Untreated medical waste: A serious threat to public health

Untreated medical wastes are accumulating at landfills in seven divisional cities, posing serious threat to public health.

These divisional cities, excluding the capital, have around 1,380 healthcare establishments -- public and private -- which produce over 20 tonnes of medical wastes every day.

Although there have been many reports on the same scenario in Dhaka city, the other divisional cities have often escaped scrutiny in this regard.

But the picture there is also quite alarming.

Photo: Rajib Raihan

With no comprehensive official data on medical wastes available, The Daily Star has obtained the approximate figure after talking with civil surgeons, city corporation officials and third parties.

The Daily Star correspondents have found an alarming picture of medical waste management -- from collecting and sorting wastes at the primary sources (hospitals and clinics) to dumping at designated landfills in Chattogram, Rajshahi, Barishal, Khulna, Rangpur, Sylhet and Mymensingh.

In these cities, there are designated bins for hazardous medical waste in almost every healthcare facility, but the healthcare professionals hardly follow the procedure regarding proper disposal of medical wastes.

According to experts, medical waste is not like other wastes and it can infect through the skin, as well as through inhalation or ingestion.

They said HIV, and Hepatitis B and C present the greatest risk from such waste. Besides, antibiotic resistant germs (superbugs) and other dangerous germs can spread from medical waste.

"Often, we observe public health hazards [cholera, typhoid or else] and we discuss only sewerage, not about medical waste. But it may be sourced from medical waste," said Prof Ahmed Abu Saleh, chairman of microbiology department at Bangabandhu Sheikh Mujib Medical University.

"Medical waste management situation is at a vulnerable stage as it has been overlooked over the years," he added.

Health Division Services Secretary Md Ashadul Islam told The Daily Star, "We are working to prepare a new development project plan (DPP) under which there would be on-site waste management in all district-level hospitals and medical college campuses." 

He added they did not have the authority to manage waste outside of these.

The DPP is at the planning stage and it would take time as like as any other project.

THE MEDICAL WASTELAND

Currently, all the landfills in the seven city corporations are situated either on low-lying wetlands or rivers, and at some points wastes are actually being dumped by the roadside.

In Sylhet, medical wastes are being dumped in Parairchak area, adjacent to a haor. In Barishal, they are being dumped in Puranpara landfill on the bank of Sapanial Khal, a seven-km long canal that flows into the Sandhya River.

Left untreated, the germs medical waste harbours easily spread through waterbodies, eventually contaminating the food chain. Experts deem this practice to be "extremely hazardous".

A divisional authority, comprised of the divisional director of Directorate General of Health Services as president, a representative of the respective city corporation as member, and a representative of the Department of Environment (DoE) as member-secretary, is supposed to look after the medical waste management.

This is according to the Medical Waste (Management and Processing) Rules 2008, a policy that is merely on paper.

As such, the authority it demands, however, has not been formed in any of the divisional headquarters.

In the absence of a committee, respective divisional city corporations broker a waste management deal between the healthcare establishment authority and a third party.

Similarly, waste collectors from city corporations or a licensed third party carry those medical waste into the landfills and dump it without it being sterilised.

The whole exercise is a clear violation of the medical waste management rules, which states "medical waste cannot be mixed with any other wastes at any stage -- while inside hospitals, while being collected, while transporting." The rules also state that the wastes should be processed separately based on classification.

A licensed third party would collect medical wastes to treat and dispose those inside a "separated, boundary-marked and protected site" inside a landfill, it added.

A third party is a person or an organisation, including an NGO, which has a monthly contract with a hospital or clinic to manage their medical wastes.

Unfortunately, be it a third party or the city corporation concerned, or any other body, nobody sterilises the medical wastes before dumping in the landfills.

The country has only one single medical waste treatment plant, which is located in Dhaka.

As a result, most medical wastes end up in landfills.

"This is absurd. Having third party does not make any sense when you are disposing all types of medical wastes together with other wastes, even after collecting separately," Dr M Maksudur Rahman, professor of geography and environment at DU, told The Daily Star.

There is a third-party service provider in these seven divisional headquarters, except in Barishal, where Prodipan, an NGO, stopped its activities in 2006 after two years of operation.

Of the remaining third-party providers, none has the required infrastructure to deal with medical wastes. According to the providers, the set-up is too costly.

