UCSF Sustainability Stories

Deborah Fleischer, Green Impact, August 2014

UCSF Exchanges Medical Waste Reduction Best Practices with Visiting Doctor from Kyrgyzstan

Group pic tour

In June, UCSF’s sustainability Website had over 6,200 unique visitors.  Of these, over six percent of the traffic originated from other countries, suggesting that UCSF’s work is gaining international attention. Gail Lee, UCSF’s Sustainability Manager, received several international visitors over the past few months, including a journalist from Denmark and most recently, Dr. Nurjan Toktobaev, the Swiss Red Cross’ key medical waste project coordinator from Kyrgyzstan.  “We were very interested in learning more about the innovative technology that Kyrgyzstan is using that we could learn from, as well as happy to share our medical waste reduction best practices,” explained Lee.  The photo here shows: Gail Lee with Dr. Toktobaev and his wife, Dr. Baktygul Toktobaev, Tim Orozco, and Cesar Prieto

After success with piloting new practices for handling medical waste in rural settings, Dr. Toktobaev came to the San Francisco Bay Area to see how medical waste is managed in an urban setting in the United States (e.g., segregation, collection, transport, treatment, waste minimization, and disposal) and to learn about mercury-free thermometers and sphygmomanometers. When Dr. Jorge Emmanuel, a consultant to the Swiss Red Cross, chief technical advisor for the United Nations Development Program, and consultant to the World Health Organization on medical waste projects, reached out to Practice Green Health to identify who could show Dr. Toktobaev the process of medical waste management and introduce him to non-mercury devices, they recommended a visit to UCSF, as well as a tour of Recology and meeting with Health Care Without Harm and the Healthier Hospital Initiative.

Kyrgyzstan’s Health Sector

AutoclaveThe Swiss Government has been supporting the health care sector reform in Kyrgyzstan, one of the poorest countries of the former Soviet Union, since 1999. Dr. Emmanuel helped created a health care waste management (HCWM) system, a model for other developing countries, and Dr. Toktobaev coordinated the successful transformation of all rural hospitals in Kyrgyzstan from open burning and dumping of medical waste to a system that incorporates waste minimization, on-site autoclaving of infectious waste, shredding, recycling, composting, safe disposal, occupational safety, and infection control.

Implementation of the HCWM system at 67 percent of the country’s hospitals resulted in a range of benefits, including:

• Reduction of waste burning, burn pits or ovens, and toxic ash;
• Elimination of open dumping anatomical waste;
• Reduction in waste left lying around hospital premises;
• Reduction in needle-stick injuries; and
• Generating new income stream from recycling sterilized plastic and metal sharps waste.

Later this year, Dr. Toktobaev will be coordinating a similar transformation of all urban hospitals in the capital city of Bishkek in conjunction with a United Nations Development Programme (UNDP) project. They are considering centralized waste treatment.  A visit to UCSF provided Dr. Tokobaev an overview of waste management in a large urban hospital, while highlighting UCSF’s best practices. 

Understand the System Before Jumping In

When Dr. Emmanuel first worked with the Swiss Red Cross in Kyrgyzstan in 2006, he took the time upfront to understand the system he was hoping to change, in order to ensure that whatever he recommended would be practical and appropriate for the cultural, socioeconomic, and political conditions.  For example in the United States, we use a lot of color-coded plastic bags to segregate and contain hospital waste. The red bags go into a waste autoclave, a device used to treat regulated medical waste by subjecting them to high pressure saturated steam at 121 °C or greater for around 15–20 minutes, after which the waste is compacted and sent to a landfill. 

Dr. Emmanuel learned during his assessment that it is very hard to find plastic bags in Kyrgyzstan, due to cost. So he, Dr. Toktobaev, and his Swiss Red Cross colleagues came up with a different system, which is actually more environmentally sustainable than single-use plastic bags.  After some experimentation, they decided to collect all the waste in porcelain enamel containers, which are cheap, easy to find in Kyrgyzstan, and completely autoclavable.  In place of color coding, they label the enamel buckets. 

Key Lessons Learned from Kyrgyzstan’s Health Care Waste Management System

Needle destroyerUCSF had the unique opportunity to learn first hand about some of the successful practices Dr. Tokobaev has implemented in Kyrgyzstan.  While some practices, such as disposing of anatomical waste in on-site cement pits, are not applicable to a urban setting, there are some innovative practices that could inform our practices here.  For example, sharps waste were being taken to open dump sites in Kyrgyzstan, where families scavenge for a living by sorting through the trash, resulting in needle-prick injuries. To improve this problem, one successful strategy was implementation of needle destroyers.

Using mechanical needle cutters, sharps waste from injections is destroyed immediately after an injection. The needle destroyer cuts the needle at the hub, allowing the needle to fall into an enclosed cup. The plastic part is then segregated by being placed in a separate labeled enamel container. At least once a day, the containers are transported to an autoclave room, where the needles and plastic are treated in the autoclave. After treatment, the plastic syringe parts are stored in sacks and sold to recyclers to be made into other products. In hospitals near metal recyclers, the treated needles, made of high-quality stainless steel, are sold to foundries.

“What used to be plastic syringes from the hospital are transformed into coat hangers, flower pots, and distributor caps,” explained Dr. Emmanuel.  He stressed, “By doing it this way, none of the waste goes to a dump site, and all of it ends up being recycled.  Another big plus is the system keeps needles out of the dumps, reducing problems with AIDS and Hepatitis from needle sticks.  On average, selling the plastics and metal creates an income stream of several hundred dollars annually, a big amount of money for a poor country,” emphasized Dr. Emmanuel.

When the needle destroyers were first introduced, there was an increase in needle-stick injuries, although many felt this was due to a new system of surveillance that was introduced at the same time. After training and careful monitoring, needle-stick injuries declined significantly. While not a high-tech solution, and not how we do things here, this is an example of a practical approach that works. And we can learn from some of this.  For example, if infected glass material is segregated and autoclaved, the glass can be recycled. Dr. Emmanuel pointed out that he is doing exactly this in another project in Lucknow, India. This approach offers benefits over incineration, which results in air pollution and toxic ash.  

Moving Forward

Dr. Toktobaev had the opportunity to see UCSF’s large autoclaves, much larger than anything they have in Kyrgyzstan, and learn from UCSF about how it handles infection control;  he was interested in learning about which hand sanitizer and disinfectants UCSF used.  He also visited the Stericycle plant in Hollister, to see a centralized system with super huge autoclaves. As he moves forward, Dr. Toktobaev’s challenge is to design a HCWM system for Bishkek, the capital and the largest city of Kyrgyzstan.  The visit to UCSF provided him an idea of what is possible when you treat some of your waste with a decentralized on-site system, as well as ideas for infection-control strategies.

Written by:  Deborah Fleischer, Green Impact:  Bring Sustainability Alive (Communications & Employee Engagement)