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HEALTH INEQUALITY & SUSTAINABLE DEVELOPMENT IN INDIA
Health Care Delivery System in India consists of three tier system, i.e. primary, Secondary, and tertiary health care. 15 % of Indian population do not have access to health care system. Expansion of health care in India has been mostly urban oriented when about 60 % 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 population would not be able to afford it, and the governments (central or state) may not find the required budget. The paper examines the total capacity in India, genesis of the system-its effectiveness, or the shortcomings, and reasons for deficiencies. understand today leads to stressed relation amongst privileged and underprivileged classes in a society. Paper examines health inequality in a conceptual or philosophical context.
Health Care Systems are more oriented towards curative health care, and do not consider impact of environmental pollutants on human health. 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 in the developing countries, including India. 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, whereas developing countries should adopt scientific advancement with modification to suit local conditions, level of awareness, and habits & practices. Existing conditions in other developing countries in the South East Asia Region has been briefly described as a case in point that in all developing countries situation remains the same-more or less. Paper examines these aspects and suggests measures for effective waste management in India.
In health matters there are gender bias, economic bias, status bias, and bias of availability of funds. Development as we
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 Existence’. The paper examines viability or relevance of ‘Sustainable Development’ vis-à-vis ‘Sustainable Existence’ in concept.
Capacity building is an essential part of Capability Approach. Capacity leads to capability. Political will, education, awareness, administrative set up etc, and development of monitoring protocols with predetermined performance indicators are required to be created.
There is great difference in the accessibility of resources. But merely by professing equitable accessibility one cannot ensure equitable sharing of resources.
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.
Take for example solid waste management system in the country. As per the present rules no one is to litter. But the municipalities do not have 100 % registration of food and eating joints that are largely responsible for littering. This gives rise to biological pollutants (fly & mosquito breeding, and bacterial pollution) causing degradation of the environment. Collection, transportation, and disposal system fails because of human failure almost at every level. This gives rise to deficiencies between policy & implementation. Therefore innovative approach may be required to be considered, such as decentralization of waste management to the community level, thermal treatment of the biodegradable waste in which the end product would be manure, instead of present system where waste is required to be transported to landfill for manure production. Waste to Energy concept will work only if the waste (without undergoing putrefaction) is transported in a time frame to the landfill sites. This hardly happens. Changes in policies at the macro level would narrow the gaps in policies & implementation.
Many examples of failed systems due to faulty capability approach can be found. Till few years ago health care waste management was only incinerator based. For the first time in Bangalore, India a ‘multi option’ approach was conceived and applied during WHO aided pilot project in the year 1999-2000, which resulted in a comprehensive health care waste management. It is recounted not only as a success story but also a point of successful health care waste management in India. Only incinerator based health care waste management was a faulty approach as it gave rise to pollutants in the atmosphere, was against the Basel Convention, and militated against Kyoto Protocol. Multi option approach has thus come out as the accepted protocol for health care waste management thus modifying policy framework resulting in better implementation.
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 itself may be subjected to analysis & modification for better implementation and results. Main thrust of the paper is that there should be two way interactions at macro and micro level for a successful capability approach.
Sunday, March 21, 2010
HIV and AIDS
DearAll,I can very well percieve that the whole focus of prevention of HIV is onbehavioural change in sex practices. This may be true but only upto an extent.Reports done in African countries indicate that sexual practice by itself maynot be the reason for increase in the incidences of HIV. Despite the fact thatthere has been reduction in STD, HIV prevelence have shown an upward trend. Whyshould it happen? The only answer is that spread of HIV is also caused by reuseof syringes without proper Disinfection, and because of sharing of syringes. Thefocus therefore has tochange from only sex related issues to also proper disposal of bio-medicalwaste, specifically the injetion waste. I hope this line finds support and westart doing something about the injection waste disposal.Dr LK Verma.e-MAIL: <http://health.groups.yahoo.com/group/AIDS-INDIA/post?postID=rCLfKQcNbUR5iosVTQQa-8xIe0t8m9L6sQud604Zaxu_hrZ5EFmPVm_hU_UQ9xwFNqx1H_MTctKT2dA>
Monday, March 8, 2010
POINTS FOR CONSIDERATION OF THE WORKING
GROUP ON HEALTH CARE WASTE MANAGEMENT
ISWA (ISTANBUL)-SEPTEMBER, 2005
Health care waste management in the underdeveloped, developing, and transitional countries is far from satisfactory. Though some improvements have taken place these are in pockets, and at many places it is not effective or scientific defeating the purpose of investment in health care waste management. There are two main reasons. One is lack of awareness and low level of education and the other is that the planners in a health care institution find it confusing to start any waste management plan scientifically. In order to help planners in the hospitals and health care institutions in these countries two aspects are of great relevance, and these are: -
A. CLASSIFICATION AS PER RECOMMENDED OPTIONS
Suggested Classification in a Hospital in Developing Countries: -
Another way of classification can be as per recommended options finalised for a hospital. This way number of categories would be less and options would be clearly defined as against present recommended option/s where many alternatives have been listed causing confusion in the mind of the planner in a hospital and in the mind of unskilled or semi-skilled waste handlers. This would reduce the number of collection boxes/containers required in a hospital. However on each of these collection containers recommended option and items to be discarded in that particular container will have to be clearly written in local language. Number of containers or collection boxes required will be in accordance with the size and technical capacity of a hospital or health care facility. For example in case of rural health care waste it may not be possible to have an incinerator for disposal of human/animal body parts and tissue waste. Therefore landfill will have to be alternative option. Similarly in case autoclave cannot be provided then chemical disinfection would be the alternative. Therefore waste management plan at a health care facility will have to be modified according to options which may be made available at that place. If this concept of option based classification is applied HCW may be classified in following five categories as below: -
Category A. Hydroclavable Waste: -
1. Infected Paper waste
2. Paper wrappings from wards & patient care areas
3. Linen waste, soiled cotton & swabs waste etc
4. Food Waste-left over from patients, or otherwise from the hospital kitchen/cafeteria
Category B. Autoclavable Waste: -
1. Pathological waste in the labs
2. Metal waste
3. Glass waste
4. Sharps waste
Category C. Incinerable Waste: -
Human & Animal tissue waste/parts
Category D. Microwavable Waste: -
Plastic waste
Category E. Landfill Waste: -
1. Human & Animal Tissue Specimen waste after washing to remove chemicals
2. Sharps waste after disinfection in small HCF
3. Sharps waste non-infected in small HCF
4. Human and Animal tissue waste, and amputated parts in small HCF where facilities for incineration is not available, nor there is an incinerator nearby to share
5. Disinfected and Shredded Metallic waste in small HCF
Thus one can see that categorization as per the recommended option would be different. It would not only reduce number of containers required but will also be clearly defined. At the same time system can be easily modified as per the type of HCF, its location, connectivity, and local practices and prejudices.
B. STEPWISE DEVELOPMENT
Steps for Formulating a Waste Management Plan: -
To lay down a waste management plan it would be simpler and perhaps much easier to follow certain steps. Stepwise development and application of a comprehensive waste management plan in a hospital/health care institution would entail the following: -
Step I
Base Line Survey: Its Aims and Purpose would be to: -
o Study geographical dimension – This is important and of greater relevance to a hospital, as it would give an idea whether a hospital is of vertical dimension or of horizontal spread, ratio between built up area and the total available area for the hospital, and the disciplines and departments etc. It would also give an indication whether on site treatment of waste can be planned or not. Is there enough space on the premises, and if so, what would be the impact on human health and environment. Therefore it is important that one carries out a detailed study of geographical and technical dimension of the hospital, which may be recorded as a technical map of the hospital, and will also help in planning movement of waste, establishing terminal treatment options etc. Public Health engineering aspect may also need to be studied so as to plan an appropriate liquid waste disposal system.
o Estimation of quantum of waste generated – Waste generation is calculated by conducting a survey. Normally waste generation is mentioned as Kg per bed per day. There are two fallacies in this. One, when one talks about Kg/bed/day obviously the total bio-medical waste generated in the hospital is divided by the number of beds to arrive at an average figure. But if the bed occupancy is lower or higher than 100 % results may be fallacious. Second, in absence of proper segregation practices mixing of infected and non-infected waste will normally take place, and in that case the survey result would again be fallacious. And in case segregation is not being practiced it would be pointless to talk about quantum of infected waste. Both these conditions are common in the developing countries and therefore researchers must be careful while coming to a conclusion about quantum of waste generated in a hospital or a HCF. Therefore it would be more realistic to express biomedical waste generation in Kg per patient per day, and to consider total waste generated in a HCF as bio-medical waste till segregation practices are put in place. Survey is the most important part of waste management plan. Though most difficult and cumbersome, it must be done meticulously. This step would achieve almost half of the task related to developing a waste management plan.
o Estimation of quantum in each category – Hospital waste is heterogeneous and contains items with different physical characteristics and attributes. Infected waste is one category, but within the definition of infected waste one would find many types of ingredients, and each one may require to be treated differently. Plastic waste for example cannot or should not be incinerated. Disinfection of sharps may requir disifection and mutilation immediately after generation. Strategy for injection waste disposal in a rural area would be separate and different.
o Determine waste generation points – Waste generation points may be many in a hospital/health care institution. It must be recorded and mapped which will help in placing containers for source separation and collection. Once the points and type and quantum at each waste generation point has been recorded capacity of waste collection bins can be planned. A hospital or health care establishment will have many OPD points where intermediary intervention in the form of needle destroyer - cum - syringe cutters may be required to be placed in sufficient number to take care of injection waste. There may be an attached dental unit where waste management may have to be planned to disinfect injection waste as well as planned strategy for disposal of chemicals waste. Laboratories will have to be visited and one may have to record work schedule so as to determine appropriate technology. Infectious wards where HIV patients are admitted will need special precautionary measure to be implemented. Similarly highly infectious wards where victims of SARS or Avian Flu are admitted will require special protocols for collection, safety precaution and handling. Thus one would see that there are many points of waste generation in a hospital where interventions will be required. What has been described above is only illustrative. Plan will have to be devised specific to a hospital or a health care institution. But determining waste generation points would be an essential step.
o Determine disinfectants and chemicals used: There are many chemicals, which are used in patient care and disinfection. Selection of terminal treatment technology would be guided by whether an item has been treated chemically. Effects of these chemicals on human health, and on environment should be studied and recorded. This would be helpful while planning waste management system.
o Chart out most appropriate route of waste movement: Route of waste movement should not cross the route normally taken for supply of medicines or patient’s food. At the same time its movement should also be away from the populated areas, or from the route of supply of medicines and food of the health care institution. Many a times it may not be possible to move the waste separately on an exclusive route but knowing the principle would lead to an informed decision, which is better than an ad hoc or uninformed decision.
o Study present system, if any: One may find no system existing in a health care institution, or a system existing but not on accepted scientific basis. Here it must be understood that a system is stepwise description of an activity, and not of any action, which neither has any scientific basis nor has stepwise attributes. Study of present prevailing system or practice and prejudices will give an idea to the planner as to what are the weaknesses, and what are the compulsions. This would help the planner in establishing an acceptable and durable system. It may not be enough to suggest and establish a system but also to ensure that it is durable. One may plan and establish a ‘State of Art’ system but if the technical and attitudinal capacity is not supportive the system established at enormous cost may deteriorate in no time. Study of the present system/practice will also provide information on the weaknesses where the planner may decide to apply educational or attitudinal intervention.
o Determine weak points in the system: Weak points in a system can be found at any stage. Old proverb that ‘chain is as strong as the weakest link’ should be kept in mind. One cannot become stronger unless the weak points are identified and corrected. That is why it is necessary to detect weak points. In fact once the weak points have been detected and recorded corrective measures can be applied in a systematic manner, not only in the initial phase when the system is being developed but also later – periodically. While conducting study to detect weak points one may dtect low level of awareness. In that case it would be beneficial to undertake measures to improve awareness and education at the initial stage itself. Methodology may be accordingly planned, such as didactic approach or IEC approach or a combination of measures, which will improve awareness. Depending upon factors such as increase in the level of awareness periodicity of such training and awareness programme may be laid down. It may be the very first step since knowledgeable health care workers would better realise the importance of waste management, and would be supportive to waste management programme. Similarly if during the study one finds that there is no system of accident reporting one would remember to include it in the waste management protocol. In a scenario of rural health care system one may find that the connectivity to the rural areas is rather poor (which may be the case in hilly terrain). In that case alternate methods for transporting waste from the PHCs to a central point for treatment of waste may have to be planned, or one may decide to disinfection and mutilation at the PHC level itself. Therefore study of the current practice and system to detect weak points are essential in developing a sound waste management system.
o Study prevalent infection control procedures and sharp management: There may not be any system of infection control or sharp management in the health care institution or there may be some system existing but not proper. In either case study will help in formulating appropriate plan for infection control.
o Study waste minimization, recycling, and reuse policies: Waste minimization and reuse or recycle policies should be studied with a view to find opportunities for waste minimization, recycling, reuse (recover), and included in the waste management protocol. Proper segregation, reuse and recycling are measures that lead to waste minimization, which in turn saves financial resources for treatment and disposal of infectious bio-medical and chemical waste.
Step II
Develop hospital specific protocol: All information collected during the previous steps would lead to development of a protocol. While the basics in the protocol would be the same modifications may have to be incorporated to suite specific health care institution. For example in a tertiary care teaching hospital one may have to include method for treatment and disposal of pathology specimen, which may not be required for a smaller hospital. Similarly protocol for a dental centre would have to be only inclusive of injection and chemical waste treatment and disposal. But safety precautions to be adopted will remain the same whether it is a large or small hospital, or a dental centre. Thus some of the features of the protocol would remain common; some may be different depending upon size and type of the health care institution.
