Members of the public became alarmed when various waste materials, including used syringes and vials of AIDS-tainted blood, washed up on beaches from Maine to the Gulf of Mexico.
During the summer of 1988, miles of waterfront along the eastern seaboard of the United States were flooded with waves of trash. The refuse found on the beaches included large quantities of hospital waste containing syringes, prescription bottles, and vials of blood. Although the washing of garbage onto beaches was by no means a new occurrence, weather patterns that pushed an unusual amount of such waste to shore combined with a growing public awareness of acquired immunodeficiency syndrome (AIDS) to give rise to a national panic.
The public’s concerns about infection were not unwarranted. On one New Jersey beach, more than one hundred vials of blood came ashore in early July, and five of the vials tested positive for AIDS antibodies. In the month that followed, more than four hundred syringes were found on the Maryland shore. Elsewhere in the country, high bacterial counts and infectious debris prompted Ohio officials to prosecute those involved in illegal dumping in Lake Erie. The previous year, a group of children in Indianapolis had been discovered playing with vials of blood found in an open dumpster outside a medical office; two of the vials contained blood that was infected with AIDS.
Legitimate fears were inflated into hysteria. Despite assurances from health officials that the AIDS virus could not survive outside the body long enough to pose a serious threat in medical waste, the presence of one syringe was sufficient to close a major beach in New York. Numerous “sightings” turned out to be misidentifications of waste, and billions of dollars in state revenues were lost as a result of beach closings.
Other medical-waste problems that had made the news in preceding years helped to fan the flames. In November of 1986, New York City firefighters discovered about fourteen hundred bags of medical waste in a warehouse. Earlier the same year, eight Boston hospitals were faced with a sudden buildup of waste as a result of an unannounced decision by area landfills to stop accepting medical waste. In July of 1987, a pipe in a Los Angeles medical center burst, dumping blood and other fluids on five employees; the employees filed a $50 million lawsuit against the facility.
One of the most publicized sources of such waste was illegal “midnight” dumping. Up through the summer of 1988, it was in many cases cheaper for a company to dump infectious waste illegally and then pay any fines incurred than to dispose of the waste by legal means; at the time, improper dumping was not even a misdemeanor offense in many jurisdictions. Regulations varied from state to state, both in the classification of hazardous wastes and in requirements for its treatment and removal. These inconsistencies allowed some health facilities to ship waste to other states for disposal, thus avoiding more stringent laws in their own states.
In 1988, estimates of medical-waste generation ranged from eight to forty-five pounds per hospital bed per day; the Environmental Protection Agency (EPA) put the figure at about thirteen pounds per patient per day. This figure had gone up during the previous few years, and it would continue to rise as a consequence of an increasing use of disposable items. Larger hospitals, it was learned, tended to generate more waste per patient.
Most medical waste is not infectious. Although figures referring to amounts of infectious waste vary, most hospitals estimate that only about 15 to 20 percent of the waste generated per patient is infectious. The category of medical waste includes all the different types of waste generated by any health care facility, including hospitals, clinics, doctors’ and dentists’ offices, and research laboratories. Most of this waste is considered noninfectious and nonhazardous and can be disposed of in landfills. Of the infectious waste left, most is incinerated. Rising costs of incineration, stricter regulations regarding emissions from incinerators in heavily populated areas, and a reduction in the number of landfills accepting even sterilized infectious waste made illegal dumping an attractive alternative for some hospitals until effective legislation was enacted to discourage the practice.
Noninfectious medical waste includes such materials as office trash, food waste, wrappings, and many laboratory wastes. About 60 percent of this general waste consists of paper and corrugated cardboard, and another 20 percent is plastics. Even most waste that comes into contact with patients is not considered infectious.
Of the waste that remains after the general waste is removed, there are three major types: chemical, infectious, and radioactive. Although it was infectious waste that so aroused public fears in 1988, chemical and radioactive wastes can be even more dangerous, difficult, and expensive to dispose of safely.
Following the events of the summer of 1988, infectious waste became the target of legislative efforts. The definition of infectious waste proved integral to the safety of waste disposal and the effectiveness of laws designed to regulate it. What is included in the category can make an enormous difference in the cost, and therefore in the decision making, regarding disposal options for health care facilities. Depending on the definition used, between 3 percent and 90 percent of all hospital waste can be classified as infectious.
In July of 1988, two sets of rules were commonly used to classify medical waste as infectious or noninfectious: the rules formulated by the EPA and the system recommended by the Centers for Disease Control (CDC).
The EPA defines infectious waste as any refuse “capable of producing an infectious disease.” This means that there must be not only a pathogenic agent capable of infecting someone but also enough of the pathogen present to produce a disease upon exposure by a susceptible host. One problem with this definition is that there is no way of testing it, because the likelihood of infection depends on the host as much as on the infectious agent.
The CDC recommendations, commonly known as “universal precautions,” are much broader and more open to interpretation. These precautions simply state that blood and body fluids from all patients should be considered potentially infectious. These precautions were issued to help protect health care workers rather than to define infectious waste, but they proved convenient for many hospitals to use because they limited infectious waste to blood and body fluids. A clarification issued by the CDC in June of 1988 further narrowed the designation to blood and body fluids containing visible blood, specifically noting that this clarification was not intended to address waste-management practices.
