PUKAR: Understanding the segregation system of dental clinics in Mumbai and Navi Mumbai region by PUKAR

Haste in Waste is Waste. 0

Biomedical Waste Management In Private Dental Clinics In Mumbai And Navi Mumbai

Mentor Priyanka Gajbhiye

Researchers Prerana Gaitonde, Visalakshi Shivaraman, Shukra Paralkar, Tanvi Tekwani, Saniyah Shaikh, Sonali Sodhi, Kalpana Jangid

Research Partner Organization PUKAR (Partners for Urban Knowledge, Action, Research)

Contents Acknowledgement

Introduction

Group Process

Areas of interest

Research Methodology

Ethical considerations

Limitations

Literature review

Primary Literature Review

Secondary Literature Review

Themes that emerged in our research

Bio Medical Waste Introduction and Guidelines

Actual condition

Accessibility

Supply of bags

Cost

Frequency

Discussion

Gaps and loopholes

Recommendations

Research Advocacy

Appendix

Consent Form For Interview

Interview questions to dentists

Dental Assistant Counter Interview Questionnaire

Questionnaire For Biomedical Waste Officer (BMC/NMMC)

References

Acknowledgement Firstly, we would like to thank PUKAR (Partners for Urban Knowledge, Action and Research) for giving us the opportunity to do this research. This research would not have been possible without our participants from the dental fraternity practicing in Mumbai and Navi Mumbai. We are extremely grateful to them for trusting us with the sensitive data that they provided, which helped us tremendously in our research. We would like to extend our gratitude to our mentor, Priyanka Gajbhiye and our alum mentor Raj Gupta. This process would not have been possible without your constant support and guidance. We appreciate all the efforts taken by Priyanka and Raj. Thank you for guiding us and being flexible throughout the journey of our research. We would also like to thank all the staff members at PUKAR without whom this research would not have been successful - Dr Anita Patil-Deshmukh, Payal Tiwari and Sunil Gangawane. A special vote of thanks to all our co-fellows at PUKAR who motivated and encouraged us, without their constant presence this research would not have been a tedious task. Last but not the least we would like to thank our family members, friends and people who knowingly or unknowingly guided and gave us that much required support during the course of this project.

Introduction Bio-Medical Waste (BMW) refers to any waste, which is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities pertaining thereto or in the production or testing of biological and including categories mentioned in Schedule I of the Bio-Medical Waste (Management and Handling) Rules, 1998.

Image showing biomedical waste taken from Mumbai Live The image shows biomedical waste generated like a bottle of dettol, radiographic films used for x-ray, casts made up of plaster and dental stone used for making caps and bridges for teeth, bottles of anesthesia (used for numbing during tooth extraction), used gloves and etc. Globally, waste disposal and handling has become a major concern. Articles about plastic waste in the Pacific Ocean amounting to 80 thousand tons of plastic twice the size of Texas has shaken up the world. Closer home, Cyclone Ochi had washed ashore tons of garbage on the beaches of Mumbai. The Maharashtra Government recently proposed a state wide plastic ban to curb issues related to waste management and handling. 4

Cyclone Ochi clears Mumbai air but dumps 80,000 kg of trash on Versova beach Image taken from India tribune Biomedical waste is an even more alarming issue. 0.33 million tons of hospital waste is generated per day in India. Most of this waste is dumped in open grounds and mixed with sewage. Imagine infectious waste such as blood, used syringes and needles of sick people, impression materials soaked in saliva being handled carelessly and left to degrade in the open or worse still, mixed with normal waste. Hospital waste has three categories â&#x20AC;&#x201C; the anatomical waste has to be incinerated, plastic waste is shredded and sent to recyclers, and sharp waste such as syringes, surgical equipment, etc., are cleaned, disinfected, dismantled and sent to metal waste recyclers A major issue related to current Bio-Medical waste management in many hospitals and private clinics is that the implementation of Bio-Waste regulation is unsatisfactory as many of them are disposing waste in a haphazard, improper and indiscriminate manner. Lack of segregation practices, results in mixing of BMW wastes with general waste making the whole waste stream hazardous. Inappropriate segregation ultimately results in an incorrect method of waste disposal.

Image showing biomedical waste like syringes, blood filled tubes in an open field. Hyderabad: 10 tons biomedical waste found Image taken from https://www.deccanchronicle.com/nation/current-affairs/270717/hyderabad10-ton-biomedical-waste-found.html This has three obvious implications: adverse effects on the environment due to irresponsible handling of biomedical waste adding to a global crisis of health and sanitation, a lack of responsibility on the part of dentists and policy makers, rapid expansion of urban spaces without a sustainable waste management plan. All these factors along with a lack of adequate evidence-based studies on this issue in India specifically Mumbai and Navi Mumbai, spurred us to embark on this journey and understand the entire biomedical waste handling process in private dental clinics. We did this to be better, responsible clinicians and conscientious humans.

Group Process An issue to be addressed The seven of us sat quietly at the end of a long exhausting day at the Oral Surgery department. It was 3:30 pm and the OPD was finally shut. We huddled together, savoring our lunch and musing about the days happenings. In addition to a high level of anxiety while performing new procedures, extreme patience to handle scared patients, information recall and dexterity, we young interns were also instructed to follow a strict protocol for biomedical waste disposal. We had to dispose the used materials or waste from the oral cavity into the appropriate bag which were blue, yellow, black and white puncture proof containers. We diligently followed this everyday in every department without wondering about the reason behind it. Well, that was until we went to a private dental clinic in the evenings to observe a private dentist at work. All of us observed a lack of all the colored bags which we were used to. We never understood the implications of this until one day our college took us on a field visit to a biomedical waste disposal plant at Taloja, MIDC called Ramky. There we saw landfills of nonrecyclable waste, massive furnaces incinerating used waste and recycling plants for dental materials. It hit us then, that those colored bags indicated the type of waste and how it should be treated so as to not harm the environment.

The PUKAR Youth Fellowship Programme We then chanced upon the Youth Fellowship with PUKAR, and felt a door open for us .We immediately took it upon ourselves as a group, to collectively understand the entire scenario of biomedical waste disposal in our city, the segregation protocols, whether it is being followed and regulated and the implications it has on the environment. We had an extremely enriching experience right from the beginning. We were anxious about being accepted into the fellowship after the detailed interview process. On receiving a confirmation, we were extremely delighted.

