8 May 2001

Dr. Rosa Orellana
Environmental Specialist
International Finance Corporation
2121 Pennsylvania Ave NW
Washington, DC 20433

Dear Dr. Orellana:

As agreed in our meeting of 19 April, we are writing this letter to inform the process of revising IFC's Health Care Facilities Guidelines. Since these guidelines are legally binding upon IFC clients, we regard them as an important opportunity to set international standards regarding the handling of medical waste and other environmental issues in the health care sector. We also think that this is an opportunity for IFC to demonstrate its vision of promoting environmentally beneficial development in the health care sector.

We are writing this letter on behalf of three international coalitions: Health Care Without Harm, the Global Alliance for Incinerator Alternatives and the Basel Action Network. Health Care Without Harm is a collaborative campaign for environmentally responsible health care made up of more than 300 organizations in 28 countries. Its 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 occupational safety or patient care. The Global Alliance for Incinerator Alternatives is a growing international alliance of individuals, non-governmental organization, community-based organizations, academics and others working to end the incineration of all forms of waste and to promote sustainable waste prevention and discard management practices. GAIA comprises approximately 100 members in over 30 countries. The Basel Action Network (BAN) is a global alliance of activist organizations dedicated to halting the proliferation of trade in toxic waste, toxic products and toxic technologies. Recently BAN has been active in helping shape the Basel Convention's guidelines on the environmentally sound management of health care wastes.

According to a recent presentation by Executive Vice President Peter Woicke, the IFC is seeking to transform its approach to environmental issues from a compliance-driven to an opportunity-driven model. The health care sector is an opportunity to demonstrate this new approach, by coupling strong compliance regulations with a vision of truly environmentally-friendly health care facilities that perpetually seek to minimize environmental impact while saving money and resources. Fortunately, the IFC will not have to ask its clients to pioneer these approaches, as much important work has already been done throughout the world on this topic.

Listed below are the issues that we find of highest importance in establishing guidelines for the health care sector. The approach outlined below is one that we employ in our own work on this issue, and it is one that has been developed by the range of organizations and health care institutions that comprise HCWH, GAIA and BAN. As such, we feel quite strongly that it constitutes both an appropriate set of minimum conditions as well as provides the direction for reasonable and achievable goals for health care institutions throughout the world.

We recognize that health care institutions vary considerably in their access to resources, trained personnel and basic infrastructure. The principles we have developed are therefore not dependent upon any of these factors; rather, they have been shown to be effective in a number of different countries, under widely varying circumstances. However, a certain quantity of resources -- including managerial time -- must be devoted to the question of waste management and waste prevention in order to develop a comprehensive waste management system. It is our belief, and this is sustained by field experience in health care institutions, that waste management is a "management problem" to be solved, not a technological problem to be "fixed." Health care waste management, as pointed out in the World Health Organization's Safe Management of Wastes from Health Care Activities starts with the basic principles of good waste segregation programs, worker training, and application of the sound principles of pollution prevention.
The six principles that our coalitions would like to see reflected in the IFC's guidelines are:

1) Emphasis on Pollution Prevention
In the past, most pollution reduction efforts were limited to "end of pipe" approaches that attempted to mitigate pollution after it had been created. However, the most effective and cheapest manner of reducing pollution is by prevention. This is in essence a question of management, not of technology choice. HCWH, GAIA and BAN advocate materials substitution and selective procurement as ways to minimize both the quantity and the toxicity of the waste produced by health care facilities. Materials substitution means: emphasizing the purchase of re-usable products, complemented by the judicious use of disposable products (instead of a total embrace of disposables), and the use of toxics-free items instead of ones containing hazardous substances. Those items that cannot be reused or whose use cannot be eliminated should be recycled. Clearly, not all items can be dealt with in this manner; for example, increasing the use of items such as disposable syringes and needles has been proven to reduce infection rates, however the employment of other disposables has not. Health care facilities' environmental management plans should address each component of the waste stream and seek out alternative inputs that would eliminate this component; if that is not practical, alternatives that reduce the quantity and toxicity of the waste are to be employed. The management plan should clearly state the various components of the waste stream and why they cannot be further reduced at the time.

2) Waste Minimization and Segregation
An essential component of pollution prevention is the proper segregation of waste streams from a health care facility. Health care wastes are some of the most diverse and complex produced in any institution. Not only must basic solid wastes be managed, but biohazardous wastes, radioactive wastes and a wide range of chemical hazardous wastes as well. The direct threat to workers and to water supplies through these last wastes is often overlooked in plans to manage health care wastes. Only when different types of waste are properly separated can each be handled and treated in an appropriate manner, allowing for re-use, recycling, disinfection, and proper disposal. Segregation is therefore a prerequisite for any sustainable waste management program. Waste minimization -- even of non-toxic wastes, such as office paper or packaging materials -- is also important in reducing the ecological footprint of an institution, and a fundamental part of pollution prevention. Where hazardous chemicals cannot be replaced by non-hazardous substitutes, facilities should minimize their use and waste. Health care institutions should include source segregation and waste minimization systems in their environmental management plans.

3) Mercury Elimination
Mercury is one of the most toxic substances employed in health care facilities -- it is a known neurotoxin with irreversible effects, particularly affecting fetuses and young children. Health care facilities are a significant source of environmental mercury contamination, largely because of the number of mercury-containing devices (such as thermometers and blood-pressure cuffs) that are used in health care. As alternatives for all mercury-containing equipment now exist, and these are considered to be of equivalent or superior efficacy in real-world conditions, health care facilities should commit to a complete mercury phase-out.

