by ALECKS P. PABICO

NOT TOO long ago, protests were at fever-pitch over how healthcare facilities in the country disposed of their waste. After all, study after study had pointed to an increasing share of healthcare waste in the total municipal solid waste stream. More importantly, that included infectious and hazardous wastes whose then rather haphazard handling, storage, treatment, and disposal had activists and other observers sick with worry about their adverse health and environmental effects.

	MEDICAL waste used to be dumped and burned along with ordinary domestic waste. [photo courtesy of HCWH]

But these days, Ester Borja, chairperson of the Waste Management Committee (WMC) of the Philippine Heart Center (PHC), is grinning from ear to ear — and it’s not because of the news of the P10,000 bonus to government employees. It’s because for almost two years now, the Heart Center has not only reduced the amount of waste it generates significantly, it has managed to earn six-figure amounts from waste trading.

This is on top of the fact that it — along with other hospitals across the country — has done away with incinerating infectious waste since 2003. Earlier this year, too, the Heart Center began phasing out gadgets (like thermometers) and equipment that use mercury, a potent neurotoxin that can cause developmental defects and can harm the brain, kidneys, and lungs.

Borja is likewise pleased to announce that the PHC's Nutrition and Dietetics Division has agreed to replace styrofoam packs with biodegradable boxes as food containers, especially for take-home meals. And for several years now, the Pharmacy Division has been using paper bags when dispensing medicines to patients. In addition, the talks have started for the hospital’s Purchasing Division and the Bids and Awards Committee to adopt green purchasing policies for medical supplies during the next bidding schedule.

The Heart Center is actually among the four Metro Manila tertiary government hospitals chosen by Health Care Without Harm (HCWH) to include in its documentation of local best practices in hospital waste management. The resulting report, which was released earlier this year, debunks an enduring perception that government-run hospitals are less capable of properly handling waste. The experiences of the Heart Center, San Lazaro Hospital, Philippine Children's Medical Center (PCMC), and Ospital ng Muntinlupa, show as well that healthcare-waste management can be effectively implemented in developing countries like the Philippines, where incineration is even banned.

“Their practices show what is doable,” says Merci Ferrer, Asia coordinator of HCWH, a global coalition of environmental health advocates working to reduce pollution in the healthcare industry. Yet even these exemplary hospitals may still be stuck in their old, wasteful — and quite harmful — ways had it not been for the growing green awareness in the last decade or so, and the eventual (if belated) moves of the government to make healthcare facilities clean up properly.

MOST HEALTHCARE waste are considered to be no more dangerous than any ordinary household trash. But there are types that do expose humans — healthcare workers and the public alike — to graver health risks. These include infectious materials that, according to an assessment done by the World Health Organization (WHO) in 2002, make up 15 to 25 percent of total healthcare waste. These could be in the form of sharps like needles, scalpels, or broken glass (one percent), body parts waste (one percent), chemical or pharmaceutical waste (three percent), and radioactive and genotoxic waste, or broken thermometers (less than one percent). (see Table)

