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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.