Our 12 month journey Right from the orientation session through the residential camps and weekly workshops, every week we learnt something valuable. The entire journey has been a learning experience of sorts; from social realities to formulating the research proposal, collecting sensitive data and brainstorming as a team to arrive at a comprehensive and concise report. PUKAR has contributed in shaping our thought process on various issues, be more sensitive to others and see the broader picture as it is. Interactions with other groups gave us important insights into our own research. Working together as a team also helped us realize each oneâ&#x20AC;&#x2122;s strengths and weaknesses and work accordingly. What truly cemented our bond was the fact that despite one of us getting married 7

and another shifting city to do her masters, each of us contributed equally to the research at every stage. Technology made communication far simpler. At every stage, our facilitator and mentor guided us as a team. We are extremely fortunate to have been a part of this fellowship to make a significant, quantifiable change to society. To call it phenomenal would be an understatement.

Areas of interest Mumbai: We interviewed several dental practitioners from Chembur, Santacruz, Goregaon, Tardeo, Kurla. A counter interview of their clinical assistant was also conducted to verify the recorded data (given by the dentist).

Bio medical waste from all the research participant dental clinics in the shown areas goes to the same facility i.e.SMS Envoclean Pvt. Ltd.

Navi Mumbai: We interviewed several dentists from Kharghar, Kamothe and Ghansoli to learn about the waste segregation and management that is practiced in their clinics. A counter interview of the clinical assistants was also taken to support our findings.

Bio medical waste from all the participant dental clinics from the shown areas goes to the Mumbai Waste Management Limited run by Ramky Group.

Research Methodology The data regarding the biomedical waste segregation was collected by using qualitative method as the primary research tool. A structured interview schedule was personally filled by us by interviewing the dental practitioners in the private dental clinics. Data was recorded regarding the awareness and actuality of biomedical waste management, segregation and obstacles if any. Being from the same profession it was an added advantage for us to openly communicate with the dentist and an in-depth data of what is actually being practiced was obtained. The study was conducted across private dental clinics in Mumbai and Navi Mumbai area, Maharashtra, India. A total of 35 dentist and 28 dental assistants were interviewed for the study. The respondents were selected by convenient sampling method. The first version of questionnaire was piloted among four dental practitioners and was then refined in the light of this pilot. The study was carried over a period of 11 months from July 2017 to June 2018. Informed consent was received detailing the audio recording and pictures of the dustbins by each respondent who were included in the study. Counter interviews of the dental assistants were conducted to understand their awareness regarding the segregation of biomedical waste. These interviews with the dental assistant also helped us in knowing whether they have received a formal training for the same. Expert interviews were conducted to understand the perspective of stakeholders ie HOD of Health Dept. of NMMC, Marketing executive at Ramky and a representative of the Chief Engineer at MPCB who the policy makers are, the government and the contractors who act as common biomedical waste treatment and disposal facility.

Ethical considerations During the data collection, cleaning and analysis we have followed the ethics of research. They are: ● The identity of people interviewed is kept hidden, is not made public. The names of the clinics taken into the research are kept hidden. ● Any person who refused to answer to our interview was not forced. ● Every interview data used in this report has been collected with the informed consent of the respondents ● The data given by the people is presented without any changes and tampering in the report.

Limitations 1) Impact of BMW on waste collector's and handlerâ&#x20AC;&#x2122;s health. 2) Failure to obtain consent for audio recording of the interviews and pictures of the waste disposal area in the clinics by some dentists. 3) Inability to schedule expert interviews with SMS Envoclean . 4) Could not visit the actual site of waste disposal hence did not get a clear picture of the waste segregation and disposal method.

Literature review Primary Literature Review In our primary literature review, we referred the official guidelines laid down by the government for bio medical waste disposal. We have held this as our standard to compare with the actual scenario. Government policy Bio-medical Waste (Management & Handling) Rules, 1998 were notified by the Ministry of Environment & Forests (MoEF) under the Environment (Protection) Act, 1986. [1]

Image taken from http://envis.nic.in/ showing the logo of MoEF& CC In exercise of the powers conferred by Section 6, 8 and 25 of the Environment (Protection) Act, 1986 (29 of 1986), and in supersession of the Bio-Medical Waste (Management and Handling) Rules, 1998 and further amendments made thereof, the Central Government vide G.S.R. 343(E) dated 28th March, 2016 published the Bio-medical Waste Management Rules, 2016. These rules apply to all persons who generate, collect, receive, store, transport, treat, dispose, or handle bio medical waste in any form including hospitals, nursing homes, clinics, dispensaries, veterinary institutions, animal houses, pathological laboratories, blood banks, ayush hospitals, clinical establishments, research or educational institutions, health camps, medical or surgical camps, vaccination camps, blood donation camps, first aid rooms of schools, forensic laboratories and research labs. The â&#x20AC;&#x2DC;prescribed authorityâ&#x20AC;&#x2122; for enforcement of the provisions of these rules in respect of all the health care facilities located in any State/Union Territory is the respective State Pollution Control Board (SPCB)/ Pollution Control Committee (PCC) and in case of health care establishments of the Armed Forces under the Ministry of Defence shall be the Director General, Armed Forces Medical Services (DGAFMS). These rules stipulate duties of the Occupier or Operator of a Common Bio-medical Waste Treatment Facility as well as the identified authorities. According to these rules, every occupier or operator handling bio-medical waste, irrespective of the quantity is required to obtain authorisation from the respective prescribed authority i.e. State Pollution Control Board and Pollution Control Committee, as the case may be. These rules consist of four schedules and five forms. 13

Analysis of the BMW data from 2005-2010 shows that there was a significant increase in the number of HCEs in Maharashtra from 2008 to 2009. The total volume of BMW generated in 2006 was higher than any other year. As in 2009, Maharashtra had a total of 46,676 HCEs (Health Care Establishment). Out of the total, 16,060 HCEs belonged to bedded and 30,616 HCEs were non-bedded.1 In 2010, Maharashtra has as total of 45,784 HCEs. Out of the total establishments, 14,438 HCEs are bedded and, 31,346 HCEs are non-bedded. It may be observed that the bedded HCEs decreased by 10 % and non-bedded HCEs increased by 2% GOVERNMENT OF INDIA MINISTRY OF ENVIRONMENT, FOREST AND CLIMATE CHANGE Biomedical wastes categories and their segregation, collection, treatment, processing and disposal options: Category

Type of Waste

Type of Bag or Container to be used

Treatment and Disposal options

Yellow

(a) Human Anatomical Waste: Human tissues, organs, body parts and fetus below the viability period (as per the Medical Termination of Pregnancy Act 1971, amended from time to time).

