Hospital Waste Causing Havoc with Human Health Hospital waste has become a very important source of spreading infection in the society. It is not that it was not so earlier but the population explosion has reduced the natural barrier and made the spread of infection that much easier. Moreover the generation of waste – per-capita has grown exponentially. Hospitals of today, which were always considered a seat of healing, have become seat of infection, instead.
Apart from the above consideration, infection contracted in a hospital settting is more difficult to treat because of mutation. Mutation in a hospital takes place in two ways. One in vivo and another in vitro. In other words infected waste strewn allover would undergo a process of mutation, which will be in proportion to the time the waste was left before disinfection. There have been doubts whether mutation in vitro is a known phenomenon. Many literatures have been consulted and it is now well established that mutation is very much possible in vitro as well.
Regeneration is a basic instict of any living species. So when the bacterial flora has to grow against an impinging atmosphere of antibiotic presence, where it cannot grow in its nascent form it has to acquire certain new features or property. That is precisely what must be happening. That would lead to mutated variety of microbial which would then dissipate as aerosol.
If the abovementioned hypothesis is accepted then it would be explainable as to why the hospital acquired infections are more difficult to treat.
It is a well-established fact that mutated varieties of microbial flora have been found in the underground water where Terramycin has been used as a food supplement of the chicks. Most glaring possible example of mutation in the viral flora is that of the AIDS, which has probably developed as a result of serialization of the otherwise non-viulent siman immunodeficiency virus (SIDS). It has been brought out by a researcher and published in the Lancet of Dc 8, 2001 that during 1950s mass scale inoculation was given in Uganda and Somalia to fight against yaws. As an accepted practice, the syringes were not disinfected considering the poverty of the countries.
How and why this so far neglected topic has caught the attention of everyone in India suddenly? And if so it is certainly not too late. With the population explosion the natural barrier, which existed due to sparse population, has reduced. Spread of infection would therefore be that much easier and that much faster. At the same time the waste generation has become voluminous as per the increasing population, since generation of waste is directly proportionate to the population. Rural to urban migration has further caused havoc to the old civic amenities, which were laid out decades ago. So the population overload is one of the very important reasons for the condition of today. Most of the urban sewage systems are at the breakdown point, and are on the verge of collapse. The society does not have budget for replacing the age-old systems. One thing leads to another and the result is that the situation is becoming bad to worse, by the day.
A large portion of resources in terms of money or trained manpower is devoted to treating diseases, and for clinical preventable measures but hardly any concerted efforts are in the offing to improve the conditions where occurrence of these preventable disease itself, becomes a remote possibility. Hospitals are supposed to be seat of healing but with the present trend it has become a seat of infection. Spread of diseases by nosocomial infection is the order of the day. At the same time hospital acquired infections are more tenacious and difficult to deal with since the infection is by a more virulent strain, which is the result of mutation. There are a number of macro-observations indicating mutation in vitro.
Similar is the case with other infections. The society spends a very large portion of its resources on the treatment of patients who have been afflicted by disease process but not much is being done to root out the cause of spread of nosocomial infection. Cross infection in a hospital and hospital acquired infection have remained an area of great concern. Much deliberations take place the year around but no one pay much heed to the root cause. Hospital waste strewn allover the hospital compound is a major source of the spread of infection but still no focused concept has been developed yet. Rag pickers still are as active as ever. Studies done in a major hospital has brought out clearly that heaps of plastic syringes are carted away to a slum area and washed, repacked and brought to their collaborators in the city. These are then stocked as new ones and sold to the unsuspecting buyers. In certain cases the nexus between the rag pickers, the medicine shop owners and some of the nursing homes as well as hospitals are well-established .
On an average about 30% of the plastic syringes come back into the circulation without disinfection. In fact the plastic syringes were encouraged and introduced so that nosocomial infections reduce as the plastic syringes were meant for single use only. However that has not happened, at least in India. An explanation offered by the WHO states “whereas introduction of the plastic syringes had the desired result in reducing the nosocomial infection in the developed countries it did not have any effect amongst the developing or the underdeveloped countries". It has been attributed to the wrong practices in the lower income group countries. It is estimated that in and around Delhi itself the total trade value of the recycled plastic ware (used in the medical management) is about Rs five crore per year.
In the US, about one billion waste syringes are generated by patients of Diabetes taking domiciliary treatment. Each plastic syringe cost about $ 1 to 1 and half. So that is a lucrative trade of about one to one and half a billion of dollars. However the better part is that in the US the regulatory authorities, general awareness of the public is such that reuse of used plastic syringes is limited to group of drug abusers or drug peddlers. Unfortunately no such statistics is available in India, but it must be matching (of course in rupees). This being the monetary attraction effective measures will be required to deal with this menace.
In an urban area in India not all the nursing homes are registered, besides the umpteen numbers of quacks practicing and flourishing at every nook and corner of these cities. In Delhi alone there are about 5000 nursing homes and hospitals registered. But there would be an equal number unregistered. Apart from the nursing homes there would easily be about 10,000 quacks in Delhi. Also there are domiciliary patients to cater to. Thus taking a comprehensive care of the biomedical waste in an urban area like Delhi would be a nightmare. The task may appear insurmountable. But with elaborate planning this can be planned and executed.
The WHO reports : -
1. Each person in the developing world receives 1.5 injections per year on the average. Hosp patients receive 10 to 100 times more injections.
2. At least 50% of all injections were unsafe
3. There was convincing link between unsafe injections and transmission of Hep B&C, Lassa virus and Malaria.
4. 20-80% of all new Hep B infections were due to unsafe injections.
5. In the world it is estimated that 16 billion syringes are sold every year, out of which 1 billion injections are given in the course of childhood vaccination program.
6. In Britain, an outbreak of Malaria took place in 1917 among soldiers who were given injections for Syphilis.
7. Introduction of disposable syringes largely reduced the problem in the developed world but not in the developing countries.
8. In India, 96% of injections were for antibiotic, vitamins and analgesics (in 1987).
9. 20% of 67 million new Hep B infections, each year in the developing world are due to unsafe injection.
