Articles on Environment and Human Health

Table of Contents

EGOCENTRIC TO ECO-CENTRIC

HEALTH INEQUALITY & SUSTAINABLE DEVELOPMENT IN INDIA

MANAGING HOSPITAL WSTE IS DIFFICULT. HOW DIFFICULT?

Pollutants & Human Health

Compromise.Compromise

HOSPITAL WASTE MANAGEMENT: MISSING LINKS

Hospital Waste Causing Havoc with Human Health

INJECTION WASTE DISPOSAL IN INDIA

EFFECTS OF VERMICOMPOSTING ON MICROBIOLOGICAL FLORA OF INFECTED BIOMEDICAL WASTE

Human Trafficking and HIV/AIDS

Case Study: Complaint of Sukhdev Vihar Residents on Health Concerns due to Emission from a nearby Incinerator

Food Waste Management: An Innovative Approach

Healthcare in India: The Road Ahead

EGOCENTRIC TO ECO-CENTRIC

“The learned is happy, nature to explore

The fool is happy that he knows no more”

- Alexander pope.

‘Gaia’ or the ecosystem of the earth is a vast collection of mass and matter which is self regulating. It is amazing that such awesome manifestation of being always remains in perfect balance. In nature everything is in a cyclic existence even in mega-timeframe.

Ecosystem of the earth consists of all the earth, atmosphere, marine world, forests, vegetations, and all living species including the human beings who are most important ingredient of the whole system.

Man is important on two counts. Firstly, because it is a thinking species, and secondly, the human activities have grave and long lasting effect on the ecosystem. Compared to other living species humans are the only species who are always trying to find another ‘niche’ for themselves in the whole earth’s ecosystem. All living species exist in complete harmony with nature. It is only the humans who consider themselves as master of universe and are always making efforts to twist or bend the rules of nature to suit material comfort and development. Humans are only one of about 1.6 million living species but have acquired the mantle to rule over all. We are the last to arrive on the history sheet of the earth but have mastered the art of destruction in the shortest time.

Life appeared on the earth about 3.6 billion years ago. And if the calendar of life on earth is compressed into 24 hrs dial the Homo sapiens arrived on the scene only one second before midnight, and industrial revolution, which has accelerated maximum change took place only 0.0001429 second before the midnight (GT Miller, 1994).

First let us consider ecological balance. It is apparent that ecology is maintained in a critical balance. Balance of such a complex arrangement is also very complex but at the same time very simple. Life is a form of energy and the body i.e. manifestation is a complex house of chemicals which render the living being apparent, and which at the end of living cycle returns to nature; and the spirit which returns to the cosmos.

On a more tangible plane the air we breathe is also maintained by balancing the gases. Whenever we breathe out we cause aberration in this balance, which fortunately is only temporary. The composition of air (Oxygen and Nitrogen etc) changes momentarily. However the flora uptakes the excess C02 emissions and use these to bind sun’s energy to provide livings with food. But it must be understood that the ability of the ecosystem to purify the air is also limited. At the same time due to human activity the forest cover is reducing day by day. Normally 33% forest cover is required to maintain adequate eco-balance, which in India has now dwindled to only about 13% or so (official figure may be about 18 %). This has resulted in other adverse impact a well. Like the soil erosion from the mountains, silt in the rivers, rising level of rivers during rainy season, floods, lack of proper monsoon etc.

Some other activity of human beings leading to eco imbalance are increasing green house gases’, air, water and soil pollution, erosion of top soil (which is essential for crops), ozone layer depletion etc. Desire to live like superhuman has led to concomitant industrial activity and resultant degradation. Malthus was a scientist of 18th century who had said that the exponential growth of human population will overtake growth of crop production and thus predicted that population will stabilize.

He had not contended with crafty mind of humans. His theory is being disproved everyday. Population continues to grow exponentially and the mother earth continues to provide life support. But, for how long?

The ability of ‘Gaia’ to support life on earth is limited. The ability of the ecosystem to clear aberration caused by activities of living species, specifically the human being is limited. The mother earth is reaching its ‘break point’. In this context it would not be out of place to mention what Mahatma Gandhi had to say ‘The earth provides enough for every man’s need but not for everyman’s greed.” (TN Khoshoo, Mahatma Gandhi, an Apostle of applied ecology - 1996).

The greenhouse gases are causing Global warming. It has been estimated that in the next few decades the Polar ice caps may partially melt to raise the ocean’s water level by 6-7 mtrs, thus submerging large number of islands and a large part of littoral land.

The beautiful balance maintained between the glaciers and the rivers and oceans is something to realise. The glaciers collect more and more ice during cooler months and give away water to rivers during summer/rainy season. But latest studies have shown that Himalayan glaciers are receding @ 30 Mtrs per year and are developing crevices which are sure sign of recession (Down to Earth, Apr 30, 1999). If glaciers cannot hold ice when high level of water is not required then one can imagine what can happen. If would be like a mother who had milk before birth of a child but dried up after.

Production of waste is in direct proportion to population growth. Where the population of other species has remained static, or dwindled; the human population has been increasing by leaps and bounds. Waste generated also has gone up accordingly and now the scene is that in all localities at least in the developing world, the heaps of waste lie all over posing serious health hazard. With limited ability to purify and re-establish the eco-balance it must be becoming more and more difficult for the nature.

While living cannot stop, progress towards reaping the benefit of scientific and material advancement cannot be rolled back, for the creation to survive through next millennium proper strategy will have to be adopted. In tact the key word today is ‘Sustainable Development’. Meaning thereby, enjoy life of today but leave the world livable for the future generations.

What needs greatest attention therefore is:

(a) To control the population
(b) To develop the awareness and concern for the future generations.
(c) To understand overload created on the ecosystem and urgent steps to minimize it.
(d) To treat the whole ecosystem as one, and not divided by geographical boundaries, because eco degradation at one place may have impact at another place.
(e) All must unite to preserve the beautiful earth and its ecosystem.

Action taken today will determine the viability of future generations. Unfortunately human beings’ life span is so limited that one cannot appreciate the gradual degradation, taking place. It is however hoped that today’s generation will realise and make sincere effort to leave a livable world to its progenies. Egocentricity in man must give way to ecocentricity in thought and action.

“Hope is the last bastion”.

“When mind stops to perceive, or to acknowledge new ideas one attains intellectual death”.

--- Lalji Verma

---Lalji Verma (2002)

HEALTH INEQUALITY & SUSTAINABLE DEVELOPMENT IN INDIA

Health of an individual is the most important individual & social asset. One may be from any strata of society for him ‘health is wealth’. And rightly health has been considered very important in the constitution of the WHO:

“The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, and political belief, economic or social condition”.

Thus one can say without hesitation that issue of health is a matter of Human Rights as well. Any violation can be construed as violation of human rights.

Widely accepted definition of health is that given by the WHO. Accordingly positive health is described as “health is a state of complete physical, mental, and social well-being and not merely an absence of disease or infirmity”. In recent years it has been further amplified to include ‘ability to lead a socially and economically productive life’

However since this definition does not take into consideration impact of environmental pollutants on human health there has been a shift in the concept of health and the global commitment is towards “Total Health’ in the recent past.

Definition of Total Health should be somewhat as “Health is a state of complete physical, mental, and social well being where life thrives in healthy environment devoid of pollutants; and not merely an absence of disease or infirmity.”

