Killing With The Hand That Cures

•  Only 7 per cent of the hospitals have incinerators.
• Hospitals don't burn more than 10 per cent of their waste. This applies to those even with incinerators. What is burnt in incinerators is mostly plastic.
•  Most of the waste is dumped by the hospitals at open sites where ragpickers wade through them.
• Ninety per cent of the ragpickers sorting hospital waste have cuts on their hands, and pus formation; even those who do use gloves, are not sufficiently protected against metal lacerations and pricks.
•  Waste segregation, instead of being done at source, is done by hospital safaiwallahs, exposing them to infection.

While no reliable study of the survival time of various bacteria, fungi and viruses is available, the time varies depending upon temperature, moisture and content of waste. Says Dr Ramesh Kumar, former head of department, microbiology, at the All India Institute of Medical Sciences (AIIMS): "The AIDS and hepatitis B virus can survive a long time if kept in moist conditions. Surrounded by protein in the form of blood and not exposed to ultraviolet rays from the sun, they can survive for weeks." While viruses don't propagate except in live cells, they can remain alive even outside the human body.

Says Bharti Chaturvedi who conducted the Shrishthi study on Delhi hospitals along with Ravi Agarwal: "It's an appalling scenario. This is in spite of the lessons that should have been learnt from the Surat plague of September 1994. At the garbage sorting area at Lok Narain Jai Prakash Hospital, we found ragpickers picking relatively unsoiled bandages with bare hands and selling them at Rs 2 per kg to durrie makers. We also discovered used glucose bottles from Ram Manohar Lohia Hospital coming to a kabari in Gol Market on a regular basis."

And since no occupational hazard study on ragpickers and hospital waste cleaners in India has been attempted, no primary statistics are available. But in Singapore, for instance, a 1994 study of 600 sewage workers to determine whether occupational exposure to sewage was associated with higher seroprevalence of hepatitis A virus infection found the level to be 2.2 times higher than the control group. Since in practice it was found extremely difficult to maintain absolute hygienic working conditions, the study went on to recommend active immunisation of the workers as the only way to prevent infection.

The situation is equally grim in India. One of the lesser known diseases that has been found to originate in places where a mixing of hospital waste and domestic garbage occurs is leptospira. The major incidence has been in south India, especially Madras. The bacteria resides in the kidneys of rats, and humans get infected if they walk barefoot on rat urine. The bacteria can infect the brain once it enters the bloodstream. And diagnosis is difficult as the initial symptoms resemble flu.

While hospital waste was included as Category 18 in the hazardous waste management rules section formulated by the Environment Ministry a few years ago, a separate category of bio-medical wastes has been on the anvil since April this year, under the Environment Protection Act of 1986. Says Laxmi Raghupati, joint director, Ministry of Environment: "We are circulating the guidelines for the approval of the Ministries of Health, Urban Development, and Agriculture as well as the state pollution control boards. We should be ready with the notification by the month-end."

 One of the points of contention is whether the present wording of the gazette designating appropriate authorities as the monitoring agency of the rules is adequate or should the rules designate a single authority. Says an Environment Ministry official: "If we don't designate a single authority then accountability goes for a six." Also, an important point, as yet undecided, is to determine the minimum size of a hospital or nursing home that can fall within the ambit of the act. Right now there is talk of including any hospital with more than 30 beds within the scope of the rules.

Says Dr S. Arora, medical superintendent of Aashlok Nursing Home, a private, 20-bed nursing home in Delhi's Safdarjung Enclave: "Though we have an obligation of disposing of our waste in incinerators, there are none available in Delhi where you can do so on a commercial basis. Obviously, it would be too uneconomical for the hundreds of nursing homes around the country to invest in incinerators."

 In the US, for instance, the cost of incineration of hospital waste works out to $2 per kg while that of transportation to landfills is $0.02 to $0.5 per kg. While similar cost estimates have not been done in India, it is important to develop India-specific methods. Says Ashok Ratan, a microbiologist at AIIMS: "We seem to specialise in wasting our limited resources. We should classify our waste into infectious and noninfectious categories. Since there is no microbiological evidence to suggest that common hospital waste is more infectious than residential waste, it can be disposed of without fear in landfills."

Ratan is a vociferous exponent of waste segregation done at source level itself. Says he: "We have no right to expose ragpickers to infection. Suitable and cheap containers must be made available at each waste generating site for different types of waste."

Since needle-stick injuries form the main risk factor through which transmission of the AIDS virus could occur among health care workers and waste segregators, Ratan advocated the use of puncture-proof bags for disposal purposes at AIIMS. "But the puncture-proof bags started disappearing for use in coffee clubs," he recalls. Ratan now advises disposal in easily available tin boxes in which disinfectant is present. While the risk of acquiring HIV from a single injury with a needle which has been used for an HIV infected person is 0.4 per cent, with the number of AIDS victims in India rising rapidly the risk definitely exists. At present a number of hospitals in Delhi use Melto, a portable needle destroyer costing Rs 5,000. The contraption burns the needles by passing electricity through them. Says Neeraj Garg of Nishika Enterprises, which is marketing the needle destroyer: "We have sold around 400 machines in Delhi. But though government hospitals readily take to the concept, private hospitals don't take to it at all. They don't want to make the investment."

 But Ratan thinks that the gadget is another example of "wasting of limited resource". Says he: "Unless you have the gadget at each point where an injection is given, it loses value. In AIIMS that would be at 1,000 places."

 Besides, as Gita Mehta, head of the department of microbiology at Lady Hardinge, points out: "They have to be operated manually. What we need is a mass needle destroyer. There are none in the market that we know of." But what needs to be avoided at all costs, is the manual bending of needles before disposal, a practice prevalent in several Delhi hospitals, including established ones like Moolchand.

The main hitch in following universal precautions, apart from the cost consideration, is mental acceptance. Says Kumar, "You have to change the mindset of a hospital. This August, for instance, there was a massive downpour and the roads were flooded near AIIMS. Water flooded till knee levels on the roads, the drains overflowed, and when it all went down, you had roads spewed with bandages, intestine entrails and even surgically removed parts of the human anatomy. It was disgusting. Hospital personnel were simply flushing these things down the drain. This is just not done."

While the notification may come into effect by the year-end, it is important that it doesn't degenerate into another piece of legislation that remains on paper to be hon-oured more in the breach than in the acceptance. For, in the breach is disease waiting in the wings.