Yellow Incineration or Plasma coloured non- Pyrolysis or deep burial chlorinated plastic bags

(b)Animal Anatomical Waste : Experimental animal carcasses, body parts, organs, tissues, including the waste generated from animals used in experiments or testing in veterinary hospitals or colleges or animal houses.

(c) Soiled Waste: Items contaminated with blood, body fluids like dressings, plaster casts, cotton swabs and bags containing residual or discarded blood and blood components.

(d) Expired or Discarded Medicines: Pharmaceutical waste like antibiotics, cytotoxic drugs including all items contaminated with cytotoxic drugs along with glass or plastic ampoules, vials etc

Incineration or Plasma Pyrolysis or deep burial* In absence of above facilities, autoclaving or microwaving/ hydroclaving followed by shredding or mutilation or combination of sterilization and shredding. Treated waste to be sent for energy recovery

Yellow coloured nonchlorinated plastic bags or containers

Expired `cytotoxic drugs and items contaminated with cytotoxic drugs to be returned back to the manufacturer or supplier for incineration at temperature >1200 0C or to common bio-medical waste treatment facility or hazardous waste treatment, storage and disposal facility for incineration at >12000C Or Encapsulation or Plasma Pyrolysis at >12000C. All other discarded medicines shall be either sent back to manufacturer or disposed by incineration.

(e) Chemical Waste: Chemicals used in production of biological and used or discarded disinfectants.

Yellow coloured containers or nonchlorinated plastic bags

Disposed of by incineration or Plasma Pyrolysis or Encapsulation in hazardous waste treatment, storage and disposal facility.

(f) Chemical Liquid Waste : Liquid waste generated due to use of chemicals in production of biological and used or discarded disinfectants, Silver X-ray film developing liquid, discarded Formalin, infected secretions, aspirated body fluids, liquid from laboratories and floor washings, cleaning, housekeeping and disinfecting activities etc.

Separate collection system leading to effluent treatment system

After resource recovery, the chemical liquid waste shall be pretreated before mixing with other wastewater. The combined discharge shall conform to the discharge norms given in Schedule III.

(g) Discarded linen, mattresses, beddings contaminated with blood or body fluid.

Nonchlorinated yellow plastic bags or suitable packing material

Non- chlorinated chemical disinfection followed by incineration or Plasma Pyrolysis or for energy recovery. In absence of above facilities, shredding or mutilation or combination of sterilization and shredding. Treated waste to be sent for energy recovery or incineration or Plasma Pyrolysis.

Red

Contaminated Waste (Recyclable) (a) Wastes generated from disposable items such as tubing, bottles, intravenous tubes and sets, catheters, urine bags, syringes (without needles and fixed needle syringes) and vacutainers with their needles cut) and gloves

Red coloured nonchlorinated plastic bags or containers

Autoclaving or microwaving/ hydroclaving followed by shredding or mutilation or combination of sterilization and shredding. Treated waste to be sent to registered or authorized recyclers or for energy recovery or plastics to diesel or fuel oil or for road making, whichever is possible. Plastic waste should not be sent to landfill sites.

White Waste sharps including Metals: (Translucent) Needles, syringes with fixed needles, needles from needle tip cutter or burner, scalpels, blades, or any other contaminated sharp object that may cause puncture and cuts. This includes both used, discarded and contaminated metal sharps

Puncture proof, Leak proof, tamper proof containers

Autoclaving or Dry Heat Sterilization followed by shredding or mutilation or encapsulation in metal container or cement concrete; combination of shredding cum autoclaving; and sent for final disposal to iron foundries (having consent to operate from the State Pollution Control Boards or Pollution Control Committees) or sanitary landfill or designated concrete waste sharp pit.

Blue

(a) Glassware: Broken or discarded and contaminated glass including medicine vials and ampoules except those contaminated with cytotoxic wastes.

Cardboard boxes with blue colored marking

Disinfection (by soaking the washed glass waste after cleaning with detergent and Sodium Hypochlorite treatment) or through autoclaving or microwaving or hydroclaving and then sent for recycling.

(b) Metallic Body Implants

Cardboard boxes with blue colored marking

*Disposal by deep burial is permitted only in rural or remote areas where there is no access to common bio-medical waste treatment facility. This will be carried out with prior approval from the prescribed authority and as per the Standards specified in Schedule-III. The deep burial facility shall be located as per the provisions and guidelines issued by Central Pollution Control Board from time to time. Barcode In order to keep a check on the proper segregation barcode system was introduced into biomedical waste management. A barcode is a pattern of parallel lines arranged in a row assigned to a specific item, good or commodity in order to identify it or scan it. A typical appearance of a barcode is shown in the following picture

Image taken from http://dynamicinventory.net/ Barcode system was introduced in the management of Biomedical Waste by The Ministry of Environment, Forests and Climate Change (MoEF& CC) under the Environment (Protection) Act, 1986. The aim of the barcode system was to make the segregation, disposal and treatment of BMW more effective and traceable in cases of wrongly segregated or disposed waste. The BMW is seen to be a growing problem not only in Mumbai and Navi Mumbai but in the entire nation. According to the draft published on 08.08.2017 about the Guidelines for Barcode System to be adopted by the Occupier or Operator of a CBWTF for ensuring compliance to the BMW management Rules, 2016 , the Ministry of Environment, Forests and Climate Change (MoEF& CC)[12] under the Environment (Protection) Act, 1986, under Rule 4, stipulates that it is the duty of every occupier to establish a Barcode system for bags or containers containing Biomedical Waste to be sent out of the premises or place for any purpose within one year from the date of notification. Also, Rule 5 of the BMW Management Rules, 2016 stipulates that it is the duty of the every operator to establish bar coding system for handling of bio-medical waste. Need for a barcode system in BMW management is for the following reasons: â&#x20AC;˘ For tracking the waste from the source to the final destination. â&#x20AC;˘ For tracing any improper disposal practise.

•

For the quantification of the waste.