Specific responsibility, duty, and authority should be clearly spelt out in the protocol. One senior person must be designated as the in charge of the waste management system. A committee should be formed which should work in close liaison with the infection control committee because one of the important aims of health care waste management is to eliminate infection, the other being environmental protection.
Efforts should be to use alternate technologies, and alternate source of energy. Many hospitals have switched on to using solar panels to meet their hot water requirements. Incinerators should be avoided as much as is possible since it stands implicated in environmental pollution and causing adverse impact on human health. Most importantly the management protocol should remain dynamic so that it can assimilate emerging technologies and system modification at the working level.
The protocol must describe source separation & collection of waste, its movement from the waste generation point to a common and movement from the common area to the terminal treatment facility, final disposal, safety measures, disinfection schedules, spill management protocol, sharp management and infection control measures, liquid waste treatment and disposal, and many other important features. Some of these are described below, in detail.
Essentially a protocol should be inclusive of a general description of the hospital or health care institution describing in short:
Its departments and technical capacity
Quantum and type of waste generated
Waste generation points
Chemicals used for patient care, and for disinfection
Technical and non-technical manpower
Awareness level regarding waste management amongst different groups of health care workers
Present practice and prejudices or compulsions, if any
Description of installed equipment and its capacity, if any
Assigned responsibility, if any
Infection Control Committee if existing
Health care waste management Committee if in existence
Note: -Many hospitals would be required to treat patients of highly infectious and contagious diseases. This may include victims of AIDS, SARS, and Avian Flu etc. These patients would normally be in isolation, and waste from these wards (including floor wash etc) would have to be disinfected at the earliest, and safety precaution of the highest order will have to be instituted.
The protocol should include the following: -
• Waste Minimization, Reuse, and Recycle Procedures: Many items of health care waste can be recycled, such as plastic waste, which will reduce burden on the health care waste management and monetary resources. Many items can be recovered, such as mercury waste, which can be collected, distilled and brought to further use in the hospital. Such a venture has paid dividends in many hospitals in the developed countries. It is of course important to remember that all these activities can be undertaken only after proper disinfection, wherever required. Reduce, Recycle, Reuse and Recover, no doubt are basic feature of a waste management plan but it must be initiated and implemented with great care, and under close supervision. It must be remembered that items intended for recycling etc have monetary value and left to loose supervision might result in malpractice.
• Identify Vendors: Recycle plan can only succeed if it is supported by a well-known list of recyclers and vendors. If not available locally it should be found out from adjacent places. Vendors should be explained that it would be an opportunity rather than an investment only. Even if there is no established vendor, say for example for plastic waste, it can be worked out with any plastic industry nearby. In case there are a cluster of smaller health care facilities, and a large facility in the same town or city all the recyclables can be channeled through the bigger facility. Procurement policies of medicines and consumables should also include buy back agreement with the suppliers. This would be specifically important in case of radioactive medicines, and part or whole of redundant equipment/s. Computers parts and other electronic equipments must be contracted at the time of purchase itself with provision of ‘take back’ scheme to reduce quantity of E-waste. Reuse of end product should be a part of the strategy, as far as possible, after waste is treated/disinfected, or rendered harmless.
• Procedure for Liquid Waste Treatment and Disposal: Liquid waste management is often neglected. In days to come liquid waste disposal would be more and more important due to mutant variants of microbes such as SARS and Avian Flu. Floor wash etc from infectious wards will have to be subjected to disinfection before disposal. Safety precautions will have to be strengthened while dealing with such cases. Principle of liquid waste disposal should be to render the liquid waste commensurate with the municipal liquid waste flowing in the sewers. Hospital liquid waste can be discharged in the municipal drains only thereafter. In fact liquid waste from infectious wards etc must be subjected to a treatment by sodium hypochlorite solution in a buffer tank before it is discharged. Many hospitals have installed liquid effluent treatment plant (ETP) on their premises, where liquid waste from all over the hospital is channeled into the ETP, and treated water and sludge is used for gardening etc. Thus the hospitals not only safeguard against environmental pollution but also benefits from such a scheme by saving monetary resources otherwise required for maintaining the green areas. It also adds to the aesthetic look of the hospital.
• Adequate and Periodic Training Programmes: Training and awareness programmes are very important feature of the system. It has to be separately designed for different groups of health care workers. Essentially one programme may be sufficient for the doctors and nurses, one programme for the paramedics, and one programme for the waste handlers. It must be periodic since many members in the staff may be changing, and also to recapitulate and reinforce knowledge. A record must be kept so as to review the schedule subsequently.
• IEC modes: One of the methods of improving awareness is information, dissemination, which can be in the form of posters in local language and displayed at vantage points in the hospital. It should be the duty of the waste management in charge to collect latest information and disseminate it by way of handouts, booklets, posters etc. Communication is another important feature of awareness programmes. Therefore a periodic meeting with all the stakeholders (including waste handlers) is important. This would provide the waste manager and the head of the institution with valuable clues if some intervention or change or modification to the programme is required.
• Periodic monitoring: Monitoring is an important tool of system evaluation. Monitoring should include periodicity, inspection schedule, maintenance of records, certification, assessment of emissions, inspection schedule of equipments, and recording findings of inspection by external agencies. Monitoring may also include results of waste minimization, recycle, & reuse programmes, which may give an indication for further improvements.
• Infection Control Measures: There is no substitute for hygienic practice, and cleanliness. Other measures would include restriction on hospital visits by relatives and public. Restriction on visits would call for a proper information & dissemination system to be developed so that there is no need for the relatives to gather in the hospital. It may call for an attitudinal change as in most places in the developing countries visiting a patient is considered a societal responsibility. Children & elderly must avoid visiting hospitals, as they are more vulnerable to infection.
All these will be required to be included in the protocol for the health care institution. Only then it will develop as a comprehensive plan of waste management.
Step III
Study procurement and supply procedures &and policies.
Purpose of such a study would be: -
o To suggest minimization
o To suggest recycling, or to identify materials that can be recycled after disinfection
o To suggest restricted movement of medicines from non-infective to infective areas. It may not necessity to allow packaging of medicines to wards (infective area) from the medical stores. This would reduce quantity of infected waste to be taken care of.
o To suggest any change in the inventory of medicines, such as procurement of mercury and other chemicals required in a hospital, and any change guided by principles of waste management. Recently many hospitals in the developed countries have done away with use of mercury, which necessitated change in procurement policy of the hospital.
Step IV
Assessment of level of awareness
Awareness is an important feature of technical capacity. It must be assessed at the beginning so that necessary interventions to improve, and to maintain awareness level amongst health care workers, separately for each group can be planned and applied. Success of a programme would very much depend upon the level of awareness. Purpose of such a study is:
o To assess baseline understanding of awareness amongst each group about hospital waste management & infection control
o To plan effective interventions
o Evaluate progress or the difference these awareness programmes make
o Reevaluate training schedules
o Determine periodicity of training and awareness programmes
o Finalise posters and handouts to improve awareness
o To hold preliminary workshop where level of awareness may be determined emperically in the scale 1-10
o To hold workshop after training and to assess improvement in the level of awareness, again in the scale of 1-10
Step V
Evaluate safety procedures
Health care workers are always at risk since they are in close contact of patients. Nurses are specifically vulnerable to accidental injuries and infection. Many studies done to determine hospital-acquired infection indicates high infection rate amongst the nurses, paramedics, and waste handlers. Adverse impact on the human health has also been noticed due to chemicals used in the health care institutions, and once again it is the nursing staff, paramedics, and waste handlers who are most prone to such adverse effects. Therefore safety to the health care workers should be paramount while planning a health care waste management system. Evaluation of safety measures should be done so as to:
o Describe the present system of safety amongst each group
o Plan interventions, such as:
Safety clothing and equipment to the health care workers, specifically the waste handlers
Preventing sharp injuries
Pre-exposure prophylaxis (PEP) and precaution amongst high risk groups
Laying protocol for waste audit, which will give an indication of gap or deficiency between waste being generated and treated/ disposed. Apart from many other advantages waste audit also indicates opportunities for minimization, recycling, and reuse/ recovery
Laying protocol for accident reporting, prevention, and post-exposure management.
Step VI
Selection and installation of equipments
Selection of equipment for waste management is the most crucial part of waste management plan. One must approach this very carefully. It may be Things are more difficult since many alternatives are available and no standardized parameters for each type of equipment are available, unlike in case of medicines and medical equipments. So at times it becomes very difficult to select proper equipment. Purchase of equipments have to follow laid down procedures and policies which may be universal for a group of health care institutions in which case one does not have the flexibility to opt for equipments as per his or her perception. Quality may be compromised due to restrictive procedure. Individual bias may play a dominant role in procurement. There may be flexibility in case of private health care facilities but flexibility cuts both ways. It may be advantageous or disadvantageous depending upon biases and predilection of the administration. Therefore it may be very difficult to lay down thumb rule in this regard. However administration of a health care institution must strive to reach a logical and most appropriate mechanism for procurement.
Scaling or standardization of range of equipments for a health care institution may be possible, but only after an extensive study. Equipments may range from ancillary equipments such as needle destroyer - cum - syringe cutter, shredder which may be required for plastic waste or metallic waste, intermediary disinfection materials such as chemicals etc, waste collection bins of different size etc, and terminal treatment options such as waste sterilization unit (commonly known as Hydroclave, Vapoclave, Bioclave etc), microwave, and autoclave etc; and equipment or machinery to transport the waste within and outside the premises. It is not possible to suggest a universal plan or scale of any of the equipments mentioned above, as it would depend upon the waste management plan devised, type and size of the hospital or the health care institution. Once again waste management plan of a health care institution will have to be specific and would include selection and scaling of equipments. However a modular plan for each group of health care institution may be possible. For example it may be possible to suggest a set of equipment and its scale separately for multidisciplinary tertiary care hospitals, dental establishments, stand alone large laboratories, blood bank; which may be extrapolated for another health care institution of the same type. But one model may not work for all types of health care institution and in all situations. Thus it is clear that scaling will have to be in consonance with the specific overall plan of waste management finalised for that health care establishment.
Once the administration of the health care institution have finalised types and number of equipments, the next step would be its procurement. Process of procurement should be finalised by a Standing Board of Procurement. It must include the head of the institution, logistic incharge, financial head, waste management incharge, head of engineering department, and incharge of infection control committee. One may co-opt other experts as required. It should be a collective wisdom, collective decision, and collective responsibility. And such a Board should remain insulated from influences. It must be kept in mind that equipments required are capital intensive and there may be subject to influences. The Board should finalise procurement of not only the equipments required but also chemicals and other smaller equipments etc required for intermediary interventions. It should also develop final disposal options, which may need to be dovetailed with either the municipal bodies in case of large health care institution, or with a larger hospital in case of smaller health care institution. The Board should be fully knowledgeable on waste generation- its quantity, and type or ingredients. It should be the duty of waste management incharge to collect all information in this regard and place it before the Board. Once options have been decided tender document will be required to be prepared.
Since standard parameters of waste management equipments, as for clinical equipment are not available tender documents must be prepared with great care. Quality of equipment should be of paramount consideration, and not the cost. Tender document should be so prepared that quality takes precedence over price. This is important since there are many manufacturers of waste management equipment in the developing countries whose quality may not always be as desired. Import of equipment should be avoided, as that would sap the meagre resources available for health care waste management. Within the given policy of procurement one may be able to get the best equipment available even though it may be the cheapest. Budget being limited one will have to strike a balance between price and quality. Time frame of supply, installation, and testing periodicity should form part of tendering. Penalty in case of delay or default should be included in the tender document. Maintenance schedules, periodic inspections, authorization, and certification etc, should be required to be included in the bids in response to the tender. It must be ensured that what is being procured is within the rules, and there would not be any difficulty in obtaining certification from regulatory authorities. Placing of order should conform to the laid down procedures, and clearly spell out the time frame and penal provisions. Installation and demonstration after installation should be a part of the order. In fact, heavier equipments should be contracted on ‘turn- key’ basis.
The health care institution/hospital should be made ready to receive the equipments before these start arriving on the site. In other words the hospital should have decided about waste movement and storage etc beforehand. Waste storage should already have been constructed so that installation of equipment is at the right place, and without waste of time. Waste Management Committee of the hospital and the hospital engineer should be closely associated with installation right from the beginning, so as to fully understand and grasp technical details of the equipment, its functioning, and maintenance schedules etc. Installation should include training to the hospital staff regarding functioning of the equipment, and all waste handlers who would be working on the equipment should be exposed to such a programme. For example, while installing needle - cum - syringe cutter/destroyer or needle remover equipment all nursing staff and the paramedics should be exposed to a training module about use and maintenance of the equipment. Similarly in case of installation of other equipments such as a Waste Sterilization Unit (Hydroclave etc), autoclave, incinerator, or microwave all those who may be working on the equipment may be trained by the supplier on how the equipment should be used, how it should be maintained, its technical details, cleaning schedules, shut down procedures and trouble-shooting measures. Once installation has been completed equipment should be run on experimental basis for some time. Record of parameters should be maintained right from the beginning so that appropriate data is generated for reference in future. End products should be subjected to predetermined laboratory tests, and other physical and chemical tests, and records maintained. Installed equipments require periodic maintenance and cleaning that must be done as per the schedule and guidelines provided by the supplier.