There has been a continuous exploitation of nature and its resources by the human beings depriving the underprivileged of natural resources. Social matrix is such that all in a society must benefit by the resources of nature in an equitable and just manner. A generation of humans must not view the earth as a commodity to be exploited and finished in his life time, but must think about how the next generations are going to find sustenance. Life is not one cycle of birth & death but is a continuous process and therefore a generation of human being has to worry about the generations to come. This Concept of life has been beautifully described by T Adeyoe Lambo, consultant to WHO in his article “Total Health” –

“It is now apparent that a more balanced consideration of the biological, social, and cultural aspect of health is needed. Life is a process and not a substance -a living system based upon the primacy of continuity and inter-relatedness throughout the universe….. If man and his family are to remain in empathy with the emerging necessities in the developing milieu, an adequate design of interdisciplinary tools will have to be made to assist in this task of providing a total health package.”^[1]

Therefore continuity in existence of life is an important aspect of living, and one cannot forget the needs of the next generation, nor can one overlook the fact that the earth and the natural resources is not the property of one nation or society, but of the whole living world. But the question is why we are not able to perceive the changes in the environment & ecology which is happening every day. The answer is ‘one life is too small a period in the time- clock of universe, and therefore one is not able to perceive gradual but definite degradation of the environment mainly caused by human activity’. Even though unlivable environment may not be manifestly visible today but would challenge the human existence in the future.

In the words of Rachel Carson, author of the famous book ‘Silent Spring’ – “Future generations are unlikely to condone our lack of prudent concern for the integrity of the natural world that supports all life”^[2]. And looking at the lack of concern today one is tempted to believe that “Man has lost the capacity to foresee and forestall. He will end by destroying the earth”.^[3] Egocentric attitude of humans has to change to ‘eco-centric attitude’.

The present scenario appears to be to carry on till catastrophe strikes. In the words of Herman Daly ‘there is something fundamentally wrong to treat the Earth as if it was a business in liquidity’. Unfortunately that is what appears to be the perception of the present generation, hapless & helpless within the confines of consumerism. The race is to exploit the earth & its eco-system as much and as quickly as possible.

Social order is primarily based on economic considerations. Just to illustrate 90 % of population sustain itself on 10 % of resources of the society whereas 10 % population consume 90 % of the resources. This is also called ’10-90’syndrome. Social and economic inequality mirrors in health sector as well, and casts a shadow of gloom over the society. Inequalities in all sphere of social determinants cause fault lines in the social matrix which brings about its own problems in its wake. End results are division in the society unsocial & antisocial activities even to the extent of terrorism. Divide between ‘haves’ and ‘have-nots’ is sharp and clear, and that causes many unwanted individual social behaviour. Therefore it is necessary to have a preview of the inequalities. There are many reasons for inequality but this article is limited to health inequality.

India is a large country having multicultural society. In about 2.4 % of land 16 -18 % of human population is cramped. Therefore density of population in India is rather high. 72 % population are in the rural areas where connectivity, availability of potable water, electricity, and other basic amenities are scarce. Health care professionals are therefore not very much enamored by getting posted to the rural areas in India. As per Indian constitution provision of health care by public sector is a shared responsibility between the Centre & States. The public sector health care system is three tiered- the Primary Health Care, Hospital Health Care, and Tertiary health care. The administrative set up is somewhat as follows: -

(a) Primary Health Sub-centres (PHSC)
(b) Primary Health Centres (PHC)
(c) Community Health Centres (CHC)
(d) District hospitals
(e) Tertiary Care & teaching hospitals and referral centres.

India has 137,000 sub-centres, 28,000 dispensaries, over 23,000 PHCs, 3,000 CHCs, and about 12,000 secondary & tertiary hospitals. The whole administrative set up may appear large but most of the health care facilities are under staffed, and understaffing is most prominent in the rural health care sector. 15 % of Indian population does not have access to health care due to reasons of unavailability or due to economic reasons. Expansion of health care in India has been mostly urban oriented when major part of population lives in rural or semi-urban locations. Mushrooming of private hospitals in India has been in the urban areas, and is profit oriented. Public health care systems are becoming extinct by the day. Insurance system may not suit Indian conditions since a very large section of rural population would not be able to afford it, and the governments (central or state) may not find the required budget.

Health Care Systems are more oriented towards curative health care, and do not consider impact of environmental pollutants on human health from the preventive angle. Reason being environmental pollution is viewed more as an environmental issue rather than health issue. Proper waste management is essential to neutralize adverse effects of environmental pollutants, including biological pollutants. There is hardly any focused attention to the growing menace of waste which is directly proportionate to growing population. Polluter pays principle is self defeating in the sense that polluters can pollute and get away with it by paying appears accepted philosophy. In fact the principle should be ‘repair and replenish’ rather than ‘polluter pays’. Trying to copy Western models in its entirety has resulted in fragmented approach and confused results. Developing countries should adopt scientific advancement, no doubt, but must modify to suit local conditions, level of awareness, and habits & practices.

There are gender bias, economic bias, status bias, and bias of availability of funds within the health care delivery in India. There are differences in the accessibility of resources. Merely by professing equitable accessibility one cannot ensure equitable sharing of resources. To remove the socio-economic bias rural health care systems will have to be strengthened. At present even if posted to a Primary Health Centre (PHC) doctors avoid going there by whatever means. This aberration can only be corrected by improving the infrastructure of the villages by improving connectivity, security, and job opportunities in the rural segment. Similarly to remove gender bias ‘care of the girl child’ will have to be the motto. Awareness will have to be developed where a family does not discriminate between a male and a female member of the family in matters of health care (which includes nutrition). Funds for health care will have to be made available to the urban & rural sector on equitable basis. Even the resources of the society will have to be spent in an equitable manner between the rich & poor to get out of the ’10-90’ syndrome.

Development as we understand today leads to stressed relation amongst privileged and underprivileged classes in a society. Economic development is considered benchmark of development but would not this approach justify industrial hyperactivity and exploitation of natural resources? In fact there is a requirement to re-examine the concept of ‘Sustainable Development’ and move towards concept of ‘Sustainable Co-Existence’ - co-existence with nature and other biological species.

There is a wide gap in policies at the macro level & implementation at the micro level in all the developing countries. For example proper legislation & rules have been framed on health care delivery & waste management in India, but implementation remains far from satisfactory. Primary Health Centres are designed for rural health care but there is hardly any cognizable action to strengthen rural health care system. Similarly in matters of waste management laws have been enacted but implementation remains unsatisfactory. Micro level factors do not guide policies etc at the macro level. Thus capacity created at the macro level fails to obtain directional capability at the micro level.

Capability must be applied with community participation at the grass root level with clear understanding of weaknesses and potential human failures, and it must remain dynamic. Predetermined performance indicators should be carefully identified in relation to the policies so that capability approach may be subject to analysis & modification for better implementation and results.

One can see that sustainable development by itself is likely to further enhance health inequality instead of correcting it. Present day bench mark of sustainable development includes industrial activities, and unless there is a substantial change in the methods adopted so far industrial activity is likely to further degrade the environment and deprive natural resources. Economic life style as well cause of industrial hyperactivity and unless something is done to change the life style of today society is going to suffer inequalities in which case health inequality would be most prominent.

Lalji Verma (2004)

MANAGING HOSPITAL WSTE IS DIFFICULT. HOW DIFFICULT?

Managing hospital waste has become difficult. But how and why this is perceived to be difficult is examined in this article. In India the healthcare waste management is regulated under Bio-Medical Waste (Management and Handling) Rules – 1998 which was promulgated after two years of deliberation. It is more than a decade but no substantial change appears to have taken place though there have been pockets of success. WHO aided pilot projects during the biennium 1999-2000 (10 of these) has somewhat helped to inculcate awareness, but the health care providers still find it difficult to implement the Rules. Even the extended deadline is over without any perceptible change.

By and large the governments and the health care providers have gone in for one type of option for treatment of the waste. No health care provider wants or has undertaken a base line survey to collect data regarding quantum of waste and its type being generated, nor about the waste generation points on its premises. Budgetary support is poor in the government run hospitals, and the corporate hospitals as well as the nursing homes find it convenient to ignore the Rules for monetary considerations.