Barcode system may be of two types as given below: (i) Designated colour coded bags as prescribed under the BMW Management Rules, 2016 containing pre-printed bar coded bags/containers or bar coded labels which can be supplied by any vendor; and (ii) Prescribed bar coded labels which can be supplied by the vendors that can be used at the source of generation by the Occupier or Operator of a CBWTF The following are the specifications of the bar code system according to the guidelines given by MoEF& Co Specification for Barcode (i) Barcode label specific to an occupier may be pre-printed directly on colour coded bags/containers or bar coded label for pasting on the colour coded bags/ containers as prescribed under the BMW Management Rules, 2016 shall be used. (ii) Barcode label should have a provision for colour coded bag as given below: • (01)- for Yellow Colour Bag • (02)- for Red Colour Bag • (03)- for White Translucent Colour • (04)- for Blue Colour card board box or Container (iii) Bar code label should also have the following provision: Name of the Health Care Facility (HCF), Place and Postal PIN Code; and unique number of the HCF may be PAN No/Authorisation Number Granted by the SPCB/PCC/DGAFMS/GST Number ( To be finalised in consultation with the Stakeholders) unique number of the Bag/containers ( To be finalised in consultation with the Stakeholders) (iv) In case of pre-printed bar coded bags, the thickness of bag should be as per BMWM Rules, 2016 i.e., more than 50 µ. Specifications of bar code label are as follows :All bar coded labels should be pasted only at the centre or close to centre of the colour coded bag or container permitted under the BMW Management Rules, 2016. However, the Bar code label should have the following specifications: • Size of bar coded label should be minimum of 100 mm X 25 mm • The barcode should be clearly legible on the label; • The Bar coded label should be tamper proof, water proof and its colour should not be faded in due course of at least for 48 hours after its use • Barcode label should be able to resist the temperatures, pressures maintained in autoclave/autoclave and should not fade its colour after autoclaving /microwaving or chemical disinfection • Barcode Labels thickness should be minimum of 50 micron and should not have any traces of heavy metals or any other objectionable chemical constituent • All barcode labels should be non-porous plastic and non-pvc • The adhesive used for barcode label should be pressure sensitive and should be of acrylic based adhesive and after use of Labels on the colour coded bags or containers, the label should not peel off on its own or by force.

Secondary Literature Review Various published papers & newspaper, online articles of real incidents: 1)

A study on waste treating technologies used for disinfecting the bio-medical waste in Greater Mumbai. (Gupta B. et al.)[2] The state of BMW Management at primary care health facilities indicates requirements of major inputs for improvement. The situation was worst in rural areas. Public sector providers in rural areas had better BMW Management system then counterparts in urban areas. In contrast, there was almost complete lack of biomedical waste management system in private sectors in rural areas. They concluded by stating that each and every healthcare facilities which generates biomedical waste, needs to set up requisite treatment facilities to ensure proper treatment of wastes and its disposal so as to minimize risk of exposure to staff, patients, doctors and the community from biomedical hazards. In the same study in New Delhi [10], only 50% of the dentists knew that their hospital had a waste management policy whereas in the current study 82.5% of dentists but only 12.5% of auxiliary staff were aware of this. Thus, awareness of the waste management policy was found to be very low among the auxiliary staff, which could be due to lack of proper educational programmes.

Awareness of Biomedical Waste Management Among Dental Professionals and Auxiliary Staff in Amritsar, India. (Ramandeep S Narang et. al.)[3]

The results of this study have demonstrated a lack of awareness of most aspects of BMW management among dental auxiliary staff in the dental hospital/clinics in Amritsar and a lack of awareness of some aspects among the dentists who work in the hospital/clinics. They provide the hospital authorities with data upon which they can develop a strategy for improving BMW management. 3) A Study: Biomedical Waste Management in India. (Kirti Mishra et. al.)[4] An analytical study was carried out of various techniques used for biomedical waste management along with the knowledge and attitude of people and healthcare workers. They found that many primary care, secondary care and tertiary facilities are in RED category and there for a lot of efforts are necessary to improve the biomedical waste management across all over country. 4) Health-care waste management in India. (Patil AD et. al.)[5] It is estimated that annually about 0.33 million tonnes of hospital waste is generated in India and, the waste generation rate ranges from 0.5 to 2.0 kg per bed per day.

The following articles were found published in reputed newspapers or online website. Note that these are only a few incidents that we are citing as reference to represent the severity of the situation, when in reality the gravity of the situation is much more: 1) Hindustan times article-18th march, 2018-Maha focuses on small clinics to treat biomedical waste[6] In August, last year, HT had reported how the Controller and Auditor General (CAG) had rapped the state environment department and MPCB for unsafe disposal of bio-medical waste. As the state recorded a 14% rise in bio-medical waste generated between 2014 and 2016, the Maharashtra Pollution Control Board (MPCB) has decided to rope in general practitioners and small clinics to ensure they treat their daily bio-medical waste safely. Details from the Union health ministry showed bio-medical waste generated in the state increased by 17% between 2014 and 2015. Mumbai recorded the highest amount of bio-medical waste in the state during the same time, according to MPCB. The numbers have steadily increased despite the state having 34 bio-medical waste treatment facilities – the highest in India.

Details from the Union health ministry showed bio-medical waste generated in the state increased by 17% between 2014 and 2015. (HT File (Representational Image) In August, last year, HT had reported how the Comptroller and Auditor General (CAG) had rapped the state environment department and MPCB for unsafe disposal of bio-medical waste. “Earlier general practitioners from clinics were exempted. Now we are concentrating on covering them with a statewide survey,” said Amar Supate, principal scientific officer and head of bio-medical waste management, MPCB. “We have started a pilot project at Nashik, where small clinics have already started collection and segregation at source. By the end of 2019, this model will be replicated across Maharashtra,” said Supate. The Bio-Medical Waste Management Rules, 2016 has enhanced the network of HCFs ensuring biomedical waste is disposed properly, said MPCB officials. According to MPCB, there are 52,704 HCFs in Maharashtra, of which 22