10. Annual estimate of infection due to unsafe injection, worldwide is
(i) Hep B --------------8-16 million
(ii) Hep C ------------- 2.3 – 4.7 million
(iii) HIV ---------------80,000-160,000
% Isolates with Methicillin resistant staph aureus has increased over a period of time from less than .1% in 1960 to 4% in 1969, 10% in 1984, 75 % in 1999, in a study carried out in the UK.
Of all hospital acquired infection the largest group is of upper respiratory tract infection-49.01% in the study carried out at an ICU at BHU, Varanasi.
The above mentioned research findings are indicative of mutation taking place in the infected discards of the hosp waste. More work is required to be undertaken to find out and establish on scientific platform the damage the untreated or uncared for hospital waste is causing to the society.
Though it can never be tangible the advantage the society will gain out of proper hosp waste management are tremendous. Perhaps the prevention of communicable diseases in number and quantity can never be specified, perhaps not even the number of cases thus prevented but the fact would remain that managing the hosp waste in a proper and scientific manner can bring about a very substantial change. This not only may save the resources of the society but also bring up the gradation of health. As per Theo Colborn-a wild life expert the human body carries more than 500 additional chemicals today than it carried in the 1920s, and it is not known how these additional chemicals are interfering with the health or degrading health of the human beings. Could the chemicals also contribute to the changed behavior and the mental outlook? It would be an interesting study if such a study can be undertaken.
Lalji K Verma
New Delhi
Apr 15, 2005
Compromise……….Compromise A meeting of SEAR countries was recently organized by SEARO. The theme was ‘injection waste disposal’. The participants were representatives from all the SEAR countries, except INDIA (No representative or official was present from India despite invitation.
The thrust was on Small Scale Incinerators (SSI) for the SEAR countries since it is perceived that these countries would not be able to afford better incinerators, or systems. SSI is basically an incinerator which is cheap to construct, but does not guarantee non-polluting emissions. No developed country (which can afford better system) has gone for it. The system has been developed with the developing countries in mind.
Affordability is a valid concern. But one should not go for such cheap systems that may give rise to unacceptable problems in future. Health & safety of the waste handlers will be at stake. Then there is always a possibility that everything including plastics and other waste will be incinerated. It is a misconception that small amounts of gaseous emission are not going to matter. All the pollutants have cumulative effect. And therefore any addition will one day or the other have undesired results. One speaker advocated even open burning! Open burning of the plastic syringes is done by dousing the waste in diesel or kerosene, and then putting a matchstick. It was also reported that test reports at one of the leading labs of the country did not detect any Dioxins! Amazing, because this test is not only very expensive but facilities are not available in the country.
The mind-set of the conceptual thinkers or the health care planners is still limited to the incinerator technology. It is unfortunate that with so much evidence of damage being caused to the environment by gaseous emission one still likes to think only about incinerator. The concern of global warming, Ozone depletion, adverse effect on the health of people, increased incidence of respiratory group of diseases does not seem to bother.
Howsoever incinerators are made safe no one would deny that it will emit particulate matters & obnoxious gases. All types of waste may find its way into it. Therefore the use of incinerator for disposal of bio-medical waste must always be limited to burning of human tissue, body parts, and animal tissue waste, which otherwise will need to be disposed off by land-burial. The perception/fact that it would be very costly to have alternate technologies is not correct. Improper disposal of bio-medical waste leads to increased morbidity in the society, costing hell of a lot more than placing a proper system for the disposal of waste. Compromise is alright so long it does not lead to unacceptable disadvantages.
Studies, in USA & UK have clearly indicated the socio-economic burden of hospital acquired infection (HAI). The study in UK indicated to have cost the NHS close to an additional billion pounds per year. Similar study results are available from USA. Pollutants in the environment are also known to cause many diseases, respiratory group being dominant. Therefore on impact and cost-benefit analysis the cheaper option may not appear cheaper any more.
The sudden concern of course is the much awaited, and much hyped Universal Immunization Program against Hep B. There should be no doubt that it will generate large volume of injection waste. Agreed, the plan is to use AD syringes but its disinfection would not be that simple since there is hardly any space between the plunger and the syringe lumen. It is also believed that the AD syringe will not be of PVC, but burning of even non-PVC plastic can give rise to emission of Dioxins. The Dioxins are known to form at lower temperature either at the time of heating or at the time of cooling. Along with, there are other toxic gases likely to be released. How effective protection to the waste handlers in a rural setting can be provided & ensured, is anybody’s guess. Open burning of even leaves can lead to Dioxins formation in certain conditions.
India has more than 22,000 PHCs. One SSI at each PHC would cost about $22,000,000. So this would be the cost of disposal of plastic syringe waste to the country.
In India, 16 million babies are added every year. Three injections are required to immunize. On an average of Rs 200 per child the cost would be Rs 9.6 billion per year. So we are looking at a budget of capital investment – Rs1 billion, and recurring – 9.6 billion. With this amount near to failsafe methods of prevention of Hep B can be put at place resulting in gross reduction in the prevalence.
Opinions may be divided on the question of going back to the glass syringe era. Scientists say that there are enough evidences that this has miserably failed because disinfection was not practiced. But after the plastic syringes replaced the glass syringes no comparative study may have been done. It may now be possible as the state Govt of MP has decided to revert to the use of glass syringes.
All the confusion in the matter of proper disposal of injection waste is only due to professed use of plastic syringes. Proper or improper disinfection of glass syringes, or reuse of plastic syringes is all matters of human failure which may happen in both the cases. Important point is that plastic syringes are viewed as a source of income by the waste handlers. The plastic syringes were introduced to limit the nosocomial infection. While it succeeded in the developed world, it failed in the developing world due to wrong practices, and the reasons for failure is still valid.
Lalji K Verma
New Delhi
Mar 17, 2003
HOSPITAL WASTE MANAGEMENT
MISSING LINKSManagement of biomedical waste received due attention in the developed countries in the late 80s, but such attention was visible in India in the early 90s only, and that too by activism of the NGOs, and intervention by the courts. Draft biomedical Rules were circulated in 1996, which culminated in the issue of extraordinary gazette dated 20 Jul 1998 by the Min of Env & Forest (1). While the rules have been promulgated by the Min of Env & Forest, supervision and implementation remains within the purview of the Min of Health & Family Welfare, and (since health is a state subject), with the state governments. Therefore dichotomy is obvious, and implementation difficult.
