How Hospitals Endanger You? Dangerous Disposals

By Kajol Singh & M H Ahssan

Ambiguous rules and lax monitoring have allowed an illegal trade in infected waste to flourish in India.

South Delhi’s Sainik Farms is home to the rich and mighty, suitably marked by marquee SUVs lining up its service lanes. The row of farmhouses extends a while to the nearby Neb Sarai, where a speeding rusty Tata 407 truck almost seems like an apparition in the April heat. But the road ahead leads to a different world — a wasteland full of plastic cans and discarded medicines, the stench of dry blood filling the air. The truck comes to a halt and discharges its cargo: jute sacks. Rag pickers crowd around and tear the bags apart for what they are eagerly waiting for: blue plastic bags labelled with a trefoil with sharp ends — the global symbol for biological hazards.
Syringes, intravenous sets and glucose bottles fall out as the bags get thrown around. The truck has just arrived from the All India Institute of Medical Sciences (AIIMS), says a man standing in front of a nearby shanty. In a small yard down a nearby lane, half a dozen men are sitting among piles of waste. In one corner, a boy with a wart on his chin is patiently sorting out his loot into little piles. After it has been sorted, the waste will be sold to plastic manufacturers from illegal industrial areas such as Kirti Nagar or Peera Garhi who will melt it into buckets, mobile phone covers or plastic bags.

In the worst-case scenario, it will be repackaged and sold back to clinics where their illegal reuse may infect hundreds of patients with hepatitis or HIV. In Modasa in northern Gujarat, an outbreak of Hepatitis B last February claimed 62 lives after syringes were allegedly reused. Though the risk is remote, bio-medical wastelands can also spread airborne diseases such as tuberculosis, pneumonia and meningitis.

Neb Sarai, incidentally, is just one such hub. In fact, reselling plastic waste, without even ensuring it is sterilised and shredded, has become common practice at government and private hospitals alike across the country. Syringes, intravenous sets, glucose bottles and so on are made of so-called ‘virgin’ plastic (as opposed to recycled one), and can be sold at Rs 10-50 per kg, depending on quality. “Everybody has an eye on the plastic,” says Dr K.G. Patel, who runs Care BMW Incineration in Ahmedabad, a bio-medical waste treatment facility. Ambiguity in the rules for bio-medical waste disposal, lax monitoring and lack of staff at state pollution control boards have allowed an illegal trade of infected waste (estimated at around Rs 100 crore) to flourish in the country, exposing millions to toxic waste.

The Plastic Trade
On paper, compliance to the rules drawn in 1998 for handling bio-medical waste is fairly good. According to the Central Pollution Control Board (CPCB), out of India’s 97,662 healthcare units — hospitals, clinics, pathological labs and blood banks — 45,661 have been approved by respective state pollution boards. For hospitals with 50 beds or more, compliance has been recorded as high as 70 to 90 per cent across states.

Waste from government hospitals is treated at state-owned facilities, if available. Or, like private hospitals, they have to tie up with authorised private bio-medical waste treatment companies — there are 155 such facilities in the country according to the CPCB.

However, while hospitals give away the incinerable waste (anatomical and microbiology), treatment providers claim that plastic waste rarely reaches them. Although plastic waste represents on an average a third of the waste generated by hospitals, only 5-10 per cent of the waste treated is plastic.

In Delhi, Synergy Waste Management in Okhla Tank says that of the 3.5 tonnes it treats every day, only 40-80 kg is plastic. Similarly, Metro Bio-Care in Samaipur Industrial area treats about 1.5 tonnes of waste every day, out of which just 100 kg is plastic, says Lalit Gupta, owner of the facility. Hospitals in Delhi are, however, charged per bed (about Rs 2.60 per day per bed) by service providers, regardless of the amount of waste collected.

“Out of greed, hospitals are keeping plastic waste and selling it, often without treating and shredding it,” says A.K. Jaggi, CEO of Semb-Ramky, a JV between the Ramky group and SembCorp, a Singapore-based waste management firm that runs eight facilities across the country. Several emails and faxes sent to AIIMS Director R.C. Deka remained unanswered.

