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.”

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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

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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

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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

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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.

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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.

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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 1: Incinerator types applicable for various waste materials.......................................................... 12 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

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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

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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.

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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

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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

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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.

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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

4

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.

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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;

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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.

7

- 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.

8

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.

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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

Source: Facility Pollution Prevention Guide, U.S.EPA, 1992

Disposal

-Disposal at a permitted facility

-Land disposal

10

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.

11

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.

12

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

13

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

risks and the improvement of standards, but since they are starting at different positions on the ladder,

14

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 NetherlandsUniversity hospital 3.9 4.4 3.3 3.35 5.24 4.2-6.5General hospital 2.5 4.5 2.7Maternity 3.4 3Mental hospital 1.6 0.5 1.3Geriatric 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 - 1.21Venezuela 1976 2.56 3.1 3.71Brazil 1978 1.2 2.63 3.8Argentina 1982 0.82 - 4.2Peru 1987 1.6 2.93 6Argentina 1988 1.85 - 3.65Paraguay 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

15

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 PercentageMexico 1975 - - 90Argentina 1982 9 7 78Brazil 1985 14 8 57Peru 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.

16

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.

17

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

18

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).

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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

20

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.

21

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. 1 1 USD = SRD 2.80

22

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

23

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.

24

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

25

both for the environment and for economic development. The Global Environment Facility (GEF) was

set up to support, with grant funds, the cost of incremental activities that have global benefits that

would not be economically justified on a narrower, national accounting framework. In 2006 the IDB

concluded that the EIA system in Suriname is basically non-existing. There is no EIA in the country.

3.3 Possibility for incineration of medical waste In the last few years there has been growing controversy over the incineration of health-care

waste. Under some circumstances, including when wastes are incinerated at low temperatures or when

plastics that contain polyvinyl chloride (PVC) are incinerated, dioxins and furans and other toxic air

pollutants may be produced as emissions and/or in bottom or fly ash (ash that is carried by air and

exhaust gases up the incinerator stack). Exposure to dioxins, furans and co-planar PCBs may lead to

adverse health effects. This happens particularly when wastes are incinerated at temperatures lower

than 800 ºC or when the wastes are not completely incinerated. Dioxins, furans, co-planar PCBs and

other toxic air pollutants may then be produced as emissions and/or in bottom or fly ash. In some

circumstances dioxins and furans can be produced under natural conditions e.g. volcanic activity and

forest fires (WHO, 2000

Currently the health-care sector in Suriname, AZP not included, does not have the possibility to

treat their medical waste on a proper way, they do not have a dedicated incinerator. The rest of the

medical institutions are reliant to the incinerator of Waspar, if there is capacity left. AZP has an in site

incinerator, dated from the early 1990, which must be replaced in a short period. They are searching for

funds to finance this project. The existing incinerator is obsolete and cannot handle all the medical

waste of the hospital any longer.

In terms of waste management the following issues are important for Suriname (IDB, 2006):

- Re-use and recycling of certain waste streams such as plastics, metal, glass, chemicals from

industry, biogas production from organic waste.

- Treatment of wastewater to improve the quality of receiving waters with an economic value in

the form of fishery, aquaculture, drinking water.

- Reduction of the consumption of water (efficiency and recycling), energy (better management,

alternative energy sources) and raw materials (efficiency and cleaner production).

26

- Application of ISO-14001 and Forest Steward Council (FSC) certification, in order to improve

possibilities to export to demanding markets as Europe, The USA and Japan, often requiring

those certificates.

- Kyoto related emission trades, financed with foreign capital (renewable energy projects, saving

of tropical forest, biogas).

3.3.1 Aspects of setting up an incinerator for medical waste Whatever waste management technology is used, best practice must be promoted to ensure

optimal operation of the system. To reduce exposure to toxic pollutants associated with the combustion

process such as dioxins, furans, co-planar PCBs, nitrogen and sulphur oxides as well as particulate

matter and to minimize occupational and public health risks, "best practices" for incineration must be

promoted, and must include the following elements (Eberg, 1998):

1. Effective waste reduction and waste segregation, ensuring that only appropriate wastes are

incinerated;

2. Installation incinerators away from populated areas or areas where food is grown, thus

minimizing exposures and thereby risks;

3. A properly engineered design, ensuring that combustion conditions are appropriate, e.g.,

sufficient residence time and temperatures to minimize products of incomplete combustion;

4. Construction following detailed dimensional plans, thus avoiding flaws that can lead to

incomplete destruction of waste, higher emissions, and premature failure of the incinerator;

5. Proper operation, critical to achieve the desired combustion conditions and emissions. In

summary, operation must: utilize appropriate start-up and cool-down procedures; achieve (and

maintain) a minimum temperature before waste is burned; use appropriate loading/charging

rates (both fuel and waste) to maintain appropriate temperatures; ensure proper disposal of ash;

and ensure use of protective equipment to safeguard workers;

6. Periodic maintenance to replace or repair defective components, including inspection, spare

parts inventory, and record keeping;

7. Enhanced training and management possibly promoted by certification and inspection

programmes for operators, the availability of an operating and maintenance manual,

management oversight, and maintenance programmes.

27

Management and operational problems with incinerators, including inadequate training of operators,

waste segregation problems, and poor maintenance, are recognized as critical issues that should be

addressed in assessment and waste management plans.

3.3.2 Strategy To better understand the problem of health-care waste management, WHO guidance

recommends that countries conduct assessments prior to any decision as to which health-care waste-

management methods be chosen. Tools are available to assist with the assessment and decision-making

process so that appropriate policies lead to the choice of adapted technologies. In support of sound

health-care waste management, WHO proposes to work in collaboration with countries through the

following strategy:

1. In the short-term Until countries have access to proven, environmentally safe options for the management of

health-care waste, incineration may still be seen as an appropriate response. Incineration

should comply with the following recommendations:

- Good practices in incinerator design, construction, operation (e.g., pre-heating and not

overloading the incinerator, incinerating only at temperatures above 800°C), maintenance and

lowest emissions;

- The use of waste segregation and waste minimization practices to restrict incineration to

appropriate infectious wastes;

- Availability of good practices tools, including dimensional construction plans, clear

operational guidelines, etc.;

- Correction of current deficiencies in operator training and management support, which lead to

poor operation of incinerators;

- Materials containing chlorine such as polyvinyl chloride products (e.g., some blood bags, IV

bags, IV tubes, etc.) or heavy metals such as mercury (e.g., broken thermometers) should never

be incinerated.

- Research and production by manufacturers of all syringe components made of the same

plastic to facilitate recycling;

- Selection of PVC-free medical devices;

28

- Identification and development of safe recycling options wherever possible (for plastic, glass,

etc.);

- Research and promotion of new waste management technologies or alternatives to

incineration;

- Promotion of the principles of environmentally sound management of health-care waste as set

out in the Basel Convention.

2. In the mid-term Further efforts to eliminate unnecessary injections to reduce the amount of hazardous health-

care waste that needs to be treated;

- Research into the health effects of chronic exposure to low levels of dioxin, furan and co-

planar PCBs;

- Risk assessment to compare the health risks associated with first incineration and secondly

exposure to health-care waste.

3. In the long-term Support of countries in the development of national guidance manuals for the sound

management of health-care waste;

- Effective, scaled-up promotion of non-incineration technologies for the final disposal of health-

care wastes to prevent the disease burden from (a) unsafe health-care waste management and

(b) exposure to dioxins and furans;

- Allocation of human and financial resources to safely manage health-care waste in countries

- Support of countries in the development and implementation of a national plan, policies and

legislation on health-care waste.

WHO aims to promote effective non-burn technologies for the final disposal of medical wastes to

avoid both the disease burden from unsafe health-care waste management and potential risks from

dioxins, furans and co-planar PCBs. WHO will:

- Prevent the health risks associated with exposure to health-care waste for both health workers

and the public by promoting environmentally sound management policies for health-care waste;

29

- Support global efforts to reduce the amount of noxious emissions released into the atmosphere

to reduce disease and defer the onset of global climate change;

- Support the Stockholm convention on Persistent Organic Pollutants (Pops);

- Support the Basel Convention (1989) on hazardous wastes and other wastes;

- Reduce the exposure to toxic pollutants associated with the combustion process through the

promotion of appropriate practices for high temperature incineration.

From the total of wastes generated by health-care activities, almost 80% are general waste comparable

to domestic waste. The remaining approximate 20% of wastes are considered hazardous materials that

may be infectious, toxic or radioactive. The wastes and by-products cover a diverse range of materials,

as the following list illustrates (percentages are approximate values):

Infectious and anatomic wastes together represent the majority of the hazardous waste, up to

15% of the total waste from health-care activities. Sharps represent about 1% of the total waste from

health-care activities. Chemicals and pharmaceuticals amount to about 3% of waste from health-care

activities. Genotoxic waste, radioactive matter and heavy metal content represent about 1% of the total

waste from health-care activities.

High-income countries can generate up to 6 kg of hazardous waste per person per year. In the

majority of low-income countries, health-care waste is usually not separated into hazardous or non-

hazardous waste. In these countries, the total health-care waste per person per year is anywhere from

0.5 to 3 kg.

3.3.3 The effectiveness of waste incinerator Burning waste has the direct intended result of volume reduction and decomposition of toxic

substances. Hence it especially saves space. In addition it also saves fossil fuels. The utilization of

energy conversion can generate electricity, provide city heating, and produced distilled water. A major

consequence is the remainder and production of emissions. About 30 percent of municipal waste

remains as slag and ashes. It is argued that incinerator reduces the toxicity of waste by inertization.

Others argue that it does not even reduce waste, but, due to the air added, generates more.