In practical terms, the EPA and CDC regulations agree on four major types of infectious waste: microbiological waste, blood and blood products, pathological waste, and “sharps,” including needles, among other things. Two other categories are covered by the EPA guidelines and under most interpretations of the CDC recommendations: contaminated animal carcass waste and communicable-disease isolation waste. The CDC recommendations do not include all waste in the latter category. In addition to these types of waste, the EPA classifies four other types of waste as optional categories, which must be evaluated by a qualified individual at the site where these optional wastes are generated. Included in this optional category are surgery and autopsy waste, contaminated laboratory waste, dialysis-unit waste, and contaminated equipment.
Disposal decisions must include a determination of whether infectious waste should be considered hazardous waste and should therefore be regulated by subtitle C of the Resource Conservation and Recovery Act
The problem with an overly broad definition of infectious or hazardous waste is that the definition will raise the volume of waste requiring special treatment and disposal to the point that the costs of proper management will make escalating health care costs skyrocket and make improper and illegal disposal more and more attractive. An overly narrow view, on the other hand, may result in injury and disease among the population exposed to the waste.
In the states hit hardest by the deluge of medical waste on beaches in July of 1988—New York and New Jersey—the reaction was immediate. Beaches were closed and kept closed until emergency cleanups were performed, and within a month Governor Mario Cuomo of New York and Governor Thomas Kean of New Jersey had worked cooperatively to ensure that their states adopted a tracking system for medical waste. By November of the same year, federal regulations were instituted to set up a tracking system and a limited regulatory program in the Great Lakes states as well as in Connecticut, New York, and New Jersey. The Medical Waste Tracking Act of 1988
Although this fast action and legislation in response to the problem seemed praiseworthy, in reality, the MWTA was not comprehensive. For example, although the act specifically designated ten states, the Great Lakes states were allowed to decline participation, and any of the three Atlantic states could opt out if it had already instituted a program at least as stringent. Other states were offered voluntary participation. All the Great Lakes states declined participation, and only four areas joined the program, two of which later petitioned out. Rhode Island and Puerto Rico participated in the two-year demonstration program mandated by the MWTA; Louisiana and the District of Columbia initially joined but did not complete the program. Only four states and Puerto Rico actually were included in the program.
Further, although the MWTA required the segregation of infectious waste from other wastes, proper packaging and labeling, and documentation by the waste generator that tracks the waste to its final destination, it did not define medical waste (except radioactive waste) as hazardous. The act specified the inclusion of all the categories the EPA had previously designated in the definition of regulated medical waste but allowed for future exclusion of four of these categories—laboratory waste, dialysis waste, contaminated equipment, and isolation wastes—if the EPA determines that their nonregulated disposal does not pose a health hazard “if improperly managed.” Also, any facility that generates less than fifty pounds per month of regulated waste is exempt from the program.
The enforcement provisions dictated by the act did make the prospect of illegal dumping much less inviting. The act provided for civil penalties of up to $25,000 per day, criminal penalties of up to $50,000 per day, and jail sentences for individuals who violate the waste-tracking requirements. These penalties are difficult to enforce, however. Although the EPA set up the program, it is the responsibility of state and local authorities to manage and enforce it. How enforcement is to be achieved is not made clear in the law, especially if disposal sites or transporters are from states not participating in the program.
The MWTA has been limited both in its effectiveness and in its duration. Although the problem of medical-waste pollution continues to be severe in the twenty-first century, it is less noticeable than it was in 1988, and the urgency of addressing the issue has faded. New waste-management methods continue to be explored, and more hospitals are installing on-site incinerators to alleviate the problem, but medical-waste disposal is expected to be an issue for some time to come.
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Burdick, Alan. “Hype Tide.” The New Republic, June 12, 1989, 15-18. Brief article presents a far calmer and more realistic view of the 1988 beach waste incidents than other popular reports at the time. -
Green, Alex E. S., ed. Medical Waste Incineration and Pollution Prevention. New York: Van Nostrand Reinhold, 1992. Highly technical volume presents one of the most up-to-date overviews of the medical-waste problem available. Included bibliographies and index. -
Onel, Suzan. “The Medical Waste Tracking Act of 1988: Will It Protect Our Beaches?” Virginia Environmental Law Journal 9 (Fall, 1989): 225-247. Impressively thorough analysis of the MWTA is an invaluable resource. Presents opposing viewpoints on the MWTA’s necessity and effectiveness. Includes bibliographic references. -
Rutala, William A., Robert L. Odette, and Gregory P. Samsa. “Management of Infectious Waste by U.S. Hospitals.” Journal of the American Medical Association 262 (September 22/29, 1989): 1635-1640. Dense but readable article by leading researchers in the field presents the statistics on which many other analyses have been based. -
U.S. Congress. Office of Technology Assessment. Finding the Rx for Managing Medical Wastes. Washington, D.C.: U.S. Government Printing Office, 1990. Along with Issues in Waste Management (cited below), provides comprehensive, well-researched coverage of the incidents and issues in medical-waste management. Includes an extensive bibliography and an appendix that contains a summary of the MWTA and discusses its implications. -
_______. Issues in Medical Waste Management. Washington, D.C.: U.S. Government Printing Office, 1988. Provides some of the most comprehensive coverage available of the incidents and issues in medical-waste management. Clearly written and well researched. Includes extensive bibliography.
Garbage Barge Mobro Cruises U.S. Atlantic and Gulf Coasts