International Finance Corporation
2121 Pennsylvania Ave NW
Washington, DC 20433

As agreed in our meeting of 19 April, we are writing this letter to inform the process of revising IFC’s Health Care Facilities Guidelines. Since these guidelines are legally binding upon IFC clients, we regard them as an important opportunity to set international standards regarding the handling of medical waste and other environmental issues in the health care sector. We also think that this is an opportunity for IFC to demonstrate its vision of promoting environmentally beneficial development in the health care sector.

We are writing this letter on behalf of three international coalitions: Health Care Without Harm, the Global Alliance for Incinerator Alternatives and the Basel Action Network.

Health Care Without Harm is a collaborative campaign for environmentally responsible health care made up of more than 300 organizations in 28 countries. Its mission is to transform the health care industry so it is no longer a source of environmental harm by eliminating pollution in health care practices without compromising occupational safety or patient care.

The Global Alliance for Incinerator Alternatives is a growing international alliance of individuals, non-governmental organizations, community-based organizations, academics and others working to end the incineration of all forms of waste and to promote sustainable waste prevention and discard management practices. GAIA comprises approximately 100 members in over 30 countries.

The Basel Action Network (BAN) is a global alliance of activist organizations dedicated to halting the proliferation of trade in toxic waste, toxic products and toxic technologies. Recently BAN has been active in helping shape the Basel Convention’s guidelines on the environmentally sound management of health care wastes.

According to a recent presentation by Executive Vice President Peter Woicke, the IFC is seeking to transform its approach to environmental issues from a compliance-driven to an opportunity-driven model. The health care sector is an opportunity to demonstrate this new approach, by coupling strong compliance regulations with a vision of truly environmentally-friend health care facilities that perpetually seek to minimize environmental impact while saving money and resources. Fortunately, the IFC will not have to ask its clients to pioneer these approaches, as much important work has already been done throughout the world on this topic.

Listed below are the issues that we find of highest importance in establishing guidelines for the health care sector. The approach outline bellow is one that we employ in our own work on this issue, and it is one that has been developed by the range of organizations and health care institutions that comprise HCWH, GAIA and BAN. As such, we feel quite strongly that it constitutes both an appropriate set of minimum conditions as well as provides the direction for reasonable achievable goals for health care institutions throughout the world.

We recognize that health care institutions vary considerable in their access to resources, trained personnel and basic infrastructure. The principles we have developed are therefore not dependent upon any of these factors; rather, they have been shown to be effective in a number of different counties, under widely varying circumstances.

However, a certain quantity of resources – including managerial time—must be devoted to the question of waste management and waste prevention in order develop a comprehensive waste management system. It is our belief, and this is sustained by field experience in health care institutions, that waste management is a “management problem” to be solved, not a technological problem to be “fixed”. Health care waste management, as pointed out in the Word Health Organization’s Safe Management of Wastes from Health Care Activities starts with the basic principles of good waste segregation programs, worker training, and application of the sound principles of pollution prevention.

The six principles that our coalitions would like to see reflected in the IFC’s guidelines are included in the following:

SIX PRINCIPLES TO INCLUDE IN THE INTERNATIONAL FINANCE CORPORATION’S (IFC) GUIDELINES**

Submitted by the following three institutions: Global Alliance for Incinerator Alternatives (GAIA), Health Care without Harm (HCWH), Basel Action Network (BAN)

