September - December 2007
Power and poisons

Waste not, want not

NOT TOO long ago, protests were at fever-pitch over how healthcare facilities in the country disposed of their waste. After all, study after study had pointed to an increasing share of healthcare waste in the total municipal solid waste stream. More importantly, that included infectious and hazardous wastes whose then rather haphazard handling, storage, treatment, and disposal had activists and other observers sick with worry about their adverse health and environmental effects.

MEDICAL waste used to be dumped and burned along with ordinary domestic waste. [photo courtesy of HCWH]

But these days, Ester Borja, chairperson of the Waste Management Committee (WMC) of the Philippine Heart Center (PHC), is grinning from ear to ear — and it’s not because of the news of the P10,000 bonus to government employees. It’s because for almost two years now, the Heart Center has not only reduced the amount of waste it generates significantly, it has managed to earn six-figure amounts from waste trading.

This is on top of the fact that it — along with other hospitals across the country — has done away with incinerating infectious waste since 2003. Earlier this year, too, the Heart Center began phasing out gadgets (like thermometers) and equipment that use mercury, a potent neurotoxin that can cause developmental defects and can harm the brain, kidneys, and lungs.

Borja is likewise pleased to announce that the PHC’s Nutrition and Dietetics Division has agreed to replace styrofoam packs with biodegradable boxes as food containers, especially for take-home meals. And for several years now, the Pharmacy Division has been using paper bags when dispensing medicines to patients. In addition, the talks have started for the hospital’s Purchasing Division and the Bids and Awards Committee to adopt green purchasing policies for medical supplies during the next bidding schedule.

The Heart Center is actually among the four Metro Manila tertiary government hospitals chosen by Health Care Without Harm (HCWH) to include in its documentation of local best practices in hospital waste management. The resulting report, which was released earlier this year, debunks an enduring perception that government-run hospitals are less capable of properly handling waste. The experiences of the Heart Center, San Lazaro Hospital, Philippine Children’s Medical Center (PCMC), and Ospital ng Muntinlupa, show as well that healthcare-waste management can be effectively implemented in developing countries like the Philippines, where incineration is even banned.

“Their practices show what is doable,” says Merci Ferrer, Asia coordinator of HCWH, a global coalition of environmental health advocates working to reduce pollution in the healthcare industry. Yet even these exemplary hospitals may still be stuck in their old, wasteful — and quite harmful — ways had it not been for the growing green awareness in the last decade or so, and the eventual (if belated) moves of the government to make healthcare facilities clean up properly.

MOST HEALTHCARE waste are considered to be no more dangerous than any ordinary household trash. But there are types that do expose humans — healthcare workers and the public alike — to graver health risks. These include infectious materials that, according to an assessment done by the World Health Organization (WHO) in 2002, make up 15 to 25 percent of total healthcare waste. These could be in the form of sharps like needles, scalpels, or broken glass (one percent), body parts waste (one percent), chemical or pharmaceutical waste (three percent), and radioactive and genotoxic waste, or broken thermometers (less than one percent). (see Table)

Table 1: Classification of Healthcare Waste
Source: DOH Health Care Waste Management Manual

(for plastic bag or containers)
General waste Comparable to domestic waste, this type of waste does not pose special handling problem or hazard to human health or to the environment. It comes mostly from the administrative and housekeeping functions of healthcare establishments and may also include waste generated during maintenance of healthcare premises. Black and green
Infectious waste Contains pathogens (bacteria, viruses, parasites, or fungi) in sufficient concentration or quantity to cause disease to susceptible hosts. This includes:

