non incineration technologies
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Non-IncinerationMedical WasteTreatment TechnologiesA Resource for Hospital Administrators,
Facility Managers, Health Care Professionals,
Environmental Advocates, and
Health Care Without Harm1755 S Street, N.W.Suite 6BWashington, DC 20009Phone: 202.234.0091www.noharm.org
Health Care Without Harm1755 S Street, N.W.
Unit 6BWashington, DC 20009
Printed with soy-based inkson Rolland Evolution,
a 100% processed chlorine-free paper.
Treatment TechnologiesA Resource for Hospital Administrators,
Facility Managers, Health Care Professionals,
Environmental Advocates, and Community Members
Health Care Without Harmwww.noharm.org
P R E F A C E iii
THE FOUR LAWS OF ECOLOGY . . .
1. Everything is connected to everything else,
2. Everything must go somewhere,
3. Nature knows best,
4. There is no such thing as a free lunch.
Barry Commoner, The Closing Circle, 1971
Up to now, there has been no single resource that pro-vided a good frame of reference, objectively portrayed, ofnon-incineration technologies for the treatment of healthcare wastes. Vendors of particular technologies have pre-sented self-interested portrayals of their technologies.Other groups such as the World Health Organization(WHO) have presented very generic overviews, usuallyequating them on par with incinerators. For those healthcare facilities and communities looking for a tool to re-ally evaluate their options for going beyond incinerationfor the effective treatment of health care wastes, the searchfor information has been problematic. It is our hope thatthis publication will provide a sound tool for all inter-ested parties.
Long before the Health Care Without Harm campaignhad a name or members, a number of prescient people including Barry Commoner, Paul and Ellen Connett, TomWebster and many others realized that the growing vol-ume of trash from all economic sectors was a huge problem,and that burning the evidence would not make it go away.Indeed, by the mid-1980s, incineration had already beenlinked to air emissions of heavy metals and particulatesas well as dioxins. They realized that the health care sec-tor presented a uniquely difficult situation because publicperception, greatly influenced by images of needles wash-ing up on New Jersey beaches and concerns about HIVand hepatitis, fed the dual notions that disposable isbetter and burning is better.
Anti-incineration experts like Commoner and theConnetts sought to inform community leaders and regu-lators in the United States that, as with municipal solidwaste, one should systematically view what comes into ahealth care facility and what leaves it everything isconnected to everything else and everything must gosomewhere rather than trying to focus only on waste.
Meanwhile, many hospital staff, such as Hollie Shaner,RN of Fletcher-Allen Health Care in Burlington, Ver-mont, were appalled by the sheer volumes of waste andthe lack of reduction and recycling efforts. These indi-viduals became champions within their facilities orsystems to change the way that waste was being managed.
In the spring of 1996, more than 600 people most ofthem community activists gathered in Baton Rouge,Louisiana to attend the Third Citizens Conference onDioxin and Other Hormone-Disrupting Chemicals. Thelargest workshop at the conference was by far the onedevoted to stopping incineration because of concernsabout dioxin emissions and other pollutants. A smallergroup emerged from that session to focus specifically onmedical waste. They were struck by the irony that hospi-tals entrusted to heal the sick and maintain wellness couldbe responsible for such a large share of the known dioxinair emissions, for at that time, the United States Envi-ronmental Protection Agency (EPA) had listed medicalwaste incinerators (MWIs) as the number-one identifiedsource.
That summer, the EPA issued its first-ever regulationsfor medical waste incinerators. These Maximum Achiev-able Control Technology (MACT) rules, issued underthe Clean Air Act, sought to control but not eliminate the emission of dioxins, furans, mercury, and other pol-lutants to the environment.
