Medical WasteTreatmentTechnologies:EvaluatingNon-IncinerationAlternatives

A Tool for Health Care Staff andConcerned Community Members

May 2000

HEALTH CARE WITHOUT HARM • THE C AMPAIGN FOR ENV IRONMENTALLY RESPONSIBLE HEALTH C A R E

ACKNOWLEDGEMENTS

This document is the result of a collaborativeprocess between a number of individuals andorganizations. We thank them for their time,input and dedication in creating and reviewingthis document (in alphabetical order):

Laura Brannen, Dartmouth-Hitchcock MedicalCenter, Lebanon, NH

Rob Cedar, Hamtramck Environmental ActionTeam, Hamtramck, MI

Doris Cellarius, Sierra Club, Prescott, AZ

Stephanie C. Davis, Waste ReductionRemediesSM, Berkeley, CA

Jamie Harvie, PE, Institute for a SustainableFuture, Duluth, MN

Jackie Hunt Christensen, Institute for Agricul-ture and Trade Policy, Minneapolis, MN

Sarah O’Brien, Vermont Public Interest Re-search Group, Montpelier, VT

Ted Schettler, MD, Science and EnvironmentalHealth Network, Boston, MA

Scott Sederstrom, Great Lakes Center forOccupational and Environmental Safety andHealth, University of Illinois, Chicago, IL

Laurie Valeriano, Washington Toxics Coalition,Seattle, WA.

SPECIAL THANKS TO

Laura Brannen, for helping to organize thedocument into a more useful format; StephanieC. Davis, for supplying her original list of healthcare waste disposal technology criteria list; SarahO’Brien, for supplying criteria for communityconcerns; and Jane Williams of CaliforniaCommunities Against Toxics and ChemicalWeapons Working Group for supplying theircriteria for waste treatment.

FEEDBACK

Health Care Without Harm would appreciate yourfeedback on this document. Please send yourcomments to:

Jackie Hunt ChristensenHealth Care Without Harmc/o Institute for Agriculture and Trade Policy2105 1st Avenue SouthMinneapolis, MN 55404USA

phone: 612-870-3424fax: 612-870-4846jchristensen@iatp.org or noharm@iatp.org

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INTRODUCTION

Historically, many hospitals with on-site incineratorsburned not only the infectious portion of their wastestream, but also solid waste and recyclable materialssuch as paper and cardboard.1 Public concerns aboutincinerator emissions, as well as the creation of federalregulations for medical waste incinerators, are causingmany health care facilities to rethink their choices inmedical waste treatment technology.

One of the guiding principles of the Health CareWithout Harm (HCWH) campaign is the commitmentto eliminate the non-essential incineration of medicalwaste and promote safe materials use and treatmentpractices. Regulated medical waste (RMW), alsocalled infectious waste, requires disinfection prior todisposal in a landfill. HCWH is committed to helpinghospitals identify the waste considered to be regulatedmedical waste in order to minimize the environmentaland human health impacts of treating that waste.

The Association of Operating Room Nurses has crafteda definition of regulated medical waste that includesfour categories of waste: sharps (used and unused),cultures and stocks of infectious wastes, animal wasteand selected isolation waste.2

According to the Centers for Disease Control andPrevention, “Hospital wastes for which special precau-tions appear prudent are microbiology laboratorywaste, pathology waste, bulk blood or blood products,

and sharp items such as used needles or scalpel blades.In general, these items should either be incinerated ordecontaminated prior to disposal in a sanitary landfill.”3

The infectious or regulated medical waste streamaccounts for about 15 percent of total hospital waste,while pathological waste is about two percent. In orderto protect public health, decontamination is required,but incineration is not a federal legal requirement.(Individuals should check state and local regulationsregarding pathological waste and chemotherapy drugs.)

REVIEWING ALTERNATIVES

Waste treatment is but one small piece of a muchlarger system of purchasing and materials manage-ment that determines the overall environmental andhealth impacts of a health care facility. In addition toregulated medical waste, health care facilities can beexpected to generate recyclable materials, whichmay be handled by a single hauler or collected asindividual commodities (e.g., cardboard, aluminum,glass); food waste, which may be composted ordiscarded with solid waste; solid waste, which ishandled like municipal trash; hazardous waste,which must be handled according to federal regula-tions; radioactive waste, also subject to federal rules;and pathological waste (tissue, body parts, etc.) Thetypes of care the facility provides, as well as pur-chasing choices (reusable versus disposable items,packaging), affect the amount and toxicity of thewastes generated.