  • cultures and stock of infectious agents from laboratory work;
  • waste from surgery and autopsies on patients with infectious diseases (e.g. tissues, materials or equipment that have been in contact with blood or other body fluids);
  • waste from infected patients in isolation wards (e.g. excreta, dressings from infected or surgical wounds, clothes
  • heavily soiled with human blood or other body fluids)
  • waste that has been in contact with infected patients undergoing hemodialysis (e.g. dialysis equipment such as tubing and filters, disposable towels, gowns and aprons, gloves and laboratory coats)
  • infected animals from laboratories; and
  • any other instruments or materials that have been in contact with infected persons or animals.
Pathological waste Consists of tissues, organs, body parts, human fetus and animal carcasses, and blood and body fluids Yellow
Sharps Include needles, syringes, scalpels, saws, blades, broken glass, infusion sets, knives, nails and other items that can cause a cut or puncture wounds. Whether or not they are infected, such items are usually considered as highly hazardous healthcare waste. Red
Pharmaceutical waste Includes expired, unused, spilt, and contaminated pharmaceutical products, drugs, vaccines, and sera that are no longer required and need to be disposed immediately. This category also includes discarded items used in handling of pharmaceuticals such as bottles or boxes with residues, gloves, masks, connecting tubing, and drug vials. Yellow
Genotoxic waste May include certain cytostatic drugs, vomit, urine, or feces from patients treated with cytostatic drugs, chemicals, and radioactive materials. Highly hazardous and may have mutagenic, teratogenic, or carcinogenic properties. Orange
Chemical waste Consists of discarded, solid, liquid, and gaseous chemicals, for example from diagnostic and experimental work, and from cleaning, housekeeping, and disinfecting procedures; may be hazardous or non-hazardous. Yellow with black band
Waste with high content of heavy metals Represents a subcategory of hazardous chemical waste, and are usually toxic. This could be mercury waste from broken clinical equipment (thermometers, blood pressure gauges, etc.) cadmium waste from discarded batteries. Yellow with black band
Pressurized containers Many types of gas are used in healthcare and are often stored in pressurized cylinders, cartridges, and aerosol cans. Many of these, once empty or of no further use, are reusable, but certain types, notably aerosol cans, must be disposed of. Red
Radioactive waste Includes disused, sealed radiation sources, liquid and gaseous materials contaminated with radioactivity; excreta of patients who underwent radionuclide diagnostic and therapeutic applications; paper cups, straws, needles and syringes, test tubes, and tap water washings of such paraphernalia. It is produced from vitro analysis of body tissues and fluids, in vivo body organ imaging, tumor localization and treatment, and various clinical studies involving the use of radioisotopes. Orange

In the same study, the WHO also cited estimates of infections worldwide caused by injections using contaminated syringes ? 21 million cases of hepatitis B virus (which was 32 percent of all new infections in 2002), two million hepatitis C virus cases (40 percent), and 260,000 HIV cases (five percent).

Yet from only nine tons of infectious waste per day based on a 2000 study done by the Metropolitan Manila Development Authority (MMDA), the figure almost doubled to 17 tons per day in a 2001 study commissioned by the Japan International Cooperation Agency (JICA), and to 27 tons a day in 2003, according to an Asian Development Bank (ADB) report. WHO has estimated that, based on population projections, local healthcare waste could reach as much as 69.5 tons per day by 2050.

In the past, many healthcare facilities relied on incinerators as a waste-disposal option. The JICA study revealed, for instance, that almost half of the 158 facilities surveyed disposed their infectious wastes through incineration. The ADB study, meanwhile, found that only about five tons of infectious wastes generated daily were disposed of either through incineration or non-burn technologies (autoclave, microwave), while 22 tons were either buried on site or irresponsibly thrown along with the rest of the municipal waste for dumping in open dumpsites or landfills.

Then in June 1999, Republic Act 8749, also known as the Clean Air Act, was signed into law, thereby signaling the end of the use of incinerators for waste disposal. Two years later, the Department of Health (DOH) began revising the existing healthcare-waste management manual developed a decade before by the agency’s Environmental Health Service and the Metro Manila Authority (now the MMDA).

The changes dealt mainly with ensuring that the manual was attuned to the provisions of the Clean Air Act and another new law that was also instrumental in pushing for reforms in the management of healthcare waste: RA 9003, or the Ecological Solid Waste Management Act of 2000. Among others, this law requires the promotion of recycling and composting in dealing with solid waste. (Previously, the disposal of hospital wastes was governed primarily by RA 6969, or the Toxic Substances, Hazardous Waste, and Nuclear Waste Control Act of 1990, which covers only infectious and pathological wastes, and expired pharmaceutical products.)

The manual’s revision, as then health secretary Manuel Dayrit explained, was meant to widely disseminate the proper use of existing technology and knowledge on healthcare-waste management. With its practical information on alternative yet safe, efficient, and environment-friendly technologies, the manual has to this day been serving as a useful guide in the planning, implementation, monitoring, and evaluation of the healthcare-waste management programs (HCWMPs) of hospitals, health centers, laboratories, pharmaceutical firms, blood banks, and other health-related establishments.

