Incineration of medical waste is a leading and easily avoidable source of dioxin, mercury and other pollution. Dioxin is a known human carcinogen and has been linked to birth defects, decreased fertility, immune system suppression and other hormonal dysfunction. Mercury can interfere with the development of the fetal brain and is directly toxic to the central nervous system, kidneys and liver.

Safer economical alternatives to medical waste incineration exist. The international Health Care Without Harm (HCWH) coalition has provided leadership in promoting non-incineration approaches to medical waste management in many countries.

The Multinationals Resource Center (MRC) (a member of HCWH) has just completed a survey - based on publicly available World Bank Project Information Documents, or PIDs - of medical waste management practices in World Bank and its sister agency, the International Finance Corporation (IFC), projects. MRC found that, in spite of the well documented dangers of incineration and the repeated attempts by HCWH and MRC to provide information to the Bank about alternatives, the World Bank group continues to include medical waste incineration in its health sector projects, with no mention of either the dangers involved or the availability of safer alternatives.

To date, MRC has identified 30 World Bank and IFC projects involving medical waste incineration in the following 20 countries: Algeria, Argentina, Brazil, Comoros, Dominican Republic, Egypt, India, Indonesia, Kenya, Lebanon, Malawi, Mexico, Nigeria, Senegal, South Africa, Sri Lanka, Turkey, Vietnam, Western Samoa and Zimbabwe.

Promoting medical waste incineration in Third World countries at the same time that this technology is being phased out in the United States and replaced with safer and more economical alternatives perpetuates a double standard in which Northern citizens are afforded a higher degree of environmental and public health protection than Third World citizens.

It is especially disheartening that the World Bank is encouraging the spread of incinerators at the same time that the United Nations Environment Program is hosting negotiations for an international treaty to phase out the production and use of persistent organic pollutants (POPs). Among the 12 priority POPs identified for action under this new treaty are dioxin and furans - both produced and released by medical waste incinerators. In June 1998, at the initial meeting for this global and legally binding POPs treaty in Montreal, Canada, delegates from 92 countries joined together to begin working towards an end to POPs. The fact that the World Bank is promoting an unnecessary POPs-producing technology, while much of the global community is working for the phase out and elimination of POPs through this treaty demonstrates once again how the Bank's environmental actions are lagging far behind those of the international community.

The Multinationals Resource Center and Health Care Without Harm call on the World Bank to immediately cease funding for medical waste incineration and to adopt a binding policy to  prohibit the unnecessary incineration of medical waste in all future projects.

II. MEDICAL WASTE INCINERATION: THE ISSUES INVOLVED

Most waste coming from a hospital or medical center is not infectious waste and poses no hospital- specific threat to public health and the environment. The paper, plastic, food waste and other materials coming from a hospital is similar to the same waste coming from hotels, offices, or restaurants, since hospitals serve all of these functions. In the United States, about 10 to 15 percent of hospital waste is considered "infectious;" while percentages may vary in less-industrialized countries, it is certain that the vast majority of waste coming from hospitals is not infectious. In fact, according to the Society for Hospital Epidemiology of America, "Household waste contains more microorganisms with pathogenic potential for humans on average than medical waste." Thus, despite many unique characteristics of health care facilities around the world, most medical waste can be managed using the same waste minimization, segregation and recycling techniques used in homes and offices.

According to the Centers for Disease Control in the United States, 2 percent or less of a typical hospital's waste stream -- body parts or pathological waste -- may need to be incinerated or specially decontaminated to protect the public health, yet World Bank projects routinely include plans for the entire medical waste stream to be incinerated. The unnecessary burning of polyvinyl chloride plastic, paper, batteries, discarded equipment and other noninfectious materials leads to emissions of dioxins and mercury as well as furans, arsenic, lead, cadmium and the generation of ash which needs to be treated as a hazardous waste.

