Located in the Jisr al-Wati district of east Beirut, the infectious medical waste treatment center of NGO Arcenciel is never empty. All day long, trucks bring in tons of waste generated by 112 hospitals in Beirut and its surroundings. Since 2003, Arcenciel has carried out a very necessary task: sterilizing medical infectious waste, which often contains contaminants and is capable of spreading diseases. Among the waste is blood, used bandages and syringes. Although it often occurs in Lebanon, these should not be mixed with domestic waste: burning or burying infectious waste without treating it first is very dangerous for the environment and public health.
Treating medical infectious waste is new in Lebanon: before 2002, sterilizing it was not common practice. Most waste was eliminated alongside domestic refuse or dumped in the open. Some was also incinerated. “We used to incinerate them by ourselves. For about one year Sukleen took them but it stopped when the Bourj Hammoud incinerator closed,” says Youssef Rahal, the former head of the waste management section at Hôtel Dieu Hospital. Until now, only two organizations have been in charge of treating medical infectious waste in Lebanon. According to Joseph Hallit, an official from the Ministry of Environment in charge of auditing hospitals’ medical infectious waste management, Arcenciel deals with 80 percent of the treated infectious waste. The remaining is taken by Safe, a sub-branch of Mirage for Waste Management & Environmental Services, which treats medical infectious waste of hospitals in the Tyre region. A handful of hospitals also treat the waste themselves, such as Haykel in Tripoli and Clemenceau Medical Center in Beirut. All of those using in-house treatment use the autoclave system, whereby a machine crushes the infectious waste, then uses very high temperatures to sterilize it. Once this is done, medical waste is no more harmful than any kind of domestic waste, and it can then be given to domestic waste treatment companies like Sukleen in Beirut or Lavajet in Tripoli. This system is considered much less harmful to the environment than incineration, which was used by hospitals before, or disposing of it alongside domestic waste or burning it in bonfires.
Syrian crisis effect
Overflowing with yellow plastic bags used to transport medical waste, the Jisr al-Wati treatment center is facing a new challenge. “We are receiving about four to five tons [of waste] every day, compared to the two and a half tons three years ago,” says the head of the center Mohammad Keserwani. While the increase can be partially attributed to a growing number of hospitals opting to treat their own waste, this is not the only reason. “With the arrival of Syrian refugees the quantity of waste has also increased a lot,” Keserwani adds, saying that Arcenciel’s system is now jammed. “It is now working 24 hours a day, compared to 12 hours before the Syrian crisis.”
“We have more breakdowns because the system is not [designed to work] so much. This sometimes forces us to move waste to another center to be treated,” he notes. Arcenciel has four other treatment centers throughout Lebanon, and activity has increased in all of them. While Arcenciel treated 1,858 tons of medical waste with infectious risks in 2011, this amount rose to 2,356 tons in 2014.
The hospitals that have an agreement with the UN to treat Syrian refugees — including 50 private and 15 public facilities — are particularly affected. One of them, Al-Kibbeh Public Hospital, in Tripoli, has noticed a significant increase in its infectious waste. “We generated 42,380 kg in 2014, whereas it was only 29,327 kg in 2012,” says the hospital’s hygiene supervisor Rania Ahmad. “New services have been added so it is only normal that infectious waste increased, but that is not the only reason. It is also due to an increase in admissions — mainly pregnant Syrian women.”
The hospital has just implemented a new system which measures the quantity of infectious waste generated by each service. “For the first week of January 2015, labor and delivery services generated 95 kg and the neonatal intensive care 91. Other services, meanwhile, produce much less infectious waste, such as the intensive care unit which made 16 kg or the emergency 26 kg,” she adds. According to figures viewed by Executive, for the past two years these services have been provided to about as many Syrians as Lebanese, meaning the hospital’s activity has significantly increased. In November 2014, 125 Syrian women delivered babies at the hospital, compared to 155 Lebanese. “For every pregnant woman, we also have to plan for two persons: once the baby is born the nursery services are also affected by an increase of infectious waste,” Ahmad explains.
In September 2014, the Ministry of Environment published a report entitled “The Lebanon Environmental Assessment of the Syrian Conflict and Priority Interventions,” which confirms this trend. “The harsh weather and tough living conditions that refugees are facing are having a direct impact on their health. This increases the burden on health care centers in Lebanon and results in an increase in the quantity of infectious medical waste that requires proper treatment before disposal,” it notes. According to the report, there was a 420 ton increase in infectious waste in 2014.