1. Emphasis on Pollution Prevention
   In the past, most pollution reduction efforts were limited to “end of pipe” approaches that attempted to mitigate pollution after it had been created. However, the most effective and cheapest manner of reducing pollution is by prevention. This is in essence a question of management, not of technology choice. GAIA, HCWH and BAN advocate materials substitution and selective procurement as ways to minimize both the quantity and the toxicity of the waste produced by health care facilities. Material substitution means: emphasizing the purchase of re-usable products, complemented by the judicious use of disposable products (instead of a total embrace of disposables), and the use of toxic-free items instead of ones containing hazardous substances. Those items that cannot be reused or those that cannot be eliminated from use should be recycled. Clearly, not all items can be dealt with in this manner; for example, increasing the use of items such as disposable syringes and needles has been proven to reduce infection rates, however the employment of other disposables has not. Health care facilities’ environmental management plans should address each component of the waste stream and seek out alternative inputs that would eliminate this component; if that is not practical, alternatives that reduce the quality and toxicity of the waste should be employed. The management plan should clearly state the various components of the waste stream and why they cannot be further reduced at the time.
2. Waste Minimization and Segregation
   An essential component of pollution prevention is the proper segregation of waste streams from a health care facility. Health care wastes are some of the most diverse and complex produced in any institution. Not only must basic solid wastes be managed, but bio-hazardous wastes, radioactive wastes and a wide range of chemical hazardous wastes must be managed as well. The direct threat to workers and to water supplies by these wastes is often overlooked in plans to manage health care wastes. Only when different types of waste are properly separated can each be handled and treated in an appropriate manner, allowing for re-use, recycling, disinfecting, and proper disposal. Segregation is therefore a prerequisite for any sustainable waste management program. Waste minimization – even of non-toxic wastes such as office paper or packaging materials—is also important in reducing the ecological footprint of an institution, and is a fundamental part of pollution prevention. When hazardous chemicals cannot be replaced by non-hazardous substitutes, facilities should minimize their use and waste. Health care institutions should include waste minimization and source segregation systems in their environmental management plans.
3. Mercury Elimination
   Mercury is one of the most toxic substances employed in health care facilities – it is a known neurotoxin with irreversible effects, particularly affecting fetuses and young children. Health care facilities are a significant source of environmental mercury contamination, largely because of the number of mercury-containing devices (such as thermometers and blood pressure cuffs) that are used in health care. Because alternatives for all mercury-containing equipment now exist, and are considered to be of equivalent or superior efficacy in real-world conditions, health care facilities should commit to a complete mercury phase-out.
4. Non-Combustion Treatment Technologies
   Healthcare facilities will inevitably produce some quantity of potentially infectious waste, which must be treated and disposed. Historically, much of this waste has been incinerated, and medical waste incineration has been documented (in several countries) as a primary source of dioxins and furans releases – through exhaust and ash. It is also a significant source of hexachlorobenzene (HCB) and polychlorinated biphenyls (PCBs). These chemicals have been recognized in the forthcoming Stockholm treaty on persistent organic pollutants (POPs) as four of the twelve priority pollutants, which all parties should “reduce the total releases derived from anthropogenic sources…with the goal of their continuing minimization and, where feasible, ultimate elimination.” That treaty calls for the use of substitute processes to prevent the formation and release of these POPs by products. Clearly, creating additional sources of dioxins, furans, PCBs, HCB, for example by financing new medical waste incinerators, or increasing the quantity of material burned in existing incinerators, contradicts the intention, if not the letter of the treaty. Fortunately, there are several other technologies for disinfecting medical waste, which do not produce POPs, such as autoclaving, micro waving, chemical disinfecting, etc. Health care projects should use non-combustion treatment technologies for that portion of infectious medical waste, which requires special treatment.
5. Community Right-to-Know and Right -to-Consultation
   The environmental impacts of an institution are felt first and foremost by the local community, including patients, workers, community residents and waste pickers (scavengers). People have a fundamental right to know about the policies and projects that affect their lives, especially when it relates to the work of a public institution such as the IFC. This requires that stakeholders are not only provided with the information that they need to participate in decision-making, but also that the information is provided before all of the critical decision have already been made. This information should include access to social and environmental monitoring reports as well as the complete environmental management plan, including critiques and comments on the plan submitted to the IFC, client, or regulatory agency; the analysis of alternatives that were considered and rejected; financial implications of the plan; updates, changes and revisions to the plan, on an ongoing basis; and, commitments made by the institution and IFC within the scope of the plan. This access must be allowed sufficiently in advance of the plan’s approval by IFC in order that the local community has time to review the plan and critique it. The IFC, in turn, must consider community comments in its review of plans and monitoring reports.
6. PVC Elimination

Polyvinyl Chloride (PVC) is found widely in the health care sector, in a variety of uses from plumbing to IV bags, yet PVC is a problematic material at every stage of its lifecycle. The production of PVC-from chlorine manufacturing to the production of the polymer itself – is an extremely polluting process releasing large quantities of dioxins, furans, mercury, and other persistent organic pollutants in the production chain. For uses in IV tubing, bags, etc., PVC is mixed with plasticizers, some of which leach out of the plastic and into the fluids being injected into the patient. Some of these, such us DEHP, have been identified as carcinogenic and as endocrine disruptors. At the end of its use, PVC continues to pose a threat, as it cannot be cleanly recycled. Disposal causes dioxin production and the liberation of heavy metals from the PVC matrix. For all these reasons, PVC use is incompatible with a sustainability program, and health care facilities should eliminate the use of PVC.

Following is a list of several documents and websites, which we hope you will find useful.

Health Care Facilities and the Environment Reference Documents

Health Care Without Harm: The Campaign for Environmentally Responsible Health Care, 1999. www.noharm.org

Eleven Recommendations for Improving Medical Waste Management, CGH Environmental Strategies 1997. www.cghenvironmental.com/elevenrecs.html

Medical Waste Treatment Technologies: Evaluating Non-Incineration Alternatives, Health Care without Harm 2000. www.noharm.org/library/docs/medical_Waste_Treatment_Technologies_Evaluatin.pdf aluatin.pdf

Non-incineration Medical Waste Treatment Technologies, Health Care without Harm 2001. Soon to be posted at www.noharm.org

Clinical Waste in Developing Countries, Glenn McRae and Ravi Agarwal 1999. www.ban.org/subsidiary/clinical.html

Setting HealthCare’s Environmental Agenda, conference proceedings 2000 www.noharm.org

Documents available by mail:

Hospital Waste Time to Act: Srishti’s Factsheets on 8 Priority Areas, November 2000

Managing Hospital Waste: A Guide for Health Care Facilities, Revised Edition 2000 Both available from Srishti, H-2 Jangpura Extension, New Delhi 110014 India srishtidel@vsnl.net

Relevant websites:

Health Care without Harm: www.noharm.org

Global Alliance for Incinerator Alternatives: www.no-burn.org

Basel Action Network: www.ban.org

Sustainable Hospitals Clearinghouse: www.sustainablehospital.org

Hospitals for a Healthy Environment www.h2e-online.org

Nightingale Institute www.nihe.org

Srishti www.toxicslink.org/srishti.htm

National Wildlife Federation on mercury: www.nwf.org/grreatlakes/resources/mercuty.html

US EPA on mercury www.epa.gov/seahome/mercuty/src/mercmed.htm

From the IICPH Resource Centre
www.iicph.org