Furthermore, there is still little known about health and environmental effects that result from

long-term exposures to low levels of these toxic chemicals. Eventually one must not forget that waste

incinerators indeed brought about a situation of uninterrupted emissions and diffusion of hazardous

30

substances by air and water. This lasted several decades in which pollutants may have entered food

chains, accumulated, and caused health risks. One can argue that this is negligible, or that we must

accept these side effects, like we do from numerous other technical processes. Nevertheless, a stream of

unwanted pollutants is present. In 2002, the results of a WHO assessment conducted in 22 developing

countries showed that the proportion of health-care facilities that do not use proper waste disposal

methods ranges from 18% to 64%.

3.3.4 Efficiency of waste incinerator

Incinerator facilities demand very high investments, which require continuous supply of waste

for about twenty years before depreciation is reached. High costs and the legitimation to attract waste

are a disincentive to adopt prevention and alternative reduction methods (Eberg, 1997).

As stated before, the PAHO concludes that the cost of hospital waste management is less than

1% of the hospital budget. The cost for operating an incinerator is also related to what the engine uses,

fuel or electricity. Furthermore, aspects as type of incinerator, the capacity, the number of cycles, onsite

or outside installation, and the volume of waste are influencing the cost structure.

A state of the art incinerator converts the heat produced from combustion into steam, which can

then be used to heat structures or to generate electricity and thus lower the cost associated with

incineration. Incinerators provide an interim solution especially for developing countries where

options for waste disposal such as autoclave, shredder or microwave are limited.

The financial resources available from the public and private sectors will necessary influence the

choice of system and the standards of operations. For government-owned health care establishments,

the government may use general revenues to pay the cost of the waste management system. For private

healthcare establishments, the government may impose direct regulations, requiring them to implement

their own waste management systems, compelling them to use public facilities, or allowing them the

choice (as happens in the USA).

The feasibility of cooperation between health care establishments should be explored as another means

of minimizing costs.

31

Table 5: The investment costs of different types of incinerators

Capacity Equipment Cost (US$)

50 kg/day Manual loading, manual de-ashing, one combustion 20.000

Chamber, without flue-gas cleaning

100kg/day Manual loading, manual de-ashing, secondary combustion 200.000

Chamber, (temperatures>1000C, residence time>1s)

without flue-gas cleaning

100kg/day Mechanical loading and de-ashing, secondary combustion 400.000

Chamber, (temperatures>1000C, residence time>1s)

without flue-gas cleaning

200kg/day Automatic loading, mechanical de-ashing, secondary 800.000

Combustion chamber, (temperatures>1000C, residence time>1s)

with flue-gas cleaning

400kg/day Automatic loading and de-ashing, secondary 1700.000

Combustion chamber, (temperatures>1000C, residence time>2s)

with flue-gas cleaning and emission monitoring

Source: WHO, 1994

Table 5 illustrates the investment costs of different types of incinerators, which depends on how much

wastes need to incinerate and which type of engine is required. Depends on these factors the investment

cost of the incinerator can be in the range of US$20.000 and US$1.700.000.

Total cost of a waste management system consist of:

- Initial capital investment

- Amortization over the effective life plant and equipment

32

- Operating cost for such elements as labor and consumables

- Utility requirements (fuel, electricity, water)

- Contractual and overhead costs.

The total cost are generally made up of the above-mentioned elements, all of which have to be carefully

considered if the most cost-effective option is to be selected.

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

Site Financing charges

Cost of land Interest

Rights of way Taxes

Site preparation and infrastructure Accounting and audit fees

Provision of utilities to site

Consultancy fees Direct operating cost

Environmental/waste management Manpower requirements (manager, operator,

Consultant driver etc.)

Engineering Yellow bags with tags for infectious wastes

Architectural Black bags for non-risk waste

Legal fees Sharp containers

Transportation costs

Construction costs Utilities (fuel, electricity, water)

Incinerator building Chemicals (for flue gas cleaning)

Waste storage room

33

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

Offices Indirect operating costs

Training

Incinerator Incinerator maintenance and parts replacements

Cost of incinerator Vehicle maintenance

Freight and storage charges Uniforms and safety equipment

Ash disposal costs

Waste transport costs Compliance monitoring of flue gas emissions

Waste collection trucks Project management and administrative

Bins/containers for transporting waste Costs for the execution and long-term From

hospital to incinerator site operation of the project

Equipment costs

Trolleys for collecting waste bags

from wards

Bag holders to be located at all

sources of waste in hospitals

Scales machines for weighting

Waste bags

Refrigerators for storage of waste if

necessary

Source: WHO, 1994

Tables 5-7 illustrate the total cost structure of a waste management system. Before starting a

waste management system, it is crucial to analyze these costs, to ensure if this system will be approved

or rejected. Furthermore, economic and environmental aspects need to take into consideration.

34

3.4 Summary

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. There is some

correlation between the average quantity of solid wastes generated daily and the number of beds in the

hospital.

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 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 n many cases. Many of the countries environmental

objectives will not be achieved as long as the institutional environmental framework is not reinforced.

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 all other medical institutes are also making use of this service, if

there is capacity left.

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

400°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.

35

The Framework Law on Environment has been under consideration since 2001 and is still nowhere

approved. The approval; of this Law will clarify the position of the key environmental institutes such as

NIMOS and will provide a start with preventive approached EIA and stricter standards. After approval,

it will take time before efficient standards and EIA procedures will be in place. Moreover, the lack of

staffing, knowledge, and monitoring equipment need to be solved. Monitoring equipment and

laboratories are scarce and enforcement is basically not applied.

NGO’s can provide publicity about the performance of foreign companies operating in the country

based on their own control and inspection. Also awareness building within the companies and among

civilians can be important to protect the environment in the absence of an official framework.

There are several types of incinerators, with different types of capacity and equipment options, with

different costs. The total costs of an incinerator are generally made up of a few elements, all of which

have to be carefully considered if the most cost-effective option is to be selected.

36

CHAPTER 4 ANALYSIS AND FINDINGS COMPARATIVE STUDY

A comparative study of medical waste treatment of at least two countries, the US and other developing

countries, and analyses thereof is applicable. The US is well in advance and can be used as a

benchmark for Suriname. Other developing countries in Latin America and the Caribbean are having

comparable health-care conditions and can be used as point of reference. The purpose of this

comparative study is to understand the commonalities and differences in medical waste treatment

methods, and through analyzing different incineration models, develop practical input for a feasible

model for the health-care sector in Suriname.

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

The following scheme illustrates the data gathering of this study:

Waste Generators

Industry

Literature review

Medical Waste data gathering

Other government institutions

Environmental organizations

Public Incineration

Health Organizations

Hospitals & Medical Laboratories

Source: Author

37

As shown in figure 2 different medical, environmental, and governmental organizations have been

taken into account, in order to gather data of the medical waste treatment alternatives in Suriname.

Models used in US and other developing countries are compared within this topic. General aspects like

issuing Framework Law, medical waste regulations, environmental objectives, and scope of waste

treatment, moreover the comparative study relies on the EU and WHO guidelines of medical waste

treatment as well as some additional issues that are not addressed by these guidelines.

4.1 Selected Models Information from interviewees led to believe that the shift to disposable products for health care

and the implementation of universal precautions have increased the quantity of medical wastes in

Suriname. The volume of wastes requires special handling, such as minimization, which can be

accomplished through incineration. The medical waste treatment in the US and developing countries

take place by the traditionally incineration, whereby the volume of waste effectively is reduced by

more than 90 percent. About 5,000 medical waste incinerators are operating in US.

The disclosure of information about environmental impacts, and the increasing public awareness

ushered in a new era of protest against waste incinerator. Several techniques had already been

developed, but two important parameters influenced the construction of what is now the fourth

generation of waste incinerators: environmental standards and economic efficiency. Guided by

these parameters, new technologies have been created to produce emissions as little as possible, in an

environmental sound way, and also have a reasonable energy return (Eberg, 1997).

For purposes of the recommendations for the medical waste treatment in Suriname, at least two

workable cases have been taken into consideration. A developed country, the US, and other

developing countries in Latin America and the Caribbean, are chosen. The US has significant

experiences on this matter. The US has its legal basis, a sound and well-defined regulations and a

comprehensive legal framework and strongly adheres to most international standards. To address

public concerns about the health and environmental implications of medical waste, US Congress

mandated the Environmental Protection Agency (EPA) to promulgate regulations establishing a

demonstration program for tracking medical waste from the generators point to final disposal. EPA is

38

also required by the Statute to determine how much medical waste is generated and what its

environmental implications are (Lichtveld, 1990).

Developing countries in Latin America and the Caribbean have comparable health care

conditions. As the WHO stated that there is a seriously constrain in developing countries by the lack of

resources, both in terms of finance and trained manpower. These countries 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).

To better understand the problem of health-care waste management, WHO guidance recommends that

countries conduct assessments prior to any decision as to which health-care waste-management

methods be chosen. Tools are available to assist with the assessment and decision-making process so

that appropriate policies lead to the choice of adapted technologies. In support of sound health-care

waste management, WHO proposes to work in collaboration with countries through the following

strategy: the short-term, the mid-term and the long-term strategy. Until countries have access to

proven, environmentally safe options for the management of health-care waste, incineration may still

be seen as an appropriate response. Incineration should comply with some recommendations. The

utilization of energy conversion can generate electricity, provide city heating, and produced distilled

water. A major consequence is the remainder and production of emissions.

A state of the art incinerator converts the heat produced from combustion into steam, which can then be

used to heat structures or to generate electricity and thus lower the cost associated with incineration.

The cost of hospital waste management is less than 1% of the hospital budget. The cost for operating an

incinerator is also related to what the engine uses, fuel or electricity. Furthermore, aspects as type of

incinerator, the capacity, the number of cycles, onsite or outside installation, and the volume of waste

are influencing the cost structure.

