Health Care Without Harm's Comments on the World Bank's Draft Medical Waste Guidance Notes

Letter from HCWH | HCWH's Comments on the Guidance Notes

June 30, 1999                                                  

Thomas E. Novotny, MD MPH
Jennifer Prah-Ruger, PhD
HDNHE
The World Bank
1818 H Street, NW
Washington, DC 20433 USA

VIA FACSIMILE: 202-522-3234             8 pages

Dear Dr. Novotny and Ms. Prah-Ruger:

I am writing to you on behalf of Health Care Without Harm: The Campaign for  Environmentally Responsible Health Care, an international coalition effort of physicians, nurses, patients, public health advocates, scientists, environmental advocates, religious institutions, and labor representatives striving for greater environmental responsibility in the health care industry. Our mission is to transform the health care industry so it is no longer a source of environmental harm by eliminating pollution in health care practices without compromising safety or care.  In particular, we are concerned about dioxin and mercury emissions resulting from medical waste incineration.

Thank you for the opportunity to review the draft of the document, HEALTH CARE WASTE MANAGEMENT GUIDANCE NOTES.  As these Notes are meant to "supplement technical guidelines that will soon be published by the World Health Organization (WHO), and not to replace these guidelines," we are somewhat at a disadvantage in our review not having access to those guidelines. We have  reviewed the WHO TEACHER'S GUIDE: MANAGEMENT OF WASTE FROM HEALTH-CARE ACTIVities, and so may base some of our comments of that. It would be useful to have all the documents together to examine and we hope to have that opportunity some time in the near future. We feel that the production of this document is a positive step for the World Bank to be attempting, since it is has been willing to fund the capital costs for improvements to health care facilities and in some cases, actual investments in waste treatment technologies. In the past, the Bank provided no guidance to its partners on this topic, and allowed (and still allows) for inappropriate technologies to be put in place.  In particular, the World Bank has heavily invested or supported investments in incineration (in most cases, to the exclusion of other treatment technologies) as a way of addressing the  environmental impacts" of health care projects. 

The document makes some important points about the problematic nature of incineration.  These include: 

o        the reference in the introduction to "avoidance of hazardous substances
whenever possible (e.g. PVC-containing products, mercury thermometers)"
which are particularly hazardous when incinerated.
 o      in section 3.2.5, "For environmental reasons, non-PVC products are
preferred" for packaging.
 o      in Annex D2: "emits toxic flue gases (including dioxins and furans...)"

In the two years that we have been addressing this issue with the World Bank, this is the first significant document that has acknowledged that these issues at least need to be taken under consideration.  We appreciate that recognition and feel that it is the basis for a fruitful dialogue.

We are, however, concerned that throughout the document, a bias for incineration dominates, despite the problems mentioned above, and indeed, that the document sometimes reads like an apology for the technology.  Your letter to "colleagues" asking for help in this review rightly states that guidance and not strict guidelines are called for because of the many variables in any situation which must be weighed in making decisions. However, in your cover letter, we feel that a common error is being committed which pervades the document and current World Bank policy, and
that is a focus on technology.  The document rightly refers to health care waste "management."  Your letter immediately leaps to, and the document itself focuses on, choices in technology and not on the full management process of which technology choice is only one part in securing the public health and worker safety goals which are the stated outcome of this project.  

The letter and the document seem to be overly defensive and bent on rationalizing why incineration should be kept as an important, if not the most important choice, rather than truly giving guidance as to all of the steps necessary for project management and health care administrators and practitioners as well as government regulators to understand and implement safe and environmentally sound waste management systems.  

In the document, you raise many important issues which we feel are obscured by this focus. Both in the cover letter and later as a note to Table D3, the authors seem to feel the need to rationalize incineration as a viable choice, pointing out that "Incineration is not the same as burning.  Proper incineration is a highly advanced technology that can adequately treat all types of special health care waste..." and "Careful management of incineration can reduce emission levels."  We were puzzled by your added comment in your letter that "these may not be appropriate in higher income countries."  By this statement, we read that you believe that incineration may not be appropriate in countries such as the United States (where it is rapidly being phased out).  Are we to assume that a technology not appropriate for environmental reasons in the United States is appropriate in other countries?

The World Bank has addressed the issue of pollutants that are created through the process of trying to solve other health or environmental problems, especially in water projects.  The WHO is addressing the issue of the use of DDT to help control the spread of malaria.  In most projects, there are always trade-offs to be considered, but where we know that one solution creates another serious problem and where alternatives exist, we are obligated to change that path.  Incineration, even as defined in this paper, is the treatment of waste to solve a potential biological problem, and in the media transfer actually does create a very real chemical pollution and public health problem. 

