Introduction

Hospital is a place of almighty, a place to serve the patient. Since beginning, the hospitals are known for the treatment of sick persons but we are unaware about the adverse effects of the garbage and filth generated by them on human body and environment. Now it is a well-established fact that there are many adverse and harmful effects to the environment including human beings, which are caused by the “Hospital waste”, generated during the patient care. Hospital waste is a potential health hazard to the health care workers, public and flora and fauna of the area. Hospital acquired infection, transfusion transmitted diseases, rising incidence of Hepatitis B, and HIV, increasing land and water pollution lead to increasing possibility of catching many diseases. Air pollution due to emission of hazardous gases by incinerator such as Furan, Dioxin, Hydrochloric acid etc. have compelled the authorities to think seriously about hospital waste and the diseases transmitted through improper disposal of hospital waste. This problem has now become a serious threat for the public health and, ultimately, the Central Government had to intervene for enforcing proper handling and disposal of hospital waste and an act was passed in July 1996 and a bio-medical waste (handling and management) rule was introduced in 1998.

A modern hospital is a complex, multidisciplinary system, which consumes thousands of items for delivery of medical care and is a part of physical environment. All these products consumed in the hospital leave some unusable leftovers i.e. hospital waste. The last century witnessed the rapid mushrooming of hospital in the public and private sector, dictated by the needs of expanding population. The advent and acceptance of "disposable" has made the generation of hospital waste a significant factor in current scenario.

What is hospital waste?

Hospital waste refers to all waste generated, discarded and not intended for further use in the hospital.

Biomedical waste

Any solid, fluid and liquid or liquid waste, including it's container and any intermediate product, which is generated during the diagnosis, treatment or immunisation of human being or animals, in research pertaining thereto, or in the production or testing of biological and the animal waste from slaughter houses or any other similar establishment. All biomedical waste are hazardous. In hospital it comprises of 15% of total hospital waste.

Bio-Medical Waste: Meaning

Bio-medical wastes are defined as waste that is generated during the diagnosis, treatment or immunization of human beings or animals, or in research activities thereto, or in the production of biological1 . In other words, it includes the following:

• Animal waste: Carcasses, body parts, etc. that have been inoculated with microorganisms infectious to humans.
• Human blood and blood products: Waste blood and materials containing free-flowing blood.
• Cultures and stocks: Culture dishes, blood specimen tubes, devices used to transfer, inoculate, and mix cultures that are infectious to humans.
• Pathological waste: Tissue coming from biopsies, surgery, obstetrical procedures or autopsies.
• Sharps waste: All hypodermic needles, syringes & tubing with needles attached, scalpel blades and lancets.
• Respiratory isolation waste: waste contaminated with blood or other potentially infectious bodily fluids from humans isolated for disease spread by respiratory or droplet transmission.

The Bio Medical Waste (Handling and Management) Rules, 1998

The indiscriminate dumping of biomedical wastes by hospitals and nursing homes was a source of pollution that caused dangers to the health and environment. In order to overcome this crisis, the Bio Medical Waste (Handling and Management) Rules, were notified in July 1998. The rules seek to introduce biomedical waste disposal practices in India. The emphasis is on ensuring a process change that will enable health care facilities to handle their waste through proper training and capacity building.

These Rules are applicable to all persons who generate, collect, receive, store, transport, treat, dispose or handle biomedical wastes. This includes hospitals, nursing homes, clinics, dispensaries, veterinary institutions, animal houses, pathological laboratories and blood banks.

Although the Bio-Medical Waste (Management and Handling) Rules have already been introduced a few years back, not much attention has been paid to bio-medical waste management so far. Even if something is done, it is most of the times not properly done2.

The hospitals and the private nursing homes have raised a hue and cry against the cost of treatment and disposal of bio-medical waste. It has been reported that the private agencies have quoted a disposal charge @ Rs. 20/bed/day3, which does not seem to be unreasonable.