4) Non-Combustion Treatment Technologies
Healthcare facilities will inevitably produce some quantity of potentially infectious waste which must be treated and disposed. Historically, much of this waste has been incinerated, and medical waste incineration has been documented as a primary source of dioxins and furans releases --through exhaust and ash -- in several countries. It is also a significant source of hexachlorobenzene (HCB) and polychlorinated biphenyls (PCBs). These chemicals have been recognized in the forthcoming Stockholm treaty on persistent organic pollutants (POPs) as four of the twelve priority pollutants, which all parties should "reduce the total releases derived from anthropogenic sources ... with the goal of their continuing minimization and, where feasible, ultimate elimination." That treaty calls for the use of substitute processes to prevent the formation and release of these POPs byproducts. Clearly, creating additional sources of dioxins, furans, PCBs and HCB, for example by financing new medical waste incinerators, or increasing the quantity of material burned in existing incinerators, contradicts the intention if not the letter of the treaty. Fortunately, there are several other technologies for disinfecting medical waste which do not produce POPs, such as autoclaving, microwaving, chemical disinfection, etc. Health care projects should use non-combustion technologies for that portion of medical waste which requires special treatment.

5) Community Right-to-Know and Right-to-Consultation
The environmental impacts of an institution are felt first and foremost by the local community, including patients, workers, community residents and waste pickers (scavengers). People have a fundamental right to know about the policies and projects that affect their lives, especially when it relates to the work of a public institution such as the IFC. This requires that stakeholders are not only provided with the information that they need to participate in decision-making, but also that the information is provided before all of the critical decisions have already been made. These should include access to social and environmental monitoring reports as well as to the complete environmental management plan, including critiques and comments on the plan and submitted to the IFC, client, or regulatory agency; the analysis of alternatives that were considered and rejected; financial implications of the plan; updates, changes and revisions to the plan, on an ongoing basis; and commitments made by the institution and IFC within the scope of the plan. This access must be sufficiently in advance of the plan's approval by IFC that the local community has time to review the plan and critique it. The IFC, in turn, must consider community comments in its review of the plan and monitoring reports.

6) PVC Elimination
Polyvinyl Chloride (PVC) is found widely in the health care sector, in a variety of uses from plumbing to IV bags, yet PVC is a problematic material at every stage of its lifecycle. The production of PVC is an extremely polluting process -- from chlorine manufacture to production of the polymer itself -- releasing large quantities of dioxins, furans, other persistent organic pollutants and mercury in the production chain. For uses such as IV tubing, bags, etc., PVC is mixed with plasticizers, some of which leach out of the plastic and into the fluids being injected into the patient. Some of these, such as DEHP, have been identified as carcinogens and endocrine disruptors. At the end of its life, PVC continues to pose a threat, as it cannot be cleanly recycled, and disposal causes the problems of dioxin production and liberation of heavy metals from the PVC matrix. For all these reasons, PVC use is incompatible with a sustainability program, and health care facilities should eliminate the use of PVC.

We also attach a list of several documents and websites which we hope you will find useful in the preparation of the guidelines. If you would like more information on any of the above topics, please do not hesitate to request it.

We look forward to establishing a fruitful dialogue on these issues, and hope that this letter is of use to you in drafting your guidelines. We will be happy to meet with you at your convenience to further discuss these questions.



Sincerely yours,

Neil Tangri International Steering Committee Member Global Alliance for Incinerator Alternatives PO Box 19405 Washington, DC 20036

Sylvia Altamira International Coordinator Health Care Without Harm 2126 P St. NW Box 150 Washington, DC 20037

Jim Puckett Coordinator Basel Action Network 1305 Fourth Ave., Suite 606 Seattle, WA 98101

cc: IFC Executive Directors
Ron Anderson, IFC
Josefina Doumbia, IFC
Rob Horner, IFC
Shawn Miller, IFC
Rachel Kyte, IFC
Graham Saul, BIC

Health Care Facilities and the Environment
Reference Documents

Documents available on the web:

Health Care Without Harm: the Campaign for Environmentally Responsible Health Care, 1999
<www.noharm.org>
Eleven Recommendations for Improving Medical Waste Management, CGH Environmental Strategies 1997.
<www.cghenvironmental.com/elevenrecs.html >
Medical Waste Incineration: A Mismatch Between Problem and Solution, Dr. Paul Connett 1997.
<www.no-burn.org/Library/mismatch.pdf>
Medical Waste Treatment Technologies: Evaluating Non-Incineration Alternatives, Health Care Without Harm 2000.
<www.noharm.org/library/docs/Medical_Waste_Treatment_Technologies_Evaluatin.pdf>
Non-Incineration Medical Waste Treatment Technologies, Health Care Without Harm 2001.
soon to be posted at <www.noharm.org>
Clinical Waste in Developing Countries, Glenn McRae and Ravi Agarwal 1999.
<www.ban.org/subsidiary/clinical.html>
Setting Healthcare's Environmental Agenda, conference proceedings 2000
<www.noharm.org>


Documents available by mail:

Hospital Waste Time to Act: Srishti's Factsheets on 8 Priority Areas, November 2000
Managing Hospital Waste: A Guide for Health Care Facilities, Revised Edition 2000
Both available from Srishti, H-2 Jangpura Extension, New Delhi 110014 India <[email protected]>


Relevant Websites:

Health Care Without Harm <www.noharm.org>
Global Alliance for Incinerator Alternatives <www.no-burn.org>
Basel Action Network <www.ban.org>
Sustainable Hospitals Clearinghouse <www.sustainablehospitals.org>
Hospitals for a Healthy Environment <www.h2e-online.org>
Nightingale Institute <www.nihe.org>
Srishti <www.toxicslink.org/srishti.htm>
National Wildlife Federation on mercury <www.nwf.org/greatlakes/resources/mercury.html>
US EPA on mercury <hwww.epa.gov/seahome/mercury/src/mercmed.htm>