BY 2003, in anticipation of the challenge they faced with the growing volume of hospital wastes, the DOH and the Department of Environment and Natural Resources (DENR) began working together on a framework that outlined the safe disposal of wastes by healthcare facilities. (By then, too, the MMDA had begged off from its task of regulating hospital waste in Metro Manila, and had asked the DOH to assume responsibility for the oversight of the waste management process in the metropolis.)

It took almost two years for the DOH and DENR to finally issue the guidelines, which was contained in a joint administrative order dated August 24, 2005. Nonetheless, the order was able to clarify the jurisdiction, authority, and responsibilities of both agencies in dealing with healthcare-waste management, thereby harmonizing their respective efforts.

The DENR, through the Environmental Management Bureau (EMB), was made responsible for issuing the required permits for firms engaging in the business of handling, storage, treatment, and disposal of healthcare wastes. EMB has also been tasked to take the lead in monitoring compliance with environmental standards of hospital waste generators, transporters, treatment, storage and disposal facilities, and final disposal facility operators.

The DOH, for its part, was put on top of the development of HCWMP training programs, assisting all health facilities in preparing their plans for the effective implementation of their waste management programs. Toward this end, the health department has constituted a technical working team (TWT) on healthcare waste management, in which 17 government hospitals, among them the Heart Center, sit as members.

The Heart Center’s Borja says the team conducts monthly meetings wherein an assigned member hospital presents its best practices in waste for benchmarking purposes. She also says, “The hospitals in the TWT are tasked to monitor and assist other hospitals which have deficiencies or difficulties in their waste management plans and programs. The team is also currently updating and standardizing the DOH Waste Management Manual.”

THE Philippine Heart Center’s infectious waste storage area located at
the back of the hospital.
[photo by Mira Mendoza]

There are viable alternatives to incineration that are safer, cleaner, do not produce dioxin, and are just as effective at disinfecting medical waste. In its 2001 report on non-incineration medical waste treatment technologies, Health Care Without Harm explored four basic processes used in medical waste treatment: thermal, chemical, irradiative, and biological.

HCWH’s FERRER praises the four government hospitals her group included in its documentation project for being able to employ alternative systems to minimize, manage, and dispose of their waste, while remaining faithful to DOH requirements. But she is particularly delighted at the various ways these hospitals are making the most out of their recyclable and reusable wastes that have in turn become effective income-generating activities.

At the 301-bed Heart Center in Quezon City, for example, Borja reports that last year, they were able to earn P642,000 from the sale of scrap paper, plastics, wood, and metals (including old elevator parts), up from just P156,000 the previous year. And in the first five months of 2007 alone, she says they had already earned P377,000 from selling recyclable trash.

The waste trade is part of the “Trash to Treasure” program of the WMC, which was set up in 2001 to monitor and implement proper waste segregation and disposal practices through approved hospital and government guidelines. The income generated from the trash sales are then used to fund additional operating expenses of the hospital, which treats an average of 10,000 in-patients and 73,000 out-patients every year.

That’s not all. Out of the discarded empty cans of soda, milk, and nutritional supplements that Borja’s committee is able to collect, the hospital gets to have wheelchairs for physically handicapped patients. This is made possible by an arrangement between the PHC and the Tahanang Walang Hagdanan Foundation, which fabricates wheelchairs out of recycled tin scraps. According to Borja (who is actually the head of the Heart Center’s Auxiliary Services Department), 220 kilograms of tin scraps can produce one wheelchair.

Even the hospital’s Christmas decorations have been made in the green spirit by the hospital’s very own nurses, who used recycled materials.

Over at the PCMC, a 200-bed government hospital in Quezon City that specializes in pediatric care, waste segregation has not only allowed the hospital to earn from recyclable non-biodegradable wastes, but also from food discards that are sold to piggery owners. (The discards do not include those from the communicable unit that goes to the infectious waste bin.)

SPACIOUS storage facility for recyclables at the San Lazaro Hospital. [photo courtesy of HCWH]

In 2004, it reported earnings of about P12,000 from the sale of dietary slops alone. For the staff’s waste segregation efforts, a profit-sharing scheme has been put in place so those directly involved could receive incentives, particularly for the sale of food wastes.

“Recycling and reuse have physically reduced our waste by 30 percent,” says Jara Corazon Ejera, deputy director of the hospital’s support services who worked in tandem with Dr. Corazon Rivera, who was the Waste Management Committee head until she retired last April.

