We need to tackle the medical waste mountain

Even before any­one had even heard of coro­n­avirus, the issue of med­ical waste was being recog­nised as an increas­ing­ly urgent prob­lem with glob­al con­se­quences.

To high­light the extent of the prob­lem we need only look at the city of Wuhan, which before the dis­ease was dis­cov­ered there was gen­er­at­ing between 40 and 50 tonnes of med­ical waste a day; three months lat­er, on March 1, that fig­ure had spiked to 247 tonnes a day.

Per­son­al pro­tec­tive equip­ment (PPE) would have, under­stand­ably, made up for a large pro­por­tion of the increase. The World Health Orga­ni­za­tion (WHO) esti­mat­ed at the time that PPE sup­plies would need to increase by 40 per cent month­ly to pro­tect front­line work­ers.

Although increased PPE demand might have sig­nif­i­cant­ly added to the amount of sin­gle-use plas­tic dis­card­ed dai­ly, its usage was already sky high in med­ical set­tings because for hos­pi­tals and their sur­geons, plas­tic offers the chance to work with tools that are cheap, durable and, most impor­tant­ly, ster­ile.

Indonesia bearing the brunt of medical waste

The envi­ron­men­tal and human cost of this wastage was demon­strat­ed dra­mat­i­cal­ly in Indone­sia, a coun­try which had been gen­er­at­ing unprece­dent­ed amounts of its own med­ical waste as it strug­gled to get to grips with the high­est death toll from COVID-19 in South­east Asia.

Com­bine this with the fact that Indonesia’s land­fills are the final rest­ing place for a sig­nif­i­cant amount of Europe’s med­ical waste and you have a recipe for the dis­as­ter that occurred at Cipeu­cang land­fill, on the out­skirts of Jakar­ta. In May, the facil­i­ty suf­fered a major wall breach and sent 100 tonnes of waste land­s­lid­ing into the near­by Cisadane Riv­er, cov­er­ing the riv­er flow and putting the lives of river­side com­mu­ni­ties at risk.

It’s unlike­ly to be a coin­ci­dence that the event hap­pened after Indonesia’s gov­ern­ment revealed that 1,480 tonnes of COVID-19 med­ical waste was pro­duced in the coun­try between March and June.

So how do we square envi­ron­men­tal respon­si­bil­i­ty with the pub­lic duty to keep high-risk hos­pi­tal per­son­nel safe while they test and treat patients for COVID-19 and oth­er pre-exist­ing life-threat­en­ing con­di­tions?

The search for alternatives

There has been a lot of atten­tion around a process called pyrol­y­sis, or chem­i­cal recy­cling at high tem­per­a­tures, after a research group from the Uni­ver­si­ty of Petro­le­um and Ener­gy Stud­ies in India sug­gest­ed it could be used to degrade polypropy­lene, a main ingre­di­ent in N95 pro­tec­tive res­pi­ra­tors, sur­gi­cal masks and sin­gle-use gowns.

How­ev­er, this is now being seen as a false dawn as many experts agree that we can’t chem­i­cal­ly recy­cle our way out of the prob­lem.

One of those experts is Pro­fes­sor Judith Enck, pres­i­dent of Beyond Plas­tics, who explains: “Chem­i­cal recy­cling is not a viable option. It doesn’t have a proven track record, can rarely exist with­out mas­sive pub­lic sub­si­dies and doesn’t scale up. Instead, a much more reli­able and eco­nom­i­cal approach is to look for inno­v­a­tive alter­na­tives to sin­gle-use plas­tics in med­ical set­tings, find­ing reusable alter­na­tives to N95 res­pi­ra­tors and oth­er forms of reusable PPE.”

We need inno­v­a­tive alter­na­tives to sin­gle-use plas­tics, and reusable alter­na­tives to N95 res­pi­ra­tors and oth­er forms of reusable PPE

An alter­na­tive could be elas­tomer­ic half-face res­pi­ra­tors (EHFRs), which are com­mon­ly used in man­u­fac­tur­ing and con­struc­tion. A 2020 study from Bay­lor Col­lege of Med­i­cine in Hous­ton found that EHFRs rivalled N95 res­pi­ra­tors in per­for­mance and fit test­ing and, most sig­nif­i­cant­ly, can be safe­ly reused by hos­pi­tal staff.

“I think the rea­son we haven’t seen elas­tomer­ic res­pi­ra­tors often used in health­care, pri­or to COVID-19, was because the issue had nev­er been pressed,” says Dr Stel­la Hines, a pul­mo­nolo­gist at the Uni­ver­si­ty of Mary­land School of Med­i­cine, who has led a study look­ing at reusable PPE. “EHFRs are clear­ly effec­tive, they pro­tect the health­care work­er and val­i­dat­ed clean­ing and dis­in­fec­tion pro­to­cols exist that can be mod­i­fied to suit the needs of the health­care set­ting.”

Cleaning up the waste streams

There is also increas­ing aware­ness that while we con­tin­ue to find ways to reuse infec­tious waste, we also need to address the man­age­ment of the non-haz­ardous mate­r­i­al that is gen­er­at­ed by health­care activ­i­ty.

Accord­ing to WHO, these benign prod­ucts make up 85 per cent of all med­ical waste and include items like the ubiq­ui­tous sur­gi­cal blue wrap, a sheet of polypropy­lene that cov­ers ster­ilised tools before surg­eries. Many hos­pi­tals are already exper­i­ment­ing with replac­ing the wrap with reusable ster­il­i­sa­tion con­tain­ers.

So could the answer to slow­ing the growth of the med­ical waste moun­tain be sim­i­lar to the mea­sures adopt­ed to deal with domes­tic waste, where­by house­holds were asked to audit and realign their habits on reuse and recy­cling?

Sonia Roschnik, inter­na­tion­al cli­mate pol­i­cy direc­tor at Health Care With­out Harm, believes it could be. She says: “Just as it’s now incum­bent on the indi­vid­ual to cut back on sin­gle-use plas­tics, recy­cle and reduce their envi­ron­men­tal foot­print, so it’s incum­bent on hos­pi­tals and clin­i­cians to try and do the same. I think the health­care sec­tor can and needs to improve its seg­re­ga­tion and hence its waste man­age­ment for reduced envi­ron­men­tal impact.”

Roschnik, who is also the for­mer direc­tor of the NHS Sus­tain­able Devel­op­ment Unit, high­lights some suc­cess­ful schemes that are already up and run­ning, includ­ing one oper­at­ing at the Queen Vic­to­ria Hos­pi­tal in East Grin­stead, which brought in a new waste scheme and imme­di­ate­ly saw a reduc­tion in clin­i­cal waste of between 10 and 15 per cent com­pared to the pre­vi­ous whole-year fig­ures.

With schemes like this being intro­duced, it’s pos­si­ble the pan­dem­ic can catal­yse think­ing on med­ical waste so envi­ron­men­tal and med­ical ethics don’t have to clash, and doc­tors don’t have to face the stark choice between patient and plan­et.

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