This waste, after all, is no small change. Delhi’s Sir Ganga Ram Hospital makes over Rs 1 lakh every month by selling plastic waste to scrap dealers, according to Dr Sudhakar Vira, senior medical administrative officer. “The hospital generates about 340 kg of waste daily, of which 130-140 kg is plastic.” While Synergy treats the incinerable waste, the hospital has subcontracted another unapproved agency, which pays the hospital to collect the plastic waste. “They collect the waste and treat it at a facility in our hospital before selling it,” says Dr Vira. Under the rules, plastic waste needs to be treated in an autoclave — a device that sterilises the waste by subjecting it to high-pressure steam at 121°C or more — and shredded to ensure that it cannot be reused.

However, when this reporter visited the facility, while the autoclave and shredder seemed to be in order, unshredded plastic waste was kept in a black bag, hidden behind a small gate, at a collection point. “We make all the efforts we can, but people at the bottom make mistakes,” says Dr Vira, explaining the slip-up.

At the other end of the city, in Saket, Max Hospital’s Chief Medical Excellence Programs Dr Arati Verma admits that the hospital too treats and sells the plastic waste to scrap dealers. However, BW was denied a visit to the hospital’s treatment facility, with Dr Verma citing construction work going on at the site. About three weeks later, another request was denied on the same grounds. An email sent to Max Healthcare CEO and Managing Director Dr Pervez Ahmed, requesting him to arrange for a visit, remained unanswered too. In Mumbai, Tata Memorial Hospital and Hinduja Hospital also treat the plastic waste themselves. While Tata and Hinduja have a hydroclave (a device that sterilises and leaves the waste dry) and autoclave respectively, shredders at both hospitals are out of order and, going by the rust eating the machines, have been so for several years. Both hospitals claim that the plastic waste is given out to NGOs free of cost.

Legally, hospitals are allowed to sell plastic waste, as long as they treat it as prescribed. However, while state pollution boards inspect common treatment facilities on a monthly basis, hospitals are not inspected regularly. Plastic waste has, however, little economic value once shredded (unless it is segregated before shredding) — no more than Rs 5 to Rs 10 per kg, so less than the cost of treatment estimated at around Rs 12 per kg. “Intravenous sets, glucose bottles and gloves are made of different types of plastic,” explains Gupta. “Once shredded, it gets all mixed so has little value.” However, if not shredded, the price may be as high as Rs 30-50 per kg.

Wockhardt Hospital in Mumbai does not account for certain plastic items such as glucose bottle as bio-medical waste, according to a hospital executive, who did not wish to be named. Bio-medical waste is, however, defined as any waste generated during diagnosis or treatment of patients. Incidentally, glucose bottles are also the most valuable waste — it can be sold for Rs 50 per kg. “All plastics are treated as biohazardous waste, kept under safe custody and given to authorised agencies,” writes Vishal Bali, CEO of Wockhardt Hospital, in an email response.

Other hospitals that sell plastic bio-medical waste, according to sources, include Rockland Hospital, Indraprastha Apollo Hospital, Holy Family Hospital, Escorts Heart Institute & Research Centre and Jaipur Golden Hospital. When contacted, Jaipur Golden’s spokesperson abruptly hung up the phone after directing BW to contact assistant medical superintendent Dr Deep Kamal. An email sent to Dr Kamal remained unanswered.

At Delhi’s Apollo, Chief Quality Officer Dr R.S. Uberoi says that while it autoclaves plastic at the hospital, none of the waste is sold. “We are doing this as an extra precaution before giving it to the authorised treatment provider.” A practice that the Manipal group has also adopted, according to CEO Dr Rajan Pai. But on why Apollo was segregating the plastic and glass waste at source, Atul Vig, chief engineer at the hospital, had no response to offer.

Dr Anita Arora, head of department of microbiology at Escorts, says that while they have an autoclave, outsourcing treatment works out cheaper. “None of our hospitals sells waste,” adds Dr Praneet Kumar, chief operating officer at Fortis. Meanwhile, J.K. Dadoo, chairperson at the Delhi Pollution Control Committee, says that he is unaware that hospitals sell plastic: “We will have to investigate this.” Dadoo says that 8.9 tonnes of bio-medical waste is generated every day in Delhi. A figure that seems woefully small considering that a hospital bed generates on an average 250 g per day (according to the CPCB itself). Even by factoring in low occupancy rates, considering that Delhi has about 90,000 beds, the actual bio-medical waste generated every day could be as high as 15 tonnes (that figure would not even include centres that do not have in-patient facilities).

