Waste disposal baffles hospitals

As she lays down her mat under a mango tree beside her house, 82-year-old Dorotia Nakiwolo wants to have her lunchtime meal but the odour around her is unbearable.
“They are at it again, burning their things,” she laments in Luganda. “What will a poor woman do?”

Nakiwolo’s house is at the backyard of Kikandwa Health Centre III in Mityana District, with only a barbed wire fence separating the health centre from her compound.
The health centre is burning waste, not merely paper or kitchen waste but medical waste, about 40 metres away from the main building.

“You can imagine the problem we have here every time that hospital burns its waste,” complaints Nakiwolo.

Nakiwolo’s neighbour, Gladys Nampijja, 31, echoes the concern: “There is an open pit where they (health centre) dump all waste including that from the maternity ward. And sometimes it takes three or so days before burning it causing an awful smell from the rotting matter and when they finally burn, the odour is much worse.”

While living nearby a health facility would be a blessing in a typical rural village like Kikandwa where residents walk kilometres to get to a health facility, Nampijja and Nakiwolo and their neighbours do not view their proximity to this health centre in the same light. They think the waste should be managed better.

The challenge
Mr Ivan Ogwang, the Laboratory Assistant at Kikandwa Health Centre III, says the centre tries to manage its waste but is limited in capacity.
“We have got no incinerator so we burn all waste except waste from the maternity ward that is dumped in a deep pit,” he says.
But even then, the problem is not wholly solved. From Ogwang’s explanation, infectious waste like used gloves, syringes and cotton wool is burnt at the centre which Dr Michael Mungoma, a physician at Mulago Hospital, says is inappropriate.

“By burning medical waste, health facilities are simply improvising,” he says. “The problem with it is that you cannot be sure that you have totally destroyed the substance. What is recommended is incineration that burns substances to ash.”

Francis Bwire Ngegemi, the Quality Assurance and Environment Management Officer at International Hospital Kampala (IHK), says incinerators should burn at temperature of 9000 degrees centigrade.

Betty Nanziri, a clinical officer and the in-charge at Kikandwa Health Centre III, says they have since adapted measures of managing the waste up to where it causes minimum danger. One of these, she says, the centre has dug a deeper placenta pit of about 20 feet.
She add: “We do not burn waste everyday but over the weekends when there are fewer people at the health centre.”

Odour, Nanziri says is unavoidable because “even when using an incinerator, there will still be smoke and odour”.

What is medical waste?
Health facilities like any other entity generate waste such as paper, kitchen waste and what is termed as medical waste.

According to Bwire, medical waste is any thing which is generated and is of no use thereafter in the diagnosis, treatment or immunisation of human beings, animals or research carried out in a health facility.

Dr Mungoma says medical waste is in two categories, infectious and non-infectious waste.
“The non-infectious medical waste is one that does not cause direct health hazard like a bottle from which drug is drawn while the infectious waste is anything that is used on a patient,” he says. This includes used gloves, needles, cotton wool or operating theatre-generated waste like body tissues, among others.

The health hazards
The challenges of medical waste management are not unique to rural health centres but urban areas too.

“Many of the health centres in Kampala do not have safe areas to dispose of medical waste,” notes Dr Mungoma. Medical waste is thus mixed with other waste like paper and dumped on dust bins.

The problem is grave in slum areas. In Kalerwe, Bwaise, Katanga and Kikoni, some of Kampala’s congested slums; clinics dispose of medical waste into streams flowing through the slums.

During its community awareness meetings at Kiteezi, Kampala city’s main dump site, the environment conservation organisation, A Rocha Uganda, documented testimonies of casual workers who with bear hands dig into the garbage looking for plastic bottles for sale.
One of them was Catharine Naluwembe. “Many times we uncover foetus, placenta and human body tissue in this garbage,” she said. This is highly infectious waste. Peter Ayinza, another casual worker, added: “Almost on daily basis we get cases where a colleague is pricked by syringes or safety pins in this garbage.” Sara Kaweesa, the National Director, A Rocha Uganda, said the reports were “horrifying”.