Step VII
Evaluate Against Performance Indicators: Any programme is launched with clear aims in mind, and for possible improvement in a system. Health care waste management is also intended to bring about positive results in overall health care delivery. It may be cleaner environment, reduction in nosocomial infection, or better health amongst health care workers. It may not be possible to measure such improvements in all spheres but there are certain areas where indeed it can be measured. The tool with which it is measured is termed as ‘Performance Indicators’. Neither laid down performance indicators are available, nor there is any textbook model, but performance indicators can be framed taking a clue from the aims and objects of an activity. It would give an indication to success of a programme and also will indicate any midway corrections/modification in the programme. It is true for all types of programmes and is also true in case of health care waste management programmes. It helps in evaluation and serves as a reference point for the future. Selection of performance indicators has to be done with great care since it is likely to affect future implementation of management plan. In case of health care waste management some of the performance indicators are suggested below:
o Decreasing incidence of accidents
o Decreasing incidence of mercury spillage
o Decreasing incidence of sharp injuries
o Increasing quantity of recycled waste
o Reducing quantity of gap between waste generated and waste treated
o Reducing nosocomial infection, and hospital infection in general
o Reducing incidence of communicable diseases in the hospital staff. For this it would be advisable to list out the diseases, which can be put under surveillance and note the incidence periodically to determine reducing trend. It could be skin disease, lung infection, HIV, HBV, HCV etc, and upper respiratory tract infection. Protocol to measure changes in the incidence will have to be determined prospectively.
o Increase in the awareness amongst each group which can be empirically measured by holding workshops on health care waste management separately for each group
By no means it is a fixed list, and may be modified as per the type and capacity of a health care institution. List may vary, and in some cases only a few of the indicators mentioned above may be applicable.
(LK Verma)
New Delhi, India
Member ISWA
GROUP ON HEALTH CARE WASTE MANAGEMENT
ISWA (ISTANBUL)-SEPTEMBER, 2005
Health care waste management in the underdeveloped, developing, and transitional countries is far from satisfactory. Though some improvements have taken place these are in pockets, and at many places it is not effective or scientific defeating the purpose of investment in health care waste management. There are two main reasons. One is lack of awareness and low level of education and the other is that the planners in a health care institution find it confusing to start any waste management plan scientifically. In order to help planners in the hospitals and health care institutions in these countries two aspects are of great relevance, and these are: -
A. CLASSIFICATION AS PER RECOMMENDED OPTIONS
Suggested Classification in a Hospital in Developing Countries: -
Another way of classification can be as per recommended options finalised for a hospital. This way number of categories would be less and options would be clearly defined as against present recommended option/s where many alternatives have been listed causing confusion in the mind of the planner in a hospital and in the mind of unskilled or semi-skilled waste handlers. This would reduce the number of collection boxes/containers required in a hospital. However on each of these collection containers recommended option and items to be discarded in that particular container will have to be clearly written in local language. Number of containers or collection boxes required will be in accordance with the size and technical capacity of a hospital or health care facility. For example in case of rural health care waste it may not be possible to have an incinerator for disposal of human/animal body parts and tissue waste. Therefore landfill will have to be alternative option. Similarly in case autoclave cannot be provided then chemical disinfection would be the alternative. Therefore waste management plan at a health care facility will have to be modified according to options which may be made available at that place. If this concept of option based classification is applied HCW may be classified in following five categories as below: -
Category A. Hydroclavable Waste: -
1. Infected Paper waste
2. Paper wrappings from wards & patient care areas
3. Linen waste, soiled cotton & swabs waste etc
4. Food Waste-left over from patients, or otherwise from the hospital kitchen/cafeteria
Category B. Autoclavable Waste: -
1. Pathological waste in the labs
2. Metal waste
3. Glass waste
4. Sharps waste
Category C. Incinerable Waste: -
Human & Animal tissue waste/parts
Category D. Microwavable Waste: -
Plastic waste
Category E. Landfill Waste: -
1. Human & Animal Tissue Specimen waste after washing to remove chemicals
2. Sharps waste after disinfection in small HCF
3. Sharps waste non-infected in small HCF
4. Human and Animal tissue waste, and amputated parts in small HCF where facilities for incineration is not available, nor there is an incinerator nearby to share
5. Disinfected and Shredded Metallic waste in small HCF
Thus one can see that categorization as per the recommended option would be different. It would not only reduce number of containers required but will also be clearly defined. At the same time system can be easily modified as per the type of HCF, its location, connectivity, and local practices and prejudices.
B. STEPWISE DEVELOPMENT
Steps for Formulating a Waste Management Plan: -
To lay down a waste management plan it would be simpler and perhaps much easier to follow certain steps. Stepwise development and application of a comprehensive waste management plan in a hospital/health care institution would entail the following: -
Step I
Base Line Survey: Its Aims and Purpose would be to: -
o Study geographical dimension – This is important and of greater relevance to a hospital, as it would give an idea whether a hospital is of vertical dimension or of horizontal spread, ratio between built up area and the total available area for the hospital, and the disciplines and departments etc. It would also give an indication whether on site treatment of waste can be planned or not. Is there enough space on the premises, and if so, what would be the impact on human health and environment. Therefore it is important that one carries out a detailed study of geographical and technical dimension of the hospital, which may be recorded as a technical map of the hospital, and will also help in planning movement of waste, establishing terminal treatment options etc. Public Health engineering aspect may also need to be studied so as to plan an appropriate liquid waste disposal system.
o Estimation of quantum of waste generated – Waste generation is calculated by conducting a survey. Normally waste generation is mentioned as Kg per bed per day. There are two fallacies in this. One, when one talks about Kg/bed/day obviously the total bio-medical waste generated in the hospital is divided by the number of beds to arrive at an average figure. But if the bed occupancy is lower or higher than 100 % results may be fallacious. Second, in absence of proper segregation practices mixing of infected and non-infected waste will normally take place, and in that case the survey result would again be fallacious. And in case segregation is not being practiced it would be pointless to talk about quantum of infected waste. Both these conditions are common in the developing countries and therefore researchers must be careful while coming to a conclusion about quantum of waste generated in a hospital or a HCF. Therefore it would be more realistic to express biomedical waste generation in Kg per patient per day, and to consider total waste generated in a HCF as bio-medical waste till segregation practices are put in place. Survey is the most important part of waste management plan. Though most difficult and cumbersome, it must be done meticulously. This step would achieve almost half of the task related to developing a waste management plan.
o Estimation of quantum in each category – Hospital waste is heterogeneous and contains items with different physical characteristics and attributes. Infected waste is one category, but within the definition of infected waste one would find many types of ingredients, and each one may require to be treated differently. Plastic waste for example cannot or should not be incinerated. Disinfection of sharps may requir disifection and mutilation immediately after generation. Strategy for injection waste disposal in a rural area would be separate and different.
o Determine waste generation points – Waste generation points may be many in a hospital/health care institution. It must be recorded and mapped which will help in placing containers for source separation and collection. Once the points and type and quantum at each waste generation point has been recorded capacity of waste collection bins can be planned. A hospital or health care establishment will have many OPD points where intermediary intervention in the form of needle destroyer - cum - syringe cutters may be required to be placed in sufficient number to take care of injection waste. There may be an attached dental unit where waste management may have to be planned to disinfect injection waste as well as planned strategy for disposal of chemicals waste. Laboratories will have to be visited and one may have to record work schedule so as to determine appropriate technology. Infectious wards where HIV patients are admitted will need special precautionary measure to be implemented. Similarly highly infectious wards where victims of SARS or Avian Flu are admitted will require special protocols for collection, safety precaution and handling. Thus one would see that there are many points of waste generation in a hospital where interventions will be required. What has been described above is only illustrative. Plan will have to be devised specific to a hospital or a health care institution. But determining waste generation points would be an essential step.
o Determine disinfectants and chemicals used: There are many chemicals, which are used in patient care and disinfection. Selection of terminal treatment technology would be guided by whether an item has been treated chemically. Effects of these chemicals on human health, and on environment should be studied and recorded. This would be helpful while planning waste management system.
o Chart out most appropriate route of waste movement: Route of waste movement should not cross the route normally taken for supply of medicines or patient’s food. At the same time its movement should also be away from the populated areas, or from the route of supply of medicines and food of the health care institution. Many a times it may not be possible to move the waste separately on an exclusive route but knowing the principle would lead to an informed decision, which is better than an ad hoc or uninformed decision.
o Study present system, if any: One may find no system existing in a health care institution, or a system existing but not on accepted scientific basis. Here it must be understood that a system is stepwise description of an activity, and not of any action, which neither has any scientific basis nor has stepwise attributes. Study of present prevailing system or practice and prejudices will give an idea to the planner as to what are the weaknesses, and what are the compulsions. This would help the planner in establishing an acceptable and durable system. It may not be enough to suggest and establish a system but also to ensure that it is durable. One may plan and establish a ‘State of Art’ system but if the technical and attitudinal capacity is not supportive the system established at enormous cost may deteriorate in no time. Study of the present system/practice will also provide information on the weaknesses where the planner may decide to apply educational or attitudinal intervention.
o Determine weak points in the system: Weak points in a system can be found at any stage. Old proverb that ‘chain is as strong as the weakest link’ should be kept in mind. One cannot become stronger unless the weak points are identified and corrected. That is why it is necessary to detect weak points. In fact once the weak points have been detected and recorded corrective measures can be applied in a systematic manner, not only in the initial phase when the system is being developed but also later – periodically. While conducting study to detect weak points one may dtect low level of awareness. In that case it would be beneficial to undertake measures to improve awareness and education at the initial stage itself. Methodology may be accordingly planned, such as didactic approach or IEC approach or a combination of measures, which will improve awareness. Depending upon factors such as increase in the level of awareness periodicity of such training and awareness programme may be laid down. It may be the very first step since knowledgeable health care workers would better realise the importance of waste management, and would be supportive to waste management programme. Similarly if during the study one finds that there is no system of accident reporting one would remember to include it in the waste management protocol. In a scenario of rural health care system one may find that the connectivity to the rural areas is rather poor (which may be the case in hilly terrain). In that case alternate methods for transporting waste from the PHCs to a central point for treatment of waste may have to be planned, or one may decide to disinfection and mutilation at the PHC level itself. Therefore study of the current practice and system to detect weak points are essential in developing a sound waste management system.
o Study prevalent infection control procedures and sharp management: There may not be any system of infection control or sharp management in the health care institution or there may be some system existing but not proper. In either case study will help in formulating appropriate plan for infection control.
o Study waste minimization, recycling, and reuse policies: Waste minimization and reuse or recycle policies should be studied with a view to find opportunities for waste minimization, recycling, reuse (recover), and included in the waste management protocol. Proper segregation, reuse and recycling are measures that lead to waste minimization, which in turn saves financial resources for treatment and disposal of infectious bio-medical and chemical waste.
Step II
Develop hospital specific protocol: All information collected during the previous steps would lead to development of a protocol. While the basics in the protocol would be the same modifications may have to be incorporated to suite specific health care institution. For example in a tertiary care teaching hospital one may have to include method for treatment and disposal of pathology specimen, which may not be required for a smaller hospital. Similarly protocol for a dental centre would have to be only inclusive of injection and chemical waste treatment and disposal. But safety precautions to be adopted will remain the same whether it is a large or small hospital, or a dental centre. Thus some of the features of the protocol would remain common; some may be different depending upon size and type of the health care institution.
Specific responsibility, duty, and authority should be clearly spelt out in the protocol. One senior person must be designated as the in charge of the waste management system. A committee should be formed which should work in close liaison with the infection control committee because one of the important aims of health care waste management is to eliminate infection, the other being environmental protection.
Efforts should be to use alternate technologies, and alternate source of energy. Many hospitals have switched on to using solar panels to meet their hot water requirements. Incinerators should be avoided as much as is possible since it stands implicated in environmental pollution and causing adverse impact on human health. Most importantly the management protocol should remain dynamic so that it can assimilate emerging technologies and system modification at the working level.
The protocol must describe source separation & collection of waste, its movement from the waste generation point to a common and movement from the common area to the terminal treatment facility, final disposal, safety measures, disinfection schedules, spill management protocol, sharp management and infection control measures, liquid waste treatment and disposal, and many other important features. Some of these are described below, in detail.
Essentially a protocol should be inclusive of a general description of the hospital or health care institution describing in short:
Its departments and technical capacity
Quantum and type of waste generated
Waste generation points
Chemicals used for patient care, and for disinfection
Technical and non-technical manpower
Awareness level regarding waste management amongst different groups of health care workers
Present practice and prejudices or compulsions, if any
Description of installed equipment and its capacity, if any
Assigned responsibility, if any
Infection Control Committee if existing
Health care waste management Committee if in existence
Note: -Many hospitals would be required to treat patients of highly infectious and contagious diseases. This may include victims of AIDS, SARS, and Avian Flu etc. These patients would normally be in isolation, and waste from these wards (including floor wash etc) would have to be disinfected at the earliest, and safety precaution of the highest order will have to be instituted.
The protocol should include the following: -
• Waste Minimization, Reuse, and Recycle Procedures: Many items of health care waste can be recycled, such as plastic waste, which will reduce burden on the health care waste management and monetary resources. Many items can be recovered, such as mercury waste, which can be collected, distilled and brought to further use in the hospital. Such a venture has paid dividends in many hospitals in the developed countries. It is of course important to remember that all these activities can be undertaken only after proper disinfection, wherever required. Reduce, Recycle, Reuse and Recover, no doubt are basic feature of a waste management plan but it must be initiated and implemented with great care, and under close supervision. It must be remembered that items intended for recycling etc have monetary value and left to loose supervision might result in malpractice.
