DECEMBER 1996 · VOLUME 17 · NUMBER 12

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E N V I R O N M E N T

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CALCUTTA -- "Dioxin? What is dioxin? No one told me about dioxin." That was how a senior government official in the Department of Health and Family Welfare in West Bengal reacted when Indian and U.S. environmentalists asked in April if the Ministry was concerned about the mounting scientific evidence identifying medical waste incinerators as among the largest sources of extremely toxic dioxin into the environment. The official, who asked not to be identified, had just described a recently approved World Bank health care sector restructuring project that his Ministry helped develop; the project includes plans for construction of medical waste incinerators throughout three states in India.

The World Bank project covers the Indian states of Karnataka, Punjab and West Bengal and calls for the construction of many incinerators. In Karnataka, hospitals with as few as 50 beds would have an incinerator installed.

At least some World Bank officials not involved with the project agree with the environmentalists that medical waste incinerators are inappropriate for India. A January 1996 report from the World Bank's South Asia office recommended against reliance on "imported high-technology incinerators that are expensive to purchase and difficult to maintain" for medical waste disposal. Rejecting incinerators, the report recommended that other "appropriate technologies," based on segregation and decontamination, be used instead.

The Bank's plans to proceed with medical waste incineration, even as the South Asia office has specifically recommended against such practices for India, have outraged Indian environmentalists and public health advocates. "We fear that the disposal of medical waste through on-site incinerators will be a cure which is far worse than the disease itself," wrote Ravi Agarwal and Bharati Chaturvedi of the Delhi-based organization Srishti and coordinators of the Indian Campaign Against Medical Waste Incineration, in an NOVEMBER 1996 letter to World Bank President James Wolfensohn.

"There is no reason to add to [India's high pollution] load, and also to introduce other deadly toxins such as dioxins and furans, which India does not even have the capability to test," they wrote. "The Bank should in fact be helping the country to leapfrog into the latest techniques of medical waste disposal in the interest of community health. This becomes even more important since most health care facilities are located in densely populated areas."

A poor response to a real problem

While there may not be a consensus on the solution, there is no dispute that medical waste is a serious problem in India.

Throughout the country, professional ragpickers sift through garbage on streets and in municipal bins and landfills to recover the glass, paper, plastic and metal which they can sell for recycling. The ragpickers serve the cities well by reducing the amount of garbage in the streets and dumps, but in the process they are exposed to disease, toxic wastes, sharp objects and other dangers.

Since most hospitals in India dispose of their medical waste by either dumping it in the regular city landfill, neighborhood trash bin or simply out the back door, ragpickers also have to contend with the special problems associated with medical waste.

Srishti has done extensive research into medical waste handling practices in India. Chaturvedi of Srishti interviewed dozens of ragpickers in Delhi who have sifted through medical waste.

"We never observed any ragpicker or other workers rummaging through medical waste using either gloves or the more common stick. They usually use their bare hands," she reports. "Sixty-six percent of the ragpickers Srishti spoke to were able to recount or show a definite instance of injury they got while handling medical waste."

Out of concern for the health of ragpickers, as well as the risks of reusing contaminated needles and other used medical equipment, the Supreme Court directed the government in March to install incinerators in all hospitals with more than 50 beds.

Activists working on waste issues in India welcomed governmental concern, but were horrified at the Court's decision to require incineration which produces dangerous air emissions, including dioxin compounds. Dioxin disrupts the endocrine, central nervous, immune and reproductive systems, and causes cancer.

"We understand the Court meant well, but they were not presented with all the facts. Had the medical waste issue been studied thoroughly, they would have rejected incineration and required cleaner, safer and cheaper technologies," explains Agarwal.

"Incineration changes the problem of medical waste from a biological problem to a chemical problem," explains Dr. Paul Connett, a chemistry professor at St. Lawrence University in New York and co-editor of the "Waste Not" newsletter. "While incineration is capable of destroying the bacteria and viruses, it forces on itself the extra task of having to destroy the material on which the pathogens are sitting: the paper, plastic, glass, and metal. It is in this process that acid gases are generated (from the chlorinated organic plastics), toxic metals are liberated (from the pigments and additives in the paper and plastic, miscellaneous items like batteries, discarded thermometers, etc.) and dioxins are formed (from any chlorine present in the waste)."

"None of these serious chemical problems is inherent to the medical waste `problem' itself," emphasizes Connett. "They all result from the supposed `solution.'"

Alarmed about the sudden rush to incinerate medical waste, Indian organizations formed an Indian Campaign Against Medical Waste Incineration, which is hurriedly educating people about the dangers of incineration and the advantages of alternatives.

