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The
city of Mumbai produces 600 tonnes of medical waste daily, from
its 3,000 hospitals and 36,000 general practitioners’ clinics.
Most of this waste enters the city’s waste disposal system,
unlabelled and non-disinfected, open to rag pickers and pests and
dumped in open landfills, liable to spread infections and diseases
that could reach epidemic proportions.
Few doctors worry about the powder keg of infectious medical waste
that major urban centres and especially the city of Mumbai are
sitting on. Those who do, fret: fret at the authorities and the
regulating bodies which though aware of the problem, haven’t yet
been able to get the mechanism working; and at the medical
fraternity that though concerned, is too self-centredly involved
with the individual patient to care for society.
The
problem
Bio-medical
waste is defined as waste generated during the diagnosis,
treatment or immunisation of human beings or animals or in
research activities. A typical medical waste bin will contain
pathological waste – human tissues, amputated or diseased limbs,
organs, foetuses, blood and other body fluids. Infectious wastes
will include soiled surgical dressings, swabs, waste from
isolation wards and cultures, dialysis equipment, gowns, towels,
etc. Sharps like needles, scalpels, blades, saws, nails, broken
glass, etc. form the third type of waste, while pharmaceutical
wastes have medicines and outdated drugs. Radioactive wastes
include solids, liquids and gases from in-vitro analysis of body
tissues and fluids.
Under the Environment Protection Act, the rules are clear. The
civic authorities in Mumbai have also brought out a training
module for hospital waste management, which clearly states that
medical waste should be segregated before disposal. Each of these
waste categories should be separately disinfected or
decontaminated before it enters the disposal system. Sharps like
needles are to be broken by needle cutters or burnt and deposited
in containers. Syringes are to be cut before disposal. Secretions
and excretions are to be decontaminated and drained, while blood
bags are to be autoclaved and incinerated.
“Segregation of hospital waste, at the source of generation, is
the key to ensure that 90 per cent of the waste which is non
infectious is treated daily. At no stage should infectious waste
come in contact with non-infectious waste,” says Dr Rajani
Desai, who did a thesis on medical waste disposal in Mumbai for a
diploma in environment and development.
While big hospitals follow procedures like hydroclaving and
autoclaving for sterilisation, the problem is with small hospitals
and nursing homes. Though a common treatment facility has been
suggested, there are few takers for the idea. Asking big hospitals
to process waste from smaller hospitals has also been turned down.
What is worse, a survey revealed that very few city doctors are
even aware of the rules laid down. Despite knowing that the waste
generated in their hospitals and clinics is infectious, medical
practitioners in Mumbai are disposing of their waste in municipal
bins without disinfecting or treating it. In most cases this is
due to sheer disinterest in waste management, as long as the
offensive bag leaves the hospital premises. “In these cases,
doctors are no different from the member of a housing society, who
does not want to segregate waste and is only interested in getting
it out of the house,” says Dr Nirmala Ganla, a gynaecologist
from Pune, who has been vermicomposting the waste from her own
hospital for three years now.
Forget waste. “I don’t understand why doctors can’t invest
in a needle breaker which hardly costs around Rs 250 for their
clinics,” says a bewildered Dr Desai. Most used needles are
capped and dumped into municipal bins. Rag pickers, who expose
themselves to infection through these sharps, then ensure that
they get recycled. Though sharps make up only one per cent of
medical waste, they are responsible for over 90 per cent of the
potential risk of transmitting diseases! A survey that she
undertook for her thesis revealed that a whopping 54 per cent of
doctors admitted to ‘recapping needles’ after use, while 34
per cent used a needle breaker. “The industry of recycling
disposable needles and syringes flourishes due to lax attitude of
regulatory machinery,” Dr Desai points out.
Under the rules, waste that is segregated and bagged has to be
transported to a common collection point. Utmost care has to be
taken during the transport that infectious waste remains separate
from non-infectious waste. The driver’s cabin should be separate
from the collection cabin, which should be totally sealed. The
vehicle must have the address of the site treatment facility along
with the telephone number and a biohazard sign on it. The driver
and the cleaner should carry a logbook and instructions to
mitigate any accident. But all these rules features remain trapped
on paper.
Awaiting
the law
After
the Parliament enacted the Environment Protection Act, in 1986,
the Bio-Medical Waste (Management and Handling) Rules, 1998, came
into force. These make it obligatory on the generators of
bio-medical waste to take steps to ensure that the waste is
handled without any adverse impact on human health and the
environment. While different treatments like incinerator,
autoclaving and microwave system or a common waste treatment
facility is envisaged, the rules provide for segregation,
packaging, transportation and storage of medical waste. Hospitals
with more than 1,000 patients per month must apply on prescribed
forms to the Maharashtra Pollution Control Board for handling
bio-medical waste.
