by Andrea West, Greengrants Grant Manager
In a victory for the Indian anti-toxics movement (and several Greengrants grantees), the Indian government has ruled that medical waste from its upcoming immunization programs will not be incinerated. This decision followed a concerted international grassroots campaign to change immunization practices worldwide, particularly in developing countries. This is especially significant as India’s immunization programs transition to auto-disable (A/D) disposal syringes beginning in 2005. A/D single-use syringes decrease the risk of disease transmission but significantly increase the amount of waste generated by immunization campaigns.
Incineration of immunization waste can release a host of toxic pollutants into the air, including mercury, lead and carcinogens, such as dioxins. Historically, immunization campaigns have provided justification for building polluting incinerators to safely dispose of large amounts of medical waste in a short time. The alternative has been landfill disposal, a notoriously unreliable and unsafe way to discard medical waste, especially risky in places like India where landfills attract impoverished people looking for items of value. Seen as the lesser of two evils, low-cost incinerators and open pit burning of waste have become standard practice in many parts of Africa, Asia and Latin America. Incinerator construction usually invites burning of other waste, compounding air pollution problems.
Faced with the challenge of disposing A/D syringes from its upcoming vaccination drives, the Indian Ministry of Health approached the Central Pollution Control Board (CPCB) in 2002 to request permission for open burning of the waste. The CPCB rejected this request, yet was unable to provide the DOH with viable and affordable alternatives to incineration. Thus began a two-year debate on disposal procedures that involved government agencies, NGOs, and multi-lateral agencies involved in the immunization campaign.
While many organizations had been working on immunization waste issues prior to this point, this decision brought the campaign to the forefront. At the grassroots level, organizations were documenting individual examples of waste disposal alternatives and evaluating their effectiveness. The Himalayan Institute Hospital Trust Facility, collected waste from more than 800 villages and brought them to a no-burn central treatment facility, and the Program for Appropriate Technology in Health (PATH) evaluated the use of needle pullers and pit disposal. Toxics Link carried out an important study on incineration alternatives, and on the policy level, meetings between World Health Organization (WHO) and PATH addressed no-burn options at the national level. These actions, HCWH’s global campaign, and the active participation by Indian groups in the Safe Injection Global Network (a division of WHO), set the stage for a real global discussion about banning incineration disposal techniques globally. In August 2004, Toxics Link and other NGOs involved in the immunization campaign finally agreed to hold a series of meetings to determine the best course of action to dispose of medical waste in India.
With a grant recommended by Global Greengrants Fund’s India Advisory Board, Merci Ferrer was able to attend the meetings and share her expertise on safe, no-burn medical waste disposal. Ferrer, the Asia coordinator of Health Care Without Harm, together with her team of researchers, had previously coordinated with the Philippine Department of Health (DOH) to document the safe disposal of 19.5 million syringes (130,000 kg of waste) without incineration during the recent Philippine Measles Elimination Campaign. Under the Philippine Clean Air Act of 1999, and in accordance with the Stockholm Treaty on Persistent Organic Pollutants, no incineration of any kind is allowed in the Philippines. Faced with the challenge of disposal under these circumstances, the Philippine DOH, with the assistance of the WHO and UNICEF, created a set of guidelines for medical waste disposal. The guidelines recommend that every participating health unit devise a simple, cheap, no-burn method of managing the waste from its immunization campaigns.
The no-burn waste management techniques recommended by the Philippine guidelines included sterilization (autoclaving and microwaving) and burying in concrete septic vaults and clay pits. These methods are cost-effective, easy to implement, and adaptable to local needs. In the study conducted by HCWH in the Philippines, this process was successful in even the most logistically challenging of sites, including mountainous regions, island communities, and rural and urban settings. Because of the simple technology involved, the procedure was successfully implemented in poor, remote areas where access to more sophisticated disposal techniques is limited.
Merci Ferrer presented the details of the Philippine program at the Roundtable on Immunization Waste Disposal in New Delhi in August 2004 where representatives of WHO, UNICEF, the World Bank, and several local and international NGOs joined the Indian Ministries of Health and Environment. Participants examined numerous case studies of immunization alternatives, and Ferrer outlined ways that the protocols from the Philippine case could be adopted by India. Within a month of the meeting, the CPCB finalized a document outlining its decision to adopt a no-burn protocol for the disposal of immunization waste. These national guidelines will be put into effect at more than 600,000 immunization sites in India and will be combined with extensive waste disposal training for medical personnel.
The Indian government’s decision further reinforces the Philippine precedent and paves the way for other governments to follow. HCWH’s campaign continues to promote these techniques to other governments around the world as its work helps to strengthen networks of public interest groups and medical personnel working for incineration alternatives. Ferrer’s participation in the India meetings represents a uniquely international collaboration that promises to support a growing worldwide community of groups working to address seemingly intractable problems with creative, viable solutions. As Ferrer says, “Immunization campaigns are expanding around the world. But we need to make sure we don’t solve one health problem by creating new health problems. This project proves there are safer ways to handle the waste.” The collaborative work of the many organizations involved in this initiative shows how even large government institutions can be shifted toward better alternatives and that timely and strategic action can lead to dramatic change.