Medical Waste: hearings

Meeting report

ENVIRONMENTAL AFFAIRS AND TOURISM PORTFOLIO COMMITTEE
27 February 2001
MEDICAL WASTE: HEARINGS

Chairperson: Ms G L Mahlangu

Documents handed out:
Department of Environmental Affairs and Tourism
Peninsula Technickon
Enviroserv
EnviroSense
Department of Health: KwaZulu-Natal
Institute of Waste Management (see Appendix 1 below)
Buhle Waste (Appendix 2)
Department of Health: Free State (Appendix 3)
Department of Health: Western Cape (Appendix 4)
Evertrade (Appendix 5)
Department of Water Affairs and Forestry (Appendix 6)
Phambili Services Waste Management (Appendix 7)
Anti-Incineration Alliance (Appendix 9)
Department of Health: Mpumalanga
Afrocare (Appendix 10)

SUMMARY
The Department of Environmental Affairs and Tourism lacks both the financial and manpower resources to implement its strategies for combating medical waste pollution in this country. While some participants proposed building new incinerators, others condemned these and advocated alternative technology.

MINUTES
Introduction
The Chairperson noted that medical waste management in South Africa is not up to standard. She said South Africa was one of the filthiest countries in the world - "on route from the international airports into South Africa's cities, you see litter everywhere". South Africa is host to the 2002 global conference and it needs to show the world that it deserves this honour. One of the best indicators for that is the National Environmental Management Act (NEMA) which has put South Africa on the international map. Ironically, local councillors have no idea what the Agenda 2001 is all about and yet they are supposed to implement it. Something should be done about this and she implored the role-players to come up with recommendations to make South Africa environmentally friendly. She was concerned that the representative from the Ministry of Environmental Affairs and Tourism was not present as the Ministry was supposed to implement recommendations from this hearing (the representative later joined the meeting). The Chair congratulated the Department of Health for sending representatives from various provinces.

Hearings
The following are some of the comments made during the submissions:
- Illegal dumping of medical waste is still common. This affects children playing at waste dumps
- Solutions or alternatives to incineration have not been adopted
- Medical waste should be labelled
- There is still improper storage of medical waste
- Ashes from the incineration is still dangerous
- Medical waste infects diseases like HIV/AIDS and Hepatitis B
- There is poor collaboration on medical waste between departments
- Some unscrupulous clinics and hospitals continue to dump medical waste in densely populated areas.
- It is difficult and expensive to manage and regulate medical waste in rural areas. In these areas, there is almost zero use of approved containers. At best there is self burning (with high levels of incomplete combustion and mishandling of ashes), or direct dumping in landfills, or burying in the ground, or at worst, indiscriminate dumping.
- Some companies in this field urged South Africa to use the latest technology to achieve global economies of scale
- Emerging black companies in this field accused established companies of monopolising tender procedures and accused them of unfair practices such as the "storing of piles and piles of medical waste instead of disposing it"
- One representative said the cost of medical waste in a South African hospital was about R43,800 per month or 20,500kg of medical waste per month, which was expensive compared to in countries in Europe.
- A representative from the Ministry of Health said that there was a proposal for dealing with Medical Waste using the principles of the World Health Organisation (WHO) and the South African Bureau of Standards (SABS) to: (i) publicise and regulate Health Care Waste, (ii) collaborate with other Departments on Health Care Waste, (iii) have on-going relations with other Departments to find non-incineration technologies, and (iv) with the Department of Environmental Affairs and Tourism (DEAT) raise funds to assist provinces
- A representative from the private medical waste management sector, Afrocare, said that there was no need for more legislation on this issue but rather a need for "enforcement!". Incineration, used in most hospitals and clinics in South Africa, was an obsolete technology. He advocated Afrocare's "non-burn" heat disinfection technology EESL that operates without harmful emissions. Developed in the United Kingdom, it costs R15 million compared to the present R100 million technology currently used and could handle medical waste more effectively. He urged the Committee to consider this new technology. He told them the issue of medical waste is "an awesome task, don't let politics mess it up".
- Evertrade, another medical waste management company, noted the international trend for tougher controls on incineration - even outright banning of it. To optimise the regulatory framework, it advocated: the establishment of a national generator database/register; rigorous regulation of treatment emissions and secondary pollutants; the implementation of phased-in generator liability; incineration removal; providing incentives for recycling; increased penalties; annual reporting by all generators and service providers.
- The representative from DEAT said his Department was concerned with the pollution of the environment caused by medical waste dumping, incinerators and generators. Their task was to put in place standards that would necessitate prosecution if violated. The serious hazards emanating from this type of pollution were cancer and HIV/AIDS. At risk were doctors, nurses, health-workers and cleaners. The Department is preparing a document on medical waste classification. In contrast to the private sector representative, he said solutions lay in the legislative framework and adherence to SABS standards, the Environmental Conservation Act (ECA) and cooperative governance. The Department was embarking on a Medical Waste pilot project in Northern Province, Mpumalanga and Northwest Province. Constraints faced by the Department were inadequate manpower and a small budget of R3 million.

Discussion
Ms Mbuyazi (IFP) asked Mr Hanekom (Health Department - Western Cape) if they had considered contracting out medical waste disposal in rural areas to private companies.

Mr Hanekom replied that they are currently contracting this work out to both small and big companies. The problem is that the province is too big and so they are planning to construct incinerators near Mossel Bay and Swartklip.

Ms Ramotsamai (ANC) noted that hospitals and clinics are blamed for medical waste pollution. What about private medical doctors?

