Status of Health Care Waste in South Africa

Health Care Waste in Southern Africa:

A civil society perspective

Llewellyn Leonard

Health Care Waste Projects Coordinator, groundWork

ABOUT THE SPEAKER

Llewellyn Leonard graduated from the University of Durban Westville and has an academic research background, with a Batchelor of Paedegogic, a Bachelor of Science (Honours) and an MSc in Water and Environmental Management. After completing his MSc, Llewellyn chose to apply his skills and knowledge within the civil society non-profit arena, rather than joining industry or government.

In 2001, Llewellyn, joined groundWork, which is a Human Rights and Environmental organisation, based in Pietermaritzburg. groundWork seeks make the link between environmental abuse and human rights in a democratic South Africa. groundWork is the only environmental justice NGO working on air pollution and health care waste campaigning in South Africa.

He has been instrumental in developing “The Isipingo Declaration on eliminating the harmful impacts of Health Care Waste and Incinerators in Southern African communities”. This is the first organised civil society declaration calling on Southern African governments to seek alternative mechanisms of dealing with waste management rather than incineration.

As part of his Health Care Waste project, Llewellyn works with two hospitals in South Africa. The idea is to make these hospitals model institution for other hospitals to follow. Already substantial improvements have been achieved since implementation of the program. Llewellyn, using his experience gained from working with hospitals is also currently developing a manual for South African hospitals to use in order that they may implement their own environmental management plans.

Abstract

Health Care Waste is a mounting problem in South Africa as in many other countries. Desktop studies show that 45% of health care waste generated in the KwaZulu-Natal province alone cannot be accounted for, suggesting that it is being illegally dumped, buried or burnt somewhere, thus affecting the health of people and the environment. The paper outlines some of the key problems that are being experienced with regard to health care waste in KZN, Swaziland and Mozambique such as the lack of segregation, education and awareness amongst the public and hospital staff, as well as the illegal dumping of health care waste in poor black residential areas. Wastes from health care facilities can pose a risk to health care workers, patients and local communities. While there is much concern about the possible spread of disease (especially from contact with "sharps" such as needles), the treatment of those wastes, through incineration, can release an array of hazardous pollutants into the air and water. Incineration has been identified as one of the major sources of dioxin in the environment due to the burning of chlorinated plastics like PVC. Mercury contamination of the environment is another concern for medical waste incinerators.

The paper also outlines the groundWork Health Care Waste and Incineration project. This includes the need for the project, considering the fact that the health care waste problems in South Africa have reached uncontrollable proportions. groundWork’s work with two under resourced rural hospitals is also touched upon, as well as the implementation of environmental management plans at these institutions since the conduction of audits of the hospital waste streams. The before and after scenario since the interception and implementation of environmental management plans at the institutions is also elaborated upon with reference to cost savings thus far for the institutions as well as the increase in occupational health and safety. Our plans for a role out campaign in South Africa using the two hospitals as case studies for other hospitals to follow will be stressed in our health care waste manual being produced for Southern Africa in the near future.

Health Care Waste in Southern Africa:

A civil society perspective

Introduction

Health Care Waste is a mounting problem in South Africa, Mozambique and Swaziland as in many other countries. Over recent years there has been numerous press statements of medical waste being disposed of in an incorrect manner. The people that have been most effected by medical waste have been the poor disadvantaged members of society. The incineration of medical waste has also caused much concern. Numerous studies indicate that incinerators have been associated with a wide variety of health problems such as disrupting the bodies hormonal, immune and reproductive systems, and have caused cancers. Previously, civil society had not been given a platform to voice their concerns regarding the health impacts that health care waste and incineration has had on their quality of life, and only recently has civil society taken a stand to state that “enough is enough”, and have sort ways to voice their concerns in a legitimate manner.

Status of Health care waste in South Africa, Mozambique and Swaziland

South Africa

South Africa occupies an area of 1,227,200 square kilometres, divided among nine provinces, with a population of around 41.2 million, and an annual population growth rate of 2.2 percent. Estimated urban population is between 57 to 63 percent, and rural population between 37 to 43 percent. There is very little control over how medical waste is stored, handled and disposed off and sometimes dumped together with municipal garbage in municipal landfill sites. Since incinerators are present at most hospitals, there is no incentive to segregate the waste. Majority of the hospitals that have on-site incinerators for health care waste do not operate satisfactorily. The worst problems arise in small rural hospitals and clinics, which are unable to give the required special care in handling medical waste because of a lack of resources. Many rural clinics open-burn their municipal waste on site in pits.

Desktop studies show that 45% of health care waste generated in the province of KwaZulu-Natal alone cannot be accounted for, suggesting that it is being illegally dumped, buried or burnt somewhere, thus affecting the health of people and the environment. Wastes from health care facilities poses a risk to health care workers, patients and local communities. While there is much concern about the possible spread of disease (especially from contact with "sharps" such as needles), the treatment of those wastes, through incineration, releases an array of hazardous pollutants into the air and water, thus affecting the health of our communities.

There is also the lack of capacity in South Africa to properly dispose of the large unnecessary amounts of health care waste being generated. There have been numerous instances where health care waste has been dumped in residential areas, thus posing a hazard to the community and environment. Due to illegal dumping in disadvantaged residential areas, there have been situations were children have been found playing with medical waste, i.e. children pricked with syringes, etc. Example, “Tygerberg Hospital treated 48 children with AZT after some were pricked with needles and others ate potentially lethal pills they found in a field in Elsie's River” (Cape Argus, September 1999). “An attempt by The Star newspaper to help track down a family member led to the gruesome discovery of corpses stacked in industrial fridges in a residential area, while 80 tons of medical waste was removed from a house in Johannesburg…” (The Star, August 2000).

