MEDICAL WASTE

A FEASIBILITY STUDY FOR SETTING UP A

“ MEDICAL WASTE ” INCINERATOR IN SURINAME

BY

GRACIELLA P. WONGSOREDJO SURINAME

“This paper was submitted in partial fulfillment of the requirements for the Master of Business Administration (MBA) degree at the Maastricht School of Management (MSM), Maastricht, The Netherlands, November 2006.”

TABLE OF CONTENTS

DEDICATION ... v

ACKNOWLEDGEMENTS... vi

LIST OF FIGURES... vii

LIST OF TABLES... vii

ABBREVIATIONS ...viii

SUMMARY ... ix

CHAPTER 1 INTRODUCTION ... 1

1.1 General overview and motivation for study...1

1.2 Research problem...3

1.3 Research objective ...3

1.4 Research questions...3

1.5 Methodology ...4

1.6 Assumption and limitations ...4

1.7 Chapter overview ...5

CHAPTER 2 LITERATURE REVIEWS ... 6

2.1 Definition of medical waste ...6

2.2 Resources of medical waste ...7

2.3 Medical waste management ...8

2.3.1 Minimization of Medical Waste ... 9

2.4 Medical Waste Management Plan...11

2.4.1 Treatment and disposal of medical waste ... 11

2.5 Incineration as means to fight waste problems ...12

2.5.1 Treatment of medical waste in the USA ... 13

2.5.2 Treatment of medical waste in the developing countries... 14

2.6 Summary ...17

CHAPTER 3 SITUATIONAL FACTORS IN SURINAME ... 18

3.1 Waste management awareness...18

3.1.1 Public sector... 20

3.1.2 Public Landfill... 20

3.1.3 Barrel incineration... 22

3.1.4 Non-state actors... 23

3.1.5 Business community ... 23

3.2 Legal and judiciary system ...23

3.2.1 Environmental Impact Assessment... 25

3.3 Possibility for incineration of medical waste...26

3.3.1 Aspects of setting up an incinerator for medical waste ... 27

3.3.2 Strategy ... 28

3.3.3 The effectiveness of waste incinerator... 30

3.4 Summary ...35

CHAPTER 4 ANALYSIS AND FINDINGS COMPARATIVE STUDY ... 37

4.1 Selected Models ...38

4.2 Analyses of the interviews and questionnaires ...40

4.2.1 Hospitals ... 41

4.2.3 In-home medical care... 46

4.3 Medical waste management ...46

4.3.1 Medical waste management plan ... 47

4.3.3 Handling of medical waste... 47

4.3.4 Vaccination and training ... 47

4.3.5 Conclusion ... 48

4.4 General aspects ...48

4.4.1 Approval Framework Law ... 48

4.4.2 Medical waste regulations... 49

4.4.3 Scope of waste treatment ... 49

4.5 Public Incinerator...49

4.5.1 On-site incinerators ... 50

4.5.2 Other options... 50

4.6 Recommendations for setting up the incinerator project ...51

4.6.1 Cost of incinerator... 52

4.7 Summary ...54

CHAPTER 5 IMPLICATIONS AND RECOMMENDATIONS... 56

5.1 Managerial implications and recommendations ...56

5.1.1 Waste Management in Suriname ... 56

5.2 Hospitals and medical laboratories ...57

5.3 Other medical institutional...58

5.4 National implications and recommendations...58

5.5 Legislation and implementation...59

5.6 Control and sanctions...59

CHAPTER 6 CONCLUSION... 61

6.1 General conclusion...61

6.2 Recommendation for further study ...62

REFERENCES ... i

APPENDICES... iii

APPENDIX 1 MEDICAL WASTE TREATMENT METHODS... iii

APPENDIX 2 DESTRUCTION METHODS ... v

APPENDIX 3 INCINERATION TYPES ... vi

APPENDIX 4 EMISSIONS FROM MEDICAL WASTE INCINERATORS ...viii

APPENDIX 5 POPULATIONS POTENTIALLY INVOLVED WITH MEDICAL WASTE ... ix

APPENDIX 6 GENERATORS OF WASTE INCINERATORS... x

APPENDIX 7 THE VOLUME OF MEDICAL WASTE IN THE USA ... xi

APPENDIX 8 MEDICAL WASTE GENERATORS IN SURINAME... xii

APPENDIX 9 DISTRIBUTION OF HOSPITALS SIZES ...xiii

APPENDIX 10 ENVIRONMENT PRIORITIES ... xiv

APPENDIX 11 BARREL INCINERATOR ... xv

APPENDIX 12 CROP PROTECTION DESIGN ... xvi

APPENDIX 13 QUESTIONNAIRE (ENGLISH)... xvii

APPENDIX 16 QUESTIONAIRE (DUTCH TRANSLATION) ... xxi

APPENDIX 17 LIST OF INTERVIEWEES... xxvi

DEDICATION

This thesis is dedicated to my mother, Lina W. Wongsoredo-Sastrowiredjo†, and to my father, Katimin Wongsoredjo, for being loving parents. They always encouraged me to be independent, to continuously learn and achieve, but foremost to enjoy life. I am outmost grateful to them.

I also dedicated this research to my fiancé, Ruberto, in thanks for his friendship, enduring love, motivation and support. This thesis would not have been possible, without his present.

ACKNOWLEDGEMENTS

First of all, I would like to state my truly appreciation and great acknowledge my supervisor, Dr. David Dingli, who not only went through the details of this study, but foremost proved great involvement and contribution in my thesis subject. His practical and academic points of view were of great input during the distinctive journey of my thesis.

Secondly, I am very thankful to the FHR School of Management and its professional staffing for making the MSM MBA Outreach Program a success. I would especially like to express my gratefulness to Mr. Hans Lim Po and Mrs. Ollye Chin A Sen for their participation, encouragements and the very warm care.

I genuinely acknowledge my employer, Dr. Jim Rasam, the CEO of N.V. INTERMED, who not only highly valued this MBA program and submitted the financial resources, but also granted me necessary time and supported me all the time.

I also acknowledge the personnel of industry, for the responses on the questionnaires, and permitting me to interview them and reproduce their information.

I had many excellent courses during this MBA program from which I learned very much. I also would like to express my thanks to the lecturers of these courses for their dedication and time. I greatly acknowledge to Dr. Arthur Sybrandy, for his critical remarks for helping defining the scope of this research.

Last but not least my MBA collogues. Their group participations and support were and will be precious to me. As a very special note, I would like to thank my dearest partner, my dear family and friends for their encouragement and support all the time.

Finally, I do owe a debt of thanks to everyone, who supports me over the last two very intensive and knowledgeable years.

