The changing face of the growing healthcare industry- from places with a typical unbearable stink of disinfectants, to the present five star look, still has to cope with the sight of the waste that hospitals generate. Blood soaked bandages, syringes, body parts, IV bottles, the list is long. Medical waste is infectious and can be hazardous too, if not disposed off in the correct manner. Even after various legislations and guidelines are in place, (Bio-Medical Waste Management and Handling Rules, 1998), medical waste continues to haunt in-house infection control in the country, since poorly managed waste can result in unhygienic conditions within and outside clinical settings.

Rules regularly flouted
Mismanaged hospital waste is a significant health concern not just for the patients and workers inside the hospitals, but also for those workers dealing with waste outside it, as well as for the entire community. Reports of medical waste rules being flouted keep appearing in newspapers from various regions, the latest catastrophe being the Modasa (Gujarat) syringe racket in 2009, which resulted in a Hepatitis B outbreak, infecting over 125 people and killing around 49. Even in the capital city of Delhi, where tremendous effort has been made to create awareness and systems for bio-medical waste (BMW) management, it continues to pose an enormous challenge.
As per CPCB Annual Report (2008), the total estimated quantity of BMW (Bio-Medical Waste) generated in the country was 413.50 tonnes/day. Of this 295.27 tonnes/day was disposed off as per the Rules. According to this report the “compliance stands at 71%,” even though at the same time another report (Performance Audit of Management of Waste in India, 2008) released by CAG (Comptroller and Auditor General of India), found various problems in the implementation of bio-medical waste rules, including problems in monitoring, segregation, fund allocation etc.

The key lies in proper segregation
According to various estimates and surveys, if proper segregation is carried out, very small amounts of waste needs to be treated. Broadly around 80-90 per cent of hospital waste is general waste, while only 10-20 per cent is infectious or hazardous. Of this, about 15-20 per cent is pathological and infectious waste, 1 percent is sharps waste, 3 percent are chemical/pharmaceutical wastes and less than 1 percent is special waste, such as radioactive, cytotoxic drugs, etc. These percentages may vary marginally depending on the type of hospital. If a hospital segregates municipal waste from rest of the infectious/hazardous waste, it can also effectively and at low cost deal with the problem, and also possibly generate revenue from the sale of treated/disinfected plastics to cover much of the waste management costs.

The dangers with bio-medical waste
There are specific streams of waste in hospitals which pose high levels of risk. For example, infectious waste contains pathogens in sufficient concentration to cause disease. Such waste is more problematic since hospital laboratories harbour not just resistant strains, but also concentrated cultures of micro-organisms, which are more potent.
Also sharp objects (like needles, knives, scalpels etc.) which have the potential to penetrate the skin, are the most dangerous category of bio-medical waste, as these can puncture the skin, leading to the transmission of blood borne pathogens.
The use of various toxic chemicals in hospitals and its laboratories are also of concern. These are often overlooked, even though similar chemicals in industrial sector have attracted attention from a safety viewpoint. In fact, surprisingly the healthcare industry is one of the major users of hazardous chemicals, even though these uses are scattered throughout the hospital.
Cytotoxic and radioactive waste are the other hazardous waste streams, the generation of both of which have increased manifold in the last few years, due to rise in cancer rates and treatment in the country. Considering that both these are genotoxic (can cause genetic harm), they have the capacity to affect future generations as well, and hospitals need to be very cautious about their proper disposal.

Waste management and carbon footprint of a hospital
On an average large hospitals which start medical waste management in their hospitals cut down their carbon footprints by approximately 0.06 MtCO2e /bed/annum (Metric Ton Carbon Dioxide Equivalent, which is the standard measurement of the amount of CO2 emissions with global warming potential)
Thus, in today’s context when climate change issues are in focus, good waste management is the hospital’s contribution to a healthy planet.

Waste management - infection control and occupational safety
Proper infection control practices in the hospitals also reduce the chances of Hospital Acquired Infections to patients. Alongside, needle stick injuries (NSI) have been identified as the largest source of transmission of blood borne pathogens to healthcare workers. For example, a study carried out at Vardhaman Medical College and Safdarjung Hospital in New Delhi showed that almost 80% of the respondents reported NSI in the preceding one year. Around 60% of them received stick injuries after use of, but before disposal of the needles. Also undisposed syringes can result in dangerous reuse. According to WHO (World Health Organisation), as many as 40% of all injections in the developing world are administered with reused, unsterile medical devices.
If all healthcare personnel exercise the mantra of medical waste management (disinfection and mutilate immediately after use) the problem of injuries to hospital staff and reuse of syringes can be curbed.

Waste management technology
Whenever medical waste is discussed, technology issues crop up. Many medical waste treatment technologies propose that segregation is not necessary, and that mixed waste can be treated or burnt. Often the medical fraternity too gets taken in, since segregation can seem to be a chore. However there is no magic bullet, and often such solutions lead to more harm than good, creating a host of new toxics like dioxins, furans, mercury emissions etc., besides carbon dioxide. When hospitals segregate, disinfect and mutilate their waste to put it through the recycling process, they cut down their carbon footprints. Segregation is taking place and should be further encouraged rather than discouraged. In this age of climate change and global warming, segregation is the key to sustainability.
The bio-medical waste rules have been in force for the last 13 years. The major focus in all these years has been on training and awareness of the hospital staff, segregation, lesser dependence on technology, monitoring of technology operations and shifting from polluting to non-polluting technologies, especially as centralised facilities. The government, hospitals and NGOs have worked hand in hand and medical waste management had shown an upward trajectory, especially during the initial years. The ongoing problems lie in the relative un-importance attached to the issue. Healthcare personnel need to be further trained to integrate infection control and medical waste management as part of patient care, and medical schools can do a lot in that direction.
Recently, in an effort to revise the rules, the Bio-medical Waste Management and Handling Rules 2010 (Draft) were open for fresh public comments. The new rules have addressed some major concerns, like roles of various government agencies and the allocation of funds, though many issues such as compliance are still pending. Some States are taking the issue seriously and have used internet, GPS, training etc. as tools to improve compliance, while few others are still in at a nascent stage. Ultimately regulatory agencies will have to gear up to manage and monitor the various centralised facilities, technologies, and in house management practices. In all this the role of public awareness will be a key factor. Finally, through waste management the larger concept of environment management gets instilled in the thinking of the hospitals, giving it an additional importance.
The writer is a Senior  Programme Co-ordinator with Toxics Link, a Delhi based environment NGO. She has been working on Medical Waste Management and Mercury issues for last thirteen years. She has researched and authored many books and articles on these issues.

The writer is a Senior  Programme Co-ordinator with Toxics Link, a Delhi based environment NGO. She has been working on Medical Waste Management and Mercury issues for last thirteen years. She has researched and authored many books and articles on these issues.

Contact the Writer .