Mr Pule (Ministry of Health) replied that medical practitioners have to register with the Medical Health Care Waste Management and have to state how they are going to dispose of medical waste. If they fail to comply, enforcement is applied.

The Chair asked if they have the capacity for enforcing these conditions?

Mr Pule replied that where loopholes existed they have been tightened. The problem lay with generators which was difficult to enforce.

Mr Mathebula (DEAT) pointed out that his Department has to manage air pollution emanating from generators. Soon after taking over as Director he noticed that this unit was not enforcing the law on generators and he decided to write a letter to the Director General expressing his impressions on this unit. Since then he could confidently say that the measurement of air pollution in the Durban south was contained. He went on to say that his Department needed something like R18 million to execute its work well.

Mr Tyler (Evertrade) commented there was a need to go beyond enforcement. There were not enough incinerators and there was a need for new technology.

Ms Nqodi (ANC) stated that DEAT should monitor new technology that comes into this country and that South Africa should not be made a dumping ground forthis type of technology.

Mr Mathebula (DEAT) said the Department was always faced with the issue of capacity. When DEAT wanted to develop its National Medical Waste Strategy, the Department was faced with a lack of resources. He spoke of the difficulties they had had with the donor country that wanted to dictate how the Strategy should be implemented. While in the process of developing that Strategy, the donor suddenly stopped working with them and started talking to the Gauteng government about the same strategy. Mr Mathebula stressed that it is a question of a lack of resources that is impeding the Department from implementing plans.

Mr September asked Eurocare whether its Heat Disinfection Unit (that costs R15 million) includes sorting and collecting or is it merely a plant. Mr Crawford of Eurocare replied that it was only a plant.

Ms Dittke (EnviroSense) made the point that the focus should be on sustainability rather than costs.

Mr Crawford said there is no sustainability without costs. He suggested that this country should stop building new incinerators and go for alternative technology.

The Chair thanked the participants for their input and adjourned the meeting

Appendix 1:
INSTITUTE OF WASTE MANAGEMENT SOUTHERN AFRICA:
PRELIMINARY SUBMISSION TO PORTFOLIO COMMITTEE

HEARING ON MEDICAL WASTE
27 FEBRUARY 2001, CAPE TOWN

ISSUES RELATING TO HEALTH CARE WASTE
The handling and disposal of health care waste (medical waste) in South Africa is a cause for grave concern, highlighted by several incidents involving its poor management during the past year. The Institute of Waste Management Southern Africa (IWM SA) welcomes the opportunity to table problems and concerns which require urgent attention from Government.

IWM SA strongly recommends that a further opportunity be afforded to the main role-players dealing with health care waste for preparing more comprehensive submissions in the light of the inadequate time allowed.

The following is a preliminary list of issues that need elaboration by IWM SA with supporting documentation at a later date:
1. Lack of policy and guidelines for health care waste handling and disposal at national and provincial level and for the siting of medical waste/haz-waste facilities
2. Lack of policy and guidelines on crematoria and cemeteries
3. Lack of clear directives on technologies alternative to incineration.
4. Lack of co-ordination and decision-making within government regulatory departments
5. Lack of capacity of enforcing agents for monitoring and control of standards at health care waste facilities
6. Lack of information about existing health care waste facilities, waste quantities disposed of, and emissions.
7. Need for training and capacity building around health care waste issues and within health care institutions
8. Inadequate involvement of the main role-players in a process such as this: IWM SA first became aware of the process via a contractor; the provincial departments and even the officials within DEAT Pretoria appear to be unaware of this hearing; the main users of health care waste facilities such as hospital groups also do not appear to be involved.
9. Need for better communication and integration amongst various processes and projects involving health care waste management throughout the country - IWM SA is aware of several such initiatives, many of which are going ahead on an ad hoc basis without involving all the sectors that ought to have input.

IWM SA, as a representative of the multi-sectoral waste community in South Africa, requests that it be notified of any waste-related hearings or Government initiatives in the future.

June Lombard
PRESIDENT

Appendix 2:
Buhle Waste

1. Medical Waste scenario prior to our tender i.e before 1 April 2000
1.1 Companies involved in Medical Waste in Gauteng were:
1 1.1 Execumed
1.1.2 Clinix
1.1.3 Sanumed
Sanumed being the biggest and the longest in the industry had the tender for all the Gauteng provincial hospitals and clinics. They (Sanumed) had more than 90% of the medical waste business in Gauteng.

1.2 Facilities available for incineration of the medical waste were:
1.2.1 The Johannesburg City Metro at Robinson Landfill site in Rossettenvile.
1.2.2 Sanumed's Roodepoort Incinerator in Roodeport.
1.2.3 Sanumed's Incinerator in Edenvale.

Only the Johannesburg Metro Incinerator has a permit, and Roodepoort according to Dr. Tris Hanekom, has two years to comply. The Edenvale situation is not clear but it is unlikely that this site has a permit due to its proximity to a residential area.

Sanumed was using the Johannesburg Metro Incinerator big time whilst their incinerators were for their exclusive use and closed to other companies. In addition, they had the exclusive use of the Tambo Memorial Hospital (TMH) until around June 2000 after we had requested for permission from the Gauteng Health Department (GHD) and TMH to make use of it as well, it was immediately closed and all operations stopped.

With all these incinerators available to them, Sanumed dumped 40 ton of medical waste in Bloemfontein according to press reports.