20,225 (bedded) generate 57,773kg bio-medical waste per day, 32,479 (non-bedded) generate 13,667kg per day, and the remaining small clinics and medical centres generate 71kg per day. Hospital waste has three categories – the anatomical waste has to be incinerated, plastic waste is shredded and sent to recyclers, and sharp waste such as syringes, surgical equipment, etc, are cleaned, disinfected, dismantled and sent to metal waste recyclers – said Supate. “The new rules also include ayurvedic and homeopathic hospitals. Households and clinics that don’t segregate this waste at source are a cause for concern. We don’t want to increase treatment centres because they will become hotspots for infections if mixed waste is brought to them,” said Supate. Swacch Bharat national expert and member of the committee that drafted the Municipal Solid Waste Management rules, Almitra Patel said, “Small clinics are aware of the new rules but tend not to dispose waste safely since they are unfairly charged for it.Small clinics need to be encouraged to tie up with larger hospitals in their vicinity, submit their waste to them, and pay a nominal fee.” KP Niyati, member of various environment impact assessment committees of the Union environment ministry said, “It is not as if people are falling more ill in the state. Mumbai is a mecca of medical tourism. The figures suggest that Maharashtra has better documentation of biomedical waste produced.” 2) Hindustan Times article-18th March, 2018- Maharashtra generates most bio-medical waste in India[7] Waste from hospitals, nursing homes, blood banks and veterinary institutions, including used syringes, bandages, amputated body parts and other human and animal bio-waste generated during medical treatment and research are categorized as bio-medical waste. Maharashtra tops the list of biomedical waste generated in the country daily, according to a document submitted by the ministry of health and family welfare in the Lok Sabha on Friday. According to the state-wise report, Maharashtra generated 53,385kg a day in 2014, which increased to 62,740kg a day in 2015 and further to 71,511kg in 2016. Second on the list is Karnataka (at 66,468kg a day), followed by Tamil Nadu (40,552kg a day) and Kerala (37,773kg a day). Goa, Karnataka and West Bengal are among the states that have seen a steady decline in the figures over the past three years. Waste from hospitals, nursing homes, blood banks and veterinary institutions, including used syringes, bandages, amputated body parts and other human and animal bio-waste generated during medical treatment and research are categorised as bio-medical waste. Experts attributed the rise to better medical facilities and reporting of figures in Maharashtra. District-wise data from the Maharashtra Pollution Control Board (MPCB) show Mumbai generates the most amount of biomedical waste in the state (14,000kg at day), followed by Pune (12,000kg a day), Nagpur (10,000kg a day) and Nashik (8,000kg a day). The public health department said the state disposes of nearly all its bio-medical waste, which is a health hazard, in a safe way. Experts, however, are skeptical whether small clinics and health establishments in urban and rural areas follow safe practices. The MPCB said in 2017-18, the bio-medical waste generation would be approximately 75,000kg a day. “The data indicate there is better reporting on bio-medical waste collection and disposal according to the central government rules, as we have the best network compared to other states,” said Amar Supate, principal scientific officer and head of bio-medical waste management, MPCB. “In cities such as Mumbai and Pune, a huge quantity of waste is collected owing to advanced medical treatment facilities.” 23

India generated 4.95lakh kg bio-medical waste a day in 2014, 5.01lakh kg a day in 2015, and 5.19lakh kg a day in 2016. 3) Article + video on First Post- Watch: Where all of Mumbaiâ&#x20AC;&#x2122;s medical waste goes[8] Mumbai's only biomedical incinerator plant for medical waste treatment is adversely impacting the health of the slum population nearby. Located in the crowded suburb of Mankhurd, the incinerator plant's chimney emits smoke 24 hours a day, since it first started functioning in 2009. As per Central Pollution Control Boardâ&#x20AC;&#x2122;s guidelines of 2016, a Biomedical plant should at least be 500 metres away from any residential area and cater only up to 10,000 beds. But this plant treats biomedical waste collected from more than 42 thousand beds across 8000 health care units, four times the permissible amount. Residents of the area have to deal with the thick smoke and stench every day. Tuberculosis, skin diseases, lung and heart disorders in newborns have become common in the area. The employees at the incinerator work 12 hours a day and are not adequately paid. Most of them quit in few months because of health issues. Several complaints have been filed against the plant by locals and activists. But nothing has stopped the plant form emitting the toxic smoke.

City's sole biomedical waste plant doesn't have MPCB approval Image taken from https://www.firstpost.com/india/watch-where-all-of-mumbais-medical-wastegoes-3483835.html

4) Article on Times of India- 24th August 2017--Inadequate management of bio-medical waste in Maharashtra: CAG[9] MUMBAI: The enforcement of biomedical waste management (BMW) rules in municipal corporations in Maharashtra was found to be inadequate in the report of the Comptroller and Auditor General 2016. The CAG audited 22 health care establishments between 2011 and 2016. Five HCEs at Nashik and Mumbai did not segregate BMWs as per the rules. Three HCEs in Nashik did not use blue/white translucent puncture proof containers. Instead, they used plastic bags. In two HCEs in Mumbai, sharp waste was mixed with incinerable waste, the CAG report found. In three HCEs, BMW was stored near the patient's bed. In 16 of the 22 HCEs, BMW containers were not labelled as per the procedure. Of the 22 HCEs inspected, 20 operated without valid authorization owing to delays from the MPCB, the CAG report said. Only 8 HCEs maintained a record of collection of BMW. The inspection of hospitals and common facilities by the MPCB was also inadequate, the CAG report found. In fact it said that the advisory committee advising the government and MPCB on the implementation of BMW rules did not meet in 2011-16.