As you know, the Philippines this month became the first country to legislate a total ban on incineration. In the United States and Europe, incineration for medical waste is increasingly being restricted to the very small fraction of the waste stream (pathological, chemotherapeutic, pharmaceutical) that may not be able to be adequately treated otherwise. The medical waste regulations passed in India ban the incineration of chlorinated plastics, something difficult to do unless waste is rigorously segregated and only a small portion is burned.  We would hope that the
World Bank Guidance document on this topic will take the lead in advancing new and environmentally sound ways in which individual facilities as well as municipal, state and national governments can address the problems associated with these wastes.  This involves, as our attached notes will indicate, moving technology choices to the end of the management plan, reducing the reliance on incineration, and clearly keeping the public health message up front. 

The goal that we share with the World Bank is that improved health care facility operations should increase public health on all levels.  Operation of facilities should not be producing pollutants and spreading them into the community, creating very serious and very real health risks, different from the biological health risk they are seeking to resolve, but no less critical. More than any other institution, health care organizations have a clear mission to advance health.  The opportunity, methods and technology all exist to reduce the environmental impacts of health care institutions. The experience is now available to confirm these opportunities.  We hope our comments will be helpful in strengthening this document and making it of use in future World Bank projects.  We are available to meet with you, as we have been in the past, to discuss these issues further.

Sincerely,

Jackie Hunt Christensen
Co-coordinator, Health Care Without Harm

CC:    Annette Pruss (WHO)
H. Saxenian, G. Boyer
C. Bartone
D. Hanrahan
M.  Dijkmam



 HEALTH CARE WITHOUT HARM COMMENTS ON:

HEALTH CARE WASTE MANAGEMENT GUIDANCE NOTES - DRAFT, BY THE WORLD BANK

June 28, 1999

Incineration

• The document's constant reference to and "apologies" for incineration are not needed and are counterproductive to accomplishing the overall goal of the Notes. 

• The document should place less emphasis on technology choices and comparisons and speak more directly and fully to the issue of "management"
  of wastes.  If a document on "technology choices" is needed, then one should be produced.

• The document correctly notes that even under best practices and with the best technology employed, incinerators still create problem emissions which create very real health problems in the community.  The composition of medical waste (heavy in chlorinated plastics and mercury-based products, as well as packaging that contains other heavy metals) makes it undesirable to be burned or incinerated.  A number of case studies in the United States have demonstrated that even with the best technologies and good segregation practices, incinerator emissions are still a problem, and hospitals and private vendors are choosing to do away with or severely limit the use of incineration.

• In section 3.2.4, as in other places in the document, in discussing technology choices, incinerators are referenced as if they were the only choice... "a large healthcare facility with adequate technical and financial capacity can consider installing an incinerator..."   Both microwave and autoclave technologies are available to fit the specifications for small and very large or regional facilities.   There is no reason to constantly refer to "incinerators" as THE technology.

• It is assumed throughout the document (e.g., 2.2.3; 3.2.3; 4.2.1) that facilities need to make ONE technology choice for treatment.  In fact, in many cases, a mix of technologies may better meet the needs of achieving the goals of the facility.  One strategy under active discussion in several cities in India include on-site or even regional non-burn technologies to disinfect the majority of the waste, and the use of regional crematoria to incinerate pathological wastes.  A small dedicated incinerator for pathological, chemotherapeutic and some pharmaceutical wastes may be able to serve the needs of a number of hospitals, while the majority of special wastes can be treated in smaller on site technologies such as autoclaves.
  If this is a guidance document, then it should provide a variety of scenarios, and not one option.

• In section 2.2.3, the document states, "Cytotoxics and other hazardous chemical wastes (see Annex A) should never be buried in a landfill, however.  Instead, they need to be incinerated at a central facility." Such a statement is prescriptive rather than guiding.  While it is certainly true that cytotoxic and hazardous chemical wastes should not be buried in a landfill, it is not good guidance to recommend that "hazardous chemical wastes," which represent a broad range of substances in a health care facility including solvents, cleaning supplies, pesticides, waste oils, batteries, mercury, etc., should be incinerated.  The document in this and in other cases jumps too quickly to the "burn solution" to solve problems.  

• In selection of technologies, it is critical to note that incinerator technology is a "high tech" complicated and expensive technology, which, as defined in this document, requires highly trained operators, maintenance of sophisticated controls, monitoring devices, and regular maintenance of multiple systems.  While the document goes to great length to distinguish between incineration and burning, WHO reports of inspecting incinerators, and HCWH observations at incinerators in India, the Caribbean, the United States and Europe, have all noted the tendency of incinerators to deteriorate into crude burning devices as systems age, funds are cut, or qualified personnel leave.