LIST OF FIGURES

Figure 1: Waste management prevention hierarchy ... 10

Figure 2: Data gathering scheme for the Medical Waste Treatment Study ... 37

LIST OF TABLES

Table 2: Quantity of waste in kg per bed per day per hospital ... 15

Table 3: Quantity of waste in kg per bed per day per country... 15

Table 4: Percentage of incinerators functioning in Latin America countries ... 16

Table 5: The investment costs of different types of incinerators... 32

Table 6: Cost of construction and operation of a health care waste incineration plant (1)... 33

Table 7:Cost of construction and operation of a health care waste incineration plant (2)... 34

Table 8: Hospitals’ size (by number of beds), average occupancy rates, and number of inpatients and outpatients ... 41

Table 9: Medical wastes produced per medical institution... 42

Table 10: Total volume of wastes incinerated by Waspar, 2005 (*AZP not included) ... 43

Table 11: Medical wastes produced in Suriname estimates from US and the Netherlands... 43

Table 12: Amount of patient and medical waste per year from medical laboratories ... 46

Table 13: Estimated investment cost incinerator project ... 53

Table 14: Investments earnings... 53

ABBREVIATIONS

ATM Ministry of Labor Technological Development and Environment AZP Academic Hospital Paramaribo

BOG Bureau for Public Health CI Conservation International DKZ Diakonessen Ziekenhuis

EIA Environmental Impact Assessment EPA Environmental Protection Agency

EU European Union

FSC Forest Steward Council GEF Global Environment Facility HC Health Control

HIV Human Immunodeficiency Virus IDB Inter Development Bank

LH s Lands Hospital

ML My Lab

MOP Plan and Strategy for Sustainable Development of Suriname MWTA Medical Waste Tracking Act

NGO Non Governmental Organization

NIMOS National Institute for environmental development in Suriname OSHA Occupational Safety and Health Administration

OW Ministry of Public Works

PAHO Pan American Health Organization

RCRA Resource Conservation and Recovery Act Suralco Surinam Aluminum Company Limited SZN Streek Ziekenhuis Nickerie

USEPA United States Environmental Protection Agency WHO World Health Organization

WWF World Wildlife Fund MZ Primary Healthcare

SUMMARY

The shift to disposable products for the health-care sector has significantly increased the quantity of medical waste in Suriname. The total amount of municipal waste in Suriname has grown to 83.000 ton in 2005, of which 181 to 264 ton represents medical waste generated by approximately 238 regulated generators. The hospitals and medical laboratories are producing 84% of the total annual medical waste.

Hospitals and laboratories in Suriname do not have the possibility to manage their medical waste in an environmentally responsible manner and well-controlled way. Unsafe disposal of medical waste can cause public health risks.

In order to analyze the above-mentioned problem statement the following general research questions, need to be answered: “What are the criteria to set up an incinerator for medical waste?, How does the current legislation and infrastructure perform with regard to these criteria?, Which environmental, social and other issues should be taken into considerations?, What possibilities does the health-care sector have to manage medical waste?, Does the health-care sector have a financial surplus for managing their medical waste on an environmentally safe way? ”.

Based on a comparative study of at least two countries, the situational factors in Suriname, different types of medical waste treatment and analyses of the results of questionnaires and interviews, it is recommended that setting up a new incinerator, supplying the potential medical waste generators.

Managing this new incinerator should be initiated by the private sector, in order to maintain a viable and on-going concern.

This study proves that the medical waste generators in Suriname do not have alternatives to dispose their medical waste in a proper way. The need for adequate options is required. Setting up a private owned waste incinerator project is urgent necessary, to ensures efficiency and effectiveness.

Approval of Framework Law and initiating a National Medical Waste Management Plan are very essential to accomplish this project.

Key words: Medical Waste Management Plan, Framework Law, Incineration, Waste Treatment, Environmental Impact Assessment.

CHAPTER 1 INTRODUCTION

1.1 General overview and motivation for study

Worldwide, the health-care sector is a constantly growing sector. There are more and more diseases that cannot be eliminated, such as Human Immunodeficiency Virus (HIV) and cancer. Medical experts are constantly experimenting to get a better and higher quality of medications and methods to eliminate or minimize the impact of these diseases. To medicate and heal diseases effectively, these experts are continuously trying to detect diseases in earlier stages. Nowadays, everyone is made more aware to have more frequent medical check-ups to prevent these deadly diseases. This awareness saves lives and is less costly for the health-care sector in the long run.

Nowadays, the shift to disposable products for health care and the implementation of universal precautions have significantly increased the quantity of medical waste. As this sector with its new developments is still growing, it is very important to manage medical waste in an environmentally friendly and safe manner.

However, we do know that the environmental and waste issue is an intractable public policy problem. Both the quantitative and qualitative aspects of the waste issue urged governments to initially respond and, subsequently, deal with these problems in a more integral way. However, there is only environmental related legislation in Suriname set up by the national institution, National Institute for environmental development in Suriname (NIMOS). Therefore, other international institutional actors are involved, such as institutions like Pan American Health Organization (PAHO), World Health Organization (WHO) and Inter Development Bank (IDB).

Waste problems are fundamentally a public health and safety issue. It is generally known that improper treatment and disposal of waste leads to serious threats to human life (Markham 1994). Waste consists of remaining products of production, services, consumption and processing activities, and all other substances people want to dispose of. Often, part of the waste can be re-used or recycled.

Gourlay (1992) stated, “Waste is more easily recognized than defined”. Waste could be all kinds of emissions, effluents, remains, leftovers, or left-behinds, and what is eventually called waste will depend on the actual context.

Nowadays, the scale of medical waste sources and the corresponding effects have reached a degree that also affects the condition of the environment as a whole. On the one hand, population

growth, economic growth and a rise of living lead to an increase in the total volume of waste, which induces a quantity-problem. On the other hand, economic and technological innovations produce all kinds of new substances that need special treatment, both during use and during disposal. The resulting complex composition of various waste streams makes careful disposal continually complicated. This forms a quality problem.

Medical waste adversely affects the environment and contributes to the overall environmental problem of solid waste disposal. Such waste can be effectively treated by chemical, physical, or biological means and disposed of in a sanitary landfill or by incineration (WHO, 1992). What is unpredictable about environmental and waste problems is that cause-effect chains are often indirect and uncertain. Besides, waste problems may vary dependent on the speed of diffusion and to the preceding time lag.

The Surinamese government, in particular the Ministry of Health, sets the rules for the total health-care sector. These rules and standards, specifically the tariffs for hospitals and medical laboratories, should be implemented by this sector. Private and public medical insurance companies are also obliged to use these rules. The hospitals and laboratories have to deal with these tariffs for servicing their patients, which is far beyond their cost price.

Knowing this financial shortage, it is very useful to research whether the hospitals have a budget surplus for setting up and managing an incinerator or whether to out-source it in order to manage their medical waste in a proper way. Outsourcing this activity can lead to more efficiency and effectiveness, so that these hospitals can focus better on their core business, namely medicating patients in the broader sense.