Medical WasteTreatment Technologies:Evaluating Non-Incineration Alternatives

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It seems certain that, given aggressive waste minimiza-tion and pollution prevention practices in the healthcare facility and the treatment options available thatdon’t involve combustion, there must be less toxic,equally cost-effective ways to treat medical waste.Thus, the Health Care Without Harm campaign decidedto investigate those non-incineration options.

Non-incineration treatment technologies are a growingand developing field. Some technologies are stillessentially prototypes, while others, such as autoclavetechnology, have been used for decades. Studies arebeing done of virtually all the technologies to assesssafety, emissions, ease of operation, and reliability. Forexample, the Underwriters Laboratories are creatingsafety standards for non-incineration technologies.4

One thing is clear and must always be addressed beforeassessing any technology: “What goes in, must comeout (or up).” Careful waste segregation and manage-ment programs, as well as attention to materialspurchased, are essential in minimizing the environmen-tal and health impacts of any technology. These issuesmust be included in any analysis of alternatives.

As stated earlier, Health Care Without Harm does notsupport the incineration of solid waste or infectiouswaste. Infectious waste should not be disinfected orsterilized in order that it may be sent to a municipal solidwaste incinerator. (For more information about HCWH’sconcerns about incineration, see Appendix A.)

CONSIDERATIONS FOR MANAGINGHOSPITAL WASTE

Health care facilities, including hospitals, clinics,doctors, dentists, morgues, or veterinary offices, generatea tremendous amount of waste in the course of treatingpatients. They generate “regulated medical waste” orinfectious waste, hazardous chemical waste, recyclable,reusable and solid waste. In order to fulfill the medicalethic to “do no harm,” it is the responsibility of the healthcare industry to create and implement waste disposalpolices for all of these waste streams that include workersafety, public health and environmental considerations,as well as regulatory compliance. Fulfilling this ethicalso calls for a cultural shift to consider disposal tech-nologies and services as part of a total wastemanagement system. This system should includeupstream waste management (elimination or minimiza-tion of some wastes, reuse and recycling of others) andthe proper, accountable operation of all disposal equip-ment, post-treatment technology management andservices (e.g., shredding, landfilled material, incinerationash, air and water emissions).

In the United States, regulated medical waste — aboutseven to fifteen percent of the total waste5 — must betreated in order to protect public health from the spreadof potentially infectious diseases. But many facilities,particularly those with medical waste incinerators on-site, have routinely burned most or all of their waste(with the exception of hazardous chemicals, whichwould be illegal). Incineration, as previously stated, hassignificant health and environmental impacts. There arealternative treatment technologies that render the wastenon-infectious and are believed to be less harmful.

Furthermore, much of the waste produced in healthcare facilities resembles household trash. Therefore, itis not unreasonable to expect that at least 30 percent ofthis waste can be recycled, reused, reduced or elimi-nated, and up to 50 percent reduction could be achievedwith aggressive actions. Tossing resources in the trashis not only a waste of resources, but can be extremelyexpensive. The economic benefits to managing andreducing the waste can have a significant benefit to thehealth care facility’s overall costs. A case in point: BethIsrael Medical Center in New York City has found thata combination of employee education, monitoring ofthe waste stream and strategic placement of “red bag”waste containers has cut the facility’s medical RMWdisposal costs by 60 percent.6

Health Care Without Harm does notendorse any technologies. We do notrecommend that this checklist serve asthe sole means of evaluating any tech-nology, but instead hope it will be usedto obtain information and to supportinformed decision-making.

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In order to give full consideration to the effects of thewaste it generates, the health care industry shouldreconsider its environmental and waste impacts. Theseissues must be included in facility-wide policies—theculture around trash and environmental programs mustbe institutionalized. Pollution prevention, recycling,reuse, environmental procurement, safer disposalchoices—these programs will not only benefit theenvironment and the health of the community, but willprovide cost-effective care and instill in healthcareworkers a sense of pride and commitment to thedelivery of effective care while doing no harm.