At the September 1996 inaugural meeting of what be-came the Health Care Without Harm campaign(HCWH), more than 30 people met to discuss the topicof medical waste incineration. Some came from nationalor grassroots environmental groups or environmentaljustice organizations; other were involved in health care.One thing that the representatives of the 28 organiza-tions who attended the meeting shared was a desire tostop the incineration of medical waste. While some ofthe attendees had specific experience with the internalworkings of the health care waste management system,many knew very little about what options a hospital mighthave for dealing with its waste. So the campaign set aboutthe process of getting its questions answered.
iv N O N - I N C I N E R A T I O N M E D I C A L W A S T E T R E A T M E N T T E C H N O L O G I E S
In the intervening four years, the members of HCWHhave learned a great deal. This knowledge has not beenlimited to the various technologies. As the campaign hasgrown from 28 organizations to 330 groups in 33 coun-tries, HCWH members have become aware of uniquechallenges that some of their colleagues face regardingwaste treatment and disposal. For instance, while medi-cal waste incinerators become less common in the UnitedStates, the technology is still being exported.
HCWH research has discovered a number of things aboutthe U.S. health care industry that were rather surprisingto many in the campaign: In 1996, literally hundreds of hospitals had onsite
incinerators, which many of them used to burn all oftheir waste;
A systematic approach to materials management islacking for many facilities. Purchasing staff in a healthsystem or hospital do not often interact with theirpeers in the housekeeping/environmental servicesdepartment and so are generally not aware of prob-lems that arise from the volume and/or toxicity ofthe medical supplies they buy for the facility. Like-wise, many product-evaluation teams in hospitals donot currently take into account the environmentalimpact of the products they choose. For example, one-quarter of all disposable plastic medical devices usedin the U.S. are now made of polyvinyl chloride (PVC).Scientific research continues to tell the world moreabout the hazards of PVC, yet staff are often unawareof information about the disposal problems associ-ated with such products;
Regulators and facility managers alike have not askedwhat HCWH considers to be basic questions aboutthe emissions of non-incineration technologies, andmoreover, emissions testing that does occur does notseem to be modified to reflect changes in waste com-position; At an American Society of HealthcareEngineering conference in 1999, one engineer listedthe criteria for the perfect treatment technologyas one that:
1. does not require a permit;2. does not require a public hearing;3. can handle all types of waste;4. does not break down easily, and if it does need
repair, is easy to fix;5. requires only one full-time employee (FTE) to
operate it, and that employee doesnt require anyspecial training;
6. does not take up much space in the physical plant;7. has no emissions; and, of course,8. costs less than what s/he had budgeted for the
Health Care Without Harm has not been able to findsuch a technology, and it seems likely that this machinedoes not exist. Indeed, as the campaign has grown andconsiderable research has been undertaken, HCWH haslearned that the vast majority of waste generated in healthcare is very much like household waste, and therefore canbe reduced, reused or recycled instead of treated andlandfilled.
As HCWH and this report have evolved, the campaignencountered the perception that if Health Care WithoutHarm is against incinerators, it must be for landfills. Thisis not the case. For one thing, this assertion does not ad-dress the need for landfilling of incinerator ash residues,which can be of considerable volume and toxicity. Nordoes it note that some non-incineration technologies canachieve significant volume reductions. HCWHs goal isto have facilities minimize the amount and toxicity of allwaste to the greatest degree possible. If steps are taken todo this, the amount of waste requiring treatment will beconsiderably less. By reducing the quantity and toxicityof waste, hospitals can not only stop incinerating waste,they can minimize the health and environmental im-pacts of landfills as well. The campaign realizes that everytreatment technology has some environmental impact.
This report seeks to achieve three primary goals: to encourage health care staff and the public to view
the management of health care-generated waste as aprocess or system of materials management insteadof a single step;
to supply the reader with information to aid her/himin evaluating non-incineration technologies for regu-lated medical waste; and
to raise questions about the public health and envi-ronmental impacts of all methods and technologiesused to treat regulated medical waste.
What this report will not do is specify any one technol-ogy for a facility. The tremendous variability in localconditions (including, but not limited to, environmen-tal, economic, regulatory, social and cultural factors)means that different technologies will be appropriate indifferent parts of the world. Health Care Without Harmdoes not endorse any technologies or companies, but moreimportantly, the campaign believes that those decisionsmust