2. The Gauteng Medical Waste Tender(post 1st April 2000)
2.1. Sanumed lost the tender, a 3-year contract which commenced on the 1st April 2000, and it went to four companies and was split into five regions as follows,
· Wits and East Rand regions went to Buhle Waste.
· Pretoria region went to Phambili Services.
· West Rand region went to Skip Waste, and
· D.S Environment was given the Vaal region.
Later, D.S Environment lost the contract to Buhle Waste due to non-performance.

2.2 The incinerator available for these companies was the Johannesburg Metro. When volumes started to increase from the new contractors, Johannesburg stopped accepting waste from them. All of a sudden they could not even handle the previous volumes they used to incinerate.

According to Mr. Dawie Beukes of the Johannesburg Metro Incinerator Mr. Du Plooy of air pollution had instructed them to use the incinerator according to the specifications and was monitoring the operations. As a result of the new rules we had no facilities to dispose of our waste. We requested Johannesburg to implement a double shift and in the meantime decided to store our waste at a warehouse located in the Roodekop industrial area. Clifford Durheim of Aids Safe Waste in Dunswart also came to our rescue. He was expecting to be issued with a license for his incinerator and agreed to keep some of our waste until he was permitted to incinerate. This of course got us into trouble with all the stakeholders in the different government departments. After a meeting with all the stakeholders it was agreed that the backlog will be disposed of at the Sanumed's Holtfontein hazardous landfill site on condition that we sign a contract to use Sanumed's incinerator. We had no option but to sign a contract with Sanumed. When you sign a contract with a monopoly they dictate the terms especially when you have your back against the wall. The contract does not favour us at all.

According to the contract, the three companies, Phambili Services, Buhle Waste and D.S Environment must provide Sanumed with a minimum of 245 ton a month (maximum 250). If we give them less than 245 ton they charge us more on a sliding scale and if we exceed 250 ton they turn us away. Once they turned us away and unknown to them we found an incinerator in Sasolburg. An inspector from the Germiston City Council came rushing to our premises looking for waste. He found nothing. And eventually they succeeded in stopping the operations in Sasolburg.

Because of the shortage of incinerators Execumed was caught storing medical waste at a house in Roodekop in August 2000. They lost all their contracts with the private hospitals and these contracts went to Sanumed. Execumed and Clinix are now out of business.

What we need to look at seriously here is the dominance of the industry by one player. Medical Waste in South Africa cannot be handled by one company. There is no company in South Africa today that has the capacity to deal with all the medical waste problems facing the country.

3. Problems and attitudes at some of the hospitals in Gauteng.
When we were awarded the contract there was a mixed reaction from the hospitals which ranged from very positive to extremely negative. At different levels the Johannesburg and Tembisa Hospitals deserve a special mention.

Right from the beginning Johannesburg Hospital was viciously resistant and up to now they are very unco-operative. Although we have the medical waste tender, they are still using Sanumed to a lesser extent and Sanumed is happily providing the service.

Appendix 3:
Free State Province Department of Health

Medical Waste Management
1. General:
1.1. Every institution is responsible for the handling, separation and incineration of their medical waste according to S.A.B.S. 0248 - 1993 and the municipal regulations.
1.2. Minor problems are experienced where the separation of general and medical waste must be done. It was found that general waste and medical waste were mixed and put in wrong colored bags. Several meetings were held in this regard. The problems were solved.
1.3. A more serious problem experienced was the handling of sharps. The section gather the sharps in special containers for incineration but it still happens that sharps land in waste bags that can cause injury to handlers of the waste. To solve this problem Technical Services are busy with an investigation to prepare a submission to management for needle incinerators to be used, for the disposal of sharps.

2. Incinerators:
2.1. Institutions are equipped with incinerators that comply with the Pollution act, act 45 of 1965. New incinerators installed also comply with the said act, as this is specified in the tender documents.
2.2. The incinerators at 3 institutions will be replaced during the 2001/2002 financial year. Four incinerators have been replaced at institutions the past year and must still be registered at the Department of Environmental Affairs and Tourism. These incinerators all comply with the act.
2.3. From time to time problems like overloading of the incinerators is experienced that causes pollution [black smoke]. This problem is being controlled with continuous on the job training. Regular visits and inspections can avoid such mishaps.

3. Sites:
No site has been registered in the province in terms of the law.

4. There are 36 healthcare institutions that is the responsibility of the Department of Health.
4.1 Three institutions: Elizabeth Ross Hospital, Vrede Hospital and Winburg Hospital will be equipped with incinerators the following year. Incinerators in use are still in a good working condition, but do not comply with the act.
4.2 Two institutions are in the process of ordering new incinerators:Bethlehem Regional Hospital Phekolong Hospital in Bethlehem
4.3. Four institutions must still be registered in terms of the law:
-Jagersfontein Hospital
-Smithfield Hospital
-Moroka Hospital in ThabaNchu
-Manapo Hospital in Qwa Qwa

5.Private Company:
5.1. We are aware of a company that offers the services of collecting, transporting and incineration of medical waste.
5.2 Institutions will still be responsible for the separation and sealing of the containers.
5.3.Containers are not removed on a daily basis and cooling facilities have to be erected.
5.4. According to the regulations the generator of medical waste is still responsible up to the incineration process.
5.5. Human tissue must be incinerated on site.
5.6. In 1997 the firm was requested to furnish the Province with a feasibility study regarding service delivery the Free State Province, but the firm did not respond.

6. It is the opinion of Health Services that the present system of waste management is still the most affordable and effective way of doing it.