Financial, economic and environmental aspects will be analyzed for this target group -hospitals and laboratories- to find out whether it is feasible to set up an incinerator for particularly medical waste treatment in Suriname. The total potential market of the target group will be defined properly- in order to know the specific measurements of the incinerator-needed to meet the demand.

This research is very relevant for the Surinamese environment. Particularly the health-care sector will benefit from this research and the awareness of the whole community will be raised to become environmentally conscious. A long-term, sustainable, safe and environmentally friendly proposal will be given, to prevent and to protect the Surinamese population from a polluted community, which can be imposed by the health sector. This research will strengthen the environmental and social-economic

developments of the total health-care sector in Suriname and especially for the hospitals and medical laboratories.

1.2 Research problem

Hospitals and laboratories in Suriname do not have the possibility to manage their medical waste in an environmentally responsible manner and well-controlled way. Unsafe disposal of medical waste can cause public health risks.

1.3 Research objective

The main objective of this study is to research the feasibility for setting up and managing an incinerator for medical waste treatment for hospitals and laboratories in Suriname in an environmentally responsible and well-controlled way. The aim for this study is to decide whether to proceed with or reject this project.

There are rules and conditions to meet for setting up and managing an incinerator for medical waste. In this research the standards and procedures of the World Health Organization (WHO) and the European Union (EU) will be used, as National Institute for environmental development in Suriname (NIMOS) has only environmentally related legislation.

Criteria’s of the WHO and EU for setting up an incineration for medical waste can affect the implementation of this project, which can impact the financials of the total investment for this project.

1.4 Research questions

In order to analyze the above-mentioned problem statement the following general research questions, need to be answered:

1. What are the criteria to set up an incinerator for medical waste?

2. How does the current legislation and infrastructure perform with regard to these criteria?

3. Which environmental, social and other issues should be taken into considerations?

4. What possibilities does the health-care sector have to manage medical waste?

5. Does the health-care sector have a financial surplus for managing their medical waste on an environmentally safe way?

These general questions structure the plan of this research analysis.

1.5 Methodology

This research project is a combination of a desk research and empirical analysis by a questionnaire and interviews. Primary data consisted of interviewing key informants from the health care sector, public waste organization and environmental organizations. Data analysis is based on the contents of all written data sources, questionnaires and interviews, and correspondences with informants. Secondary data collection consisted of acquiring public health documentation; formal studies and research reports, professional journals, and media information. There are no statistics available on medical waste in Suriname.

Estimates of waste from the four largest hospitals and the two largest laboratories were used to determine the total quantity of medical waste produced in Suriname. The methodology for this research supports a quantitative character. As a quantitative analysis, it performs a systematic and in-depth research approach for managing medical waste. To facilitate data analysis, the questionnaire was developed. The essence of this questionnaire has been incorporated in this research. This questionnaire was developed to evaluate the current situation of medical waste management and to determine the potential quantity of medical waste. Its focus is on the feasibility study for processing or not processing this incineration project for medical waste of the hospitals and medical laboratories.

1.6 Assumption and limitations

In this research some assumptions and limitations have been made. The targeted group is limited to the four largest hospitals and two largest privately owned medical laboratories in Paramaribo (Capital of Suriname). Having collected data from this target group, an assumption was made to estimate the total potential market of medical waste of the whole health-care sector. There is a correlation between the patient and the quantity of medical waste that is being produced.

This research is mainly concerned with solid wastes generated in medical establishments. All other kinds of waste are not outlined in this research. A feasibility study for this project, in the sense of financial, economic and environmental aspects is outlined. These three aspects are described in this research.

Because of the confidentiality of medical data, there is lack of a proper database system of hospitals and medical laboratories, medical waste data are very discreet. Comparison of incineration systems within the region is not possible at this stage, because of lack of data on this topic and the

time- frame limitation for this research. Numbers of persons suffering injuries and infections related to contact with medical waste have not been made known prior to this research.

1.7 Chapter overview

This research is structured by finding the answers to the research questions. As a result, the general outline of the rest of this paper is the following.

Chapter 2 starts from the theoretical definition of medical waste and its key concepts. The criteria and procedures for handling medical waste in an environmentally responsible way are illustrated in this chapter. Furthermore, issues as the importance and criticism of waste management are enclosed. The theoretical model that has been used is also captured in this chapter. A summary is given after every chapter.

The situational factors in Suriname of waste management are illustrated in chapter 3. The awareness of waste management for the public as the private sector is discussed. The current legislation on environment issues and the social context are elaborated in this chapter. The matter of policies and legislation on waste management in Suriname, as well as the possibilities for setting up an incineration system for medical waste is captured. Aspects as policy and control for incineration of medical waste by the government are taken into consideration.

Chapter 4 works out the selected models and analysis of the data collection. The data collection process is explained in this chapter. The analysis and findings of comparative study are illustrated for the understanding of the feasibility study of this research. These findings support the recommendations for setting up the incineration project

The managerial implications and recommendations of medical waste management are elaborate don in chapter 5. The hospitals and medical laboratories are discussed regarding these matters. National implications and recommendations are discussed within the legislation and implementation. The control and sanctions on this topic are captured.

In chapter 6 the conclusions and recommendations on this research are summarized. Research questions are answered on this subject. Finally, this chapter formulates recommendations for medical waste treatment in Suriname.

CHAPTER 2 LITERATURE REVIEWS

2.1 Definition of medical waste

Medical waste adversely affects the environment and contributes to the overall environmental problem of solid waste disposal. Such waste can be effectively treated by chemical, physical, or biological means and disposed of in a sanitary landfill or by incineration. Medical waste is not to be considered “hazardous” by the definition of Resource Conservation and Recovery Act (RCRA of 1976, Waste management Concepts 1998).

This research is mainly concerned with hazardous and solid wastes generated in medical establishments. Several wordings are used for which the following definitions are proposed (WHO, 1994):

- Hospitals wastes means all waste coming out of hospitals out of which around 85% are actually non-hazardous wastes, around 10% are infectious wastes, and around 5% are non- infectious but hazardous wastes.

- Medical wastes can be defined as any waste which is generated in the diagnosis treatment, or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals (vaccines). For the purpose of this research any solid waste of animals is excluded.