In the Rules itself many areas remain uncovered, or not properly addressed. There are issues, which need to have been addressed properly.
The monitoring and policing agencies involved are the Min of Env &Forest, Central and State Pollution Control Boards/Committees, and the prescribed authorities of each state as constituted, apart from the Min of H &FW. By an amendment to the Rules the State Pollution Control Boards/Committees have been designated as the as the prescribed authority. So the monitoring and the licensing authority are merged into one regulatory body. This may lead to unfair practices. For example if a particular health care facility has been permitted to run by the prescribed authority then it may be difficult for the same agency to penalize in case laid down standards are not satisfied during periodic monitoring.
There is no agency earmarked to render advice or help to the health care facility, in case required or solicited. It is well known fact that many healthcare facility sincerely want to lay down proper system, but have no one to help them to conceptualize and lay down a proper system. The case of Kerala Qualified Medical Practitioners Association of Kerala is a case in point, and is illustrative. The office bearers of the Assn. recently gave a presentation at a prearranged meeting in the Min of Env & Forest. They came all the way from Trivendrum for giving the presentation, is demonstrative of their sincerity (2). They brought out the following problems: -
1. plans and proposals are based on the western model and not suited to Kerala due to
• High humidity
• High rainfall
• High density of population
Note. When they approached the KSPCB and other authorities they did not get much help. Generally they were directed to some consultant. Some hospitals installed equipment at a high cost as suggested by the consultant but such plants are not running properly. Aerobic treatment plant for liquid waste was suggested and is installed at places. This indicates that local conditions were not taken into consideration while giving advice.
..
• Incinerators are not feasible due to density of population and public opposition
Note Density of population of Kerala is high, the public well educated and aware. They understand and take stand on these kinds of issues.
Their plea therefore has been to get the KSPCB associated with studies to find suitable method to deal with biomedical waste in their state. It can very well be inferred that the will is there but there is a lack of expert advice. The same is true for most of the health care institutions. The Rules therefore should have addressed to the advisory responsibility.
While dealing with the duty of the occupier the Rules state that” It shall be the duty of every occupier… to take all steps to ensure that such waste is handled without any adverse effect to human health and the environment”. Then it states “every occupier … To ensure requisite treatment to the waste at a common area waste treatment facility, or any other waste treatment facility”. So if anything goes wrong anywhere, be it in transportation the waste or improper treatment at the common area the poor occupier is responsible. Whereas the fact remains that once the waste leaves the premises then the occupier will hardly have anything to do with it, or have any sort of control. (Para- 4 & 5 of the Rules). Hence the occupier has been charged with a responsibility which he cannot fulfill.
Even the clause to permit storage for upto 48 hours is not scientific considering the climate of this country. This provision appears to have been copied from the western countries where the climatic conditions are quite different. Normally bacterial life cycle is of about 20 minutes in a warm and humid climate. By storing the waste (condition to store the waste may not be ideal anywhere in India as on today) the bacterial flora in the hospital waste may have undergone about three cycles per hour. Desiccation and aerosolisation would occur thereafter, thus causing spread of nosocomial infection in the society (3). Though essence of provisions in the Rules are intended to ensure no harm to the human health or the environment, this particular clause tends to do precisely the same, that is to cause harm to the human health.
Provision regarding type of vehicle at para-6 of the Rules is rather vague, and does not fit in the scientific perception. Whereas scientifically such vehicle should be specified to be air conditioned with airtight separate compartments, the Rules have left it to the ingenuity of the Transport Department or any prescribed authority by the government! In such a situation understanding and appreciating the nuances of the biomedical rules is essential but cannot be ensured.
Initially the authorization is to be granted for three years as per the Gazette, Para – 7. The periodic monitoring is to be done by the pollution control boards. The prescribed authority has powers to grant further extension. Thus a situation appears to have been created in the Rules by which the control mechanism appear fragmented and without natural rapport. Moreover as per para –10 an annual report is to be submitted to the prescribed authority by the occupier which in turn will be submitted to the CPCB by 31st Mar every year. Where does the State Pollution Control Boards/Committees come in is not clear.
There is a very sensible provision in the Rules at para – 9. That is to have an Advisory Committee at every state and the centrally administered territories. But this important provision has not been activated and remains a sleeping instrument of administration. Moreover the role of the Advisory Committee has been restricted to advising Govt. /pollution control boards only, and not to the occupier. Question is where does the ‘poor’ occupier get technical advice?
The categories of waste prescribed in the Gazette and option for treatment and disposal are confusing. For example cat I & II waste need not have been mentioned separately. The suggested method of disposal remaining the same these two categories could have been grouped together. Microwaving has been suggested as one of the alternatives to treat waste sharps! Sharps may contain blades, scalpels etc. These are larger metal pieces hence not suitable to be treated in a microwave since it may damage the magnetron of the microwave equipment. Incineration has been suggested for discarded medicines including cytotoxic drugs. No doubt this can be done in incinerator, but those incinerators run at much higher temperature to ensure complete destruction of the chemical compounds of these medicines. At such low level of awareness and will to implement it will be too much to expect that occupiers will install higher capable incinerators. Again this provision appears to have been copied from the provisions of the advanced countries without due scientific deliberation.
At the footnotes at Table-I it is mentioned “There will be no chemical pre-treatment before incineration”. What must be understood is that some category of the waste will have to be chemically treated to render it non-infectious. Therefore the provisions should have read “No waste which has undergone chemical treatment will be incinerated”.
More importantly the Gazette fails to address four very important issues: -
1. Occupational Hazard
2. Application of labor laws
3. Protection to the waste handlers
4. Human Rights
It is unfortunate that health care management is not recognized as an occupational hazard in the Indian law. Many other occupation like mining etc which give rise to diseases, are recognized as activities with occupational hazard, but not the health care. This has to be debated. There are umpteen scientific studies which clearly bring out that a large number of health care providers continue to suffer from diseases acquired in the course of their duty. (4) Regularly, morbidity/mortality keep on taking place amongst the health care providers due to infection contracted while treating patients suffering from infectious diseases. But no cognizance is taken. Only in the armed forces compensation by way of grant of attributability is provided for.