Appendix 4:
Western Cape Department of Health
Compiled by E Hanekom: Public Health Services

MEDICAL WASTE MANAGEMENT IN THE WESTERN CAPE
INTRODUCTION
The careful and responsible control of infection affects us all, from the health care worker in the clinics to the man in the street. With the increase of AIDS and Hepatitis B at a most critical stage, we need now strong and clear environmental legislation to prevent any unnecessary infection through the handling of potential infectious waste and also to prevent constant air pollution from inadequate incinerators.

SCENARIO IN THE WESTERN CAPE
In the Western Cape we have two modern incinerators permitted by the Dept of Environmental Affairs and Tourism. These incinerators are located near the Metropolitan area (Delft and Visserhok) and cover urban centers extensively. To cover the rural areas of this province to the same extent is difficult and expensive due to size of this province. The future developments in this field are promising and include the following:
· a possible incinerator near Mosselbay;
· medical waste treatment plant in Milnerton new technology micro waves; and
· identification of another possible site for a medical waste incinerator by the Cape Metropolitan Council near the Swartklip landfill site.

A comprehensive medical waste survey (covered 910 medical waste generators) was done in the Cape Town Metropolitan area in 1998. This survey did cover medical waste handling from the point of generation to the disposal there-of. This study has shown the following:
Total 127 334 kg of medical waste is generated monthly in the Metropolitan area;
- 69% of this waste comes from the provincial hospitals;
- 86% of medical waste generators do dispose of their waste safely;
- 93% of medical waste generators do store their waste safely;
- 94% of medical waste generators do separate medical waste from their other waste;
- 73% of medical waste generators have a health and safety policy in place regarding the handling of medical waste; and
-88% of medical waste handlers are trained to handle medical waste.

This survey has shown that medical waste is handled responsible in the Metropolitan area but there is room for improvement. This survey was also rolled out to the more rural health regions of this province to get the total picture of how medical waste is being handled. These results should be available in the second half of this year.

ILLEGAL DUMPING INCIDENTS
During 1998/1999 this province were plagued by several incidence where medical waste was found to be dumped illegally and this sparked an outcry from the affected communities. The Provincial Minister of Health instituted a task team to investigate these incidents. The task team did report the following:
· Medical legislation is fragmented and therefore makes it problematic to apply;
· There is a lack of a proper definition of medical waste in the legislation;
· Although there are several pieces of legislation dealing with some part/processes of medical waste handling, there is not much teeth in dealing with medical waste at the coal face (local authority level):
-6 national acts;
-7 codes and standards:
-ordinances
· The fines are far to low if you take into account the possible risk of this type of waste to the community.

Due to the fact that the medical waste generators involved in the illegal dumping incidents were doctors, the task team report was also sent to the Medical and Dental Professional Board.

To overcome the problem of a lack of awareness amongst communities several attempts were made by the Province and Local Government to educate people (especially children) and to build capacity in communities. This included several talks on community radios, posters, flyers and talks at schools by Environmental Health Officers.

The Provincial Minister of Local Government also started in 1999 with an initiative through WECLOGO to put provincial medical waste legislation on the table. This legislation is still in draft format but it is a real attempt to cover medical waste handling comprehensively.

Appendix 5:
EVERTRADE MEDICAL WASTE

BIO HAZARDOUS WASTE AND ITS COMMUNITY IMPLICATIONS
Report to Parliament 27/2/2001

MISSION STATEMENT
To solely focus on the provision of bio hazardous waste service to generators, which
provides solutions for user, nosocomial, organisational and community risks

PATHOGENICITY IN SOUTH AFRICA
The Disease Burden
* 70% of global AIDS sufferers are in Sub Saharan Africa
* Estimated 1 in 5 HIV positive in SA
* Essentially a disease of the young (death rate of 15-49 year olds has almost doubled in last ten years in SA)
* Alarming levels of opportunistic infections

The Impact
* Significant economic dislocation (effects on workforce and skills base)
* Huge burden on health care delivery system
* Severe social dislocation (breakdown of family unit and effect on children)
* Comprehensive demographic instability
* Infection control nightmare

BIO HAZARDOUS WASTE IN SA - CURRENT URBAN STATUS
POINT OF GENERATION
- Inadequate containers
- Little training
- No compliance review

COLLECTION
- No systemic control

TREATMENT
- Treat host material to deal with bio burden
- Secondary stream highly toxic

DISPOSAL
- Hopefully treated
- Uncontrolled
- Toxic substance

BIO HAZARDOUS WASTE IN SA - CURRENT RURAL & HOME CARE STATUS
Rural
- Almost zero use of containers - if any type of container is in use it is a matter of pure improvisation
- Self burning at best (with very high level of incomplete combustion), or direct dumping to landfills, or burying in the ground, or at worst, indiscriminate dumping
- Total mishandling of ash or residues
- Poor levels of infection control awareness

Home care
- Bio hazardous waste is dumped into normal municipal waste stream

INTERNATIONAL TRENDS
- Regulating generator liability
- Tougher controls on incineration, even banning
- Introduction of standards for systemic controls
- Increasing moves towards recycling
- Global pressure on non compliant nations

KEY ISSUES OF BIO HAZARDOUS WASTE
· Confronting the problem
· Switching emphasis to infection control and service
· Establishment of a national generator database
· Understanding the spectrum of generator environments
· Waste classification
· Effective containerisation
· User convenience
· Training
· System integrity
· System compliance
· Compliance with international standards and practices
· Industry auditing
· Rural and home care servicing

OPTIMISING THE REGULATORY FRAMEWORK
· Implement phased in generator liability
· Registration of generators and service providers
· Rigorous regulation of treatment emissions and secondary pollutants
· Remove incineration as benchmark for regulatory framework
· Incentivise recycling
· Increase penalties significantly
· Annual reporting for all generators and service providers
· Public/private sector cooperation

KEY ECONOMIC ISSUES
· Local economies of scale
· Life cycle costing approaches
· Supporting local capital investment
· Exporting to achieve economies of scale benefits

Appendix 6:
DEPARTMENT OF WATER AFFAIRS

POLICY ON THE DISPOSAL OF MEDICAL WASTE
I. All medical waste must be incinerated for at least 1 second at 800 0C in an incinerator with a valid licence in terms of the Atmospheric Pollution Prevention Act, 1965 (Act 45 of 1965), which has available capacity.