[pullquote]“In [addressing] the Syrian crisis, priority is given to food and health care supplies … but infrastructure is forgotten”[/pullquote]
“We would like to buy another autoclave in order to increase our sterilizing capacity, but it costs around $500,000,” explains the head of the environment program at Arcenciel Olivia Maamari. “In [addressing] the Syrian crisis, priority is given to food and health care supplies — including vaccines — but infrastructure is forgotten, yet it needs to be reinforced because it is weakened by this crisis.”
A lack of needed protocols
This increase, while emanating from a particular context, highlights a long standing and serious issue: infectious waste is not properly treated in Lebanon. According to the September 2014 report, “Review of records for the quantity of infectious waste collected and treated at Arcenciel facilities in 2013 revealed that 72.2 percent of the waste (303,4 t/y) [is] being collected and treated by autoclaving and shredding while the remaining (116,8 t/y) [is] being disposed of in the environment.” Minister of Environment Mohammad Machnouk spoke about this problem in late December, after dangerous medical waste was discovered in coastal and mountainous areas.
Some hospitals fail to treat all their infectious waste. “I saw some sharp containers, plasters with blood in municipality garbage cans,” says Ghazwa Barakat, who is in charge of waste management at Nini Hospital in Tripoli. Barakat was a consultant for a UNDP-led project in two hospitals in South Lebanon in 2010 and 2011 in coordination with the Ministry of Environment, and completed a study on infectious medical waste management for the Union of Private Hospitals in Lebanon in 2012. According to this report, only 32 percent of public hospitals treated their infectious waste in 2012, compared to 54 percent of private ones. “There is a lack of understanding about infectious waste in our country, even among the top management staff. Often, people are not convinced of the importance of treating this waste,” she says. In some cases, hospitals set an infectious waste treatment disposal plan but don’t use it. Barakat stresses the importance of regular staff training sessions to avoid these missteps.
[pullquote]“The Ministry of Health makes no distinction between hospitals that respect the law and those that don’t”[/pullquote]
According to Barakat, it is also a money issue, since treating infectious waste correctly is costly. It requires separating infectious and domestic waste, as well as special garbage cans for infectious waste and special containers for syringes. A low-temperature room also has to be procured for infectious waste storage. Every step of the process requires trained staff and managers. “At Nini hospital, we pay $6,000 per year for sharp object containers and $10,000 for yellow plastic bags,” Barakat adds. Organizing staff training also comes at a significant cost. “However, the Ministry of Health makes no distinction between hospitals that respect the law and those that don’t. It reimburses the hospital $26.50 per night for every patient, regardless of what the hospital does or doesn’t do.”
Barakat suggests that the Ministry of Health should increase its support for hospitals that carry out infectious waste treatment properly. The Ministry of Health did not reply to Executive’s request for an interview to explore this point. Some hospitals merely ensure they prioritize services, because they don’t have money for other systems, like waste management. Hallit adds that some establishments just want to save money: “A lot of Lebanese hospitals are family businesses whose main aim is to make profits. In these facilities, decisions are often made by people who do not have any skills concerning medicine and waste management, they don’t see the necessity to spend money on it.”
“Many stakeholders have studied the possibility of establishing a treatment center, but at this point all of them have stopped, saying it is not advantageous,” says Viviane Sassine, the head of the chemical safety department at the Ministry of Environment. This point of view is shared by Najib Jaber, in charge of quality control at Safe. “Until now, there is no collective consciousness among health professionals concerning the importance of treating medical waste,” he says. “The more they realize the importance of such measures, the more they will treat their medical waste, and this in turn will create a lucrative business to treat it.”
According to him, at this point it has not developed into a very attractive market. “In addition to the large amount of Lebanese bureaucracy, companies need to have a lot of money. Building a medical waste treatment plant costs around $500,000, and it is not very lucrative yet,” he says, adding that Mirage can handle the low profit margins because it is not their main activity. “We did it because it was the continuity of our waste treatment activity but it is not the most profitable activity we have.” Mirage provides a wide range of services, such as street sweeping, hazardous waste management and water treatment. Jaber explains that Safe charges either $0.60 or $0.70 per kilogram of waste, depending on how far the hospital is from their treatment center. While he refuses to give an exact figure for how profitable the enterprise is, he denies it is a significant contributor to company’s overall profits. “We have a very small margin and we cannot consider it something that is very lucrative, because we only treat three or four tons of infectious medical waste per month. It is not enough to generate significant margins,” Jaber says. “If the aim was to make a profit we would increase our prices.” He adds: “We make profits mostly from our hospital cleaning and maintenance service. The infectious waste treatment is a service we offer because our aim is to protect the environment.”
