Many hospitals in Britain are disposing of dangerous clinical waste
illegally. From next week, their managers, along with the chief executives
of their health authorities, will be held responsible. They will risk personal
prosecutions, fines of £20 000 and 6 months’ imprisonment if the
hospitals they control continue to flout regulations that are being introduced
to halt the hazardous and polluting disposal of clinical waste. This is
the latest move in the government’s plan to make hospitals as accountable
as private organisations for the way rubbish is collected, stored and incinerated.
But tight budgets are forcing hospital managers to concentrate their limited
resources on patient care rather than on waste disposal.
Clinical waste is the name given to rubbish containing human and animal
tissue, blood, excreta, drugs, swabs and syringes, as well as nontoxic items
such as old newspapers and dead flowers. Between 200 000 and 400 000 tonnes
of it are collected each year in the yellow plastic bags that may often
be seen littering hospital premises. A survey in 1988 by Grundon, a private
waste disposal company, found that these bags are on average picked up and
put down eight times on their way to the incinerator, risking damage to
the bags and injury to porters. Medical staff usually place syringes and
blades, known as ‘sharps’, in plastic or cardboard containers to prevent
injuries, but not always. Grundon’s survey discovered 12 hypodermic needles
on the floor of a truck transferring clinical waste to the incinerator at
one London hospital.
The waste should be burnt at a minimum temperature of 1000 °C to
reduce the toxicity of the emissions and ash produced. But most of Britain’s
800 hospital incinerators are so old and inefficient that they will never
be able to do this, even with substantial refurbishment. Between 60 and
70 per cent of them are fit only for the scrapheap, says David Boyd, director
of the National Association of Waste Disposal Contractors. For instance,
of 36 hospital incinerators in Wales studied by the House of Commons Select
Committee on Welsh Affairs in its report Toxic waste disposal in Wales published
in March 1990, only six operated in the range between 800 °C and 1000
°C. The rest of the incinerators burnt rubbish at lower temperatures,
one as low as 400 °C.
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Until a year ago, hospitals could not be prosecuted for any violation
of environmental law. As government property, they came under the protection
of the sovereign, enjoying what is known as ‘Crown immunity’. The National
Health Service and Community Care Act of 1990 removed this immunity, and
since last April the whole of the National Health Service, hospitals included,
has been subject to the full force of environmental legislation. Hospitals
have had to conform with the less stringent requirements of the law very
quickly, but the tough standards demanded by the 1990 Environmental Protection
Act, including the requirement to operate incinerators at a minimum temperature
of 1000 °C, are being phased in. Hospital incinerators will not have
to meet them in full until 1 October 1995, so people living downwind of
a hospital incinerator may continue to be subjected to smelly toxic smoke
for some years to come.
Hospitals are struggling to sort out their waste disposal operations.
As soon as the NHS lost its Crown immunity, health authorities should have
obtained licences for most of their incinerators from their local waste
regulation authority, which for most of them is the county council. And
yet in spite of a warning from Stephen Dorrell, the health minister, many
did not and still have not done so, contrary to section 3(1) of the 1974
Control of Pollution Act. In August last year, Gateshead Health Authority
was fined £1000 for running the incinerator at its Queen Elizabeth
Hospital without a licence. This followed a private prosecution by Trevor
Payne, a local resident, who blames the death from leukaemia of his four-year-old
daughter on pollution from the hospital’s incinerator.
Licence dodging
‘You could prosecute your local hospital yourself for the price of a
court summons,’ says Boyd. ‘Almost all the hospital incinerators in the
country are operating illegally.’ Only those disposing of waste generated
on the premises and capable of burning no more than 200 kilograms per hour
do not need to be licensed. Most hospital incinerators burn between 200
and 500 kilograms per hour and dispose of waste from nearby clinics and
general practitioners. Some even dispose of nonclinical waste such as police
records.
In February this year, North Tyneside Health Authority was fined £2500
for using an incinerator without author-isation (This Week, 8 February).
Under the terms of the 1990 act, an application should have been lodged
with the district council’s environmental health department by 1 October
1991. It is this act that, from 1 April, will make hospital managers and
the chief executives of health authorities personally liable for breaches
of the law. The next step in the four-year programme of phased improvements
introduces lenient interim standards, such as a restriction on the volume
of particulates emitted from incinerators and a ban on the production of
black smoke. It also requires health authorities and environmental health
officers to agree a strategy for meeting the ultimate deadline in 1995.
After 1 October 1992, hospitals will be encouraged not to run incinerators
that do not meet fully the standards laid down in the 1990 act, unless it
will be possible to bring them up to standard at reasonable cost. The aim
is to prevent hospitals wasting resources making improvements to plant that
will have to be scrapped anyway, and to minimise the number operating polluting
incinerators right up to the 1995 deadline.
But cash shortages in the NHS are preventing hospital managers from
meeting environmental objectives. The government has not provided any money
specifically to help with the reorganisation of waste disposal operations.
