HEALTH CARE WITHOUT HARM
The Campaign for Environmentally Responsible Health Care
c/o CCHW, P.O. Box 6806, Falls Church, VA 22040

August 1, 1997

James Wolfensohn, President
The World Bank
1818 H Street, NW
Washington, DC 20433

RE: Medical Waste Management in Developing Countries

Dear Mr. Wolfensohn:

I am writing to you on behalf of Health Care Without Harm: The Campaign for Environmentally Responsible Health Care, a national coalition effort of physicians, nurses, patients, public health advocates, scientists, environmental justice advocates, religious institutions, and labor representatives striving for greater environmental responsibility in the health care industry. Our 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 safety or care.  In particular, we are concerned about dioxin and mercury emissions resulting from medical waste incineration.

Dioxins and related chlorinated organic compounds are extremely potent toxic substances that produce a remarkable variety of adverse effects in humans and animals at extremely low doses.  These compounds are persistent in the environment and accumulate in magnified concentrations as they move up the food chain, concentrating in fat, notably in breast milk. They are distributed globally and are present in every member of the human population.  Dioxin is known to be  carcinogenic.  Interacting directly with DNA through a receptor-based mechanism, dioxin also acts as an endocrine disruptor with adverse effects on reproduction, development, and the immune system.  Developing organisms are  particularly susceptible in all species studied, and extraordinarily small fetal exposures to dioxin frequently have permanent, life-long effects.  Mercury is also bioaccumulative and is toxic to the kidneys and nervous system.  Readily converted to its organic form in the environment, mercury interferes with normal brain development. In the United States, current environmental levels of mercury are sufficient to prompt 27 states to advise pregnant women and women of reproductive age not to eat fish caught in local waters.

Medical waste incineration contributes the second largest source of dioxin and mercury pollution to the American public. Given that medical professionals in the U.S. take an oath to "First, Do No Harm," it is ironic and deeply concerning that the health profession and their institutions are such significant contributors to the public health threat of environmental pollution, putting present and future generations at risk. It is equally ironic and concerning that the World Bank, an institution committed to sustainable development, is encouraging the spread of this toxic and unnecessary technology to developing countries. As a step towards the overall goal of more environmentally responsible health care, our campaign is focusing on the concrete issue of medical waste incineration as a serious environmental public health threat. Chlorinated plastics, principally PVC (Polyvinyl Chloride), are a major source of chlorine which is necessary for dioxin generation in
incinerators, and at present most hospital waste contains more than twice the amount of chlorinated plastic as does regular municipal waste.  Mercury in the medical waste stream is principally derived from thermometers, blood pressure gauges, batteries, and fluorescent lamps.  Much medical waste in the U.S. and elsewhere is disposed of in incinerators which lack
anti-pollution controls.  However, even state-of-the-art incinerators which produce cleaner air, in turn generate ash that is more toxic, with higher concentrations of dioxin and mercury.  The ash must still be disposed of, typically in landfills.

In the United States and other industrialized countries, due to growing concern about the health and environmental impacts of medical waste incineration, progress is being made towards replacing them with safer and more economical alternatives. The American Public Health Association passed a resolution in November of 1996 calling for "Prevention of Dioxin
Generation from PVC Plastic Use by Health Care Facilities."  The American Nurses Association adopted a similar resolution in June of 1997.  There are a number of pioneering hospitals, such as Dartmouth- Hitchcock in New Hampshire, Fletcher Allen Health Care in Vermont, and Beth Israel Medical Center in New York City, which are addressing the issue of medical waste disposal in an environmentally responsible manner by mandating more comprehensive waste segregation and recycling efforts and finding substitutes for PVC containing plastics. 

Yet, in spite of the mounting scientific evidence linking incineration to dioxin and mercury emissions and the growing public opposition to medical waste incineration in both the North and South, the World Bank continues to recommend and fund medical waste incinerators in health and environmental projects without full disclose of the risks involved or alternatives
available.  In a sampling of four World Bank Task Managers responsible for projects involving medical waste management, all Task Managers recommended incineration. Only one had heard of dioxin and when questioned about the
wisdom of increasing dioxin output in Pakistan through incinerating medical waste, he replied "Frankly, Pakistan has greater concerns than dioxin. That is something we only have the luxury to worry about here." None of the Task Managers questioned was aware of the dangers of incineration or had considered safer, more economical alternatives. This is  extremely worrisome coming from an institution which claims to be "Greening the Entire Portfolio" through ensuring "that *all* Bank activities take environmental concerns into account." (Emphasis in original, "Environment Matters," Fall
1996, published by the World Bank) The Health Care Without Harm Campaign encourages the World Bank to:

I. assume greater responsibility for decreasing environmental toxicant--principally dioxin and mercury--generation and exposure from medical sources;

II. educate your staff and borrowing government colleagues about dioxin prevention and responsible medical waste management;

III. encourage the phase out and elimination of medical supplies made of PVC plastics or containing mercury where alternatives are available in all Bank projects;

IV. encourage recycling efforts leading to 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;

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

We look forward to a response from the World Bank detailing progress on the above steps towards meeting the interrelated goals of environmental and public health protection.

To assist health professionals in the United States in taking pro-active steps towards more environmentally responsible health care, Health Care Without Harm has developed a pollution prevention program which offers concrete, step-by-step recommendations addressing the issues of how best to handle health care product purchasing and waste disposal in a manner that is environmentally responsible without compromising patient safety or care.  We encourage the World Bank to promote similar projects in the countries in which you operate. Information on how to implement waste minimization programs in health care  facilities is available in two publications of the American Hospital Association--An Ounce of Prevention: Waste Reduction Strategies for Healthcare Facilities and Guidebook for Hospital Waste Minimization and
Program Planning. Additional information can be obtained from the Health Care Without Harm Campaign.

Sincerely,

Charlotte Brody, R.N.
Coordinator
Health Care Without Harm