II. Should there be technological options other than incineration available for the treatment of biohazardous waste (excluding anatomical parts, radioactive waste and chemotherapeutic waste), which will have final results with regard to impacts to the environment and human health similar to, or better than, that of incineration, the Department will consider motivations to use these technologies. This implies that all infection risk/potential should be completely eliminated over time, and the waste should no longer be recognisable as of medical origin.

PROCEDURE TO BE FOLLOWED FOR OBTAINING APPROVAL FOR THE UTILISATION OF TECHNOLOGIES ALTERNATIVE TO INCINERATION FOR THE HANDLING OF MEDICAL WASTE
1. An application must be submitted to the Department, and the application must be supported by an extensive motivation report containing a general technical assessment of the technology. The information required in the motivation report/general technical assessment (GTA) must include, but is not limited to, the following:

1.1. A detailed description of the project life cycle (e.g. construction, commissioning, operation etc.)
1.2. A detailed description of the proposed technology;
1.3. A product life cycle: all processes and procedures to be used in the implementation of the proposed technology, including the following:

1.3.1. Types of medical waste to be treated and any methods for sorting this waste
1.3.2. The final products resulting from the proposed technology;
1.3.3. Classification of the final product according to the document Minimum Requirements for the Handling, Classification, and Disposal of Hazardous waste,
1.3.4. The location where the final products will be disposed of, including detail regarding any legal obligations and constraints at that location; as well as specific operational procedures and precautions that must be followed by the Site Operator;
1.3.5. Sustainable evidence that the final products resulting from the proposed technology will have effects similar to, or better than, the effects of incineration on the environment and on human health, including reliable tests conducted over time to determine the presence and/or persistence of the following:

· Escherichia coli
· Streptococcus faecalis
· Proteus vulgaris
· Proteus sp.
· Klebsiella aerogans
· Alcaligenes faecalis
· Micrococcus spp.
· Staphylococcus aureus
· Staphylococcus albus
· Pseudomonas aeruginosa
· Candida albicans
· Hepatitis B
· HIV
· HIV infected cells

1.3.6. A water management plan addressing all issues with regard to water quality and quantity (including a detailed water balance),
1.3.7. A detailed mass balance,
1.3.8. If transportation of medical waste from different sources to a central point is required, all precautions necessary to minimise the risk of spillage,
1.3.9. The impacts of the processes, procedures and final products as well as the disposal methods on the environment and on human health; and
1.3.10. A conclusion containing a clear statement by the applicant, supported with reliable evidence, to the effect that this alternative technology will have effects similar to incineration on the environment and on human health.

2. The Department may, during the process of evaluating the application, require any additional information from the applicant that may be necessary to reach a decision.

3. Should an application to use an alternative technology at a specific Waste Disposal Site be approved by the Department, the Permit Holder of that specific site must be approached by the successful applicant with a request to dispose of the final product resulting from this technology at that Site.

4. Should the Permit Holder at that Site give his consent to the applicant, in consultation with parties involved in his Site, that the waste resulting from the use of this technology may be disposed on at his Site, the Permit Holder must then submit an application for a Permit amendment to the Department, since all Permits for landfill sites exclude medical wastes to be landfilled, unless it has been incinerated.

5. The Department will then consider the application for a Permit amendment, as submitted by the Permit Holder of the Site.

6. Should the application for a Permit amendment be approved, the permit amendment will then include specific conditions to control the disposal of this waste in a manner that is acceptable to all parties.

7. Only after the Permit Holder has received the approved Permit amendment, may this technology be used to handle medical waste.

Appendix 7:
Submission: Phambili Waste Management Services

27/02/2001

Our Company is an integrated Waste Management Company, involved in medical waste, Domestic Waste, Water and Sanitation. Prior to our company's involvement in medical waste, one or two company ran the medical waste industry. Medical Waste in South Africa was never handled properly, no scrubbers, and over the years, systems used by these companies, were used as a benchmark, on how medical waste was to be handled. The medical waste industry was dominated by one or two companies, not willing to allow new black companies, to operate in this market. When Black Companies were awarded the medical waste tender, in line with governments vision of ensuring that black companies were empowered. Suddenly, there was an outcry, about the lack of standards. Claims of medical boxes, found in storerooms and residential houses. As it stands, none of these new black companies were involved in any illegal activities. In fact, they are doing an excellent job, in line with the minimum requirements of the authorities.

Phambili Services has since undertaken various missions abroad, to investigate and see how medical waste is been handled, treated and destroyed. None of the current medical waste facilities are licensed, except for one or two. It is estimated that Gauteng alone produces an estimated +- 1150 Tons of medical waste. This includes both private and provincial hospitals. We also know, that there are about 87 incinerators at various provincial hospitals that function below the minimum requirements. Thus, the need for a new medical environmental destruction facility, in line with the national waste management strategy. It is clear that, there is not enough capacity and regional facilities must be established.