Table 1: Classification of Healthcare Waste Source: DOH Health Care Waste Management Manual
WASTE TYPE	DESCRIPTION	COLOR CODE (for plastic bag or containers)
General waste	Comparable to domestic waste, this type of waste does not pose special handling problem or hazard to human health or to the environment. It comes mostly from the administrative and housekeeping functions of healthcare establishments and may also include waste generated during maintenance of healthcare premises.	Black and green
Infectious waste	Contains pathogens (bacteria, viruses, parasites, or fungi) in sufficient concentration or quantity to cause disease to susceptible hosts. This includes: cultures and stock of infectious agents from laboratory work; waste from surgery and autopsies on patients with infectious diseases (e.g. tissues, materials or equipment that have been in contact with blood or other body fluids); waste from infected patients in isolation wards (e.g. excreta, dressings from infected or surgical wounds, clothes heavily soiled with human blood or other body fluids) waste that has been in contact with infected patients undergoing hemodialysis (e.g. dialysis equipment such as tubing and filters, disposable towels, gowns and aprons, gloves and laboratory coats) infected animals from laboratories; and any other instruments or materials that have been in contact with infected persons or animals.	Yellow
Pathological waste	Consists of tissues, organs, body parts, human fetus and animal carcasses, and blood and body fluids	Yellow
Sharps	Include needles, syringes, scalpels, saws, blades, broken glass, infusion sets, knives, nails and other items that can cause a cut or puncture wounds. Whether or not they are infected, such items are usually considered as highly hazardous healthcare waste.	Red
Pharmaceutical waste	Includes expired, unused, spilt, and contaminated pharmaceutical products, drugs, vaccines, and sera that are no longer required and need to be disposed immediately. This category also includes discarded items used in handling of pharmaceuticals such as bottles or boxes with residues, gloves, masks, connecting tubing, and drug vials.	Yellow
Genotoxic waste	May include certain cytostatic drugs, vomit, urine, or feces from patients treated with cytostatic drugs, chemicals, and radioactive materials. Highly hazardous and may have mutagenic, teratogenic, or carcinogenic properties.	Orange
Chemical waste	Consists of discarded, solid, liquid, and gaseous chemicals, for example from diagnostic and experimental work, and from cleaning, housekeeping, and disinfecting procedures; may be hazardous or non-hazardous.	Yellow with black band
Waste with high content of heavy metals	Represents a subcategory of hazardous chemical waste, and are usually toxic. This could be mercury waste from broken clinical equipment (thermometers, blood pressure gauges, etc.) cadmium waste from discarded batteries.	Yellow with black band
Pressurized containers	Many types of gas are used in healthcare and are often stored in pressurized cylinders, cartridges, and aerosol cans. Many of these, once empty or of no further use, are reusable, but certain types, notably aerosol cans, must be disposed of.	Red
Radioactive waste	Includes disused, sealed radiation sources, liquid and gaseous materials contaminated with radioactivity; excreta of patients who underwent radionuclide diagnostic and therapeutic applications; paper cups, straws, needles and syringes, test tubes, and tap water washings of such paraphernalia. It is produced from vitro analysis of body tissues and fluids, in vivo body organ imaging, tumor localization and treatment, and various clinical studies involving the use of radioisotopes.	Orange

In the same study, the WHO also cited estimates of infections worldwide caused by injections using contaminated syringes ? 21 million cases of hepatitis B virus (which was 32 percent of all new infections in 2002), two million hepatitis C virus cases (40 percent), and 260,000 HIV cases (five percent).

Yet from only nine tons of infectious waste per day based on a 2000 study done by the Metropolitan Manila Development Authority (MMDA), the figure almost doubled to 17 tons per day in a 2001 study commissioned by the Japan International Cooperation Agency (JICA), and to 27 tons a day in 2003, according to an Asian Development Bank (ADB) report. WHO has estimated that, based on population projections, local healthcare waste could reach as much as 69.5 tons per day by 2050.

In the past, many healthcare facilities relied on incinerators as a waste-disposal option. The JICA study revealed, for instance, that almost half of the 158 facilities surveyed disposed their infectious wastes through incineration. The ADB study, meanwhile, found that only about five tons of infectious wastes generated daily were disposed of either through incineration or non-burn technologies (autoclave, microwave), while 22 tons were either buried on site or irresponsibly thrown along with the rest of the municipal waste for dumping in open dumpsites or landfills.

Then in June 1999, Republic Act 8749, also known as the Clean Air Act, was signed into law, thereby signaling the end of the use of incinerators for waste disposal. (see sidebar) Two years later, the Department of Health (DOH) began revising the existing healthcare-waste management manual developed a decade before by the agency's Environmental Health Service and the Metro Manila Authority (now the MMDA).

The changes dealt mainly with ensuring that the manual was attuned to the provisions of the Clean Air Act and another new law that was also instrumental in pushing for reforms in the management of healthcare waste: RA 9003, or the Ecological Solid Waste Management Act of 2000. Among others, this law requires the promotion of recycling and composting in dealing with solid waste. (Previously, the disposal of hospital wastes was governed primarily by RA 6969, or the Toxic Substances, Hazardous Waste, and Nuclear Waste Control Act of 1990, which covers only infectious and pathological wastes, and expired pharmaceutical products.)

The manual’s revision, as then health secretary Manuel Dayrit explained, was meant to widely disseminate the proper use of existing technology and knowledge on healthcare-waste management. With its practical information on alternative yet safe, efficient, and environment-friendly technologies, the manual has to this day been serving as a useful guide in the planning, implementation, monitoring, and evaluation of the healthcare-waste management programs (HCWMPs) of hospitals, health centers, laboratories, pharmaceutical firms, blood banks, and other health-related establishments.