As Dr. Paul Connett, of St. Lawrence University in Canton, New York, explains, "The reason for this is simple: while incineration is certainly capable of destroying the bacteria and viruses, it forces on itself the extra task of having to destroy the material on which the pathogens are sitting: the paper, cardboard, plastic, glass and metal. It is in this process that acid gases are generated (from the chlorinated organic plastic present), toxic metals are liberated (from the pigments and additives in the paper and plastic products as well as other miscellaneous items like batteries, discarded thermometers, etc.) and dioxins and furans are formed (from any chlorine present in the waste). None of these formidable chemical problems is inherent to the medical waste ‘problem' itself; instead they all result from the supposed ‘solution.'"

The pollution from medical waste incinerators is significant. While comprehensive studies have not been conducted in other countries, in the United States the Environmental Protection Agency has identified medical waste incinerators as a leading source of both dioxin and mercury pollution in that country's environment and food supply. For this reason, as well as for the economic advantages of non-incineration approaches to waste management, medical waste incineration is becoming an obsolete technology in the United States.

Dioxin

According to the U.S. Environmental Protection Agency, medical waste incineration is among the top sources of dioxin. Dioxin is a common name for a class of 75 chemicals. Dioxin has no commercial use. It is a toxic waste product formed when waste containing chlorine is burned or when products containing chlorine are manufactured. PVC (polyvinyl chloride) plastic is a major source of the chlorine in medical waste. Dioxin is atmospherically transported and enters the food chain long distances from its point of origin. Dietary sources of dioxin, which account for 90 percent of human exposure, are meat, dairy products, eggs and fish. Dioxin builds up in fatty tissues. Because of the high fat content of breast milk, nursing infants are exposed to about 50 times the adult dose and may receive more than 10 percent of their total lifetime exposure during the nursing period, a time when they are most vulnerable to the toxic effects of dioxin.

Dioxin can cause:

A.  Cancer. Dioxin is a proven human carcinogen according to the International Agency for Research on Cancer (IARC). Liver, lung, stomach, soft and connective tissue cancers as well as Non- Hodgkin's lymphoma have all been associated with dioxin.

B.  Immune System Effects. Low exposures to dioxin result in increased susceptibility to bacterial, viral and parasitic diseases.

C. Reproductive and Developmental Effects. In animals, dioxin exposure causes decreased fertility, decreased litter size, and inability to carry pregnancies to term. Maternal exposure results in offspring with lowered testosterone levels, decreased sperm counts, birth defects and learning disabilities. Human studies report lowered testosterone levels in exposed workers and birth defects in children of Vietnam veterans exposed to high dioxin concentrations in Agent Orange. Nursing human infants exposed to high dioxin concentrations in breast milk had significantly lower levels of the thyroid hormone necessary for normal development of the brain.

D. Hormone Disruption: Dioxin behaves like a hormone by way of attaching to a receptor and altering the genetic activity in cells. Since human hormones can exert effects at levels of parts per trillion, small amounts of dioxin could cause a chain reaction in the body.

Mercury

Medical waste incineration is also a primary source of mercury pollution. Mercury is a heavy metal found in the earth's crust. It is used for a variety of industrial purposes and is found in many everyday items, such as batteries and paints. In the medical field, mercury is used in thermometers, blood pressure devices (sphygmomanometers), and dilation and feeding tubes, as well as batteries and fluorescent lamps. Where the use of these items is significant, medical waste may account for 20 percent of the mercury in the solid waste stream.

Mercury cannot be destroyed through incineration. Following release through a smokestack, mercury is deposited back to land or to surface waters where it will essentially remain indefinitely. It exists in both an inorganic form (elemental mercury) and in an organic form called methyl mercury. Elemental mercury can be converted to methyl mercury by microorganisms such as bacteria. Methyl mercury is more biologically available, meaning that it can interact with human cells and damage them.

Mercury pollution exists widely in the environment and concentrates in animals and ultimately in the human body. Mercury pollution threatens a country's food supply, especially fish. According to the US Environmental Protection Agency's 1997 Report to Congress, 39 U.S. states have determined that all or some of their lakes, streams and rivers are too contaminated with mercury to allow people to eat the fish and seafood from those bodies of water.