In India, there are about o.6 million hospital beds, over 23,000 Primary Health Centers, thousands of registered nursing homes, countless unregistered nursing homes and dispensaries, and above all a very large number of quacks practicing at every nook and corner of urban, semi-urban, and rural localities. The hospitals are tertiary care hospitals usually associated with teaching colleges, district hospitals (more than 2,000), and health care dispensaries. There are a number of path labs of which hardly any data is available. As nursing homes, a large number of these path labs are not registered. WHO estimates that India is on the verge of having an HIV epidemic. Tuberculosis and HIV combined, is taking great toll on the human health and life. Hepatitis B and C infections are on the rise. Mortality due to Hepatitis C has gone up significantly. No scientific study has been done to determine ‘add on morbidity’ due to infected waste being thrown on the streets and gutters, but it is anybody’s guess that indiscriminate disposal of the infected waste is mainly responsible for the increased morbidity due to communicable and infectious diseases in India. The vulnerable group includes the health care workers, the waste handlers, and the most affected- the rag pickers. Reuse of plastic syringes and other plastic material used in the health care is a thriving business of crores of rupees. More than one million are engaged in rag picking (more than one hundred thousand in Delhi alone). The estimated figure of yearlybusiness on this score in Delhi alone is more than INR 50 million per year. It would not be fair to blame the rag pickers only for this as the circle of connivance starts from the hospitals itself. It thereafter goes to the waste handlers, then to the rag pickers, to the packaging outlets situated in a decrepit area of a ‘basti’, to the medical shop, and finally sold to the unsuspecting patients or their relatives.

It must be appreciated that a proper hospital waste management system is systemic and not an exercise to find ‘end of pipe line’ solution. There is no doubt that successful implementation would grossly reduce the morbidity in the society by reduction in the nosocomial infection, and hospital acquired infection. Relatives and friends visiting the hospital, apart from healthcare workers are at risk, and proper waste disposal in the hospital would render the atmosphere less infective. Atmospheric pollution being caused by improper disposal of hospital waste remains a matter of great concern. There is no doubt in the mind of any educated or enlightened person that improper hospital waste management is the source of many communicable and infectious diseases. But when it comes to doing anything about it there is a lack of will, and there is a lackadaisical attitude towards the problem. Even the regulatory authorities have to take the blame for not doing enough to ensure implementation. The confusion starts at the very beginning. The MSW (Management and Handling) Rules – 2000, and the Bio – Medical (Management and Handling) Rules – 1998, both take the authority from Environmental Protection Act – 1986 (29 of 86). Whereas it is clearly mentioned in the Env Prot Act and the MSW Rules - 2000 that these apply to whole of India, no such specific mention is made in the Bio-Medical Waste Rules – 1998. So there is confusion as to the dictates or the guidelines framed by the central government or any of its agency will be applicable in the whole of India or not. And if so, with what legal force? The Biomedical Management and Handling Rules – 1998 is under revision at the Ministry of Environment and Forests, Govt of India.

The Msw Rules – 2000 clearly spells out the responsibility on the part of the municipal corporations/ civic bodies such as Panchyats etc, and the individual citizen. Some of the responsibility on the part of the municipal authorities etc is illustrative. It is the responsibility of the municipal authorities: to a) ensure that no littering on the roads take place, b) organize house to house collection, c) conduct awareness programs, d) devise ways to collect, transport in closed vans, and ensure disposal by any prescribed method such as composting etc. The responsibilities on the part of the citizen are: a) ensure segregation at source & delivery, and b) to avoid littering.

Admittedly the infected waste has to be dealt with differently, but why responsibilities like: a) to prohibit littering on the roads and any area outside the premises of the health care facility, and b) to conduct awareness programs cannot be assigned to the authorities in the Bio – Medical Rules itself!

Initially due to public awareness and court’s interventions orders were passed that any health care facility having more than 50 beds were required to have incinerator as incinerators were thought to be the final answer to the problem of biomedical waste. Thankfully with acquisition of better knowledge alternate disposal technologies were also permitted. Otherwise the protruding stacks of the incinerators would have dotted the whole skyline of any city. Though now alternative technologies are permitted as per the Bio – Medical Rules, it takes a long time to change the mindset of the people, and even now most of the health care providers & decision making authorities talk of incinerator only. When Delhi Govt. wanted to go in for acceptable solutions autoclaves were bought with a lot of fanfare. It was announced that “very soon heaps of IV fluid bottles, syringes and other plastic hospital waste …. May be a thing of past” (Times of India, Delhi Ed Oct 19, 1999). 12 years down the line situation has hardly improved. Indiscriminate throwing of the waste is still seen in most of the hospitals. Rag picking and recycling of the plastic hospital waste is still a thriving business of crores of rupees. There is hardly any change in the applied knowledge and awareness. Waste handlers still are without protective clothing and gears.

Basing disposal only on one type of system in itself is unscientific. Every disposal system has limitation and therefore can handle only few types of waste. No single technology can scientifically take care of all types of hospital waste. In any case installing autoclave was devoid of due scientific consideration, and therefore bound to fail. Autoclaves increase the weight and volume of the waste and therefore require a compactor along with. The treated waste was intended to be sent for land – burial which is not permitted in cities having population more than 5 lakhs as per the BMW Rules - 1998. Even if the treated waste is sent for burial outside the city limits, suitable land would be difficult to find – year after year. Therefore a proper deliberation is essential before incurring huge capital investment.

The CAG report (Times of India, Apr 4, 2002) is rather disconcerting. It says many Govt hospitals did not even apply for authorization whereas the corporate private hospitals did. Transportation of the infected waste was by wheelbarrows. No personal protective clothing was provided to the waste handlers. (Incidentally this aspect is not even touched upon in the Rules). Delay in lifting the waste ranged between 3 – 58 days! (Instead of the permissible limit of 48 hours).

Obviously there is either defiance of rules, or lack of understanding; or sheer callousness.

Now there is a number of Common Area Facility coming up at different cities. Perhaps moves are afoot in Delhi as well. Would that be an answer? Again transportation of infected waste over long distances will be the most difficult part of the scheme. For transporting infected waste, air-conditioned vans with appropriate compartment may ideally be required. Despite the provision in the MSW Rules, covered vans are not provided for transporting municipal waste, and it remains un-enforced. To enforce air-conditioned vehicles for transporting hospital waste would be too much to expect, and only theoretical. Even if enforced it would add to the cost substantially. Hence CFT would remain a costly option but a viable solution in the present circumstances.

Scientifically as well, by the time infected waste is lifted, say by 12 to 48 hours the infection would have already spread by proliferation of the bacterial flora, and aerosolization. Hence spread of nosocomial or hospital acquired infection would have already taken place. The aim to control or prevent spread of infection would thus remain unachieved. Moreover a couple of interesting points of law must also be considered. Firstly, as per the Rules the ‘occupier’ is responsible to ensure that no harm is caused to the human health by improper disposal of the hospital waste. But once the waste leaves hospital premises the occupier would neither have the control, nor have the means to ensure safe transportation and disposal so that no harm comes to the human health or the environment. In case he ensures disinfection on site then the waste can be lifted, transported, and disposed off as MSW. In this case there will be no requirement of having elaborate arrangements, such as air conditioned vehicles etc. The secondly, transportation and disposal of body parts may not be that simple. Without a proper inventory listing and tracking system it may be impossible to track the human body parts (at times it may be a still borne fetus or even corpse of infant, or body part of an individual) attracting medico – legal provisions. Therefore would not disinfection on site at least for the bigger hospitals be a better, more scientific, and cheaper option? For the smaller hospitals and nursing homes a mobile hospital waste management system can be developed with a bit of R&D effort. The waste can be collected in the mobile system, disinfected at pre-designated points, and at the end of the day the residue may be disposed off at the designated site away from the populated area. The mobile system will have non-incineration alternate technology of waste treatment, and whatever can be recycled after disinfection can be sold to the vendor. Biodegradable waste can be converted as manure, or briquetted for use as manure or fuel. This perhaps will be a viable solution to the problems being faced by the nursing homes.