Medical waste can be specified in 10 categories of solid waste items (Medical Waste Tracking Act of 1988). These are characterized by the potential to transmit infection and by the risk they pose to human health and the environment. These categories are:

1. Sharps that have been used in patient care or in medical, research, or industrial laboratories, including hypodermic needles, syringes, Pasteur pipettes, broken glass and scalpel blades;

2. Cultures and stocks of infectious agents and associated biological, including cultures from medical and pathological laboratories, cultures and stocks of infectious agents from research and industrial laboratories, wastes from the production of biological, discarded live and attenuated vaccines, and culture dishes and devices used to transfer, inoculate and mix cultures;

3. Pathological wastes, including tissues, organs, and body parts that are removed during surgery or autopsy;

4. Waste human blood and products of blood, including serum, plasma, and other blood components;

5. Contaminated animal carcasses, body parts, and bedding of animals that were exposed to infectious agents during research, production of biological, or testing of pharmaceuticals;

6. Wastes from surgery or autopsy that were in contact with infectious agents, including soiled dressings, sponges, drapes, lavage tubes, drainage sets, under pads, and surgical gloves;

7. Laboratory waste from medical, pathological, pharmaceutical, or other research, commercial, or industrial laboratories that were in contact with infectious agents, including slides and cover slips, disposable gloves, laboratory coats, and aprons;

8. Dialyses wastes that were in contact with the blood of patients undergoing hemodialysis, including contaminated disposable equipment and supplies such as tubing, filters, disposable sheets, towels, gloves, aprons, and laboratory coats;

9. Discarded medical equipment and parts that were in contact with infectious agents;

10. Biological waste and discarded materials contaminated with blood, excretion, excudates (sic), or secretion from human beings or animals that are isolated to protect others from communicable diseases.

2.2 Resources of medical waste

About 75 to 80 percent of all medical waste is generated by the hospitals, which are the most easily identifiable sources. As a result, hospitals are the primary target for this research, but they are not the only generators of medical wastes. Sources of medical waste can be categorized in regulated and non-regulated sources. The range of potential generators includes the following:

- Hospitals. This category includes facilities providing general medical and surgical care, psychiatric care, treatment of tuberculosis, and services in specialties such as obstetrics and gynecology, eye/ear/nose/throat, and rehabilitation.

- Intermediate care facilities. This category includes nursing homes and facilities for in-patient care for the developmentally disabled.

- Clinics and physicians.

- Dental offices.

- Laboratories. This category includes the full spectrum of research, medical, industrial, diagnostic, manufacturing, and pharmaceutical preparation laboratories.

- Other sources of Medical waste. The remaining generators of medical waste are Funeral homes, Emergency medical services, Home health care, Public health units, Blood banks, illicit drug users, Medical schools and Nursing schools.

Changes in the health care delivery system have resulted in increases in medical waste from non- regulated or residential sources. The number of injuries to refuse workers from sharp objects (often referred to simply as sharps) in residential solid waste is increasing and appears to coincide with the increasing trend to in-home health care (Ostler, 1998). Several trends that have contributed to this increase in medical waste from non-regulated sources are as followings:

- Hospital patients are released on an outpatient basis more frequently.

- Many one-time use items that not come within the jurisdiction of the regulations are available over-the-counter for small livestock operations or nonprofit entities.

- The use of disposable items in the home has increased.

- The number of users of illicit intravenous drugs has increased.

Because of these trends, efforts must be made to educate the public regarding safe disposal methods for home health care medical waste. Educating people about the ethic of good medical waste management is also imperative, making them understand that proper medical waste management is essential to protect public health and the environment.

2.3 Medical waste management

In recent years, the shift to disposable products for health care and the implementation of universal precautions have significantly increased the quantity of medical waste. The quantity of wastes requiring special handling could be greatly reduced by educating the public so that they can identify which wastes can be handled as solid wastes and which wastes must be segregated and handled as medical wastes.

Waste management is a directed approach to the systematic management of medical waste from the point of generation to the point of final disposal. This includes the elements of generation, storage, collection, transfer and transport, recycling, reduction, processing, recovery, and final disposal. The management of medical waste begins when and where an item ceases to be useful for its intended purpose and enters the waste stream.

In the USA, approximately 5 percent of persons hospitalized will develop evidence of a hospital-acquired infection annually. In contrast, much less information is available on communicable diseases caused by medical waste. The annual injury rates for occupations in the health care and sanitary service industries vary from 10-20 per 1000 workers. Most work-related injuries among health care workers are sprains ad strains due to overexertion.

It is a requirement that every employer need to provide a Hepatitis B vaccination to every employee. If an employee is exposed to a pathogen, the employer needs to provide their employee with a series of vaccinations and a follow-up medical consultation. At the WHO consultation Professor Shiro Shirato, chairman of the Japanese Society for research on medical waste, reported that in July 1987, two young interns in pediatrics- a 25 year old woman and a 28 year old man-were accidentally infected by syringes; these incidents resulted in their deaths from acute hepatitis B.

2.3.1 Minimization of Medical Waste

In recent years, the shift to disposable products for health care and the implementation of universal precautions have significantly increased the quantity of medical wastes. The quantity of wastes requiring special handling could be greatly reduced by educating the public so that they can identify which wastes can be handled as solid wastes and which must be segregated and handled as medical waste. The minimization of medical waste can also be accomplished through (Ostler, 1998):

- Reuse, - Recycling, and

- Source reduction.

Reuse

The use of disposable health care products is suggested, that disposables reduce liability issues, control infection, save labor cost for reprocessing, and minimize exposure to chemicals used in the sterilization process. However, the identification of items that can be segregated for return, reuse (by cleaning, disinfecting, or sanitizing), or reprocessing can significantly reduce the total volume of waste generated.

Recycling

Waste minimization can occur through recycling of the many components involved with medical waste. These components include the plastics and metals in syringes, the glass in tubes, and personal protective equipment. Due to risk of exposure to infection, however, recycling of regulated medical wastes involves substantial reprocessing to sanitize or disinfect the original components.

Source reduction

Source reduction is an action that reduces the generation of waste at the source. This often refers to the decreased generation of solid waste. This is accomplished by changing or reducing consumer consumption, increasing product durability, reparability, or reducing packaging, and introducing new production technologies that are less wasteful.

Figure 1: Waste management prevention hierarchy

Method Activities Applications

- Environmentally friendly design of new products - Product changes - Source elimination

-Modify product to avoid the use of solvent

-Modify product to extend coating life Source reduction

(Highest priority)

Recycling ^-Reuse

-Reclamation

-Solvent recycling -Metal recovery from a spent plating bath -Volatile organic recovery

Treatment

-Stabilization -Neutralization -Precipitation -Evaporation -Incineration -Scrubbing

-Thermal destruction of organic solvent -Precipitation of heavy metal from a spent plating bath

Disposal -Disposal at a

permitted facility

-Land disposal

Source reduction receives the highest priority because it can reduce or even eliminate the need for less desirable methods that are lower on the hierarchy. In figure 1 example applications and activities are given for source reduction and the other waste management methods.