Regional Systems

• Section 4 details a list of advantages to considering centralized facilities to treat and responsibly dispose of special health care wastes. While these are good considerations, it would be helpful for the document to also point out some of the disadvantages which need to be addressed which, our experience has shown, prevents health care facilities from supporting this approach.   

  1. The facility loses control of the waste and cannot always document its proper treatment.   

  2. There is not always a back-up system to guarantee continued service if the central facility has to shut down for maintenance or for other reasons.
    
  3. Costs of sending wastes to such a facility are uncertain.   

  4. Transport of wastes to such a facility is not always secure.   
  

  5. The involvement of the private sector does not always mean that strict regulation and monitoring will be carried out, and many private sector firms still attempt to guarantee profits with "put or pay" contracts as a pre-requisite to their investment in such a facility.

• Clear and strict operations and monitoring standards for such a facility must be put in place, with clear enforcement power to back it up. 
• Centralized facilities require that strict and rigorous segregation and management systems exist at each participating facility - once the waste gets to the centralized facility it cannot be further segregated, and contaminated loads will create problems.  Centralized facilities will not be able to run safely if good practices are not already in place at the institutions.
• Regarding centralized facilities, it would be useful for the World Bank to be more specific on what a well run ("best practices") facility would look like.  The guidance document would be strengthened by several scenarios to illustrate what is meant here.

• Section 4.2.1 details some of the criteria for selecting technologies. These include, "capital cost, operating cost, ease of operation, local availability of spare parts, local availability of operational skills, demonstrated reliability, durability, and environmental impact."  All of these are important, but we believe that the underlying evaluation criteria should be the basic maxim of practicing medicine: that which DOES NO HARM. How the technology as it operates (e.g., emissions) could impact public health should be the primary consideration that informs all the rest. Decision-makers should consciously consider whether the use of such a technology is merely turning a potential biological risk into a very real chemical risk.

• In table E2 in Annex E, the only cost data for treatment of wastes is provided for the Incinerator option.  Again, this would indicate that the only treatment the document takes seriously is incineration. In the past, we have noted the lack of data on operating costs of other technologies, which, like the capital investment costs, tend to be far lower than incineration, at least in the experience in the United States.  If the World Bank is to seriously provide guidance, this information deficiency must be corrected.  There are companies and facilities willing to work to gather and share this data.

Annex D: Technology Considerations

• The first line of this Annex should be the first line of this document:
  "The choice of technology for waste treatment and disposal should always be driven by the objective of improving current health and environmental impacts."  We would change it however to indicate that "implementing a sound waste management system and set of practices should be driven..." The emphasis on technology needs to be diminished.  But this statement is key to the whole document, and if truly followed, is incompatible with the heavy emphasis on incineration found throughout the document.
• This annex stimulates a number of questions.  For example, in the first chart the first technical requirement for treatment and disposal of Special HCW is the elimination of hazardous characteristics of the waste.  While incineration can, in most cases, be counted on to destroy biological hazards, it directly fails the final requirement of "avoidance or minimization of secondary impacts from disposal system."    While the chart does not specify it, the way it is constructed appears to establish a hierarchy of technical requirements placing environmental impacts at the
  bottom.
• The technical requirements also cover a number of issues that really have little to do with the choice of any specific technology.  For instance, scavenging and disease vectors are problems of the collection and transportation system.  Our studies in India demonstrate that much scavenging occurs before the waste even leaves the hospital, and then during the collection, storage and transportation to a central facility. How well a system avoids scavenging and disease vectors, as well as other issues, depends on the quality of the management of the system, education of the workforce, and reliability of the tools used in collection and storage.  It is the total management system that counts, not the choice of technology. The constant focus on technology obscures the real work that needs to take place, and the real need for investment in education, training, and basic tools and supplies, not in technology.
• In table D2, the listing reads a little too stale and not as if it were really drawn from examination of equipment working in the field.  Some of the issues raised concerning microwaves and autoclaves (e.g., high costs, high maintenance and wastewater) would certainly be disputed by some manufacturers and their operating history and by the operating history of many facilities using these technologies.  In past conversations with the World Bank, HCWH members have noted the Bank's constant and strong skepticism that any technology other than incineration would ever work outside higher income countries, but the Bank has shown no interest in investigating this assumption.  Our investigation and experience is that these technologies can and do work in a variety of countries.  Table D2 also underrates the problems associated with adding more incineration to many cities where air quality is already largely compromised (a major reason incinerator ban was passed in the Philippines).  It also under-emphasizes the problems associated with incinerator ash, which needs special disposal, often as a hazardous waste.
• The notes after Table D3 on incineration need additional comment.  First, while the "ideal" operating conditions are cited for a properly operating incinerator, the paper does not indicate what percentage of incinerators running in the "higher-income" countries are able to consistently meet these standards even with well trained personnel, good monitoring, adequate finances, and good overall waste management systems.  We know of no incinerator operating today that has a good track record of meeting standards and not being cited repeatedly for air quality violations where monitoring and enforcement are in place.  A number of "state-of-the-art" incinerators have been shut down.
• In reference to Dioxins and Related Compounds, the document provides good and clear information on the danger of these compounds. However, it should clearly indicate that where studies have determined the primary sources of dioxins and related compounds that put the public health at risk are municipal and medical waste incinerators.  It has been noted in this section that measurement of dioxin is expensive and problematic in most  countries.  The technical requirements of table D1, however, are inadequate in allowing decision-makers to make informed decisions on this point.  If the key is avoidance, then the only logical decision would be to NOT chose incineration at all.  We know the risk exists -- dioxin will be produced in incineration -- but we cannot measure it.  The guidelines do not provide
  guidance, but suggest either a guessing game or an opportunity to skip over this "non-measurable" output.  We would suggest that the document needs to be re-written with this information up front and incineration clearly put in perspective as a very limited piece of the puzzle, suitable to treat only a very small fraction of the waste stream under very tight controls.

