Health Care Waste in Southern Africa:
A civil society perspective
Llewellyn Leonard
Health Care Waste Projects Coordinator, groundWork
ABOUT THE SPEAKER
Llewellyn Leonard graduated from the University of Durban Westville and has an academic research
background, with a Batchelor of Paedegogic, a Bachelor of Science (Honours) and an MSc in Water and
Environmental Management. After completing his MSc, Llewellyn chose to apply his skills and knowledge
within the civil society non-profit arena, rather than joining industry or government.
In 2001, Llewellyn, joined groundWork, which is a Human Rights and Environmental organisation, based in
Pietermaritzburg. groundWork seeks make the link between environmental abuse and human rights in a
democratic South Africa. groundWork is the only environmental justice NGO working on air pollution and
health care waste campaigning in South Africa.
He has been instrumental in developing “The Isipingo Declaration on eliminating the harmful impacts of
Health Care Waste and Incinerators in Southern African communities”. This is the first organised civil society
declaration calling on Southern African governments to seek alternative mechanisms of dealing with waste
management rather than incineration.
As part of his Health Care Waste project, Llewellyn works with two hospitals in South Africa. The idea is to
make these hospitals model institution for other hospitals to follow. Already substantial improvements have
been achieved since implementation of the program. Llewellyn, using his experience gained from working
with hospitals is also currently developing a manual for South African hospitals to use in order that they may
implement their own environmental management plans.
ABSTRACT
Health Care Waste is a mounting problem in South Africa as in many other countries. Desktop studies show
that 45% of health care waste generated in the KwaZulu-Natal province alone cannot be accounted for,
suggesting that it is being illegally dumped, buried or burnt somewhere, thus affecting the health of people
and the environment. The paper outlines some of the key problems that are being experienced with regard to
health care waste in KZN, Swaziland and Mozambique such as the lack of segregation, education and
awareness amongst the public and hospital staff, as well as the illegal dumping of health care waste in poor
black residential areas. Wastes from health care facilities can pose a risk to health care workers, patients
and local communities. While there is much concern about the possible spread of disease (especially from
contact with "sharps" such as needles), the treatment of those wastes, through incineration, can release an
array of hazardous pollutants into the air and water. Incineration has been identified as one of the major
sources of dioxin in the environment due to the burning of chlorinated plastics like PVC. Mercury
contamination of the environment is another concern for medical waste incinerators.
The paper also outlines the groundWork Health Care Waste and Incineration project. This includes the need
for the project, considering the fact that the health care waste problems in South Africa have reached
uncontrollable proportions. groundWork’s work with two under resourced rural hospitals is also touched
upon, as well as the implementation of environmental management plans at these institutions since the
conduction of audits of the hospital waste streams. The before and after scenario since the interception and
implementation of environmental management plans at the institutions is also elaborated upon with
reference to cost savings thus far for the institutions as well as the increase in occupational health and
safety. Our plans for a role out campaign in South Africa using the two hospitals as case studies for other
hospitals to follow will be stressed in our health care waste manual being produced for Southern Africa in the
near future.
Health Care Waste in Southern Africa:
A civil society perspective
Introduction
Health Care Waste is a mounting problem in South Africa, Mozambique and Swaziland as in many other
countries. Over recent years there has been numerous press statements of medical waste being disposed of
in an incorrect manner. The people that have been most effected by medical waste have been the poor
disadvantaged members of society. The incineration of medical waste has also caused much concern.
Numerous studies indicate that incinerators have been associated with a wide variety of health problems
such as disrupting the bodies hormonal, immune and reproductive systems, and have caused cancers.
Previously, civil society had not been given a platform to voice their concerns regarding the health impacts
that health care waste and incineration has had on their quality of life, and only recently has civil society
taken a stand to state that “enough is enough”, and have sort ways to voice their concerns in a legitimate
manner.
Status of Health care waste in South Africa, Mozambique and Swaziland
South Africa
South Africa occupies an area of 1,227,200 square kilometres, divided among nine provinces, with a
population of around 41.2 million, and an annual population growth rate of 2.2 percent. Estimated urban
population is between 57 to 63 percent, and rural population between 37 to 43 percent. There is very little
control over how medical waste is stored, handled and disposed off and sometimes dumped together with
municipal garbage in municipal landfill sites. Since incinerators are present at most hospitals, there is no
incentive to segregate the waste. Majority of the hospitals that have on-site incinerators for health care waste
do not operate satisfactorily. The worst problems arise in small rural hospitals and clinics, which are unable
to give the required special care in handling medical waste because of a lack of resources. Many rural clinics
open-burn their municipal waste on site in pits.