• Identify Vendors: Recycle plan can only succeed if it is supported by a well-known list of recyclers and vendors. If not available locally it should be found out from adjacent places. Vendors should be explained that it would be an opportunity rather than an investment only. Even if there is no established vendor, say for example for plastic waste, it can be worked out with any plastic industry nearby. In case there are a cluster of smaller health care facilities, and a large facility in the same town or city all the recyclables can be channeled through the bigger facility. Procurement policies of medicines and consumables should also include buy back agreement with the suppliers. This would be specifically important in case of radioactive medicines, and part or whole of redundant equipment/s. Computers parts and other electronic equipments must be contracted at the time of purchase itself with provision of ‘take back’ scheme to reduce quantity of E-waste. Reuse of end product should be a part of the strategy, as far as possible, after waste is treated/disinfected, or rendered harmless.
• Procedure for Liquid Waste Treatment and Disposal: Liquid waste management is often neglected. In days to come liquid waste disposal would be more and more important due to mutant variants of microbes such as SARS and Avian Flu. Floor wash etc from infectious wards will have to be subjected to disinfection before disposal. Safety precautions will have to be strengthened while dealing with such cases. Principle of liquid waste disposal should be to render the liquid waste commensurate with the municipal liquid waste flowing in the sewers. Hospital liquid waste can be discharged in the municipal drains only thereafter. In fact liquid waste from infectious wards etc must be subjected to a treatment by sodium hypochlorite solution in a buffer tank before it is discharged. Many hospitals have installed liquid effluent treatment plant (ETP) on their premises, where liquid waste from all over the hospital is channeled into the ETP, and treated water and sludge is used for gardening etc. Thus the hospitals not only safeguard against environmental pollution but also benefits from such a scheme by saving monetary resources otherwise required for maintaining the green areas. It also adds to the aesthetic look of the hospital.
• Adequate and Periodic Training Programmes: Training and awareness programmes are very important feature of the system. It has to be separately designed for different groups of health care workers. Essentially one programme may be sufficient for the doctors and nurses, one programme for the paramedics, and one programme for the waste handlers. It must be periodic since many members in the staff may be changing, and also to recapitulate and reinforce knowledge. A record must be kept so as to review the schedule subsequently.
• IEC modes: One of the methods of improving awareness is information, dissemination, which can be in the form of posters in local language and displayed at vantage points in the hospital. It should be the duty of the waste management in charge to collect latest information and disseminate it by way of handouts, booklets, posters etc. Communication is another important feature of awareness programmes. Therefore a periodic meeting with all the stakeholders (including waste handlers) is important. This would provide the waste manager and the head of the institution with valuable clues if some intervention or change or modification to the programme is required.
• Periodic monitoring: Monitoring is an important tool of system evaluation. Monitoring should include periodicity, inspection schedule, maintenance of records, certification, assessment of emissions, inspection schedule of equipments, and recording findings of inspection by external agencies. Monitoring may also include results of waste minimization, recycle, & reuse programmes, which may give an indication for further improvements.
• Infection Control Measures: There is no substitute for hygienic practice, and cleanliness. Other measures would include restriction on hospital visits by relatives and public. Restriction on visits would call for a proper information & dissemination system to be developed so that there is no need for the relatives to gather in the hospital. It may call for an attitudinal change as in most places in the developing countries visiting a patient is considered a societal responsibility. Children & elderly must avoid visiting hospitals, as they are more vulnerable to infection.
All these will be required to be included in the protocol for the health care institution. Only then it will develop as a comprehensive plan of waste management.
Step III
Study procurement and supply procedures &and policies.
Purpose of such a study would be: -
o To suggest minimization
o To suggest recycling, or to identify materials that can be recycled after disinfection
o To suggest restricted movement of medicines from non-infective to infective areas. It may not necessity to allow packaging of medicines to wards (infective area) from the medical stores. This would reduce quantity of infected waste to be taken care of.
o To suggest any change in the inventory of medicines, such as procurement of mercury and other chemicals required in a hospital, and any change guided by principles of waste management. Recently many hospitals in the developed countries have done away with use of mercury, which necessitated change in procurement policy of the hospital.
Step IV
Assessment of level of awareness
Awareness is an important feature of technical capacity. It must be assessed at the beginning so that necessary interventions to improve, and to maintain awareness level amongst health care workers, separately for each group can be planned and applied. Success of a programme would very much depend upon the level of awareness. Purpose of such a study is:
o To assess baseline understanding of awareness amongst each group about hospital waste management & infection control
o To plan effective interventions
o Evaluate progress or the difference these awareness programmes make
o Reevaluate training schedules
o Determine periodicity of training and awareness programmes
o Finalise posters and handouts to improve awareness
o To hold preliminary workshop where level of awareness may be determined emperically in the scale 1-10
o To hold workshop after training and to assess improvement in the level of awareness, again in the scale of 1-10
Step V
Evaluate safety procedures
Health care workers are always at risk since they are in close contact of patients. Nurses are specifically vulnerable to accidental injuries and infection. Many studies done to determine hospital-acquired infection indicates high infection rate amongst the nurses, paramedics, and waste handlers. Adverse impact on the human health has also been noticed due to chemicals used in the health care institutions, and once again it is the nursing staff, paramedics, and waste handlers who are most prone to such adverse effects. Therefore safety to the health care workers should be paramount while planning a health care waste management system. Evaluation of safety measures should be done so as to:
o Describe the present system of safety amongst each group
o Plan interventions, such as:
Safety clothing and equipment to the health care workers, specifically the waste handlers
Preventing sharp injuries
Pre-exposure prophylaxis (PEP) and precaution amongst high risk groups
Laying protocol for waste audit, which will give an indication of gap or deficiency between waste being generated and treated/ disposed. Apart from many other advantages waste audit also indicates opportunities for minimization, recycling, and reuse/ recovery
Laying protocol for accident reporting, prevention, and post-exposure management.
Step VI
Selection and installation of equipments
Selection of equipment for waste management is the most crucial part of waste management plan. One must approach this very carefully. It may be Things are more difficult since many alternatives are available and no standardized parameters for each type of equipment are available, unlike in case of medicines and medical equipments. So at times it becomes very difficult to select proper equipment. Purchase of equipments have to follow laid down procedures and policies which may be universal for a group of health care institutions in which case one does not have the flexibility to opt for equipments as per his or her perception. Quality may be compromised due to restrictive procedure. Individual bias may play a dominant role in procurement. There may be flexibility in case of private health care facilities but flexibility cuts both ways. It may be advantageous or disadvantageous depending upon biases and predilection of the administration. Therefore it may be very difficult to lay down thumb rule in this regard. However administration of a health care institution must strive to reach a logical and most appropriate mechanism for procurement.
Scaling or standardization of range of equipments for a health care institution may be possible, but only after an extensive study. Equipments may range from ancillary equipments such as needle destroyer - cum - syringe cutter, shredder which may be required for plastic waste or metallic waste, intermediary disinfection materials such as chemicals etc, waste collection bins of different size etc, and terminal treatment options such as waste sterilization unit (commonly known as Hydroclave, Vapoclave, Bioclave etc), microwave, and autoclave etc; and equipment or machinery to transport the waste within and outside the premises. It is not possible to suggest a universal plan or scale of any of the equipments mentioned above, as it would depend upon the waste management plan devised, type and size of the hospital or the health care institution. Once again waste management plan of a health care institution will have to be specific and would include selection and scaling of equipments. However a modular plan for each group of health care institution may be possible. For example it may be possible to suggest a set of equipment and its scale separately for multidisciplinary tertiary care hospitals, dental establishments, stand alone large laboratories, blood bank; which may be extrapolated for another health care institution of the same type. But one model may not work for all types of health care institution and in all situations. Thus it is clear that scaling will have to be in consonance with the specific overall plan of waste management finalised for that health care establishment.
Once the administration of the health care institution have finalised types and number of equipments, the next step would be its procurement. Process of procurement should be finalised by a Standing Board of Procurement. It must include the head of the institution, logistic incharge, financial head, waste management incharge, head of engineering department, and incharge of infection control committee. One may co-opt other experts as required. It should be a collective wisdom, collective decision, and collective responsibility. And such a Board should remain insulated from influences. It must be kept in mind that equipments required are capital intensive and there may be subject to influences. The Board should finalise procurement of not only the equipments required but also chemicals and other smaller equipments etc required for intermediary interventions. It should also develop final disposal options, which may need to be dovetailed with either the municipal bodies in case of large health care institution, or with a larger hospital in case of smaller health care institution. The Board should be fully knowledgeable on waste generation- its quantity, and type or ingredients. It should be the duty of waste management incharge to collect all information in this regard and place it before the Board. Once options have been decided tender document will be required to be prepared.
Since standard parameters of waste management equipments, as for clinical equipment are not available tender documents must be prepared with great care. Quality of equipment should be of paramount consideration, and not the cost. Tender document should be so prepared that quality takes precedence over price. This is important since there are many manufacturers of waste management equipment in the developing countries whose quality may not always be as desired. Import of equipment should be avoided, as that would sap the meagre resources available for health care waste management. Within the given policy of procurement one may be able to get the best equipment available even though it may be the cheapest. Budget being limited one will have to strike a balance between price and quality. Time frame of supply, installation, and testing periodicity should form part of tendering. Penalty in case of delay or default should be included in the tender document. Maintenance schedules, periodic inspections, authorization, and certification etc, should be required to be included in the bids in response to the tender. It must be ensured that what is being procured is within the rules, and there would not be any difficulty in obtaining certification from regulatory authorities. Placing of order should conform to the laid down procedures, and clearly spell out the time frame and penal provisions. Installation and demonstration after installation should be a part of the order. In fact, heavier equipments should be contracted on ‘turn- key’ basis.
The health care institution/hospital should be made ready to receive the equipments before these start arriving on the site. In other words the hospital should have decided about waste movement and storage etc beforehand. Waste storage should already have been constructed so that installation of equipment is at the right place, and without waste of time. Waste Management Committee of the hospital and the hospital engineer should be closely associated with installation right from the beginning, so as to fully understand and grasp technical details of the equipment, its functioning, and maintenance schedules etc. Installation should include training to the hospital staff regarding functioning of the equipment, and all waste handlers who would be working on the equipment should be exposed to such a programme. For example, while installing needle - cum - syringe cutter/destroyer or needle remover equipment all nursing staff and the paramedics should be exposed to a training module about use and maintenance of the equipment. Similarly in case of installation of other equipments such as a Waste Sterilization Unit (Hydroclave etc), autoclave, incinerator, or microwave all those who may be working on the equipment may be trained by the supplier on how the equipment should be used, how it should be maintained, its technical details, cleaning schedules, shut down procedures and trouble-shooting measures. Once installation has been completed equipment should be run on experimental basis for some time. Record of parameters should be maintained right from the beginning so that appropriate data is generated for reference in future. End products should be subjected to predetermined laboratory tests, and other physical and chemical tests, and records maintained. Installed equipments require periodic maintenance and cleaning that must be done as per the schedule and guidelines provided by the supplier.
Step VII
Evaluate Against Performance Indicators: Any programme is launched with clear aims in mind, and for possible improvement in a system. Health care waste management is also intended to bring about positive results in overall health care delivery. It may be cleaner environment, reduction in nosocomial infection, or better health amongst health care workers. It may not be possible to measure such improvements in all spheres but there are certain areas where indeed it can be measured. The tool with which it is measured is termed as ‘Performance Indicators’. Neither laid down performance indicators are available, nor there is any textbook model, but performance indicators can be framed taking a clue from the aims and objects of an activity. It would give an indication to success of a programme and also will indicate any midway corrections/modification in the programme. It is true for all types of programmes and is also true in case of health care waste management programmes. It helps in evaluation and serves as a reference point for the future. Selection of performance indicators has to be done with great care since it is likely to affect future implementation of management plan. In case of health care waste management some of the performance indicators are suggested below:
o Decreasing incidence of accidents
o Decreasing incidence of mercury spillage
o Decreasing incidence of sharp injuries
o Increasing quantity of recycled waste
o Reducing quantity of gap between waste generated and waste treated
o Reducing nosocomial infection, and hospital infection in general
o Reducing incidence of communicable diseases in the hospital staff. For this it would be advisable to list out the diseases, which can be put under surveillance and note the incidence periodically to determine reducing trend. It could be skin disease, lung infection, HIV, HBV, HCV etc, and upper respiratory tract infection. Protocol to measure changes in the incidence will have to be determined prospectively.
o Increase in the awareness amongst each group which can be empirically measured by holding workshops on health care waste management separately for each group
By no means it is a fixed list, and may be modified as per the type and capacity of a health care institution. List may vary, and in some cases only a few of the indicators mentioned above may be applicable.
(LK Verma)
New Delhi, India
Member ISWA
STRENGTHENING PUBLIC
HEALTH SECTOR
Public Health Sector in India consists of Referral hospitals, Teaching hospitals, District hospitals, and rural health sector. Backbone of rural health care is the Sub-centers, Primary Health Centers (PHCs), Community Health Centers (CHCs), and the district hospitals. There are about 137,311 Sub-centers, 22,842 PHCs, 3043 CHCs, and over 1000 District Hospitals. Each PHC is intended to provide primary health care to a population of 20,000 to 30,000. Sub-Centers cater to a population of about 5,000 each, and are the first contact point between a patient & health care system. Laid down ratio of population to a Sub Center, PHC or CHC have all been overtaken by population growth, and as it stands today the services at these health care facilities fall far short of the targets & indicators.
