Published on: 15/06/2020
This article was written with Kim Worsham, founder of FLUSH
During the COVID-19 pandemic, the world became aware of the importance of improving WASH for communities (and that for many, the first line of defense against COVID-19 is out of reach). It also became obvious how vital it is for healthcare facilities to have proper access to WASH so that patients and medical professionals have a fighting chance to recover from illness and prevent the spread of infectious disease. And, let us not forget the striking risks of exposure for essential workers like janitors and waste handlers and their need for appropriate personal protective equipment (PPE).
One in five healthcare facilities in the world lacks access to essential WASH services, which has hurt a lot of the Global South’s ability to recover from COVID-19 and reduce spreading. In Niger, where IRC is working with the Conrad N. Hilton Foundation on a WASH in healthcare facilities programme, baseline data from two communes is shocking: most healthcare facilities do not have access to WASH facilities.
Baseline information of access to WASH and waste services in Niger, based on 2019 Public Water Service of Municipalities Report. (Adapted from a presentation by I. Krukkert)
With the surge of concern and need for healthcare, however, the world urgently needs to start addressing how we can make sure medical waste is not contaminating our environment and increasing the spread of other diseases in the future. With the COVID-19 pandemic, the volume of medical waste has quickly risen, as have questions of proper disposal and waste labourers’ working conditions.
Globally, one in four healthcare facilities lacks basic waste management services (WASH in Healthcare facilities, 2019 baseline report), meaning that healthcare staff safely segregate waste into at least three bins and hazardous waste is treated and disposed of safely. The three bins are for general waste, infectious waste, and sharps. Where does this medical waste go if it’s not managed? The odds are pretty high that they end up in the environment.
Fortunately, about 85% of healthcare facility waste is non-hazardous, and facilities can dispose of it along with general solid waste, which means it will likely end up at the local dumpsite. However, this doesn’t mean that healthcare facilities actually manage their solid waste properly or at this basic level. An evaluation of WASH and Environmental Conditions in 40 healthcare facilities in a rural district (Kabarole) in Western Uganda found that the facilities did not commonly practice proper bin use or waste segregation.
The remaining 15% of healthcare waste is hazardous - namely those that are infectious, chemically hazardous, radioactive, or sharp. When hazardous waste is treated, the common methods in healthcare facilities in the Global South are autoclaving and incineration. Autoclaving uses steam to sterilise medical waste, which is then often landfilled. Incineration of hazardous medical waste aims for controlled burning. Both practices can be part of a good waste management system; however, they can also pose health risks indirectly. Poor incineration practices can cause severe environmental pollution, including the release of highly toxic carcinogens like dioxins and furans, which is harmful for surrounding communities (2004 WHO Policy Brief). Disposing of untreated healthcare wastes can contaminate waterways, especially when landfills are not properly engineered and managed.
When practising landfill dumping, healthcare facilities must appropriately manage this waste to prevent dangerous exposure. Used needles are generally the most hazardous of healthcare waste because they can easily cause stabbing injuries and subsequent infections. Sharp waste is also highly infectious - needle-stick injuries have a 30% Hepatitis B transmission rate. When hazardous waste is poorly segregated from nonhazardous waste, general waste has a high risk of getting contaminated (2018 Africa Waste Management Outlook).
Exposure to hazardous medical waste is especially worrying for janitors and waste workers. The opportunities for skin contact with medical waste are ample, especially when:
The COVID pandemic has brought to our attention the hazardous conditions in which untrained and unprotected healthcare workers work. These vulnerable (and often overlooked) workers are essential and also deserve PPE and training to do their jobs effectively, with their health protected and risks minimised and/or controlled. In Pune, India, the waste workers cooperative (SWACH) is working hard to protect their #CoronaWarriors with PPE and food rations, educate the public on how to support the waste workers, and advocate with the city to amend waste disposal protocols. The efforts are commendable, as seen in the picture below. More places need to protect waste workers better, especially with the influx of hazardous medical waste being disposed of.
The adjusted waste pickup schedule in Pune issued by the municipality with instructions for households. Households can dispose of medical waste including sanitary napkins and diapers daily so long as it is labelled with a red dot – a simple but effective mechanism alerting waste workers not to open these packages (Times of India, 25 May 2020)
For healthcare facilities that opt for incineration in resource-scarce settings, simpler single-chamber incinerators are all too common; these technologies don’t reach high enough temperatures or control the emitting gases. Curiously, given that single-chamber technology may be the best available option for the area, it meets the requirements for basic waste management service at a healthcare facility, assuming it is a transitional measure (as described in a 2019 WHO report on treatment technologies of hazardous medical waste).
In Addis Ababa, Ethiopia, a study of hospital incinerators paints a very stark reality. Nearly all of the incinerators (93%) were single-chamber brick incinerators, none of the chimneys were of appropriate lengths and none of the hospitals’ incinerator operators (janitors) were trained. Only a few of the “modern” incinerators were functioning and properly used! Inadequate incineration of hazardous healthcare waste is a serious environmental and public health concern (2017 Hospital incineration study in Ethiopia).
WHO and UNICEF developed a methodology to improve WASH and waste management in healthcare facilities, called WASH-FIT. Essentially, the approach includes assembling a team that completes a hazard and risk assessment for the healthcare facility, develops an improvement plan for waste management, and monitors implementation. The approach promotes the use of bins required for basic waste management.
There are lots of improvements to be made around the management of healthcare waste worldwide, especially if we’re trying to reduce pandemic-prone diseases and climate change at the same time. The WASH-FIT methodology is a first step to thinking beyond the boundaries of the facility and where healthcare wastes (and also faecal waste) end up and if they are properly disposed of and treated.
Special thanks to Aditi Dikey (SWACH Cooperative) for insights into the cooperative and Tettje van Daalen (IRC) for editing.
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