As an emergency room physician, Caesar Djavaherian is naturally concerned with the health of his patients. But that mission, he said, is being pursued at the expense of the environment.
Consider the amount of waste that his department generates: "So currently every patient is examined using gloves," he said. "And then if they're vomiting, we have little plastic containers for vomiting, which everyone gets. Every patient is put into a bed with new sheets on it — it's all rubbed down with a disposable cloth, like a Clorox wipe. ... When we start an IV, insert a catheter, there's plastic. We use gowns — thick paper gowns — that are thrown away. All the packaging is plastic, certainly not recyclable. The medications come packaged in plastic. If you're using an IV, the liquid is also in a thicker plastic — two layers of plastic. ... The vast majority of the garbage we generate is paper and plastic."
Add all this up, multiply it by every patient seen every day, and it's a bit mind-boggling. "The amount of waste is unreal — it would turn your stomach," said Djavaherian, who works at North Bay Hospital in Fairfield and who's also the chief medical officer of ER Direct, an East Bay company that makes house calls, which the Express featured in March. "Every outpatient, every operating room, every one produces, in some cases, a small roomful of waste. ... It all goes into the garbage can. The garbage gets emptied six, seven times a day. I just wish more people were aware of this."
What surprises Djavaherian, who considers himself somewhat of an environmentalist, is that none of the ten hospitals he has worked for in his career have recycled this waste, which means the bulk of it ends up in the landfill. The question is, why?
While various federal and state laws and regulations prevent certain waste and patient records from being thrown into the recycling bin, Djavaherian believes there is plenty of material that could theroretically be recycled, reused, or swapped out for nondisposable items. And the effect could be enormous. Although reliable statistics on hospital waste in the United States are hard to come by, Practice Greenhealth — a nonprofit organization based in Reston, Virginia, that promotes sustainability in the health care industry — estimates that US hospitals produce more than 5.9 million tons of waste annually (or 33 pounds per staffed bed per day). But that number is based on data from its members, which have already reduced their waste streams. In other words, the actual amount of waste is likely much higher.
What is clear is that most of the plastic generated by the health care industry is not recycled. This is especially problematic given that the use of plastic has grown dramatically over the years, as medical suppliers have increasingly moved toward disposable items and packaging them in kits, in which one item may be used for a procedure and the rest are thrown away. Although some hospitals, like Kaiser, have begun setting aside these unused items and shipping them overseas, a recent article by the industry news site PlasticsToday.com noted that "American hospitals generate more than 400,000 tons of plastic and other packaging waste every year, and the percentage recycled is close to zero." Despite efforts to reduce medical waste in this country, overall the opposite has been true — the amount of waste generated has only increased. And so have the costs of disposing of it.
Many hospitals have begun to look at ways to reduce their energy consumption and waste output — mainly because of the huge costs associated with these factors — such as composting food, reducing water use, and recycling computers. But, in general, hospitals still lag behind the rest of society in terms of their recycling.
So why don't hospitals recycle more, and why isn't anyone holding them accountable? There are multiple possible explanations. Recycling isn't as easy as just throwing any plastic in a recycling bin: not all of the plastic used is recyclable, according to the Healthcare Plastics Recycling Council, and oftentimes items contain multiple kinds of material, which complicates their recyclability. There's also the issue of perceived costs — after all, hospitals would need to buy extra containers, hire more workers to sort the trash, and train its staff. And a wrong item thrown in the wrong bin could lead to fines in the tens of thousands of dollars.
But ultimately, experts agree, diverting recyclables from the waste stream would save hospitals money. As things stand now, rising medical waste-disposal costs aren't just burdening hospitals, they're burdening patients, too.
Hospitals are essentially hotels, so they produce a fair amount of trash. But regulations enacted to reduce infectious disease and environmental pollution appear to have led to an increase in waste.
Until relatively recently, the way we disposed of and treated our medical waste was essentially a "free-for-all." That's according to Mike Gastellum, managing partner and one of the co-owners of Hayward-based Barnett Medical Services, a company that transports and disposes of medical waste and also sells medical supplies to some 1,800 customers.