Themes that emerged in our research Bio Medical Waste Introduction and Guidelines Proper management of Biomedical waste (BMW) generated in a healthcare facility is one of the most important functions of a healthcare worker (HCW) as its improper management not only poses risk to human beings and environment. Medical care is vital for our life and health, but the waste generated from medical activities represents a real problem of living nature and human world. Improper management of waste generated in health care facilities causes a direct health impact on the community, the health care workers and on the environment. Every day, relatively large amount of potentially infectious and hazardous waste are generated in the health care hospitals and facilities around the world. Indiscriminate disposal of BMW or hospital waste and exposure to such waste poses serious threat to environment and to human health that requires specific treatment and management prior to its final disposal. The problems of waste disposal in the hospitals and other health-care institutions have become issues of increasing concern. Biomedical waste irrespective of the source it is generated from, major or minor, needs to be segregated at the primary source and has to undergo appropriate disposal. the number of upcoming dental clinics in the cities is increasing, one can find at least 2-3 clinics in every lane, hence though the quantity produced by one clinic may put the clinic into the minor source category, considering the overall waste generated by such a source citywide, one cannot turn a blind eye to it. The definition of Bio Medical Waste (BMW)-according to Biomedical Waste (Management and Handling) Rules, 1998 of India “Any waste which is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities pertaining there to or in the production or testing of biologicals.” We zeroed down on this on this topic thinking about this: Biomedical Waste generated from the major sources is usually segregated at the point of generation but is it so with the minor sources too? When we consider private dental clinics in populated cities like Mumbai and Navi Mumbai, we can find at least 2-3 in every lane, is the biomedical waste generated from this minor source finding its appropriate disposal or is it mixed with municipal solid waste? Since this is our common community and we learnt quite a bit about BMW disposal norms from our dental college and attached dental hospital, we set out to see how much of this was practically being followed in the real world out there. Since most dental practitioners own a private clinic, we thought of it as the best area to explore as these ‘minor’ sources of BMW generation are often not spoken about. In the process, we first researched for guidelines laid down for this purpose and as to ‘who’ is handling this BMW waste. 26

Hereâ&#x20AC;&#x2122;s what we found: The Maharashtra Pollution Control Board (MPCB) is in charge of this domain. Our self-assumed hypothesis that- the Brihanmumbai Municipal Corporation (BMC) or the Navi Mumbai Municipal Corporation (NMMC) were in charge of this- was washed away.

However, the MPCB does not directly handle the BMW either! There are 2 big giants who hold the monopoly of this business in their hands viz. â&#x20AC;&#x201C; SMS ENVOCLEAN Private Limited in Mumbai and Mumbai Waste Management Ltd run by the Ramky Group in Navi Mumbai. The MPCB has entirely given them the responsibility of BMW management in the said areas, which are also the areas where we conducted our research. The MPCB has laid down certain guidelines to be followed by the Common Bio Medical Waste Treatment Facility (CBMWTF)- which is the name given to establishments like SMS Envoclean etc.

These are as follows: Biomedical wastes categories and their segregation, collection, treatment, processing and disposal options Category

Type of Waste

Type of Bag or Container to be used

Treatment and Disposal options

Yellow

(a) Human Anatomical Waste: Human tissues, organs, body parts and fetus below the viability period (as per the Medical Termination of Pregnancy Act 1971, amended from time to time).

Yellow Incineration or Plasma coloured non- Pyrolysis or deep burial chlorinated plastic bags

(c) Soiled Waste: Items contaminated with blood, body fluids like dressings, plaster casts, cotton swabs and bags containing residual or discarded blood and blood components.

(d) Expired or Discarded Medicines: Pharmaceutical waste like antibiotics, cytotoxic drugs including all items contaminated with cytotoxic drugs along with glass or plastic ampoules, vials etc

Incineration or Plasma Pyrolysis or deep burial* In absence of above facilities, autoclaving or micro-waving/ hydroclaving followed by shredding or mutilation or combination of sterilization and shredding. Treated waste to be sent for energy recovery

Yellow coloured nonchlorinated plastic bags or containers

(e) Chemical Waste: Chemicals used in production of biological and used or discarded disinfectants.

Yellow coloured containers or nonchlorinated plastic bags

Disposed of by incineration or Plasma Pyrolysis or Encapsulation in hazardous waste treatment, storage and disposal facility.

Separate collection system leading to effluent treatment system

After resource recovery, the chemical liquid waste shall be pretreated before mixing with other wastewater. The combined discharge shall conform to the discharge norms given in Schedule III.

(g) Discarded linen, mattresses, beddings contaminated with blood or body fluid.

Nonchlorinated yellow plastic bags or suitable packing material

Red

Red coloured nonchlorinated plastic bags or containers

Puncture proof, Leak proof, tamper proof containers

Blue

(a) Glassware: Broken or discarded and contaminated glass including medicine vials and ampoules except those contaminated with cytotoxic wastes.

Cardboard boxes with blue colored marking

Disinfection (by soaking the washed glass waste after cleaning with detergent and Sodium Hypochlorite treatment) or through autoclaving or microwaving or hydroclaving and then sent for recycling.

(b) Metallic Body Implants

Cardboard boxes with blue colored marking

This is published on the official website of SMS ENVOCLEAN PRIVATE LTD. They have given the said information regarding the tender given to them by MPCB and the work they claim to carry out. â&#x20AC;&#x2DC;We are operating in the jurisdiction of Mumbai City. Company initially started its operations in the year 2009. SMS ENVOCLEAN Private Limited was appointed by Municipal Corporation of Greater Mumbai. Tender was finalized & project was authorized by Maharashtra Pollution Control Board in the year 2007. Municipal Corporation of Greater Mumbai has allotted land on BOOT basis to M/s. SMS Envoclean Private Limited. 33

We are common Biomedical waste Treatment Facility (CBWTF) serving to 11,037 clients. We have our full fledged plant located near Deonar with Incinerator, Autoclave, Chemical Disinfection and Shredding Facilities. We are having 59 vehicles for BMW collection and each vehicle has its assigned routes and ensures regular biomedical waste collection as per required frequency. Company has been employed with qualified and skilled staff for Management of the facility. We are providing bar-coded bags to our customers as per the categories of Biomedical Waste Rules 2016, also providing Trainings to our customers on regular basis with a dedicated team and training modules for the same.’ However, as per the answers we got in our interviews with the dentists and their assistants, we found that Envoclean did not provide with colour coded bags as claimed on their website. The dentists also had a common complaint about irregular frequency. About Ramky (as found on their website)[11] Similarly, Ramky Group has claimed the following regarding the contract given to them and their services.

‘Mumbai Waste Management Ltd is providing service for Bio Medical Waste Collection, Transportation & Disposal since 2003 in Navi Mumbai, Panvel, Rasayani areas on daily basis. The Navi Mumbai Municipal Corporations along with Pollution Control Board have appreciated our efforts of managing the Bio-medical waste. MWML has client base of about 1900 Bio-medical waste generators and the waste is collected on daily basis from all of them through 10 No’s of dedicated vehicles. Vehicles equipped with electronics weighing, bar code reading facility and GPS. The entire operation of recording of waste is automated and manual interference is avoided in total operations. Our facility is equipped with Incineration System with equipment like Primary Combustion Chamber with temperature range of 800oC to 850oC, Secondary Combustion Chamber with temperature range of 1050oC to 1100oC, Venturi Scrubber, Spray Quencher, ID Fan & 30 meters Chimney, Autoclave, Shredder, Gas Monitoring Device, Effluent Treatment Plant and Computerization. ● MWML has the consent issued by Maharashtra Pollution Control Board. ● MWML has Agreement with Navi Mumbai Municipal Corporation for collection, Transportation & Disposal of Bio Medical Waste. 34

â&#x2014;?