Even with Rivera’s departure, Ejera says they have not made any deviations from their usual practices, except in the case of the disposal of disposable diapers, which they used to regularly compost. They had to abandon that practice, however, after erroneous media reports accused them of burying infectious waste within the hospital compound. Remarks Ejera: “What people don’t know is that 60 percent of what makes up disposable diapers is compostable. The plastic portion is the only thing disposed.”

For a smaller hospital like Ospital ng Muntinlupa, which has limited financial resources, the sale of recyclable materials like newspapers, ink cartridges, aluminum cans, and plastic bottles has helped augment its waste management budget. The revenue is in fact covering the expenses of the housekeeping department, primarily for emergency purchases of supplies such as cleaning agents, additional trash bins, and doormats.

Built in 2001 and originally managed by a foundation, the 149-bed capacity hospital was turned over to the city government in April 2006. The transition from private to public operation, including abiding by the government procurement process, has proved challenging to the hospital administration and staff. But this has not deterred them from instituting a cost-efficient and resourceful waste management system that has even produced role models like Landré Jebone, housekeeping officer-in-charge who was recently awarded as “Huwarang Lider ng Muntinlupa” for waste management.

The 900-bed capacity San Lazaro Hospital, meanwhile, is demonstrating how waste management is possible on a large scale. The hospital, the DOH-designated referral center for infectious diseases, even has its own healthcare-waste management manual, based on the standards set by the health department, crafted by its Waste Management Committee.

THE STRENGTH of San Lazaro’s waste-management system lies in part in its training program. Hospital staff get regular waste management training for five days every quarter, during which they not only listen to lectures on proper waste handling, but are taken to ecological tours of landfills and waste treatment facilities. After completing the training course, selected participants are trained further as future trainers or facilitators.

As for the Heart Center, the HCWH says in its report that the key to its success is the “strong leadership of a very visible waste management committee” which has gained the active support of the hospital administration and most, if not all, of its 1,800 staff in implementing its waste management programs. This in turn has helped the hospital’s dedicated WMC to minimize waste to the lowest level possible. But one of its notable practices is the way it monitors infectious waste generated by each nursing unit, from both the staff and patients. A monthly bar chart is drawn to observe the trend in the volume of infectious waste produced. The unit that has the highest volume of wastes is then invited to attend the WMC’s meeting for clarification and recommendations on how to reduce waste.

“Similarly, the unit and the staff (that) have shown efforts to reduce their wastes through proper segregation are given a letter of appreciation in recognition of their support,” says Borja, happy to announce that last year’s recipients of the special citation were the Operating Room and Renal Division.

Aside from the bar graph, compliance is also monitored through surprise waste bin inspections by WMC members. “If necessary, pictures will be taken and these will be shown as video materials during employee/patient orientation programs,” says Borja. Should admitted patients miss any session on the standard operating procedures arranged by the nursing staff, they are given on-the-spot instructions during inspection by the committee.

Some healthcare industry insiders estimate that of the total waste generated by local hospitals, only 10 percent is infectious waste. But aside from the fact that such waste can pose serious health and environmental risks, the special attention given to it by the Heart Center’s WMC is also because the hospital has to pay a service waste treatment provider, Chevalier Enviro Services Inc., between P20 to P25 per kilogram of pathogenic or infectious wastes. Big hospitals like the Heart Center generate some 200 kg to 400 kg of these kinds of waste per day, which means the PHC could be paying Chevalier a low of P1.4 million per year to a high of P3.65 million.

Yet precisely because of the potential hazards posed by infectious wastes, Borja says the WMC’s work does not end after the hospital has turned over its infectious wastes to Chevalier, as it continues to monitor their transport and off-site treatment by the private service contractor.

“The ‘cradle-to-grave’ responsibility of the hospital is assumed from the time the infectious wastes are generated, collected from the hospital, treated at the plant, and disposed to its landfill,” insists Borja.

As such, the committee requires Chevalier to submit permits, clearances, certificates of compliance, technology performance/efficiency tests, and other pollution-control requirements for inspection and validation. The waste treater is also required to attend monthly WMC meetings whenever there is a report of non-compliance from both parties.

For sure, there are still some lapses in waste management, due mainly to budgetary constraints, even among the PHC and the three hospitals that agreed to be part of HCWH’s documentation project. But Ferrer says of the four exemplary hospitals, “By taking part in the study, they did not only take steps to better their own facilities and share what they knew, they also showed how hospitals should be at the forefront of promoting proper waste management. We hope other hospitals would take the first step.”