Desktop studies show that 45% of health care waste generated in the province of KwaZulu-Natal alone
cannot be accounted for, suggesting that it is being illegally dumped, buried or burnt somewhere, thus
affecting the health of people and the environment. Wastes from health care facilities poses a risk to health
care workers, patients and local communities. While there is much concern about the possible spread of
disease (especially from contact with "sharps" such as needles), the treatment of those wastes, through
incineration, releases an array of hazardous pollutants into the air and water, thus affecting the health of our
communities.
There is also the lack of capacity in South Africa to properly dispose of the large unnecessary amounts of
health care waste being generated. There have been numerous instances where health care waste has
been dumped in residential areas, thus posing a hazard to the community and environment. Due to illegal
dumping in disadvantaged residential areas, there have been situations were children have been found
playing with medical waste, i.e. children pricked with syringes, etc. Example, “Tygerberg Hospital treated 48
children with AZT after some were pricked with needles and others ate potentially lethal pills they found in a
field in Elsie's River” (Cape Argus, September 1999). “An attempt by The Star newspaper to help track down
a family member led to the gruesome discovery of corpses stacked in industrial fridges in a residential area,
while 80 tons of medical waste was removed from a house in Johannesburg…” (The Star, August 2000).
At present, the KZN Department of Health, does not have one incinerator that meets the legal requirements
for the disposal of medical waste due to government's failure to monitor and enforce laws governing
incineration. For a long time civil society have lobbied government to stop incineration and implement nonthermal technologies. groundWork had even resorted to taking government to court after numerous attempts
to have the Ixopo incinerator shut down, since it was the largest incinerator in KZN and had been poorly
managed. Audit reports had shown that the incinerator had failed to meet important health and safety
conditions of its permit. These included exceeding emission levels prescribed, as well as failing to meet the
required temperature to prevent the release of certain chemicals such as dioxins into the environment. The
incinerator was also located in the middle of a primary dairy producing area in South Africa.
Incinerators are dangerously polluting technologies that will virtually undermine the objectives of the POP’s
treaty. The Stockholm Convention on POP’s, which has been ratified by South Africa, identifies waste
incinerators as the principle source of dioxins and furans, which belong to the initial 12 substances being
targeted for continuing minimization and ultimate elimination by the global community. Government has
targeted these 12 pollutants because they are extremely dangerous to human health. Recently, the KZN
Department of Health took a policy decision to halt the incineration of medical waste in the province (The
Mercury, 20 November 2002). Instead the department will seek to treat and dispose of health care waste
using environmentally safer, non-combustion technologies. As of last year, two first ever non-thermal
treatments were set up in KZN, and a third is soon underway.
Mozambique
In Mozambique, the situation with regard to health care waste is much worst than that for South Africa.
Mozambique has a population of around 18,000,000 people. Mozambique does have not a strong waste
management system. Only in June 2003 for the first time were regulations for health care waste
management implemented. These regulations are however weak and does not adequately address the
problems of waste management, although it is seen as a start towards the process for health care waste
management. Incineration is still seen as an option for the final the disposal of health care waste. According
to the regulation, nothing is done to consider other waste solutions such as the 3 R's (reduce, reuse and
recycle). An audit of two hospitals waste streams where conducted by the environmental justice NGO,
groundWork in May this year. The report for the Maputo Central hospital audit found that no waste
management systems where in place at the institutions, neither where any colour coded bagging system
being used. There were also no policies in place. Only black bags are used at the hospital for all types of
waste, beside domestic waste these include infectious medical waste (e.g. dressings, used swabs, sanitary
pads, used gloves, in fact all waste contaminated with blood and bodily fluids). This also includes small
aborted fetuses. Only body parts are separated from the rest of the waste.
Although a municipal service existed, hospitals needed to find their own means of transporting this mixed
waste to the dumpsite. At the dumpsite waste pickers sort through the hospital waste and are exposed to the
potential dangers of medical waste. There have been numerous instances were rag pickers have been
pricked by needles, etc. Civil society are not aware of the dangers of being exposed to such dangers since
the ultimate aim is survival.
Government has not been instrumental in combating the problems being faced with regard to health care
waste. The Mozambique government had been on the process of arranging a quick solution for the waste
management crisis this year. It has been stated that government wanted to give a good impression to the
participants of the AU meeting in July this year. For them the solution for medical waste and household
waste will be incineration.
Swaziland
Swaziland has a population of approximately 1,104,343. There is a general lack of institutional waste
management capacity at all levels in Swaziland. This is reflected at both national and local authority level
with skills deficiencies, lack of implementing waste management tools, financial shortages and inadequate
institutional support. Moreover little monitoring and enforcement of existing legislation takes place due to the
unclear, fragmented and often overlapping allocation of responsibilities amongst the various authorities. The
Swaziland Waste Regulations of 2000 require licensing of all waste management facilities such as
incinerators. There is currently no medical or industrial incinerator in the country that has a licence to
operate. The Swaziland Environmental Authority currently lacks enforcement and monitoring of the existing
incinerators.
