It is 8am. Krishna Kumar Gurung switches on the geyser connected to the autoclave machine.
He started working at the national referral hospital in Thimphu as a ward boy 29-years ago. His routine has not changed much. The 51-year-old wears the gloves, an apron and a facemask and gets ready to autoclave the infectious waste ferried by an ambulance to the storage house.
Anything that comes in contact with patients’ blood and body is autoclaved and treated before disposing to the landfill. Once autoclaved, the waste is claimed to be non-infectious.
The autoclave machine takes about an hour to treat 45 -65kgs of waste under high stream pressure of over 132 degree Celsius. The whole process of autoclaving medical waste starts from carrying the waste inside the chamber to re-package it into an appropriate size to fit the trolley that goes inside the machine. The process to complete the treatment and pile the red waste bags outside the chamber, ready for disposal takes about two hours.
Before the waste bags are treated, a white tape with an invisible strap is stuck on each bag. After the autoclave, the invisible strap turns black, a mark to identify the treated waste from the non-treated.
The hospital installed the autoclave machine in 2007. The hospital, on an average, produces about 160kgs of infectious waste every day. Last year, the hospital recorded about 61,000kgs of infectious waste, four times more than the previous year.
Every morning, the hospital’s ward boys and cleaners collect the waste and transport it to the hospital’s waste storage house located above the mortuary.
Infectious waste produced by the health centres comprise of blood-soaked bandages and gauze, discarded surgical gloves, cultures, stocks, and swabs that are highly infectious.
Krishna Gurung said that all infectious waste that is brought to the storage house is autoclaved the same day. “We autoclave the waste at least twice a day and keep it ready to be collected by Greener Way’s garbage truck.”
Deputy Nursing Superintendent with the hospital, Chhimi Lhamu, said the hospital is currently facing a problem in disposing waste as collection has become irregular.
“Greener Way has limited number of collection trucks which frequently breaks down. When we call them, they always say they are sending the vehicle. The waste remain at the storage house for days.”
Earlier when Thimphu Thromde managed waste collection in the city, she said the garbage truck picked up the waste from the hospital’s storage house twice a day. “In two trips, all garbage bags were cleared.”
However, after the thromde outsourced waste collection to Greener Way, the waste lies at the storage house for days.
“When we call the Greener Way, they say the truck is on the way but it never reaches us. Sometimes they pick up once a week,” Krishna Gurung said. “There is a school just below and the hospital colonies around the storage house. It is not safe to have waste especially infectious waste stored in an open space for a long time.”
Another staff at the storage house said it was risky to keep infectious waste stored in open for days especially during summer. “We can never say that all waste is 100 percent treated.”
Chimmi Lhamu said that earlier, sharp waste was first autoclaved, treated and then some were disposed in a deep burial pit while some dumped at the landfill with other medical waste. After considering its hazard to the waste pickers at the landfill, the hospital now shreds the sharp waste including needles after autoclaving.
Hazardous waste is a non-infectious waste that can harm humans like needles, syringes, and surgical instruments. Pathological waste is disposed in the deep burial pit near the storage house. It includes body parts, placenta or fetuses, and are said to contain pathogens that can give rise to diseases. Pharmaceutical waste include expired and incomplete used drugs while chemical waste is generated during disinfection like chlorine solution.
Records with the health ministry show that the generation of medical waste from health centres across the country increase by about 15 to 20 percent every year.
Health facilities across the country produced 358 metric tons (MT) of medical waste between 2014 and 2015. About 421MT of medical waste were reported in 2015 – 2016.
Programme analyst with Infection Control and Medical Waste Management Programme, Pem Zam said that with the expansion of health facilities and new health services being introduced, medical waste is expected to increase.
According to WHO, she said that if there is good segregation at source then general waste should comprise about 80 percent of the total waste from health centres. The remaining should be infectious waste.
Autoclave facility is available in eight hospitals across the country – the three referral hospitals in Thimphu, Gelephu and Mongar, and at the hospitals in Phuentsholing, Samtse, Tsirang and Wangdue. In hospitals with no autoclave facilities, infectious waste is chemically treated by dipping or soaking it in a chlorine solution and then disposing it to the landfill.
Pem Zam said the guidelines and regulations stress too much on segregation and people do segregate at the source. But, after segregation, because of lack of space to store the segregated waste, people dispose the waste.
Even in gewogs, she said that the BHU IIs segregate waste but because of lack of storage facility and lack of options, they openly burn the waste.
The deep burial pits in villages that are supposed to have a lifespan of five to six years get filled faster because of the sharps waste. In few health facilities, there will not be enough land to construct new pit, even if there is, she said budget becomes an issue.
“Budget to the gewogs is now decentralised and the dzongkhags need to have their own plan to manage waste,” she said. “Now, whenever there is a new hospital construction plan, we are incorporating the infrastructure to manage waste effectively, she said.
A modern health care waste management pilot project has been initiated in Phuentsholing hospital since 2016 with support from WHO. As part of the project, a waste storage house has been constructed along with a deep burial pit. The general waste is segregated into different compartments and once the compartments fill, the waste is sold to scrap dealers across the border.
Shortage of trained staff to manage medical waste is another issue facing the health facilities. Pem Zam said people are trained in waste management and made the focal person only to be transferred.
Sweepers and cleaners, she said, are meant for cleaning, but they are also managing waste. “These staff in hospitals where we have the waste management infrastructure are taken to Phuentsholing general hospital for about six days and trained on the timing to collect, segregate and manage waste.”
Kuensel however, learnt that those involved in managing waste have not received any training and that they learnt the work on the job. Those who avail trainings, the workers claim, are not involved on the ground in managing waste.
Pem Zam said waste management programme is guided by the NEC rules and regulations. “We recently had a meeting with NEC and they ask why there is a problem in implementing the rules,” she said.
Limited fund and human resources are some of the issues that restrict effective waste management. “Until we have a separate fund for waste management, I don’t think much could be done,” she said. “A separate fund for waste management is important if we were to address the waste problem. In the 11th Plan, there was no funding for waste.”
Since 2014, the Drug Regulatory Authority manages the disposal of pharmaceutical waste from private pharmacies across the country.
Officiating Chief Regulatory Officer with DRA’s Marketing Control Division, Pelden Chejor said pharmaceutical waste is also classified into hazardous and non-hazardous and different methods are involved in their disposal.
However, today, the pharmaceutical waste is incinerated at a cement factory in Gomtu. The authority has incinerated about 13MT of pharmaceutical waste between 2014 and 2017.