An Alternative Systems Approach to
Healthcare Waste Management

The problems in healthcare waste management stem from a failure of both practice and technology. Lack of waste segregation, unsafe waste handling, dumping of untreated waste, preferential procurement of toxic products, extensive use of disposable materials, inadequate procedures for clean-up and containment of spills, weak inventory controls of time-sensitive pharmaceuticals and reagents, and inappropriate classification of non-infectious waste as bio-hazardous waste are examples of poor practices that lead to high rates of healthcare waste generation in health facilities.

Attempts to solve the challenge of infectious waste disposal through burning and incineration have been less than satisfactory in many developing countries, even without considering the serious problems of dioxin formation and release. In many cases, the incinerators cause objectionable smoke and odors; break down frequently; are difficult to properly operate and maintain; produce toxic ash; and discourage efforts at segregation, recycling and waste minimization. The solution, therefore, must address both the practices and technologies used.

There is a growing understanding that proper treatment of infectious healthcare waste must be part of a facility-wide systems approach to waste management. At the level of "on the ground" intervention, the approach must involve institutionalizing best environmental practices at healthcare facilities in order to minimize the production of healthcare waste. In addition, the systems approach entails the use of appropriate technologies that do not involve combustion of healthcare waste. Together these components comprise an Alternative Systems Approach to healthcare waste management that can effectively reduce and ultimately eliminate releases of dioxins and mercury.

Improving Waste Management Practices

In general, good healthcare waste management practices include all of the following components: pollution prevention; waste minimization; correct classification and segregation; proper containerization and color-coding; safe handling and collection of waste; labeling and signage; and proper storage, transport and final disposal of waste. Priority in this project is given to pollution prevention and waste minimization, the latter entailing environmentally preferable procurement practices, source reduction, material substitution, safe reuse, recycling and composting of waste where possible.

Hazardous healthcare wastes (infectious, chemical and radiological wastes) typically comprise about 15% or less of the total waste generated by healthcare facilities. A system of rigorous segregation as well as pollution prevention and waste minimization can greatly reduce the amount of waste that requires special treatment. Achieving this requires transforming a healthcare facility in all of the following ways: changes in administrative policy; the development, with stakeholder participation, of effective plans with clear definitions of roles and responsibilities; followed by consistent and effective implementation of the agreed plan. Regular training at all levels of the facility and motivational programs to promote behavioral change are of paramount importance. Monitoring, periodic evaluation, continuous program improvements and full consideration of occupational safety and personal protection are essential.

Many of the best practices used to minimize or eliminate dioxin releases are similar to those required for minimizing or eliminating mercury releases. Specifically, mercury waste management requires the development of a mercury reduction plan that considers critical opportunities for material substitution, training, spill response and recovery, personal protection, segregation, containment, long-term engineered storage and encapsulation or amalgamation.

Improving Waste Treatment Technologies

Environmentally sound technologies are the other critical part of the Alternative Systems Approach. Alternative technologies suitable for the treatment of healthcare waste include the following: autoclaves or retorts, with or without shredders to reduce waste volume and render healthcare waste unrecognizable; integrated or advanced steam systems such as rotating autoclaves, combined pressurized steam-internal shredding units, hydroclaves, etc.; microwave systems; and alkaline hydrolysis to decompose tissues, anatomical and animal wastes, and possibly chemotherapeutic waste.

These technologies are well-established and have been in operation for at least a decade, or many decades in the case of standard autoclaves. They effectively decontaminate waste, but do so below temperatures at which combustion and dioxin formation take place. A number of other alternative technologies, such as chemical disinfection systems using chlorine and emerging technologies such as irradiation and plasma pyrolysis, raise occupational safety or environmental issues including dioxin formation and are not considered as appropriate solutions in this project. Learn more about non-burn alternatives to incineration.

Alternative technologies must be capable of meeting international standards on microbial inactivation, be easy to operate and maintain, and be affordable enough to gain acceptance by health facilities. Possible low-cost designs for resource-limited areas include locally made, small- to medium-scale pressure vessels using electricity, gas, solar or other local fuels, as well as small manual and electrical shredders. These appropriate technologies are being developed for Africa as part of this project. Learn more about the project's work in Tanzania toward this end.

Mercury-free technologies include digital, glass alcohol, galinstan and tympanic thermometers, as well as aneroid sphygmomanometers. Mercury-containing medical preservatives, fixatives and reagents can also be replaced with mercury-free substitutes that are now commercially available. As the demand for mercury-free products increases, the cost of these devices and mercury-free formulations will continue to decrease. Learn more about mercury-free alternatives.

This project is demonstrating the effectiveness of this alternative systems approach to healthcare waste management in model health facilities in each of the seven project countries. Learn more about the project's global goal and objectives, structure and partners, and expected benefits, or the project's work in Argentina, India, Latvia, Lebanon, the Philippines, Senegal, and Vietnam.