Last April, medical waste workers at Ibn al-Jazzar University Hospital in Kairouan (160 kilometers southwest of Tunis) found amputated toes from a female surgical patient. An administrative investigation was initiated and the human parts were delivered to the municipality for appropriate disposal.

Last April, medical waste workers at Ibn al-Jazzar University Hospital in Kairouan (160 kilometers southwest of Tunis) found amputated toes from a female surgical patient. An administrative investigation was initiated and the human parts were delivered to the municipality for appropriate disposal.

The head of the surgical department at Kairouan Hospital says: “Human organs and body parts left in surgical theaters are disposed of directly in the morgue, placed in refrigerators and delivered to the municipality under a contract to be buried in licensed places.”

Yet Correspondents investigated the matter and found negligence and laxity to the degree of malpractice by firms in charge of the disposal and treatment of medical waste. This negligence goes far beyond Kairouan Governorate and includes the majority of Tunisian cities.

Tons of waste

Official sources indicate that Tunisian hospitals house nearly 25,000 beds with an estimated 2.25 kilograms of daily waste per bed. The annual amount of health waste produced nationally is over 16,000 tonnes, 7,000 tonnes of which are hazardous waste and 9,000 tonnes are similar to domestic waste.

The Ministry of Health (MoH) organizes medical waste sorting and disposal under the Ministerial Order No. 2745 of 2008 which defines medical waste as “all physiological materials produced by the body.” Waste is managed by a specialized company – Environment Wassat Company (EWC) – contracted by public hospitals, clinics and private sanatoriums.

The EWC was founded pursuant to the Ministry of Environment and Sustainable Development (MESD) Resolution No. 19 of 2009, which authorizes it to “carry out the activities of collecting, sorting, storing, transporting, treating and removing medical waste in public and private hospitals and institutions in Kairouan, Mahdia, Sousse and Monastir.” The maximum processed quantity is set at six tons per day.

These laws governing medical waste management (MWM), albeit strict, have not prevented abuse and neglect, and consequently health and environmental risks, due to a lack of effective controls.

Poor waste disposal

Despite being the head of Kairouan Branch of the Waste Management Agency (WMA), Mehdi Nakhli took a long time to uncover the identity of the person who disposed of medical waste near WMA’s headquarters. The matter drew his attention and prompted him to monitor the place. He finally discovered that a doctor threw the medical waste from his own clinic into containers for domestic waste.

The doctor however claims that he only wanted to indirectly protest the WMA, blaming it for the neglected sector.

Pursuant to its law governing its work, the WMA oversees waste management, starting with houses and institutions of different activities and ending with the landfill controlled by the EWC.

The last to know

WMA does not have any database on medical waste in Kairouan Governorate. Although a regional agency with direct responsibility for all waste matters, it has been absent from waste management and control activities at a regional level, according to its supervisors. This denies the WMA’s access to simple information, such as the quantities of medical waste collected each day, which raises several questions about the role of the WMA and why it was originally created.

“We in the WMA do not know the quantity of medical waste,” says Nakhli. “This is because we have no specialist or consultant.”

In 2012, however, a consultant was appointed as part of an MWM project, with US$ 5.5 million funding by the United Nations Environment Program (UNEP). Under the project, five consultants were appointed in other governorates, but this consultant was transferred to another place, according to Nakhli who expressed surprise at the move and its negative reflection on MWM’s efficacy.

Nakhli also criticizes WMA’s exclusion and MESD’s central practices, stressing that the WMA does not engage in management and sensitization activities. The MESD, says Nakhli, has repeatedly organized activities in Kairouan, without informing or involving the WMA.

In light of WMA’s marginalization and the lack of a database, Nakhli is afraid of continuous disposal of medical waste in streets, sidewalks and random dumps. However, the most dangerous, in his opinion, is “ECW’s random operation method, which should coordinate with the WMA, in removing the risk of toxic and radioactive medical waste before throwing it in landfills.”

Violations and the company’s conscience

According to the agreed contract, the ECW should collect medical waste from public hospitals, private clinics and sanitariums, and remove hazardous medical waste in two stages, first sterilizing it to lower the risks of contamination.

According to an email sent by the WMA, abut 60 tons of medical waste is deposited in the landfill per month, which includes: syringes, secretions, blood-contaminated bandages, x-ray images and small surgical scalpels.

All of these items are supposed to be sterilized. Nakhli however expresses fears in two areas, which he considers an inevitable consequence of the absence of control mechanisms.

