A trip to the hospital does not usually reveal what happens at the back. It’s here where discarded blood and body cells and parts from surgeries, pharmaceuticals, medicine bottles — tonnes of hospital waste — undergo. In the case of the Kenyatta National Hospital, this might be as much as one tonne a day estimated to be half the medical waste generated in the city. Quite understandably, it’s not usually open to the public.

Most of these generally end up in incinerators — the most affordable medical waste disposal method for most hospitals. But a lot of it slips through the system to get us worried.

Incinerating waste at temperatures between 800-1,100 degrees Celsius kills viruses, bacteria and other pathogens but the ash still contains dangerous heavy metals such as mercury and cadmium. Best practice dictates that such ash be buried.

However, as this author found out, this is better said than done. Lack of sufficient equipment to safely dispose of waste and failure to observe best practices was a common feature in most hospitals visited in this survey.

From releasing dangerous fumes and ash openly to the surroundings to dumping medical waste together with general waste, the local medical waste management landscape still has a long way to go.

Raw medical waste and toxic ash from incinerators ends up in open dumps like Dandora and Eastleigh posing a health risk to thousands of people salvaging plastic and metal for recycling and residents living nearby. Significant hospitals such as Kenyatta National Hospital which have good incinerators have run from reasons to bury toxic ash. Few hospitals have a scrubber system where fumes are filtered to eliminate potentially toxic gases including dioxins from burning plastic — a common material discarded by physicians.

A recent study on the worldwide status of waste management rankings Nairobi as one of the worst in waste management. Residents living near Dandora reported that a large number of respiratory ailments and were found to have unacceptably high levels of heavy metals such as lead in their blood. Dandora dumpsite reeks of heavy metals which can hinder brain development as our individual evaluations confirmed.

Walking through the dumpsite opened during the 1970s reveals unlikely materials that end up here. Lying in the pile of an unsightly mixture of plastic bags and organic waste, one frequently finds bloodied gloves, dressing bandages, needles, discarded drugs and a host of other metals tucked away.

out of their small amounts, it isn’t difficult to conclude that this come from smaller hospitals, clinics and dispensaries not willing to spend on the proper disposal of waste. Level five hospitals, previously called provincial hospitals such as Nakuru, are largely well equipped with incinerators that could combust pathological waste into ash and water, states Kinoti.

A peek at the Dandora dumpsite reveals an unsightly mixture of plastic, food remains, animal products and all manner of waste the town discards. Every couple of minutes a truck makes its way through the hills of garbage the city has accumulated over decades. The steady flow of trucks falls silent at dusk.

However, as dark falls, another group, mostly only trucks hurriedly enter the dumpsite, quickly offload their contents and make their departure, all within a few minutes — well aware of their wrongdoing. A closer look at the dumped material reveals used needles, bloodied bandages, pharmaceuticals and a slew of other waste from hospitals. We found syphilis and HIV test kits.

Early in the morning, a County Government of Nairobi earth mover turns over the waste mixing it with garbage ready to receive the next batch for the day.

Tens of people descend on the site, sorting the garbage with their bare hands. While some solely focus on milk packets which they wash in a sewage tunnel, others are interested in salvaging metals from the burnings heaps, fuelled by the excessive gas underneath.

Still others are following the food stays they collect to feed animals — all determined to make a living. A prick out of an infected needle and they might end up getting serious infections including HIV.

all of them seem too aware of the danger, but they must feed their kids, a man, shielded only by a pair of gumboots, states.

The National Environmental Management Authority and the County Government of Nairobi didn’t respond to our enquiries.

Yet the threat of medical waste in the nation does not begin or end here. Medical facilities try to safely dispose of the waste to several levels of success. A huge number incinerate their waste, but lack the prerequisite air pollution control equipment to guard against materials such as sulphur, known collectively as flue materials, getting into the environment.

In such cases, residents living near such facilities are vulnerable to respiratory infections. Dioxins from plastics are known to cause serious respiratory complications and cancer.

A recent report detailed that the elevated levels of heavy metals such as lead in vegetables grown and sold in Nairobi. Lead is a dangerous metal which can cause retardation in children. Some farmers in Kinangop were recently in the spotlight for using sewage to cultivate their crops largely sold in the city.

Incinerators below standard

Dumping of toxic ash is not the sole problem facing the medical waste management landscape. The state of gear is wanting, some dating several decades back and ill equipped to minimize pollution.

Most people hospital below level five have de Montfort incinerators where temperatures aren’t controlled and are most likely to pollute as they lack scrubber systems. “Unfortunately this type of incinerators are typical in district hospitals and health centres,” Kinoti says. Workers are also not well protected in mid-level hospitals. Because of the design of the incinerators, medical waste is loaded manually and workers who mostly don’t have protective equipment are exposed, she says.