The financial resources available from the public and private sectors will necessary influence the

choice of system and the standards of operations. For government-owned health-care establishments,

the government may use general revenues to pay the cost of the waste management system. For private

healthcare establishments, the government may impose direct regulations, requiring them to implement

39

their own waste management systems, compelling them to use public facilities, or allowing them the

choice (as happens in the USA). Incinerator facilities demand very high investments, which require

continuous supply of waste for about twenty years before depreciation is reached. High costs and the

legitimation to attract waste are a disincentive to adopt prevention and alternative reduction methods

In Latin America and the Caribbean countries, especially in large hospitals and clinics, installation of

large onsite incinerations are in some cases, oversized equipment, which lead to high operating and

maintenance cost, resulting in emission of smoke, contaminating particles and bad odors in the

atmosphere. In Brazil and Mexico central incineration systems are installed in which the municipality

and medical waste are treated very efficiently. A central incinerator can reduce both the total

investment cost and the operating and maintenance costs and facilitating the achievement of higher

levels of efficiency and technical capacity. Although, 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.

4.2 Analyses of the interviews and questionnaires The data on which this study is based derived from medical waste management literature,

interviews and questionnaires. Many of these data are not readily available. Assumptions and

estimations are made to assess the quantity of medical waste produced by health-care sector in

Suriname. Data collected from multiple sources may not reflect identical amount of medical waste.

With that in mind, several estimates will be provided whenever possible in this research. The

questionnaire was distributed to the four main hospitals and two largest private medical laboratories in

Paramaribo.

Interviewees stated that data of medical waste is neither registered by the particular medical

institutions, nor by the health care authorities. Estimates of the quantity of medical waste produced by

the four main hospitals and the two labs help determine the magnitude of the total volume of medical

waste generated in Suriname. Estimates of the volume of medical waste are made, based on the figures

gathered from Waspar. Furthermore, the data on which the estimates are based were derived from

medical waste literature of the US and the Netherlands, regarding the volume of municipal and medical

waste.

40

4.2.1 Hospitals The health care sector in Suriname consists of seven Hospitals, which five of these are located

in Paramaribo, one in the East, and one in the West of the country. In the interior there are no hospitals,

but there are some clinics of the Primary Healthcare (MZ). The hospitals in Paramaribo, except for the

Academic Hospital Paramaribo (AZP), can deliver their medical wastes to Waspar to get incinerated.

The AZP is a state-owned hospital. With its 465 beds, 18,000 hospitalizations per year and

210,000 outpatients visiting the various policlinics per year, The AZP is the largest hospital in

Suriname, also functioning as the academic hospital for the Anton de Kom University of Suriname and

training of medical specialists. The AZP is currently the only hospital with an onsite incinerator,

generating the most medical waste of all the hospitals. Their average medical waste is about 36% of the

total waste generated, which is much higher than the WHO standards of 10-25%. The main reason for

this, is that all waste produced by the patient is categorized as infectious medical waste.

Table 10 illustrates the hospitals’ size by number of beds, average occupancy rate, the number of

inpatients and outpatients of the four main hospitals:

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

outpatients

Hospitals

Beds

Average

Occupancy Rate

Inpatients

Outpatients

AZP 465 65% 18.000 210.000

LH 315 63% 10.500 39.800

DKZ 215 65% 10.080 40.040

RKZ 165 62% 9.700 30.500

Source: Author

4.2.1.1 Hospital size

The number of beds traditionally determines the hospital size. As table 10 shows, the number of

beds for these four hospitals is between 165-465. These hospitals can be categorized, as “small

hospitals”, because the number of beds is less than 500 (Lichtveld, 1990). According to Rutala and

41

Sarubbi, there is a positive correlation between size and waste generation rate. Because large hospitals

generally offer more services than smaller ones, this is probably the case.

4.2.1.2 Occupancy rate

One of the determinants of the amount of medical waste hospitals generate is occupancy rate.

The average occupancy rate for all hospitals in the USA is 62.4 percent, while this average rate is 63.8

percent for the four main hospitals in Suriname.

4.2.1.3 Inpatient and Outpatient ratio

In general, inpatients generate more medical waste than outpatients do. The inpatient/outpatient ratio

for all hospitals in the USA is 0.07 percent, although this ratio is 0.09 percent for AZP and between

0.25 to 0.32 percent for the 3 other hospitals in Suriname. The ratio for these 3 hospitals is much higher

than AZP. Because AZP offers more services, such as an emergency department, than the other

hospitals, this is probably the case. However, the reliability of this ratio as an indicator for waste

generation is influenced by the increasing number of services provided on an outpatient basis and a

change in the type of services provided on this basis.

4.2.1.4 Waste type and quantity

The term “Infectious waste” is used to describe a subset of medical waste that has been

traditionally managed separately by hospitals. USA hospitals generate infectious waste at a rate of 3.7

kg per bed per day. The average infectious medical waste of AZP is about 0.41 kg per bed per day,

while the average of the other 3 hospitals is between 0.14 and 0.18 kg per bed per day. The reason for

these lower averages for hospitals in Suriname is probably the significant use of non-disposables and

reuse of materials, such as cloths instead of paper wipes. The average figures obtained in various Latin

American countries for the generation of solid wastes in hospitals range between 1.0 and 4.5 kg per bed

per day (WHO, 1994).

Table 9: Medical wastes produced per medical institution

Based on the answers of the questionnaires and interviews the following table can be shown:

42

Medical institution

Medical waste

Kg/per day kg/per year

In %

Hospitals 366 133.590 74%

Medical Laboratories 45 16.425 9%

Other Medical Institutions 86 31.390 17%

General Total 497 181.415 100%

Source: Author

Table 9 illustrates that the hospitals in Suriname are the primary generators of waste by volume,

producing 74 percent of the total annual regulated medical waste, while in the US this is about 77

percent. However, regulated waste generation rates within the hospital category vary significantly.

Based on the data from the questionnaires, the total volume of medical waste generated in Suriname is

about 181 ton per year.

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

Based on the data of Waspar the following table can be shown:

Medical institution Type of waste Kg/per day kg/per year In %

Medical Waste 514 187.714 60%Hospitals*, medical labs and

other medical institutions Other waste 343 125.413 40%

General Total 857 312.857 100%

Source: Author

Table 10 illustrates that the hospitals (AZP not included), medical labs and other medical institutions in

Paramaribo deliver medical waste at Waspar for roughly 187 ton per year, which is 60 percent of the

total waste.

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

Based on medical waste literature of the US and the Netherlands the following table can be shown:

43

Country

Type of waste

Municipal waste Medical waste

(Per year) (Per year)

Population

Ratio

Municipal waste

per capita

US 158 million ton 500.000 ton 281 million 562 kg

Netherlands 8.1 million 25.000 ton 16 million 506 kg

Suriname 83.000 ton 265 ton 495.000 169 kg

In table 11 the estimate quantity of medical waste in Suriname is based on the ratio municipal waste per

capita. Therefore, an assumption is also made that the living standard in Suriname is as a third of the

Netherlands. Based on this assumption and the ratio municipal waste per capita the volume of medical

waste in Suriname is about 265 ton per year.

Tables 9 to 11 illustrate that the total volume of medical waste in Suriname is in the range of 181 and

265 ton per year. When, Waspar incinerates 187 ton, AZP about 70 ton, Suralco roughly 5 ton, than

where the remaining of 3 ton medical wastes were been treated. There is no data available of the

treatment of this considerable amount of more or less than 3000 kg medical waste per year. Probably

this amount of medical waste is dumped in the landfill mixed with municipal waste. Because a few

years ago, some landfill workers found used needles and body parts in this area.

The issue of medical waste treatment is very concerning, because of the absence of well-functioning

control system and compliance with environmental laws and regulations. However the medical

institutions are responsible for ensuring an adequate waste management plan. Stakeholders and

authorities in the health-care sector are required to be more aware of the treatment of medical waste in

an environmental friendly and safe manner. This is very essential to minimize environmental pollution,

but foremost to prevent public and health risk injuries.

4.2.2 Medical laboratory

Currently, there are three private medical laboratories in Suriname. The head office of these

three medical laboratories is situated in Paramaribo. The two labs, Health Control (HC) and My Lab

(ML) have several branches in and around Paramaribo and in the other Districts. Although, the medical

wastes of all these branches are collected centrally, at the head office, from whereon it will be delivered

44

at Waspar or other incineration. The wastes include blood and blood products, cultures and stocks of

infectious agents, sharps and needles. To assure proper identification, waste sharp containers are

normally red in color and maybe imprinted with the universal biohazard symbol. Inappropriately

managed sharps increase the opportunity for injury and infection in occupational subgroups, such as

personnel handling garbage. Scientific literature has reported the transmission of infectious agents by

contaminated sharps. However, almost all these transmissions occurred during patient care or

laboratory procedures (before the sharp is discarded), and therefore are not associated with medical

waste (Lichtveld, 1990).

45

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

Medical Laboratory Patients per year Medical waste kg per year

Health Control 45.500 8.710

My Lab 28.600 5.475

MediLab 11.700 2.240

General total 85.800 16.425

Source: Author

4.2.3 In-home medical care In-home medical care is becoming an increasingly important source of medical waste. Sharps

are predominant type of waste associated with in-home medical care. The Suriname Diabetes

Association (SDES) estimates that 10% of the population has diabetes, although only 5% have been

diagnosed and less than 1% have been registered. One percent of all diabetic patients are estimated to

use insulin. Each patient is estimate to use one sterile needle for each of the two required daily insulin

injections, most often administered at home. Based on this data, insulin-dependent diabetics are

estimated to have used roughly 1500 kg per year sterilized syringes.