Health is all pervasive and healthy body & mind is an asset to any society. Any measure which falls short of achieving this aim may be termed as a deficiency or shortfall. Second rate health of people will give rise to only second rate people. One often hears criticism that with one billion people we do not have world class athlete or scientist. But we tend to forget that in that one billion hardly 30 % or 30 million enjoy proper physical & mental health.
National Health Policy aimed to achieve ‘Health for all by 2000 AD’ was declared in the year 1983 (1). The same slogan has been repeated in a recent announcement by the Vice Chairman Planning Commission aiming to achieve the same aim by the year 2020 (2). The only difference is the time interval of two decades. There is no road map. With budgetary support ranging between 3-5% in different Five Year Plans and 3-9 % expenditure on health in different States for the last many decades how this is going to be accomplished is difficult to envision. The investment in health care sector has in fact declined from 1.3 % to 0.97 % of GDP (in 1999) (3). 13 to 15 % of Indians do not have access to health care facility. Rural health infrastructure remains in a very poor state. The situation is further complicated by health being a State Subject. The functions of the Central Govt are set out in accordance with the Article 246 of the Constitution, under Union List & Concurrent list. Regulation and development of medical, pharmaceutical, dental, and nursing professions fall under the Central jurisdiction, so does the Control of Drugs and Poison within the Concurrent list. Prevention of extension of communicable diseases from one unit to another also falls under the Concurrent list (4). Rest of the functions relating to health care comes under the State function. Therefore parameters, results, inputs, and indicators differ from sate to state and at times widely. Realistic and enforceable policies are required to upgrade health care facilities.
There are stringent rules and procedures, and standards laid down for drugs and pharmaceuticals but not for equipments. Functions of the Drug Controller of India are limited to certifying new drugs, regulating import of new drugs, and laying down pharmaceutical procedures. Procurement policies are elaborate, and in detail. Under the Drug & Cosmetic Act 1940 (as amended) the regulation of manufacture, sale & distribution of drugs is primarily the concern of the State authorities (5). Thus it is obvious that implementation very much depends upon on the State authorities.
There are no standards, for equipments. One has to rely on declared parameters of the manufacturers. So far sophisticated electro-medical equipments are concerned this may not be a problem area as the standards may be verifiable and known. But for other equipments (including equipments for bio-medical waste treatment) it is an area of acute problem. There are no laid down standards for incinerator, hydroclave, or shredder. It must be appreciated that improper waste disposal is the root cause for most of environmental degradation, and communicable diseases with mutated variants of microbes. SARS is one example. Recent epidemic of viral disease which has affected a large number of children in Andhra Pradesh recently is another example. Experts are now convinced that around 30 % of incidence of AIDS is caused by improper disposal of infected syringe waste.
Equipment maintenance is so poor that at any given time about 40 % of these equipments remain unserviceable for want of proper maintenance (6).
Technical services have to be necessarily provided by the health care professionals – doctors, nurses, paramedics, but the non-technical services may be managed by others. Health care establishments in the public sector find themselves seized with the problem of looking after the non-professional services also. This affects the quality of patient care. Services like cleanliness, laundry, patient food, security, IT etc can always be outsourced. Outsourcing is the ‘in thing’ in the private health care facilities.
As per the WHO 45 to 50 % of all injections given in the developing world are either unsafe or unnecessary (7). Main cause of hospital acquired infection (HAI) is improper hospital waste disposal resulting in higher morbidity demanding increased facilities & resources of the society. Proper disposal of bio-medical waste as the core issue is still to be recognized with due importance. HAI is a matter of great concern to all health care planners. A study in UK (and since expenditure in patient care in UK is all funded by the public sector there cannot be any more accurate indicator) indicates clearly that ‘in excess’ expenditure on account of treating HAI costs the state exchequer an additional amount of about one billion pounds per year. It amounted to an estimated loss of 8.7 million man days (8). Manifest illness, sub-clinical affliction, infection control, environmental health, pollution & waste management, all have to be viewed together. Only then one can aspire to achieve a healthy society with improved health care. Therefore establishing a Waste Management Authority of India (WMAI)’ will not be a bad idea (9).
As per Mr Theo Colborn a wild life expert, the human body carries 500 more chemicals than it carried before 1920s (10). This reflects on the health and behavior pattern of individuals. Definition of ‘positive health’ must change to include absence of pollutants in the body and aim should be to achieve ‘Total Health’. The apt definition therefore would be “A state of complete physical, mental and social well being, where life thrives on in healthy environment devoid of pollutants; and not merely absence of disease and infirmity.”
Therefore there is a necessity of reviewing the statutory rules in order to improve its applicability, and effectiveness.
Health being a State subject, it is not possible for the Central authorities to intervene effectively and at will. Sale and distribution of spurious drugs, fluids, and blood is everyday news. The State machineries, for some reason have not proved effective. It is necessary to establish federal authority for periodic monitoring, & empowered to issue directives overriding the State’s directive in case it is at a conflict.
Health care in India has many shortcomings. It needs a general revamping. Specific weaknesses have to be identified, and strengthened. There are weaknesses in the statutory provisions, regulatory rules, and control mechanisms. These need to be studied and corrected.
New Delhi
May 14, 2003 (LK Verma)
References
1. National Health Policy Document
2. ‘Vision 2020’ released by Shri KC Pant, Vice Chairperson Planning Commission – Times of India, Jan 24, 2003
3. National Health Report-1997
4. Park’s textbook of Preventive & Social Medicine, 15th edition, page 601
5. Indian Pharmacopoeia, 1994
6. Paper presented during ‘QUEST – 2001’ Conference – Lt Col RK Chaturvedi, Associate Professor, Department of HA, AFMC
7. Hospital Waste in Latin America – J Monreal (1991), WHO/PEP/RVD/94.1
8. ‘The Socio-economic Burden of Hospital Acquired Infection’ – Rosalind Plowman et al, Apr 1994 to May 1995
9. Article ‘Needed: a National Waste Management Authority’ –Verma LK, Pharmabiz Hospital Review, Nov 16 – 30, 2002
10. Indian express Nagpur, Jun 22, 1997
HEALTH SECTOR
Public Health Sector in India consists of Referral hospitals, Teaching hospitals, District hospitals, and rural health sector. Backbone of rural health care is the Sub-centers, Primary Health Centers (PHCs), Community Health Centers (CHCs), and the district hospitals. There are about 137,311 Sub-centers, 22,842 PHCs, 3043 CHCs, and over 1000 District Hospitals. Each PHC is intended to provide primary health care to a population of 20,000 to 30,000. Sub-Centers cater to a population of about 5,000 each, and are the first contact point between a patient & health care system. Laid down ratio of population to a Sub Center, PHC or CHC have all been overtaken by population growth, and as it stands today the services at these health care facilities fall far short of the targets & indicators.
Health is all pervasive and healthy body & mind is an asset to any society. Any measure which falls short of achieving this aim may be termed as a deficiency or shortfall. Second rate health of people will give rise to only second rate people. One often hears criticism that with one billion people we do not have world class athlete or scientist. But we tend to forget that in that one billion hardly 30 % or 30 million enjoy proper physical & mental health.
National Health Policy aimed to achieve ‘Health for all by 2000 AD’ was declared in the year 1983 (1). The same slogan has been repeated in a recent announcement by the Vice Chairman Planning Commission aiming to achieve the same aim by the year 2020 (2). The only difference is the time interval of two decades. There is no road map. With budgetary support ranging between 3-5% in different Five Year Plans and 3-9 % expenditure on health in different States for the last many decades how this is going to be accomplished is difficult to envision. The investment in health care sector has in fact declined from 1.3 % to 0.97 % of GDP (in 1999) (3). 13 to 15 % of Indians do not have access to health care facility. Rural health infrastructure remains in a very poor state. The situation is further complicated by health being a State Subject. The functions of the Central Govt are set out in accordance with the Article 246 of the Constitution, under Union List & Concurrent list. Regulation and development of medical, pharmaceutical, dental, and nursing professions fall under the Central jurisdiction, so does the Control of Drugs and Poison within the Concurrent list. Prevention of extension of communicable diseases from one unit to another also falls under the Concurrent list (4). Rest of the functions relating to health care comes under the State function. Therefore parameters, results, inputs, and indicators differ from sate to state and at times widely. Realistic and enforceable policies are required to upgrade health care facilities.
There are stringent rules and procedures, and standards laid down for drugs and pharmaceuticals but not for equipments. Functions of the Drug Controller of India are limited to certifying new drugs, regulating import of new drugs, and laying down pharmaceutical procedures. Procurement policies are elaborate, and in detail. Under the Drug & Cosmetic Act 1940 (as amended) the regulation of manufacture, sale & distribution of drugs is primarily the concern of the State authorities (5). Thus it is obvious that implementation very much depends upon on the State authorities.
There are no standards, for equipments. One has to rely on declared parameters of the manufacturers. So far sophisticated electro-medical equipments are concerned this may not be a problem area as the standards may be verifiable and known. But for other equipments (including equipments for bio-medical waste treatment) it is an area of acute problem. There are no laid down standards for incinerator, hydroclave, or shredder. It must be appreciated that improper waste disposal is the root cause for most of environmental degradation, and communicable diseases with mutated variants of microbes. SARS is one example. Recent epidemic of viral disease which has affected a large number of children in Andhra Pradesh recently is another example. Experts are now convinced that around 30 % of incidence of AIDS is caused by improper disposal of infected syringe waste.
Equipment maintenance is so poor that at any given time about 40 % of these equipments remain unserviceable for want of proper maintenance (6).
Technical services have to be necessarily provided by the health care professionals – doctors, nurses, paramedics, but the non-technical services may be managed by others. Health care establishments in the public sector find themselves seized with the problem of looking after the non-professional services also. This affects the quality of patient care. Services like cleanliness, laundry, patient food, security, IT etc can always be outsourced. Outsourcing is the ‘in thing’ in the private health care facilities.
As per the WHO 45 to 50 % of all injections given in the developing world are either unsafe or unnecessary (7). Main cause of hospital acquired infection (HAI) is improper hospital waste disposal resulting in higher morbidity demanding increased facilities & resources of the society. Proper disposal of bio-medical waste as the core issue is still to be recognized with due importance. HAI is a matter of great concern to all health care planners. A study in UK (and since expenditure in patient care in UK is all funded by the public sector there cannot be any more accurate indicator) indicates clearly that ‘in excess’ expenditure on account of treating HAI costs the state exchequer an additional amount of about one billion pounds per year. It amounted to an estimated loss of 8.7 million man days (8). Manifest illness, sub-clinical affliction, infection control, environmental health, pollution & waste management, all have to be viewed together. Only then one can aspire to achieve a healthy society with improved health care. Therefore establishing a Waste Management Authority of India (WMAI)’ will not be a bad idea (9).
As per Mr Theo Colborn a wild life expert, the human body carries 500 more chemicals than it carried before 1920s (10). This reflects on the health and behavior pattern of individuals. Definition of ‘positive health’ must change to include absence of pollutants in the body and aim should be to achieve ‘Total Health’. The apt definition therefore would be “A state of complete physical, mental and social well being, where life thrives on in healthy environment devoid of pollutants; and not merely absence of disease and infirmity.”
Therefore there is a necessity of reviewing the statutory rules in order to improve its applicability, and effectiveness.
Health being a State subject, it is not possible for the Central authorities to intervene effectively and at will. Sale and distribution of spurious drugs, fluids, and blood is everyday news. The State machineries, for some reason have not proved effective. It is necessary to establish federal authority for periodic monitoring, & empowered to issue directives overriding the State’s directive in case it is at a conflict.
Health care in India has many shortcomings. It needs a general revamping. Specific weaknesses have to be identified, and strengthened. There are weaknesses in the statutory provisions, regulatory rules, and control mechanisms. These need to be studied and corrected.
New Delhi
May 14, 2003 (LK Verma)
References
1. National Health Policy Document
2. ‘Vision 2020’ released by Shri KC Pant, Vice Chairperson Planning Commission – Times of India, Jan 24, 2003
3. National Health Report-1997
4. Park’s textbook of Preventive & Social Medicine, 15th edition, page 601
5. Indian Pharmacopoeia, 1994
6. Paper presented during ‘QUEST – 2001’ Conference – Lt Col RK Chaturvedi, Associate Professor, Department of HA, AFMC
7. Hospital Waste in Latin America – J Monreal (1991), WHO/PEP/RVD/94.1
8. ‘The Socio-economic Burden of Hospital Acquired Infection’ – Rosalind Plowman et al, Apr 1994 to May 1995
9. Article ‘Needed: a National Waste Management Authority’ –Verma LK, Pharmabiz Hospital Review, Nov 16 – 30, 2002
10. Indian express Nagpur, Jun 22, 1997
PROCUREMENT REFORMS
IN HEALTH SECTOR
Preamble
Health Care sector in India consists of public & private facilities. Private, sector by and large are concentrated in the urban areas. Public sector is spread all over, in the urban as well as in the rural areas. Backbone of rural health care is the Primary Health Centers (PHCs) and Community Health Centers (CHCs). These function under the health care machinery of the state governments, and under the technical control of District Hospitals. In India, there are 22,842 PHCs, 3043 CHCs, and over 1000 District Hospitals. Each PHC is intended to provide primary health care to a population of 20,000 to 30,000. In this task the PHCs are aided by Sub-Centers which cater to a population of about 5,000, and are the first contact point between a patient & the health care system. India has 137,311 such Sub Centers. Ratio of population to a Sub Center, PHC or CHC have all been overtaken by population growth, and as it stands today the services at these health care facilities fall short of the target, or indicators of success.