Mercury causes neurological toxicity. It attacks the body's central nervous system; it can also harm the brain, kidney's and lungs. It can cross the blood-brain barrier as well as the placenta. Methyl mercury from contaminated fish easily crosses the placenta and enters the brain of the developing fetus. The critical effect from prenatal exposure to methyl mercury is psychomotor retardation.

The Solution

The World Bank Project Information Documents (PIDs) summarized in Attachment A imply that incineration is the only solution to medical waste disposal. MRC has not found one PID which reflects an integration of the real solutions -- responsible procurement (eg. avoid PVC plastic and mercury based products), waste reduction, segregation, reuse and alternative treatment technologies -- in any World Bank project.

Waste Reduction

The most important part of waste management is waste minimization. Waste reduction begins with the initial process of procurement of hospital supplies. Purchasing professionals working with vendors can considerably increase the amount of reusable items and decrease the amount and toxicity of waste generated. Minimizing packaging and buying products that are durable rather than disposable, when feasible, all lead to reduced waste disposal. Investing in improving procurement practices easily pays off in both lower procurement costs and decreased waste management requirements.

Waste Segregation

Waste segregation, essential for successful recycling and widely practiced with household waste, is perhaps the most important step in reducing the volume and toxicity of the medical waste  stream. Waste segregation has the added benefit of decreasing risk to workers. If the bulk of waste which is not potentially infectious is mixed with the small percentage which is potentially infectious, the entire waste stream becomes a potential hazard. If waste which is not potentially infectious is kept separate from infectious waste, the paper and cardboard products, glass, some plastics, and metals can be easily reused or recycled in existing markets. Waste segregation is not difficult to implement with adequate investment in education, regulations, monitoring and enforcement. There are many examples of hospitals in the United States, as well as some in less-industrialized countries, which have implemented some level of successful waste segregation programs in order to protect public health and the environment and to reduce waste disposal costs. The best way to design an appropriate waste reduction and segregation system for any hospital is to conduct a waste assessment to become familiar with the waste types and generation patterns in all areas of the hospital. However, none the World Bank Task Managers interviewed by MRC planned to include waste assessments as part of their proposed projects.

Reuse

Hospitals can reduce their waste stream, cut costs and reduce their negative impact on the environment through a conscious procurement preference for reusable products that meet the need of health care workers and their patients. Many hospitals in developing countries have reprocessing facilities to sterilize instruments and materials for reuse. Investments in upgrading and enhancing these facilities to increase the use and safety of use of reusable materials would contribute significantly to addressing the waste problem. After several decades of decline in the United States and Europe, reusables are making a comeback. Many common single-use disposable products have safe, reusable alternatives including sharps containers, gowns, linens, bedpans, urinals, dishware, etc. Responsible systems for waste segregation and, when appropriate, reuse will address many of the problems with the unregulated scavenging and reuse of medical supplies which occurs in many Third World countries.

Alternative Treatment Technologies

Even the hospital with the best waste reduction, segregation and reuse program will still produce some waste that is potentially infectious. Almost none of this waste needs to be incinerated to be rendered harmless and unidentifiable. Various technologies have been developed to sterilize and reduce the volume of medical waste without incineration. In 1997 alone, 1,500 non-incineration medical waste treatment facilities were installed in the United States. Interest in these alternative technologies is also increasing in other countries.

Autoclaves are the most commonly used medical waste treatment alternative in the United States and are growing in popularity in other countries. An autoclave destroys infectious agents though the use of steam heat and pressure. Unlike incineration, however, the materials are not burned, reducing the risk of dioxin production. Frequently wastes are shredded before autoclaving in order to facilitate the process. Autoclaves are less expensive and are easier to maintain and repair than modern incinerators.  Most hospitals are already familiar with autoclaves as they use smaller ones in their laboratories to sterilize equipment.

Another alternative technology is microwaving, which uses radiant energy to heat water that is sprayed into the waste. Once the water reaches its boiling point, it boils the microbes, rendering most of them harmless. Other technologies, including chemical disinfection, rotoclaves, and thermal treatment systems are also available. While none of the alternative technologies are totally risk-free, they can be combined with an effective program of waste reduction and segregation to reduce the environmental impacts and the financial costs of medical waste disposal.

