AS HORROR stories about recycledsyringes and quilts packedwith used surgical cotton keeppouring out of the dirty backyards of our hospitalsthe'country finally sees actionthoughbelatedon medical wastemanagement. The problem standsdiagnosedbut the treatmentlabours under a cloud ofconfusion.

The question is whether tofollow the Westwhich usedincinerators to deal with thehospital waste problem lastdecadeonly to modifyrestrictor even dump these gadgets asunviable and environmentallyharmful propositionsor tolook for safeir alternatives.Even as incinerator manufacturersin India and abroad strive tocash in on the newfound opportunity and marketenvironmentalists are busypushing foralternatives like segregationand chemical and electro-thermaltreatment of waste.

True to the trendit was theSupreme Court (sc)which had set the ball rolling.On March 21996the Scinresponse to a public interestlitigation for cleaning Delhifiled by advocate B L Wadehrahad directed the Delhi stategovernment to installincinerators in all hospitals andnursing homes (having over 50beds) in the capital for burningoff their waste. What had pavedthe way to the Court'sdecision was the April 1995ministry of environment andforests (MEF) draft rule - theBio-Medical Wastes(Management and Handling) Rules1995- regarding thedisposal of biomedical wastes.

But waste keeps piling up in the backyards of hospitalsinmunicipal dumpsites and landfills. Schedule I of the MEF draftrule provides the different categories of bio-medical wasteswhich include the following:
• human anatomical wastes (human tissuesorgans)

• blood and body fluids

• animal wastes

• microbiological wastes

• highly infectious wastes

• discarded medicines

• discarded glassware

• disposables

• waste sharps (needlessyringesscalpelsblades)

• liquid wastes

• slaughter house wastes

• incineration wastes (ash from incineration of any bio-medical wastes)

• bio-technology wastes (genetically engineered organisms or products and their culture)

The rule makes it mandatory for hospitalsnursinghomes and clinics having more than 30 beds or catering tomore than 10patients per monthto install incineratorson their premises. The smaller facilities are required toset up common incinerators. The rule also directs veterinaryinstitutionsanimal houses and slaughter houses generatingmore than 200 kg of biomass waste per day to installincinerators.

Another important facet of the draft rule is the ban onimport and export of biomedical wastes. In the early'90saninternational furore had broken out when it was found thatmedical wasteincluding bloodsoaked bandageswas beingclandestinely imported to Frande from Germany. Segregationof wastes at the source prior to storage or transportation hasalso been made mandatory undet the rule.

Certain hospitals have set qp expensive incinerators. Theliterature of one particular Indi4'n manufacturer lays claim toall 22 major medical incineratorA installed in Delhi. Accordingto Greenpeace campaigner Ann"e Leonardmany manufacturerswho suffered due to opposition to incinerator technology in the West are now eagerly looking forward to enter India (see Interview).

Seeds of death
The problem of clinical waste disposal has acquired gargantuan proportions in today's cities. While about one-and-a-halfkg of waste is produced per bed per dayof the total waste generated by hospitals47per cent is biomedical wastecontaminated with disease -carrying pathogens. According toresearchers from Delhi's G B Pant Hospitalpathogens whichcause hepatitis-B (a chronic and lethal liver ailment carried by43million Indians)for instancecan remain in the blood atneedle-tips or bandages and spread infections for a long time.At the Delhi-based Tuberculosis Hospitalleftovers from thekitchen find their way into a binwhich has become a breedingground for the very bacterium which the hospital was set up todemolish. Ailments like laptospiraa brain infectiongerminate at places where hospital wastes mix with householdgarbage.

Internationallythere have been alarming reports ofanatomical waste popping up at dumpyards near settlements.The Lancet (Vol 343) had reported that poor slum-dwellers inOlindaBrazilfound human parts in the city's garbage dumpwhich sometimes even ended up as part of their food. in a single inspectiona team sent by Olinda's acting health secretaryfound human fatskinfoetusesbrains and breasts in thedumpyard. In 1995human foetuses were found near a nursing home in HapurUttar Pradesh (up) according to localpolice and residents.