The provision of the Factory Act does not apply to the health care provider (5). Hospitals and dispensaries are not within the definition of factories. This may be a correct perception, since hospitals cannot and should not be considered as a factory; lest it loses its value of human angle. Hospitals are much more than the factories. Factories have connotation of dry and disdained place where the only consideration is the input and the output in the monetary terms, and it is concerned only with production, at times, with complete disregard to the human needs and aspirations. But that is not to say that those in the business of health care should be left to suffer, in awesome respect. Time has come when this issue has to be debated seriously. Not doing so would not only be against the principles of Human Rights, but also against the international labor laws, of which India is a signatory (5).
In conclusion, therefore it may be said that the Rules and its provision and application need to be seriously debated and amendments made wherever considered necessary. And it is essential to take help from medical professionals having knowledge of the subject of ‘biomedical waste’.
Bibliography
1. Bio Medical (Management and Handling) Rules,1998
2. Minutes of the 5th Meeting of the Steering Committee on Bio Medical Waste, Min of Env & Forest.
3. Souvenir – VI National Conference on Hospital Infection Control, Feb 2-4, 2001, Jaipur.
4. WHO/PEP/RVD/94.1
5. Hospital Waste Handlers and Labor Laws – Krishnamurthy et al. Published – 1999.
Lalji K Verma
RELEVENCE OF ENVIRONMENTAL EDUCATION
IN THE 21ST CENTURY
Quest of man for better living explains the environmental exploitation. Every other living species know how to live in complete harmony with nature except the human beings. Resources of the nature are being used, and not replenished in every field and industrial activity. In fact industrial activity of the 18th century can be said to be the watershed in the development of exploitive societies. With the industrial revolution one can easily see the connection of population explosion which again is an indirect cause of environmental degradation. Environmental resources are limited whereas the human population is not. With increase in human population there is demand for more houses, more clothes, more buildings, more hospitals, vehicles, aircrafts, and everything else; and greater generation of waste. Human activities put a strain on the resources of the nature and exploitation leads to ecological imbalance. When we see the population growth in the last few centuries it is clear that every 100 years the population has been more than doubling:
Year Population1750 791 million
1850 1262 million
1950 2526 million
2000 Over 6000 million
-And the population is growing exponentially in geometric progression. Malthusian theory that it will limit itself due to limit on availability of food stands falsified due to ingenuity of human mind. How long this ingenuity will let the growing human population sustain is yet to be seen.
Effects of growing population are: -
Migration
Urbanization
Industrialization
Construction Activities
Hospitals & Health Facilities
Morbidity
Waste generation including bio- medical Individual & Societal stresses
Stress related to diseases
Consumerism
Environmental Quality
Environmental Health
Quality of Food
Quality of Air
Quality of Water
Quality of soil
Physical & mental tolerance
Lower Health Status
Environment is something which surrounds, and environment & ecosystems are interdependent. It is the environment which sustains life on the planet. Basic fact is that the building blocks of life start from the capture of solar energy. If there were no plants or green life there would be no chlorophyll action and no life even if there was enough sun’s energy. Pollutants of human activity threaten human existence, and it is no more a question of ‘sustainable development’ but simply a question of ‘sustainable existence’. Pollutants cause environmental degradation of every conceivable dimension. It would be uncared for pollutants which will threaten the human existence and may not be shortage of food or water in the coming centuries. Progress and environmental sustainability appear adversarial but both can co-exist provided we take care of waste products in a manner that the waste of one can be used as input of resources of the nature for other activities. Today, there are initiatives focused towards ‘Zero Waste’ concept. Therefore one should aspire for achieving sustainable existence through application of principles of Zero Waste Concept.
That would only be possible when one knows about the environmental pollutants due to human activities. Environmental pollutants can be grouped in four categories as follows: -
1. Physical Pollutants
2. Chemical pollutants
3. Radiological pollutants
4. Biological pollutants
Noise pollution, pollution caused by floods, hurricanes, heat & GHG, particulate emission, global warming are all a result of physical pollution. Chemical pollutants are by far the biggest in the group. It means pollution caused by any of the chemical pollutants such as the Green House Gases, Dioxins & Furans, volatile gases, arsenic, mercury etc. Radiological pollutants would mean any waste or procedure which carry radiological waste along with such as the radiological means of treatment & diagnosis, x-rays, radiotherapy etc. But the chemical pollutants are by far the biggest scourge. Chemical pollutants are by–product of industrial activities, as well as of patient care activities. Chemical pollutants are also of the group commonly known as ‘dirty dozen’.
POPs are a group of toxic chemical pollutants harmful to human and wild life health (in fact all animals, birds, plants, and the human beings)
12 POPs also known as “dirty dozens” are listed by UNEP:-
-Aldin
- Chlordane
- Dieldrion
- DDT
- Dioxin
- Furan
- Hexachlor benzene
- Heptachlor
- Mirex
- Polychlorinated biphenyles
- Toxaphene
- Endrin
Other chemical pollutants are pesticides, herbicides, insecticides, chemicals used during war such as ‘agent orange’ etc, chemical fertilizers, chemicals in health care waste & in municipal waste etc.
Microorganisms cause diseases in humans. There is a relationship between host, environment, and the agent. All these act on each other and amongst each other to cause a disease. This is to say that biological pollutants would cause disease only when interaction between host, environment, and the agent has a positive derivation. Due to the fact that a lot many microbial floras in untreated medical waste keep on proliferating there is always a chance of bacterial mutation. SARS & Avian Flue is results of mutation and the microbes are becoming more deadly by the day.
Pollutants are known to cause many adverse effects on the health of an individual. Most of these chemical pollutants are neurotoxic and nephrotoxic. In fact most of these chemicals are known to cross the placental and blood brain barrier. Thus a child is exposed to the ill effects of all these pollutants from the womb itself. Dioxins have a predilection for depositing in the fatty tissues ad therefore there is greater prevalence of breast cancer etc amongst population living near to incinerators. All these pollutants enter food chain, bio-magnify through trophic levels and are cumulative. Thus effects of these chemicals are result of accumulated dosage. Wastes generated from industrial activities get accumulated in the aquifer by leaching, such as mercury waste, which also undergo the process of bio-magnification in the food chain. Thus one would find higher concentration of mercury in the tuna fish which is at the top of marine life in the context of trophic level. Children are more vulnerable to the ill effects of the pollutants as they consume more food, water, and air proportionately due to higher metabolic rate. Most of these chemicals get absorbed through skin, and thus a child is exposed to the chemical pollutants during early part of childhood more than adults while they play in the grass and come in contact with the foliage.