Infected hospital waste including hazardous waste can be managed only by a system approach utilizing multi-option of technologies. Therefore to lay down the system, a schematic approach is required. This is a stepwise activity, which must be undergone at each of the health care facility. It is necessary for the hospitals to appoint a waste management committee, which should work in close coordination with the infection control committee of the hospital. Inculcating awareness and periodic training also should form a part of the responsibility of the committee. The hospital should undertake a base line survey in order to determine the quantum and ingredients of the hospital waste, and determine the points of generation of waste. Educate all classes of health care workers-doctors, nurses, paramedical staff and the waste handlers. It should recommend and ensure protective clothing for all the health care workers. The committee should develop a schematic waste movement and treatment policy, and ensure its implementation. Inventory and data recording should form an integral and repeated task for the committee. Disinfection and mutilation of sharps should be specifically ensured.

In the whole gamut of infection control, accident reporting and taking remedial measure is rather important and must not be left sight of. Safe handling and safe transportation should be ensured. Audit and periodic re-evaluation would be quite helpful in fine- tuning the system. The system so developed should follow the general principles no doubt, but it needs to be ‘hospital or health care facility’ specific to an extent.

To the question ‘how difficult’ the situation can be summarized as follows: -

a) The rules are not clear-cut, and at places; confusing and unscientific.
b) No agency has been assigned the task of spreading awareness.
c) Even the decision-makers demonstrate lack of knowledge and confusion.
d) Stance of the regulatory authorities and those who lay down the policies has been wavering.
e) There is lack of will to enforce implementation.
f) There is dichotomy at the top. Min of Env&Forest have promulgated the Rules, but implementation is not within their purview.
g) There is no agency to advise or guide the health care providers.

There is an urgent need to rethink on the whole issue. A separate body needs to be created; such as ‘Waste Management Authority of India’ which in order to be effective must be autonomous. This body can take care of solid waste management, as well. It is important to note that management of infected hospital and municipal solid waste has to be tackled together to achieve cleaner environment.

It is true that human suffering is not a core issue for our country. But it must be appreciated that healthier body and mind can contribute to the society much better. Right to life is a fundamental right in the constitution of India. Right to live includes ‘healthy living’. One must aspire to achieve ‘Total Health’ and not only ‘Positive Health’. It should be living with complete absence of pollutants from the body, where life thrives in a clean and healthy environment; and not merely absence of disease or infirmity.

Lalji Verma (2004)

Pollutants & Human Health

Any change in the environment has deleterious effect on human health. Ingredients in health care waste (HCW) contain chemical and biological pollutants which cause morbidity and diseases. Environmental pollution as such also causes disease and infirmity. Pollution of Air, Water, soil, and aquifer are a reality today. Aquifer of West Bengal and Bangladesh are heavily polluted with arsenic. Arsenic poisoning amongst the population in villages in Bangladesh, West Bengal (India), and in many other parts are causing great concern today, and requires substantial resources of the society to deal with this menace.

A newly formed organization in Bangladesh- ‘Forum for Arsenic patients’ has threatened to sue the UNICEF for compensation of the 30,000 wells dug in Bangladesh by UNICEF. 63% were found contaminated with Arsenic.

-Source: DTE, August 31, 1999

Other metallic chemicals such as cadmium, chromium waste etc; also have toxic effects on human health. Test conducted in Medak district of Andhra Pradesh, India showed mercury was 115 times the permissible limits. WHO permissible limit (recommended) is 10 ppb. The National Geographic Research Institute (NGRI) found arsenic level as high as 700 ppb. Manganese level in ground water in Bangladesh was 15 times the permissible limit and nickel was 4 -20 times^[4]. All these chemicals cause sub-clinical & manifest disease and afflictions. Sub-clinical concentration may not manifest as a disease but may manifest as behavioral changes and aberration in personality disposition. WHO’s Report on violence indicates that there has been an increase in violence the world over. Every hour 28 persons die of violence in South East Asian (SEA) countries. 600-1100 requires hospitalization 19. As per Uton Muchtar, former Dir WHO, SEARO, globally one in seven deaths among women is caused by violence in the age group up 15-44 (Most productive years of life). 317,000 deaths are caused due to violence in the SEA Region^[5].

Pollution of aquifer by resistant strain of bacteria has been reported in a study conducted in the USA. Terramycin has been used in farms as growth promoters. Researchers found resistant strains as far as one-sixth of mile downstream from two swine facilities that used antibiotics as growth promoters. Use of tetracycline has been pushing the evolution of these resistance genes. The genes are transferred to bacteria where they can travel long distances in the environment. There may also be horizontal transfer of resistant genes^[6]. Researchers in US have uncovered new route of bacterial transmission.

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Once transferred, the resistant genes of the bacteria in hardier soil-waterborne ones pass to underground water. Nearly 70% of all antibiotics produced in the US are fed to animals as growth promoters^[7].

Human health is greatly influenced by air pollution and by biological contents of HCW. Easily it can be said that 30% of all respiratory group of diseases are caused by air pollution. Children and elderly people are specifically vulnerable to air pollution. There have been many acute air pollution episodes during last century caused by human activity where people have died in great numbers: -

Abbildung in dieser Leseprobe nicht enthalten

And, the great Bhopal gas tragedy caused by leakage of Methyl Isocynate (MIS) gas from Union Carbide Pesticide Plant in Bhopal, India in December, 1984 where about 7000 people died, lakhs maimed, and thousands borne thereafter with birth defects. Population of the city still continues to suffer delayed effects of the pollutant.

The interesting point to note is that all the air pollution tragedies took place in the winter months. It was due to temperature inversion (a meteorological phenomenon where the natural dissipation of heat and hot or warm air (with pollutants) is stopped and do not dissipate to the upper atmosphere. The trapped heat waves get reflected back on the surface of the earth thus causing global warming^[8].

Inversion

Normally warm air rises up carrying particulate pollution with it. But due to meteorological phenomenon called ‘Inversion’ a layer of cool air gets entrapped between layers of warm air. The warm air thus does not rise trapping particulate pollution. Inversion has been responsible for air pollution tragedies in Meuse valley, New York, London etc. All have occurred in winter months is a point to note.

Many chemicals are used in hospitals which have adverse effect on human health. Gases and particulates as pollutants in the air cause adverse effect on human health. These are generated by burning HCW as well. Emissions from stack of incinerator burning health care waste and chemicals used in a health care establishment are as follows:-

GASES & VOLATILE ORGANIC COMPOUNDS (VOC)

(a) Carbon monoxide:

Carbon monoxide (CO) is produced by internal combustion engines, burning of coal etc. In fact the greatest concentration of CO in day to day life is found in commuting, and in proximity of motor vehicles. Regular accidents leading to death takes place in winter in India when poor people sleep with burning coal/ wood/cow dung cakes inside a closed room or ill ventilated enclosures. CO combines with hemoglobin to produce carboxyhaemoglobin thus denying carriage of oxygen. Brain and heart are specifically susceptible to lack of oxygen caused by CO in blood which reduces oxygen carrying capacity of the hemoglobin, and also, the ability of tissues to extract oxygen present in the hemoglobin at low pressure. Carbon monoxide also interferes with intracellular transport of oxygen in muscles.

(b) Carbon Dioxide:

Carbon dioxide or CO2 is a naturally occurring component of atmosphere. Directly it does not have any adverse effect on human health but its concentration in the atmosphere may give rise to conditions not conducive to human health. It is an important Green House Gas hence higher concentration of CO2 would have all the ill effects of GHG as has been described previously. CO 2, (along with CO) is also a marker for measuring combustion efficiency of an incinerator.