Back in the day, medical waste on the East Coast was essentially taken out onto barges and dumped into the middle of the Atlantic Ocean. When syringes and other garbage began washing up on beaches, Congress enacted the Medical Waste Tracking Act of 1988, which helped set the standards for government regulation of medical waste. The act expired in 1991, after which time states were given regulatory authority.
Before we go further, it's important to understand the various distinctions in medical waste. For the purposes of this article, "medical waste" and "hospital waste" refer to any waste that a hospital produces. The majority of hospital waste is noninfectious solid waste: It gets picked up by municipal garbage trucks and heads to the landfill. Then there's Regulated Medical Waste, which in California is governed by the Medical Waste Management Act. Regulated Medical Waste, or biohazardous waste, is further broken down into two categories: the first includes sharps and anything thrown into the "red bag" (laboratory waste, human surgery specimens or tissues, and other bodily fluids) and is usually sterilized before heading to the dump; and incineratables, which include pharmaceuticals, trace chemo, and pathological waste, and, as their name suggests, must be incinerated. Hospitals and clinics usually pay companies to pick up their Regulated Medical Waste, which is much more expensive to treat than solid waste.
Over the years, hospitals and medical supply companies have increasingly turned to disposable plastic items because of concerns over infectious disease. But using all that plastic isn't always necessary, and disposable instruments are not necessarily better or more protective against spreading disease than nondisposable ones are (as long as they are properly sterilized). "Twenty years ago, everything was reusable," said Beth Eckl, the director of the environmental purchasing program for Practice Greenhealth. "Now everything in the OR [operating room] is disposable. Because of infection-control issues, serious ones, we've gone to more disposables. That's an area that can be changed. Many of our hospitals have had success with reusables."
Not only have medical supplies become more disposable, but they're also increasingly packaged in kits. This means that when a kit is opened but only one item is used, the rest is thrown away. In fact, according to the industry news site SurgicalProductsMag.com, 85 percent of the plastic in a hospital's waste stream has never come into contact with a patient.
Djavaherian cites the common tracheotomy procedure — in which an incision is made into a patient's neck to allow him or her to breathe — as an example. "We used to have an ear/nose/throat kit," he said. "It would have equipment to dilate the hole and make it bigger. All that equipment was stainless steel and would be sterilized and reused. Now we have a [disposable] kit. Everything except a small four- to five-inch piece of plastic is thrown away." He estimates the size of the kit to be ten-by-eight-by-four inches. "We just throw all of that in the garbage."
As medical supplies have become more disposable and packaged together — creating more waste — the cost of disposing of and treating medical waste has also increased. One reason for the increase is the fact that commercial medical waste incinerators no longer operate in California.
In 1990, the California Air Resources Board tightened its dioxin standards for medical waste incinerators (which emitted both dioxins and mercury). Meanwhile, there was increasing pressure from the public to close these polluting facilities, even though they were meeting the Air Resourecs Board's standards, according to Jack McGurk, former chief of the Environmental Management Branch of the California Department of Health Services. In December 2001, the last medical waste incinerator in California — Integrated Environmental Systems, which was based in Oakland — closed.
Environmentalists and many community members hailed the closure as a victory, but this move ultimately led to increased medical waste costs because now all incineratables are trucked out of state. "So now we ship all our expired pharmaceuticals to either South Texas, North Dakota, or Utah," said Gastellum. "Now think about all the tens of thousands of gallons of diesel fuel that is burned up in all the trucks taking the stuff there and all the way back. So where's the tradeoff? Which one is worse? All that diesel fuel being burned up or the incinerator?
"So it's kind of a perplexing situation going on," he continued. "And think of also the incredible expense that's being added ... [it] eventually gets pushed onto the customers. So when they talk about the cost — everything going up — it's in everything: It's in not only the medicine cost but it's also in stuff like this, in disposing."