Environment regulation
Improper waste disposal contravenes Section 12(1) of the National Environment Waste Management Regulations, 1998 which states: “An industry shall not discharge or dispose of waste in any state into the environment, unless the waste has been treated in a treatment facility and in a manner approved by the lead agency in consultation with the Authority.”
The Authority in this case is the National Environment Management authority (Nema).

Regulation and supervision
Dr Mungoma says it is the responsibility of Ministry of Health (MOH) or Kampala Capital City Authority (KCCA) to ensure proper disposal of waste.
Dr Jacinto Amandua, MOH’s head of Clinical Services Department, says medical waste management should begin at the point where it is generated - at a health facility.
“For instance, we have the Investigations Control Committees chaired by a senior doctor who among other functions ensures safety at a health facility, medical waste management inclusive,” he says.

Dr Amandua notes that except for pharmaceutical waste such as expired drugs that is centrally collected and disposed of by the National Medical Stores, waste management supervision is not at MOH but at Local Government level, KCCA for the case of Kampala.
“We have got a waste management policy whose implementation should be at Local Government level. MOH cannot be allover (the country) so Local Governments should be in charge,” he says, advising this writer to consult KCCA on the case of Kiteezi and related matters in Kampala.

Mr Peter Kauju, KCCA’s spokesman, denied that medical waste is disposed of at Kiteezi. Kauju said while issuing licences, KCCA ensures that health facilities have proper mechanisms of disposing of waste or require them to have private waste collectors then KCCA supervises their operations. “We have teams around the city who supervise these health facilities,” he says.

Put to him that despite the regulations, health facilities dispose of waste in unsafe ways, the KCCA spokesman, says: “Our supervision has been intensified that we have prosecuted people over improper waste disposal.”

Mr Kauju says the Solid Waste Ordinances of 2000 put the responsibility of waste management and disposal to the person who generates it. “One for instance is required to move waste to a nearby collection centre”.

Nema’s waste management regulations spell out the right to proper waste disposal though not many people are aware of this provision.
Nampijja is one of them. They have never informed the authorities about their plight.

About the waste

Medical waste management
Management of medical waste is as critical as the clinical services offered by the health facilities yet small health facilities like Kikandwa Health Centre III and big hospitals like Mulago National Referral Hospital all grapple with the problem. It is not uncommon for example to spot used cotton wool on the floor at Mulago hospital. The problem is multifaceted.

It has got to with how managers of the facilities apply the basic principles of waste management but also the number of patients visiting the facility and their level of knowledge on wastes management. “You have got to know what waste it in order to be able to manage it,” says IHK’s Bwire.

Waste management is a process and every stage is as important. Bwire says the process involves sorting, handling, interim storage and its final disposal.

Sorting
This involves categorizing and temporary storage of waste. Bwire explains that sorting waste is important because “mixing of waste exposes the waste manager to risks of infection like when prinked by a syringe dumped in a kitchen waste container.” Colour codes are used in sorting waste. While red (infectious) and black (general) are used, some hospital make further subdivisions for easier management. IHK for instance one of the biggest private hospitals in the country has six sub divisions
• Black for paper and kitchen waste
• Red for infectious waste
• Yellow for rubber and plastics
• Green for chemotherapy waste
• Blue for broken glasses, and
• sharps containers for sharps like syringes
Wastes disposal
There is no-site and off-site disposal. On-site disposal includes incineration, treatment and burying of waste. The other option is rather very expensive. It is the use of Tire Recycling Machinery with Double Shaft Shredder. This machine can be used to dispose off waste like operating theatre-generated waste such as amputated body parts. It slices and crushes the body tissues into liquid which is then connected to the septic tank. Its cost is between $300,000-460, 00 or at least Shs750 million.
But Bwire suggests that health facilities can apply simple practices.
• Use of ash mixed with water poured into waste pits. Ash enhances decomposition and enables limited use of acid that quickens the process of decomposition but is harmful to the environment
• Wrap waste in decomposable materials before dumping into pit. Wrapping create heat that quickens decomposition. It is estimated for example that the placenta takes 2-3 months to decompose
• Hire NEMA licenced companies to carry out safe disposal.