Note: - CO2 and CO, both is emitted from burning of carbonaceous contents in health care waste.

(c) Nitrogen Dioxide.

Nitrogen dioxide is a gas highly reactive, and in presence of sunlight and oxygen combines with hydrocarbons to form ozone, and other photochemical gaseous species. At times and during certain meteorological phenomenon it may combine with aerosols to form nitrous and nitric acids and give rise to secondary acidic particles. Principal sources of NO2 emission in the atmosphere are aircrafts, automobiles, power plants, and burning of fossil fuel. NO2, NO and SO2 get oxidized and hydrolyzed to form secondary pollutants such as H2SO4, HNO3 and HCL. NO2 can travel long distances as primary or secondary pollutants. Measures such as raising the height to stack only dissipate these obnoxious gases to wider and distant areas, mostly downwind. The possible advantage of raising the stack height is that the emission from the stack could be above inversion level in the atmosphere^[9]. It helps the pollutants to travel longer distances. Similarly Sulfur dioxide is mainly a product of combustion process, burning of fossil fuel, and activities related to power generation. It has been established that long exposure of as little as 0.1ppm of NO2 in air can result in increase in incidence of bronchitis and have adverse effect on performance of lungs over a period of 2 -3 years. This basically is due to inflammatory changes. NO2 may be emitted from burning of HCW with fossil fuel, and in certain other conditions.

(d) Ozone.

Another important gaseous pollutant is ozone. Ozone is an oxidant gas generated in the atmosphere by chemical reaction of volatile organic compounds, and nitrogen oxides in presence of sunlight. It may not be in the emissions but may get formed by chemical reaction of other gaseous emissions from incineration. It is a naturally occurring gas in the upper atmosphere and protects from the damaging effects of ultraviolet radiation of sun. There are other man made sources as well, industrial activities such as manufacturing etc. Health effects are immediate but transient reduced lung function. Long term exposure is suspected to lead to chronic lung disorders such as asthma and chronic bronchitis. It accelerates the ageing process of the lungs. In certain Health care establishments ozone is used for sterilization & disinfection.

(e) Sulfur oxide .

Emission of sulfur oxide increased steadily during the last century in the USA, reaching a peak of 32 million tons per year. After the ‘Clean Air Act’ was passed in 1963 it declined, and is estimated to be stable at 23 million tons per year. Accidental exposure to high concentration can cause severe airway obstruction, and pulmonary dysfunction for up to a year. Studies of alveolar lavage have demonstrated increase in macrophages and mast cells indicating inflammatory process. Severe wheezing has been noticed due to bronchial constriction at exposure to 0.5 ppm and exposure to 1ppm during moderate exercise in adolescents with asthma demonstrated 25% decrease in FEV1 (forced expiratory volume per second), 67% increase in respiratory resistance and 50% decrease in maximum flow rate^[10]. Exposure of humans and animals to sulfur dioxide particulates and acid aerosols has been associated with respiratory morbidity. Unplanned disposal and treatment of health care waste would give out sulfur dioxide in gaseous emission from burning the waste in incinerators.

(g) Dioxins & Furans.

Dioxins & Furans are compound organic gases of the family of Persistent Organic Pollutant, (also known as ‘dirty dozen’) normally produced by burning of waste with insufficient control and supervision. These gases are compounds of chlorine and are emitted when polyvinyl plastics (PVC) are burnt. It may be recalled that health care waste contain higher percentage of plastics as compared to municipal waste and therefore it is important that its implication be fully understood since even in low concentration it has the potential to cause serious impairment of human health. But PVC is not the only source. Burning of many other items at lower temperature in the range of 2500C to 4500C may lead to formation of these gases. In the context of dioxin formation this is commonly known as ‘window temperature’. Organic carbon & copper act as catalysts for dioxin formation (both are contained in the fly ash) if the flue gas contains chlorinated organic compounds or metal chlorides and is cooled slowly in an oxygen rich environment^[11]. Once formed these gases do not degrade easily. In other words the formation may be dictated by certain conditions but the destruction or degradation is relatively immune to environmental changes. Dioxins and furans are stable gases, once produced. Both these group of gases have been implicated in adverse impact on human health, including causation of cancer. There are more direct evidences of Dioxins causing cancer than furans. Dioxins are highly carcinogenic to guinea pig but less to mice and humans. Individual susceptibility plays an important role.

Dioxin emission is important to understand since in very minute concentrations it is potentially hazardous to human health – as an immediate as well as delayed effect, but at the same time production or emission of dioxin is totally preventable. Dioxins can cause cancer, is toxic to reproductive system, suppresses the immune system, is hepato-toxic, causes neurological dysfunction and is toxic to skin. It is not soluble in water, has prevalence for deposition in the fatty tissues including lipids, crosses the placental barrier, is secreted in breast milk, and is terotogenic. It is quite a stable gas once formed and is cumulative. It enters the food chain, bio-magnifies and cause delayed effects on humans. In a study undertaken by Institution of Medicine of USA it was concluded that “there were sufficient evidence of an association” between exposure of herbivores contaminated with dioxins and increased risk to soft tissue sarcoma, non-Hodgkin’s lymphomas, Hodgkin’s disease and chloracne linked evidence of respiratory cancers, prostate cancer, multiple mycloma, spina bifida in children born to exposed parents; and acquired porphyrea & birth defects. Immune system disorders and male infertility also have been described as effects of dioxin exposure. Exposure is estimated by chemical analysis of either adipose tissues or lipid fraction of serum^[12]. However the testing for dioxins is very expensive. One test may cost as much as $1000 to $3000. Not more than 100 laboratories are there in the world which can test for dioxins, and most of these are located in USA, Europe and Japan. Half life of Dioxin is reported to be 6-12 years^[13].

Cumulative effect of dioxins can be well understood by going through the story of what happened in ‘Love Canal’ New York USA. In a report it has been stated that in ‘Love Canal, New York’ waste containing approximately 200 tons of dioxins were dumped in landfill during 1940-70 by an industrial unit. Later houses and schools were built. When waste began oozing and collecting in puddles in late 70’s the neighborhood was evacuated. This happened despite the fact that dioxin is not soluble in water. It also indicates the sustaining quality of the pollutant against the decaying properties of nature. Dioxins can find its way into body by many routes. It could be by ingestion (through food chain), inhalation (directly from atmosphere), or through skin when children play on grass contaminated with Dioxins.

Despite knowing the carcinogenic nature of dioxins there has hardly been any concern for human life during war, as is evident from the fact that during the Vietnam War the US spread ‘Agent Orange’-a potent dioxin emitting chemical over Vietnam to destroy the vegetations which was obscuring aerial view of hide outs. Report of the EPA prepared in 1980 states that dioxin poses a threat to human health. The green peace released a report saying “No margin of safety” revealing there is no safe level for dioxins exposure.

Sources of Dioxins have been studied and it has been found that medical waste incinerators give out 130 to more than 10,000 g TEQ per year. The other sources are as follows^[14]:-

SOURCES OF DIOXINS

Abbildung in dieser Leseprobe nicht enthalten

Incinerators have been implicated in dioxin formation in a big way, and more and more evidences are surfacing regarding emission of dioxins by medical waste incineration. As per a report in India “another well known source of dioxin is the biomedical waste incineration”. A Public Interest Litigation (PIL) was filed by BI Wadhera, a Delhi based environmentalist and lawyer in Delhi High Court in 1998. CPCB undertook a survey as directed by the court and found no single incinerator maintained proper temperature in the secondary chamber as specified. In another study undertaken by SHRISHTI–a Delhi based NGO, 60% of the 59 BMW incinerators located in North Delhi hospitals, 38% were incinerating plastics. In Mumbai too it was found that out of 10 BMW incinerators eight lacked basic design parameters and burning of PVC plastics was a practice going on unabated.