At the time of Integrated Environmental Systems' closure, medical waste treatment and hauling cost between 16 and 20 cents per pound, according to a 2002 report by McGurk. These days, disposing of regulated medical waste can cost anywhere from 21 to 35 cents a pound, said Gastellum (by comparison, solid waste costs between 3 and 9 cents a pound).
Another factor in rising medical waste disposal costs is the fact that hospitals are more wasteful. A study by Johns Hopkins researchers last year found that some 90 percent of operating room waste that ends up in red bags does not actually meet those standards. This could be due to the fact that hospital staff err on the side of caution so as to avoid contamination. But this means hospitals end up paying more to dispose of their medical waste: Hazardous and regulated medical waste — which is much more expensive to dispose of than noninfectious waste — accounts for 86 percent of medical waste costs. It's safe to say these costs are passed on to patients. According to the American Hospital Association, the health care industry spends $10 billion annually to dispose its waste, but could reduce that amount by $4 to $7 billion, as the vast majority (85 percent) of a hospital's overall waste is municipal solid waste, 60 percent of which could be recycled or composted.
What this means is that it's often much more costly to dispose of an item than to buy a new one. "The sad part of this industry and some of the scary stories that are involved in it is that some of the waste costs ten times more to get rid of than when the customer — the customer being like a doctor or a dentist — bought it off the shelf," said Gastellum. "They paid $25 or $40 bucks for a gallon of it, then it costs them $90 to get rid of it. So it's staggering — the diference in prices. ... Some of the stuff costs so much to treat it — that's what drives the disposal price."
Pharmaceuticals are one of the medical waste industry's biggest concerns — not only because of the environmental pollution related to their incineration, but also because many people still dispose of their unused drugs improperly by throwing them in the garbage or flushing them down the toilet, which pollutes our environment and our water supply. Alameda County had been paying for drug disposal sites, but most recently passed a landmark ordinance requiring pharmaceutical companies to shoulder the burden — the first of its kind in the nation. But at this point, it's unclear whether the county can enforce the ordinance, or whether the pharmaceutical industry will sue to stop it.
In light of the huge costs associated with disposing of medical waste, the industry has begun looking at ways to reduce, reuse, and recycle in recent years. Most of this has occurred in the front-end of hospital operations, since hospitals are also huge users of resources. "Hospitals are ... the fourth-largest user of energy, and one of the largest users of water in the community," said Practice Greenhealth's Eckl.
For many hospitals, energy and water consumption are sort of the low-hanging fruit when it comes to waste reduction. Locally, Washington Hospital in Fremont, a member of Practice Greenhealth, has decreased its solid waste from 65 percent of its total waste to 62 percent in the past two years, according to spokeswoman Gisela Hernandez. It's also increased its reduce-reuse-recycle rates from 27 to 31 percent in the same time period. The hospital composts its food waste, recycles alumnium cans, accepts unused medication from the community, and has decreased its energy and water consumption.
Recycling on the patient-care side of hospital operations may be more challenging, but even the slightest reduction in waste can add up to huge savings. For example, Eckl said that Kimberly-Clark Corporation just launched a program to recycle its blue wrap — the plastic that covers all sterilized surgical instruments and is pulled off before a patient even enters the room. According to the CalRecycle Hospital Waste Reduction and Recycling Team, the health care industry estimates that nearly 20 percent of the waste stream is from surgical services, a large percentage of which is clean blue wrap.
Another example of recent improvement: Fluid-suction containers have traditionally made up 40 percent of the waste in the ER, said Eckl. Typically, they're treated with chemicals and then thrown away. "Now we have resuable cannisters," she said. Similarly, containers that hold used sharps have traditionally been thrown away. But now there are reusable sharps containers, said Gastellum.