About 10 % of the diabetic population uses blood glucose tests, and self-monitoring of blood

glucose is becoming increasingly common. Based on information on frequencies of self-testing of

blood glucose, an estimated 390.000 self-administered blood glucose tests were used in 2005. If one

lancet is used for each blood test, 390.000 lancets were used in 2005. Again, no estimates are available

concerning the amount of waste in kg per year these lancets represent. However, this group of diabetics

produced an estimate of 2000 kg medical waste yearly, which is treated as municipal waste.

4.3 Medical waste management Nationwide, 81.000-ton municipal solid wastes are created yearly. Medical waste is a part,

albeit a small one at 0.3%, about 265 ton per year. 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 hospitals and labs. Simultaneously, the impetus to recycle, reuse, and reclaim

products is paramount to adequate manage solid medical waste, now and in the future.

46

4.3.1 Medical waste management plan The hospitals and labs in Suriname do not have a systematic approach of medical waste

management, meaning from the point of generation to the point of final disposal. They nevertheless

have a written medical waste management plan. This plan must include the elements of the generation,

segregation, storage, collection, transport, and final disposal. However, small generators may not

require a written plan, but they should train their personnel in the proper handling, packaging, and

transport of medical waste. The waste management plan together with an operations plan, outline the

policies and procedures consistent with OSHA blood borne pathogens standard. This plan shall be

reviewed and updated as necessary. The USEPA recommends that each regulated generator of medical

waste require establishing a medical waste management plan with basic components.

4.3.3 Handling of medical waste The collection of medical waste in the hospitals and labs takes place from several departments

respectively branches to a central location, from where the transport in an open truck starts through the

final disposal. An appropriate storage room for medical waste is not available, which must be cool

(refrigerated) especially for medical waste that can decay, such as blood and blood products. During

storage, the packaging method should ensure that no vermin or rodent could get access to the waste,

primary if the waste cannot be treated immediately after generation.

The wastes are packed in different colored bags, such as in Red bags with the “Biohazard”

remark for particularly infectious medical waste, and in Black bags for non-infectious waste. Sharps

and needles are first packed in plastic containers and than in boxes or plastic bags, because of the risks

for cuts, scrapes, or punctures. The blood and blood products are packed in double bags, because

leakage and dripping can take place during the transportation. Pathological wastes and body parts are

collected and frozen, which are once or twice in a week, picked up by a contractor and buried in a

public cemetery.

4.3.4 Vaccination and training The employees of the hospitals and labs are not consequently vaccinated against Hepatitis B,

particularly those who are in contact with infectious medical waste. It is a requirement that every

employer need to provide a Hepatitis B vaccination to every employee. If an employee is exposed to a

47

pathogen, the employer needs to provide their employee with a series of vaccinations and a follow-up

medical consultation.

These medical personnel are not adequate trained for handling medical waste. Instructing

employees about the principal of good medical waste management is very essential. Making them be

aware of proper medical waste management is important to protect their self, the public health and the

environment.

4.3.5 Conclusion Although, the hospitals and labs do not meet the basic elements for an appropriate medical waste

management, they are convinced to implement these aspects within a workable plan. They also propose

that the Framework Law need to be approved, within a short time, which can strengthen the legislations

and regulations for particularly medical waste management. Create more possibilities for these health-

care providers in such a way that there are more facilities with extensive capacity for treating their

medical waste in an environmental responsible manner at a reasonable price. They are really concerned

that medical waste is not treated on an adequate way. A structural control system for medical waste

disposal must be enforced, in order to manage the waste on an appropriate way.

4.4 General aspects Based on the general aspects illustrated in the comparative study some recommendations will

be made for the feasibility of a (private) medical waste incinerator in Suriname.

4.4.1 Approval Framework Law The approval of the Framework Law is opted as highest priority, foremost it has been presented

since 2001 to the Council of Ministers and Assembly. Followed by effective standards and a well-

equipped inspection and enforcement system. New regulations on (hazardous) waste fits into an

existing framework of national laws of (medical) waste, on public health and safety, on the

management of air and water pollution, and on transport safety.

48

4.4.2 Medical waste regulations After approval of the Framework Law, the regulations for medical waste must be the next

priority, with its rules and an adequate and well-structured control system. General elements of medical

waste legislations, such as defining environmental objectives, defining responsibilities of generators,

classification of wastes, standards for waste transport, and penalties for non-observance of

requirements must taken into consideration.

The Ministry of OW, Environment Inspection, BOG and NIMOS as governmental actors are

engaged in waste policy in Suriname. Ministry of ATM is a legislative and planning actor, responsible

for waste acts and national programmes. These governmental actors are required to facilitate

appropriate waste disposal, in combination of waste reduction strategies, and environmental as well as

different societal interests.

In most countries in Latin America and the Caribbean, 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 (PAHO, 1992). Besides the general principles, these most

essential aspects must clearly be defined regarding the (medical) waste regulations.

4.4.3 Scope of waste treatment The current situation for waste treatment in Suriname is as following, an on-site incinerator at

the Academic Hospital, a central Public incinerator, the Public landfill, Barrel incinerators in several

rural areas, and an on-site incinerator of the Suralco. These two on-site incinerators are not available

for other waste generators, nevertheless only the Public Incinerator, the Public Landfill, and Barrel

incinerators are obtainable for other waste generators.

4.5 Public Incinerator The Public incinerator is not managed very properly. There is lack of efficiency and

effectiveness. Privatizing this operation or selling to other related company can be more competitive

and manage to be profitable, to sustain the on-going concern. A disadvantage is the small capacity of

the incinerator and the outdated model, reaches temperature of only 600-700ºC, and without air

pollution control system.

49

4.5.1 On-site incinerators Above-mentioned options of Public incinerator can be modified for the on-site incinerator of

the Academic Hospital. Disadvantages are the small capacity of the incinerator and the obsolete model,

without air pollution control. AZP is currently at phase of investing in a new incinerator, with more

capacity so it can be available for other medical waste generators. Finding the funds for this project is

the obstacle at this moment, because it is a capital-intensive investment.

The on-site incinerator of Suralco can be outsourced or sell to other company that can manage

more efficient. As the Suralco has an over-capacity of about 85%, there is excessive space for other

waste generators. The location of this incinerator is ideal, not in a populated area. Placing this

incinerator in a more central area, not faraway from the other waste generators, is optional. An

advantage is the less working hours, because of the under utilization.

4.5.2 Other options Besides, evaluating and restructuring the managing of existing incinerators in Suriname, implementing

new incinerator for proper (medical) waste treatment is an option to assess. Whenever possible, waste

reduction, recycling, reuse, and reclamation should be considered as waste management alternatives to

incineration.

Decontaminate medical waste can be managed by heat treatment (sterilization or autoclaving),

chemical treatment, and radiation treatment. Each method’s effectiveness and efficiency depends on

factors such as contact time, bioload (number of microorganism in the material to be treated), organic

content, volume, and physical state of the waste (liquid or solid).

Landfills disposal traditionally have been used in the US for solid waste disposal. At a proper managed

sanitary landfill, all waste is covered daily, percolation of large amounts of rainwater through the waste

material is prevented, access to the waste material is controlled, and migration of waste material or

leakage from the landfill is prevented or controlled. Groundwater is generally monitored and leakage

collected.

50

4.6 Recommendations for setting up the incinerator project Incinerators operate at their maximal efficiency when their capacity is large. When the wastes

they burn have a sufficiently high calorific value, when the burn produce a sufficient amount of heat to

evaporate the moisture in the wastes and raise the temperature of the burning wastes without the

addition of extra fuel. In order to ensure complete combustion-so that odors and smoke are kept to a

minimum-, the temperature must be high -higher than temperatures commonly achieved in municipal

incinerators-, and the wastes must be held at this high temperature for a sufficient time, and agitated or

turned sufficiently to ensure that all the mass is burned. Hence, the three T’s of incineration-

Temperature, Time end Turbulence (WHO, 1994).

In the industrialized world, standards requirements for hospital incinerators have been rising rapidly.

The most modern types have rotary kilns that guarantee sufficient turbulence by causing the wastes to

tumble over as they burn. There is usually a secondary combustion and minimize smoke and odors.

Temperatures of about 1000ºC are attained in the secondary combustion chamber. At the high

temperatures attained in such incinerators even needles may disintegrate.

In Paramaribo it may be appropriate to use one incinerator to serve a number of medical establishments

in the area. If this is the case, care must be taken to ensure that the method of transport of wastes to the

central facility is safe and reliable. The location of the plant and the height of the chimney must be

carefully considered, with respect to prevailing wind directions and surrounding elevations, to

minimize problems caused by the emissions. It is important that the method of loading the waste into

the plant does not expose the operators to any avoidable risks. Ashes from incinerators may be buried

in the municipal dump.

Finally, it is recommended that setting up more waste incinerators, supplying the potential (medical)

waste generators will improve efficiency and effectiveness. This incinerator is required to meet the

demand of optimal quality and service. The latest technology incinerator with air control system and

minimum (air) pollution, the most appropriate capacity, located in a central area, to provide and

facilitate the potential medical waste generators. Guidelines for medical waste treatment of the EU,

WHO, USEPA, and NIMOS need to take into consideration and be implemented in medical waste

management project.

51

Furthermore, managing this new incinerator(s) should be initiated by a private sector, in order to

maintain a viable and on-going concern. The potential medical waste generators are eager to pay more

than the current price of SRD 102, for quality and sustainable pick up service.

4.6.1 Cost of incinerator There are several types of incinerators, with different capacity. The most modern types used in

industrialized countries have rotary kilns, which meet standards requirements of hospital incinerators.