By starting at the top of the environmental management hierarchy and working down, waste generation and the overall environmental path of production activity can be minimized. Waste management through a combination of source reduction, recycling, waste treatment, and final disposal constitutes a total systems approach to pollution prevention. The philosophy of pollution prevention is to minimize waste generation as much as feasible. Waste treatment changes the form or composition of a waste stream through controlled physical, chemical, or biological processes that reduce the amount of waste material.

2.4 Medical Waste Management Plan

Any medial waste management program enclosed a plan. While small generators may not require a written plan, they should still train their personnel in the proper handling, packaging, and transport of medical waste generated in the course of their duties. Large generators should prepare a written management and operations plan outlining policies and procedures consistent with Occupational Safety and Health Administration’s (OSHA) Blood borne Pathogens Standards. The plan should be reviewed and updated as necessary.

2.4.1 Treatment and disposal of medical waste

Waste treatment is any method, technique, or process designed to change the biological character or composition of waste to reduce or eliminate pathogens so that the waste no longer poses a hazard to persons who may be exposed to it (see appendix 1 treatment methods).

Two principal methods used to reduce the volume of medical waste are grinding and shredding and compaction (see appendix 2 destruction methods). Regulated medical wastes or infectious wastes that have been treated by an effective method are no longer biologically hazardous. Once such treated wastes have been packaged so that their treatment is evident, they are no longer subject to management as medical waste and may be collected, mixed with other wastes, and disposed of as ordinary waste.

Incinerator ash and other solid wastes can be disposed of in a properly sited and constructed sanitary landfill.

2.5 Incineration as means to fight waste problems

The primary methods of treatment are incinerator, autoclaving or steam sterilization, irradiation, and thermal inactivation. The choice of which treatment method to use depends on the physical composition of waste and the different types of packaging selections. Each of the ten categories of medical waste described previously may require a different method of treatment, destruction, and disposal suitable to its own peculiarities and in compliance with any applicable regulations (Ostler, 1998).

Incineration systems are typically used for biologically toxic or highly concentrated organic waste streams and wastes that are not easily degradable using other treatment technologies, such as those containing dioxins. The heat content of the waste is also a consideration. Incineration systems are available for the destruction of all waste forms including liquids, solids, and gases. Table 1 summarizes the various types of incineration systems applicable for each of these waste types. Note that air pollution control systems, which are required for the removal of particulates and acid gases from the incinerator flue gas, are an integral part of incineration systems (see appendix 3 incinerator types).

Table 1:Incinerator types applicable for various waste materials

Incineration Liquids Solids/Sludges Soil Gases

Liquid injection X X

Plasma arc X X X

Rotary kiln X X X X

Fluidized bed X X X

Circulating bed X X X X

Source: Waste Policy and Learning

It has been a frequent practice in countries of Latin America and the Caribbean, especially in large hospitals and clinics, to install large in site incinerations to burn within the precincts of the establishment most, and in some cases, all of the solid wastes generated. The result has been the installation of oversized equipment that, in addition to requiring a significant initial investment, has high operating and maintenance cost and most of the time functions precariously or remains unused.

Defective operation of these units results in emission of smoke, contaminating particles and bad odors in the atmosphere.

There are some interesting experiences with central incineration systems in which the municipality or some company from hospitals, clinics, and health establishments are transported for treatment. Systems of this type have been implemented in the city of Sao Paulo, Brazil, and in Mexico city, Mexico, but unfortunately little or no previous separations of wastes is undertaken (PAHO, 1991)

The PAHO stated that central incinerator has the advantage of reducing both the total investment cost and the operating and maintenance costs and facilitating the achievement of higher levels of efficiency and technical capacity. In contrast, it involves greater transportation costs and the introduction of additional environmental and heath risk factors associated with the transport of infectious wastes outside the hospital. In addition, this solution is applicable to large cities where the quantity of wastes to be incinerated makes it possible to achieve proper costs and efficiency.

The technical and economic feasibility of providing adequate treatment and final disposal of medical wastes is directly related to the possibility of implementing effective source separation of the hazardous fractions. Mixing infectious wastes with the rest of the wastes makes it necessary to treat the whole mass with the same procedures and precautions applicable to infectious wastes, making the operation more extensive and difficult. This approach has been applied in countries such as Chile and Cuba, where source separation of infectious fractions is practiced and then incinerated, biodegraded, or sterilized in small units especially designed to treat this type of waste (WHO, 1991).

2.5.1 Treatment of medical waste in the USA

In the USA -population of 285 million, nationwide 158 million tons of municipal solid wastes are created yearly. Medical waste is a part, although a small one at 0.3%- 500,000 tons- is generated by approximately 380,000 regulated generators (see appendix 8). The 7,118 hospitals in the USA are the primary generators of waste by volume, producing 77 percent of the total annual regulated medical waste.

Incineration traditionally has been hospitals primary method for medical waste disposal. This process converts combustible materials into noncombustible residue or ash. In addition, the combustion process can effectively reduce waste volume by 90 percent or more (US. EPA, 1988).

Three basic types of incinerators are currently available for medical waste disposal: multiple- chamber, rotary kiln, and controlled-air. Of those, the controlled-air incinerators are the most widely used. Approximately 5,000 medical waste incinerators are operating in U.S. hospitals, each for an estimated 4 to 10 hours per day, 5 days a week. Smaller units, with feed capacities of 200 pounds per

hour or less, tend to be operated the least. Approximately 60 percent of the 5,000 units have a design feed capacity of less than 200 pounds per hour, and some have been in operation for more than 20 years. Most small units have no pollution control devices and were designed solely to destroy medical pathological wastes such as body parts and tissues (Lichtveld, 1990).

Stack sampling data available for medical waste incinerators are very limited. EPA conducted a thorough review of all medical waste incinerator sampling data, which indicated medical waste incinerators can emit various products of complete and incomplete combustion (see appendix 5 chemicals in medical waste incinerator emissions). However, not enough data are available to determine the typical emissions of medical waste incinerators or the emissions from a medical incinerator not being operated properly.

Recent mutagenicity studies using the Ames Salmonella typhimurium (TA98) assay indicate stack fly ash and particulate emissions from medical waste incinerators are less mutagenic -able to cause changes in the genetic material of living cells- than emissions from wood stoves, automobile gasoline, and residential furnaces (Driver, Rodgers, Claxton, 1989).

The chemical constituents of ash resulting from medical waste incineration have not been characterized. Laboratory research indicates the ash could contain chlorinated aromatic hydrocarbons, chlorinated dibenzofurans, and chlorinated-p-dioxins. In addition, it may contain lead or cadmium (Hagenmaier, 1987).

2.5.2 Treatment of medical waste in the developing countries

The term developing countries will be used as a concise and convenient term to refer to countries that have a per capita GNP less than the world average, which might also referred to as economically less developed, or low-income countries. These countries are in tropical areas and are seriously constrained by lack of resources, both in terms of finance and trained manpower (WHO, 1994).