The need for additional facilities is dire, but this should not be above the environmental concerns of the affected parties. Since incineration is not considered environmentally - friendly, we believe that they must be phased out We believe that the core business of the department of Health should be providing healthcare to the people. Therefore, the collection, transportation, treatment and destruction of medical waste should be left to waste management companies.

Phambili is supportive of the National Waste Management Strategy, which seeks to introduce standards to the medical waste industry. We caution that, as these standards must be both practical and enforceable. They must also take into account, the history and challenges facing the medical waste industry, and in particular black business.

We are aware of the various regulatory authorities handling the licensing and monitoring of these facilities, and appeal to them to be more flexible and transparent in their approach to the medical waste industry.

Appendix 8:
Mpumalanga Department of Health
Hearing on Medical Waste

TERMS OF REFERENCE:
Health Care (Medical) Waste issue / problem in the Mpumalanga Province and the affects of Health Care (Medical) Waste on the Department of Health.

BACKGROUND:
1 The World Health Organisation (WHO) defines health care waste (medical waste) as follows:
"Health care waste includes all the waste generated by Health Care establishments, research facilities and laboratories. In addition, it includes the waste originating from "minor" or "scattered" sources such as that produced in the course of health care undertaken in the home (dialysis, insulin injections,) etc. (WHO, Geneva, 1999, Safe management of wastes from Health Care Activities)."

2. Provincial Health Care Centres
Number of Provincial Health Care Centres in the Mpumalanga Province:
Hospitals: 27
Clinics: > 200

3. Health Care (Medical) Waste consists of:
- Infectious waste; Pathological waste;
- Sharps and needles; Pharmaceutical waste;
- Genotoxic waste (mutagenic, teratogenic or carcinogenic properties);
- Chemical waste;
- Wastes with high content of heavy metals;
- Pressurized containers;
- Radioactive waste (*).
(*) Radioactive waste to be handled and disposed of in accordance with the Nuclear Energy Act, 1993 (Act No.131 of 1993).

4. Legislation, codes of practice etc. regarding Health Care Waste (Medical Waste):
- The Health Act, 1977 (Act No.63 of 1977.);
- The Hazardous Substances Act, 1973 (Act No.15 of 1973.);
- The Atmospheric Pollution Prevention Act, 1965 (Act No.45 of 1965.);
- The Environmental Conservation Act, 1989 (Act No.73 of 1989.);
- The Occupational Health and Safety Act, 1993 (Act No.85 of 1993.);
- The National Road Traffic Act, 1998 (Act No.7 of 1998.);
- The National Environmental Management Act, 1998 (Act No. 107 of 1998.);

- The White Paper on Integrated Pollution and Waste Management for South Africa, Government Notice No.227 of 17 March 2000.

- Various Codes of Practice and Guidelines by:
- WHO, (World Health Organization);
- SABS codes;
- Mpumalanga Province Draft Medical Waste Policy of the year 2000;
- Basel Convention, 22 March 1989;
- Convention on Biological diversity (Earth summit), Rio de Janeiro, 5 June 1992.

ISSUE AND PROBLEMS OF HEALTH CARE (MEDICAL) WASTE
1. Facilities for disposal of Health Care (Medical) Waste:
- At present using hospital incinerators;
- Incinerators to be upgraded, repaired, properly maintained;
- Trained staff to deal with disposal of Health Care Waste;
- Disposal of "Hazardous Waste" after incineration process.

2. Financial Implications:
- Cost of disposal of Health Care Waste namely:
- at Health Care premises;
- at private Hazardous Waste disposal sites;
- transportation of Health Care Waste.

3. Alternative to Incineration of Health Care (Medical) Waste:
At present there is no known alternative.

4 Uniform handling of Health Care (Medical) Waste:
At present there is no uniform standard I policy / guideline regarding the handling and disposal of Health Care (Medical) Waste which leads to confusion, dangerous and unsafe practices.

5 Labelling and Identification of Health Care (Medical) Waste:
The labelling of Health Care (Medical) Waste should comply to legislation especially when it is transported.
Colour coded waste disposal bags should be used.

6. Rural areas:
The concept of burning Health Care (Medical) Waste and the burying of placentas is still practised in the rural areas.

7 Storage facilities for Health Care (Medical) Waste:
The storage facilities of Health Care (Medical) Waste should be upgraded to prevent nuisances and public health dangers.

8. Requirements of other Departments:
The Department of Health should comply with the legal requirements of
other Departments such as:
- Department of Water Affairs and Forestry;
- Department of Environmental Affairs and Tourism;
- Department of Labour;
- Local authorities.

AFFECTS OF HEALTH CARE (MEDICAL) WASTE ON THE DEPARTMENT OF HEALTH (MPUMALANGA PROVINCE).
1. Diseases:
Diseases can be spread easily where Health Care (Medical) Waste is the mode of transmission, e.g.:
- HIV infection;
- Tetanus;
- Hepatitis;
- Septic wounds / abscesses;
- Infectious diseases not elsewhere mentioned;
- Diarrhoea;
- Ebola Marburg Viral Diseases.

2. Access:
Cases have occurred where unauthorized persons I members of the public or children have access to Health Care (Medical) Waste.

3. Disposal:
Illegal and accidental dumping of Health Care (Medical) Waste often occurs.
Health Care (Medical) Waste accidentally disposed of on G- (General) waste disposal sites.