An existing but unenforced law
Lebanese law, however, requires hospitals to take care of their infectious waste. Issued in September 2004, Decree 13389 amended an earlier decree issued in 2002, implementing Environmental Law 444, approved by Parliament the same year. This law defines how to manage infectious medical waste and presents ways to ensure and verify the efficiency of the sterilization process. In 2010, the Ministry of Environment conducted an audit to check whether hospitals are respecting the rules. “We took the initiative to sue 88 hospitals, 16 public and 72 private ones, which do not respect the rules,” says Sassine. However, five years later, none of the violators have been forced to close or have paid a fine. “After we pressed charges, many hospitals provided us with information about their infectious waste treatment processes. The court asked for a second visit to be conducted,” says Sassine. “But they did not rule against anyone.”
“I have seen places where there are yellow plastic bags in boxes, but they were not used by the staff,” notes Hallit, who was in charge of the latest audit of waste management in hospitals undertaken by the Ministry of Environment in 2013 and 2014. “Hospitals spent many years without being subjected to controls; it takes time to spread the culture of waste management.”
[pullquote]The Ministry of Environment lacks human and financial means to monitor infectious waste management[/pullquote]
However, a former employee of the Ministry of Environment, who was dealing with the infectious waste issue and spoke on condition of anonymity, argues that the ministry lacks human and financial means to monitor infectious waste management. “There is not enough staff to regularly check [whether] the law is being implemented, to make sure that accreditations are renewed regularly,” he says. “There is not enough [in the]budget. Even if the law exists, it is nearly impossible to enforce.”
Arcenciel and monopoly
Arcenciel’s medical waste treatment system was funded partly via donations. Since 2003, it has received $1,485,278 from the European Union, the Spanish Agency for International Development Cooperation (AECID) and the French Agency for Development (AFD). According to the head of the waste management program, Arcenciel is barely able to cover operating costs, so it does not make any profit. The initial price Arcenciel charged medical establishments was $0.55 per kilo in 2003, and this has now been increased to $0.60. “We are not looking to make any profits,” Maamari says. Revenues from Arcenciel’s medical waste management program and the donations they have received funded the building of waste treatment centers, as well as training for hospital staff on proper waste management and autoclave maintenance. “Our aim is to serve the public interest. Thus, we made an official proposal to the Ministry of Environment to give our entire network to an incorporated company. The health establishments that use the network would be shareholders, proportional to the number of beds they have.” Until now, however, the ministry has not responded to the request.
[pullquote]Arcenciel has a near monopoly on the sterilizing sector[/pullquote]
More than 10 years after Arcenciel first began treating infectious waste, another fact is clear: the NGO has a near monopoly on the sterilizing sector. George Khayat, the owner of hospital equipment supplier Khayat Medical, tried to enter the market but failed. In 2002, he answered to a tender for selling and managing a common autoclave which would be used by four hospitals: AUBMC, Saint-Georges, Makased and Hôtel Dieu. “I calculated the expenses needed for installation, waste sorting, collection and sterilizing: it was $0.35 per kilo,” he explains. This figure is much lower than the $0.55 per kilo demanded by Arcenciel when it started in 2003. At this price, Khayat says he was planning to have a 25 percent profit margin per kilo. “I then did the Environmental Impact Assessment (EIA), but for one year and a half the Ministry of Environment did not give me any answer.” Finally, the ministry asked Khayat to hold a public meeting in Beit Mery, where the autoclave was planned to be established. Hôtel Dieu’s former waste management head Rahal recalls: “As soon as people heard it was for medical waste they were strongly opposed to the project … It is always the same problem when it comes to infectious waste: companies can never find a place to set up their treatment system because public opposition is very strong.” Without the approval of the municipal council, Khayat never got authorization from the Ministry of Environment. “I lost more than $20,000,” Khayat laments.