QUESTIONS TO ASK BEFORECONSIDERING ANY TREATMENTTECHNOLOGIES

The decision about which medical waste treatmenttechnology to utilize is a complicated process and goesfar beyond cost considerations.

The following list of questions is designed to help healthcare decisionmakers identify criteria to be evaluated andinformation needs to be addressed when deciding whattechnology and/or disposal services to use.

This checklist may also help to increase overall aware-ness of environmental, economic and worker safety andhealth considerations.

Decisions about the type of waste treatment technologychosen often have significant impacts on the surround-ing community, and the community should be wellinformed so that they may participate fully in sitingdiscussions and technology choices.

The objective of this checklist is to provide a basic setof questions that should be considered. The health carefacility or community might have specific issues thatthese criteria do not address.

Waste Management inHealth Care Facilities -Past, Present and Future

WASTE SEGREGATION PRACTICES

Properly sizing your equipment has cost, labor, facilityand operational implications. If you size your equip-ment prior to waste segregation and minimizationactivities, you may purchase more capacity than youneed. Consider your current practices. If significantlymore than 15 percent of your facility’s waste is consid-ered regulated medical waste, you may haveopportunities for reductions.

◗ Has your facility done a comprehensive audit of allof the various waste streams and products/suppliespurchased to better identify impact on disposalsystems and services?

Using this list: Many of the followingquestions are addressed to healthcare facility staff who will be involvedin technology selection and possiblyeven maintaining and operating theequipment. However, in discussingconcerns about waste treatment anddisposal, concerned residents areencouraged to confirm that thehealthcare staff are addressing therange of the issues mentioned below.

The questions can also be used asan opportunity to bring togetherhealth care decisionmakers andcommunity members to discusswhich criteria are most important totheir respective constituencies and toidentify areas of common concern orconflict.

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◗ Does your facility have or plan to implementaggressive waste and pollution prevention, reuseand recycling programs as part of this process?This includes defining waste streams, providingclearly designated waste containers and signage fordifferent waste streams, and educating staff on theproper waste segregation.

◗ Can your facility’s waste streams be separated bytype (e.g., corrugated cardboard, office paper,aluminum cans, food waste)? Have the volumeand weight of each waste stream been measured orestimated?

◗ Can your facility’s staff identify from whichdepartments or areas of the facility certain types ofwaste are more common? And which have thegreatest potential for reduction or elimination?

◗ Has your facility considered a facility-widecomputerized tracking system to help identifywaste streams and assist in the waste segregationprogram?

◗ Are all employees trained to identify infectious andhazardous materials and dispose of them accordingto safety and disposal regulations?

◗ Does your facility use mercury-containing prod-ucts? If so, what steps are being taken to ensurethat mercury is not being disposed with infectiousor solid waste?

◗ Does your staff know the procedures for handlingand disposal of low level radioactive wastes? Dothe loading dock and/or packaging areas havefunctioning equipment to detect, prior to disposal,any low-level radioactive wastes (LLRW) that werediscarded?

◗ Does your facility have a recovery program forutensils and surgical instruments? (Loss of theseitems can be a substantial annual avoidable cost.Some waste companies can provide this additionalrecovery and sterilization service.)

◗ Does your facility have a battery recovery program?

ORGANIZATIONAL/STAFF ISSUES

Most facilities undertaking a comprehensive approachto managing their waste have an infrastructure tofacilitate the program.

◗ Has a task force been identified in your facility toexamine current waste treatment and disposaltechnologies and become informed, “in-houseexperts” on available options? Are members of thefollowing departments represented: administration,infection control, engineering, health and safety,laboratory staff, physicians, nursing, housekeepingand environmental services, procurement/ con-tracts/ purchasing, and union representatives?

◗ What education needs to happen to change histori-cal or cultural habits for current disposal systemsand waste services?

◗ What level of commitment is your facility willing toundertake to ensure all parameters will be considered?

FACILITY AND OPERATIONAL ISSUES

The type of treatment technology chosen will most likelyaffect current practices and procedures in your facility’swaste management operations. This includes laborconsiderations, waste handling practices, implications onphysical space, loading docks, all utility costs, truckingand transportation. The decision to go with on-site or off-site treatment involves at least some of the considera-tions listed below. Questions listed under on-sitetreatment should also be asked of your off-site treatmentvendors. Some issues are joint considerations.