III. WORLD BANK FUNDING OF MEDICAL WASTE INCINERATION

In spite of all the evidence linking medical waste incineration to severe toxic pollution and the easily available information on alternative approaches to medical waste management, the World Bank routinely continues to include medical waste incinerators in its health sector projects.

MRC first learned of World Bank funding for medical waste incineration while interviewing an official of the West Bengal Ministry of Health and Family Welfare in Calcutta, India in April 1996. The official reported that the World Bank had recommended incinerators at hundreds of hospitals throughout the State and that the Bank had not provided any information regarding problems with incinerators or availability of alternatives.

Alarmed that the World Bank is encouraging a discredited and highly polluting technology, MRC began investigating other World Bank group projects which involve medical waste management. In every project for which we could confirm a technology choice, we found that the Bank is including incineration.

The Bank cannot plead ignorance to defend its continued promotion of incineration. A January 1996 report published by the World Bank's South Asia Regional Office, "India's Environment: Taking stock of Plans, Programs, and Priorities," actually recommended against incineration for medical waste. This report instead recommended the very alternatives which HCWH and an increasing number of hospitals around the world advocate:

"Long-term environmental policies, guidelines and statutes should be linked with immediate requirements to segregate and decontaminate medical waste at its source. This linkage should include appropriate technology for sustainable environmental and public health protection, rather than imported high-technology incinerators that are expensive to purchase and difficult to maintain."

Yet, just three months later, the Bank approved a health sector project in the same country - India - which included plans for hundreds of incinerators throughout the country. In Karnataka, hospitals with as few as 50 beds would have had incinerators installed.

Fortunately, public pressure by concerned organizations in India and the United States forced the Task Manager of this project to put incineration on hold while both he and the Indian state governments involved in the project researched the issue further. While incineration has not been ruled out in this project, the World Bank Task Manager, Tawhid Nawaz, reports that all funding for incinerators in this project has been stalled since the public controversy erupted. Subsequent PIDs for Indian health sector projects led by Nawaz are the only PIDs MRC uncovered which acknowledge potential risks of incineration, but still do not rule out selection of this technology.

In spite of the controversy surrounding incineration in the India project, the Bank continues to include incineration in  projects around the world. MRC has identified 30 projects which involve incineration in at least 20 countries. An inventory, compiled from publicly available documents, of World Bank Group projects which include medical waste incineration is included as Attachment A.

IV. MRC'S AND HCWH'S CONCERNS

Concerns about medical waste management in Bank projects

MRC, along with dozens of other HCWH member organizations around the world, is  concerned that the World Bank is promoting a technology in developing countries that is highly polluting, expensive and unnecessary. As the dangers of medical waste incineration and the availability of alternatives has become widely known, incineration is fast becoming obsolete in industrialized countries. In the United States, for example, there were approximately 4,500 medical waste incinerators in the early 1990's; today less than 2,500 remain and the bulk of these are likely to be closed because they can not comply with the latest U.S. Environmental Protection Agency medical waste incinerator regulations.

It is inappropriate and irresponsible for the World Bank to continue including incineration in its health sector and related projects. Such projects perpetuate an environmental double standard in which Northern citizens are afforded a higher degree of environmental safety than those in the global South. This is especially unconscionable when it has been proven that investments in alternative non- burn technologies can be less expensive in purchase price and operation, and investments in staff training on proper segregation and waste management would significantly increase worker safety and public health.

Concerns about Inadequate NGO Consultation in World Bank Decision Making

In addition to our concerns about the environmental and health implications of the Bank's promoting a highly polluting technology, we are also concerned about the low level of education within the Bank and the repeated instances of Bank staff disregarding NGO input on this issue. While each instance may be not be significant alone, the overall pattern is one which leaves us highly skeptical of the Bank's sincerity in addressing medical waste management with an open and consultative process.