There have also been reports of recycling of hospital waste.Workers in Delhi's hospitals regularly pilfer used syringes anddrip bottleswhich sell at rates between Rs 10-25 a kg. In 1991The Pioneer reported a well-knit racket operating from thebackyard of Delhi's All India Institute of Medical Scienceswhich cleaned used syringes and transported them in bulk toMeerut in up. Slum-dwellers near another Delhi hospital -the Loknayak Jai Prakash Narayan Hospital - were reportedly selling used cotton to make gaddis (mattresses).

A nationwide concerted effort isobviouslyneededto tackle the immensely complicated problem. Ironicallywhile the nation is striving to provide safer medicare to itscitizens through the use of disposablesunhygienicwaste disposal methods have grossly undermined allwell-intentioned efforts.

Is incineration the solution?
An incinerator converts solid waste into liquidand then gaseous form and releases it to theatmospheregenerating toxic chemicals likedioxins and furansformed directly fromchlorine and chlorinated products like surgical gloves and cathetersin the process. Thesechemicals - carcinogenic properties of dioxins are well known - are found in incineratorash at levels of the order of micrograms pergram of ashmuch of which finds its way intodomestic and municipal landfills.

During a recent survey of 10 governmenthospitalsfive private hospitalsseven smallprivate nursing homes and 10 governmentdispensaries in Delhi by Vatavarana Delhi-based environmental NGOit was found that20per cent of these hospitals had bhattis(crude large ovens) for incinerators. Fifty percent either burned the waste in the open ordumped it in landfills; 10 per cent took theirwastes to other hospitals which had incinerator facilities and 20 per cent had incineratorswhich were mostly out of order. Most of thesehospitals were found to be operating incinerators at 400-500'cwhereas they are required tobe operated at 1200Temperature controldevices are vital to incineration. If the exhaustgases in medical waste incinerators are notrapidly cooledthey run the risk of elementsre-forming into dioxins and furans.

Experts are of the opinion that instead ofadopting end-of-the-pipe solutions like incinerationa more systematic approach needs tobe taken for disposal of these wastes (Down ToEarthVol 4No 23); medical waste reduction and selectivereuse need to be focussed on. Segregation of waste into theinfectious and the non-infectioushoweveris an area whichhas generally suffered from gross neglect. Says Ravi Agarwaland Bharati Chaturvedi of Srishtia Delhi-based NGOThough the 1995 rules recommend incineration only for select waste streams, in the absence of waste segregation practices, all kinds of wastes reach the incinerator.

A series of three Srishti reports point out that the incineration process does not destroy matter; it merely changes thechemical composition and toxicity of the substances burnt.The report argues that by transforming solid and liquid toxicwastes into gaseous emissionsincinerators actually increasethe volume of waste by mixing it with airand dispersing pollutants into the atmosphere.

A two-year Danish National Environmental ResearchInstitute studypublished in 1990had found that hospitalwastes contributed 30 per cent of the dioxins and furans producedeven though they made up only one per cent of thetotal waste generated. In one of the most comprehensive health risk assessments of medical waste incineration carriedout by the California department of health services along withthe California air resources board in 1990it was found thatdioxins and metals like cadmium exercised the most significant carcinogenic effects. In 1991in UKa hospital incineratorwas believed to be the cause behind leukemia which killed acitizen - an incident which prompted the much-discussedcase against the Gateshead Health Authority. Says RaviAgarwalThere is already so much international debate on this controversial technology, and India is still bent upon adopting it.

Medical waste incineratorsparticularly in developingcountriesoften carry out 'batch processing' of their contents:the wastes are fed in batches on an :s arrives basis'. Theincineratorhencedoes not fire continuouslyas is recommended for optimising performance and minimisingemissions. In Latin Americathere is a tendency to installoversized incinerators. These are either inefficiently utilised orare ineffective since they have to be filled with too little wasteleading to batch processing or with waste which was nevermeant to be incinerated.

In Indiano regulatory minimum or maximum temperature standards are followed for incineration. It is the manufacturer who decides and prescribes recommended temperatureranges depending on the type of waste and incinerator. Thepicture in developed countries - wherever incinerator technology is still in use - is not rosy either. In Washingtonusarecent survey showed that between 48-87 per cent of the state'soperating incinerators were without emission control equipment. In UKaccording to a study of 36 hospital incinerators inWales carried out in March 1990only six operated betweenthe temperature ranges of 800'c to 10while the restoperated at a temperature as low as 400'cleading to a danger of dioxin production.