◗ Does your facility currently have the labor and staffexpertise to maintain the equipment, or wouldadditional training be needed?

◗ Does your facility have the physical space andadequate facility design? (e.g., if you are usingoffsite treatment, is your facility already equippedwith adequate storage space, loading docks, etc.?)

◗ Are off-site treatment options limited, expensive ordoes your facility have concerns about the localoptions? (e.g., the local commercial treatment facilityhas numerous emissions violations; your hospital/clinicis in a rural area and the nearest commercialtreatment facility is hundreds of miles away.)

◗ Cost

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ON-SITE TREATMENTTECHNOLOGY ISSUES

◗ How important is volume reduction in choosing atechnology? What is the ratio of waste produced byyour facility to the waste treated by the treatmenttechnology? Is the technology dependent on acertain volume of material?

◗ How would waste reduction programs affect theprocess? If the waste volume changes radically forany reason (e.g., reduced patient-days, merger,better waste minimization efforts), will thistechnology still meet the treatment needs?

◗ Have staff from your facility talked to colleagues atother facilities about their disposal options, madecomparisons, discussed technologies, contracts andservices, as well as violation histories and rangesof service costs?

◗ What is the local and state regulatory climate foronsite treatment technologies? (Some types oftechnologies require more complicated permitsthan others. Incinerators typically have morecomplex—and thus expensive—permits than mostautoclaves, as an example). Does your facility havestaff on-site who are trained and certified to fulfillthe testing requirements, time, etc., involved inthese permits? If not, consider those staffing andtesting costs in your evaluation.

◗ How long has the treatment technology been inuse, and where? Has your facility’s staff researchedthe various vendors within a type of technology(e.g., autoclaves, microwaves, chemical treatment)?Will the vendor give you a list of references tocontact?

◗ What is the estimated “life” of this equipment?

◗ What volume of waste can the technology treat?Will it always be operating at peak capacity, or willthere be wide variations in the amount of wastetreated?

◗ What are the operational cost implications of usingthis technology? What are the environmental andfiscal impacts of utilities usage (electricity, waterand sewer)?

◗ What is the safety and repair history of the wastedisposal equipment?

◗ What worker safety and ongoing equipmenteducation is required and who provides it?

◗ What are the cost(s) of equipment failure and needfor a back-up or alternative system?

◗ Is waste fed into the treatment system automati-cally (by machine) or by hand (stop feed)? Whatimpact does this have on your facility’s stafflimitations?

◗ Can equipment repair be completed within 24hours without an emergency clause and/or addi-tional costs?

◗ Does the technology require ancillary equipmentsuch as shredders? Are they an integral part of thetreatment process? Does the landfill require them?What are the total associated costs for this equip-ment? Are there any worker-safety concerns withthis equipment?

◗ How is the volume and weight of the wastemeasured with the disposal equipment? Whomeasures it? Is it cost-effective to weigh the wasteson-site?

MANAGEMENT OF SHARPSAND SPUTUM CANISTERS

◗ How are sharps treated in your facility? Has yourfacility considered a sharps container reuseprogram? How would this impact the disposalsystem? How does the waste treatment technologyyour facility is considering handle sharps?

◗ How are sputum canisters treated in your facility?How does the waste treatment technology yourfacility is considering handle them?

OFF-SITE TREATMENT ISSUES(COMMERCIAL TREATMENT FACILITIES)

◗ What are the line-item transportation costs forintra- or interstate taxes, tipping fees, etc?

◗ How many trucks will enter and leave the facilitydaily? Will traffic vary by day of the week, orremain fairly constant?

◗ From what geographic area will waste be ac-cepted? What sort(s) of waste?

◗ Is it possible to bargain collectively with areahealthcare facilities for RMW treatment wastedisposal services?

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◗ Are there any violations against the treatment siteyour facility is considering? Is that facility fullypermitted? Are there any community concernsabout the facility?

◗ Have staff from your facility or a contractedconsultant visited the waste treatment site for acomprehensive audit and evaluated environmentalhealth and safety and operational issues?

◗ Are there any community or environmental healthconcerns associated with this off-site facility? If so,in what ways could the health care facility facilitatepositive changes and reconciliation of those concerns?