Swaziland has about 400 hospitals, health care centres and clinics. These facilities have no common
standards for source separation, collection bins, collection equipment for the disposal of medical waste.
There is no clarification of responsibilities and co-operation between the different operating entities, with the
hospitals often incinerating their own medical waste in old, poorly managed and sub-standard incinerators.
Some health centres connected to a specific hospital, transport their medical waste to the nearby hospital
and incinerate the waste. Medical waste is generally disposed of by the use of incinerators or it is simply
dumped together with other waste types at landfill sites.
Some of the common problems being experienced in South Africa, Mozambique and Swaziland with
regard to Health Care Waste include the following:
No Segregation / On-site incinerators
The problem firstly is that there is a large amount of health care waste produced at medical institutions.
Segregation of waste is not being carried out at most hospital institutions. Many hospitals have on-site
incinerators and incinerate waste at “no cost”; therefore sometimes there is no incentive to rigidly segregate
waste. This has also lead to a system where staff, treat all waste as dangerous.
Education and Awareness amongst public
The degree of health education and hygiene awareness among the public is a critical factor in deciding the
risks posed by health care waste. In the societies, there is a significant proportion of the population that is
illiterate and unaware of the dangers, and it is these people who are most at risk.
Training of Health Care Staff
There is an acute need for training on hospital hygiene for hospital staff on the proper handling and secure
storage of health care waste.
Most hospitals lack proper Waste minimisation plans
Most medical institutions do not have their own internal policies for waste segregation and therefore no
waste minimization plan. If proper plans are in place, then there would not be the problem of over handling of
waste and the creation of large amounts of health care waste that would require disposal.
Rural clinics areas are not provided with proper services
Besides Mozambique were the problem is widespread, it seems that the worst problem arises in small rural
hospitals and clinics, which are unable to give the required special care in handing health care waste
because of being constrained by a lack of resources. Proper handling of health care wastes is a complicated
issue when resources are scarce. Resources that are lacking include disposal materials to carry out
segregation effectively, i.e. lack of proper colour coded bags or sharps containers, etc.
What is groundWork doing?
Our health care waste and incineration project
Who is groundWork?
groundWork is a young South African NGO committed to the process of reducing the impacts of health care
waste and incineration and the potential impacts that it poses towards enhancing a sustainable society.
Health care waste project
The health care waste and incineration project was undertaken considering the fact that the health care
waste and incineration problems in South Africa have reached uncontrollable proportions. Our Health Care
Waste and Incineration Project was established in 2001. This project uses the twin prong strategy of
working both with medical waste institutions to assist them in reducing their wastes, as well as with
communities affected by the unsafe dumping or burning of health care waste.
This project aims to reduce and, where possible, eliminate the harmful effects of both health care waste and
incineration on human health and the environment in Southern Africa.
The overall objective of the project is that civil society has a greater impact on environmental governance,
with the immediate objective of the project being that relevant authorities are cooperating with affected
communities to reduce the impacts of health care waste and incineration. This goal is based upon the fact
that as community based organisations (CBO’s) and non-government organisations (NGO’s) there has to be
a positive relationship between the state and affected communities. This would endeavour to be in line with
the authorities’ constitutional responsibility to ensure that every South African lives in an environment that is
not harmful to his/her health and well being.
To ensure that the objectives for the project are fulfilled, certain outputs have been formulated. One of the
outputs is that a strategy for greening at least one hospital will be formulated. groundWork is currently
working with two under-resourced hospitals to make them model institutions for other hospitals to follow. The
aim is to help the institutions to reduce the amount of waste produced thereby saving costs and increasing
occupational health and safety. Currently, two of the hospitals that have been identified for greening are
Ngwelezana hospital at Empangeni as well as Edendale hospital in Pietermarizburg. This had commenced
with a skillshare by groundWork and international network Health Care Without Harm (HCWH) in 2001 for
the two hospitals so as to provide insight into proper health care waste management. This Skills Share visit
was conducted at not only the above two mentioned institutions, but also at the Good Shepherd hospital in
Swaziland. Reports for all the hospitals visited were formulated after the audit on findings, solutions and
possible steps that the institutions could take to improve waste management practices.
Findings by the Health Care Waste team
Three findings were particularly significant in examining waste management practices at the South African
hospitals that were toured.
