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Safe disposal of hospital wastes

Q&A service leads to intermediary role

by Rewat Yangyeun and Tien-ake Tiyapongpattana

Hospital waste can be a dangerous health hazard, especially if it is simply dumped in landfills. RISE-AT has been supporting hospitals in Chiang Mai that are loooking for better solutions. A working group has been formed to develop an efficient incineration concept. RISEAT is playing an important role in facilitating planning and decision-making processes. Approaches in Chiang-Mai could be applicable nationally.

When monsoonfloods washed away a small Chiang Mai hospital's accumulation of infectious wastes in mid-1995, its staff started to worry. Where might the wastes go? Would they contaminate the flood waters? Who might become infected? Following normal procedures, the wastes had been separated from the hospital's ordinary garbage, but the floods carried them downstream before they could be disposed of. Since disposal was problematic anyway and the hospital's staff knew about the newly established RISEAT, a first contact was made.

Initially, the query was perfectly straightforward. The hospital had long had difficulty disposing of its infections wastes. Not only are effective incinerators expensive, but the available municipal services do not distinguish between ordinary garbage and toxic or infectious wastes. The hospital therefore wanted to know whether RISE-AT knew of any good, low-cost incinerators that it could install. It would then be able to burn its own wastes before they were washed away or were dumped into the ordinary communal landfill.

Health hazard

Through contacts at the Asian Institute of Technology (AIT) in Bangkok, RISE-AT was able to refer the hospital to a Hungarian incinerator that might serve its purposes. However, the query interested RISE-AT so much that, after talking the problem over with the hospital, it decided to see whether other hospitals in Chiang Mai had similar problems. A survey conducted among the city's 28 hospitals in late 1995 produced an unequivocal answer: Yes!

Unfortunately, some of the hospitals felt the issue was too sensitive to discuss. Even so, 18 of the 28 responded to RISE-AT's questionnaire. It turned out that as each hospital bed generates roughly 0.4 kgs of wastes per day, the 4,762 beds in the 18 responding hospitals generate some 1.8 tons of waste per day. The majority of responding hospitals separate their wastes and most of these, generally the larger ones, incinerate them. However, not only are most of the incinerators substandard but the majority of Chiang Mai's hospitals, perhaps even as many as 20 out of 28, do not incinerate at all. In other words, because the municipality does not distinguish between types of solid waste, quite large quantities of infectious waste that may even include diseased organs, whether separated by the hospitals or not, are dumped in ordinary landfills where they constitute a substantial public health and environmental hazard. Quite clearly, it would be advantageous if a better solution could be found.

By this time, RISE-AT was fully committed to the problem. So in late January 1996, it organised an informal working group among staff from some of the hospitals it had surveyed. Technicians from the leading hospital, Maharaj, were invited to share their experience with incineration. Officials from the Provincial Health Office, the municipality and the Thailand Research Fund were invited to attend.

The discussions identified a cluster of quite intricate technical and economic problems. For although incineration is the obvious way to safely dispose of infectious wastes, it is neither cheap nor necessarily easy. On the financial side the capital cost of the equipment is often greater than a small hospital wanting to buy its own incinerator can afford. Technically, incineration must occur at high temperatures. Otherwise the smoke and toxic gases produced from rubber gloves and disposable syringes among other items, not to mention the possible survival of harmful bacteria and viri from diseased tissues, make it a greater health and environmental hazard than just combining the wastes with the normal garbage stream. And if the municipality cannot offer a communal incinerator, should the hospitals form some sort of co-operative to set up their own system? If so, how, where, what are the costs, how would it work and be paid for?

As these issues emerged they began to ramify into the overall waste management problem faced by Chiang Mai (cf. previous story). In a farreaching move, the working group therefore established a formal organisation - The Working Group for Chiang Mai Hospital Waste Management. Chaired by the Provincial Health Officer, and including representatives from the municipality, the Thailand Research Fund, and 11 Chiang Mai hospitals and facilitated by RISE-AT, the CHWM held its first meeting on 2 February 1996. It met again in late April at RISE-AT and has since been informed by the municipality of its intention to move the incinerator from Maharaj Hospital to municipal land so as to operate it as a municipal service for all Chiang Mai hospitals.