MRC and HCWH have written letters of concern to Bank officials; these letters, samples of which are included in the attachments, have gone unanswered for over a year. One letter introduced HCWH, offered further information and asked specific questions about the Bank's plans for medical waste management. Another letter expressed concern over inconsistencies in the environmental categorization of World Bank projects involving medical waste incineration. Of the first six projects MRC identified which included medical waste incineration, one was classified category A, three were category B and two were category C. The letter, which requested clarification on the inconsistencies and which offered to provide additional information on medical waste management options, was never answered.

Also included in the attachments is a letter from Glenn McRae, Vice President of CGH Environmental Strategies, Inc to Richard Ackerman, Manager of Environmental Unit for the World Bank's South Asia Region written to present to Ackerman and his staff the findings of Mr. McRae's assessment of conditions in hospitals in India in November 1997. Mr. McRae undertook this assessment at the request of NGOs and private hospitals in Mumbai, New Delhi and Calcutta and worked with MRC to produce a set of waste management recommendations for state governments and municipal authorities. After MRC requested a meeting with Mr. Ackerman and other Bank staff, McRae was asked to provide additional information and questions on medical waste management issues, which he did in this April 6, 1998 letter. To this date, despite several email and phone follow- up messages, Mr. McRae has received no acknowledgment or response.

An Indian environmental NGO and member of HCWH, Srishti, wrote to World Bank President James Wolfensohn in October 1996. Srishti stated: "There is no reason to add to India's high pollution load, and also to introduce other deadly toxins such as dioxin and furans which India does not even have the capability to test. The Bank should be helping the country to leapfrog into the latest techniques of medical waste disposal in the interest of community health. This becomes even more important since most health care facilities are located in densely populated areas..." This letter, which called for alternatives to incineration, also went unanswered.

MRC has requested the opportunity to organize a HCWH briefing on responsible medical waste management options for Bank staff. Although we have been able to arrange smaller meetings within the Bank, the requested briefing has been repeatedly delayed by Bank staff. In December 1998, MRC requested the opportunity to hold a presentation for Bank staff the following month when a number of HCWH experts were visiting Washington. We waited for an answer for weeks and finally, in January 1999, our offer was turned down. At that time we were told that we could conduct the briefing in the first or second week of March and that the Bank would be in touch with us to confirm a date. As of June 1999, no one  from the Bank has contacted us with the promised date for a briefing.

In a January 6, 1999 email, Gabriela Boyer, an employee of the Water and Urban Development sector of the World Bank,  provided MRC with a number of reasons for the Bank's declining MRC's and HCWH's offer to hold an informational briefing that month. Among the reasons were that the Bank was developing a guidance note on medical waste management and the meeting with HCWH "will serve as the final step in finalizing the  guidance note..." and that the environmental engineer for Urban Development, Carl Bartone, would be out of the office during the week of the proposed HCWH briefing. Ms. Boyer stated that "having it [the briefing] in the next couple of months may bring greater results." In spite of the Bank's stated interest in delaying informational briefings on incineration until the guidance note is finished, just weeks later, on February 10, 1999, the Bank hosted a presentation for Bank staff by an incinerator company, Seghers Better Technology Group.

The invitation to interested Bank staff, distributed by Carl Bartone, specifically stated that the incinerator industry representative would include information about incineration of health care waste. The February 2nd invitation even apologized for the short notice, but Mr. Bartone stated that he had only learned of the incinerator company's visit that afternoon.

The sincerity of the Bank's NGO consultation process is thrown into question when the leading international coalition working on medical waste management was shut out of the process until "the final step in finalizing the guidance note" on an issue about which it is both experienced and deeply concerned. The fact that an incinerator company can contact the Bank offering a  resentation and an invitation is circulated that same afternoon, when MRC and HCWH were denied the opportunity to make a presentation after contacting the Bank one month ahead of the proposed date to allow ample time for planning makes these questions more poignant.

MRC has interviewed over a dozen Task Managers responsible for projects which include medical waste incineration. Across the board, we have been discouraged by the lack of knowledge of even basic information about medical waste management and, even worse, the lack of interest in learning more about this vital public health and environmental issue.