Cash to upgrade, rebuild or replace incinerators must come from existing
budgets. ‘Financial provision for the disposal of clinical waste is subsumed
within overall allocations,’ said Dorrell last May. With an election looming
and the NHS one of the key electoral issues, managers are under pressure
to put all available resources into reducing waiting lists and providing
higher standards of patient care.
Disposing of the waste to current environmental standards will be expensive,
especially as run-down incinerators cannot simply be refurbished. According
to Des Mitchell, a waste disposal specialist at Warren Springs Laboratory,
an agency of the Department of Trade and Industry, ‘There is simply no point
in trying to upgrade most of the existing plant – most of it is near the
end of its working life in any case.’ Old plant often runs at barely 600
°C, and has no equipment, such as filters and scrubbers, to remove toxic
chemicals and particulates, which emerge as black smoke. The technology
is distinctly 19th century, says Tim Brown, director of the National Society
for Clean Air, the organisation based in Brighton that led the campaign
for the withdrawal of Crown immunity from hospital incinerators.
New waste disposal plants must be built of modern materials capable
of withstanding operating temperatures of more than 1000 °C. To reduce
the toxicity of emissions, the plant must also ensure that the combustion
gases spend at least two seconds in an oxidising environment in a secondary
chamber. It should also incorporate equipment, such as alkaline wet scrubbers,
to remove acidic compounds and particulates. The law recommends that exhaust
gases be rapidly cooled to minimise the risk of elements re-forming into
toxic compounds, including dioxins and furans.
These compounds are carcinogens, and among the most toxic chemicals
produced in industrial processes . When their precursors, carbon, hydrogen
and chlorine, are present, they form spontaneously between temperatures
of 250 °C and 400 °C, with a peak at 300 °C. Low-temperature
incinerators, and most incinerator flues, can thus act as dioxin factories.
According to Clive de Grey, Grundon’s manager of clinical waste, some hard-pressed
NHS hospitals have been ‘running a chemicals factory’ by operating their
incinerators at temperatures as low as 300 °C to save fuel. This opinion
is supported by a two-year study by the Danish National Environmental Research
Institute, published in 1990 by the journal Chemosphere. Comparing the products
of combustion of hospital and general municipal waste, the Danish investigation
found that the hospital waste contributed 30 per cent of the dioxins and
furans produced, even though it made up only 1 per cent of the total waste.
Eliminating chlorinated plastics, such as PVC, from the waste would
reduce the amount of chlorine in the combustion chamber and so help to cut
down the quantity of dioxins and furans produced. Mitchell suggests that
careful tuning of existing plant could also bring about dramatic reductions
in emissions. But in the long term, he sees big and expensive equipment
as the only solution. Boyd suggests that just 20 or so strategically located
large incinerators, with a capital cost of some £60 million, could
burn all the nation’s clinical waste. Additional storage and transport costs
would also be incurred. He says this is a much more economical alternative
to replacing existing hospital plant, which, at an average cost of £500
000 per unit, could cost around £400 million.
Private treatment
The lack of preparation for the changes threatens to turn what should
be an orderly process into a scramble. A rash of prosecutions and injunctions
could shut down many NHS incinerators, leaving stacks of rotting clinical
waste to be disposed of. The private sector would be well-placed to benefit
from such disarray.
Private contractors feel that they’ve been getting a raw deal after
investing heavily in new plant to prepare for the enactment of tough environmental
legislation. They expected health authorities to turn to them, their equipment
and expertise, when the government withdrew Crown immunity from the NHS.
‘They saw a pot of gold on the horizon and built new, high-quality incinerators,’
says Brown. ‘The four-year moratorium let them down.’ According to Boyd,
‘health authorities are simply running their dirty old plant into the ground,
while our members’ new high-temperature incinerators are running at 50 per
cent capacity.’
One such plant is Grundon’s incinerator at Colnbrook near Heathrow airport,
which can burn waste at a rate of one tonne an hour. It is using its spare
capacity to burn clinical waste imported from Germany, where tougher laws
make disposal more expensive. But director Norman Grundon remains optimistic
about the prospect of making a profit from disposing of Britain’s clinical
waste: ‘I’m sure we’ll soon be turning the corner, as legislation forces
the pace of change,’ he says. So confident is he, that plans are well in
hand for a parallel incinerator that will double the firm’s capacity.
This fits in with the government’s plans for the future of clinical
waste incineration. Opening the Colnbrook plant in March 1989, the then
health minister Roger Freeman forecast that ‘many hospitals will have to
look to the private sector for complete management of waste from ward to
incineration. This is right and proper.’
However, if hospitals cannot afford to upgrade their own services, how
will they pay someone else to do the job for them? Grundon charges £360
to dispose of a tonne of clinical waste; most hospitals run their existing
plant for little more than the cost of the fuel, which can work out as low
as £30 per tonne of waste. Brown says the real issue is not who disposes
of the waste but how the operation is done: ‘We don’t care who burns the
waste, the public or the private sector, as long as it’s done cleanly and
to a high standard.’ But how will these high standards be enforced? The
question of regulation is looming large.