At present, the KZN Department of Health, does not have one incinerator that meets the legal requirements for the disposal of medical waste due to government's failure to monitor and enforce laws governing incineration. For a long time civil society have lobbied government to stop incineration and implement non-thermal technologies. groundWork had even resorted to taking government to court after numerous attempts to have the Ixopo incinerator shut down, since it was the largest incinerator in KZN and had been poorly managed. Audit reports had shown that the incinerator had failed to meet important health and safety conditions of its permit. These included exceeding emission levels prescribed, as well as failing to meet the required temperature to prevent the release of certain chemicals such as dioxins into the environment. The incinerator was also located in the middle of a primary dairy producing area in South Africa.

Incinerators are dangerously polluting technologies that will virtually undermine the objectives of the POP’s treaty. The Stockholm Convention on POP’s, which has been ratified by South Africa, identifies waste incinerators as the principle source of dioxins and furans, which belong to the initial 12 substances being targeted for continuing minimization and ultimate elimination by the global community. Government has targeted these 12 pollutants because they are extremely dangerous to human health. Recently, the KZN Department of Health took a policy decision to halt the incineration of medical waste in the province (The Mercury, 20 November 2002). Instead the department will seek to treat and dispose of health care waste using environmentally safer, non-combustion technologies. As of last year, two first ever non-thermal treatments were set up in KZN, and a third is soon underway.

Mozambique

In Mozambique, the situation with regard to health care waste is much worst than that for South Africa. Mozambique has a population of around 18,000,000 people. Mozambique does have not a strong waste management system. Only in June 2003 for the first time were regulations for health care waste management implemented. These regulations are however weak and does not adequately address the problems of waste management, although it is seen as a start towards the process for health care waste management. Incineration is still seen as an option for the final the disposal of health care waste. According to the regulation, nothing is done to consider other waste solutions such as the 3 R's (reduce, reuse and recycle). An audit of two hospitals waste streams where conducted by the environmental justice NGO, groundWork in May this year. The report for the Maputo Central hospital audit found that no waste management systems where in place at the institutions, neither where any colour coded bagging system being used. There were also no policies in place. Only black bags are used at the hospital for all types of waste, beside domestic waste these include infectious medical waste (e.g. dressings, used swabs, sanitary pads, used gloves, in fact all waste contaminated with blood and bodily fluids). This also includes small aborted fetuses. Only body parts are separated from the rest of the waste.

Although a municipal service existed, hospitals needed to find their own means of transporting this mixed waste to the dumpsite. At the dumpsite waste pickers sort through the hospital waste and are exposed to the potential dangers of medical waste. There have been numerous instances were rag pickers have been pricked by needles, etc. Civil society are not aware of the dangers of being exposed to such dangers since the ultimate aim is survival.

Government has not been instrumental in combating the problems being faced with regard to health care waste. The Mozambique government had been on the process of arranging a quick solution for the waste management crisis this year. It has been stated that government wanted to give a good impression to the participants of the AU meeting in July this year. For them the solution for medical waste and household waste will be incineration.

Swaziland

Swaziland has a population of approximately 1,104,343. There is a general lack of institutional waste management capacity at all levels in Swaziland. This is reflected at both national and local authority level with skills deficiencies, lack of implementing waste management tools, financial shortages and inadequate institutional support. Moreover little monitoring and enforcement of existing legislation takes place due to the unclear, fragmented and often overlapping allocation of responsibilities amongst the various authorities. The Swaziland Waste Regulations of 2000 require licensing of all waste management facilities such as incinerators. There is currently no medical or industrial incinerator in the country that has a licence to operate. The Swaziland Environmental Authority currently lacks enforcement and monitoring of the existing incinerators.

Swaziland has about 400 hospitals, health care centres and clinics. These facilities have no common standards for source separation, collection bins, collection equipment for the disposal of medical waste. There is no clarification of responsibilities and co-operation between the different operating entities, with the hospitals often incinerating their own medical waste in old, poorly managed and sub-standard incinerators. Some health centres connected to a specific hospital, transport their medical waste to the nearby hospital and incinerate the waste. Medical waste is generally disposed of by the use of incinerators or it is simply dumped together with other waste types at landfill sites.

Some of the common problems being experienced in South Africa, Mozambique and Swaziland with regard to Health Care Waste include the following:

No Segregation / On-site incinerators

The problem firstly is that there is a large amount of health care waste produced at medical institutions. Segregation of waste is not being carried out at most hospital institutions. Many hospitals have on-site incinerators and incinerate waste at “no cost”; therefore sometimes there is no incentive to rigidly segregate waste. This has also lead to a system where staff, treat all waste as dangerous.

Education and Awareness amongst public

The degree of health education and hygiene awareness among the public is a critical factor in deciding the risks posed by health care waste. In the societies, there is a significant proportion of the population that is illiterate and unaware of the dangers, and it is these people who are most at risk.

Training of Health Care Staff

There is an acute need for training on hospital hygiene for hospital staff on the proper handling and secure storage of health care waste.

Most hospitals lack proper Waste minimisation plans

Most medical institutions do not have their own internal policies for waste segregation and therefore no waste minimization plan. If proper plans are in place, then there would not be the problem of over handling of waste and the creation of large amounts of health care waste that would require disposal.

Rural clinics areas are not provided with proper services

Besides Mozambique were the problem is widespread, it seems that the worst problem arises in small rural hospitals and clinics, which are unable to give the required special care in handing health care waste because of being constrained by a lack of resources. Proper handling of health care wastes is a complicated issue when resources are scarce. Resources that are lacking include disposal materials to carry out segregation effectively, i.e. lack of proper colour coded bags or sharps containers, etc.