As the WHO stated, it will not be possible for all medical establishments everywhere in the world to achieve the highest possible standards in a short time. In many ways it is better to adopt the incremental approach, which states that any improvement is better than none, even if the standards are not yet what would be desired. The management of medical waste should be seen as a ladder, and managers should be striving to climb up the ladder-that is making improvements in the reduction of

it is not helpful to feel that nothing has been achieved unless one is at the top. The important thing is to be moving upwards.

Table 2 shows the total amount of hospital waste (including non-hazardous component) generated in some industrialized countries:

Table 2: Quantity of waste in kg per bed per day per hospital

Type of hospital Norway Spain UK France USA Netherlands

University hospital 3.9 4.4 3.3 3.35 5.24 4.2-6.5

General hospital 2.5 4.5 2.7

Maternity 3.4 3

Mental hospital 1.6 0.5 1.3

Geriatric 1.2 9.25 1.7

Source: WHO/Europe Publications ERS 97

Monreal (1994) quoted figures of 1-to 4.5 kg/bed .day for generation of solid wastes from hospitals in Latin America. Although, in the USA the range of 3.5 kg/bed. day was registered in the 1940s and higher than 6-8 kg/bed. day for the 1980s. The leading causes of this progressive increase in the rate of generation of solid medical wastes are the continuous increase in the complexity of medical care and the growing use of disposable material.

Table 3: Quantity of waste in kg per bed per day per country

Country Year of study Generation (kg/bed.day)

Minimum Median Maximum

Chile 1973 0.97 - 1.21

Venezuela 1976 2.56 3.1 3.71

Brazil 1978 1.2 2.63 3.8

Argentina 1982 0.82 - 4.2

Peru 1987 1.6 2.93 6

Argentina 1988 1.85 - 3.65

Paraguay 1989 3 3.8 4.5

Source: WHO/Europe Publications ERS 97

The WHO stated, technical problems are the poor segregation of hazardous wastes at source due to the low education of personnel in charge; this lack of segregation results in the hazardous component being

10 to 40% of the total instead of less than 10%. There is a lack of proper storage of sharps, which explains the numerous injuries among waste handlers. Very frequently hospital waste are dumped together with municipal garbage, with the common exception of human body parts and foetuses that are buried separately for cultural reasons. Hospital incinerators are also used, however they seem to be inappropriate technology in many situations, as a high percentage (57 to 92%) do not operate satisfactorily.

Experiences in Latin America show the tendency to install oversize incinerators, so that they are not efficiently utilized, and that often the incinerators that are used are not specifically designed for medical waste (Monreal, 1991). Operational problems included high emissions of smoke, unpleasant odors, and the generation of incompletely mineralized ash which was difficult to handle. Table 4 shows the percentages of incinerators that were functioning poorly or not operated at all.

Table 4: Percentage of incinerators functioning in Latin America countries Country Year of study Total studied Number of incinerators functioning

poorly or not at all

Number Number Percentage

Mexico 1975 - - 90

Argentina 1982 9 7 78

Brazil 1985 14 8 57

Peru 1985 25 23 92

Source: WHO, 1991

As a rule, the existing legislation, regulations, and standards in Latin America and the Caribbean with respect to handling of solid medical wastes are inadequate; they are too general in many cases and too rigid. In most countries, legislations and regulations only establish general principles without clearly defining the responsibilities of the different institutions involved, without properly identifying the different categories of wastes, instituting regulations for handling or mechanism for surveillance and control.

2.6 Summary

Medical wastes constitute a risk to public health and the environment. Certain medical wastes must be regulated, and the responsible party has to release a document to provide guidelines for state programs.

Between 75 and 80 percent of all medical waste is generated by hospitals, which are the most easily identifiable sources. As a result they are primary target for regulation, but they are not the only generators of medical wastes. The range of potential generators includes a wide variety of sources from medical home care to users of controlled substances (drug abusers).

Clearly, the most effective way to deal with this environmental burden is to strive to reduce the quantity of waste created, on a small scale in homes or on a large scale in industrial operations.

Wherever possible, waste reduction, recycling, reuse and reclamation should be considered as waste management alternatives to incineration.

Research indicates medical waste does not contain any greater quantity or different types of microbiological agents than residential waste, and viruses present in solid waste tend to adsorb to organic matter and deactivate.

Inadequate incineration of medical waste plastics may produce of incomplete combustion, such as furans and dioxins.

Incinerator can be a very effective method of treatment of infectious wastes, but many do not operate as they should, combustion temperatures are often too low so that there are problems of odor and smoke, and sharps in the ash may still be a hazed.

Land filling of infectious wastes may be the only feasible disposal option for many developing countries in the short and medium term.

In the Latin American countries the content of solid medical wastes that are contaminated microbiologically fluctuates between 10 and 40%, while in the USA this varies from 5 to 10%.

The existing legislation, regulations, and standards in Latin America and the Caribbean with respect to handling of solid medical wastes are inadequate; they are too general in many cases and too rigid.

CHAPTER 3 SITUATIONAL FACTORS IN SURINAME

The total amount of municipal waste in Suriname has roughly grown to 83.000 ton in 2005.

About 181 to 264 ton represents medical waste generated by approximately 238 regulated generators.

The hospitals and medical laboratories, which are the primary generators of medical waste by volume, are producing 84% of the total annual regulated medical waste. Hence, this group of generators is an adequate representative of the total health care sector in Suriname.

3.1 Waste management awareness

There is an increased worldwide awareness of the need to adopt a preventative approach through cleaner production to achieve waste minimization and efficient use of raw materials. Many obstacles (sociological, attitudinal, technical, economical) have to be overcome to effectively implement this approach, which is however the key to achieving sustainable industrial development. In particular, the cost effectiveness of cleaner production in comparison to end of pipe” solutions is not full recognized (UNEP, 1994).

The handling of solid wastes generated in hospitals and health establishments presents special risks and difficulties due, basically, to the infectious nature of some of their components. Contributing to such risks are the heterogeneity of their composition, the frequent presence of sharp objectives, and the possible presence of smaller quantities of toxic, flammable, and radioactive substances of low intensity. Notwithstanding this, most of the wastes that a hospital produces do not present greater risks than those associated with common municipal wastes.

Inadequate handling of solid hospital wastes not only can create risk situations that threaten the health of the hospital population-personnel and patients-but can also cause of environmental deterioration that transcends the limits of the hospital precincts, generating annoyances and loss of well-being in the adjacent population and risking the health of those sectors of the community that, directly or indirectly, come in contact with infectious or contaminated material when wastes are transferred outside the hospital for treatment or final disposal (WHO, 1991).