The Mumbai Municipal Corporation too has brought out its Municipal
Solid Waste Management and Handling Rules, which were to be
implemented from January this year. But, with only a handful of
housing societies in Mumbai actually following waste segregation,
it is no surprise that hospitals and doctors too are lackadaisical
about their roles in waste segregation.
As of today, there are no fines levied on doctors if they don’t
disinfect their infectious wastes. A private firm has been
contracted to collect wastes from hospitals across the city. There
are times when the vehicle to collect waste comes once in four or
five days, which could be hazardous to infectious wastes. “It is
not that small clinics do not have any provision for sterilisation.
They do autoclave their scalpels and gowns and aprons. What stops
them from even using something like the pressure cooker to pass
steam at high temperature through their infectious wastes, before
disposal? The waste will get disinfected… But nobody is
interested,” adds Dr Desai.
The
dangers of incineration
Till
recently, Mumbai had a huge incinerator at Sewri, where infectious
medical waste was incinerated – burnt at high temperatures, one
of the oldest waste disposal methods known to man. In fact, the
developed world has spent immense manpower and money trying to
build the biggest and the best incinerators for their wastes.
It has proved to be a disaster worse than the problem it was
supposed to solve.
While pathogens were killed at high temperatures, incinerators
turned a medical problem into a chemical one. Medical waste
contains more plastic per volume than municipal waste and much of
this plastic is chlorinated. The materials on which pathogens
existed when burnt have been found to release chemicals, acid
gases, halons and toxic heavy metals, dioxins and furans into the
atmosphere, which are endocrine or hormone disruptors. Dioxins are
fat-soluble substances that get deposited in adipose tissues once
they enter the body. They affect binding of proteins and hence
also affect hormones including thyroid, estrogens, androgens,
glucocorticoids, gastin and insulin. Lancet magazine
concluded that this is the “precise reason for increase in
incidence of sterility in both the sexes, rise in breast cancer
and a tremendous increase in the community of diseases like
thyroid affections, diabetes mellitus and an increase in cancer in
the younger age groups”.
While the municipal corporation has been persuaded not to insist
on incinerators in big hospitals, and the Sewri incinerator has
been shut down, there are other city hospitals which have
incinerators which may not be following the procedures laid down
by the pollution control boards on the height of chimneys and the
specifications of the gases let out.
In Mumbai, it is a known fact that ragpickers have been burning
PVC wires to extract copper coils at dumping grounds and at
municipal bins. The dioxins and furans let out in the atmosphere
are of little concern to the authorities. Wholesale burning of
garbage, irrespective of whether there is any plastic waste in it,
is common in housing societies as well as municipal bins, if the
garbage remains uncollected for days.
Reduce,
Reuse, Recycle?
In
the medical fraternity, gowns, gloves, aprons, towels as well as
scalpels, saws, nails, etc. are recycled after adequate
sterilisation through autoclaving. Waste reduction, though, has
never been the mantra of any hospital or clinic, nor is detailed
thought given to it. Dr Desai worked on re-introducing glass
syringes in hospitals, to reduce the amount of disposable syringes
and hence plastic as waste in the atmosphere. She has met with
some success. In the operation theatre of two hospitals where she
functions as an anaesthetist, glass syringes are used instead of
plastic syringes, unlike the trend worldwide.
“We leave the option to the doctors, they can use plastic
syringes. But my contention was, if you can sterilise the other
instruments in an operation theatre, then why not syringes?” she
asks. Following that bit of common sense, two charitable hospitals
in Mumbai, the Arogya Nidhi Hospital and the Ramkrishna Mission
Hospital have started using glass syringes in the operation
theatres. Used exclusively by anaesthetists, glass syringes are
duly sterilised and used with disposable needles on the patients.
“It is mostly younger doctors who are uncomfortable with
reusable syringes, and believe only plastic syringes are truly
sterile,” she says. Though she reserves her views on the
sterility of the needles and syringes. “If the doctor has to
rely on someone for the sterility of the instrument, why not on
the sister in the hospital or on the staff, who are anyway present
in the hospital? How can you rely on a label simply because it
says it is sterile?” she counters.
The process can be followed in charitable institutions because
glass syringes can cut costs for the patients. Besides, with
syringes being used in hospitals mainly for administering drugs
and not aspirating blood, there is almost no chance of
contamination, as long as one uses disposable needles. But as of
now, Dr Desai is the lone ranger on this difficult road.
