An Insight into the Repercussions of Medical Waste and its Disposal.
A safe injection does not guarantee safety for a community unless disposed of correctly. This article aims to address a topic which is by no means novel but is often overlooked when considering safety issues surrounding injections: safe disposal and afterlife of medical waste. In the last two decades, there has been a concerted push to reduce the reuse of syringes through global mandates, additions of auto-disable features, and educational efforts. While this effort has scored important successes for safer injections of vaccines worldwide, it has failed to eliminate another factor contributing to the spread of bloodborne disease from sharps injuries in medical waste disposal.
Last month in rural Bihar, one of the poorest and least developed states in India, we had the opportunity to meet Kumar. Kumar has spent the last 20 years working in Gaya, collecting medical waste from upwards of 60 villages with a handful of colleagues. He then transports the waste to a recycling center, sorting it by hand for resale. For the most part, the waste is made up of used, uncapped syringes and other (blood-contaminated) medical products. Sold to plastic recyclers by weight, these products earn Kumar approximately 12000 rupees a year (146$). At 0.33 cents a day, Kumar’s take home is well below the poverty line for India and offers little growth to his family of 7 young children. One major health concern lies in Kumar being injured from the medical waste (a needle, scalpel, or sharp object), which could leave him exposed to blood or other body fluids. From a sharps injury, there is a high risk of contracting HIV or other bloodborne diseases and last year more than 1 million deaths globally were related to infectious diseases from unsafe practices with syringes.
The ideal scenario would be for a used syringe to be placed into a sharps box and then be safely delivered to a toxic waste facility for machine processing and incineration. Yet, the reality often involves sorting through waste by hand and a randomized process of disposal. This especially occurs in lower-income settings and rural areas where waste management cannot rely on formal systems to protect patients and workers. Even within the ideal scenario, we seem to pay little attention to the afterlife of medical products. Focus falls on the safety regulations of a medical procedure but in turn, does not provide safety to those involved in the hospital economy. This economy surrounds each healthcare setting and needs to be supported by a shift in policy, technology, and responsibility.
As Kumar showed us his process, he pointed out that his work does involve regular sharps injuries. “This one (a sharps injury) is from yesterday”, he tells us as he pointed to an open wound on his right hand, “but for such problems, I get a tetanus shot when I can afford it and have time.” While Kumar’s concern for tetanus prevention is valid, this does not protect him from the real danger of infectious disease from his weekly sharps injuries. Kumar is not alone, and across India, this informal practice is relied on for disposal of medical waste in rural communities, private pharmacies, and in public healthcare facilities. While shocking to me, recounting this interaction to Nergish Sunavala, former (marginalized community) journalist for the Times of India, she quite rightly reminded me that Kumar’s setup is one of the developed cases, for I didn’t see any children that day working on the 6 recycling sites I visited. In recent years, impressive developments nationally have improved India’s life expectancy to 70 years; however, at waste disposal sites this number falls to 36 years. Kumar has beaten these odds so far.
Outside of this being an insight into the system’s reliance on Kumar and his colleagues to manage household and medical waste, there are legal consequences too. Failing to correctly dispose of medical waste goes against the Bio-Medical Waste (management and handling) Rules of 1998, under section 269, Negligent Act (likely to spread infection of disease dangerous to life) and section 278 (making atmosphere noxious to health) of the Indian Penal Code (IPC). 10 years ago, the Times of India published a series of official and undercover stories detailing how poor medical waste management at hospitals led to doctors being charged for culpable homicide. The used syringes poorly discarded were traced to hepatitis and HIV cases in patients, government waste sweepers, and ragpickers. An assessment at the time found 48 of 50 hospitals failed to meet regulations leaving workers vulnerable in even the most developed and best-funded of situations.
It would be easy to take this example as an illustration of how a lack of funding to systems within low to middle-income countries is fueling the high number of sharps injury-related fatalities (almost 1 million a year); however, this issue exists globally. Along with the countless articles recording syringes washing on beaches across the globe (pop icon Billy Joel even referenced “hypodermics on the shores” in We Didn’t Start the Fire), medical waste is an issue that can touch all corners of our planet.
As Indian doctors were being charged for culpable homicide in 2015, across in the United States waste in Materials Recovery Facilities (MFRs) was also being manually sorted. Shockingly, needlestick injuries were and often still are one of the top three causalities reported at MRFs. While there is no trace of repercussions for sharps injuries at MFRs, both section 269 and section 278 seem applicable to workers' rights internationally. Last weekend, a worker at my local recycling center in the south-west of England, assured me that “I have had all my injections,” and that I shouldn’t worry about his occasional sharps injuries because they have a quarantine box (similar to the cardboard boxes full on used syringes Kumar had shown us the week prior). Once again, vaccination is key but does not protect against the worst bloodborne diseases that can be transmitted by used syringes.
Medical waste disposal has decades of regulations and recommendations, yet it is still not an easy feat to achieve at any scale. Our own familiarity with medical waste recently increased alongside the use rapid COVID tests (in addition to surgical masks) in the last 3 years. Yet, after testing, where did you dispose of your test? While it didn’t include the threat of inflicting a sharps injury on your community’s trash collectors, it was testing for an infectious virus which has the potential to seriously harm with long-term side effects. With the roll-out of home testing, there was a lack of medical waste management to protect those working on the frontline. In a recent interview, Jim Anderson at Stericycle, one of America’s largest medical waste disposal companies, explained the challenge of COVID waste was it being “decentralized”. It fell outside of the healthcare system’s disposal routes making it harder to track and collect. This issue sounds much like the challenge LMICs face in their rural and underfunded areas, which rely on the services that Kumar and his colleagues provide to keep their communities safe and clean while risking their own health.
While the lack of awareness for bloodborne diseases from a sharps injury is sadly not a surprise, what is a shock is our quiet reliance on informal medical waste management to keep it out of sight and out of mind. It is quite clear that progress has been made since the earlier days of the HIV pandemic when syringe reuse and medical waste disposal was driving millions of new infections. For Kumar and tens of millions of individuals like him, it is also clear we have a long way to go before we have solved this problem. We have a responsibility to consider disposal, and to consider the related challenges that a range to societies might have. No two communities are alike, but by listening to the needs of our users we have the chance to support pre-existing systems with a guaranteed safety for Kumar. To achieve this, we need policies that function across a range of infrastructures, encouraging awareness and responsibility beyond a safe injection and to a complete product lifecycle that protects all individuals of the supply chain.