Therefore there are many reasons why one should know about the environment. But most important one is for the survival of the generations to come, for sustainability, and for existence with healthy surroundings and healthy environment. Education to a child starts from birth. Child learns to cry to demand food (milk). Thus there is acquired knowledge through self realization. The other would be imparted knowledge which comes through teaching and learning by examples. It is the later type of gathering knowledge where the role of elders is relevant. It is the bounden duty and responsibility of each citizen to impart knowledge to the children through teaching, examples and actions etc. Education on environment must not only come from the teachers and school but also from parents and elders in the family and society.
Environmental education today is inescapable and must be included in teaching schedule at all levels. Many tools may be employed for this, but the most important tool would be demonstrative teaching and training which will have greater impact on the mind of a child. Interactive group discussions, debates etc should be included in the teaching curriculum of schools and colleges. Demonstrated evidences of environmental degradation such as fly and mosquito breeding, putrefaction of waste, river pollution, water pollution etc could be some of the areas. Simple hygiene practices should be demonstrated and practiced in schools. Principles of healthy food intake, use of chemicals &fertilizers in agriculture & in food preservation, and its ill effects etc should be taught. Advantage of organic farming should be taught in schools. In fact it is rather surprising that there is hardly any emphasis on farming and agriculture in schools in a country like India where 80 % of population is agro-based.
Waste management such as segregation & collection of household waste in proper containers could be one of the important teaching schedules. Composting and other methods of waste disposal should form a part of syllabus. Children should be exposed to health care waste, its infectivity and danger it poses to the society at large. Facts that health care waste may be responsible for higher incidence of communicable diseases, higher hospital admission, compromised health status, and aberration in the personality of an individual etc should be included in the syllabus.
Astronomer Sir Martin Rees give 50-50 chance of making it to the 22nd century. The way we are exploiting the resources of the nature and the way wanton destruction is taking place almost everyday due to violence and terror his prediction may not be totally out of place. It is high time humanity wakes up to the challenges it has built upon itself to survive and thrive in the 21st & 22nd century.
Lalji K Verma
New Delhi
September 7, 2004
Future opportunities-health care in India
Healthcare in India: The Road Ahead During the past decade there has been tremendous advancement in the health care scenario in India. Mainly spurred by economic growth private health care facilities have sprouted in all urban localities. The public sector spending still remains a dismal .9 % of GDP. With insurance scheme recently on the anvil it may go up marginally by introducing 1% cess on Income Tax for health care which primarily will be used for health insurance. How far will this succeed in removing health inequality in the country will remain debatable. Because health inequality is not only governed by economic consideration but many other factors, such as low level of awareness, poor connectivity, economic and gender bias etc. 15 % of Indian population do not have access to health care due to various reasons. Rural health care facilities are almost non-existent.
As per World Bank, India has a vast network of rural health care infrastructure but acutely deficient of trained manpower, and other facilities which would make such infrastructure capable. In other words there is a wide gap in capacity & capability. India has about 137,000 Sub-centres, 23,000 Primary Health Centres (PHCs), about 3,000 Community Health Centres (CHCs), and about 12,000 secondary and tertiary hospitals. Public Sector manpower includes about 29,000 doctors, 18,000 nurse midwives, 134,000 auxiliary nurse midwifes (ANMs), and about 60,000 paramedical staff (Min of Health & Family Welfare 2000). Thus availability of doctors is just about 1 per thousand, that of nurses is still lower at 0.9 per thousand, and for midwives the figure is just 0.2 per thousand. Total beds in India are about 0.7 per thousand (a total of about 8 Lakhs beds) whereas as per the WHO standards it is supposed to be at least 5 per thousand (about 40 Lakhs beds).
So, in the future substantial addition is likely to take place in hospital beds. Assuming that hospital beds in a decade would be 4 per thousand that would amount to more than four fold increase in the bed strength in the country. Only on account of hospital beds it would amount to an investment opportunity of more than INR 24,000 Crores (assuming each bed would cost about INR 10 Lakhs which would include other technical & non-technical infrastructure and equipment; and work services) in a decade. In fact this estimate is going to go up with awareness regarding waste management having taken roots in the health care sector by about additional INR 10, 000 per bed. Apart from this if the rural health care infrastructure is to be improved it would require heavy investment to improve infrastructure in the villages, such as basic amenities and connectivity. Most importantly the public health care is on the decline. Void is being filled up in the urban areas but there is no agency to fill the gap in the rural areas. Private health care facilities are not likely to invest in villages since these are profit oriented. Insurance scheme is being thought about but whether it will help the situation is debatable. Such schemes are likely to fail since it does not take two things in account. One is that insurance by itself is not going to cure a patient. He/she will have to be brought to a tertiary care hospital which does not exist at many places near a rural area. And even if there is one, connectivity being poor time taken would be more than acceptable. Moreover ethos and practices in the India are such that one patient is usually accompanied by one or two relatives. Insurance will not cover their expenditure. Taking all these in consideration it is doubtful whether insurance will be helpful to the rural population. Thus benefit of insurance would be limited to urban population, by and large. And one should not forget that more that 70 % of population live in villages in India. Need is to improve infrastructure at the villages- improve technical capability of the PHCs, improve awareness amongst the village population, institute better hygienic practices, improve availability of potable water, improve connectivity (in time frame), and create facilities which would at least not distract medical professionals from getting posted to rural areas. No doubt, these measures would require heavy investment; but an investment which is likely to give cost-effective and durable results.
Indian economy is on the move. Spending power amongst middle class, who form the bulk of population, has been growing continuously. We have had 7 % growth successively for the fourth fiscal year. With economic growth there is changed aspiration and expectation. Healths being primary to healthy growth of a society, hospitals are bound to mushroom. Already we are having many chains of hospitals in the country. These are all in the private sector and in urban areas, but with passage of time such chains and state of the art hospitals are likely to come up even in the rural areas. With growth in the health sector there will be demands for manufacture & supply of equipment, construction of hospitals, training of medical staff, and continued awareness programmes all through the year.