Only two Task Managers MRC interviewed had heard of dioxin. One did not know the sources of this most potent man-made toxin known to science.  The other Task Manager who had heard of dioxin told an MRC representative that he was not concerned because he felt dioxin is a luxury that only people in the West can be concerned with and that the people of Pakistan [where a Bank project proposed incineration] had other things to worry about.

When MRC expressed concern about incinerators in a project in Senegal, that Task Manager responded "Don't worry, all the incinerators will be small and locally made" and refused additional information on the topic. Because small incinerators burn waste in batches, which requires constant heating up and cooling off, thus maximizing the duration of the combustion temperatures in which the greatest level of dioxin is produced, they can actually be more hazardous than larger incinerators. In addition, it is impossible to imagine that "small and locally  made"

Incinerators in Senegal will come close to meeting the environmental standards - which are still incapable of eliminating health risks - of the modern, and extremely expensive, incinerators in use in industrialized countries. In spite of growing public concern about medical waste incineration in Bank projects, the World Bank has failed to provide a list of projects involving medical waste incineration to concerned NGOs. In February 1998, a delegation of Health Care Without Harm representatives met with David Hanrahan in the Bank's Environment Department. The HCWH members requested a list of all projects involving medical waste incinerators and were told that the list was not readily available. On March 6, 1998, HCWH wrote to Hanrahan asking specifically when such a list would be available. The letter explained "Since inappropriate medical waste management has such serious and easily avoidable environmental and public health implications, we are certain that it is in the Bank's own interest to compile such a list. Without such a list, it is impossible to know where the Bank is involved in medical waste management and thus impossible to ensure the Bank's contribution is the most cost-effective and environmentally responsible." Over one year later, the Bank has not provided the requested list.

V. THE WORLD BANK'S HEALTHCARE WASTE MANAGEMENT GUIDANCE NOTES

On May 28, 1999, Tom Novotny, CDC Liaison at the World Bank, and Jennifer Prah-Ruger, Bank Economist, released the World Bank's Healthcare Waste Management Guidance Note for a brief public comment period. Health Care Without Harm is preparing a detailed critique of the Bank's Healthcare Waste Management Guidance Note. When completed, this document will be available at www.noharm.org or directly from Health Care Without Harm or the Multinationals Resource Center.

While MRC and HCWH welcome this long-promised Guidance Note and recognize some positive recommendations within it, we regret that it continues to present incineration as a viable waste management option. The Note does acknowledge concerns with incineration.  Specifically, it states that incinerators emit toxic flue gases, including dioxins and heavy metals. It also warns that "on-site incineration may be neither cost effective nor environmentally sound" and states that such  small-scale rudimentary facilities are not recommended.

However, the Note does not reflect the significant threats of large scale incinerators but instead promotes the concept of  "environmentally sound incineration". The Bank goes as far as stating that "Incineration is not the same as burning. Proper incineration is a highly advanced technology that can adequately treat all types of special health care waste."

In another example, Section 3.2.4 of the Note states "environmentally sound incineration...will necessarily take place off-site. However, a large healthcare facility with adequate technical and financial capacity can consider installing an incinerator and even providing services to other nearby healthcare facilities (at cost.)"

HCWH and MRC also regret that the Bank's authors did not make use of the extensive resources Health Care Without Harm has available on medical waste management. Although the Note describes itself as an attempt "to synthesize the currently available knowledge and information in the field of healthcare waste management," it neither cites nor includes any HCWH resource or contact in the "Information Sources and References" section which includes eleven reports and five organizations from which further information is available.

 VI. RECOMMENDATIONS

The Multinationals Resource Center and Health Care Without Harm recommend that, as long as the World Bank is involved in medical waste related projects, the World Bank must:

I. Assume greater responsibility for decreasing environmental toxicant--principally dioxin and mercury--generation and exposure from medical sources in World Bank projects;

II. Educate Bank staff about dioxin prevention and responsible medical waste management;

III. Require the establishment of procurement policies which phase out and eliminate medical supplies made of PVC plastics or those instruments containing mercury where alternatives are available in all Bank projects;

IV. Require the inclusion of policies leading to segregation and waste reduction efforts for the separation of infectious and hazardous waste from the conventional waste stream with the goal of reducing the amount of medical waste that needs to be specially treated in all Bank projects;

V. Invest in training and education programs in proper waste management and worker safety practices and policies for health care staff at Bank funded project sites.