Prism Bangladesh Foundation (PBF) started its operation in Sylhet and Rangpur from the beginning of this month.

"It's not like that PBF can manage it alone. First, we need waste separated from the hospital. There is a lack of practice among the healthcare professionals for multiple reasons," Istiak Mahfuz, district coordinator of Prism in Rangpur, told The Daily Star.

"When you are serving more than double your capacity, then it is tough for everybody to manage waste properly," he added.

He also said that medical waste management was costly and technology-oriented, estimating that even the most basic set-up would need more than Tk 2 crore.

The health expert said only 50 hospitals and clinics out of 153 have signed contract with Prism in Sylhet, while the number is 100 out of 210 healthcare facilities in Rangpur.

In Chattogram, Chattogram Seba Sangstha collects waste and dumps those into a separate place of the dumping ground of city corporation at Halishahar.

The organisation has no standard arrangement to sterilise medical wastes. They process wastes through a manual procedure. They serve 60 percent of the total 270 hospitals and clinics in the city.

While visiting, our correspondents observed that separate types of medical wastes are often mixed with other wastes.

Nobo Waste Management Service Ltd handles 41 percent medical wastes of 220 hospitals and clinics in Mymensingh while Prodipan handles 115 healthcare facilities out of 220 in Khulna.

In Rajshahi, there is no third party to treat medical waste. Prism has recently struck an agreement but is yet to start its operations there.

NO ONE KNOWS THE RULES

The current handling of medical waste is in direct violation of the Medical Waste (Management and Processing) Rules 2008, which states "medical wastes could not be mixed with other wastes at any stage -- while producing inside hospitals, while collecting from hospitals, while transporting, and would be processed separately based on classification".

Besides, many city corporation officials are not even aware of the rules.

In fact, since the rules were made, not much has been done in this regard, with those concerned calling them flawed, which need to be looked into. All these years, no revision has been done.

Officials concerned say the government doesn't have a standard infrastructure yet to deal with medical waste, and the waste rules cannot be implemented until the flaws are corrected.

"We have a lot of things to do," Dr Sattyakam Chakraborty, line director (hospital service management) of the DGHS, told The Daily Star recently.

DoE officials confirmed that they "haven't been able" to enforce the 2008 rules "for various reasons."

They also acknowledged that there was no "authority" in any divisional headquarters.

"We haven't gone outside Dhaka for enforcement of the rules yet. In Dhaka, we only go for enforcement when we receive allegations," Begum Rubina Ferdoushi, director (monitoring and enforcement) told The Daily Star.

"In fact, it is tough to work on the basis of the current regulation. We [DoE] are working to update it so that it would be viable up to the root level [upazila]," she added.

Ziaul Haque, a director of the DoE and also one of the officers working on updating the medical waste rules, told The Daily Star, "There are numerous contradictions in the 2008 rules. It is not clear where would be the office of the authority or under which organisation (DoE, DGHS or city corporation) the third party would be given a licence.

Besides, a single organisation has to get three types of licences for collecting, transporting and disposing medical waste; it's not feasible. We would start to amend the rules soon."

He said every hospital and clinic must obtain two certificates -- the location certificate and the environmental clearance certificate -- from the DoE.

The latter includes a clause, which requires medical facilities to have a contract with their respective city corporation for waste management.

"We just see whether the hospitals and clinics have contracts with respective city corporation or not," said Ziaul Haque.

Asked who would be held responsible for overseeing medical waste management, Ziaul said, "City corporations are responsible for all types of waste management, while the DoE is responsible for monitoring [the management]. It's a big question whether they are doing it properly or not."

Emdadul Hoq, deputy secretary of the LGD ministry, told The Daily Star "The city corporations are responsible. But according to the rules, it should be managed properly. But in reality, there is no standard waste management system. We are working on it."

The Daily Star has talked with the high-officials of four city corporations and all of them said there was an absence of proper waste management.

They even said that they were unaware of the 2008 rules or any other specific guidelines regarding hospital waste management.

(The Daily Star will run separate stories on the seven city corporations and their handling of medical wastes.)

Our correspondents from Chattogram, Rajshahi, Barishal, Khulna, Rangpur, Sylhet and Mymensingh contributed to this report.