There is usually a secondary combustion and minimize smoke and odors, and reaches temperatures of

about 1000ºC, attained in the secondary combustion chamber. At the high temperatures attained in such

incinerators even needles may disintegrate.

Based on the estimated potential medical waste of 265 ton per year, an engine with a minimum

capacity of 1000 kg per day is required (1 year = 52 weeks @ 5days). If, a cycle is about six to eight

hours, than two cycles are needed per day. The initial investment of this type of incinerator is roughly

US$50.000 (benchmarked with investment of Waspar). Other cost, such as cost for land, cost for

building, fuel cost, labor cost and other operating cost can be estimate about US$ 73.500 per year (see

table 13). When pick up services are included, the cost for collecting waste must be calculated too.

Indirect cost such as training cost, uniforms and safety equipment cost, ash disposal costs, and waste

collection trucks should also take into consideration.

Currently the price is US$3,57 for 20 kg waste. Assume that the medical waste is about 60 percent of

the total waste; the total waste is roughly 442 ton. Based on these assumptions and supplying 100% of

the potential waste market, the first year a profit of US$5.400 will be earned (this is the best case). The

return on investments of this incinerator project ($85.000 = investment incinerator, land and building)

will be after approximately 12,5 years (see table 14). As other countries experienced the pay back

period of about 20 years for incinerators projects, this specific case can be acclaimed feasible.

2 1 USD = SRD 2,80

52

Table 13: Estimated investment cost and earnings of incinerator project

Type of cost/investment Remarks Per year in US$ Incinerator investment $50.000 Service per year $250 per month 3.000 Depreciation 10 years (10% per year) 5.000 Diesel $0.93 per liter (1250 liter per month) 14.000

Labor 2 operators, 1 finance & administration,

1 all rounder, 1 manager 29.500 Utility 5.100 Others 13.400 Land investment $10.000 Building investment $25.000 Depreciation 10 years 3.500 Total Overhead 73.500 Turnover S3.57 @ 20 kg (442 ton waste) 78.900 Net Profit 5.400

Source: Author

Table 144: Return on Investments

Year Profit per year in US$ Total Profit in US$ 1-10 5.400 54.000 11-12 13.900 27.800 13 13.900 13.900 95.700

Source: Author

When purchasing any incinerator, it is very important to include an agreement with the manufacturer or

distributor for maintenance and service, in order to prevent out of working of the incinerator for long

periods. Furthermore, critical spare parts must be enclosed within this contract. The total cost are

generally made up of the above-mentioned elements, all of which have to be carefully considered if the

most cost-effective option is to be selected.

53

4.7 Summary

Most of the medical waste data are not on hand available and due to the confidentiality of the

information, assumptions and estimations are made to assess the quantity of medical waste produced by

the health-care sector in Suriname. The questionnaire was distributed to the four main hospitals and

two largest private medical laboratories in Paramaribo.

The hospitals in Suriname are the prime waste generators by volume, producing 74 percent of the total

annual regulated medical waste, while in the US this is about 77 percent. Their average medical waste

is about 36% of the total generated waste, which is much higher than the WHO standards of 10-25%.

The main reason for this, is that all waste produced by the patient is categorized as infectious medical

waste.

The total volume of medical waste in Suriname is in the range of 181 and 265 ton per year. If, Waspar

incinerates 187 ton, AZP about 70 ton, Suralco roughly 5 ton, than the concern is where the remaining

of 3 ton medical wastes have been treated or dumped. There is no data available of the treatment of this

considerable amount of more or less than 3000 kg medical waste per year.

The hospitals and labs in Suriname do not have a systematic medical waste management approach,

from the point of generating of waste to the point of final disposal. They nevertheless have a written

medical waste management plan.

The hospitals and labs do not meet the basic elements for an appropriate medical waste management,

but they are convinced to implement the basic aspects within a workable plan. They also propose that

the Framework Law need to be approved, within a short time, which can strengthen the legislations and

regulations for particularly medical waste management.

The approval of the Framework Law is opted as highest priority, foremost it has been presented since

2001 to the Council of Ministers and Assembly. Followed, by effective standards and a well-equipped

inspection and enforcement system.

54

Besides, evaluating and restructuring, managing of existing incinerators in Suriname, implementing

new incinerator(s) for proper (medical) waste treatment is an option to assess. Whenever possible,

waste reduction, recycling, reuse, and reclamation should be considered as waste management

alternatives.

It is recommended that setting up new incinerator(s), providing the potential (medical) waste generators

will improve efficiency and effectiveness. It is a requirement that this incinerator meets the demand for

optimal quality and service. The latest technology incinerator(s) with air control system and minimum

(air) pollution, the most appropriate capacity, should be located in a central area, to facilitate the

potential medical waste generators. Guidelines for medical waste treatment of the EU, WHO, USEPA,

and NIMOS need to take into consideration and implemented in medical waste management project(s).

55

CHAPTER 5 IMPLICATIONS AND RECOMMENDATIONS

In chapter four, a set of treatment and disposal methods for medical waste was recommended.

Implementation of these treatment methods will have managerial implications for the potential

companies and the existing waste generators. In paragraph 5.1, some recommendations for these

institutions will be made. For ultimate waste disposal, the Surinamese government must implement

goal-oriented priorities. Some of these recommendations are described in paragraph 5.2.

5.1 Managerial implications and recommendations

5.1.1 Waste Management in Suriname Adopting any method for medical waste disposal within the Surinamese context will have

implications for the potential company and the existing provider of waste incineration. In addition, this

will be a solution to the waste generators in the health-care sector, and the community in general. This

will lead to competitiveness and efficiency, which is positive in the customer’s perspective. It can

improve responsible and safe waste management.

The technical and economic feasibility of providing adequate treatment and final disposal of medical

wastes is directly related to the possibility for 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 intense,

expensive, and difficult. This approach has been applied in countries such as Chile and Cuba, where

source separation of infectious fractions is normal practiced and then incinerated, biodegraded, or

sterilized in small units especially designed to treat this type of waste (WHO, 1991).

Approval of the Framework Law by the Council of Ministry will enforce the rules to be followed. As

well as, the medical waste regulations with a well-equipped control system will ensure the rules to be

followed. This would strengthen the awareness process of treating waste in a responsible and safe

manner. It is also recommend that simultaneously an awareness program must be initiated, aimed at the

health-care sector in general and potential investors in particular. Approval of the Framework Law and

56

the waste regulations will encourage the health-care sector to implement a waste management plan. It is

recommend that health care and environmental authorities stimulate and facilitate the medical waste

generators to initiate this essential plan.

As the WHO (1991) stated that the human element is more important than the technology. Almost any

system of treatment and disposal that is operated by well trained and well motivated staff can provided

more protection for staff, patients and the community than an expensive or sophisticated system that is

managed by staff who do not understand the risks and the importance of their contributions the

management of medical waste. Hence, as starting the awareness process, also the waste generators

must initiate training programs for their employees. As the employees of waste generators, waste

handlers, transporters, and other employees within the total chain, from generation to waste disposal

requires to be vaccinated for Hepatitis B.

5.2 Hospitals and medical laboratories For large hospitals an on-site incinerator is the solution, where the quantity of wastes to be

incinerated makes it possible to achieve proper costs and efficiency. It is recommend setting up a

central incinerator that will provide more possibility for the medical waste generators in and around

Paramaribo. The distance for transportation from the generators to the incinerator will not be far, which

will be more cost efficient.

A central incinerator can reduce both the total investment cost and the operating and maintenance

costs and facilitating the achievement of higher levels of efficiency and technical capacity. Although, 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.

It is recommended that a private investor need to manage the waste incineration project with a more

social and community minded approach. The reasons for and the benefit for implementing a private-

owned incinerator for (medical) waste treatment for hospitals or medical laboratories should be

efficient and effective waste disposal. This will increase the value of the health-care, by focus on the

core business to improve organization performance, and contribute to the long-term survival of the

medical institutions.

57

Hospitals and medical laboratories must increase their awareness of managing medical waste on a

proper way. This might have positive effects on the organization. When the medical waste generators

decide to comply with the medical waste plan some time must be taken to discuss the impact on the

company and necessary adaptations on the internal organization. It requires diligence and care from a

chain of people, starting with the nurse or doctor who use the equipment and supplies that become

waste, continuing through the porter or laborer who provides clean sacks or containers and carries away

the waste, on the mechanics or technicians who keep the vehicles and equipment in good condition,

finishing with the person responsible for ensuring that residues are disposed of in the correct way. If

any of these are careless in their work, or allow scavengers access to the waste, the chain is broken and

dangers follow.

5.3 Other medical institutional Other medical waste generators should also work on a waste management plan. It is also

recommended to strive for one national waste management plan for both non-hazardous and hazardous

waste, for more co-operations, and more transparency. Training their employees in handling medical

waste, and vaccinate the employees against Hepatitis B is also recommended.

The reasons for and the benefit of having a private-owned incinerator for (medical) waste treatment for

other medical institutions are more or less as the group of hospitals and medical labs. The only

difference can be in the scale of medical waste.

5.4 National implications and recommendations Based on expression of some interviewed persons, there is need for improvement of values and

standards for primary waste issues nation wise. Developing and starting awareness programs and

relevant programs for educational systems can stimulate this culture change. Improvement in basic

skills, knowledge and attitude is needed to reduce waste in the environment on national level.

It is highly recommended that the Environmental Framework Law-defining responsibilities and in a

second stage environmental standards and Environmental Impact Assessment (EIA) procedures

urgently need to be approved. The approval of the Law, subsequent installation of environmental

58

authorities, adoption of standards, could provide a sound basis for further environmental protection in

the country.