As per the National Health Policy 2002 aggregate annual health expenditure is about INR 80, 000 Crores. R & D in health sector is just about 1150 Crores. Goals set to be achieved by year 2010 is to increase the allocation in health sector (centre) to 2 % of GDP, and to increase state sector spending from present 5.5 % to 7 %. Thus we have to look at investment opportunity to the extent of at least INR 80,000 to 100, 000 Crores every year up to year 2010. If the proportion of doctors, nurses, and paramedics is to be improved (which will have to be improved to cater for increasing hospital beds) then many more educational institutions will have to be created and run. One can very well imagine what it would mean. It will mean tremendous addition in the infrastructure which would require all sorts of consumables & durables required to establish and run a training establishment. All these will be a challenge and opportunity for Indian Companies to come forward and deliver.
For example if only the future requirement of equipment for health care waste management is taken into consideration the scenario would be some what as follows: -
· Assuming there will be a four fold increase in hospital beds
· Assuming that waste management plans are as per the rules
At the rate of about INR 10, 000 per bed estimate it would be about INR 800 to 1000 Crores as per present projections & requirements; and about INR 3200 to 4000 Crores in the next 5 years. Therefore there is no doubt that health care sector is going to have a major change and allocation of resources from the public as well as private sector is going to go up many times.
Much of medical and dental equipment are imported at present. Thus investment cannot be said to be cost-effective as much as it could be. Therefore there is an acute need for indigenization of manufacture of equipment and medicines in the country, which has tremendous scope. Of course, research & development in manufacture of equipment & also in medicines will have to go hand in hand only then one can expect a substantial change in the present scenario. Present scene of research is rather dismal in terms of allocation of financial resources, trained manpower, and unfortunately the mind set where every researcher tries to emulate the WEST. No doubt scientific advancement which has taken place in the developed countries must be taken advantage of but application must be tuned to conditions, infrastructure, and practices & beliefs as per local conditions. This is truer in areas of applied research. In certain cases research & development will have to be in areas which can be directed as per need. More research will have to be undertaken in areas, such as environmental health, system application research for hospitals and medical institutions, applied research for rural health care etc, where capacity will have to be translated to capability. Only then advancement will be beneficial to public at large without discrimination and division of resources. If India has to gain advantage (in health care sector) of present economic boom applied research will have to be dominant area of research. All these would not only be a challenge but tremendous opportunity to the business sector in the country.
Health tourism is a recent development in India. Patients from other countries are attracted due to reasonable good quality of medical care and also due to low cost in comparison to other developed countries. Long waiting period in countries like the UK is another reason whereby patients from many countries are coming to India these days for medical treatment & management. It is easily an industry of about 1000 Crores per year. As per statistics published in Asia Times Jul 19, 2003 “hospital services, health care equipment, managed care and pharmaceuticals are poised to grow by 13 percent annually for the next six years. India's health care industry could grow exponentially, as have software and pharmaceuticals over the past decade. The government believes that only 10 percent of the market potential has been tapped. With global revenues an estimated $2.8 trillion, health care is the world's largest industry”
All in all it would be apparent that health care sector has large potential for growth and offers challenges & opportunities together.
To the question should Indian industries aspire to take a lead in the health care sector the answer is an emphatic ‘YES’. It is technically, administratively as well as financially feasible and is capable.
Lalji K Verma
New Delhi
HEALTH INEQUALITY & SUSTAINABLEDEVELOPMENT IN INDIA Health of an individual is the most important individual & social asset. One may be from any strata of society for him ‘health is wealth’. And rightly health has been considered very important in the constitution of the WHO:
“The enjoyment of the highest attainable standard of health is one of the fundamental right of every human being without distinction of race, religion, political belief, economic or social condition”.
Thus one can say without hesitation that issue of health is a matter of Human Rights as well. Any violation can be construed as violation of human rights.
Widely accepted definition of health is that given by the WHO. Accordingly positive health is described as “health is a state of complete physical, mental, and social well-being and not merely an absence of disease or infirmity”. In recent years it has been further amplified to include ability to lead a socially and economically productive life”
However since this definition does not take into consideration impact of environmental pollutants on human health there has been a shift in the concept of health and the global commitment now is towards “Total Health’ .
Definition of Total Health should be somewhat as “Health is a state of complete physical, mental, and social well being where life thrives in healthy environment devoid of pollutants; and not merely an absence of disease or infirmity.”
There has been a continuous exploitation of nature and its resources by the human beings depriving the underprivileged of natural resources. Social matrix is such that all in a society must benefit by the resources of nature in an equitable and just manner. A generation of humans must not view the earth as a commodity to be exploited and finished in his life time, but must think about how the next generations are going to find sustenance. Life is not one cycle of birth & death but is a continuous process and therefore a generation of human being has to worry about the generations to come. This Concept of life has been beautifully described by T Adeyoe Lambo, consultant to WHO in his article “Total Health” –
“It is now apparent that a more balanced consideration of the biological, social, and cultural aspect of health is needed. Life is a process and not a substance-a living system based upon the primacy of continuity and inter-relatedness throughout the universe….. If man and his family are to remain in empathy with the emerging necessities in the developing milieu, an adequate design of interdisciplinary tools will have to be made to assist in this task of providing a total health package.”[1]
Therefore continuity in existence of life is an important aspect of living, and one cannot forget the needs of the next generation, nor can one overlook the fact that the earth and the natural resources is not the property of one nation or society, but of the whole living world. But the question is why we are not able to perceive the changes in the environment & ecology which is happening everyday. The answer is ‘one life is too small a period in the time- clock of universe, and therefore one is not able to perceive gradual but definite degradation of the environment mainly caused by human activity’. Even though unliveable environmental may not be manifestly visible today but would challenge the human existence in the future.
In the words of Rachel Carson, author of the famous book ‘Silent Spring’ – “Future generations are unlikely to condone our lack of prudent concern for the integrity of the natural world that supports all life”[2] . And looking at the lack of concern today one is tempted to believe that “Man has lost the capacity to foresee and forestall. He will end by destroying the earth”.[3] Egocentric attitude of humans has to change to ‘eco-centric attitude’.
The present scenario appears to be to carry on till catastrophe strikes. In the words of Herman Daly ‘there is something fundamentally wrong to treat the Earth as if it was a business in liquidity’. Unfortunately that is what appears to be the perception of the present generation, hapless & helpless within the confines of consumerism. The race is to exploit the earth & its eco-system as much and as quickly as possible.