POPs are a group of toxic chemical pollutants harmful to human health and wild life (in fact all animals, birds, plants, and the human beings)

12 POPs also known as “dirty dozen” are listed by UNEP:-

-Aldin
- Chlordane
- Dieldrion
- DDT
- Dioxin
- Furan
- Hexachlor benzene
- Heptachlor
- Mirex
- Polychlorinated biphenyles
- Toxaphene
- Endrin

POPs are found in blood and in tissues in humans in all parts of world. It Transfers through placenta. There is a strong evidence of association between blood level of DDT/DDE, dioxin etc and elevated incidence of breast cancer. India has banned use of 9 out of 12 POPs. Not banned so far are: DDT, PCBs, dioxins & furans. Stockholm convention on POP was finalized after 2½ years deliberation at Johannesburg in Dec. 2000. Ninety one countries have signed the treaty.^[15].

Health Care Waste contains a lot many metallic ingredients which when converted to gas dissipate in the atmosphere finally settling on foliage etc. and enter the food chain. Even if not burnt these metallic chemicals when released in the drains cause accumulation in the water bodies and enter the food chain.

All these gaseous pollutants may be directly responsible for health effects or indirectly as a part of particulate matter due to toxic effects of its components. So, discussions on impact on human health will have to be with the understanding of gaseous pollutants combined with particulate pollutants.

Particulates.

Most dangerous of air pollutants are particulates. Sources are many: power generation plants, incineration, open burning, cooking with fire wood and cow dung (biomass) industrial activity etc, and natural phenomena such as storm, gusty, wind, hurricane etc. The particulates vary in sizes and normally are expressed in µm dimension. In 1987 the Environmental Protection Agency (EPA) of the United States of America restructured National Ambient Air quality to PM10. In 1997, the EPA proposed new standard for PM less than 2.5µm in aerodynamic diameter^[16]. Now the particulate matters in nanometer are considered dangerous and harmful to human health. Particulates are harmful as such and as mechanical carriers of many chemical pollutants which piggy back on the particulates. Impact on health would therefore be combined. It causes respiratory morbidity and mortality. Larger particles may get trapped in upper respiratory tract such as nostrils and trachea, but smaller ones find their way to alveoli. Some researchers (Seaton & Colleagues) have hypothesized that alveolar deposition of ultra fine particulates cause inflammation and release of systemically active cytokines^[17].

Dispersion by wind play a major role in spreading microbes as particulates form garbage dumps, and therefore insistence on secured landfill. Impact of particulate matter is mainly on respiratory system. Respiratory infection & inflammation due to exposure to ambient air having higher content of particulates is well known. In a study funded by US based Health Effects Institute has shown 0.5% increase in overall mortality for every 10 µg per m3 increase in PM10. This effect was slightly greater for deaths due to heart and lung disease than for total deaths. The researchers found that these tiny particles were wreaking havoc on human health quite independently of other air pollutants. It was found that in cities there was 1% increase in hospital admissions, and about 2% increase in cases of pneumonia and COPD in the population above 65 years of age for each 10 µg/ m3 increase in PM10 level. Curiously, the study found more hospitalization at lower level of particulate pollution^[18]. Health effects of ultra fine particles less than 0.1micron in diameter has also been studied, and it has been found that there is a delayed effect as against immediate effect for fine particles. Exposure to biomass smoke, outdoor and indoor air pollution in urban and rural areas has also been studied. One study in Western India found 50% increase in still birth in women exposed to indoor smoke during pregnancy. Considerable amount of carbon monoxide was detected in the blood stream of women cooking with biomass. Annual deaths due to air pollution in urban areas in developed countries was found to be 294 per year (252 in urban indoor), and much higher in developing countries –as much as 2706 per year (644 in urban indoor, and 1876 in rural indoors)^[19]. In a study carried out by TERI, India, it has been estimated that industrial activity may have been responsible for increase in PM level from 2 lakhs tons to 30 lakhs tons in 1997. It is to be noted that population increase has been only 10-12% per year. Vehicular pollution has increased from 15 million tons in 1947 to 1030 million tons in1997^[20].

Liquid particulate matter generally categorized as “mist” includes rain drops, fog and sulfuric acid mist. Some particulate matter is biological, such as viruses, bacteria, spores, fungus and pollens. Particulate matter may be organic or inorganic; both types are very important environmental pollutants. Concentration is expressed in micrograms per cum or µg/m3.

This clearly indicates damaging effect of biomass burning for heating and other purposes. Deaths due to indoor pollution in the developing world has been estimated by a study on indoor air quality by ESMAP, World Bank in September 2000,^[21] in which estimated deaths in India has been found to be 28%; figures for China is 29%; Sub-Saharan Africa is 22%; as against 1% in Latin America. A major portion of mortality due to indoor air pollution is by particulate matter. Larger particulates great trapped in nostrils while breathing at rest. But smaller particles get through the filtering mechanism of the body and alveolar deposition is appreciable at particulate diameter between 2 and 4 µm. During breathing at rest 10% of compact particles of 0.5 to 1 µ diameter tend to be deposited in the alveoli.^[22] Alveolar macrophages (AM) in deep sputum are bio-indicator of health impact due to particulate deposition. Those exposed to air pollution of higher density and for a longer duration do show raised AM in sputum. Concentration of air pollutants including particulate matter remains higher in winter months as this very much depend upon aero- dynamic profile of the atmosphere. There is reduced effect of these pollutants during rainy season as the air pollutants get washed down on the surface with rain^[23]. Coastal settlements are less vulnerable to air pollution due to dissipation by air currents from over the oceans and seas. Inhabitants in tropical zones have the advantage of not having to face the adverse impact of meteorological phenomenon of ‘Inversion’. But in hilly terrain, and defiles effects will be more pronounced due to reduced air movement. Therefore ecosystem of a hilly or mountainous region is considered more fragile.

Effects of Air pollution on individuals will depend upon: -

(a) Nature of pollutant,
(b) Concentration of Pollutants,
(c) Duration of exposure,
(d) State of health & susceptibility of receptor,
(e) Age group of the receptor.

Impact on health will also depend upon frequency and depth of breathing. An adult and healthy human being breaths about 22,000 times per day and consumes about 16 kg air per day^[24]. Two aspects are important to understand. One is that children are more vulnerable to pollution since they consume more air, water and food in volume to volume ratio as their basal metabolic rate (BMR) is higher. And second is that elderly people are more vulnerable to air pollution as health of respiratory system of elderly population remains compromised to an extent as such. Air pollution may therefore cause critical damage amongst elderly people earlier than in healthy young adults.

Adverse impact of particulates can be very well appreciated by comparing what happened during 1952 & 1962 coal gas tragedies in London. Maximum and average smoke measurements were more or less the same, but the particle concentration was only 20% in 1962 episode compared to 1952 episode. Result was much lower casualties (3500 excess deaths in 1952 and only 700 in 1962)^[25].

LONDON GAS TRAGEDY

Abbildung in dieser Leseprobe nicht enthalten

Lead is one of the components of health care waste. It is toxic to human beings. Effects of lead positioning are known since the BC era and it is well documented. It is known to cause toxicity in the humans either as a slow poison or as an instant poison. Though main source of lead pollution is gasoline, medical waste also contributes to lead air pollution, mostly from waste generated on dental procedures. The ingress to human body is by inhalation, ingestion, and absorption through skin. Deposition rate of airborne lead is about 40%^[26]. Absorption rate in children is greater since they inhale greater volume of air in relation to body mass as compared to adults. Absorption through GI tract is about 10 to 15% greater in children due to higher absorption rate.

