the Indian people, public health, and the environment. Of the eleven recommendations that we are making, it is no accident in giving attention to treatment technologies as ninth. Without proper attention being paid to one through eight on this list, whatever decisions being made for treatment and disposal will be insufficient, if not counter productive. The mass incineration of hospital waste given current practices of waste disposal will not reduce risk to workers (this is where the greatest risk of disease transmission or chemical exposure exists) and will actually create a greater threat to the general public as mercury and other heavy metals are spewed out into the general air of India’s cities, or dioxin and furans are created from the combustion of plastics such as PVC which is growing in use in medical packaging in India.
If the overall goal of waste management is to prevent disease transmission from waste products, then the emphasis should be placed on the "management" aspect of the process and not on the "technological fix" which time and again has proven to be an expensive diversion rather than an effective solution.
Center for Disease Control (CDC) standards for medical waste treatment are very specific about what is necessary for the safe and thorough treatment of potentially infectious wastes. CDC guidance is reflected in the statements in this and all previous sections.
(10) DEVELOP AN INFRASTRUCTURE FOR THE SAFE DISPOSAL AND RECYCLING FOR HAZARDOUS MATERIALS
There was little or no observable capacity for the management, treatment, recycling or final disposal of hazardous wastes in India (e.g. chemicals, mercury, batteries). Hospitals seeking to segregate hazardous wastes are left with little or no option for safe disposal. Pollution prevention and the choice of nonhazardous or less hazardous material is the only real option left to hospitals, which should be followed regardless of the existence of a hazardous waste management infrastructure in India.
One of the most thorough guides to hazardous wastes in hospitals is the USEPA publication:
Guides to Pollution Prevention: Selected Hospital Waste Streams (EPA/625/7-90/009).
The overuse of toxic substances such as gluteraldehyde as general disinfectants, and the lack of disposal options for wastes such as mercury pose an extremely serious public health hazard (as well as a threat to worker safety). These materials generally disposed directly down the storm drain which in the case of one hospital ran directly into a small pond by a housing development used by the families of hospital staff to wash clothes and bathe. In other cases they find their way into the local water courses also used by large numbers of the population for washing and drinking. There is no pre-treatment. Even if there was a sewage treatment plant these chemicals would still pose a major threat.
(11) DEVELOP AN INFRASTRUCTURE FOR SAFE DISPOSAL FOR MUNICIPAL SOLID WASTE
Improper disposal of all wastes, municipal solid waste, hazardous wastes, industrial wastes, human wastes, etc. poses a major health hazard throughout India. The development of sanitary landfills, sewage treatment plants and other waste management facilities is necessary to securing public health in the country, and providing for the ultimate safe disposal of those wastes which cannot be otherwise recycled, composted or reused. Just as in the discussion of medical waste management, proper segregation and pollution prevention, combined with a clear definition of the problem and the goal will provide the best, most environmentally safe and cost-effective solution to waste disposal. Health care facilities need to be able to tie into a municipal system of proper waste management to ensure that they are meeting their mission of providing for the public health. Until such an infrastructure exists there are numerous decisions and actions that any hospital can make (listed above) to begin the process of improving their waste management practices and ensuring public health and worker safety today.
Self-explanatory, but necessary if medical waste is ultimately going to be managed properly.