Population pressure not only have direct but many indirect effects as well. Rapid growth of industries in the urban belt causes migration from rural to urban areas. Regular migration is a well known fact of today. The main causes are lack of job opportunity, insecurity, and lack of infrastructure in the rural areas. The deficit between job-seekers and availability of opportunities is wide forcing people to migrate in search of means of livelihood. The effect is disastrous. The migrant population perceives the urban society something to exploit till they get assimilated in the urban milieu. This cycle keeps on going and will only stop once the shortcomings of the rural sector gets corrected, either by urban benefits extending to the rural areas or by rural stabilization. That will take a long time to materialise.
Health sector is no exception. It also suffers from instability in the rural & urban societies. Private health sector boasts of quality medical service, but is limited to the urban areas. Since it is profit driven it is never likely to be of value to the rural masses. National Health Policy aimed to achieve ‘Health for all by 2000 AD’ was declared in the year 1983 (1). The same slogan has been repeated in a recent announcement by the Vice Chairman Planning Commission aiming to achieve the same aim by the year 2020 (2). The only difference is the time interval of two decades. There is no road map as to how this is going to be achieved. With budgetary support ranging between 3-5% in different Five Year Plans and 3-9 % expenditure on health in different States for the last many decades how this is going to be accomplished is difficult to envision. The investment in health care sector has in fact declined from 1.3 % to 0.97 % of GDP (in 1999) (3). 13 to 15 % of Indians do not have access to health care facility. Rural health infrastructure will have to be strengthened, which at present remains in a very poor state. The situation is further complicated by health being a State Subject. The functions of the Central Govt are set out in accordance with the Article 246 of the Constitution, under Union List & Concurrent list. Regulation and development of medical, pharmaceutical, dental, and nursing professions fall under the Central jurisdiction, so does the Control of Drugs and Poison within the Concurrent list. Prevention of extension of communicable diseases from one unit to another also falls under the Concurrent list (4). Rest of the functions relating to health care comes under the State function. Therefore parameters, results, inputs, and indicators differ from sate to state and at times vary widely. Realistic and enforceable policies are required to upgrade health care facilities.
Procurement
Procurement in any health care facility is capital intensive. 40 to 60 % of the outlay in any health care institution goes for equipment. And upgrades are frequently required as electro- medical equipments improve or modify rapidly & frequently. To suit the requirement frequent addition/alteration are required in the civil work. The support for the civil work not being under the control of hospital authorities more often than not it takes time and a lot of effort for the hospital staff to get the required changes done. This all reflects on the quality of patient care and their disposal. Procurements in the health care sector are related to: -
1. Works
2. Goods
3. Services
Works
Works include civil work, construction of hospital-its designing & maintenance. Rapid and frequent modifications are required to meet the requirements of changing pattern of equipments and ancillaries. As far as the public care health facilities are concerned professional approach to construction of hospitals is lacking. There is normally a resistance to include hospital planning experts in the group. The result is that at any health care facility present a dismal look, hardly cheerful environs for the patients.
Color code, the flooring, and many other aspects of hospital construction require special attention. The floor of a health care facility should be smooth so as to minimize the chances of harboring microbes. Similarly wooden furnitures accumulate dirt and microorganism, hence should not be allowed in the patient care area. Look of a health care facility needs to be aesthetically designed to appear pleasing and patient friendly. Designing of a health care facility also has to take into consideration the type of the health care facility. If it is a sanatorium it has to be suitably designed so as to provide wide areas of garden etc, and recreational facility. If a psychiatric hospital is being planned it has to have facilities for occupational therapy. Rehabilitation centers have to be planned keeping the requirement of rehabilitation in mind. If it is artificial limb center it has to have parallel bar walking areas etc, and facilities for different physiotherapy exercises. Well designed hospital with natural light and air circulation is important for patient recovery. Expertise available in the public sector is inadequate. Expenditure on designing and construction of a hospital is thus remain not cost-effective. At best it is just 40 – 50 %. It is better to invest 110% and achieve 80-90% cost-effectiveness than to invest 100% and achieve only 40-60% of cost- effectiveness. Cost-effectiveness has to be measured it terms of achievement of desired or intended parameters.
Design of PHC & CHC should be standardized, and be on a modular concept. Though the manpower of each PHC & CHC is standardized the building design, the services and the maintenance agencies are not standardized. Similarly district level hospitals should also be on a standard pattern so as to ensure, or at least try to ensure standard patient care.
Even for day today maintenance there is no dedicated task force available, and maintenance task in a hospital is just one of the tasks of the public works services. Under the circumstances it becomes difficult to attain speedy repair or maintenance. More so in case of electro-medical equipments which requires specialized handling, maintenance & repair.
Goods
Procurement of goods in a health care establishment may be viewed in two groups. These are drugs and pharmaceuticals, and equipments. There are stringent rules and procedures, and standards laid down for drugs and pharmaceuticals. The same cannot be said about the equipments. The regulatory authority regarding drugs and pharmaceuticals is the Drug Controller of India, but his functions are limited to certifying new drugs, regulating import of new drugs, and laying down pharmaceutical procedures. The procedures are laid down in the DGS&D manual. Procurement policies are elaborate, and in detail. Under the Drug & Cosmetic Act 1940(as amended) the regulation of manufacture, sale & distribution of drugs is primarily the concern of the State authorities while the Central authorities are responsible for approval of new drugs, laying down the standards for the drugs, and coordination with a view to bring about uniformity in enforcement of the Act (5).
Central Drugs Laboratory, Calcutta (established under this Act) is the national statutory laboratory of the Govt of India for quality control of imported drugs & cosmetics. Its functions include active collaboration with the WHO in preparation of International Standards & specifications for International Pharmacopoeia. Central Indian Pharmacopoeia Laboratory is also a statutory body for quality control of drugs and cosmetics (including contraceptives), and is an appellate authority in disputes relating to the quality of condoms (5).
Thus it is obvious that there are elaborate rules/policies regarding drugs in India. Implementation very much depends upon on the State authorities. It
is a common knowledge that manufacturers of spurious drugs are thriving because of indifferent attitude of the controlling agencies, but hardly any effective measure is enforced. Those who get caught wriggle out by unfair means and indulge in the malpractice all over again. This exemplifies the loose control exercised by the regulatory authorities.
As far as the equipments are concerned there are no regulations, policies or standards to cover all equipments and intruments. This makes things difficult. One has to rely on declared parameters of the manufacturers, which in principle appear comprehensive but may differ in standards. The differences may be very wide and may be difficult to comprehend at the initial stage till one faces difficulties during maintenance. So far sophisticated electro-medical equipments are concerned this may not be a problem area as the standards may be verifiable and known. But as far as the other equipments are concerned it may be an area of acute problem, especially in the procurement of bio-medical waste treatment equipments. There are no laid down standards for incinerator, hydroclave, or shredder. This aspect being recent to India poses great difficulties in absence of standards. The acquisition therefore will remain totally dependant on the collective or individual wisdom, or knowledge about these technologies and its application which will bear upon acquisition of these equipments. And knowledge, as well as its application being poor in India it would be a matter of chance, or luck if one hits upon acquiring appropriate technology or the make for appropriate application. It must be appreciated that improper, or no waste disposal is the root cause for most of environmental and social degradation.
Even for proven equipment maintenance is so poor that at any given time about 40 % of these equipments remain unserviceable for want of proper maintenance (6).
Process of acquisition of (medicine or equipment) follows principle of L-1 as per laid down rules or the guidelines. That means once the QRs are laid down the lowest bidder has to be given the supply order. Therefore it is absolutely essential that the QRs are laid down with utmost care so that unreliable suppliers are excluded. Nevertheless at times procurement lacks quality due the insistence to follow the principle of L-1. Medicines are indented by generic names. There are umpteen numbers of firms producing the same medicine with the same formula, and some of these may have sprouted only a few days ago. These firms have the advantage of quoting a lower price because of low infrastructural investment but neither have the same dependability nor assured quality. Therefore at least in procurement of medicines one has to review the principle of L-1, its validity for universal application viewed in the context of reliability. In fact bar coding may be one of the measures which can be adopted to ensure quality.
Services
Health care establishments are complex entities encompassing general administration to health care administration, canalizing technical know how, establishing and maintaining rapport with the public at large, and the society it serves, and presenting a patient friendly ambience and atmosphere. It is difficult task to achieve.
Services in a health care establishment are technical, & non-technical. Technical services have to be necessarily provided by the health care professionals – doctors, nurses, paramedics, and staff trained in patient care (preventive, promotive, and rehabilitative aspects of health care), the non-technical services may be managed by others. Health care establishments in the public sector find themselves seized with the problem of looking after the non-professional services also. This cuts on the available time to look after the patients and related professional work thus affecting the quality of patient care. Services like cleanliness, laundry, patient food, security etc can always be outsourced. And in the present day scenario even the IT functions of the facility (without compromising confidentiality) can be outsourced. Outsourcing is the ‘in thing’ as far as the private health care facilities are concerned. The same cannot be said about the public sector facilities.
The Problem
It can thus be seen that there are problem areas which need to be corrected if health for all is to be achieved. What is done must have State machinery as the focus since health is a State subject. Some measures are described in the subsequent paragraphs.
Suggested Solution
Constitutional/Statutory/Regulatory
Health is all pervasive and healthy body & mind is an asset to any society. At the same time measures are also required to prevent misuse of drugs by bringing in better uniformity at the state level health care delivery system. Any measure which falls short of achieving this aim may be termed as a deficiency or shortfall. Second rate health of people will give rise to only second rate intellectuals. Therefore the health standards and quality of health care should be of paramount concern in any society. With the growth in population malpractices have set in, and therefore there is an urgent need to provide stringent and effective measures. With the population growth the waste generation has also grown exponentially, the natural barrier has reduced (thus spread of infection with greater ease); load on the urban health care facilities has increased substantially, bringing in malpractices in many forms. The quackery has gone up in absence of strict controls. As per the WHO 45 to 50 % of all injections given in the developing world are either unsafe or unnecessary (7). This is a potent source of spread of infection, resulting in higher morbidity demanding increased facility. It would thus be seen that ultimately it is the resources of the society which gets depleted. Definition of positive health, as per the WHO, talks only of absence of diseases & infirmity. Whereas today, our body has been polluted by chemicals, which may not manifest clinically; but have adverse effect on the physiology of human body, or on the behavior pattern. Chemical pollutants in the body affects health and behavior pattern of individuals. It is an area of research to determine these adverse effects. Therefore the definition of ‘positive health’ must change to include absence of pollutants in the body and aim should be to achieve ‘Total Health’. The apt definition therefore would be “A state of complete physical, mental and social well being, where life thrives in healthy environment devoid of pollutants; and absence of disease and infirmity.” Proper disposal of bio-medical waste is the core issue in the health sector which is still to be recognized with importance it deserves. Hospital Acquired Infection (HAI) is a matter of great concern to all health care planners. A study in UK (and since expenditure in patient care in UK is all funded by the public sector there cannot be any other better indicator) indicates clearly that over expenditure on account of treating HAI costs the state exchequer an additional amount of about one billion pounds per year. In terms of man-days lost, it amounted to an estimated 8.7 million days (9). Therefore establishing a ‘Waste Management Authority of India (WMAI)’ will not be a bad idea (10). Manifest illness, sub-clinical affliction, infection control, environmental health, pollution, and waste management, all have to be viewed together. Only then one can aspire to achieve a healthy society with improved health care.
There is therefore a necessity of reviewing the statutory rules in order to improve its applicability, and effectiveness. The present rules do not provide intervention by the Central authorities at will. The State machineries vary widely in controls and inspection standards. Federal laws, therefore appear to be the answer. The argument that it will be against the basic principles of democratic pattern of the country is baseless. The US has over riding federal laws and is a successful democracy. For example law and order is a State subject. This includes protection against infiltration. What havoc this has caused in the country, especially in Border States, is for all to see. There are many other examples which can be quoted, but the intention is to limit the argument relevant to the issue.
Health being a State subject, it is not possible for the Central authorities to intervene effectively. Sale and distribution of spurious drugs, fluids, and blood is everyday news. The State machineries, for some reason have not proved effective. The standards of enforcement differ from State to State depending on the political will, vote-bank equation, level of awareness, economical health, and organizational support or protection. A large number of diseases spread by unsafe injections, blood transfusion, use of narcotics leading to sharing of syringes etc. At most of the time the Central authorities remain a mute witness despite the resolve and capacity to intervene. Spread of infection respect no boundaries. Hence it is necessary to establish federal authority for periodic monitoring (apart from the routine monitoring of the State apparatus). The federal agency must be empowered to issue directives overriding the State’s directive in case it is at a conflict. The whole question on this issue is already under consideration of a high powered committee headed by the chairman of CSIR.
Works Related
Construction of the PHCs & CHCs must be entrusted to experts in the field by outsourcing. The existing infrastructure should also be modified as per the modern standards through experts groups in hospital construction. A standard design concept should be introduced with the concept of modular system for all the States. Designing the buildings with ancillary support is a specialized job. Maintenance of the building, electrical fittings, and many other support services relating to the structure of a health care facility can be easily outsourced to achieve better results, and to save on the effort of the professionals which will ultimately reflect positively on the health care. Presently maintenance of general medical equipment at peripheral hospitals & at the CHC etc is at the mercy of state workers who are ill-trained and not dedicated. Of late a welcome trend has set in for sophisticated medical equipments, i.e. Annual Maintenance Contract (AMC). This in a way is outsourcing. The same concept is required to extend to all levels of health care. Therefore there is a case for considering dedicated and specifically trained task force for maintenance of health care facilities, which can be specific to a large hospital or health care facility or cater to a typical group.
