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Healthcare waste management: The global paradox

Article  in  Waste Management & Research · June 2008

DOI: 10.1177/0734242X080260031101

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Los Angeles, London, New Delhi
and Singapore
http://www.sagepub.com
Copyright © ISWA 2008
ISSN 0734–242X
Waste Management & Research
2008: 26: 215–216

Editorial
Healthcare waste management – the global
paradox
It is very difficult to under-
stand when working in the
field of healthcare waste
management why the pro-
fessionals engaged in health-
care appear to be blind to the
need to improve the han-
dling of the waste that they
produce in caring for their
patients. They appear to
overlook the fact that the
wider public also needs pro-
tection and that preventative
medicine should be practiced
in and for the community as a
whole. It is also essential that
the principle of duty of care
is observed in ensuring the
waste from hospitals is being
managed in a way that is stra-
tegically sound. The situation in the Naples area of Italy is a
case in point, where there is no adequate waste management
strategy for the region, where up to 250 000 tonnes of waste
has been allowed to decompose on the streets, and where
local doctors confirm that diseases more commonly found in
developing countries are now appearing in Naples.
Research carried out in the field and reported in this
Journal indicate that there are many countries in the world
that do not have national legislation or the basic and yet sim-
ple techniques for the segregation and treatment of the
infectious and dangerous waste materials. In these countries
hazardous healthcare waste materials are still allowed to be
mixed with all the other waste produced in a hospital for ulti-
mate disposal in what are frequently just dumps, and often in
places where there is a community living on the dump and
scavenging is taking place on the site.
In 1999 the World Health Organization (WHO) devel-
oped a simple mass action model, which suggests that each
year there are approximately 8–16 million new cases of hepa-
titis B virus, 2.3–4.7 million cases of hepatitis C virus and
80 000–160 000 cases of human immunodeficiency virus
(HIV) resulting from unsafe injections. These unsafe prac-
tices are attributable to, among other things, very poor waste
management systems and the kind of practices that occur if
there is no proper system of healthcare waste management
in operation. For example, injection devices may be collected
and categorized for resale, either to medical establishments
or for drug abuse. These devices are very often not properly
sterilized and this has led to severe public health problems.
Ineffective waste management in hospitals can have serious
public health consequences arising from infection and injury
both to staff engaged in healthcare or in the waste manage-
ment industry and also to the public at large. However, there
are still professionals working in the healthcare sector who
advise their governments that no hard evidence exists to sug-
gest that there is a need to have segregation and proper
treatment systems for the infectious and dangerous waste
emanating from a hospital. They have not carried out the
necessary research themselves and have turned a blind eye to
the problem. I would therefore suggest that this is an area
that demands further research.
The International Solid Waste Association (ISWA) Work-
ing Group on Healthcare Waste has, since its formation in
1996, been very conscious of the perils of the mismanage-
ment of healthcare waste and over the past 10 years or so,
has been co-operating with the WHO in promoting good
practices through education, training and the production of
suitable handbooks. The WHO publication The Safe Manage-
ment of Wastes from Healthcare Facilities published in 1999 and
known as the ‘Blue Book’ is well known internationally and is
at the moment being reviewed to bring it right up to date
with current thinking.
Since the beginning of the twentieth century, hospitals in
a large number of industrialized countries have had access to
on-site boiler plant and incinerators for the disposal of waste
produced in healthcare. Hazardous healthcare waste has cer-
tain characteristics that make it distinctive. It can be highly
infectious and can contain very toxic materials and also body
parts, which require sensitive handling. The public’s percep-
tion of risk as a result is heightened and whenever such waste
has been incorrectly handled it has received wide and
adverse media attention. In the latter half of the twentieth
century a number of events combined to act as a catalyst for
the changes that have led to the improvements in the man-
agement and disposal of healthcare waste in these countries.
In essence the events were the growth in the use of disposa-
ble equipment, the steady improvements required in inciner-
ation equipment deemed necessary to meet the legal

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 Editorial
requirements for gas emissions and the growing public
awareness of environmental issues. It also has led entrepre-
neurial companies to take the opportunity to develop large-
scale alternative technologies for the treatment of healthcare
waste, based upon existing techniques of disinfection.
Incineration has had a long history that has been marred
in the past by the problems of inadequate cleaning of output
gases causing nuisance to neighbours, together with the pro-
duction of dioxins. However, the current state-of-the-art
incineration technology means that treatment of waste can
take place with minimum risk to the environment from air pol-
lution. It can also deal with all waste materials that are pro-
duced. The cost, both capital and operational, will be more
expensive than the alternative or disinfection technologies.
The rendering safe of infectious waste by the alternative
technologies depends on the operational conditions and the
nature of the waste being produced. The protocols for
assessing the efficacy of these technologies have been devel-
oped, but only over the last 20 years, and the standards are
still under review and being improved by an iterative process,
although they still have to receive international standard
approval. There is also a shortage of research material avail-
able for the alternative technologies in contrast to that for
incineration, which is a technology that has had a long his-
tory and therefore, received much more attention. In spite of
this there are many alternative technology appliances in
operation throughout the world. The disposal of untreated
hazardous healthcare waste in a landfill site should only be
an option in extreme cases where the authorities are incapa-
ble of providing any other means of treatment. In the Euro-
pean Union it is illegal to dispose of untreated healthcare
waste in a landfill site.
The ISWA Policy on Healthcare waste is as follows:
‘ISWA advocates that proper attention is given to safe
and sustainable management of healthcare waste.
ISWA supports the sustainable management of health-
care waste by the segregation, storage, transport, treat-
ment and final disposal of healthcare waste.’
The sustainable management of healthcare waste is now
receiving much more attention in countries where mature
systems are in use and controlled by national legislation.
Research in this area is now being reported in this Journal
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and more should be encouraged. There are good reasons to
promote a sustainable approach to healthcare waste man-
agement. The first reason is that in a lot of areas the health-
care sector can be the largest employer and it is one way of
encouraging the population as a whole to think in a sustaina-
ble way. Secondly the quantities of material resources used in
this area continues to grow and ways need to be found to
reduce the amount used, and for recycling or recovery to be
encouraged without detriment to health or the environment.
The principles of sustainable development have not been
fully addressed by international and national organizations
when advising upon best practice for healthcare waste man-
agement and this will be attended to in the revised WHO
Blue Book. Research also is needed in how to engage deci-
sion-makers at top and senior level, both nationally and
locally, as well as the media to promote the concept of sustain-
able development in the management of healthcare waste.
In conclusion, the awareness of and systems for health-
care waste management are continuing to slowly improve on
a global scale but it is quite clear that very much more needs
to be done. We are always faced with the fact that as micro-
organisms evolve, there are new strains that cause human
disease continually emerging. HIV, severe acute respiratory
syndrome (SARS), Creutzfeldt–Jakob disease (CJD), Influ-
enza H5N1, West Nile virus, Lyme disease, Escherichia coli
0157, Ebola, Q Fever and Marburg. In addition there are
infections occurring where micro-organisms are becoming
resistant to conventional treatment, e.g. extensively drug-
resistant tuberculosis (XDR-TB), methicillin-resistant Sta-
phylococcus aureus (MRSA), vancomycin-resistant Staphylo-
coccus aureus (VRSA). Pandemics occur intermittently and
where suitable and sufficient systems of healthcare waste
management are in place this will certainly help to control
the spread of disease.
Bill Townend
International Environment Consultant,
Wokingham, UK
E-mail: w.townend@ntlworld.com
Giovanni Vallini
WMR Associate Editor and
University of Verona
E-mail: giovanni.vallini@univr.it