The bio-medical waste received attention of Supreme Court of India in B L Wadehra v. Union of India4, where a writ was filed under Article 32 of the Constitution of India against the concerned authorities to provide clean and healthy environment. It was clear from various provisions of the Delhi Municipal Corporation Act and the New Delhi Municipal Council Act that the Municipal Corporation (MCD) and the Municipal Council (NDMC) constituted under Acts are under a statutory obligation to scavenge and clean the city of Delhi. It is mandatory for these authorities to collect and dispose of the garbage/waste generated from various sources in the city. The MCD and the NDMC have been wholly remiss in the performance of their statutory duties. Apart from the rights guaranteed under the Constitution the residents of Delhi have a statutory right to live in a clean city. The Courts are justified in directing the MCD and NDMC to perform their duties under the law. Non-availability of funds, inadequacy or inefficiency of the staff, insufficiency of machinery etc., cannot be pleaded as grounds for non-performance of their statutory obligations. Thus the Supreme Court issued various directions to MCD and NDMC regarding collection and disposal of garbage to keep the city clean.

Here, the court passed an order directing MCD to place on record the list of all garbage-dumping places, collection centers and steps being taken by those authorities to keep the city clean. In response to this, the MCD filed an affidavit in which the issue of waste from hospitals, dispensaries, maternity and child welfare cadres, primary health centers and clinics were also referred to. It was highlighted that except one hospital no other health care establishment, in Delhi had installed incinerators to burn the hospital waste.

Finally examining the facts and circumstances, the court directed the Government of India, through the Secretary, Ministry of Health, Government of National Capital Territory of Delhi through the Secretary, Medical and Public Health, MCD through its commissioner and the NDMC through its Administrator to construct and install incinerators in all the hospitals/nursing homes, with 80 beds and above, under their administrative control. This may be done preferably within nine months. A responsible officer of each of these authorities shall file an affidavit in the court within two months indicating the progress made in this respect.

The court also directed the MCD and NDMC to issue notices to all the private hospitals/nursing homes in Delhi to make their own arrangements for the disposal of their garbage and hospital waste. They may be asked to construct their own incinerators. In case these hospitals are permitted to use facilities (for collection, transportation and disposal of garbage) provided by the MCD and NDMC then they may be asked to pay suitable charges for the service rendered in accordance with law5.

This case reflects judicial dynamism, which includes self-sufficiency of the judiciary in handling and deciding complex technologies medi-sciences issue and that too in its infancy stage6. The dynamism, if implemented will bring the judicial justice from the judgment book to justice in action7.

Rationale of hospital waste management

Hospital waste management is a part of hospital hygiene and maintenance activities. In fact only 15% of hospital waste i.e. "Biomedical waste" is hazardous, not the complete. But when hazardous waste is not segregated at the source of generation and mixed with non-hazardous waste, then 100% waste becomes hazardous. The question then arises that what is the need or rationale for spending so many resources in terms of money, manpower, material and machine for management of hospital waste? The reasons are:

• Injuries from sharps leading to infection to all categories of hospital personnel and waste handler.
• Nosocomial infections in patients from poor infection control practices and poor waste management.
• Risk of infection outside hospital for waste handlers and scavengers and at time general public living in the vicinity of hospitals.
• Risk associated with hazardous chemicals, drugs to persons handling wastes at all levels.
  "Disposable" being repacked and sold by unscrupulous elements without even being washed.
• Drugs, which have been disposed of, being repacked and sold off to unsuspecting buyers.
• Risk of air, water and soil pollution directly due to waste, or due to defective incineration emissions and ash.

Approach for hospital waste management

Based on Bio-medical Waste (Management and Handling) Rules 1998, notified under the Environment Protection Act by the Ministry of Environment and Forest (Government of India) following are the ways for hospital waste management.