Procurement related
Rules regarding procurement of drugs are well laid out. The necessity is to implement the provisions in letter and spirit. Giving more teeth to the Central authorities will make the desired difference. But there are no laid down standards relating to acquisition of equipments. There is a requirement to create an appropriate authority for this purpose to function under the Drug Controller, Govt of India. Procurement is by and large market driven, and trade pressure at times is quite obvious.
To safeguard the interest of the state & the organization a Standard Purchase Committee should be established at each district level which should cater to the purchases of medicines & equipment of the CHC & PHC of that district, and health care facilities up to district hospital level. Larger hospitals and teaching hospitals may have their own Standard Purchase Committees. Duration of members should be fixed with provision of rotation to minimize corruption.
There is a requirement to create instruments to ensure quality assurance, uniformity and maintenance standards.
Summary of Recommendations
• Review of statutory bodies, its powers, and regulatory mechanism/methodology at the Central & State level
• Create a Waste Management Authority to deal with waste management in a comprehensive & effective manner.
• Greater control over the State authorities to ensure uniformity.
• Create Federal structure for better control & implementation
• Introduce standard design and modular concept for the hospitals, CHCs & PHCs, and other health care establishments, as far as possible.
• Provision of dedicated engineering task group for maintenance of hospital building, infrastructure, electric fittings, and ancillary services; or to provide technical guidance & control in case these services have been outsourced.
• Standardization of equipments of all types
• Outsourcing all the non-technical services
• Stricter vigilance & implementation
• Effective management of bio-medical waste
• In order to ensure quality acquisition the concept of L 1 needs to be reviewed
• Formation of standard purchase committee with provision of changes of members on a rotational basis
• Greater care while laying down QRs for acquisition so as to eliminate poor quality manufacturers
• Provide regular review of the provisions and regulations in order to improve/modify
• Bar-coding of medicines to indicate quality
Conclusion
Health care in India has many shortcomings. It needs a general revamping. Specific weaknesses have to be identified, and strengthened. Unless weaknesses are identified it is not possible to strengthen. Resolve to implement has to improve. There are weaknesses in the statutory provisions, regulatory rules, and control mechanisms. These need to be studied and corrected. Dr Mashelkar Committee is considering the issue, and it is hoped that it comes up with recommendations in the national interest; and in the interest of health care. The bottom line of course is clean, transparent, and corruption free dealings and acquisitions.
New Delhi
May 14, 2003 (LK Verma)
References
1. National Health Policy Document
2. ‘Vision 2020’ released by Shri KC Pant, Vice Chairperson Planning Commission – Times of India, Jan 24, 2003
3. National Health Report-1997
4. Park’s textbook of Preventive & Social Medicine, 15th edition, page 601
5. Indian Pharmacopoeia, 1994
6. Paper presented during ‘QUEST – 2001’ Conference – Lt Col RK Chaturvedi, Associate Professor, Department of HA, AFMC
7. Hospital Waste in Latin America – J Monreal (1991), WHO/PEP/RVD/94.1
9. ‘The Socio-economic Burden of Hospital Acquired Infection’ – Rosalind Plowman et al, Apr 1994 to May 1995
10. Article ‘Needed: a National Waste Management Authority’ –Verma LK, Pharmabiz Hospital Review, Nov 16 – 30, 2002
IN HEALTH SECTOR
Preamble
Health Care sector in India consists of public & private facilities. Private, sector by and large are concentrated in the urban areas. Public sector is spread all over, in the urban as well as in the rural areas. Backbone of rural health care is the Primary Health Centers (PHCs) and Community Health Centers (CHCs). These function under the health care machinery of the state governments, and under the technical control of District Hospitals. In India, there are 22,842 PHCs, 3043 CHCs, and over 1000 District Hospitals. Each PHC is intended to provide primary health care to a population of 20,000 to 30,000. In this task the PHCs are aided by Sub-Centers which cater to a population of about 5,000, and are the first contact point between a patient & the health care system. India has 137,311 such Sub Centers. Ratio of population to a Sub Center, PHC or CHC have all been overtaken by population growth, and as it stands today the services at these health care facilities fall short of the target, or indicators of success.
Population pressure not only have direct but many indirect effects as well. Rapid growth of industries in the urban belt causes migration from rural to urban areas. Regular migration is a well known fact of today. The main causes are lack of job opportunity, insecurity, and lack of infrastructure in the rural areas. The deficit between job-seekers and availability of opportunities is wide forcing people to migrate in search of means of livelihood. The effect is disastrous. The migrant population perceives the urban society something to exploit till they get assimilated in the urban milieu. This cycle keeps on going and will only stop once the shortcomings of the rural sector gets corrected, either by urban benefits extending to the rural areas or by rural stabilization. That will take a long time to materialise.
Health sector is no exception. It also suffers from instability in the rural & urban societies. Private health sector boasts of quality medical service, but is limited to the urban areas. Since it is profit driven it is never likely to be of value to the rural masses. National Health Policy aimed to achieve ‘Health for all by 2000 AD’ was declared in the year 1983 (1). The same slogan has been repeated in a recent announcement by the Vice Chairman Planning Commission aiming to achieve the same aim by the year 2020 (2). The only difference is the time interval of two decades. There is no road map as to how this is going to be achieved. With budgetary support ranging between 3-5% in different Five Year Plans and 3-9 % expenditure on health in different States for the last many decades how this is going to be accomplished is difficult to envision. The investment in health care sector has in fact declined from 1.3 % to 0.97 % of GDP (in 1999) (3). 13 to 15 % of Indians do not have access to health care facility. Rural health infrastructure will have to be strengthened, which at present remains in a very poor state. The situation is further complicated by health being a State Subject. The functions of the Central Govt are set out in accordance with the Article 246 of the Constitution, under Union List & Concurrent list. Regulation and development of medical, pharmaceutical, dental, and nursing professions fall under the Central jurisdiction, so does the Control of Drugs and Poison within the Concurrent list. Prevention of extension of communicable diseases from one unit to another also falls under the Concurrent list (4). Rest of the functions relating to health care comes under the State function. Therefore parameters, results, inputs, and indicators differ from sate to state and at times vary widely. Realistic and enforceable policies are required to upgrade health care facilities.
Procurement
Procurement in any health care facility is capital intensive. 40 to 60 % of the outlay in any health care institution goes for equipment. And upgrades are frequently required as electro- medical equipments improve or modify rapidly & frequently. To suit the requirement frequent addition/alteration are required in the civil work. The support for the civil work not being under the control of hospital authorities more often than not it takes time and a lot of effort for the hospital staff to get the required changes done. This all reflects on the quality of patient care and their disposal. Procurements in the health care sector are related to: -
1. Works
2. Goods
3. Services
Works
Works include civil work, construction of hospital-its designing & maintenance. Rapid and frequent modifications are required to meet the requirements of changing pattern of equipments and ancillaries. As far as the public care health facilities are concerned professional approach to construction of hospitals is lacking. There is normally a resistance to include hospital planning experts in the group. The result is that at any health care facility present a dismal look, hardly cheerful environs for the patients.
Color code, the flooring, and many other aspects of hospital construction require special attention. The floor of a health care facility should be smooth so as to minimize the chances of harboring microbes. Similarly wooden furnitures accumulate dirt and microorganism, hence should not be allowed in the patient care area. Look of a health care facility needs to be aesthetically designed to appear pleasing and patient friendly. Designing of a health care facility also has to take into consideration the type of the health care facility. If it is a sanatorium it has to be suitably designed so as to provide wide areas of garden etc, and recreational facility. If a psychiatric hospital is being planned it has to have facilities for occupational therapy. Rehabilitation centers have to be planned keeping the requirement of rehabilitation in mind. If it is artificial limb center it has to have parallel bar walking areas etc, and facilities for different physiotherapy exercises. Well designed hospital with natural light and air circulation is important for patient recovery. Expertise available in the public sector is inadequate. Expenditure on designing and construction of a hospital is thus remain not cost-effective. At best it is just 40 – 50 %. It is better to invest 110% and achieve 80-90% cost-effectiveness than to invest 100% and achieve only 40-60% of cost- effectiveness. Cost-effectiveness has to be measured it terms of achievement of desired or intended parameters.
Design of PHC & CHC should be standardized, and be on a modular concept. Though the manpower of each PHC & CHC is standardized the building design, the services and the maintenance agencies are not standardized. Similarly district level hospitals should also be on a standard pattern so as to ensure, or at least try to ensure standard patient care.
Even for day today maintenance there is no dedicated task force available, and maintenance task in a hospital is just one of the tasks of the public works services. Under the circumstances it becomes difficult to attain speedy repair or maintenance. More so in case of electro-medical equipments which requires specialized handling, maintenance & repair.
Goods
Procurement of goods in a health care establishment may be viewed in two groups. These are drugs and pharmaceuticals, and equipments. There are stringent rules and procedures, and standards laid down for drugs and pharmaceuticals. The same cannot be said about the equipments. The regulatory authority regarding drugs and pharmaceuticals is the Drug Controller of India, but his functions are limited to certifying new drugs, regulating import of new drugs, and laying down pharmaceutical procedures. The procedures are laid down in the DGS&D manual. Procurement policies are elaborate, and in detail. Under the Drug & Cosmetic Act 1940(as amended) the regulation of manufacture, sale & distribution of drugs is primarily the concern of the State authorities while the Central authorities are responsible for approval of new drugs, laying down the standards for the drugs, and coordination with a view to bring about uniformity in enforcement of the Act (5).
Central Drugs Laboratory, Calcutta (established under this Act) is the national statutory laboratory of the Govt of India for quality control of imported drugs & cosmetics. Its functions include active collaboration with the WHO in preparation of International Standards & specifications for International Pharmacopoeia. Central Indian Pharmacopoeia Laboratory is also a statutory body for quality control of drugs and cosmetics (including contraceptives), and is an appellate authority in disputes relating to the quality of condoms (5).
Thus it is obvious that there are elaborate rules/policies regarding drugs in India. Implementation very much depends upon on the State authorities. It
is a common knowledge that manufacturers of spurious drugs are thriving because of indifferent attitude of the controlling agencies, but hardly any effective measure is enforced. Those who get caught wriggle out by unfair means and indulge in the malpractice all over again. This exemplifies the loose control exercised by the regulatory authorities.
As far as the equipments are concerned there are no regulations, policies or standards to cover all equipments and intruments. This makes things difficult. One has to rely on declared parameters of the manufacturers, which in principle appear comprehensive but may differ in standards. The differences may be very wide and may be difficult to comprehend at the initial stage till one faces difficulties during maintenance. So far sophisticated electro-medical equipments are concerned this may not be a problem area as the standards may be verifiable and known. But as far as the other equipments are concerned it may be an area of acute problem, especially in the procurement of bio-medical waste treatment equipments. There are no laid down standards for incinerator, hydroclave, or shredder. This aspect being recent to India poses great difficulties in absence of standards. The acquisition therefore will remain totally dependant on the collective or individual wisdom, or knowledge about these technologies and its application which will bear upon acquisition of these equipments. And knowledge, as well as its application being poor in India it would be a matter of chance, or luck if one hits upon acquiring appropriate technology or the make for appropriate application. It must be appreciated that improper, or no waste disposal is the root cause for most of environmental and social degradation.
Even for proven equipment maintenance is so poor that at any given time about 40 % of these equipments remain unserviceable for want of proper maintenance (6).
Process of acquisition of (medicine or equipment) follows principle of L-1 as per laid down rules or the guidelines. That means once the QRs are laid down the lowest bidder has to be given the supply order. Therefore it is absolutely essential that the QRs are laid down with utmost care so that unreliable suppliers are excluded. Nevertheless at times procurement lacks quality due the insistence to follow the principle of L-1. Medicines are indented by generic names. There are umpteen numbers of firms producing the same medicine with the same formula, and some of these may have sprouted only a few days ago. These firms have the advantage of quoting a lower price because of low infrastructural investment but neither have the same dependability nor assured quality. Therefore at least in procurement of medicines one has to review the principle of L-1, its validity for universal application viewed in the context of reliability. In fact bar coding may be one of the measures which can be adopted to ensure quality.
Services
Health care establishments are complex entities encompassing general administration to health care administration, canalizing technical know how, establishing and maintaining rapport with the public at large, and the society it serves, and presenting a patient friendly ambience and atmosphere. It is difficult task to achieve.
Services in a health care establishment are technical, & non-technical. Technical services have to be necessarily provided by the health care professionals – doctors, nurses, paramedics, and staff trained in patient care (preventive, promotive, and rehabilitative aspects of health care), the non-technical services may be managed by others. Health care establishments in the public sector find themselves seized with the problem of looking after the non-professional services also. This cuts on the available time to look after the patients and related professional work thus affecting the quality of patient care. Services like cleanliness, laundry, patient food, security etc can always be outsourced. And in the present day scenario even the IT functions of the facility (without compromising confidentiality) can be outsourced. Outsourcing is the ‘in thing’ as far as the private health care facilities are concerned. The same cannot be said about the public sector facilities.
The Problem
It can thus be seen that there are problem areas which need to be corrected if health for all is to be achieved. What is done must have State machinery as the focus since health is a State subject. Some measures are described in the subsequent paragraphs.
