Waste wars: Hospitals need to manage biomedical trash

In the wee hours of January 28, two trucks carrying biomedical waste from Kozhikode in Kerala crossed borders into Karnataka dump them in empty plots in Nanjangud area of Mysuru. The two drivers of the trucks had driven 200 km from Kozhikode to Nanjangud 10–12 times in the past and had evaded police net every time. This time, luck ran out. Police, acting on a tip-off from residents, followed the truck soon after they crossed the borders and caught the duo red-handed while trying to dump the waste in Adakanahalli industrial area.

Investigations revealed that the medical waste was mixed with biodegradable waste in Kozhikode and being transported to neighbouring states.

While the truckers, the last-mile support staff in this operation, were remanded, the investigation has not yet revealed the true culprit—the contractors and the hospitals—involved in the crime.

Though Karnataka raised the issue with Kerala, it was not followed up seriously by the two governments.

Since this particular incident drew the Karnataka Chief Minister BS Yediyurappa’s attention, the issue turned political, prompting the Kerala government to assure strict action against violators.

“I have directed the DC (deputy commissioners) of respective districts, the environment department and pollution control board to take stock of the situation and check surreptitious activities of individuals and agencies from Kerala who are indulging in this illegal activity,” Yediyurappa said.

How farmers are lured

Truckers and medical institutions dumping waste in Karnataka is nothing new. It has been going on unabated since 2013 with no strict adherence to rules.

Mysuru, Kodagu, Chamarajanagar and Mangaluru district report such violations more often. This, despite Mysuru being ranked one of the top 10 cleanest cities in India, as per Swachh Bharat Abhiyaan data compiled annually since 2015.

In neighbouring Tamil Nadu, bordering districts of Pollachi and Coimbatore also face similar concerns.

In October 2016, residents and environmental activists in Coimbatore lay siege to 23 trucks from Kerala carrying degradable and biomedical waste, to be dumped on the outskirts of the city (Ettimadai) in private agricultural land.

Lack of water is said to have forced farmers to quit agriculture and lease their land for waste segregation. Reports indicate that they were lured with money by agents for allowing the waste to be poured into their lands.

Revenue officials and police personnel from the district later arrested those involved.

It was found that the biomedical waste was not being treated as per provisions of Bio-Medical Waste Rules 1989, as amended in 2019.

What rules say

The biomedical waste management rules, 2016, which has guidelines to pre-treat laboratory waste, microbiological waste, blood sample as prescribed by the World Health Organisation, are not strictly adhered to.

Biomedical waste include syringes, scalpels, lancets, tissues, lab cultures, unused/expired or contaminated vaccines and drugs from hospitals, nursing homes, medical research centres, clinics, and medical shops.

As per rules, operators of biomedical waste treatment and disposal facilities are required to establish bar-coding and global positioning system for handling of biomedical waste.

Smaller clinics need to register with formal recyclers and get a registration certificate from them. Besides, approval from the pollution control board to dispose of waste was also mandated.

Rising hospitals, rising waste

The rise in healthcare facilities catering to the growing population has resulted in the generation of large-scale biomedical waste. This, getting mixed with municipal waste is a matter of grave concern.

Effective biomedical waste management is not only a legal necessity but also a social responsibility. Rag pickers and municipal waste pickers often encounter blood-soaked cotton, unwrapped used sanitary napkins, discarded syringes and needles.

Improper handling of these could lead to infections through blood-borne pathogens such as Hepatitis B, HIV among others.

Kerala problem

It is estimated that each hospital bed generates about 1.5–2 kg solid waste and 450 litres of liquid waste per day.

Incidentally, Kerala, which is geographically small in size compared to states like Maharashtra, Karnataka, Bihar and Uttar Pradesh, generates 71,976.14 kg of biomedical waste per day, the highest in the country from its 1.2 lakh hospital beds.

In contrast, Karnataka generates 65,621.2 kg of waste daily while Maharashtra and New Delhi generate 62,418 kg and 26,757 kg per day.