MWML have Barcoding system to maintain the record of Bags sale with barcode stickers, Waste receipt HCE wise, Waste disposal batch wise.â&#x20AC;&#x2122;

Image showing a biomedical waste management van taken from the official website From our interviews with dentists owning private clinics, our findings pointed majorly towards many of them not following the exact prescribed protocol. There could be various reasons for this such as lack of communication, lack of enforcement of guidelines etc. According to one dentist, they found it difficult to follow the proper protocol as no clear guidelines were given by the government. This leads us to wonder as to why they are not aware of the guidelines laid down by the MPCB. Perhaps their respective contractors- Envoclean/Ramky have not enforced upon them, these guidelines either. To dive further into the actual condition today, we looked for incidents giving us any clue about this situation.

Actual condition This section presents extracts from the conducted interviews with the practicing dentists of the private dental clinics across various locations in Mumbai and Navi Mumbai. The scheduled and conducted interviews helped us to gain the insights about the awareness of the dentists in the management of biomedical waste generated in their clinic, adaptation and adherence of the dentist to the BMW guidelines provided by the government, difficulties in understanding the policy, the space constraints, lack of knowledge about the color coded bags and confusions about the appropriate disposal techniques were few of the many issues that were highlighted. This chapter will leave the reader pondering upon the otherwise neglected topic of waste management and disposal. This is a known fact that, inadequate management or inappropriate handling of the biomedical waste may have serious health consequences and impacting the environment causing more harm than goodthat the healthcare industry is vowing for, as it carries a higher potential for infection and other secondary health hazards. 1) Emergence and concentration of dental clinics in urban sector and how it influences BMW management: With almost 310 dental colleges in India that churns out around 26000 dentists every year and with a new dental clinic opening in every nook and corner of the city, can you estimate the amount of generated biomedical waste? Itâ&#x20AC;&#x2122;s massive and hence the outlined method for the biomedical waste disposal and segregation must not be overlooked. Along with the constraints like supply outstripping the demand for dentists, saturation in the dental market and financial consideration, the issue of appropriate and correct disposal of the generated biomedical waste is not only a legal necessity but also a social responsibility. The carelessness towards biomedical waste will not only affect the health of the patients but will also be a potential hazard to the healthcare workers and general population. No doubt that the biomedical waste management comes with a cost but if this cost is not borne by the dentists then this careless attitude will take a toll on the general health of the public and also cause an irrevocable environmental response. Amongst the interviewed dentists, it was noted that 82.85% were registered with biomedical waste management service whereas 17.15% were not registered and disposed it along with municipal solid waste. Amongst the registered dentists 51.72% were enrolled with SMS Envoclean and 48.27% were registered with the Ramky group. 2) What prevents Dentists from not registering with BMW treatment facility? 16.66% found space in the dental clinic inadequate as the clinic was not spacious enough to accommodate another dustbin for biomedical waste segregation. 16.66% were aware of the infrequent visits paid by the waste handler by their interaction with various groups on social media and hence the roadblock here was the storage of waste for a period of one week in their clinic until itâ&#x20AC;&#x2122;s collected; therefore, they preferred disposing the biomedical waste along with the municipal solid waste daily.

50% of the dentists reported cost as a constraint due to which they did not enroll with the biomedical waste disposal facilities. Few of the dentists considered the biomedical waste segregation as â&#x20AC;&#x153;additional expenseâ&#x20AC;? and termed it as unaffordable thereby avoiding it. Less patient flow in the clinic accounting to less biomedical waste generation discouraged some from spending money on the biomedical waste treatment facility. Some also considered the waste generated in the clinic as not hazardous as it consisted only of gloves and cotton and hence disposed it along with municipal solid waste. Why is segregation of biomedical waste at the source of generation i.e. at the dental clinic important? Recently biomedical waste has emerged as an issue of major concern for hospitals and clinics. Biomedical waste segregation is the most important step in the entire process of waste management as it requires special attention to be given to the relatively smaller quantities of infectious and hazardous waste, thereby reducing not only the risks but also the cost of handling, treatment and disposal. 3)Why is colour coding of disposal bags necessary? According to a WHO report 80% of the biomedical waste is general waste that is not infectious, 15% is infectious and not hazardous wherein 5% is infectious and hazardous.

Segregation of biomedical waste in appropriate colour coded containers is the most important aspect of waste management as specific treatment is given to the generated waste depending upon their infectious and hazardous potential.

Image showing non-chlorinated plastic bags for biomedical waste disposal Image taken from https://www.indiamart.com/sanghavi-fresh-nfast/ Awareness and adherence amongst the dentists about the colour coding according to biomedical guidelines: 37

Of all the interviewed dentist 80% were aware of the biomedical waste segregation protocol; however, on reading the fine print it was observed that they were following their own perceived interpretation of the guidelines. Only 8.57% were found to be adhering to the said protocol. 20% of the dentist were completely unaware of the BMW guidelines for waste segregation. Most of the dentists registered with Envoclean claimed that even though they were aware of the color coding they must not to be held accountable for improper segregation as they were not provided with the other color-coded bags. What we question is: why aren't the dentists being provided with all the color-coded bags? Is unawareness the cause of it? Is there a mutual understanding between the dentist and the contractors to cut on the cost by using only a single coloured bag? It was noted that proper segregation of waste was not followed even after the provision of all three colour coded bags to the dentist as they were unaware of the segregation protocol and dumped the waste randomly into the bags . Most of the dentist claimed that they were not provided with the guidelines for proper waste disposal. No training was provided by the government or the contractor for disposal and management of biomedical waste. It is a fact that BMW guidelines are available on the Internet but the norms are not executed in the practice. â&#x20AC;&#x153;Latex gloves should not be put into the red bag and hence I use the black bagâ&#x20AC;? as quoted by one of the interviewed dentist. Convenience and availability were the two prominent trends noted in the adherence of the protocol. Those who claimed they have both bags were found to be in the possession of only a single coloured bag.