Social order is primarily based on economic considerations. Just to illustrate 90 % of population sustain itself on 10 % of resources of the society whereas 10 % population consume 90 % of the resources. This is also called ’10-90’syndrome. Social and economic inequality mirrors in health sector as well, and casts a shadow of gloom over the society. Inequalities in all sphere of social determinants cause fault lines in the social matrix which brings about its own problems in its wake. End results are division in the society unsocial & antisocial activities even to the extent of terrorism. Divide between ‘haves’ and ‘have-nots’ is sharp and clear, and that causes many unwanted individual & social behaviour. Therefore it is necessary to have a preview of the inequalities. There are many reasons for inequality but this article is limited to health inequality.
India is a large country having multicultural society. In about 2.4 % of land 16 % of human population is cramped. Therefore density of population in India is rather high. 72 % population are in the rural areas where connectivity, availability of potable water, electricity, and other basic amenities are scarce. Health care professionals are therefore not very much enamearoured by getting posted to the rural areas in India. As per Indian constitution provision of health care by public sector is a shared responsibility between the Centre & States. The public sector health care system is three tiered- the Primary Health Care, Hospital Health Care, and Tertiary health care. The administrative set up is somewhat as follows: -
(a) Primary Health Sub-centres (PHSC)
(b) Primary Health Centres (PHC)
(c) Community Health Centres (CHC)
(d) District hospitals
(e) Tertiary Care Hospitals and referral centres.
India has 137,000 sub-centres, 28,000 dispensaries, 23,000 PHCs, 3,000 CHCs, and about 12,000 secondary & tertiary hospitals. The whole administrative set up may appear large but most of the health care facilities are under staffed, and understaffing is most prominent in the rural health care sector. 15 % of Indian population do not have access to health care due to reasons of unavailability or due to economic reasons. Expansion of health care in India has been mostly urban oriented when major part of population lives in rural or semi-urban locations. Mushrooming of private hospitals in India has been in the urban areas, and is profit oriented. Public health care systems are becoming extinct by the day. Insurance system may not suit Indian conditions since a very large section of rural population would not be able to afford it, and the governments (central or state) may not find the required budget.
Health Care Systems are more oriented towards curative health care, and do not consider impact of environmental pollutants on human health from the preventive angle. Reason being environmental pollution is viewed more as an environmental issue rather than health issue. Proper waste management is essential to neutralize adverse effects of environmental pollutants, including biological pollutants. There is hardly any focused attention to the growing menace of waste which is directly proportionate to growing population. Polluter pays principle is self defeating in the sense that polluters can pollute and get away with it by paying appears accepted philosophy. In fact the principle should be ‘repair and replenish’ rather than ‘polluter pays’. Trying to copy Western models in its entirety has resulted in fragmented approach and confused results. Developing countries should adopt scientific advancement, no doubt but must modify to suit local conditions, level of awareness, and habits & practices.
There are gender bias, economic bias, status bias, and bias of availability of funds within the health care delivery in India. There are differences in the accessibility of resources. Merely by professing equitable accessibility one cannot ensure equitable sharing of resources. To remove the socio-economic bias rural health care systems will have to be strengthened. At present even if posted to a PHC doctors avoid going there by whatever means. This aberration can only be corrected by improving the infrastructure of the villages by improving connectivity, security, and job opportunities in the rural segment. Similarly to remove gender bias ‘care of the girl child’ will have to the motto. Awareness will have to be developed where a family does not discriminate between a male and a female member of the family in matters of health care (which includes nutrition). Funds for health care will have to be made available to the urban & rural sector on equitable basis. Even the resources of the society will have to be spent in an equitable manner between the rich & poor to get out of the ’10-90’ syndrome.
Development as we understand today leads to stressed relation amongst privileged and underprivileged classes in a society. Economic development is considered benchmark of development but would not this approach justify industrial hyperactivity and exploitation of natural resources? In fact there is a requirement to re-examine the concept of ‘Sustainable Development’ and move towards concept of ‘Sustainable Co-Existence’- Co-existence with nature and other biological species.
There is a wide gap in policies at the macro level & implementation at the micro level in all the developing countries. For example proper legislation & rules have been framed on health care delivery & waste management in India, but implementation remains far from satisfactory. Primary Health Centres are designed for rural health care but there is hardly any cognizable action to strengthen rural health care system. Similarly in matters of waste management laws have been enacted but implementation remains unsatisfactory. Micro level factors do not guide policies etc at the macro level. Thus capacity created at the macro level fails to obtain directional capability at the micro level.
Capability must be applied with community participation at the grass root level with clear understanding of weaknesses and potential human failures, and it must remain dynamic. Predetermined performance indicators should be carefully identified in relation to the policies so that capability approach itself may be subjected to analysis & modification for better implementation and results.
One can see that sustainable development by itself is likely to further enhance health inequality instead of correcting it. Present day bench mark of sustainable development includes industrial activities, and unless there is a substantial change in the methods adopted so far industrial activity is likely to further degrade the environment and deprive natural resources. Economic life style is a direct result as well cause of industrial hyperactivity and unless something is done to change the life style of today society is going to suffer inequalities in which case health inequality would be most prominent.
New Delhi (Lalji K Verma)
Sep 20, 2005
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[1] WHO, World Health, Dec 1975, Page – 3.
[2] Silent Spring By Rachel Carson – P 13. (1987)
[3] Saying by Albert Schweitzer, Nobel Laureate German Philosopher, Physician, and Humanitarian.
Aids Prevention From: "Dr. L.K.Verma"
Date: Tue Jan 13, 2004 9:40 am
Subject: Iinjection waste disposal and HIV/AIDS
DearAll,
I can very well percieve that the whole focus of prevention of HIV is on
behavioural change in sex practices. This may be true but only upto an extent.
Reports done in African countries indicate that sexual practice by itself may
not be the reason for increase in the incidences of HIV. Despite the fact that
there has been reduction in STD, HIV prevelence have shown an upward trend. Why
should it happen? The only answer is that spread of HIV is also caused by reuse
of syringes without proper Disinfection, and because of sharing of syringes. The
focus therefore has to
change from only sex related issues to also proper disposal of bio-medical
waste, specifically the injetion waste. I hope this line finds support and we
start doing something about the injection waste disposal.