First, the ECW may not collect all the produced medical waste since he has already seen hospital rubbish thrown into domestic waste receptacles. Second, when the trash worker removes the bag by hand, he is immediately vulnerable to the risks of poking from syringes and secretions like blood, especially since trash workers do not wear protective clothing. The collected medical waste is also being dumped in landfills designated for domestic waste, in violation of health and environmental procedures followed by both the MoH and the MESD.

Unsupervised company

In addition to WMA’s incompetence, there is the problem of unqualified private companies in charge of medical waste collection and management, which further complicates the issue.

It is well known that private waste management companies are regulated by a book of conditions stipulating that they shall keep a record of the quantities of waste collected, treated and deposited in the landfill.

“That is what should be done,” says Tariq Najjar, a health technician at the Kairouan Health Department Health Protection Section (HPS). “But in fact, it is neither controlled nor followed-up by the appropriate authorities. This increases the uncertainty surrounding this file, which is dangerous to human beings and the environment.”

Through his fieldwork, Najjar, who follows medical waste noticed “a sorting deficit by often unqualified health workers in hospitals.”

Regarding the foot parts found, the hospital’s director attributes it to a defect in initial sorting. In hospitals, medical waste is put in red, yellow or black plastic bags according to their type and nature. The HPS trains health workers and provide them with work means and protection equipment. The WMA is responsible for the course of medical waste outside the hospital. However, these preventive operations, says Najjar, “remain fragile with regard to sorting quality.”

Despite the negligence that threatens major risks to the population’s health, private waste management companies operating in Kairouan and other governorates are allocated large budgets. Figures indicate that the ECW gains up to 1,100 pennies (US$ 0.5) for each kilogram, which is a heavy financial burden, according to the WMA.

This allows room for discretion and misconduct by the hospital administration that may be overburdened by the money paid to the ECW. According to numerous testimonies, the administration puts quantities of medical waste with domestic waste undertaken by the municipality to avoid paying extra costs for the ECW.

To do their full job, collection and management companies, according to specialists, should take other costly measures, which cuts into profit margins.

According to the sector experts, after sorting, the ECW should transfer medical waste to furnaces for processing through moist heat technology, removing waste risks significantly. Nonetheless, the process is costly.

This opens the door for a critical question: “What if the ECW does not process medical waste and instead deposits it directly in the landfill? What if the ECW avoids enormous expenses and thinks the same way the hospital administration does?”

“This assumption is possible in the absence of immediate and close surveillance,” say both Nakhli and Najjar.

Blind trust monitoring

Formally, the MESD Ocean Protection Agency (OPA) is tasked with monitoring the sorting companies operating in many governorates. Head of the OPA Branch in Kairouan Khalid bin Khadija says the WMA is responsible for monitoring companies since medical waste is under its competence. It is clear that he tries to evade the monitoring responsibility despite the fact that such companies have industrial activity and supposedly have a ‘Health Effects on Ocean’ Certificate granted by the MESD without consulting its regional structures.

Khadija underscores that the MESD is represented by an environmental expert who only reports to the OPA Central Bureau without keeping him updated.

“No reports are submitted to the OPA Branch in Kairouan,” he says. “In the case of any infractions, the OPA sends an expert to examine the situation and report to it. Monitoring is done through sudden visits or after communications and complaints of damages. We intervene in case of complaints, but it is not possible to make sure 100 percent of the time. And the book of conditions is likely to be violated,” says Khadija.

The monitoring process lacks the equipment needed to check the waste sent by the ECW to the landfill. There are no mechanisms to investigate waste risks and whether or not untreated toxic or radioactive waste has been thrown in.

“The process is done through eye observation using traditional and random monitoring,” says Khadija. “In case of any doubts, we let the ECW monitor its work by professional conscience… and certainly it will not violate the law for fear of punishment.”

This blind trust is closer to the Sufi order than to a professional operation of a department responsible of people’s lives. Note that the financial fines provided for by law are small (TND 5,000/US$ 2,500) and can be challenged before the court.

Surprisingly, this trust, which violates the law, continues despite recording a deficit in ECW’s work at the level of waste treatment. It transports medical waste from health institutions directly to the landfill without being treated.

The most important deficit in Kairouan Governorate is that the ECW has refused to contract with three local hospitals (in the towns of Ula, Hajeb Oyoun and Nasrallah), which are 45-70 kilometers away from its headquarters, to avoid transport costs. As a result, these hospitals throw medical waste in uncontrolled dumps, such as sidewalks or agricultural land, together with domestic waste, which has become a hotbed of loose animals and livestock and a source of danger to citizens.

Najjar stresses that no law binds the ECW to contract with these hospitals, calling on professional bodies to intervene to prevent health and environmental pro