1. Segregation of waste

Segregation is the essence of waste management and should be done at the source of generation of Bio-medical waste e.g. all patient care activity areas, diagnostic services areas, operation theaters, labour rooms, treatment rooms etc. The responsibility of segregation should be with the generator of biomedical waste i.e. doctors, nurses, technicians etc. (medical and paramedical personnel). The biomedical waste should be segregated as per categories mentioned in the rules.

2. Collection of bio-medical waste

Collection of bio-medical waste should be done as per Bio-medical waste (Management and Handling) Rules. At ordinary room temperature the collected waste should not be stored for more than 24 hours.

Type of container and colour code for collection of bio-medical waste

3. Transportation

Within hospital, waste routes must be designated to avoid the passage of waste through patient care areas. Separate time should be earmarked for transportation of bio-medical waste to reduce chances of it's mixing with general waste. Desiccated wheeled containers, trolleys or carts should be used to transport the waste/plastic bags to the site of storage/ treatment.

Trolleys or carts should be thoroughly cleaned and disinfected in the event of any spillage. The wheeled containers should be so designed that the waste can be easily loaded, remains secured during transportation, does not have any sharp edges and is easy to clean and disinfect. Hazardous biomedical waste needing transport to a long distance should be kept in containers and should have proper labels. The transport is done through desiccated vehicles specially constructed for the purpose having fully enclosed body, lined internally with stainless steel or aluminium to provide smooth and impervious surface, which can be cleaned. The drivers compartment should be separated from the load compartment with a bulkhead. The load compartment should be provided with roof vents for ventilation.

4. Treatment of hospital waste

Treatment of waste is required:

• To disinfect the waste so that it is no longer the source of infection.
• To reduce the volume of the waste.
• Make waste unrecognizable for aesthetic reasons.
• Make recycled items unusable.

5. Safety measures

5.1 All the generators of bio-medical waste should adopt universal precautions and appropriate safety measures while doing therapeutic and diagnostic activities and also while handling the bio-medical waste.

5.2 It should be ensured that:

• Drivers, collectors and other handlers are aware of the nature and risk of the waste.
• Written instructions, provided regarding the procedures to be adopted in the event of spillage/ accidents.
• Protective gears provided and instructions regarding their use are given.
• Workers are protected by vaccination against tetanus and hepatitis B.

6. Measures for waste minimization

As far as possible, purchase of reusable items made of glass and metal should be encouraged. Select non-PVC plastic items. Adopt procedures and policies for proper management of waste generated, the mainstay of which is segregation to reduce the quantity of waste to be treated. Establish effective and sound recycling policy for plastic recycling and get in touch with authorised manufactures.

Conclusion

The constant movement of garbage poses a serious threat with emission levels contributing to bad air quality and the rissk of disease. While it would be absurd to immediately consider a life without such hazardous materials, it would definitely be a step towards a cleaner future by adopting better technologies, including “safe” recyclable materials and working towards eliminating toxic products in our own society through proper channel. A policy that makes polluters responsible for the full social costs of disposing of their solid wastes is needed. The rule making authority and the judiciary have performed their task satisfactorily, but they have further to restructure and advance the regulating machinery so that the biomedical waste does not transform into an environmental hazard in India. Dissemination of information and peoples participation will play a significant role in this regard to curb the growing menace of biomedical waste.

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1 Section 3(5), The Bio-Medical Waste (Management and Handling) Rules, 1998.  
2 http://www.ganga-icdp.org/word/Report%20BMW-%20Cover%20Page.doc.  
3 Dr. Sunil Kant, “Proceedings of the National Symposium on Medical Waste Management held at J.L. Auditorium, AIIMS, New Delhi, 27th & 28th Sept 1996” , 728 Jour. of Acad. of Hos. Adm. 62 (1995-96).  
4 AIR 1996 SC 2969. 
5 Ibid.
6 C.M.Jariwala, ‘The Biomedical Waste: Directions of Law and Justice’, Journal Of Indian Law Institute, vol 41, 1999, p.358.
7 See supra note 8 at 381.