The first was that, the fear of diseases like HIV and hepatitis had led hospitals to treat most of the waste as if
it were potentially infectious. In fact, most waste in hospitals 90% or more, if properly segregated was simply
trash, much of it packaging similar to what you would find in any shop or office. A lack of good segregation
meant that a large amount of unnecessary non-infectious waste was being generated. With good
segregation of wastes, less than 10% would need to be treated to disinfect it.
The second finding, was the general perception that the best way to deal with all waste from hospitals was to
burn it. This is based on the incorrect assumption that most wastes in hospitals are somehow contaminated
and represent a threat. The specific danger in hospital waste is related mostly to the presence of large
numbers of sharps such as syringes with needles. These specific wastes do pose a danger of transmitting
disease, and require special treatment, although not necessarily incineration.
The third finding concerned the chemical, mercury. Mercury is a highly potent neurotoxin, especially
dangerous to pregnant women and children. In hospitals, it is found primarily in thermometers and blood
pressure devices (sphygmomanometers). The skills share group was shocked to find that in each hospital
literally kilos of mercury were released into the hospital environment (and out into the community
environment) every year through accidental equipment breakage. There was found to be very little
awareness of the dangers of mercury amongst hospital staff.
What has been about some of these problems? Reaching out to staff and communities: Education
and Awareness
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Monthly education and awareness meetings with staff are conducted and the specific dangers in
hospital waste and incineration was/is communicated on a regular basis. groundWork had also
produced pamphlets for the hospital and the surrounding communities on the health effects of
incineration as part of awareness and education.
Through tours of their own institutions, staff were able to see, that in fact, most waste 90% or more,
if properly segregated was simply trash, much of it packaging similar to what you would find in any
shop or office. Staff could see that through a lack of good segregation, this meant that a large
amount of unnecessary non-infectious waste was being generated. With good segregation of
wastes, less than 10% would need to be treated to disinfect it
Hospital was helped to formulate a hospital waste minimization plan. Staff where trained and are
continually being trained on segregation of waste. Posters on waste segregation is currently being
formulated in both English and Zulu
groundWork has produced a mercury and pesticide fact sheets for communities and the hospital on
the dangers of mercury and pesticides, etc. Posters in the hospital have been formulated on how to
clean up a mercury spill. Currently, we are trying to get digital non-mercury equipment into the
hospitals. The hospitals do not purchase mercury containing blood pressure cuffs any more – use
digital.
Some achievements at the institutions since implementation of the program
Edendale Hospital
 A proper waste minimization plan has been formulated
 Red bags containing infectious medical waste has dropped from average of
250 – 300 to around 70 bags per day
 Secure storage area for red bags has been built - no community access
 Proper segregation has lead to the initiation of recycling of papers and cardboards,
the hospital staff have learnt to “EARN” from their waste
 Intern training workshops conducted on regular monthly basis
 Inspection tools used to monitor each ward for cleanliness and identify wards who do not segregate
waste.
 Posters and signs in both English and Zulu are being formulated
EDENDALE HOSPITAL
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COST PER MONTH - 2002
Ngwelezana Hospital
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Proper colour coded bagging system in place
Posters and signs in both English and Zulu are being formulated
Incinerator has since been shut down
A dumpsite, which was used for dumping ash from the incinerator and medical waste
from the hospital has been cleared and no longer exists.
Municipality which had previously rejected to haul away pharmaceutical waste such
as vials has now agreed to accept these waste thus reducing red bagging costs.
Pharmacy has now implemented clear bags as opposed to the past red bags.
Costs have reduce from R55 000, 00 per month to R35 000,00 per month, with red
bag statistics showing red bags reduced from 1402 red bags (December 2001)
to 987 red bags (December 2002).
Both hospitals, after the Skills Share, now seem to see medical waste as a serious issue that needs to be
tackled, and hold regular meetings to discuss progress and discuss further methods for improvement.
Currently, groundWork is working on having a role our campaign in the future. groundWork is developing a
‘Guide for the management of health care waste for South African hospitals’ We will be using the two
hospitals as case studies in the manual for other institutions to follow.
Conclusion
It is a fact that every health care facility can take immediate steps to reduce the environmental harm that
results from purchasing and waste disposal practices. This must be seen as a front-end solution to the waste
problems that are being experienced in our societies. The idea is to tackle the root of the problem by moving
away from incineration and implementing the three R’s (reduce, reuse and recycle). This would have to firstly
be followed by prevention. Once a proper waste management plan has been implemented at institutions it
would pay handsomely (i.e. financial benefit, improved staffed morale, increased occupational health and
safety, improved regulatory compliance and the strengthening of relationships with the surrounding
community). It is however, important to stress that the problems of health care waste are greatest in rural
areas that are constrained by a lack of resources and it is at these levels that immediate intervention is
required. It is essential that we tackle the root of the problem if any positive long-term sustainable solution is
to be reached.