Reducing the environmental cost of saving lives

Guided by the concept of ‘planetary health,’ it’s time to get serious about waste management in the health sector

Open burn pit on hospital grounds, Nepal

The push to achieve Universal Health Coverage is expanding access to health services for millions of people worldwide. It is also fueling an exponential rise in healthcare-related waste which is harmful to both human health and the natural world. Joint action by global health actors, including German Development Cooperation, is needed to identify and implement sustainable approaches to waste management.

Syringes. Surgical gloves. Bloody bandages. Food scraps. Plastic bottles and bags. Batteries. Foil packaging. Expired pharmaceuticals. Lab cultures. Day by day the waste piles up in shallow pits on the grounds of hospitals and clinics in low-income countries around the world. Once a week, or more frequently if needed, the contents of the pits are set alight and toxic smoke wafts across the health facility and into nearby residential areas. Inside, hospital corridors and storerooms are crammed full with old X-ray machines, refrigerators, air conditioners, computers and laboratory devices which have stopped working or been taken out of use. Much of this e-waste will eventually make its way, untreated, to municipal landfills or be crudely dismantled at informal recycling centres.

Sadly, this scenario is the norm, rather than the exception, in many parts of the world. While health workers are in the business of preventing illness and saving lives, inadequate systems for managing growing volumes of healthcare-related waste mean that health institutions are also a source of harm for both human health and the natural world. Healthcare waste containing infectious materials can contaminate normal household waste when these streams are mixed together at the same municipal waste site. Toxic emissions from open burning can negatively impact on the development of children’s brains, nervous systems and reproductive systems, and improperly disposed of electronic waste can poison the soil and water supplies upon which people depend. That the environmental cost of saving lives is not always immediately apparent does not mean that it isn’t there.

Scaled-up services and digitisation compound an existing problem

Syringe casings at a hospital in Nepal

While the problem of healthcare-related waste is not a new one, it is becoming increasingly acute as a result of two parallel developments. The first is the rapid scaling-up of testing and diagnostics linked to the global fight against major diseases such as HIV/AIDS, malaria and tuberculosis. To give but one example, to meet UNAIDS 90-90-90 targets it is estimated that by 2021 some 28 million people will require annual HIV viral load (VL) tests to monitor their response to antiretroviral therapy. And while VL tests are crucial for patient monitoring, the environmental side effects should not be ignored: VL testing platforms use chemical compounds such as guanidinium thiocyanate as reagents and the resulting waste, which contains small amounts of cyanide, requires specialised disposal to protect the health of laboratory workers and local residents. VL waste should not end up in open burn pits or landfills, but at present the scale-up of VL testing is far outpacing the development of appropriate waste management systems.

Second is the rapid digitalisation of the health sector, including the transition from paper- to computer-based recordkeeping and the introduction of high-tech medical equipment to replace older mechanical models. While digitalisation is helping to improve the quality of information for clinical and public health decision making, it is also generating new categories of waste at an enormous scale. Too often, these devices and machines end up in landfills or at illegal recycling sites where they are stripped for parts in a way that puts both people and the environment at risk.

An inadequate response

In most low-income and many middle-income countries, capacity to deal effectively with waste – and particularly with potentially hazardous healthcare waste – is limited. The problems are multi-faceted, ranging from a lack of appropriate laws and policies for different types of waste, to the absence of systems to safely segregate, store, transport and dispose of hazardous waste, to limited awareness of and practical know-how in recycling and upcycling.

The World Health Organization recommends that governments allocate sufficient resources to implement comprehensive healthcare waste management systems, and at the same time requests that development partners include an adequate contribution towards the management of waste associated with their interventions. In practice, however, the global health community has remained largely silent on this topic. Enthusiasm for the roll-out of new diagnostics, treatments and digital solutions has not been matched in recent years by accompanying investments to help countries think through the management and safe disposal of hazardous and e-waste which are direct by-products of large-scale global health initiatives.

A healthy environment is the basis for healthy lives

There is reason for hope, however. The transition from the Millennium Development Goals to the Sustainable Development Goals has signalled a major shift in how we acknowledge the interdependencies of economic, social and ecological dimensions of development. It is increasingly clear that no one goal can – or should – be achieved without addressing and carefully calculating potential trade-offs with the others.

Seen from a health perspective, this means that achieving SDG 3 – ensuring healthy lives and promoting wellbeing for all ages – will only be possible if there is clean water and sanitation (Goal 6), decent work conditions (Goal 8), and action to counter balance climate change (Goal 13), as well as simultaneous progress towards the other goals. This approach is embodied in the new ‘planetary health’ movement, which aims to transform the field of public health into one which considers human health in the context of the natural ecosystems upon which humans depend. Applying a planetary health lens, the issue of waste management becomes even clearer: central to safeguarding the environment is our ability to deal with the waste that is being generated by our own activity – including through the growing health care industry.

Bringing healthcare waste management to scale in Nepal

Separating waste at source

Within German Development Cooperation, some health programmes have started to take on the challenge of waste management. In Nepal, the project “Support to the Health Sector Programme” (S2HSP), implemented by GIZ on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ), has been working in Bidur municipality – home to the Trishuli District Hospital – to not only improve waste segregation and management practices starting at this hospital, but also to build support for a comprehensive approach to waste management for the municipality as a whole.

Before the cooperation with S2HSP began, one-third of the 35 kilograms of waste produced each day at Trishuli was hazardous – well above the 15-20% estimated by the World Health Organization as typical for health facilities – because of the intermingling of various forms of waste. S2HSP trained healthcare workers and support staff to work safely with waste and to better understand the risks posed by common forms of hazardous waste, such as sharps, used bandages, and other materials contaminated with blood or body fluids. Waste is now separated into different categories at source throughout the hospital, thereby reducing the overall proportion of hazardous waste, and an autoclave is now being used to sterilise the infectious waste so that it can be disposed of safely as part of the municipal waste stream.

Despite this progress, it has become clear that safely disposing of certain types of risk waste, such as pharmaceutical, chemical and e-waste, is still beyond the scope of a single hospital to manage independently. Waste management at individual health facilities is of only limited value if the overall municipal waste management system is not able to properly treat and dispose of hazardous waste alongside other streams of waste leaving health facilities. The challenge for the next phase, therefore, is to work with the municipality, along with other external partners, such as KfW, WHO, and UNDP, to set up an integrated healthcare waste management system in other municipalities in the western part of Nepal.

Germany has a unique role to play

An environmental wave is building. Around the world, and increasingly led by young people, there is growing public pressure on decision-makers to tackle issues at the intersection of the environment and human health: air pollution, climate change, chemical residues in the food chain, plastics clogging the oceans. Safe waste management is an integral part of the answers to many of these challenges, and the demand for such approaches is poised to grow.

In the health sector a handful of development partners, including UNDP, Gavi, the Global Fund and Medicins sans Frontieres, have begun to pay more attention to waste management as part of their core activities. But the scope of the problem is enormous and much more needs to be done to close the gap between the vision of planetary health and the reality on the ground. Germany has often played a pioneering role in environmental protection and German Development Cooperation, with its unique combination of financial and technical cooperation, is well placed to support countries to develop and implement safe waste management systems – including those for managing hazardous healthcare waste. Waste is everybody’s business. We can and should do more.

Franziska Fürst & Karen Birdsall

March 2019

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