18 March, 2002

RE: Health Facilities: Health Care Waste Management Guidance Document

Dear Dr. Orellana:

We have appreciated the opportunities that you have afforded us to participate in and comment on the process to produce the IFC guidance document on Health Care Waste Management. The final document should provide much needed support to IFC and other institutional personnel working on this issue and some structure within which to make good decisions that protect workers, the public and the environment.

In reviewing the draft document we wish to congratulate the authors on the attempt to provide a succinct overview that challenges project personnel to acknowledge the very serious hazards in managing health care wastes (especially those beyond biohazard/infectious waste), and provide guidance on establishing plans and programs to mitigate those hazards. The emphasis on segregation as the essential strategy to minimize the hazardous portion of the waste stream, and the multiple referrals to pollution prevention through product elimination or substitution is also an important contribution to making new health projects safer to workers, patients and the public. As you know from a review of the materials that we have shared with you in the past these are the essential principles through which we work with health sector projects.

Last year we shared six principles that our coalitions would like to see reflected in the IFC's guidelines:

1) Emphasis on Pollution Prevention

2) Waste Minimization and Segregation

3) Mercury Elimination

4) Non-Combustion Treatment Technologies

5) Community Right-to-Know and Right-to-Consultation

6) PVC Elimination

For the most part we find that there has been effort to accommodate these areas in the IFC draft. There are however a series of issues, that if addressed, we believe will strengthen this document by both creating greater internal consistency and taking advantage of field experience in health care waste management in facilities in a number of countries that we have had experience with. The IFC document relies significantly on the WHO manual Safe Management of Wastes from Healthcare Activities. This 1999 publication is in need of updating according to the authors. There is also a heavy reliance on European and United States specific sources, that are applicable for broad standard setting (e.g., best standards for air emissions standards) but are less helpful in terms of specific approaches to management.

There are two memos attached to this letter that address a series of specific points in the document that we hope you will find of help in the final revisions, and seriously consider during your process of finalizing them. The first memo outlines specific points section by section with a focus on management. The second memo is focused on emissions limits that were utilized to govern incinerator operations.

Together these memos detail our concerns that are summarized as follows:

1. Mercury: There is no mention in the document of mercury. Given the global concern around mercury pollution from health care institutions, the prevalence of mercury within such institutions and the special handling that mercury requires, we find this omission particularly surprising. We recommend including a statement of intent to minimize, properly handle and eventually eliminate mercury use in health care institutions. This could be incorporated in a general statement under "Philosophy" about the elimination of hazardous materials including PVC. The Health Care Waste Management Plan should also include special provisions for handling and storing mercury and mercury-contaminated wastes.

2. Incineration: As we have previously stated, incineration as a treatment technology (often confused as a disposal method) is a substandard process that globally has caused far more harm than it has prevented. Minimizing and then eventually eliminating incineration should be the long term goal of any initiative, whether it is evaluated through a risk prevention, environmental health, worker safety, or economic standard. In addition, the standards selected for emission controls are based on erroneous interpretations of the least strict guidelines from the USA and EU. While the IFC phases out its funding of incinerators, it should insist upon emissions standards that are at least as stringent as US and EU levels. This is the subject of the attached second memo.

3. Waste categorization: The categorization of wastes (introduction and in Tables 1 and 2) is not consistent, and is constructed in a manner that does not lend itself to being applied in a management framework. These issues are covered in the first attached memo.

4. Chemical waste minimization: There is little discussion about the need for minimization of chemical use, and the proper handling and disposal of these chemicals. Currently, they are typically either discharged to the sewer or sent out for incineration in technologies not designed for hazardous chemical wastes. This area tends to be the weakest link in most international documents addressing health care waste. While management of Infectious Wastes is based on a perception of the possible risk present in those wastes, the management of chemical wastes must be based on the very real knowledge of the dangers inherent in these materials, many of which are toxic and genotoxic.

5. Occupational safety and health: The focus on worker safety and health issues is laudable. Additional attention should be given to the monitoring and safety concerns of workers regularly exposed to hazardous chemical substances, whether in the lab working with solvents and formaldehyde, or among incinerator or other treatment technology operators.

6. Community involvement: Again this is a particularly good addition. Much of what we have observed about health care waste management programs in different countries that is positive has resulted from an open process between the institution and its neighbors, educating the public about the reality of health care wastes (e.g., most of it is safe general trash), and the ways in which the institution will operate to minimize the risks associated with the small amount of hazardous wastes.

These key points are further elaborated in the attached memos that we hope will provide some valuable assistance in the final development of the document. We would be happy to discuss any of these points with you, or provide you with additional materials if they would be of value.

This letter has been written 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 350 organizations in 38 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 over 200 members from 54 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. BAN has been active in helping shape the Basel Convention's guidelines on the environmentally sound management of health care wastes.

Sincerely,