Currentlythe pollution control devices available for medical waste incineration systems are wet or dry acid scrubbers(to remove/neutralise acid gases)bathhouse (fabric filters)electrostatic precipitators (to remove airborne particulatematter) and hybrid dry/wet scrubbers and afterburners.But the repair and maintenance costs of these devices aresteep and there is very rarely any backup system in case of afailure in operations.

Another major problemsays the Srishti reportsis the disposal of incinerator ashwhich consists of both fly ash andbottom ash. This ash is highly toxiccontaining large concentrations of heavy metalsdioxins and furans. The ash isdumped into landfills where it is rarely or insufficientlycovered with inert material. This results in groundwater pollution through leaching. It can also play havoc with the healthand safety of scavengers and ragpickerswith liberal amountsof sharps like needles constituting part of the waste. Nearly 93 per cent of hospitals and nursing homes in Delhi surveyedby Srishti use the Municipal Corporation of Delhi wastestream to dispose off their garbage.

This' means the disposal of medical waste in alandfill depends upon the highly suspect and debatableefficiency of collection demonstrated by the localmunicipal ward. "Even internationallywhile the law oft6nstipulates stringent requirements on handling the ashthere isusually no clear guidance on its disposalinformed Ravi Agarwal.

The alternatives
Incinerators, clearly, are pass6 in the developed world. Industrialised countries are witnessing a concerted move towards non-incineration technology. Nearly 80 per cent of the hospitals in California use alternatives to on-site incineration, which include the following broad categories:
• mechanical treatment

• chemical treatment

• plasma torch

• thermal deactivation

• electro-thermal deactivation

• autoclaving

• microwaving and

• electron beam sterilisation

These alternate technologies boast of much lower operational costs than that incurred in running sophisticated incinerators. Says Agarwal,The running cost of anideal incinerator with all the pollution control gadgets in theus is $1.5 million for incinerating 250 kg/hourwhereasautoclaving and microwaving would cost only one-third of theincineration cost."

Autoclaving or steam sterilisation is normally used forreusable items; an estimated 45 per cent of infectious medicalequipment in the West is made amenable for reuse throughthis technology. "What is clearly required is a comprehensivewasie management system that deals with the problem notonly at all levelsbut works from the bottom up and not fromthe top downsays Bharati Chaturvedi.

The Southeast Asian regional office of the World Health Organization (WHO) had undertaken a survey in 1994 to assess the status of hospital waste management in the countries of the region. A P Hirano, an environmental health engineer from the promotion of environmental health unit, WHO, pointed out,Although hospital waste management hasbecome a serious con@ern in Southeast Asiaonly a few governments in the region 4ave adequate programmes for propercollection and disposal'of waste from hospitals." The surveyconcluded that the eicisting unsatisfactory management ofhospital wastes needed to be gradually changed through aprocess of legislationwith sustained enforcement of rules andregulations and systeinatic training and orientation of thestaff involved.

A 1991 Congressiorial report of the us office of technologyassessment had aISG recommended a "comprehensive wastereduction and materiai@ management approach to waste management"saying that "while there is no one preferred treatment methodsource separation practices are the key to targeting particular wastes for the most appropriate tr6tmentmethods".

Srishtion its parthas put forth a few recommendationsfor a systematic approach to waste management in itsreport. The list includes measures like waste auditaccountabilityinventory controlcategorisation of medical wastesspecific air emission standards for medical wastes andfinallyawarenesseducation and training of personnel.We have to be more accountable for the waste we generate and adopt cleaner technologies and not incineration for managing the ever growing menace of hospital wastes,assertsRavi Agarwal.

The premier judicial body in the country seems to haverecognised that. In a judgement on May 7the scdirected theCentral Pollution Control Board to examine emission levelsfrom installed incineratorsand to set emission level standardsin the wake of the anti-incineration call to "consider the bestdisposal technologies". The next hearing on the issue has beenscheduled for July this year.

With inputs from Max Martin and Madhumita Dutta