COST

There are cost issues associated with every type oftreatment technology. When summarizing cost implica-tions for each treatment and disposal option, alsoconsider the following issues:

◗ Capital equipment costs;

◗ Installation and facility costs: installation labor,facility modifications - cement pad(s), curb cuts,sewers, electricity, space, security, etc.;

◗ Direct labor costs: number of employees needed tooperate the RMW treatment and disposal equipment;

◗ “Down time” costs: including repair (parts andlabor), and alternative treatment;

◗ Utility costs;

◗ Permitting and compliance fees: water and airtesting fees should be included in annual operatingcosts. For comparison purposes, testing fees forincinerator ash should be included;

◗ Fines: depending upon permitting requirementsand state and federal regulations, violations ofpermits or emissions may result in fines;

◗ Compare cost per-ton of disposal for each technol-ogy under consideration. If your facility iscurrently using on-site or off-site incineration, besure to include ash disposal in your estimate ofcurrent costs to contrast with potential future costsof new technology. Regular testing of incineratorash may designate periodic loads to be hazardousand must be sent out as hazardous waste. Estimateat least an annual occurrence;

◗ All transportation, processing and tipping fees;

◗ Supply costs - personal protective equipment, spillsupplies, special bags (for example, some auto-clave systems require particular bags), collectioncontainers (boxes or reusable containers);

◗ Indirect costs/benefits - community satisfaction,environmental leadership.

ENVIRONMENTAL AND ETHICALAND COMMUNITY ISSUES

◗ What are the organic and inorganic emissions tothe environment and to what media (air, water,land)? Dioxin and mercury are examples of suchemissions. In what volume are these pollutantsreleased?

◗ Which emissions are regulated and by whichauthorities? (Local, state or federal regulators maymonitor different pollutants. Total emissions of anypollutant should be considered, not only releases toone medium, such as air.)

◗ Of the emissions that have been identified, which,if any, are harmful to human health or the environ-ment? What are those effects (such as cancer,hormone disruption, reproductive effects orcumulative impacts)?

◗ What is the reputation and reliability of the wastedisposal company, and/or treatment technology?

◗ Should facility waste be disposed outside of thecity/county/state in which it is generated if there isan economical alternative?

◗ What opportunities have been provided for com-munity input into the waste treatment decisionprocess?

◗ Does the treatment process produce odors? Has thefacility documented all available options to reduceodors and related complaints?

◗ How many years is the facility scheduled tooperate?

◗ How will the surrounding community be informedof any accidents or emissions violations from thetreatment facility?

◗ Will the facility increase traffic in the neighbor-hood (e.g., through trucks hauling waste,chemicals, etc.)?

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◗ Is the technology noisy (for workers as well as thecommunity), and how is this defined and docu-mented?

◗ Is a permit for the treatment facility issued onlyonce, or is it periodically reviewed, with opportu-nity for renewed public input?

◗ What are the zoning issues related to the project?

◗ Are there other facilities in the community orneighborhood that pose the same or similarproblems as those of the proposed treatmenttechnology?

REGULATORY AND COMPLIANCE ISSUES

◗ What permits does the technology require in orderto operate?

◗ Is a public hearing required?

◗ Does everyone working on waste issues in thefacility know the pertinent federal, state, county orcity regulations and are they working to maintaincompliance?

◗ What pollution control equipment is required forthis technology? Is there additional equipment thatis available to reduce environmental emissions?What equipment will be used to monitor emissions,and how often?

◗ Can the facility and surrounding community’ssewer or septic system handle the waste treatmentequipment’s discharges?

◗ Has someone at your facility estimated the cost(s)associated with environmental, health and safetyviolations related to prospective waste disposalequipment?

◗ What are the estimated costs for emissions testing,liability, violations and clean-up?

HAZARDOUS WASTE MANAGEMENT

◗ What residuals (waste still left after treatment)remain when the treatment process is complete?Can all potential residuals be fully identified beforedisposal? Will any require treatment as hazardouswaste? What are the estimated costs associatedwith this disposal? What is the liability attached tothis residual waste?