Cost-effectiveness

This welcome decision in principle largely solves the initial problem and shows the efficacy of the working group approach. However, actually implementing it may take time, and as RISE-AT's earlier investigations showed, the issue is not that simple.

Essentially, the safe disposal of infectious wastes is a cost to hospitals which they are morally obliged to meet. Now that an incinerator may soon become available, the issue switches from just disposal to efficient, cost-effective waste handling. RISE-AT identified the following areas for a more comprehensive concept at the 2 February meeting:

- apply all possibilities of pretreatment of wastes, especially on-site inactivation

- pre-collection and separation/recycling of wastes by type and hazard

- further in-hospital collection and transportation

- suitable and effective technologies for inactivation/disposal such as thermal, chemical or irradiation methods

- post-treatment issues including disposal of residues - management and staff skills and training needs

- equipment operation plans and manuals

- emergency plans (if the municipal incinerator is nonoperational)

-follow-up and monitoring of the waste treatment system (by which institution, how often and so forth).

The full investigation of all these areas within the context of the amount of wastes to be handled and the prevailing health and sanitation standards would permit the identification of the most cost effective cluster of waste treatment options both by individual waste and as an integrated infectious waste management system. Bearing in mind such things as transport costs of as much as 10 Baht per kg for, in some hospitals, up to 200 kgs of wastes per day to the central incinerator, such issues are far from trivial.

In one sense, both the formation of the Working Group and the decision to use the Maharaj Hospital incinerator for other hospitals also means that RISE-AT's role is over. But there are other senses in which it is still needed. The whole issue of wastes is still so sensitive between hospitals that they welcome RISEAT's presence as a neutral body through whom they can work. And, impending public health legislation that will soon require all hospitals to incinerate their wastes promises to force the issue to the attention of even those hospitals that at present are doing nothing.

This means that RISE-AT, working through the group, could still play an important role in facilitating the series of investigations outlined earner. But because their outcomes under the new legislation would be important to all hospitals in Chiang Mai the impact could be very much greater than was originally imagined. And if it is assumed that the law will come into force within a year and that hospitals will then have another year's grace period within which to begin incineration, something like a two-year investigation horizon emerges. Given that by that time incineration must be adopted by all hospitals, it follows that within the same time frame they need to investigate all the other aspects.

A further issue that has not yet been considered concerns the expansion of the concept as a whole. The group has so far been working and thinking purely in terms of Chiang Mai city. But there are many other hospitals in the province. Hospitals in other provinces will also have to obey the new law. Thus the group may unwittingly have begun to formulate general concepts and approaches that might be applicable nationally.

In any case, RISE-AT stands ready to play an intermediary role, facilitating the investigation, planning and decision-making processes as a neutral body able to mobilise technological and managerial expertise from qualified resources inside and outside the country. It is precisely this role that is proving to have immense value in working towards appropriate solutions for specific problems.

Rm

A Chiang Mai, une ville du Nord de la Thande, d'importantes quantitde dets hospitaliers ont emport par les inondations de la mi-1995. Alarmpar cette situation, l'administration hospitali a contacte service d'information RISEAT pour borer une vaste strate d'mination des dets hospitaliers. Les projets d'mination des dets oduit qu'un groupe de travail doit borer pourraient avoir nombre de retomb positives, m audele la seule ron de Chiang Mail

Extracto

Las inundaciones arrastraron a mediados de 1995 los desechos de hospitales de la ciudad de Chiang Mail A rade ello, la administracie hospitales establecintacto con RISE-AT, a fin de elaborar un esquema integral pare el saneamiento de residuos hopitalarios. Las propuestas sobre soluciones econas pare el saneamiento de desechos, elaboradas por un grupo de trabajo, podr tener efecto malle Chiang Mail