As the European Union (EU) stated that the overall environment performance in Suriname is not very

positive, it is recommend improving on this by prioritizing environment issues on the political agenda.

Many environmental objectives in the countries will not be achieved as long as the institutional

environmental framework is not enforced. Most of Surinamese environment objectives will not be

achieved as long as the institutional environment framework is not enforced.

It is recommended that the Surinamese government pays the debts to the health sector on time.

Government commitment and support is needed to reach an overall and long-term improvement of the

situation of the health care. 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.

5.5 Legislation and implementation The Framework Law will arrange environmental institutional set-up and responsibilities and

will provide specific standards and rules for inspection and enforcement and sanctions. The Framework

Law also arranges for EIA, chemical waste, permit procedures, audits, plans and strategies. After

approval NIMOS will become the Environmental Authority under Ministry of ATM and the second

phase of activities will be implemented, including the establishment of specific environmental

standards and EIA rules. The erroneous vision that care for the environment and clear regulations have

a negative impact on the attraction for foreign investors and on the growth of industrial and trade

sectors in general.

5.6 Control and sanctions Legislation is ineffective unless there is adequate enforcement and sanctions. Enforcement

requires an inspector that is trained to recognize the special aspects of (medical) 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 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

59

clearly defining the responsibilities of the different institutions involved, without proper identifying the

different categories of wastes.

It is recommended that Suriname must carry out EIA at different levels. These include the project,

program or policy levels, the national level, and the sectoral or regional levels. EIA’s can play a major

role in building environmental capability in the country. NIMOS has established a system for scooping

of activities for which an EIA should be carried out.

60

CHAPTER 6 CONCLUSION

6.1 General conclusion This study proves that the health-care sector in Suriname does not have alternatives to dispose

their medical waste in an environmentally and safe way. The need for adequate options is required.

Setting up private-owned waste incinerator project(s) is urgent necessary to ensure efficiency and

effectiveness. The Surinamese government and the health-care sector should become more aware of the

implementation of a national (medical) waste management plan, and the significance of these standards

for a sustainable environment and prevention of health-care risks. This written Waste Management

Plan should address at least the following issues:

- Identification of medical waste

- Segregation of hazardous and non-hazardous wastes

- Proper procedures for waste collection

- Packaging and labeling of waste

- Storage

- Procedures in case of Spill

- Transportation

- Treatment, destruction, and disposal

The US is well advance in medical waste treatment and can be use as a benchmark for Suriname. Based

on the analyses of comparative study, the situational factors of Suriname and the Return on Investment,

is setting up a private-owned incinerator project appears to be feasible. Approval of Framework Law

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

Waste Management Plan evolves from interplay of all social sectors and institutions. Of all actors, two

play an indispensable role: the environmental movement, which proved to be in their right in many

cases and has contributed to a great deal of waste management; and the government, which has the

democratic power and authority to settle matters on collective actions.

61

Management and operational problems with incinerators, including inadequate training of operators,

waste segregation problems, and poor maintenance, are recognized as critical issues that should be

addressed in assessment and waste management plans.

Elements of successful waste strategies, which can be followed, are:

- Early discussions with the public

- Openness to public views and suggestions

- Strong emphasis on waste reduction actions

- Safe management of existing facilities

- Safe design of new facilities

- A facility operator who has public confidence.

Implementing these elements can also strengthen the awareness process nation wise.

6.2 Recommendation for further study As the medical waste generators do not have adequate options to dispose their medical waste, it

is suggested that this project must be implemented within a period of one to two years. It is required

that health-care authorities search for potential investors, with technical advice and support from

International Organizations such as the WHO, PAHO and IDB, to achieve this feasible project.

Implementation of awareness programs will increase the ultimate result in finding investors, access to

capital at lower costs, and contribution in the development of the Surinamese Medical Waste

Management. A further study can be initiated in a broader scope of the subject, in the sense of outlining

the total waste management in Suriname.

62

REFERENCES

Driver, J.H, Rodgers, H.W, Claxton, L.D. Mutagenity of combustion emissions from a biomedical

waste incinerator. In: Proceedings, The 1989 Incineration Conference, Knoxville, Tennessee. Irvine,

California: University of California, 1989.

Eberg J, Waste Policy and Learning. Policy dynamics of waste management and waste incineration in

the Netherlands and Bavaria, Utrecht, 1997.

European Commission. Provision of services in the sector of cooperation related to: Framework

contract EuropeAid/119860/C/SV/Multi. Lot 6: Environment. Beneficiary country: Suriname.

Preparation of a country environmental profile for Suriname. Final report (Mr. Leo Verstappen), June

2006. Consortium, Agrifor consultant.

Gandy, M. Recycling and the politics of urban waste. London: Earthscan Publications, 1994.

Hagenmaier H, Kraft M, Brunner H, Haag R. Catalytic effects of fly ash from waste incinerator

facilities on the formation and decomposition of polychlorinated dibenzo-p-dioxins and polychlorinated

dibenzofurans, 1987.

Lichtveld, M.Y, Rodenbeck, S.E., Lybarger, J.A. The public health implications of medical waste: A

report to congress. U.S. Department of health & human services, public health service, agency for toxic

substances and disease registry, Atlanta, Georgia, 1990.

Michaelsen GS, Vesley d. Disposable hospital supplies; some administrative and technical

implications. Hospital management, 1966.

Monreal, J. Considerations on the management of hospital wastes in Latin America. Environmental

Health Program, PAHO/WHO, 1991.

Ostler, Neal K., Nielsen John T. Waste Management Concepts. Prentice Hall, New Jersey, 1998.

i

Rutala, W.A, Sarubbi, F.A. Management of infectious waste from hospitals. Infect control, 1983.

Schwarz, M., Thompson, M. Divided we stand. Redefining politics, technology and social choice. New

York: Harvester Wheatsheaf, 1990.

U.S. Environmental Protection Agency. EPA guide for infectious waste management. Washington,

D.C.: U.S. Environmental Protection Agency, Office of Solid Waste and Emergency Response, 1986.

United Nation Environment Programs (UNEP). Wastes and their treatment, Information Sources,

Nairobi, 1994.

Weale, A. The new politics of pollution. Manchester, New York: Manchester University Press, 1992.

Wynne, B. Risk management and hazardous waste in the European Community. In: H.Otway, M.

Peltu; Regulating industrial risks. Science, hazards and public protection. London, Butterworth & Co,

1985.

Wynne, B. Risk management and hazardous waste. Implementation and the dialectics of credibility.

Berlin, New York: Springer verslag, 1987.

ii

APPENDICES

APPENDIX 1 MEDICAL WASTE TREATMENT METHODS

The primary methods of treatment of medical waste are:

Incineration

Autoclaving or steam sterilization

Irradiation

Thermal inactivation.

The choice of which treatment method to use depends on the waste’s physical composition and the

different types of packaging selection. 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.

Ad. A Incineration An incinerator is a multi-chamber facility with a secondary chamber that operates at temperatures of

800-1200 ºC. At these temperatures, the pathogens are removed and the high volume of plastics

reduced. In addition to the removal of infectious agents from medical waste at high temperatures, an

incinerator also minimizes acid emissions and results in an 85 to 92 percent volume reduction of the

waste. Incineration, therefore, not only largely eliminates the hazards of pathogens, but also

significantly reduces the amount of waste going into the nation’s landfills.

Although incineration is a suitable treatment for most types of infectious waste and reduces landfill and

transportation cost, it also creates air emissions problems. If not done properly and completely,

incineration may allow infectious agents to be released stack emissions and wastewater effluents, and

the ash residue may become hazardous and subject to regulations under Resource Conservation and

Recovery Act (RCRA). Proper control of air emissions can be achieved by using air pollution control

devices, such as scrubbers and electrostatic precipitators.

iii

A state of the art incinerator cover the heat produced from combustion into steam, which can then be

used to heat structures or to generate electricity and thus lower the cost associated with incinerator.

Incineration is currently the most popular method for treating regulated medical waste. The

development of large, regional incinerators with state-of-the-art air pollution control equipment is

encouraged and to eliminate many on-site incinerators (those located at the site of the hospital, research

laboratory, or other medical-waste generator) that cannot meet EPA performance standards.

Ad. B Autoclaving or steam sterilization This method of treating waste involves the utilization of saturated steam within a pressure vessel at

sufficient temperatures and duration to kill infectious agents that are present. This method is efficient

with small quantities of low density and low water content wastes, but is not effective for wastes such

as large body parts and fluids. This method also should not be used to treat toxic chemicals,

radioisotopes, and chemicals that may become volatile in steam treatment. While steam sterilization

does not produce pollutants, it also does nothing to reduce mass of material that must be land filled.

Ad. C. Irradiation For certain materials that cannot be thermally treated, it may be possible to expose these wastes to

ultraviolet or ionizing radiation in an enclosed and shielded chamber. While this method requires very

little expenditures of electrical or steam energy, it requires a high cost for initial equipment purchase,

operator training, ongoing acquisition of radiation sources, and ongoing disposal of the decayed

radiation source. This method also provides very little penetration of the waste with ultraviolet

exposure and those areas shadowed by other waste will not be effectively treated.

Ad. D Thermal inactivation This method reduces or eliminates infectious agents in waste by transferring heat to continuously fed

batches of the waste. This batch-type unit is a vessel heated by exchangers or a jacket filled with steam.

Thermal inactivation of solid waste is accomplished by the application of dry heat in an electrically

operated oven. Air circulation in the vessel, adequate temperatures, and adequate duration are

important to proper operation of the unit. The waste should be mixed before treated with this method to

obtain maximized homogeneity during both the loading and heat application steps.

iv

APPENDIX 2 DESTRUCTION METHODS

- Grinding and Shredding

The process of grinding and shredding treated and untreated medical wastes reduces the overall volume

of the waste, but not the weight. This process allows the waste to be handled more easily to facilitate

treatment, makes it more homogenous for uniform treatment, and renders it unrecognizable.