Hospitals and medical suppliers are increasingly taking initiatives to reduce the amount of plastic they use. But anecdotal evidence suggests these efforts are not yet nearly as widespread as they should be. Erin Ford, who has been a nurse for fifteen years and is currently an RN in the post-anesthesia care unit at California Pacific Medical Center in San Francisco, said the majority of the equipment and supplies — except for hazardous waste and sharps, which must be specially disposed of according to law — goes into the trash can. "Most everything goes into regular trash," she said, citing empty IV bags, IV tubing, oxygen face masks, EKG leads, soiled bandages and tissues, plus Bair Paws — huge plastic gowns that patients wear pre-operatively — as examples.
And yet, "anything plastic could probably be put into a [recycling] bin," she said, "everything from nasal cannulas to open saline bottles to humidified oxygen bottles — even the IV bags that are empty — we throw them in the trash. There's nothing on them." What's more, anything that's expired — even if it's unused — must also be thrown away, she said. "We go through all the supply rooms and if anything is outdated we throw it away," she said. Other nurses who work or have worked in other Bay Area hospitals and private doctor's offices interviewed for this story also said recycling didn't exist where they worked and that everything is thrown away.
For hospital staff, throwing everything away isn't mandatory, but it appears to be the easier option. Take scalpels, for example, which used to be predominantly stainless steel and sterilized before each use but are now disposable — they've got plastic handles and a tiny stainless steel blade at the end. Anna, a nurse who works at a private surgery clinic in San Francisco and only wanted to go by her first name, said she believes disposable scalpels are more popular because they're cheaper, but also because of the lessened risk associated with simply being able to throw the item away after using it. "It's easier to buy cheaper disposable scalpels — cleaning and sterilizing is more of a risk," she said. "That's a risk for someone to get poked."
There's also logistical hurdles to recycling. Ford said one nurse at her hospital wanted to recycle saline bottles, but the effort was scrapped. "There's not a team hired to take away the recycling," said Ford. "Our housekeeping already have their hands full — they're not ready to take on that task." One nurse, who did not want to be identified for fear of repercussions, said a local private doctor's office she used to work at did not even recycle bottles and cans, and when she tried to institute it — even volunteering to take the bottles and cans home to recycle herself — no one on staff participated and the idea was eventually dropped. "It's just not part of the culture," she said, referring to the non-recycling nature of her peers.
Ultimately, it seems an entire shift in hospital culture is what's needed. "I think they more instill in you about cross-contamination and infectious disease than the recycling," said Ford. "That's not really mentioned at all in orientations or upkeep. We have to take mandatory tests online all the time to keep up with OSHA standards, but it's never really based on recycling, it's based on safety concerns of the patient. We need the resources and money, then you can train the staff."
Indeed, money may be the biggest issue of all. Sorting recyclables means adding another job to the work of nurses and doctors, which may represent too much to a hospital's bottom line, said McGurk, who currently runs his own health-care consulting business, Systems Improvement Initiators Inc. "The hospital's thinking, 'Wait a minute, you're a highly-paid individual. Do we want to take the time to do that?'"
Following the East Coast medical waste washup in the late Eighties, the American Hospital Association and the US Environmental Protection Agency signed an agreement to reduce our country's medical waste — the efforts of which eventually became Practice Greenhealth. Among the Memorandum of Understanding's goals was to reduce overall medical waste by 33 percent in 2005 and 50 percent by 2010 — ambitious targets, to be sure. Though numbers of how much waste that actually represented were not mentioned, it's clear that those goals not only haven't been reached, but the trend has gone the opposite way: medical waste output in the United States has only increased.
In 1987, the EPA reported the per-bed per-day hospital waste generation to be 13 pounds. Some estimates put the number closer to 23 pounds per day per bed. Regardless, that's much lower than current numbers. Today, Practice Greenhealth estimates that amount to be 33 pounds per day per bed — and that's only including hospitals that have already reduced their waste.
Until more hospitals decide that the cost of not recycling is greater than the cost to do so, our country's medical waste will continue to pile up in our landfills — or wash up on our beaches (medical waste was recently found on a beach in New Jersey).
"The bigger issue is why don't we have a bigger incentive in recycling all this stuff," said Caesar Djavaherian. "I don't think I have a great solution other than avoiding hospitals."