Incidentally, Kerala emerged as the best state in the country for its healthcare performance, as per the Health Index report, jointly prepared by the World Bank and Niti Aayog in 2018.

According to Central Pollution Control Board, Kerala has the highest number (about 27%) of healthcare institutions in India. And almost 90% of biomedical waste generated in the state is handled by IMAGE, an agency established by the Indian Medical Association.

As on June 30, 2019, a total of 14,327 healthcare establishments were affiliated to IMAGE (1,935 bedded healthcare institutions and 12,392 non-bedded healthcare institutions).

Puzzled at the high amount of waste generated by Kerala, experts argue that it could be because the state promptly reports the data while other states might not have been generating and giving complete data.

Cutting costs, raising burden

Dr Asok Kumar KK, district representative of Kozhikode at IMAGE, says while the illegal dumping is not by their workers engaged in waste collection, he said it could be coming from hospitals close to borders that do not want to spend much money on treating medical waste.

“One could be the cost aspect and another is the distance as we have only one treatment plant in Palakkad in Kerala. The state government is investigating the illegal dumping case alleged by the neighbouring state and there will be some direction issues post that,” Kumar added.

While Kerala is looking to set up a second plant in Palode in Thiruvananthapuram, there’s stiff opposition from locals and the village panchayat.

As per the 2018 report of Central Pollution Control Board, about 27,427 instances of violations under Biomedical Waste Management Rules were reported.

While all states have the problem, it is the courts that have come to the rescue to stop the menace.

For instance, the Supreme Court on February 18 issued a notice to the Delhi government on rampant illegal and unauthorised biomedical waste burning being carried out in south Delhi.

Last September, the Allahabad HC asked the Uttar Pradesh government to apprise it of action taken to recover fines from medical institutions which lack biomedical waste treatment plants.

Need for waste treatment, training

There are 200 authorised common biomedical waste treatment and disposal facilities (CBWTF) in 28 states. However, Goa, Andaman Nicobar, Arunachal Pradesh, Lakshadweep, Mizoram, Nagaland and Sikkim do not have CBWTFs. Besides this, there are 12,296 captive treatment and disposal facilities, according to the Ministry of Health. In 2018, India generated about 608 MT of biomedical waste.

“Despite the improvement in waste management process, biomedical wastes are not fully segregated at source. So the risk of infectious waste product being dumped in open spaces poses serious risks,” says Prof Venkatramana GV of the University of Mysuru. However, this has been to an extent solved with colour coding of bins at healthcare institutions.

Venkatramana had in the past suggested that the government should make it compulsory for healthcare facilities to get their healthcare personnel trained from accredited training centres in biomedical waste management. His observation came after his study in private and public hospitals which showed lack of awareness among medical fraternity.

A study conducted in Odisha dental college in 2016 revealed that 44% of dental students were not aware about the management or recycling and reusing of biomedical waste.

Leading hospitals like All India Institute of Medical Sciences (AIIMS) and Ram Manohar Lohia Hospital in New Delhi, Manipal Hospital in Bengaluru, Apollo Hospital in Hyderabad, Kailash and Sharda hospital in Uttar Pradesh have all been fined in the past for improper management of biomedical wastes generated by them.

Framing rules is easy, but who will implement and educate people, asks Dr Rajan Sharma, IMA’s national president. “In half the states, pollution control boards do not act at all although biomedical waste management being a grave concern.”

Members of India Medical Association, which manages waste for Kerala healthcare institutions through IMAGE, say lack of cooperation of doctors and healthcare institutions hinders effective implementation of the law.

Experts suggest that in addition to segregating waste at source, disinfection of waste at the point of generation reduces the chances of transmission of infections.

“Waste management is beyond just data and adherence to the rules and regulations. It has to be supported by appropriate education, training, commitment of healthcare staff at the grassroots level,” IMA’s national vice-president Dr Prabhakaran GN says.