In March, at the invitation of members of the Campaign, Connett visited India to participate in educational seminars and discussions with activists, government decision-makers, hospital administrators and members of the media. Together Connett and Indian anti-incinerator activists held meetings in Delhi, Bhopal, Bombay and Calcutta. "The generally low level of awareness of the dangers of incineration worried me," reports Connett. "But the greatest shock came in Calcutta where we learned who was behind the planned construction of so many incinerators --the World Bank!"

The Campaign has already scored a major victory. On May 7, in response to joint petitions from the Campaign and the Delhi Medical Association, the Supreme Court modified its previous order, announcing that hospitals are not obliged to have incinerators but may use any environmentally friendly technology to dispose of medical waste. The Court also ordered the Indian Central Pollution Control Board to develop standards, currently being finalized, for incinerators and other medical waste technologies.

The Supreme Court's revised decision is a step in the right direction, but is far from a total victory because it still allows for incineration.

Medical waste incineration and dioxin

Although at first glance medical waste incineration may not seem like a significant environmental threat, it is in fact a major problem, even in industrialized countries, where the process is far more carefully monitored than it ever might be in India.

In 1994, the U.S. Environmental Protection Agency identified medical waste incinerators as the largest known source of dioxin into the United States, emitting 5,100 grams out of a total 9,300 grams of dioxin toxic equivalents released each year. A June 1996 study issued by the Center for the Biology of Natural Systems at New York's Queens College identified medical waste incineration as providing 48 percent of total dioxin deposited in the Great Lakes region of the United States and Canada; municipal waste incineration, the next largest source, accounted for 22 percent.

Although far greater amounts of municipal and other forms of waste are incinerated, incinerating medical waste generates dramatically higher proportions of dioxin. German scientists discovered in 1987 that dioxin levels in medical waste incinerator ash could be two orders of magnitude higher than in municipal incinerator ash.

There are a number of reasons why medical waste incinerators release such high levels of dioxin. First, medical waste contains much higher levels of plastic, especially chlorine-containing polyvinyl chlorides (PVC), than other waste streams. Second, medical waste incinerators tend to have less pollution control equipment and less trained operating staff. Finally, medical waste incinerators tend to burn batches of waste rather than run continuously; that increases the start-up and cooling-down times, when dioxin formation is greatest. Attempts to reduce dioxin formation in medical waste incinerators through removing all PVC prior to burning, installing expensive air pollution equipment and better training staff will never eliminate dioxin formation and greatly increases the cost of incineration.

Dioxin is only one of many environmental problems associated with incineration. Incinerators also emit heavy metals and produce toxic ash which requires special handling.

Fortunately, non-burn medical waste technologies are readily available and are less-expensive than on-site or regional medical waste incinerators equipped with advanced air pollution control devices. These technologies, which are already in widespread use in industrialized countries, include first shredding hospital waste for volume reduction and to avoid reuse and then sterilizing the material, usually with either high-temperature steam, microwaving or chemical disinfection.

Stopping the Bank's dioxin plans

Apparently, the Indian government and World Bank officials responsible for the project were unaware of the extensive literature documenting the relationship between incinerators and dioxin.

The project was not even subjected to review by the Bank's Environment Department. World Bank policy requires an environmental impact assessment be done for any project likely to have an adverse environmental impact.

Although the project includes construction of numerous incinerators known to be major dioxin emitters, Bank officials classified the India health care project as Category "C" -- meaning it would have no environmental impact and no environmental study was needed -- ironically citing the new medical waste disposal facilities as reassurance. The Staff Appraisal Report states, "The proposed project would not raise any environmental concerns. The project would enhance medical waste disposal at health facilities where necessary."

As Multinational Monitor was going to press, Agarwal and other activists in India were making plans to voice their opposition to incineration at a meeting with Tawhid Nawaz, the World Bank task manager for the health care project, on his upcoming trip to India in late November. Nawaz has agreed to look into the criticisms of incineration and the advantages of the alternatives which environmentalists and health advocates are recommending.

Salim Habayeb, a World Bank physician working with Nawaz, assured Multinational Monitor that the Bank would not promote a technology that is dangerous for both people and the environment. "We'll go out of our way for anything that protects the environment. It's our duty."

But the Bank has already approved the project, funds have already been disbursed and at least one of the states had already started spending on the project before the task manager even learned of the dangers of incineration. Nawaz will have to act fast to prevent Bank-funded dioxin sources from being constructed in the name of public health in India.