According to him, the arbitrary way approvals are given discourages other entrepreneurs from investing in the market: “At the same time I was awaiting an answer from the Ministry of Environment, another company, Env-Sys, received approval in 40 days.” The former employee of the Ministry of Environment, who was employed by the ministry at that time, says that no technical approval was given for Env-Sys by the director general or minister of environment allowing it to treat infectious waste. He adds that Khayat’s company was the most serious of those trying to get the ministry’s approval. “There is a lot of corruption in the ministry,” he notes. “Choices to give accreditation to establishments in charge of sterilizing infectious waste are not based on objective and technical criteria, but rather political or personal ones.”
Things were easier for Safe because the tender they answered was published by the Abbasyeh municipality in Tyre. As it was the municipality’s decision to acquire a medical waste treatment plant, there was no local opposition. “We decided to apply for a financial grant offered by the EU to Lebanese municipalities which had projects to treat waste,” explains Abbasyeh’s mayor Ali Ezzedine, who was vice-mayor in 2005, the year the tender was submitted. The municipality won the grant and the treatment plant opened in 2008. The land and the treatment plant are owned by the Abbasyeh municipality, which chose Safe to manage it. “According to public tender regulations we have to choose the cheapest company. Safe was the one,” Ezzedine says. Safe now treats infectious waste from three hospitals and two polyclinics.
[pullquote]”I have a lot of customers who would like to enter the market, but it is very hard to change the current system”[/pullquote]
Jacques Chahine, general manager of Edessa, a company which conducts EIA and studies for prospective companies that want to enter the infectious waste treatment market, corroborates that challenges exist in the sector. “I have a lot of customers who would like to enter the market, but it is very hard to change the current system in Lebanon that gives 80 percent of the market to Arcenciel, even if our studies show that it could be easy to offer cheaper prices than those of the NGO.” According to him, it is also due to the law. “Arcenciel started its work with a special authorization to treat infectious waste, because Decree 13389 was not implemented at that time,” Chahine explains. Arcenciel started to treat infectious waste in 2003, but didn’t get its first license until 2005. “But for companies that have tried to enter the market after 2004, it is hard to meet the ministry’s requirements.” Arcenciel’s Maamari clarifies that the Ministry of Environment had started to audit the NGO’s centers in early January in order to renew their licenses, adding that they have all done the EIA since 2003.
Haykel hospital in Tripoli launched a general environmental protection plan in 2005 and recycling is now a general rule in the establishment. This is not all. Treatment of infectious waste is part of the plan too. Haykel is one of the few Lebanese hospitals that has purchased its own autoclave for sterilization. “It requires a lot of investment at the beginning, but in the long run it is cheaper than Arcenciel. The cost is $0.50 per kilo,” explains Imane Abdo, head of waste management at Haykel. The hospital invested $37,000 in the machine at first, which has a capacity of treating 10 kg per 30 minute cycle. The hospital treats about 120 kg of infectious waste every day. Abdo underlines that the process is complex and onerous. In addition to the special plastic bags, boxes and purified water needed for the machine, the hospital has to send reports about biological indicators and waste treated every two months to the Ministry of Environment, as well as regularly training its staff. “The process is very intensive, I think that is why there are not so many hospitals which have their own autoclave,” Abdo says.
In a context where infectious waste treatment is still perceived to be more of a burden than a necessity, hospitals prefer to call on Arcenciel, as exemplified by Tripoli’s Al-Salam Hospital. “I started to look at the process to purchase an autoclave, but when I saw all the monitoring and reports we have to do, I decided that it was simpler to work with Arcenciel, even if it is a bit more expensive,” admits Al-Salam’s director Gabriel Sabeh. This commonly held thought is lamented by infectious waste treatment professionals. As Edessa’s Chahine says, infectious waste is highly dangerous and should not be moved by trucks — as Arcenciel does — but rather treated on site.
A lot more remains to be done to make medical infectious waste management optimal. A large proportion of medical facilities are not subject to the Ministry of Environment’s oversight. According to Decree 13389, medical establishments other than hospitals should also treat their infectious medical waste. Labs, aesthetic centers or dentist clinics are not inspected at all in Lebanon. The lack of human resources at the Ministry of Environment makes their effective supervision difficult. “We are just three employees in the department,” says Sassine. “We started with hospitals and we will continue to audit the other facilities but we don’t know when.”