- Compaction Generally a hydraulic ram is used to compress the waste against a rigid surface area within an

imperious container such as a storage drum. This method reduces waste volume and renders the waste

unrecognizable, but does not reduce the hazards of disease transmission. Because the containers can be

damaged, the potential for accidental releases of the contaminated waste increases. Therefore, this

method is not recommended for untreated waste.

v

APPENDIX 3 INCINERATION TYPES

Liquid injection systems Liquid hazardous waste or hazardous material is introduced into the combustion chamber through

injection nozzles that produce fine droplets that mix with injected air and fuel in the combustion zone.

These fine droplets combust rapidly and completely, producing flame temperatures of 1200 to 1300 ºF

for reaction times of 0.1 to 2 seconds. These incinerators can be used for all pump able organic wastes

but cannot handle waste with significant particulate content because of the potential for nozzle

clogging. Heat recovery is possible from these systems, both acids gas scrubbing with caustic solution

and dry or wet systems for particulate removal may be necessary to meet emission control standards for

incineration systems.

Particular Arc systems The plasma arc system is actually a pyrolysis-a waste treatment process that involves the chemical

decomposition of material by heat, in the absence of oxygen, yielding a gaseous or liquid product that

can be used as a fuel- system, providing high temperature destruction of hazardous wastes or hazardous

materials in the absence of oxygen. A high temperature (9000ºF) plasma gas is developed within the

system by passing an electrical charge between a plasma burner and the bottom of the plasma reactor.

Plasma arc systems are particularly applicable for destroying of high chlorine content wastes, such as

those containing chlorinated pesticides, PCB’s, or dioxins and can be treat both liquids and sludges that

can be fluidized by adding liquid so as to not clog the waste injection system.

Rotary kiln systems Rotary kiln systems consists a long, inclined \, slowly rotating, refractory-lined tube in which solids,

sludges, and/or liquids are placed. Auxiliary fuel is provided at the inlet end of the skin, and as the kiln

slowly rotates, the waste mixture in the kiln is tumbled, providing the turbulence necessary to

effectively mix and heat the waste. The kiln itself is designed to raise the temperature of the waste

material so that combustible waste components are volatized and bright to approximately 500 to 600 ºF

before entering the secondary combustion chamber. Additional liquid waste and/or auxiliary fuel is

added to the secondary combustor, where the final destruction of the gaseous waste products take place

at 1200 to 1500 ºF. Ash residue from the combusted solids exits the outlet end of the kiln, and

additional heat recovery and acid gas/particular removal are provided.

vi

Fluidized bed and circulating bed systems

Fluidized bed incinerators utilize a bed fine, inert packing material to provide turbulence and heat

transfer to the waste stream being incinerated by preheating and fluidizing the bed. Passing the

combustion air at a flow rate high enough up through the bed to expand it by 25 to 30 percent of its

original volume fluidizes the bed. Once the bed reaches the desired combustion temperature, normally

750 to 1000 ºF, the waste feed is initiated at multiple points throughout the fluidized bed. The system is

effective for the incineration of slurries and sludges, but cannot treat soils or viscous wastes.

vii

APPENDIX 4 EMISSIONS FROM MEDICAL WASTE INCINERATORS

Number of

Incinerators

Pollutant sampled Range (lb/ton feed)

Hydrogen chloride 28 0.7-99.4

Cadmium 3 0.05x10-4-580x10-4

Lead 3 0.94x10-4-580x10-4

Total Chlorinated Dibenzofurans 4 3.25x10-6-21.9x10-6

Tetrachlorodibenzodioxin 4 0.04X10-6-1.07X10-6

Total Chlorinated-p-dioxin 4 1.43X10-6-12.5X10-6

Sulfur Dioxide 2 1.47-3.01

Nitrogen Oxides 2 5.75-7.82

Particulates 28 0.05-36.49

* U.S. EPA, 1988

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APPENDIX 5 POPULATIONS POTENTIALLY INVOLVED WITH MEDICAL WASTE

Treatment and disposal and method used*

Methods used ____

Population Decontamination Sanitary Sewer Incineration Landfill

Health care providers/workers X X X X

Veterinarians/Animal care workers X X

Laboratory workers X X

Janitorial workers X X X X

Laundry workers X X X X

Refuse workers X

Wastewater workers X

Maintenance Plant Operators X X

Morticians X X X

* U.S. EPA, 1998

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APPENDIX 6 GENERATORS OF WASTE INCINERATORS

TIME SPAN FUNCTION FEATURES__________________

‘rat abatement” very incomplete combustion;

volume reduction stench; steam production

1960-1985 volume reduction electricity production

resource recovery emissions problems

1985-2000 landfill alternative combined heat and power;

waste-to-energy air pollution control;

recycling of residues

2000-after waste-to-energy specific waste streams;

substance cycle energy and substances

leak processor recovery

* Eberg, J. Waste policy and learning, 1997

x

APPENDIX 7 THE VOLUME OF MEDICAL WASTE IN THE USA

The following figures were collected in the USA by the USEP, 1990:

Source Quantities

(Tons/year)

Hospitals 359.000

Nursing Homes 29.600

Physicians offices 26.400

Clinics 16.700

Laboratories 15.400

Dentists offices 7.600

Veterinarians 4.600

Funeral homes 3.900

Blood banks 2.400

Total 465.600

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APPENDIX 8 MEDICAL WASTE GENERATORS IN SURINAME

Generators Number Hospitals 7

Private Medical laboratory 3

Psychiatric clinic 1

Physicians Offices 110

Private Medical Center 1

Regional Health Centers (RGD) 53

Blood bank 1

Dentists Offices 25

Youth Dentist Offices (JTV) 5

Medical Skills Lab 1

Nurse School Center (COVAB) 1

Bureau of Public Health (BOG) 1

Primary Health Care (Medische Zending) 1

Home for the Elderly 13

Dermatology Clinic 1

Rehabilitation Office 1

Tuberculosis Center 1

Family Planning Services (St. Lobi) 1

Bureau of Pharmaceuticals (BGVS) 1

Other Health Care facilities 10

Total 238

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APPENDIX 9 DISTRIBUTION OF HOSPITALS SIZES

Hospital size in bed Hospital

465 Academisch Ziekenhuis Paramaribo (AZP)

315 ‘s Lands Hospitaal (LH)

225 Diakonessen Hospitaal (DKZ)

300 Rooms Katholieke Ziekenhuis (RKZ)

175 Streek Ziekenhuis Nickerie (SZN)

60 Military Hospital (MH)

10 Albina Hospital (AH)

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APPENDIX 10 ENVIRONMENT PRIORITIES

MOP defines the following environment priorities:

Suriname must define an effective and up-to date environmental legislation in which clear standards

and priorities are laid down;

- Old and obsolete legislation must be adapted;

- Environmental issues should be dealt with on the relevant level and with participation of all

involved civilians;

- Everyone should receive adequate information on the environment, especially with respect to

hazardous substances and activities in their neighborhood;

- The inhabitants of the inland and other local communities play a crucial role in environmental

protection and sustainable development, due to their specific knowledge and traditions. The

authorities must enable them effectively to fully participate in the decision processes with

respect to the environment and natural resources in their resources;

- To safeguard environmental quality for future generations it is necessary to actively improve

environmental conditions, apart from environmental protection;

- The negative environmental impacts from companies’ emissions of toxic substances and

discharges of chemical waste must be reduced by effective legislation and levies.

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APPENDIX 11 BARREL INCINERATOR

The current design used is shown in the figure below. There are 3 holes similar to the one shown in

figure 1, equally spaced around the bottom of the barrel.

Figure 3- Incinerator design currently used

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APPENDIX 12 CROP PROTECTION DESIGN

CPA has a suggested design for a barrel incinerator to burn pesticide containers. They have a best

practice guide for constructing and handling their particular design of incinerator. It appears that

extensive research has been done to optimise this design. Some modifications are made to the

following design of the incinerator and the grate.

Figure 4 - CPA design for barrel

Figure 5 - CPA design for grate

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APPENDIX 13 QUESTIONNAIRE (ENGLISH)

Questionnaire (English)

A. Personal

1. What is your personal background (education, working experience)?

a. Secondary school b. High school

c. University d. other

2. How long do you work for the organization?

………………………………months/years

3. How do you describe your function (tasks, responsibilities)?

a. Medical b. Technical

c. Support d. other

a. Staff b. Middle management

c. Top management c. other

4. What is your position in the organization?

……………………….

B. Operational

5. What is the business of your organization?

a. Hospital b. Medical Lab

c. Medical institution c. Other

6. How much patients does the organization/department treats / services per day/week/month/year?

………………………..patients per day/week/month/year

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7. How much medical waste does your organization/department have to deal with per

day/week/month/year?

………………………..kg/ton per day/week/month/year

8. Does your organization have a waste management policy? Do they have a plan to manage their

medical waste on an environmental and safety way? e.g. Does the department(s) separate the wastes in

hazardous and non-hazardous, is the collection centralized?

a. Yes b. No

9. If yes, what is the policy/criteria/procedure(s)/standards/treatment for handling of medical waste?

Are these criteria carrying out in manual/procedures?

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

10. What can you define as medical waste?

a. Hospital waste b. Clinical waste c. Infectious waste

d. Pathological waste f. Chemical and Pharmaceutical wastes

e. Other

11. How do you store medical waste?

a. Cooled b. Room temperature c. Other

Temperature

……………………………..