VI. Substitute alternative non-burn methods of sterilization of infectious waste--i.e. autoclaving, microwaving, and other technologies in World Bank projects.

VII. Integrate NGO consultation into all stages of World Bank projects and discontinue allowing easier access to Bank staff for industry representatives than for concerned NGOs.

VII. NOTES AND REFERENCES

1. US Environmental Protection Agency, "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; Mercury Study Report to Congress, Volume I: Executive Summary, USEPA Office of Air, December 1997.

2. Environmental Working Group, "Greening Hospitals: An Analysis of Pollution Prevention in America's Top Hospitals," Washington, D.C., June 1998.

3. Environmental Working Group, "First, Do No Harm," Washington, D.C., March 1997, based on Rutala,W.A. and Mayhall, C.G, 1992 and personal communications with Hollie Shaner, CGH Environmental Strategies, VT and Laura Brannen, Dartmouth-Hitchcock Medical Center, NH.

4. Shaner, Hollie; McRae, Glenn; and Leach-Bisson, Connie, "An Ounce of Prevention: Waste Reduction Strategies for Health Care Facilities," American Society for Healthcare Environmental Services, 1996.

5.  Rutala, W.A. and Mayhall, C.G. "Society for Hospital Epidemiology of America Position Paper," Infection Control and Epidemiology, 13:38-48. Reprinted in Leach Bisson et al., 1993.

6. Ibid.

7.  "Hospital wastes for which special precautions appear prudent are microbiology laboratory waste, pathology waste, bulk blood or blood products, and share items such as used needles or scalpel blades. In general, these items should either be incinerated or decontaminated prior to disposal in a sanitary landfill." Quoted from "Infectious Waste" factsheet, Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, Updated January 21, 1997.

8.  Dr. Paul Connett, "Medical Waste Incineration: A Mismatch Between Problem and Solution," in The Ecologist Asia, Vol. 5., No. 2., March/April 1997.

9.  US EPA, Estimating Exposure to Dioxin-Like Compounds, Vol. II: Properties, Sources, Occurrence and Background Exposures, USEPA, Office of Research and Development, EPA/600/6-88/005Cb, external review draft, June, 1994.

10. For additional information on the health effects of dioxin, see: Gibbs, Lois and the Citizens Clearinghouse for Hazardous Waste, "Dying from Dioxin: A Citizens' Guide to Reclaiming Our Health and Rebuilding Democracy", South End Press, 1995. (ISBN 0-89608-525-2)

11. World Bank undertakes environmental screening of each proposed project to determine the appropriate extent and type of Environmental Assessment (EA) needed, if any.  Projects are classified as Category A, B, or C. A proposed project is classified as Category A if it is likely to have significant adverse environmental impacts that are sensitive, diverse, or unprecedented. EA for a Category A project examines the project's potential negative and positive environmental impacts, compares them with those of feasible alternatives (including the "without project" situation), and recommends any measures needed to prevent, minimize, mitigate, or compensate  or adverse impacts and improve environmental performance. A proposed project is classified as Category B if its potential adverse environmental impacts on human populations or  environmentally important are less adverse than those of Category A projects. These impacts are site-specific; few if any of them are irreversible; and in most cases mitigatory measures can be designed more readily than for Category A projects. The scope of EA for a Category B project may vary from project to project, but it is narrower than that of Category A EA. Like Category A EA, it examines the project's potential negative and positive environmental impacts and recommends any measures needed to prevent, minimize, mitigate, or compensate for adverse impacts and improve environmental performance. A proposed project is classified as Category C if it is likely to have minimal or no adverse environmental impacts.  Beyond  screening, no further EA action is required for a Category C project.