◗ If chemicals are used to treat the waste, are theyhazardous by themselves? If so, what are thepotential health and environmental impacts for theworkers and the community? Does someone inyour facility know what potential reactions mayoccur from a combined mix of facility wastes andsewer disposal wastes?

◗ Does the production of any chemical required bythe treatment process have harmful environmentalor health impacts?

◗ Does the treatment process release radioactiveisotopes? If so, how are those isotopes contained?

VENDOR ISSUES

◗ Does the vendor (of the equipment or waste hauler)or any of its subsidiaries or contractors have anyviolations (environmental, criminal, etc.)? If so,how have those violations been handled?

◗ Is the vendor willing to meet with your facility’sstaff committee to answer specific questions aboutthe equipment and technology?

CONTRACT ISSUES

◗ Has your facility reviewed current contracts,whether in a Group Purchasing Organization(GPO) or not, to better understand disposal op-tions, obstacles and potential discussion areas froma waste and energy perspective?

◗ Has your facility’s staff discussed the length ofcontract that best suits your needs? How does thatcompare with the contract being offered?

◗ What is the waste management plan/back-upservice option for down times? Is there an extrafee, or is it part of the contract?

◗ Have current waste service contracts been reviewedand rewritten for educational, health and safetystandards, and to maximize reuse, recycling, andrecycled-content?

◗ What contract constraints are negotiable in order toget the best equipment and services for your facility?

◗ What is the length of the contract? Is it a “put orpay” contract, (i.e., one that guarantees the healthcare facility will supply a certain amount of wasteor pay to make up the difference)?

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Please keep in mind that there may be additionalissues that are not raised here but may be veryimportant to your health care facility or your com-munity. These questions are meant to help people

identify and prioritize issues of concern, as well as tostimulate the collection and release of new dataabout non-incineration technologies to the healthcare industry and the public.

REFERENCES

1 Dwain Winters, USEPA Dioxin Policy Project, BinationalToxics Strategy Dioxins/Furans Work Group conference call,October 5, 1999.

2 Association of Operating Room Nurses, Inc., AORN PositionStatement, “Regulated Medical Waste Definition and Treatment:A collaborative document,” in Standards, RecommendedPractices and Guidelines (Denver: Association of OperatingRoom Nurses, 1998) 113-116.

3 “Infectious Waste” factsheet. Hospital Infections Program,National Center for Infectious Diseases, Centers for DiseaseControl and Prevention. Atlanta, GA. Updated: January 21,1997. http://www.cdc.gov/ncidod/diseases/hip/waste.htm

4 “Standard of Safety for Alternative Technologies for theDisposal of Medical Waste - UL 2334,” http://www.ul.com/eph/medwaste.htm

5 Greening Hospitals: An Analysis of Pollution Prevention inAmerica’s Top Hospitals, Environmental Working Group/HealthCare Without Harm, June 1998, based on Rutala, W.A. and C.G.Mayhall, Society for Hospital Epidemiology of America positionpaper. Infection Control and Hospital Epidemiology 13:38-48.1992; and personal communication with Hollie Shaner, FletcherAllen Healthcare, VT and Laura Brannen, Dartmouth-HitchcockMedical Center, NH.

6 Brown, Janet, 1993. “Hospital Waste Management that SavesMoney — and Helps the Environment and Improves Safety.”Medical Waste: The Environmental Publication for the Health-care Industry. 1(10), July, 1993 and personal communicationwith Janet Brown, as cited in “Greening” Hospitals.

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We have several concerns regarding the burning ofwaste generated by health care (both solid waste

and regulated medical waste).

◗ Incineration produces both toxic air emissions andtoxic ash residue.1 The air emissions affect thelocal environment, and in many cases, may affectcommunities hundreds or thousands of miles away.The ash residue is sent to landfills for disposal,where the pollutants have the potential to leach intogroundwater. (It must be noted that waste treatedby other methods and then landfilled will alsoproduce leachate.)

◗ In addition to releasing the pollutants contained inthe waste stream to the air and into the ash, burningmedical waste actually creates new toxic com-pounds, such as dioxins.

◗ Medical waste incineration has been identified by theU.S. Environmental Protection Agency as the thirdlargest known source of dioxin air emissions,2 andcontributes about 10 percent of the mercury emis-sions to the environment from human activities.3

◗ Many, if not most, on-site medical waste incinera-tors burn not only infectious waste, but also readilyrecyclable items such as office paper and card-board. This destroys resources and prevents costsavings that could be recouped through recycling.