4. Collaboration:
Poor collaboration and coordination between departments regarding
Health Care (Medical) Waste disposal and handling of waste.
Different policies, guidelines and the interpretation of such with regard to
Health Care (Medical) Waste.

5. Human factor:
Several difficulties can be referred to human factors, such as:
- Understanding the problem;
- Lack of training;
- Lack of supervision;
- Lack of interest.

Prepared by: C. J. Barnard
Control Environmental Health Officer: Occupational Health
For Mpumalanga Department of Health

Appendix 9:
Anti-Incineration Alliance (AIA)

Information on Incineration
· Internationally there is a move away from incineration
This is true in America, India, Greece. Germany, France, Japan, Turkey, and the Netherlands. One of the consequences of this is that incinerator companies are taking their technology East (Eastern Europe) and South.

Turkey - In 1999 the Turkish Environment Minister, Ms. Imren Aykut, announced that all waste incinerators, especially toxic industrial waste and hazardous hospital waste plants, must be dismantled and phased-out. According to official data, about 114,000 tons of hospital wastes are generated in Turkey annually.

France - In 1999 French authorities closed down three municipal waste incinerators in Lille, because of the high dioxin concentrations in locally produced cow's milk.

Massachusetts, America - In 15 years Massachusetts reduced its number of medical waste incinerators from 150 in 1983 to just 15 in 1998.

· It is hazardous to the environment and therefore is not sustainable.
Incinerators do not make waste disappear - they reduce it to ash and to atmospheric emissions, both of which are potentially hazardous. Incineration liberates toxic chemicals from otherwise stable matrices (eg plastics) and it creates toxic by-products like dioxins and furans from chlorinated plastics. It generates toxic ash or toxic effluent. Fly ash from scrubbers is particularly high in toxins.

· It is dangerous to health
There is now increasing evidence that incinerators pose a health threat. Many highly toxic substances emitted from municipal waste incinerators (including dioxins, furans, cadmium, lead and mercury) are known to disrupt the body's hormonal (endocrine), immune and reproductive systems as well as cause cancers.

A 1996 study published in the Brltish Journal of Cancer found that people who live within 10 kms of a municipal solid waste incinerator have an increased likelihood of getting several different cancers. A Japanese court ordered the shut-down of an incinerator because: "There is a possibility of deepening serious damages to the residents' health and properties as a result of contamination of water resources and atmosphere because of dioxin emissions from the incinerator.." The incidence of disease at Aloes Incinerator in Port Elizabeth is eight times higher than in the rest of PE.

· It is the most costly method of dealing with waste
Incinerators are extremely expensive to install and run. These costs are expected to increase as regulations are tightened and monitoring standards are raised. Disposing of the ash residue from incinerators is also expensive, as it needs to be treated as a hazardous substance.

A state of the art' incinerator in America can cost up to US$210 million (ie R1,2 billion). An incinerator recently built in Amsterdam, Netherlands, cost $600 million (R3,6 billion) and even this state of the art incinerator cannot entirely prevent emissions of dioxins and other toxic gases.
The airborne emissions from incinerators are expensive and difficult to control. To maintain low emissions an incinerator must be meticulously operated and the air control equipment must be optimally maintained. If you are offered a cheap means of incineration it can only be of an inferior quality, inefficient, and therefore highly dangerous to the environment and health. Incineration does not make economic sense.

· It does not create jobs
Incinerators show little economic return. Incinerators provide little employment opportunities for the large capital investment needed. Much local public money leaves the community and is paid into the hands of large private sector and or multi-national companies to operate the incinerators.

· It does not encourage waste minimisation
Incinerators encourage a consumer-orientated and waste-generating society. Incinerators require a minimum amount of waste to be delivered each day in order to remain operational. This is a deterrent to waste minimisation. Incinerators compete with recycling and re-use schemes. In contrast with incineration, separating and recycling waste provide opportunities for employment of local people, and money so spent remains in the community.

We need to move away from waste disposal to waste management and waste minimisation.

WHAT IS DIOXIN?
Dioxin is the most toxic substance known.
· Dioxin is the common name for a class of 75 chemicals scientifically known as chlorodibenzo-dioxins. They commonly occur with another group of highly toxic chemicals known as furans. In this discussion, the term
dioxins is used to refer to both dioxins and furans.

· Dioxins are classified as persistent organic pollutants (POPs) ("persistent" means that once they are manufactured, they resist being broken down).

· They are unwanted by products (ie they are not intentionally produced) from processes that involve heat, organic matter and chlorine. (ie, when products containing both chlorine and carbon are burnt).

· As waste products, dioxins are emitted into the air and wastewater. Dioxin remains in the environment for a long period of time and builds up in the food chain. At each successive level of the food chain the dioxins bioaccumulate. In the air they are carried great distances. Airborne dioxins and furans fall to the ground and into water bodies with dust and rain. Airborne dioxins settle on grass that is digested by cows, sheep and other animals, which in turn are digested by humans While dioxins may enter the human body through breathing polluted air, the primary way they are digested is through eating the meat and dairy products from animals that have been exposed to dioxins. Dioxins are also transferred from mother to child through breast milk.

One gram of dioxin (approximately the size of a Smartie) is enough to contaminate one million people. A tiny amount is enough to do a lot of harm. There are no safe' levels of dioxins. Exposure to any amount of dioxin, no matter how small, is dangerous.

The way to test for levels of dioxin is NOT through air pollution monitoring (ie what is inhaled), but through monitoring the build up of emissions through the food chain.