12. How does the organization get rid of their medical waste?

a. Incineration b. Auto clave

c. Landfill c. Other

13. Does your organization have an incinerator for medical waste?

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a. Yes b. No

If yes, what is the capacity?

………………………………kg/hour

14. How long is this incinerator functioning?

………………………………year(s)

15. What are the technical specifications of the incinerator?

Usage:

a. Diesel b. electricity c. other

Temperature:

a. <800 °C b. <1000 °C c. >1000 °C d. other

16. Which department(s) is/are involved with medical waste management?

…………………………………………………………………………….……..

17. Collection:

a. Centralized b. Decentralized c. other

18. Are there handling procedures?

a. Yes b. No

19. How medical waste is being collected?

a. Red Bag with “Bio Hazardous” b. Red Bag with “medical Waste” c.Other

20. How medical waste is being transported?

a. “Open” truck b. “Closed” truck c. Other

21. Are employees trained for this job?

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a. Yes b. No

22. Are the employees tested with Hepatitis B and/or C?

a. Yes b. No

23. Are others (external sources) also using this facility?

If yes, who and how frequent, how much payment, agreement (liabilities),

24. If no, how does your organization get rid of medical waste

a. Waspar b. Crematorium c. OW/Landfill d. Other

Frequency

……………………per week/month

How much does it cost?

…………………………..SRD/USD per month/year

Collection

a. Own b. Outsource c. Channel d. Other

25. What can you add to this interview/questionnaires, in order to get more information on this topic?

………………………………………………………………………………….

………………………………………………………………………………….

………………………………………………………………………………….

………………………………………………………………………………….

………………………………………………………………………………….

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APPENDIX 16 QUESTIONAIRE (DUTCH TRANSLATION)

Questionnaire (Dutch translation)

A. Persoonlijk

1. Wat is uw genoten opleiding?

a. MULO b. Middelbare school

c. Universiteit d. Overige opleiding(en) .......................................

2. Hoe lang werkt u voor de organisatie/instelling?

………………………………maand/jaar

3. Hoe categoriseert u uw funktie (taken, bevoegdheden)?

a. Medisch b. Technisch

c. Ondersteunend d. Overig ...................................................

a. Medewerker b. Staf functionaris

c. Directie c. Overig ...................................................

4. Wat zijn uw taken en bevoegdheden binnen de organistie?

…………………………………………………………………………..

…………………………………………………………………………..

B. Operationeel

5. Wat is de aard van uw organisatie?

a. Ziekenhuis b. Medisch Lab

c. Medische instelling c. Overig ................................................

6. Hoeveel patienten worden verzorgd/behandeld/getest door uw organisatie/afdeling per

dag/week/maand/jaar?

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………………………..patienten per dag/week/maand/jaar

7. Hoeveel medisch afval genereert uw organisatie/afdeling per dag/week/maand/jaar?

………………………..kg/ton per dag/week/maand/jaar

8. Heeft uw organisatie een medisch afval beleid? Hebben ze een plan om medisch afval op een milieu

vriendelijke en veilige manier te beheren? Vb. Wordt het afval per afdeling gescheiden in gevaarlijke

en niet-gevaarlijke stoffen, is de vuil ophaal gecentraliseerd?

a. Ja b. Nee

9. Indien ja, wat is het beleid/criteria/procedures/standaarden/regels voor medisch afval beheer? Zijn

deze criteria in een handboek vervat?

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

10. Wat verstaat u onder medisch afval?

a. Ziekenhuis afval b. Klinisch afval c. Infectie afval

d. Pathologisch afval f. Chemisch en Pharmaceutisch afval

e. Overige …………………………………………………………..

11. Hoe slaat u medisch afval op?

a. Gekoeld b. Kamer temperatuur c. Overig ...............................

Temperatuur

……………………………..°C

12. Hoe wordt medisch afval in uw organisatie afgevoerd?

a. Verbrandingsoven b. Auto claaf

c. Vuilstort plaats c. Overige .................................................................

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13. Beschikt uw organisatie over een verbrandingsoven voor medisch afval?

a. Ja b. Nee

Indien ja, wat is de capaciteit ?

………………………………kg/uur

Hoe lang fungeert deze verbrandingsoven?

………………………………jaar

14. Wat zijn de technische kenmerken van deze verbrandingsoven?

Verbruik:

a. Diesel b. electriciteit c. Overig …………………………..

Temparatuur:

……………………….°C

15. Welke afdeling(en) zijn betrokken met het medisch afval beheer?

…………………………………………………………………………….……..

Collecteren :

a. Centraal b. Niet centraal c. Overige ..........................

16. Zijn er instructies/procedures voor het medisch afval beheer ?

a. Ja b. Nee

17. Hoe wordt medisch afval verpakt ?

a. Rode zak met “Bio Hazard” b. Rode zak met “medisch afval”

c. Overig …………………………………………..

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18. Hoe wordt medisch afval getransporteerd?

a. “Open” truck b. “Gesloten” truck c. Overig ……………………………

19. Zijn de werknemers opgeleid voor deze job?

a. Ja b. Nee

20. Zijn deze medewerkers gevaccineerd tegen Hepatitis B en/of C?

a. Ja b. Nee

21. Maken anderen ook gebruik van uw verbrandingsoven?

a. Ja b. Nee

Indien ja, wie maakt hier gebruik van en hoe vaak, hoeveel moeten ze betalen, is er sprake van een

contract? ....................................................................................................................................

....................................................................................................................................

....................................................................................................................................

22. Indien u niet over een eigen verbrandingsoven beschikt, hoe wordt het medisch afval afgevoerd?

a. Waspar b. Crematorium c. Openbare stortplaats

d. Overig ………………………………………………………………

Frequentie/hoeveel keren?

……………………................................................per week/maand/jaar

Hoeveel betaald u per keer?

…………………………..................................SRD/USD per maand/jaar

23. Hoe vindt de ophaal van medisch afval plaats ?

a. Zelf b. Uitbesteed

c. Contractor d. Overig ..........................................................................

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24. Wat kunt u aan deze vragenlijst toevoegen, om zodoende meer informatie over dit onderwerp te

genereren ? ……………………………………………………………………………….....

………………………………………………………………………………….

………………………………………………………………………………….

………………………………………………………………………………….

…………………………………………………………………………….…….

xxv

APPENDIX 17 LIST OF INTERVIEWEES

- Anton de Kom University of Suriname, Mrs. Dr. Ir. L.Zuilen, Lecturer

- BOG, Mrs. M. Sno, head department epidemiological

- JMC, Mrs. W.Saridjo, Office Manager

- MY LAB, Mrs. K. Sewgobind, Chief Operations Officer

- NIMOS, Mrs. C.Resomardono

- NIMOS, Mrs. N. Del Prado

- Waspar, Mrs. S. Saridjan, Board of director

xxvi

APPENDIX 18 MEDICAL WASTE MANAGEMENT PLAN

The USEPA recommends that each regulated generator of medical waste to establish an infectious waste management plan with the following basic components: Identification

Segregation

Proper Collection

Packaging

Labeling

Storage

Spill response

Transportation

Treatment, destruction, and disposal of medical waste.

Ad.1 Identification

The waste management plan should provide procedures for the identification of items in the

waste streams that will be designated as medical or infectious waste.

Ad.2 Segregation

The plan should include operational procedures for separating infectious wastes from

noninfectious wastes at the point of generation. Segregation is very important, especially for generators

who plan to transport their waste off site for disposal.

Ad.3 Proper Collection

The plan should include procedures for properly collecting and depositing infectious wastes into

special primary containers and then placing them into more mandatory for off-site transportation.

Ad.4 Packaging

The plan should include purchase of primary and secondary packaging that is consistent with

OSHA’s Blood borne Pathogens Standard. This means that (1) sharps should be place in impervious,

puncture resistant, rigid containers to eliminate the hazard of physical injury, (2) liquids should be

placed in capped or tightly stopper bottles, flasks, or containment tanks, and (3) solid and semisolid

xxvii

wastes should be placed in plastic bags or lined corrugated boxes. Packaging should be strong and

durable enough to ensure the exclusion of vermin or rodents and maintain its integrity during storage

and transportation. Secondary packaging may consist of either corrugated boxes or reusable containers.

Ad.5 Labeling

Primary and or secondary containers must be properly labeled in accordance with the following:

Information must be permanently printed in indelible ink on all sides and must be clear and easy

readable

The international biological symbol must be displayed in red or orange with a contrasting

background and must be of a size suitable to the package or container.

The words “Biohazardous Waste”, or similar phrase, in red or orange with a contrasting

background must be of a size suitable to the package or container.

Packaging containing infectious substances and regulated medical waste must contain the

following statement: In case of damage or leakage, immediately notify public health authorities.

Ad.6 Storage

During storage, the packaging method should ensure that no vermin or rodent could get access

to the waste. If the waste cannot be treated immediately after generation, the time in storage should be

minimized and the waste should be kept at a low enough temperature (refrigerated) to slow the waste’s

decaying and putrefaction processes.

Ad.7 Spill response

Procedures should be in place in the event that a spill of regulated medical waste occurs, and

employees should be trained to implement these procedures. One method is to cordon off the area and

douse the spill with a high-powered bleach or disinfectant spray.

Ad. 8 Transportation

Once the primary waste containers have been double bagged and placed in secondary

containers, they are generally moved (within the generator facility) using cards identified with the

universal biological hazard symbol. Before being loaded onto a vehicle, waste to be transported from

xxviii

generators to off-site treatment facilities should be placed in containers that are rigid, leak proof, and

resistant to busting punctures, moistures, and tears.

If generator does not transport the waste itself, it should make arrangements for pickup with

responsible third-party transporters or the treatment, storage and disposal facility that will be receiving

it.

xxix