The population of Suriname in general is not seriously aware of waste management and the handling of it in an environmental friendly and sustainable way. Although the health-care providers are really concern about this issue, because they are aware that handling medical waste on an improper

way can cause lots of health risks for the different health care workers, and principally for the total environment and the community in general on the long run.

In the Plan and Strategy for Sustainable Development of Suriname (MOP) for the period 2006- 2011, environment receives significantly more attention than before and the Plan is fully focused on sustainability. It is stated as a basic condition that the environment must be a crucial factor in social and economic development to guarantee a healthy environment for future generators. Environment will become an integrated part of the development process and can no longer be seen as a separate issue.

The MOP refers to the Rio declaration of 1992, defining the right on a healthy and productive life in harmony with nature. MOP takes this statement as a basis. All present activities should take into account that future generations have the same right. More in practice, MOP defines that environment from now is a cross cutting issue, which will have to be taken into account in all projects and development mechanism (see appendix 11, a listing of these priorities).

The absence of waste management, lack of awareness about the health hazards, insufficient financial and human resources and poor control of waste disposal are the most common problems connected with health-care wastes. Many countries do not have appropriate regulations, or do not enforce them. An essential issue is the clear attribution of responsibility of appropriate handling and disposal of waste. According to the 'polluter pays' principle, this responsibility lies with the waste producer, usually being the health-care provider, or the establishment involved in related activities (WHO, 2000).

Regulations in Suriname have been drawn up for different sectors and awareness campaign among civilians and industrial sectors have been launched. An overall Environmental Framework Law- defining responsibilities and, in a second stage environmental standards and Environmental Impact Assessment (EIA) procedures-has been submitted for approval by now responsible Ministry of Labor Technological Development and Environment (ATM). The approval of the Law, the subsequent installation of environmental authorities, the adoption of standards, etc. could provide a sound basis for further serious environmental protection in the country. Practical actions in the form of planned installations for the treatment of waste and wastewater were not identified. Most activities for improvement in the environment are donor related. The donors and NGO’s have clear programmes and actions for the preservation of the biodiversity and building environmental awareness among the population and industries (EU, 2006).

3.1.1 Public sector

An increasing number of countries worldwide have adopted regulatory frameworks for (hazardous) waste management, however there is a need to build enforcement capabilities and to create a management unit within the public administration, in particular in developing countries (UNEP, 1994).

As stated before, Suriname does not yet have legislations on environmental topics. Although there are some related environmental regulations. Referring to the absence of the Framework Law: at present the environmental content of the existing sectoral legislation is weak, very fragmented and largely depending on case-by-case decisions of the politicians in charge. The approval of the Framework Law will hopefully bring a significant change, if followed by effective standards and a well-equipped inspection and enforcement system.

The European Union (EU) stated that the overall environment performance of Suriname however is not very positive. So far environment has not received priority on the political agenda and the resulting negative impacts on the environment are evident in many cases. Many of the countries environmental objectives will not be achieved as long as the institutional environmental framework is not reinforced.

The health sector was severely affected by fiscal problems in the late 1990s as the government fell seriously behind on payments to major hospitals and healthcare institutions. There has been a heavy loss of trained personnel through emigration: estimates published in 2001 suggested that 82% of nurses trained between 1970 and 1998 were working overseas. Despite the lack of public investment, Suriname’s healthcare indicators are generally comparable with those of its Caribbean neighbors.

Government commitment and support is needed to reach an overall and long-term improvement of the situation, although immediate action can be taken locally. Health-care waste management is an integral part of health-care, and creating harm through inadequate waste management reduces the overall benefits of health-care.

3.1.2 Public Landfill

The Ministry of OW is regulating the municipal waste in and around Paramaribo. Households within this area are collecting their wastes, without segregation, which are manually picked up by the OW-employees on regular days (2-3 times per week) and transported in an open truck to a public

landfill, where it will be burned in the open air. This landfill, located in Ornamibo, does not have the minimum requirements, whereas groundwater and soil or land monitoring takes place.

The owner or operator must implement a groundwater assessment program to determine whether hazardous waste is actually entering groundwater. The assessment program requires the owner or operator to determine what is contaminating the groundwater, extend of the contamination, and the rate of the contamination migration. Groundwater monitoring reports are also required (Ostler, 1998).

The households do not have to pay for this public service, although indirectly through paying taxes. These wastes are not being separated such as glasses, plastics, and organic, inorganic, hazard, non-hazard, which may cause injuries at the burning process in the open landfill. There are no figures available to know if there were injuries in the past.

There is a possibility that medical and hazardous wastes are dumped in this landfill. No figures are available on this matter. Although, a few years ago there was a consternation, when they found an amputed leg in this landfill. Afterward, it became clear that it belongs to one of the hospitals. These pathological wastes are normally being collected and cooled by the hospitals, which are picked up by a contractor, that bury them in a public cemetery.

The NIMOS as an independent environmental organization gives advice(s) to the government and other private organizations for a long term and sustainable environmental solutions. The most essential criteria for waste management treatment are setting the rules and regulations for environmental issues. Aspects such as segregation of waste, the collection and handling of waste and foremost the control from the government are also very crucial.

Hospitals in Paramaribo, the Academic Hospital (AZP) not included, and other medical institutes collected their medical wastes and burned in the incinerator of the Surinam Aluminum Company Limited (Suralco) for years. This took place once in a week or month, depends on the total amount of medical waste within that period. This seems to be very inefficient and ineffective for the Suralco to burn medical waste of other medical institutes in their incinerator, located in their compound.

After a few years, in 2001, Suralco donated the two semi-private hospitals (RKZ and DKZ) an incinerator. This incinerator has been installed at Waspar, a semi-private laundry company, who is responsible for the management, and maintenance and service. This instrument was primarily for medical waste treatment of these two hospitals, but in practice other medical institutes are also making use of this service.

Because there is lack of finances the service and maintenance of the incinerator were not done on a regular plan, as prescribed in the maintenance schedule. This leads to an inadequate functioning of this instrument. In some cases medical waste could not be burned for months (6-12 months), due to a broken incinerator. In these periods the hospitals and other medical institutes were forced to seek for other alternatives. These alternatives are burning their wastes in their backyard, or dumping in the public landfill, or burning in the backyard of the crematorium in a barrel, or holding these wastes till the incinerator of Waspar works again.

The cost for burning medical waste at Waspar is about SRD15¹ for each bag of 10-20 kg. The wastes are being collected and delivered daily or weekly at Waspar, depends on the volume of medical waste of each medical institute. These waste are burned daily from 8.00-16.00 pm, 5 days a week. This incineration is a double chamber, with a diesel engine, instrument and reaches temperature between 600-700 ºC, which is very essential for burning medical wastes. The capacity of this incinerator is about 600kg per cycle. In most of the cases the total medical waste exceeds this capacity, so there is always a burden to get rid of waste for the medical institutes.