Organic lead compounds such as Tetra ethyl and Tetra methyl get absorbed through skin. The effects of lead positioning are on the central nerves system, the urinary system and the gastro intestinal system. On the Central nervous system the victim may complain of headache, dizziness, sleep disturbance, and memory deficit etc. Changes in personality, such as increased irritability to convulsions and delirium have been reported. More severe cases of poisoning may lead to coma, and death. Rarely, it leads to acute encephalopathy. Effects in urinary system are damage to the proximal tubule and urinary dysfunction. On the gastro intestinal system it produces epigastric discomfort, nausea, anorexia, and dyspepsia, all resulting in weight loss. At higher blood concentration levels beyond 80µg/dl these symptoms may be accompanied with severe abdominal cramps usually associated with constipation. The patients may also suffer from arthralgia.

Lead crosses the placental barrier resulting in pre-mature membrane rupture and pre-term delivery which have been associated with high lead contents in the foetal membrane^[27]. In some reports lead has also been considered as terotogenic. Insufficient intake of iron, calcium and vitamin D amongst children in the disadvantaged group may further enhance the effect of lead positioning. It has become increasingly clear that adverse and subtle neurological effects can be demonstrated at lead exposures which are prevalent in the modern western society. Obviously the situation in the developing countries would be worse. Lead reduces the hemoglobin formation thus causing anemia. Organic lead is soluble in fat hence preferentially accumulates in brain.

(ii) Mercury.

Mercury is one of the ingredients of hospital waste which has been a matter of great concern all over the world. Mercury is released in the atmosphere when health care waste having mercury content is burnt & enters the food chain same way as other pollutants. Mercury also enters the food chain when waste effluents are discharged in drains. Uses of mercury in the health care establishments are plenty and it is difficult to totally eliminate it. By and large 10% of all mercury pollution in the atmosphere is attributed to burning of hospital waste. Mercury is a globe trotter and can travel far and wide. Raising stack height on the incinerators only helps in horizontal spread of gaseous form of mercury. Mercury gets absorbed by inhalation, ingestion, and through skin and mucus membrane. Alkyl mercury compounds are most toxic, accumulates in both soft and hard tissues. Inorganic mercury is converted to more toxic compounds primarily by methylation by anaerobic micro organisms in the rudimentary layer of sea and lakes. Merely one Gm of mercury is enough to pollute a lake bigger than 8 hectares^[28]. A typical large hospital may be discharging as much as 3-8 Kg of the metal annually. In a study conducted by an NGO-‘Toxics Link’ only thermometer breakage in one hospital accounted for about 70 Gm of mercury in the hospital waste per month^[29]. In another study they also found that 45 Kg of mercury waste is generated from all the dental care establishments in Delhi during a year^[30]. Study in the USA has indicated that even if use of mercury is stopped in dental treatment today it will take about 15 years to rid the denture of US citizens having dental amalgam in their mouth, and may generate about 1000 MT of mercury waste over this period of 15 years^[31]

Once mercury compounds (and all such pollutants) accumulate on the foliage and water it egresses in the food chain; and through trophic levels reach higher concentrations by a process known as bio-magnification. It would therefore be correct to assume that large fish such as Tuna Fish etc. at the top of marine food chain would have higher concentration of mercury compound (methyl mercury). Marketing of sea foods has been regulated where the content of methyl mercury has been ordained to be less than 1 PPM. One would recall the Minamata episode where factories in Japan using mercury & chlorine to produce vinyl chloride were discharging effluents in the sea. This resulted in methyl mercury concentration in fish which when consumed by the humans caused food poisoning of a severe nature resulting in many deaths, not only in Japan but in different parts of world.

Mercury compounds pass through placental barrier and have been found in mother’s milk. Mercury has deleterious effects on urinary system (causes proteinuria, tubular and glomerular dysfunction). It is neuro-toxic causing changes in neurological functions, and causing emotional changes such as anxiety and timidity, changes in personality and behavior, deficit in performance level, parasthesia, hypotonia, tremor and visual impairment.

It has been reported that eating sea food with high level of mercury can affect brain development of older children as indicated in a study published in the online edition of journal ‘Nature’. The finding intensifies the ongoing debate about the health effects of mercury. Some researchers advocate that methyl mercury is toxic only to foetus & infants, and older children are unlikely to have developmental problems. But the study conducted by researchers from Harvard School of Public Health at the Faroe Islands in North Atlantic (where inhabitants eat a lot of sea food and whale meat) found that children aged seven had a slower transmission of electric signal along a particular circuit in their brain than was normal. When children became 14 years old the disruption became even worse. The findings suggest that safety messages about mercury should also highlight the toxin’s potential impact on children of all age group^[32].

India does not produce mercury and relies totally on imports. During 1998-2001 the annual import stood at 170-190 tons which is 10% of global consumption. Mercury consumption by Indian Caustic –Chlorine companies is at least 50times higher than the average European consumption. Though mercury is not consumed in the process it gets lost during operation as soon as it is used. 70 tons of mercury thus enters the environment every year. And this trend is increasing. Mercury is used in clinical thermometers, sphygmomanometers, bulbs, dental amalgam etc. which adds to environmental mercury load once discarded. Thus total environmental mercury would be about 125 tons per year of elemental mercury. This would be about 5 times than the total mercury discharged in Minamata Bay in 36 years. In India, 44% of mercury goes unaccounted^[33].

Gases & Chemicals Used in Hospital Environment

Many types of gases and chemicals are used in the hospital environment for patient care and investigation, disinfection, and sterilization. Some can be said to be the end product of a procedure. For example, the photographic development solutions used in x-ray departments have fixer and developer. The fixer contains hydroquinone, potassium hydroxide, and silver. The developer contains gluteraldehyde. Acetic acid is used in the process of developing x-ray films. While silver is recovered other chemicals are normally discharged in the sewer. Therefore here chemical waste is generated in a process. These chemicals and gases have peculiar chemical properties and impact on health. Mercury by far is the most potent source of environmental degradation. Primary source of mercury in a hospital include broken thermometers, blood pressure instruments, and gauges etc containing mercury. Mercury spills must be recovered by containment, and reused after distillation. Distillation is a simple procedure which can turn waste mercury waste to useful & reusable recovered mercury. In fact in one hospital in Israel it has been tried and implemented resulting in a saving of $ 37,000 per year. There are many solvents used in the hospital. These include solvents used in Path Labs, in histology departments, embalming procedure etc. The solvents used include halogenated compounds such as methyl chloride, chloroforms, freons, trichloethylene, and trichlormethane. The non-halogenated ones are xylene, acetone, ethanol, methanol, and ethyl acetate etc. Xylene and ethanol are used in the histology and cytology departments. Tissues on which a chemical has been used would be considered hazardous waste. So far all these chemical wastes are usually discharged in the drains, at least in the developing countries. To achieve proper disposal it would be necessary to contain all these chemicals and bring them to reuse after proper treatment. Distillation may be a viable option. Some have reported availability of fractional distillation system which is equipped with a microprocessor and automatically distill, fractionate, and purify solvents^[34]. Formaldehyde is used in pathology labs, in dialysis unit, for preserving specimens, and in embalming. By and large formaldehyde waste is discharged in the sewer-a practice which is not eco-friendly. Formaldehyde must be contained and reused after purification. Radioactive waste gets generated in the nuclear medicine and clinical testing departments. It is normally contained in leak proof lead containers and buried till these decay in the normal process. Chemotherapy wastes are contained in almost all ingredients of HCW, personal protective clothing, gauze pads, sharps used for injection of the chemotherapy agent etc. The method of disposal followed is either landfill or incineration. However it must be appreciated that the latter option may not be acceptable at many places considering views against incineration, and landfill may not be a viable option in developing countries due to lack of available secured landfill sites. Anesthetic gases are nitrous oxide, ethrane etc, and other gases used as inhalation anesthetics. Exposure to these gases may result in acute toxic effects, and possibly reproductive disorders as well as carcinogenic effects. There are other chemicals used for cleaning and disinfection purposes such as hypochlorite solution. Since it is a chlorinated compound it must be handled with due precaution.