Lakji K Verma.
Environment for All
Dear Dr Verma, I was very interested by your message and am glad you
emphasised the animals and environment as well as people. I don't always
have time to read the messages but yours held my attention. Thank you
sincerely Zelda Jeffers
From: "LK Verma, India" <>
Reply-To: "HIF-net"
To: "HIF-net"
Subject: [hif-net] Poverty, equity and health research (5)
Date: Sat, 6 Aug 2005 11:27:40 -0400
Thanks for the initiative. It is much needed area to deliberate upon. Many
things are going wrong, in my opinion as far as the efforts of
making the world a healthier world is concerned. Some of the thoughts are
appended below: -
1. Let us consider the environment. Is it for everyone? Humans have 'human
rights', but does animal world has rights? And what about 'environmental
rights', or rights of the environment. Only because environment cannot
speak for itself it cannot be left to be exploited as one feels or
perceives. Even in the human world do all have equal opportunity to draw
from the resources of nature? As is well known living being is a
combination of cosmic energy & body or the mass from the resources of
nature-water, air, elements, chemicals, salts etc. Upon death cosmic
energy flows to the Almighty, and the rest to the nature. But we tend to
own the resources of nature, and thus influence the future generations.
The point is that we have to stop and think of more logical concepts of
sustainability from the presently usual connotation - 'Sustainable
development'; because in the fold of Sustainable Development' one has to
accept environmental damage or degradation caused due to industrial
activity, and industrial activity has been one most important single cause
of environmental degradation. So in other words the civilization of today
has to endure effects of consumerism, changing life style, and industrial
activity (so called development) in order to be there tomorrow in a world
where environment would still provide sustenance. Does not it appear
contradictory! As we know and understand industrial activity can it be
without exploitation of nature, and therefore sustainability and
development appear contradictory. Mind you the resources of nature is
finite whereas the population (unchecked) and the desire of the man
remains infinite. The world has witnessed the adverse effects on
environment and human & animal health of industrial activity driven
'development'. Instead the concept should change to 'Sustainable
Existence' which would make better sense.
2. Health inequality. There are many strata of population suffering with
health inequality. Reasons are many, such as non-accessibility of medical
help, lack of quality health services within reach of all, geographical
limitations in form of difficult & inaccessible terrain, economic reasons,
and a host of other reasons. Economic and gender bias are two most
important reasons for health inequality, and both these are more
pronounced in the developing world. In India, public sector health care
facilities are becoming extinct gradually but surely, and giving way to
private health care facilities. No doubt private health care facilities
may promise to offer better health care but fact remains that even now
60-70 % Indian population live in rural segment, are poor, and cannot
afford private health care, or for that matter universal insurance.
Moreover private health care facilities are concentrated in the urban
areas, and are profit oriented. Primary health care with all its laudable
aims have failed to provide quality health care. Prevention (which to my
mind is the essence of medical practice) has taken a back seat.
Immunization campaigns, to my thinking cannot be considered a preventive
measure since resorting to mass immunization existence of mutated variants
have been recognized. Point is that we must strive to create situations
where parasitic, bacterial, and viral overload does not take place in the
environment. AIDS virus is a mutated variant which has surfaced and now
threatens the survival of many, and now we are spending billions
(resources of the society) to combat the scourge, and trying to develop
vaccines against it, against which in all likelihood there will be
development of resistant strains. But how much is being done to ensure
proper disposal of infected or infectious waste in the blood banks, and in
the community of injectable drug users? Most of the resources are directed
towards safe sex practices which may be more difficult to achieve. Take
malaria for example. Lot of resources are committed to treating the
manifest cases, but not much of resources are directed towards improving
the public health engineering systems. Mosquitoes and the parasite in its
determination for survival have demonstrated that it can develop
resistance to many chemicals, and indeed so has been the story of fight
against malaria but to develop situations where mosquito breeding is
minimized takes a back seat at the time of allocation of resources.
Similar is the case with viral hepatitis (HBV). Not much is being done to
improve sanitary conditions in rural & urban areas. Time and again reason
of an outbreak has been the mixing of sewage with drinking water but
greater emphasis and resources are directed towards treating the manifest
cases, and research to discover more & effective vaccines. And in all
these situations-be it epidemic, or water scarcity, or natural calamity;
it is the weaker sections of the society who bear the brunt. Some times I
feel that prevention & curative aspects of medical practice run contrary
to each other. Even the development indicators which are based on economic
parameters may have to be redefined to include social development
(educational, health parameters, declining crime rate, and measures to
bridge the wide gap in the wages etc in a society) in its ambit, and new
development determinant tools may have to be fabricated.
3. Research & Development. Environmental pollutants are of four types.
Physical, Chemical, Biological, and Radiological. All these have effects
on human health. A lot of research is being done in the areas of
environment but not much visible research is being done in the area of
impact of environmental pollutants on the human health, not at least in
the developing world. We are more concerned with R&D on manifest diseases,
and in the area of clinical medicine. I am not suggesting that it is not
important but a lot of efforts are required to find a base line data
regarding impact of environmental pollutants on the human health.
Legislative framework further complicates the issue. All rules
and legislation fall within the purview of environmental laws, and
therefore at times concern for human and animal health gets lower
priority. Multiplicity of regulating agencies (which is the case in most
of the developing countries) create confusion leading to non-compliance
and non-performance. Many very genuine efforts fail to achieve the desired
result due to lack of systematic approach keeping the local conditions,
traditions, and compulsions in mind; to a problem in the
developing countries, and in some cases even in the developed world. Take
for example waste management-MAW or BMW. Handling of both are far from
satisfactory, and is not giving results commensurate with the effort or
allocation of resources. there is a lack of concept of 'system
application', and singular regulatory, and advisory authority. When we
have to take in reckoning uneducated and poor masses we have to act like a
mother who disciplines a child, and at the same time teaches the
lessons required for survival, and tries to remove hurdles in the living
activity of a child. A lot of research is required to develop effective
systems, be it in the area of regulations or in the areas of system
application.
Main purpose of posting this is to draw discussion. I would welcome
comments/suggestions.
Dr Lalji K Verma
New Delhi, India