Suggested Solution
Constitutional/Statutory/Regulatory
Health is all pervasive and healthy body & mind is an asset to any society. At the same time measures are also required to prevent misuse of drugs by bringing in better uniformity at the state level health care delivery system. Any measure which falls short of achieving this aim may be termed as a deficiency or shortfall. Second rate health of people will give rise to only second rate intellectuals. Therefore the health standards and quality of health care should be of paramount concern in any society. With the growth in population malpractices have set in, and therefore there is an urgent need to provide stringent and effective measures. With the population growth the waste generation has also grown exponentially, the natural barrier has reduced (thus spread of infection with greater ease); load on the urban health care facilities has increased substantially, bringing in malpractices in many forms. The quackery has gone up in absence of strict controls. As per the WHO 45 to 50 % of all injections given in the developing world are either unsafe or unnecessary (7). This is a potent source of spread of infection, resulting in higher morbidity demanding increased facility. It would thus be seen that ultimately it is the resources of the society which gets depleted. Definition of positive health, as per the WHO, talks only of absence of diseases & infirmity. Whereas today, our body has been polluted by chemicals, which may not manifest clinically; but have adverse effect on the physiology of human body, or on the behavior pattern. Chemical pollutants in the body affects health and behavior pattern of individuals. It is an area of research to determine these adverse effects. Therefore the definition of ‘positive health’ must change to include absence of pollutants in the body and aim should be to achieve ‘Total Health’. The apt definition therefore would be “A state of complete physical, mental and social well being, where life thrives in healthy environment devoid of pollutants; and absence of disease and infirmity.” Proper disposal of bio-medical waste is the core issue in the health sector which is still to be recognized with importance it deserves. Hospital Acquired Infection (HAI) is a matter of great concern to all health care planners. A study in UK (and since expenditure in patient care in UK is all funded by the public sector there cannot be any other better indicator) indicates clearly that over expenditure on account of treating HAI costs the state exchequer an additional amount of about one billion pounds per year. In terms of man-days lost, it amounted to an estimated 8.7 million days (9). Therefore establishing a ‘Waste Management Authority of India (WMAI)’ will not be a bad idea (10). Manifest illness, sub-clinical affliction, infection control, environmental health, pollution, and waste management, all have to be viewed together. Only then one can aspire to achieve a healthy society with improved health care.
There is therefore a necessity of reviewing the statutory rules in order to improve its applicability, and effectiveness. The present rules do not provide intervention by the Central authorities at will. The State machineries vary widely in controls and inspection standards. Federal laws, therefore appear to be the answer. The argument that it will be against the basic principles of democratic pattern of the country is baseless. The US has over riding federal laws and is a successful democracy. For example law and order is a State subject. This includes protection against infiltration. What havoc this has caused in the country, especially in Border States, is for all to see. There are many other examples which can be quoted, but the intention is to limit the argument relevant to the issue.
Health being a State subject, it is not possible for the Central authorities to intervene effectively. Sale and distribution of spurious drugs, fluids, and blood is everyday news. The State machineries, for some reason have not proved effective. The standards of enforcement differ from State to State depending on the political will, vote-bank equation, level of awareness, economical health, and organizational support or protection. A large number of diseases spread by unsafe injections, blood transfusion, use of narcotics leading to sharing of syringes etc. At most of the time the Central authorities remain a mute witness despite the resolve and capacity to intervene. Spread of infection respect no boundaries. Hence it is necessary to establish federal authority for periodic monitoring (apart from the routine monitoring of the State apparatus). The federal agency must be empowered to issue directives overriding the State’s directive in case it is at a conflict. The whole question on this issue is already under consideration of a high powered committee headed by the chairman of CSIR.
Works Related
Construction of the PHCs & CHCs must be entrusted to experts in the field by outsourcing. The existing infrastructure should also be modified as per the modern standards through experts groups in hospital construction. A standard design concept should be introduced with the concept of modular system for all the States. Designing the buildings with ancillary support is a specialized job. Maintenance of the building, electrical fittings, and many other support services relating to the structure of a health care facility can be easily outsourced to achieve better results, and to save on the effort of the professionals which will ultimately reflect positively on the health care. Presently maintenance of general medical equipment at peripheral hospitals & at the CHC etc is at the mercy of state workers who are ill-trained and not dedicated. Of late a welcome trend has set in for sophisticated medical equipments, i.e. Annual Maintenance Contract (AMC). This in a way is outsourcing. The same concept is required to extend to all levels of health care. Therefore there is a case for considering dedicated and specifically trained task force for maintenance of health care facilities, which can be specific to a large hospital or health care facility or cater to a typical group.
Procurement related
Rules regarding procurement of drugs are well laid out. The necessity is to implement the provisions in letter and spirit. Giving more teeth to the Central authorities will make the desired difference. But there are no laid down standards relating to acquisition of equipments. There is a requirement to create an appropriate authority for this purpose to function under the Drug Controller, Govt of India. Procurement is by and large market driven, and trade pressure at times is quite obvious.
To safeguard the interest of the state & the organization a Standard Purchase Committee should be established at each district level which should cater to the purchases of medicines & equipment of the CHC & PHC of that district, and health care facilities up to district hospital level. Larger hospitals and teaching hospitals may have their own Standard Purchase Committees. Duration of members should be fixed with provision of rotation to minimize corruption.
There is a requirement to create instruments to ensure quality assurance, uniformity and maintenance standards.
Summary of Recommendations
• Review of statutory bodies, its powers, and regulatory mechanism/methodology at the Central & State level
• Create a Waste Management Authority to deal with waste management in a comprehensive & effective manner.
• Greater control over the State authorities to ensure uniformity.
• Create Federal structure for better control & implementation
• Introduce standard design and modular concept for the hospitals, CHCs & PHCs, and other health care establishments, as far as possible.
• Provision of dedicated engineering task group for maintenance of hospital building, infrastructure, electric fittings, and ancillary services; or to provide technical guidance & control in case these services have been outsourced.
• Standardization of equipments of all types
• Outsourcing all the non-technical services
• Stricter vigilance & implementation
• Effective management of bio-medical waste
• In order to ensure quality acquisition the concept of L 1 needs to be reviewed
• Formation of standard purchase committee with provision of changes of members on a rotational basis
• Greater care while laying down QRs for acquisition so as to eliminate poor quality manufacturers
• Provide regular review of the provisions and regulations in order to improve/modify
• Bar-coding of medicines to indicate quality
Conclusion
Health care in India has many shortcomings. It needs a general revamping. Specific weaknesses have to be identified, and strengthened. Unless weaknesses are identified it is not possible to strengthen. Resolve to implement has to improve. There are weaknesses in the statutory provisions, regulatory rules, and control mechanisms. These need to be studied and corrected. Dr Mashelkar Committee is considering the issue, and it is hoped that it comes up with recommendations in the national interest; and in the interest of health care. The bottom line of course is clean, transparent, and corruption free dealings and acquisitions.
New Delhi
May 14, 2003 (LK Verma)
References
1. National Health Policy Document
2. ‘Vision 2020’ released by Shri KC Pant, Vice Chairperson Planning Commission – Times of India, Jan 24, 2003
3. National Health Report-1997
4. Park’s textbook of Preventive & Social Medicine, 15th edition, page 601
5. Indian Pharmacopoeia, 1994
6. Paper presented during ‘QUEST – 2001’ Conference – Lt Col RK Chaturvedi, Associate Professor, Department of HA, AFMC
7. Hospital Waste in Latin America – J Monreal (1991), WHO/PEP/RVD/94.1
9. ‘The Socio-economic Burden of Hospital Acquired Infection’ – Rosalind Plowman et al, Apr 1994 to May 1995
10. Article ‘Needed: a National Waste Management Authority’ –Verma LK, Pharmabiz Hospital Review, Nov 16 – 30, 2002
Pollutants & Human Health
As has been discussed earlier 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.
Foot Note: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 content 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 limits and nickel was 4 -20 times . 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 .
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 . Researchers in US have uncovered new route of bacterial transmission.
Growth Promoter antibiotics in food Pigs Pigs Guts
Excreta soil underground water human beings.
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 .
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: -
Place Date Excess deaths in numbers
Meuse Valley, Dec. 1930 63
Belgium
London , U.K. Dec. 1952 3500
New York, USA Nov. 1953 200
London, U.K. Dec. 1962 700
Osaka, Japan Dec. 1962 60
And, recently 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 .
Foot Note:
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 are 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 . 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 . Exposure of humans and animals to sulphur 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 . Once formed these gases do not degrade easily. In other words the formation may be easy 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 borne 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 . However the testing for dioxins is very expensive. One test may cost as much as $1000 to $3000. Not more than 50 laboratories are there in the world which can test for dioxins, and all of these laboratories are located in USA, Europe and Japan. Half life of Dioxin is reported to be 6-12 years .
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 neighbor hood 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 :-
SOURCES OF DIOXINS
Municipal Waste 1000-10,000 g. TEQ/Year
Cement Kilns & Boilers 90 – 1000 g. TEQ/Year
Wood Burning (Industrial) 30-1000 g. TEQ/Year
Forest Fire 40 – 900 g. TEQ/Year
Wood Burning (Residential) 30 – 150 g. TEQ/Year
Sewage Sludge Incineration 10 – 100 g. TEQ/Year
Coal Combustion 50 – 150 g. TEQ/Year
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 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 were located in North Delhi hospitals, and 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. This appears to be the Indian reality.
Foot Note:
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 dozens” 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. India is yet to ratify .
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 USA restructured National Ambient Air quality to PM10. In 1997, the EPA proposed new standard for PM less than 2.5µm in aerodynamic diameter . 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 piggyback 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 .
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 . 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) . 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 1.0-1.2% per year vehicular pollution has increased from 15 million tons in 1947 to 1030 million tons in1997.
Foot Note:
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, 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 get 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 µm and 4 µm. During breathing at rest 10% of compact particles of 0.5 to 1 µ diameter tends to be deposited in the alveoli. 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 . 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 . 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) .
LONDON GAS TRAGEDY
OF 1952 & 1962:
A COMPARISION
---------------------------------------------------------------------------------
1952 1962
Excess deaths
3500 700
(excl. 2000in the county)
24 hrs average 4000 µg/m3 800 µg/ m3
particulate matter
SO2 (Max) 1.5 ppm 1.5 ppm
SO2 (Average) 0.95 ppm 0.80 ppm
Inference: - Particulates play a dominant role in causing mortality/morbidity.
It is thus well established that particulates cause high incidence of morbidity & mortality hence burning of waste must be avoided.
Volatile Organic Compounds (VOC)
(i) Lead.
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% . 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 . 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 . 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 . 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 . 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
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 Minimata 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 .
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 Minimata Bay in 36 years. In India, 44% of mercury goes unaccounted .
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 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 . 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.
Thus 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 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.
Lalji K Verma
As has been discussed earlier 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.
Foot Note: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 content 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 limits and nickel was 4 -20 times . 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 .
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 . Researchers in US have uncovered new route of bacterial transmission.
Growth Promoter antibiotics in food Pigs Pigs Guts
Excreta soil underground water human beings.
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 .
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: -
Place Date Excess deaths in numbers
Meuse Valley, Dec. 1930 63
Belgium
London , U.K. Dec. 1952 3500
New York, USA Nov. 1953 200
London, U.K. Dec. 1962 700
Osaka, Japan Dec. 1962 60
And, recently 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 .
Foot Note:
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 are 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 . 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 . Exposure of humans and animals to sulphur 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 . Once formed these gases do not degrade easily. In other words the formation may be easy 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 borne 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 . However the testing for dioxins is very expensive. One test may cost as much as $1000 to $3000. Not more than 50 laboratories are there in the world which can test for dioxins, and all of these laboratories are located in USA, Europe and Japan. Half life of Dioxin is reported to be 6-12 years .
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 neighbor hood 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 :-
SOURCES OF DIOXINS
Municipal Waste 1000-10,000 g. TEQ/Year
Cement Kilns & Boilers 90 – 1000 g. TEQ/Year
Wood Burning (Industrial) 30-1000 g. TEQ/Year
Forest Fire 40 – 900 g. TEQ/Year
Wood Burning (Residential) 30 – 150 g. TEQ/Year
Sewage Sludge Incineration 10 – 100 g. TEQ/Year
Coal Combustion 50 – 150 g. TEQ/Year
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 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 were located in North Delhi hospitals, and 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. This appears to be the Indian reality.
Foot Note:
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 dozens” 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. India is yet to ratify .
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 USA restructured National Ambient Air quality to PM10. In 1997, the EPA proposed new standard for PM less than 2.5µm in aerodynamic diameter . 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 piggyback 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 .
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 . 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) . 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 1.0-1.2% per year vehicular pollution has increased from 15 million tons in 1947 to 1030 million tons in1997.
Foot Note:
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, 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 get 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 µm and 4 µm. During breathing at rest 10% of compact particles of 0.5 to 1 µ diameter tends to be deposited in the alveoli. 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 . 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 . 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) .
LONDON GAS TRAGEDY
OF 1952 & 1962:
A COMPARISION
---------------------------------------------------------------------------------
1952 1962
Excess deaths
3500 700
(excl. 2000in the county)
24 hrs average 4000 µg/m3 800 µg/ m3
particulate matter
SO2 (Max) 1.5 ppm 1.5 ppm
SO2 (Average) 0.95 ppm 0.80 ppm
Inference: - Particulates play a dominant role in causing mortality/morbidity.
It is thus well established that particulates cause high incidence of morbidity & mortality hence burning of waste must be avoided.
Volatile Organic Compounds (VOC)
(i) Lead.
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% . 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 . 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 . 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 . 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 . 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
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 Minimata 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 .
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 Minimata Bay in 36 years. In India, 44% of mercury goes unaccounted .
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 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 . 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.
Thus 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 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.
Lalji K Verma
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