Integration into an overall Waste Management

• Plan for the municipality or country
  - The management, treatment and disposal of special health care wastes do not happen in a vacuum.  Attention needs to be given to improving the overall management of all wastes in a locality, as any system for special health care waste will need to tie into the solid waste system at some point.

Resources

• In the Author's introductory note they mention that this is a working document that "attempts to synthesize the currently available knowledge and information in the field of healthcare waste management.  There is much interest, but a lack of practical information in this rapidly developing field."  In point of fact we feel that there is a vast wealth of knowledge and experience that the World Bank has not yet successfully drawn upon in relation to address this issue.  In the past three years, we have relied heavily on practitioners from health care institutions in the United States who have developed model waste management systems.  Much of that experience was documented in two manuals published by the American Hospital Association, An Ounce of Prevention: Waste Reduction Strategies for Health  Care Facilities (1993) and the Guidebook for Hospital Waste Reduction Planning and Program Implementation (1996).  Both of these volumes are in wide circulation throughout the world, and are cited in literature ranging from the Federal Register to numerous medical and environmental journals as key guidance documents in the field.  The authors, Hollie Shaner, R.N. and Glenn McRae have a wide range of experience with working directly with facilities, with governmental agencies, product manufacturers and private firms specializing in waste treatment and disposal in the United States and  Canada as well as the Caribbean, India, New Zealand and Australia.  In addition to drawing  directly on their experience, we have also investigated the experience of other facilities, particularly in the United States and
  in India, who have implemented specific programs to segregate and reduce the amount of waste that needs special treatment.  Such programs are becoming more common and result in lower costs, increased worker safety, improved public health and lower environmental impact in operating facilities.  This range of experience, some of it coming from several of the largest health care systems in the United States, and some of it coming from innovative initiatives launched by NGOs in partnerships with hospitals in India, has been virtually ignored by the World Bank, despite repeated attempts to present these findings and this information to Bank officials.
• While we are anxious to see and evaluate the new WHO guidelines, anticipated by this World Bank document, we must note that many of the problems that we have identified with this document also exist in the Teacher's Guide produced by the WHO.  Many of the assumptions that the WHO is following in terms of proper management of special health care waste appear to be predicated on the same problematic ground as this document, with an over-emphasis on technology as opposed to process.  Other key documents such as those mentioned above need to be included.
• The contact information provided is also questionable.  We would like to know what direct assistance can be given by US AID, The World Bank, or WHO/EURO, especially given the generic contact information.  Our experience in the past with the UWEP is that they have very limited information in this field, though can provide more useful information and guidance on overall waste management systems.  There is a real need for a centralized information source, and for real capacity to be built in each of these institutions on this topic.  In the meantime, listing these contacts presents a false sense of security that there is actually real assistance available.
• In Annex F and again in Annex H, as well as elsewhere in the document, reference is made in a number of cases to "outside expertise."  It would be useful to have guidance on how to evaluate such expertise, and to have an indication that the World Bank would build into its financing packages support for the enlistment of such expertise (more than just choosing a technology) at the beginning of projects.

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