The 1990 act relies heavily on the stretched resources of district environmental
health departments, which must act as regulators and advisers to health
authorities. While accountability is an important aspect of regulation and
the departments are generally open in their dealings with the public, this
is for them a new, complex area for which training, extra staff, computers
and pollution monitoring equipment will be needed. Yet no funds have been
committed by central government; instead, money must be approved by local
authority finance committees, in fierce competition with a host of other
needs, many of which councils see as more urgent.
The only extra income for environmental health departments comes from
the fees for applications to operate a polluting plant – £800 for
a first application, and £500 for a renewal. This may be enough to
assess and monitor a simple hospital incinerator but, under the 1990 act
and for the same fee, the departments are also responsible for regulating
large multi-stack factories with boilers, incinerators, spray booths and
a multitude of polluting industrial processes. This leaves many districts
out of pocket, possibly preventing them carrying out fully all their tasks.
By contrast with the attitude of the National Society for Clean Air,
Greenpeace is opposed to all incineration. ‘It is a classic example of back-end
thinking,’ says Madeleine Cobbing, the organisation’s campaigner on toxic
waste. ‘We should be asking the right question at the outset: how we can
avoid producing the waste, not what the easiest way is to get rid of it.
If incineration is the answer, it must have been a stupid question.’
Current fashion in the health service encourages the opposite, with
outside contractors providing single-use sterile packs and labour-saving
disposables. This contradicts the government’s statement in its 1990 White
Paper on the environment, Our Common Inheritance, that its ‘first priority
is to reduce waste at source to a minimum’.
Alternatively, the volume of clinical waste could be reduced by isolating
the hazardous element, which, in Britain, accounts for less than 10 per
cent of the total. The resulting small fraction of true clinical waste need
not be incinerated, says Cobbing. It could be pressure-cooked to eliminate
pathogens, and the leftovers buried.
In Germany, careful segregation ensures that 95 per cent of clinical
waste is hazardous material, and each hospital bed is expected to take a
year to fill an 18-kilogram bin with it. In Britain, each bed generates
this much in a week, and the trend is firmly upwards. Cobbing sums it up:
‘As things stand we have health service practices which increase waste,
together with a regulatory regime which is a recipe for confusion.’
Oliver Tickell is a freelance journalist interested in environmental
issues.
Alan Watson is an environmental consultant specialising in energy and
waste.
* * *
THE TOXIC COCKTAIL OF CLINICAL CARCINOGENS IN ASH AND SMOKE
The toxic dioxins and furans are polychlorinated aromatic hydrocarbons.
According to the Department of Environment, in its paper Dioxins in the
environment published in 1989, there are 75 forms of polychlorinated dibenzodioxin
(PCDD, or dioxin) and 135 forms of polychlorinated dibenzofuran (PCDF, or
furan), all of which are likely to be produced by waste incinerators.
Their toxicity is expressed in terms of TCDD, or 2,3,7,8-tetrachlorodibenzo-p-dioxin,
which Greenpeace dubs ‘the world’s most toxic synthetic chemical’. According
to the US Environmental Protection Agency, the tolerable daily intake of
dioxins and furans is 6 thousand-million-millionths of a gram (6 x 10-15
grams) of TCDD equivalent per kilogram of body weight. At this rate of consumption,
the EPA estimates that the risk of developing a cancer is increased by one
chance in a million.
In Britain, the DoE estimates that the average daily consumption is
up to 500 times the EPA limit. In its 1989 study, the department reports
that the daily intake is between 1 and 3 million-millionths of gram (between
1 and 3 x 10-12 grams) per kilogram of body weight.
The latest European Community draft directive, published in 1990, specifies
a limit of one ten-thousand-millionth of a gram (10 -10 grams)
of TCCD-equivalent per cubic metre of undiluted emissions. In Britain, HM
Inspectorate of Pollution, which the 1990 Environmental Protection Act makes
responsible for regulating incinerators burning more than one tonne of waste
per hour, accepts the same limit.
The act sets design and temperature standards for hospital incinerators.
However, it is unclear whether these standards will reduce the toxicity
of emissions and ash produced to the limits acceptable for a larger plant.
Where these standards cannot be met, the act sets a toxicity limit of one
thousand-millionth of a gram (10-9 grams) of TCCD-equivalent per cubic metre.
This limit is ten times the European one for larger incinerators. Also,
the restrictions will not affect existing plant until October 1995 even
though, according to a study published in May last year in the environmental
journal ENDS, some hospital incinerators are emitting dioxins and furans
at concentrations that are hundreds or thousands of times as high as the
European limit.
Dioxins and furans are also found in incinerator ash at levels of the
order of micrograms per gram of ash. However, while the law stipulates stringent
requirements on handling the ash, there is no clear guidance on its disposal.
Some ash is treated as hazardous waste, but much of it finds its way into
ordinary domestic landfill sites.