A moderate size incinerator costs an average of Sh20 million before installation, obviously a high shot for hospitals. Insert the high maintenance costs and the fact that these centers guzzles several thousands of litres of fuel to operate daily and you end up getting a very high bill.

“However, the high cost of incinerators is no explanation for polluting the environment,” states Kinoti. “Hospital waste contains mercury and can create furans which are extremely toxic and can cause cancer and severe respiratory diseases,” she says.

Medical facilities which don’t have incinerators are required to have contracts with specialised waste disposal companies to deal with their waste. For some, this is merely an unnecessary hurdle they have to undergo before acquiring a permit to run a hospital. Little is done to comply. A number don’t follow through with these requirements posing a huge health risk to the public and the environment.

Hospitals categorize their waste otherwise for their safe handling during transportation, storage, treatment and disposal,” says Bernard Runyenje, assistant chief public health officer, Kenyatta National Hospital.

Highly infectious waste are those expected to be comprising highly infectious pathogenic organisms such as bacteria and viruses while overall waste may consist of office paper. Normally in red packages, infectious waste require special care throughout the process of waste disposal and are assumed to be treated at source. It’s not however unusual to find a worker carrying a yellow or reddish disposal bag without gloves or some other protective equipment.

Tissues that decompose quickly such as amputated limbs are disposed of quickly or placed under refrigeration. The majority of these highly infectious waste — except radioactive waste — should most appropriately end up at the incinerator, Dr Runyenje says. But he also admits that incinerators in rural areas don’t meet these specifications.

A fantastic incinerator should have more than 1 room where waste is burnt in the first room, so that there’s increased temperature in the second room and gases can be burnt in the third room, he says. At the end of the process, the majority of the waste was burned to an acceptable level. Clinics and dispensaries often operating in highly populated areas frequently flout the regulations, openly burning their waste using paraffin and charcoal to avoid the cost of safe disposal. Half burned waste isn’t hard to spot in dumps on roadsides and quite visible in municipal dumpsites.

Incineration however does not get rid of toxic fumes and heavy metals — if anything it could disperse toxic fumes to a wide areas if not done correctly. The scrubber system is intended to reduce such pollution but the system is expensive and most hospitals visited don’t have it. The gas from the incinerator is passed via fluid to remove any particulate matter — inside a scrubber system. Such gases may include carbon dioxide, carbon dioxide, dioxins and furans which can cause serious diseases such as cancer.

The minimal height of a chimney should be at least 10 feet above the tallest building around to minimise direct exposure to residents. Anything that comes out of the chimney should be dispersed away from nearby buildings.

“Sometimes it’s difficult to know what you’re emitting to the surroundings. If you launch it directly to human beings, then you expect to have some health issues, while it’s inhalation of carbon monoxide, carbon dioxide, dioxins or furans,” Dr Runyenje says. A high chimney shouldn’t however be seen as a replacement for a scrubber system, adds Kinoti. A high chimney only disperses fumes farther to residents who may not even be aware of them, she observes.

To many, including waste managers interviewed, ash from incinerators, or any ash for that matter is not harmful — a misplaced notion that could be contributing to its dumping. The truth is that they contain harmful metals such as mercury, lead and cadmium as our individual evaluations confirmed.

Incineration reduces the waste to about 10 per cent of their original volume. However, the remaining ash usually contains very large content of heavy metals. Such should normally be buried in sanitary landfills to prevent it from leaching to the ground, but this practice appears rare in the nation.

Whether through sheer negligence, or lack of space and facilities or reluctance to satisfy the associated costs, medical waste nevertheless ends up in our surroundings. When disposed in open ground, heavy metals readily leach to the groundwater or make an immediate approach to our food chain.

Bottom ash under normal conditions should be buried, but most health centers don’t have disposal grounds. These burial grounds aren’t present either at Dandora where officials claimed the ash was taken to be buried.

Some companies are licensed to handle hazardous waste. But, Dr Runyenje nonetheless notes that not many handle general medical waste.

A number of incinerators in public hospitals were in a state of disrepair leaving tonnes of toxic waste piling up and posing a threat to the public.

Kenyatta National Hospital includes a floor where tonnes of waste are kept awaiting disposal.

Its newly acquired incinerator from India is the most advanced among the hospitals visited consisting of two chambers for maximum combustion. The wide network of smoke pipes contributes to a room where the smoke is passed through a fluid to remove fumes and other residue.

The resulting black slime contains a few of the dangerous metals. However, the layout and arrangement of the holding area does not meet specifications and some of it seeps to the floor, a source tells us.

The incinerator cannot be operated during the day because the nursing school is only metres away.

The location of incinerators in relation to offices, hospitals and other residential is a common problem in many centers. The one at the Chiromo School of Physical and Biological Sciences for example is not in operation as it sits near an embassy.

One incinerator in Nakuru County is perilously close to the maternity ward, some smoke move directly to patients.

The situation plays out in a number of other hospitals around the country who also lack additional air pollution control equipment.

