Diseases related to the mismanagement of all types of municipal solid waste — organic, paper, cardboard, metals, glass, and plastics — cause between 400,000 and 1 million deaths each year in low- and middle-income countries, according to new research by Tearfund.
Paradoxically, waste generated by health care services contributes to these deadly health and environmental impacts.
The World Health Organization estimates that 15% of health care waste is hazardous and may be infectious, toxic, or radioactive. Yet, health care facilities in LMICs are chronically underfunded, understaffed, and misunderstand waste management. The issue is only set to worsen as a result of the COVID-19 pandemic and its associated waste.
New technologies minimizing medical waste creation could be the solution. But conversely, environmental experts have argued that LMICs need simple, cheap waste management solutions and changes in policy to reduce environmental harm and save lives successfully.
COVID-19’s disastrous environmental impact
“Even in normal times, hospitals in most countries were not at par managing the waste, and now the challenge is much, much bigger,” said Mushtaq Memon, regional coordinator for resource efficiency at the United Nations Environment Programme.
As hospital beds began filling with COVID-19 patients — which even before the pandemic can generate between 0.2 and 0.5 kg of hazardous waste per bed a day — and hospital waste overflow with single-use facemasks and personal protective equipment, in April 2020, UNEP urged countries to follow its Compendium of Technologies for Treatment/Destruction of Healthcare Waste.
This definitive guide to managing health care waste includes a comprehensive list of the technologies available.
It also charts the most common risks posed by inadequate waste management, including dysfunctional incinerators leading to infectious waste being discarded with municipal waste or burned in open pits; children and scavengers sustaining needle stick injuries when sharps waste is thrown onto open dump sites; and dangerous, untreated chemicals left in landfills contaminating water supplies.
The development of COVID-19 vaccines also increased the amount of sharps waste health facilities have to manage. COVAX alone — a global initiative aimed at equitable access to COVID-19 vaccines directed by Gavi, the Vaccine Alliance — hopes to deliver at least 1.3 billion doses — each administered using single-use syringes — to 92 LMICs by the end of 2021.
These vaccines arrive accompanied by sharps boxes. But it is up to the countries themselves to manage the waste generated. Memon believes vaccine producers should be responsible for collecting the waste back under a policy called Extended Producer Responsibility.
“It's vital to make sure that we're not causing more destruction than we're trying to prevent as we're on missions to eradicate viruses.”
— Brad Barnes, digital marketing manager, OnSite Waste TechnologiesIs medtech the solution?
In the U.S., OnSite Waste Technologies has developed a preventative solution to sharps waste: The TE-5000, a small, office printer-sized machine. It can heat and condense about 160 used syringes in 90 minutes to form a non-hazardous plastic brick that has decreased in volume by 80%, and can be thrown out safely into domestic waste.
“All the machine needs is a standard 110-volt outlet,” said Brad Barnes, digital marketing manager at OnSite Waste Technologies. He believes the product could help LMICs. But with a current international sales price of $5,000 — unaffordable for many health facilities — he suggests governments or WHO to procure the devices.
“Our whole motto is to reduce the amount of spend and waste generated in medical practices,” he said. “It's vital to make sure that we're not causing more destruction than we're trying to prevent as we're on missions to eradicate viruses.”
German company DiaMonTech has also developed medical technology — or medtech — to help reduce waste associated with the monitoring and treatment of diabetes through its non-invasive glucose-monitoring tool.
The tool shines an invisible infrared light beam into diabetes patients’ skin to count glucose molecules, rather than requiring them to prick a drop of blood on a disposable paper test strip.
Worldwide, WHO reports about 422 million people have diabetes, the majority living in LMICs. If they check their blood four times a day, that amounts to almost 1.7 billion test strips annually.
“You don't need any test strips with our device,” DiaMonTech CEO Thorsten Lubinski said. The device is currently the size of a shoe box and needs to be plugged in. But the company plans to develop it to be the size of a mobile phone in the future, which can be charged with a similar charger once a week. “Once we understand better how to mass manufacture it, and get the scales of economy, then we will expand our market to LMICs,” he said.
Arthur Ziwa, an environmental health technologist at Zambia’s University Teaching Hospital, said he would “love” for the facility to invest in such waste-minimizing solutions. But he said waste reduction and management is a low priority for hospital directors. One of the hospital’s two incinerators has been broken since the beginning of 2021.
“When you put in that request [to management] to say: we need this part for the incinerator, they would say, no — we've got other stressing issues that we should look into rather than making the incinerators work.” As a result, hazardous waste waiting to be incinerated piles up outside, attracting rats, cockroaches, and flies, he said.
Ziwa highlighted that another challenge is convincing procurement managers of the importance of buying different colored bags to help health workers correctly segregate different wastes: infectious, domestic, and hazardous. When the facility runs out of sharps bins, Ziwa fashions less safe alternatives from used water canisters. “People think we're just wasting money — that these things are not important,” he said.
Back to basics
NGO Health Care Without Harm is working to promote more environmentally-conscious waste management practices around the world. Technology is an important part of the solution, but it has to be well supported, said Ruth Stringer, international science and policy coordinator at Health Care Without Harm.
“If you work in the development field, you know that probably half of all of the equipment for all sorts of applications is sitting there unused,” she said. “It might have been the wrong specification, they might not have had the power they needed, they might not have had the staff, or they can't maintain it.”
Before “trying to get fancy” with tech, health settings should start with basic systems such as disinfecting waste or sterilizing surgical instruments using autoclaves, which is a high-pressure steam, and water cleaner, Stringer said.
The looming waste crisis that will follow COVID-19 vaccinations
Multilateral development banks providing finance for vaccine procurement and the COVAX Facility require countries to submit waste management plans detailing how they would handle waste from the COVID-19 response — but is that enough?
In Kathmandu, Nepal, the NGO has helped a hospital develop a sharps waste management scheme whereby practitioners cut off needles from used syringes immediately after use with a manual cutter. They disinfect the syringes in an autoclave and sell them to recyclers for INR30 per kilo (41 cents), while they seal and send the small volume of remaining needles to landfill.
“To maintain a health care waste management system, you're talking about maybe half to 1% of the entire [health care center] budget,” said Stringer.
Another change Stringer recommends is more green procurement. She gives the example of facemasks for oxygen delivery, which have been vital for treating COVID-19 patients.
“A lot of them are PVC, which is single-use,” she said. “PVC is a horrible material, very toxic to manufacture. If you dispose of it, if you burn it, you get [highly toxic chemicals called] dioxins.” Alternatively, facilities could purchase silicone masks, which can be disinfected in an autoclave and reused.
Stinger wants donors and aid professionals to make green procurement choices when supporting health efforts in LMICs, as well as include waste management support in projects.
Above all, she believes raising awareness of the issues caused by waste mismanagement is imperative. “You’ve got to have the staff. You've got to have the training,” she said. “Otherwise, all the technology in the world is going to be useless.”
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About the author
Gabriella Jóźwiak@GabriellaJ
Gabriella Jóźwiak is an award-winning journalist based in London. Her work on issues and policies affecting children and young people in developing countries and the U.K. has been published in national newspapers and magazines. Having worked in-house for domestic and international development charities, Jóźwiak has a keen interest in organizational development, and has worked as a journalist in several countries across West Africa and South America.