While studying for her thesis, she has also noticed that
pharmaceutical wastes, including drugs and especially after they
have expired, find their way into municipal bins. Most doctors
seem unaware that they can return drugs to the manufacturers and
get newer drugs in return. “These drugs are dumped in charitable
hospitals, where some doctors might even administer them to the
patients,” she adds. A lot of medicines that go to the dustbins
can be used more profitably only if doctors overlook the fact that
the medicines were free, and tried to make better use of them.
Vermiculture:
deep burrowing earthworms
In
Pune, a doctor couple is being fined for not participating in the
city’s medical waste disposal system. Dr Nirmala Ganla, a
gynaecologist and her husband, a paediatrician, who run a nursing
home in the city, have been using vermiculture to transform their
hospital waste to rich compost fertiliser for the past several
years.
If dumping is not the answer and urban centres discover that their
waste management systems have overgrown landfills, the only
alternative that holds promise for waste disposal seems to be in
going back to mother earth. And as the case of Dr Ganla shows,
earthworms have succeeded in reducing even the toughest of
pathogens to compost dust.
Dr Ganla, who heads a 12-bedded maternity home in Pune, built two
concrete dustbins three feet long, three feet high and two feet
wide against their compound wall in 1997. On a bed of coconut
fibre, vegetable peels and vermicompost, the Ganlas converted
9,000 sanitary napkins, 850 placentae, and dressing materials from
approximately 700 surgeries, to mud. The two bins have been
absorbed around 300 kilos of waste in the past seven years. As an
excited Dr Ganla says, “The bioreactor has worked silently
without making its presence felt – there is no smell, it does
not attract flies and the result is rich manure”.
There have been few takers for the technology that requires
self-discipline for segregation and some amount of preparation for
the technique. Except for a few rural doctors, where waste
disposal systems are almost absent, and a handful of maternity
homes in Pune, nobody has tried to pick up the programme from the
Ganlas. “On the contrary, we are being charged a fine – apart
from the fees we are still giving the corporation for the
collection of the waste, which we no longer give the municipal
body – for not using the municipal waste”, says Dr Nirmala.
Ironically when they went to Goa for a lecture, they were
encouraged by the reaction of the medical fraternity, since Goa
still does not have a waste disposal policy. However, with the
Environmental Protection Act (EPA) coming into force, and the
pollution control boards getting involved, a policy is being set
in place in the young state – for incinerators!
The Ganlas had the microbiology department of BJ Medical College
carry out a study on the compost produced. Treated waste from the
bins was compared to untreated hospital waste and virgin garden
soil. The results were eye opening. The treated group was
environmentally safe and compared favourably with the garden soil.
To make the study more rigorous, the Ganlas injected salmonella
cultures and Hepatitis B blood samples into the treated samples
and the garden soil. Salmonella disappeared in three weeks in both
samples, while Hepatitis B could not be detected in the treated
samples in four weeks, though remained in the garden soil even
after five weeks.
While Pune municipal officials came to see the wonder of nature,
nobody is willing to pick it up for widespread use. “We cover
our bins with leaves so that anybody who peeps in will feel it is
a garbage bin,” says Dr Ganla. “These are small things that
you have to take care of, if you want the technology to
succeed.” Today Pune hospitals are encouraged to have
incinerators and many of them fail to meet the pollution board
regulations. “We have given up,” she adds, “with no adequate
support from the doctors, what else could we do!”
However, with the EPA recognising the merits of vermicomposting,
the Municipal Solid Waste Management and Handling Rules calls for
“processing biodegradable waste through composts,
vermicomposting, anaerobic digestion or other biological
processes”. Land
filling, in fact, has under the EPA been restricted to “non
biodegradable, inert waste or other wastes not suitable for
recycling or for biological processes”.
The
solution: doctors treat thyself
Today,
municipal waste management is a chapter absent from the medical
curriculum. Over generations, doctors populate hospitals without
any appreciation of the kinds of waste generated in hospitals and
how to handle them. Most hospitals are unaware of the term
“waste managers”. The few hospitals that do have such
officials don’t go any further. Still, “waste managers” are
better than believing hospitals do not need to manage waste at
all!
Waste management is an ongoing programme. With newer diseases
attacking humankind, it is incumbent on the part of the medical
fraternity to ensure that hospitals don’t become breeding
grounds for infections. Staff and employees have to be regularly
updated on the latest happenings in the field of medical waste
management and reorientation programmes are a must with doctors at
all levels in the hospital. “Waste management in hospitals
should be surveyed monthly to look at possibilities of improving
the disposal system,” says Dr Desai.
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