3.1.3 Barrel incineration

The barrel incinerator is currently used at many sites in the interior of Suriname for the burning of medical waste, as advised by the WHO. The incinerator is only designed to reach temperatures of 800°C and it is therefore not possible to totally reduce the glass in the same way as plastics. At the achievable temperature the glass may distort slightly due to softening but will not totally burn (glass melts at a temperature of 1400°C or above).

However, any material left should no longer be contaminated. The same applies to the needles.

Care must still be taken in handling the ash and left over waste due to sharp glass edges and needles.

However, the De Montfort incinerator is the preferred solution for disposing of infectious waste as it degrades the harmful gases much more effectively. Therefore a long-term solution to the disposal of medical waste is to build a De Montfort incinerator at regional centres in the interior and infectious waste transported to those centres. At present this is not economically feasible and so the barrel incinerator is used as a short-term solution (see appendix 13-15 types of incineration). The incineration should be carried out at least 50m from any buildings to reduce the risk of exposure to harmful gases.

Where this is not feasible, incineration should be done as far as possible from any building.

3.1.4 Non-state actors

Most environmental Non Governmental Organizations (NGO) in Suriname is concentrated on the protection of biodiversity and natural parks. The main ones, Conservation International (CI) and World Wildlife Fund (WWF) implement their activities in coordination with the authorities. The Foundation for Natural Protection STINASU takes responsibility for the management of the Brownsberg National Park, a favorite tourist attraction not far from Paramaribo, regrettably still threatened by on-going mining activities (EU, 2006).

3.1.5 Business community

The largest industry in Suriname, Suralco, operates under international environmental standards and has published an extensive set of position papers per environmental issue, e.g. air pollution, Bauxite Mine Rehabilitation Standards and Guidelines, biodiversity, cleaner production, climate change, fresh water resources, land management etc. The large state owned oil company Staatsolie also operates according its own environmental regulations. These companies have far more information, equipment and experience in the environmental issues than the authorities that are supposed to regulate and control them.

There are some industry complexes, near a river or canal, where private manufacturers and service companies are settled, where they slack their wastes into the water. Dumping these waste into the water, without handling and inspecting before can lead to water pollution.

3.2 Legal and judiciary system

New regulations on (hazardous) waste must usually fit into an existing framework of national laws of municipal waste, on chemicals and pesticides, on public health and safety, on industrial permits, on public sewer systems, on the management of air and water pollution, and on transport safety. Regulations and classifications now need to pay regard to the Basel Convention so as to be as compatible with the regulations in other countries (Eberg, 1997).

Government actors are the Ministry of OW and ATM, Environment Inspection, BOG and NIMOS. Within the Ministry of OW, especially the Environment Inspection department is engaged in waste policy. Ministry of ATM is a legislative and planning actor, responsible for waste acts and national programmes. Its main concern is to facilitate efficient waste disposal, guided by the ladder

principle, which means a combination of waste reduction strategies taking into account environmental as well as different societal interests.

Legislation is ineffective unless there is adequate enforcement. Enforcement requires an inspectorate that is trained to recognize the special aspects of (industrial) waste, while at the same time continuing to deal with more traditional pollution problems. The PAHO argues that, as a rule, the existing legislation, regulations, and standards in Latin America and the Caribbean with respect to handling of solid hospital wastes are inadequate; they are too general in many cases and too inflexible.

In most countries, legislation and regulations only establish general principles without clearly defining the responsibilities of the different institutions involved, without properly identifying the different categories of wastes, instituting regulations for handling or mechanisms for surveillance and control.

Monreal has suggested that legislation should cover the following aspects:

- Definition of solid hospital waste, including definition of the different component fractions, especially those that, because of their hazardous nature, require special treatment.

- Establishments of standards for the control of the occupational, health, and environmental risks associated with the handling of solid hospital wastes as well as emergency procedure standards.

- Establishment of incentives for reducing the quantity of wastes produced and promotion of recovery and recycling

- Standardization of the requirements for each alternative for proper handling of hospital wastes.

- Establishments of a pricing system for services provided by third parties.

- Establishment of effective surveillance and control of the sanitary handling of hospital solid wastes.

The Framework Law will arrange the environmental institutional set-up and responsibilities and will in a later stage provide specific standards and mechanism for inspection and enforcement. The Framework Law also arranges for EIA, chemical waste, permit procedures, audits, plans and strategies.

After approval NIMOS will become the Environmental Authority under ATM and the second phase of activities will be implemented, including the establishment of specific environmental standards and EAI obligations. The erroneous vision that care for the environment and clear regulations have a negative impact on the attraction of foreign investment and on the growth of industrial and trade sectors in general. The lack of priority for environmental care applies to both the authorities and individuals.

The technical institute NIMOS was placed under ATM instead of under the National Council for the environment as was the case previously. The National Council for Environment now is an advisory board to ATM. The National Action Plan of 1996 plan eventually led to the establishment of NIMOS. NIMOS, set up with EU and IDB assistance, is a small institute counting within 7 technical staff and 6 supporting staff. EU and IDB assisted in the drawing up of the Framework Law.

The Environmental Framework Law is with the Council of Ministers and Assembly for final approval. The delay is the result of administrative and political reasons, e.g. at the first drawing up of the Framework Law ATM was not fully involved and now holds the central position (IDB, 2006). IDB was, together with EU involved in the first phase of NIMOS. Assistance for a second phase is under consideration, depending on the approval of the Framework Law. IDB is now reviewing the possibility of carrying out a Strategic EIA for the Guyanas.

3.2.1 Environmental Impact Assessment

Environmental Impact Assessment (EIA) is a flexible procedure used to identify, analyze, and recommend steps to deal with potentially significant environmental impacts of a proposed investment project, program or development policy. It ensures that decision makers review significant environmental issues and evaluate them as an integral part of the proposed project, program or policy.

The purpose of EIA is to ensure that the development options under consideration are environmentally sound and sustainable, and that any possibly adverse environmental impacts are recognized early in the project cycle and taken into account in project design. EIA also ensures that environmental concerns are taken care of early in program design and policy preparation. EIA identifies ways to improve projects, programs and policies environmentally and minimizes, or compensates for adverse impacts. When initiated early in the project cycle, that is, before the full feasibility study stage, EIA has three major benefits (see appendix 12). In addition, EIA's can play a major role in building environmental capability in the country.

Analysts can carry out EIA’s at a number of different levels. These include the project, program or policy levels, the national level, and the sectoral or regional levels. The basis components of the EIA process include screening, EIA preparation, conducting EIA, implementation and supervision, and completion and evaluation.

In 1992 the World Bank’s World Development Report focused on the links between development and the environment, and highlighted opportunities for “Win-Win” policies that are good