Exposure to dioxins has been shown to cause the following in humans
· cancer mortality in workers and community residents
· increase in glucose intolerance leading to diabetes
· decrease in size of genitals (testes)
· immune system depression
· birth defects
· low testosterone
· sterility

Dioxins and furans make up two of the nine substances listed in the proposed international (UNEP) convention on persistent organic pollutants (POPs). South Africa is party to the drafting of this agreement. The agreement will mandate global, legally binding measures to reduce and/or eliminate releases into the environment of dioxins amongst others.

As of 1998.
USA - Since 1985, at least 280 incinerator proposals in the USA have been defeated or abandoned due to public opposition. In the same period 73 waste-to-energy incinerators were built. Since 1985, in California, 32 out of 35 incinerator proposals have been quashed. In New York City all 5 of the incinerator proposals put forward were defeated

Australia - In the past 1(1-15 years every attempt to site a hazardous waste incinerator has failed: due to public opposition.
There are no licensed hazardous waste incinerators in Australia.

Spain - Since 1990, 32 incinerator proposals have been stopped due to public opposition, culminating in 1994 with the announcement by the Spanish government that it would no longer promote or fund hazardous waste incinerator projects.

U.K. - Since 1989, 7 out of 8 toxic waste incineration proposals have been defeated. The eighth successful proposal was, however, never built as the developers decided it would not be commercially viable as there was insufficient suitable waste. In addition, 4 out of 5 municipal waste incinerator proposals were defeated.

SA - 1997 - Drum incinerator defeated in South Durban

1998 - Medical waste incinerator shut down due to public opposition in Aloes, P.E.

The ALTERNATIVES to incineration:
The three Rs reduce, reuse and recycle - together with composting.

The best possible alternatives to incineration are waste reduction and separation. Wherever possible separate. recycle, reuse and compost your waste. Manufacturers need to be encouraged to stop producing substances, which cannot be recycled, reused or composted.

Efficient reuse. recycling and composting schemes for the non-toxic section of household waste can recover between 45% to 75% of the original volume, thus reducing the need for landfills. Some of the cost incurred by recycling can be recovered by selling the re-usable materials

Separating and recycling waste provide opportunities for employment of local people, and money so spent remains in the community.

The National Waste Management Strategy (NWMS) Strategic Options Discussion Document (3 August 1998) promotes the strategy of waste recycling, the objectives of which would be:

1. to save resources and reduce the environmental impact by reducing the amount of waste disposed at landfills
2. To make recycling viable as a form of job creation (p42)

The document also states that:
"Waste separation at source is proposed.. Appropriate legislation must be promulgated which promotes recycling by introducing economic subsidies to recycle. The establishment of full-scale recycling centres that implement labour intensive practices will create employment in the communities and will minimise salvaging at landfill sites. (p43)

MEDICAL WASTE
Medical waste incineration converts a BIOLOGICAL PROBLEM into a set of formidable CHEMICAL problems

Incineration of medical waste has been identified as probably the main source of dioxins as hospital waste contains large quantities of chlorinated medical products and organic products, and it is the burning together of these two kinds of matter that generates dioxins.

Medical waste incinerators are also a major source of mercury contamination

In 1996 new medical waste regulations were passed in India, which prohibited the burning of chlorinated plastics in medical waste incinerators.

The available alternatives to medical waste incineration are simple and cheaper.

Only a very small portion (about 6%) of hospital waste is potentially contaminated and/or infectious (human tissues and organs, blood, blood-contaminated glass, tubing and sharps). The rest is general waste from the kitchens, canteens and offices.

Alternative technologies for the treatment of the infectious component of medical waste include:
· autoclaving (high temperature steam sterilisation)
· rotoclaving
· microwaving
· chemical/mechanical disinfection
· steam sterilization
· etc.

These alternative methods are less capital intensive, cheaper to operate and have fewer emissions.

Three simple steps to reduce dioxin production in the treatment of medical waste:
1. Identify chlorinated products in your facility, especially PVC plastic products (blood bags, surgical gloves, surgical aprons, patient ID bracelets, tubing)
2. Substitute chlorinated products for non-chlorinated products. These are mostly disposable products (eg plastic aprons) and can be replaced with products that can be reused (eg fabric aprons)
3. Separate chlorinated products from infectious matter, and dispose of them separately. Microwaving, autoclaving, steam thermal systems or chemical disinfection can treat chlorinated products, which have come into contact with infectious matter.

Pathological waste is the one section of the hospital waste stream that can be safely burnt

MUNICIPAL WASTE
Municipal waste incinerators are the second highest source of dioxins (second only to medical waste incinerators) in the USA

Municipal waste contains a high amount of chlorine (for example in paper which has been bleached with chlorine) as well as organic matter (foodstuffs). The burning of chlorine in the presence of organic matter is what generates dioxins and furans.

Ash produced by municipal waste incinerators must be handled as hazardous waste.

When you incinerate three tons of trash, you convert it into one ton of potentially hazardous ash which no-one wants.

When you separate three tons of trash, you convert it into 1 ton of recyclables, one ton of compost and one ton of education.

This approach is better for your children, your community, the national economy, and planet earth.

Appendix 10:
Afrocare
It disposes of clinical waste using a Heat Disinfection System which processes waste using non-burn technology. The resulting residue can then be safely disposed of as industrial non-hazardous waste.

[PMG ed note: promotional material about Afrocare not included]

Attached article to Afrocare presentation:
Heat disinfection of clinical waste: microbiological assessment and monitoring of effectiveness by Holiday, M et al (British Journal of Biomedical Science 2000; 57: 107-113