Ajay Fulmali, regional officer at the Maharashtra Pollution Control Board (MPCB), on his part, admits that reselling of plastic by hospitals has become a major problem. “But how can we monitor? We cannot check every hospital to see if they are treating plastic waste properly.”

Impracticable Rules
About 14,068 healthcare facilities have been authorised to treat their waste themselves, according to the CPCB. Many more may be selling waste without authorisation. It is an impossible task for state boards to ensure all these facilities are treating the waste adequately. “Some amendments to the rules may be needed,” says H.K. Karforma, senior environmentalist at the CPCB.

The current rules also allow a different treatment option (other than autoclaving) for plastic waste: chemical treatment with sodium hypoclorite solution. “Chemical treatment is messy and unpredictable,” says Dr Rohini Kelkar, head of microbiology at Tata Memorial Hospital. Besides, while each autoclave is required to have graphic or computer recording devices that monitor temperature and generate reports, there is no way to ensure that the chemical treatment has been executed properly. Any hospital can also claim that it is treating plastic waste without having any facilities to show for.

As a result, the rules as they are today are virtually impossible to enforce. Were hospitals no longer allowed to treat their own waste and autoclaving made mandatory, ensuring better waste disposal may become easier.

Treatment Facilities: Few And Far
For the process to work seamlessly, India needs to increase the number of common treatment facilities. Today, there are several districts in dire need of more facilities. Mumbai, for instance, does not have a single operational incinerator.

Nine years ago, the Bombay Municipal Corporation (now called Greater Mumbai Municipal Corporation) allocated land at GTB tuberculosis hospital in Sewree to EA Infrastructure Operations to set up a treatment facility. But the incinerator had to be closed down after a few years when local residents protested. “We were well under the permissible emission norms,” says Jignesh Paresh, director at EA Infrastructure, with a sigh, as he flips through a pile of old lab reports. “And that was the land we were allotted,” he grumbles, saying that he invested Rs 6 crore to set up the facility.

A new tender was launched and awarded to a different firm, SMS Envoclean, in Deonar. The new facility is, however, still not operational. “We have identified 11 more districts in Maharashtra for setting up treatment facilities,” says Valsa Nair Singh, MPCB chairman, adding that the board is about to launch new tenders.

Yet, setting up more treatment facilities cannot solve everything. Take the case of Gujarat: the state has one of the highest numbers of treatment facilities (12). This did not prevent the Hepatitis B outbreak in Modasa.

Mehul Patel, who runs SembRamky’s facility in Ahmedabad, says that following the outbreak, things have improved. “Until February, we were collecting 1.3 tonnes of waste per day. Now we get 2 tonnes, including syringes, glucose bottles and intravenous sets — things we never used to get. Hospitals have become more cautious.”
“We have now started inspecting hospitals regularly,” says C.L. Meena, chairman of the Gujarat Pollution Control Board (GPCB). Hospitals such as Sterling, the largest private hospital in Ahmedabad, now have security check points at the back entrance to ensure that waste is not smuggled out, says Chief Medical Officer Dr Chandramauli Rawal.

However, Patel is doubtful that the positive changes will last. “In three months, people will have forgotten and things will go back to normal,” he says with a disheartened smile. Gujarat counts 18,630 medical units generating close to 15 tonnes of waste per day, according to GPCB.

Moreover the GPCB, with its current strength of 445 people, is facing a staff crunch: 426 positions are vacant. It does not have a full- time chairman either; Meena is secretary at the finance department. Similarly in Maharashtra, Nair Singh is principal secretary at the environment department. “We can only monitor to an extent that is humanly possible,” she says.

Increasing the staff in pollution control boards would help, but may not be enough.

After all, lack of resources is an evil plaguing almost every single government department in the country. Designing laws that will take this reality into account may be a good alternative, especially when the health of millions is at stake. Allowing the treatment of waste only at common facilities that can be regularly monitored and making plastic waste treatment by autoclave mandatory, would be welcome changes. Let us hope it does not take another epidemic for that to happen.