◗ Medical waste incineration’s identification as aprimary source of some very toxic pollutantsstands in direct contradiction to physicians’ oathsto “do not harm.”

DIOXINDioxin belongs to a family of 419 chemicals withrelated properties and toxicity, but the term “dioxin” isoften used to refer to the 29 that have similar toxicity.

Dioxin is one of the most toxic chemicals known tohumankind. While exposure of the general populationoccurs through the ingestion of many common foods,

children exposed in utero during critical periods ofdevelopment appear to be the most sensitive andvulnerable to the effects of dioxin.4 Dioxin exposurehas been linked to disrupted sexual development, birthdefects and damage to the immune system. Specifi-cally, dioxin has been associated with IQ deficits,hyperactive behavior and developmental delays.5 , 6

The International Agency for Research on Cancer(IARC), an arm of the World Health Organization, lastyear acknowledged dioxin’s cancer-causing potentialwhen they classified it as a known human carcinogen.7

The U.S. Environmental Protection Agency (EPA) hasdetermined that most Americans are exposed to dioxinthrough ingestion of common foods, mostly meat anddairy products. Dairy cows and beef cattle absorbdioxin by eating contaminated feed crops. The cropsbecome contaminated by airborne dioxins that settleonto soil and plants. Dioxins enter the air from thou-sands of sources including incinerators that burnmedical, municipal and hazardous waste.8

MERCURYMercury is a potent neurotoxin, which means it attacksthe body’s central nervous system; it can also harm thebrain, kidneys and lungs. It can cross the blood-brainbarrier as well as the placenta. Mercury poisoning cancause slurred speech, impaired hearing, peripheralvision and walking, muscle weakness, mood swings,memory loss and mental disturbances. The risks ofdamage to the nervous systems of developing fetusesand young children are primary reasons for fish-consumption advisories, aimed at discouragingpregnant women, women of child-bearing age, andyoung children from eating too much fish. Studies doneon women who ate methylmercury-contaminated fishor grain showed that even when the mothers showedfew effects of exposure, their infants demonstratednervous-system damage.

If mercury-containing items are put into a “red bag” forinfectious waste and sent to an incinerator, mercury

A P P E N D I X A

Why is Health Care Without Harm Opposed to Incineration?

PPPPP. O. O. O. O. O. B O. B O. B O. B O. B OX 6 8 0 6X 6 8 0 6X 6 8 0 6X 6 8 0 6X 6 8 0 6 ‹ F A L L S C H U R C HF A L L S C H U R C HF A L L S C H U R C HF A L L S C H U R C HF A L L S C H U R C H, V, V, V, V, V A 2 2 0 4 0A 2 2 0 4 0A 2 2 0 4 0A 2 2 0 4 0A 2 2 0 4 0

TTTTT : 7 0 3 . 2 3 7 . 2 2 4 9: 7 0 3 . 2 3 7 . 2 2 4 9: 7 0 3 . 2 3 7 . 2 2 4 9: 7 0 3 . 2 3 7 . 2 2 4 9: 7 0 3 . 2 3 7 . 2 2 4 9 ‹ FFFFF : 7 0 3 . 2 3 7 . 8 3 8 9: 7 0 3 . 2 3 7 . 8 3 8 9: 7 0 3 . 2 3 7 . 8 3 8 9: 7 0 3 . 2 3 7 . 8 3 8 9: 7 0 3 . 2 3 7 . 8 3 8 9 ‹ E M A I LE M A I LE M A I LE M A I LE M A I L : N O H A R M @ I A: N O H A R M @ I A: N O H A R M @ I A: N O H A R M @ I A: N O H A R M @ I AT PT PT PT PT P. O R G. O R G. O R G. O R G. O R G ‹ W W WW W WW W WW W WW W W. N O H A R M . O R G. N O H A R M . O R G. N O H A R M . O R G. N O H A R M . O R G. N O H A R M . O R G

will contaminate the air. (This can happen with non-incineration technologies as well. If mercury goes intotreatment equipment, it will come out.) Airbornemercury then enters a global distribution cycle in theenvironment, contaminating fish and wildlife.