Ash dumped in open floor are an open feature in several of leading facilities which may potentially poison ground water .

With people living near such facilities, they are inevitably exposed, and risk serious respiratory infections and serious diseases including cancer. The Kenyatta National Hospital incinerators operate at night to minimise exposure to the students at the School of Nursing barely a dozen metres away.

A source told this writer that the soils were so contaminated they might have to be skimmed off and buried. Meanwhile, residents will have to contend with dangerous, potentially carcinogenic, ash emanating from such facilities.

Larger hospitals such as Nairobi Women’s Hospital are stepping in to help smaller ones incinerate their waste. “The cost of the incinerator is too high for them to manage,” states Thomas Imboywa, who’s in charge of one of these at the Nairobi Women’s Hospital, one of the largest in the region. On a daily basis, he manages the safe disposal of the days squander.

The incinerator, a huge blue structure sits about 100 square metres of space slightly off the primary building and sports a high chimney, towering above the nearby building.

“Medical waste is incinerated within 24 hours,” states Imboywa. But when a practice or hospital does not turn in any waste for weeks on end, it raises eyebrows, Imboywa states. He’s familiar with many such cases and the hospital is quick to repudiate such contracts according to their policy. Some healthcare facilities may only secure a contract with them to wade through National Environmental Authority (Nema) regulations but have no intention to safely dispose of the waste, Imboywa observes. But, not all medical waste ends up in such specialised facilities. Instead, in places like Kibera they’re doused with paraffin and burnt in the open.

“But in this instance, sharps will remain and the waste can still remain infectious because they cannot reach the required temperature,” Imboywa said. The truth is the material can remain infectious because they may not reach the required temperatures.

Devolution could make it worse

As more hospitals come up in tandem with the growing population, a rethinking how medical waste is treated will be inevitable. The devolution of resources has seen more clinics and dispensaries put up in previously unreached areas. But the resources are so limited to place up waste disposal facilities such as incinerators.

Besides being expensive, Dr Runyenje agrees that if these facilities were to put up their own incinerators, there could be more pollution and authorities will have more difficulty supervising them.

“There’s need to pool incineration facilities for medical and hazardous waste,” he says. These centres can serve as emission monitoring points for authorities. “It will be easier to set controls from such a central facility. “In the Technical Working Group, we’re looking at how counties can pool their centers together and have their medical waste incinerated at a central point. It’ll be very expensive in the long term to have every facility to have its own incinerator that cannot operate at full capacity,” he says.

The best waste disposal procedure is controlled tipping being practiced in the majority of Europe and North America where it’s buried in layers, Dr Runyenje states. “The advantage with this method is that the property can still be used for other activities. It’s the only pledge of disposal of any form of waste,” he says.

Kariobangi, which currently hosts light industries, was a controlled tipping site before start dumping at Dandora. “Counties should be thinking of controlled tipping instead of investing heavily in incinerators,” he says.

General waste can have many recyclable materials but proper segregation which could make this possible is still lacking in the nation.

The effectiveness of recycling is dependent on the effectiveness of segregation.

The issue, according to Kinoti, is enforcement of the law. While bigger hospitals are trying to correctly dispose of the waste, some smaller clinics may be spoiling it, she says. The fact that generators cannot monitor their waste once it’s given to waste collectors is yet an additional issue according to her.

“There are many quacks doing waste management blending household waste with hazardous waste. This can pose a significant health issue,” states Kinoti. Since they drain waste bins from homes, waste collectors can cause serious contamination in households. “Waste collectors who are collecting hazardous waste should be dedicated waste handlers and shouldn’t handle other general waste,” Kinoti says.

Effluent from the scrubber system should be taken for treatment to eliminate heavy metals and other pollutants. However, the sewerage system is broken and a lot is discharged along the way. Sewage pipes are sometimes deliberately punctured and effluent used as fertiliser for crops.

“The legislation on sound medical waste disposal should be enforced, district and health care centres should install larger incinerators to deal with waste from smaller fee. We should have dedicated health waste managers,” Kinoti says.

 

by: http://allafrica.com/stories/201411111021.html

“There are many quacks doing waste management mixing household waste with hazardous waste. This can pose a serious health problem,” says Kinoti. Since they empty waste bins from homes, waste collectors can cause serious contamination in households. “Waste collectors who are collecting hazardous waste should be dedicated waste handlers and should not handle other general waste,” Kinoti says.

Effluent from the scrubber system should be taken for treatment to remove heavy metals and other pollutants. But the sewerage system is broken and a lot is discharged on the way. Sewage pipes are sometimes deliberately punctured and effluent used as fertiliser for crops.

“The law on sound medical waste disposal should be enforced, district and healthcare centres should install larger incinerators to handle waste from smaller fee. We should have dedicated healthcare waste managers,” Kinoti says.

 

by: http://allafrica.com/stories/201411111021.html