One can see that chemicals used in a hospital are essential to patient care but all cannot be disposed in eco-friendly manner. Therefore principles of management of this type of waste have to be precautionary, i.e. better control and management, minimization, and better inventory control.

Thus it would be apparent that health care waste has greater potential to cause ill health & environmental damage. This happens largely because one tends to ignore nature’s limitation and finite quantum. In fact one must consider nature as a part of existence along with all of us. Nature and the mankind are not in a duel across a fence for survival, but are together for existence. Nature and the mankind, in fact all that is there are part of co-existence; and no part can be classed to be adversarial. When the humans set to exploit the environment they lose something of their own as well. When water is taken out in greater quantity than what is replenished a disproportionate equation gets created which in the long run harms the all living species, and at all levels. When economic development takes place ignoring human development unstable societies are created. It is therefore necessary to follow rules of the nature for environmental protection, which in turn is poignantly basic to enjoyment of highest standard of health.

Compromise….Compromise

The thrust was on Small Scale Incinerators (SSI) for the SEAR countries since it is perceived that these countries would not be able to afford better waste management systems for hospital waste. SSI is basically an incinerator which is cheap to construct, but does not guarantee non-polluting emissions. No developed country (which can afford better system) has gone for it. The system has been developed with the developing countries in mind.

Affordability is a valid concern. But one should not go for such cheap systems that may give rise to unacceptable problems in future. Health & safety of the waste handlers will be at stake. Then there is always a possibility that everything including plastics and other waste will be incinerated. It is a misconception that small amounts of gaseous emission are not going to matter. All the pollutants have cumulative effect. And therefore any addition will one day or the other have undesired results. It is also reported that test reports at one of the leading labs of the country did not detect any Dioxins! Amazing, because this test is not only very expensive but facilities are not available in the country.

The mind-set of the conceptual thinkers or the health care planners is still limited to the incinerator technology. It is unfortunate that with so much evidence of damage being caused to the environment by gaseous emission one still likes to think only about incinerator. The concern of global warming, Ozone depletion, adverse effect on the health of people, increased incidence of respiratory group of diseases does not seem to bother.

Howsoever incinerators are made safe no one would deny that it will emit particulate matters & obnoxious gases. All types of waste may find its way into it. Therefore the use of incinerator for disposal of bio-medical waste must always be limited to burning of human tissue, body parts, and animal tissue waste, which otherwise will need to be disposed of by land-burial. The perception that it would be very costly to have alternate technologies is not correct. Improper disposal of bio-medical waste leads to increased morbidity in the society, costing a lot more than placing a proper system for the disposal of waste. Compromise is alright so long it does not lead to unacceptable disadvantages.

Studies, in USA & UK have clearly indicated the socio-economic burden of hospital acquired infection (HAI). The study in UK indicated to have cost the NHS close to an additional billion pounds per year. Similar study results are available from USA. Pollutants in the environment are also known to cause many diseases, respiratory group being dominant. Therefore on impact and cost-benefit analysis the cheaper option may not appear cheaper.

The sudden concern of course is the much awaited, and much hyped Universal Immunization Programme against Hep B. There should be no doubt that it will generate large volume of injection waste. Agreed, the plan is to use AD syringes but its disinfection would not be that simple since there is hardly any space between the plunger and the syringe lumen. It is also believed that the AD syringe will not be of PVC, but burning of even non-PVC plastic can give rise to particulate emission. How effective protection to the waste handlers in a rural setting can be provided & ensured is anybody’s guess.

India has more than 23,000 PHCs. One SSI at each PHC would cost about $22,000,000. So this would be the cost of disposal of plastic syringe waste to the country.

Opinions may be divided on the question of going back to the glass syringe era. Scientists say that there are enough evidences that this has miserably failed because disinfection was not practiced. But after the plastic syringes replaced the glass syringes no comparative study may have been done in India. It may now be possible as the state Govt of MP has decided to revert to the use of glass syringes.

All the confusion in the matter of proper disposal of injection waste is only due to professed use of plastic syringes. Proper or improper disinfection of glass syringes, or reuse of plastic syringes is all matters of human failure which may happen in both the cases. Important point is that plastic syringes are viewed as a source of income by the waste handlers. The plastic syringes were introduced to limit the nosocomial infection. While it succeeded in the developed world, it failed in the developing world due to wrong practices, and the reasons for failure is still valid.

[...]

---

^[1] WHO, World Helath Dec 1975, Page – 3.

^[2] Rachel Carson Silent Spring , P 13. (1987)

^[3] Saying by Albert Schweitzer, Nobel Laureate German Philosopher, Physician, and Humanitarian.

^[4] Down To Earth, August 31, 1999

^[5] Madan P. Upadhaya Regional Advisor – disability/Injury Prevention and Rehabilitation, WHO-SEARO as reported in Times of India, Delhi Edition, dated 23-11-02.

^[6] News Article in Daily Newspaper The Hindu, Delhi Edition, dated 14 Jun 2001

^[7] ‘Down To Earth’ May 31, 2001

^[8] International Encyclopedia of Ecology and Environment Vol. -11 (1995)

^[9] Ed - William N. Rom, Environment & Occupational Medicine (III Edition), –Page - 1514

^[10] Ed - William N. Rom, Environment & Occupational Medicine (III Edition), Chapter 114)

^[11] Paul Darley, Thermal Treatment, Waste Management World: Jul-Aug 2004, P- 54.

^[12] Ed-William N. Rom , Environment & Occupational Medicine III Edition (1998), PP – 1185 – 1203

^[13] Journal of toxicology & Environmental Health 1992:35: 29-38

^[14] Exon JH, Kollar LD, Estimated annual US toxic equivalent (TEQ) dioxin emission from combustion. Environment Health Prospect 1982; 46:137-140. Extracted from ‘Environment & Occupational Medicine William N. Rom III Edition’ (1998), P-1193.

^[15] Down To Earth, June 30, 2001

^[16] William N. Rom, Environment & Occupational Medicine (1998 ), III Edition, P-1514.

^[17] Seaton & Collegues. Lancet 1995:345:176-178

^[18] J Semet et all. 2000. Health Effects Institute’s Research Report NO. 94; as reported in Down to Earth April 15, 2002

^[19] Report of the Committee on Environment & Health (MOEF), May 2000, Reported in PARIVESH, CPCB, Sep. 2001

^[20] News Item, Daily News paper Rashtriya Sahara: Delhi Edition. March 6, 2001

^[21] Indoor Air Quality, ESMAP, World Bank, Sep. 2000, as reported in PARIVESH: Air Pollution and Human Health: September 2001: CPCB

^[22] ibid

^[23] Verma LK, Theses work: ‘Ambient air pollution at different points in Faridabad City’ March, 1997.

^[24] International Encyclopedia of Ecology & Environment (1995) Vol.11 (Air Pollution) P-49

^[25] William N. Rom, Environment & Occupational Medicine (1998 ), III Edition, Page-1513

^[26] William N. Rom, Environment & Occupational Medicine (1998 ), III Edition, P-977

^[27] William N. Rom, Environment & Occupational Medicine (1998 ), III Edition, P-983

^[28] Down To Earth, July 31, 2004.

^[29] ibid

^[30] Toxics link , April 2003

^[31] Waste News Apr 7, 2005

^[32] Down To Earth. Mar 15, 2004. Page – 24

^[33] Down To Earth, September 15, 2002 Page 27

^[34] EPA/625/7-90/009, June 1990