OTHER HAZARDOUS POLLUTANTSMany other hazardous pollutants have been identifiedin the emissions from medical waste incinerators:

REFERENCES ( FOR APPEND I X A )( FOR APPEND I X A )( FOR APPEND I X A )( FOR APPEND I X A )( FOR APPEND I X A )

1 “Issues in Medical Waste Management Background Paper,”Office of Technology Assessment, Congress of the United States,OTA-BP-O-49, October, 1988.

2 Inventory of Sources of Dioxin in the United States (EPA/600/P-98/002Aa), National Center for Environmental Assessment,USEPA, April 1998, p. 2-13.

3 Mercury Study Report to Congress, Volume I: ExecutiveSummary, USEPA Office of Air, December 1997. p. 3-6

4 Pluim, HJ, Koope, JG, Olie, K., et al. 1994. “Clinicallaboratory manifestations of exposure to background levels ofdioxins in the perinatal period.” Act Paediatr 83:583-587;Koopman-Esseboom C, Morse DC, Weisglas-Kuperus N, et al.1994. “Effects of dioxins and polychlorinated biphenyls onthyroid hormone status of pregnant women and their infants.”Pediatr Res 36: 468-473; Pluim HJ, de Vijlder JJM, Olie, K, etal. 1993. “Effects of pre- and postnatal exposure to chlorinateddioxins and furans on human neonatal thyroid hormoneconcentrations.” Environmental Health Perspectives 101: 504-508; Weisglas-Kuperus N, Sas TCJ, Koopman-Esseboom C, etal. 1995. “Immunologic effects of background prenatal andpostnatal exposure to dioxins and polychlorinated biphenyls inDutch infants.” Pediatr Res 38: 404-410; Huisman M,Koopman-Esseboom C, Fidler V, et al. 1995. “Perinatalexposure to polychlorinated biphenyls and dioxins and itseffect on neonatal neurological development.” Early HumanDevelopment 41: 111-127.

arsenic, ammonia, benzene, bromodichloromethane,cadmium, carbon tetrachloride, chromium,chlorodibromomethane, chloroform, cumene, 1,2-dibromoethane, dichloromethane, dichloroethane, ethylbenzene, lead, mesitylene, nickel, particulate matter,naphthalene, tetrachloroethane, toluene,trichloroethane, 1,1,1-trichloroethane, trichloroethyl-ene, trichloromethane, vinyl chloride, and xylenes.9

Analysis of emissions of other treatment methods isnecessary to determine if these emissions occur in theabsence of combustion.

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5 “Workshop[s] on Perinatal Exposure to Dioxin-like Com-pounds. I-VI. Summar[ies],” Environmental Health PerspectivesSupplements, Vol. 103, Supplement 2, March 1995.

6 Health Assessment Document For 2,3,7,8-Tetrachlorodibenzo-P-Dioxin (TCDD) And Related Compounds, Vol. 1 of III, and Vol. IIof III, USEPA, Office of Research and Development, EPA/600/BP-92/001b and EPA/600/BP-92/001c, external review draft; andDevito, M.J. and Birnbaum, L. S. (1994) “Toxicology of dioxinsand related chemicals.” In Dioxins And Health, Arnold Schecter,ed., NY: Plenum Press, 139-62, as cited in Dying From Dioxin: ACitizen’s Guide To Reclaiming Our Health And RebuildingDemocracy, Gibbs, L.M. and the Citizens Clearinghouse forHazardous Waste, Boston: South End Press, 1994, pp. 138-139.

7 “IARC Evaluates Carcinogenic Risk Associated with Dioxins,”International Agency for Research on Cancer press release,February 14, 1997.

8 Estimating Exposure To Dioxin-Like Compounds, Volume I:Executive Summary, USEPA, Office of Research and Develop-ment, EPA/600/6-88/005Ca. June 1994 review draft, p. 36.

9 Draft Technical Support Document To Proposed Dioxins AndCadmium Control Measure For Medical Waste IncineratorsCalifornia Air Resources Board, 1990, pg.51, as cited in“Medical Incinerators Emit Dangerous Metals And Dioxin, NewStudy Says,” RACHEL’S ENVIRONMENT & HEALTH WEEKLY#179, May 2, 1990.