Picture taken at a dental clinic that had only one color bag. We also recorded that dentists who claimed having two coloured bags didnâ&#x20AC;&#x2122;t have any.

The above picture shows that 3 bags were used black, yellow, red. Picture taken during observation in a clinic in Mumbai. 39

Most of the dentists had minimum of two dustbins. A dentist was also found possessing all colour coded bags and no dustbins. The total number of dustbins varied from one to six.

Picture taken at a clinic where only one dustbin and a single color of bag was used.

Picture showing a single color bag and improper disposal of plastic glasses in it taken during observation in a clinic. 40

Out of which eight of the dentists found space as a constraint for BMW segregation. Most of the dentists did not consider space as an issue and were willing to practice the waste segregation at source; however, several of them were not willing to work around the space for segregation of biomedical waste.

Image taken at a certain clinic showing gloves being disposed in a yellow bag. Ideally, Gloves should be put in a red bag. The waste bags are also open and not confined in a dustbin. The sharps were disposed in a separate container by most of the dentists, while few of them had an incinerator in the dental office, in some cases needles were broken with the help of a cutter.

The above picture shows a plastic puncture proof container in which the sharps should be kept in the clinic. Few of them disposed the needle in red or yellow bags after capping the needle or after placing it in between two plastic glasses. We also noted that some dental practitioners disposed the sharps in an empty glove box. Few dentists disposed the puncture proof containers (provided for sharps) either into the red bag or handed it separately to the collector.

To support our findings counter interviews of dental assistants were conducted.

73.3% of dental assistants were aware about the color coding; however, the knowledge was limited to their interpretation of the waste segregation guidelines.

76.7% of the assistants knew which waste is to be dumped in which colour bag.

93.3% did not encounter any problems while handling the biomedical waste.

66.7% received basic training by the dentist himself for handling the biomedical waste; however, we noted that no formal training was given.

80% didn't undergo any pathological screening test for blood transmitted diseases.

Accessibility Supply of bags On comparison of our interviews with the dentists and our expert interviews with Ramky, MPCB, NMMC we noted some stark discrepancies. As stated previously, amongst the registered dentists 51.72% were enrolled with SMS Envoclean and 48.27% were registered with the Ramky group. While all the dentists in Mumbai who were registered under Envoclean were only provided with red bags (as opposed to the prescribed yellow and red bags for private dental clinics) and those registered with Ramky had yellow as well as red bags. We were informed by the interviewed dentists that they obtain a total of 20 bags in a packet and these packets are to be ordered according to their needs (desired colour bags and quantities). The fee for the bags is not included in the yearly subscription charges. This quotation also varied as we shall see in the subsequent section. 65.51%- used only red bags. 17.24%- used red and yellow bags. 6.89%- used only yellow bags. 3.44%- used yellow and blue bags. 3.44%- red and black (for biomedical waste too). 3.44%- yellow and blue/black bags. The expert interview with Ramky revealed that they supply both yellow and red bags; however, a contrasting scenario was noted in the dental clinics as the dentists did not use allocated bags in the righteous manner. Meanwhile, the interviewed official from Ramky claimed to be supplying and receiving equal number of red and yellow bags. According to our interviewed dentists, Envoclean was supplying only red bags; however, the Envoclean website claimed that the company supplies both yellow and red bags to the dental practitioners so as to segregate waste depending upon its infectious and hazardous potential.

Cost 83% dentists cited cost as major roadblock for not availing these services. In Mumbai it is Envoclean who handles the biomedical waste and it is Ramky in Navi Mumbai. Every dentist has to pay a yearly subscription fee to the company of their choice for their biomedical waste management. This fee is inclusive of waste collection from the clinic; however, separate charges are applicable on ordering of the colour coded bags.

When enquired about the cost to avail these services, mixed opinions were obtained. There was a lack of standardised cost amongst different dentists in the same area. What was even more surprising was that the variation was considerable and it was ranging from Rs.2000 per annum to Rs.7000 per annum. For Ramky the yearly subscription ranged from Rs. 2200 to 7000. Out of the 48.27% of dental practitioners who were registered with Ramky, 50% were aware of the costs incurred, 28.57% paid between Rs. 2200 to 4000 excluding bags and 71.4% paid between Rs. 4000 to 7000 for the same service. Out of the 51.72% of dentists who subscribed to Envoclean, 60% admitted to the cost paid by them. Out of the 60% (who mentioned about the charges) 44.4% shelled out between Rs. 3000 to 4000, another 44.4% paid between Rs. 4000 to 5000 and 11.11% paid an exorbitant fee of Rs. 5000 to 6000 per annum excluding the provision of colour coded bags.

In addition to this cost plays a huge role for a dentist when the quantity of waste generated in his clinic is minimal therefore disposing a partially filled bag and then paying more to order a new packet makes no sense. When the patient flow itself is so less, why would one invest money in buying waste disposal bags when they can easily use the same bag for upto a week? If this is the yearly subscription fee then why is it variable? Why is there no standardised cost? Why do different dentists in the same area pay different subscription charges? Is the variation in the charges due to the opted frequency of biomedical waste collection from the clinic? This is a huge loophole which needs to be addressed. There is an urgent need for accountability on the part of the biomedical waste management companies as well as the dental practitioners. Economics play a huge role in determining the frequency of collection, annual fee for the dentist as well as the charges for the colour coded bags. All these differences raised serious questions about the economics involved in supply of bags, treatment of waste, cost of transportation, profit made by the companies, the loss to the dentists and the impact on the environment ultimately.

Frequency Storing biomedical waste in the clinic for a long period of time poses health hazards to the dental team as well as the patients. Apart from the foul odour, breeding of insects and fulminating bacteria is a major concern. Blood and saliva soakedcotton; impression materials as well as used gloves tend to decompose rapidly. Also, recyclable items if stored for a considerable period could become unrecyclable. 47

On considering all the above mentioned pointers , the frequency of biomedical waste collection is extremely important, so as to maintain adequate hygiene. Collection of waste in monsoon was a concern for 1 of our interviewed dentist. We tried to explore the frequency of collection all over the city and noted that a majority of them i.e. 55.17% had their waste collected once a week, 24.13% had it collected twice a week while 3.4% had it collected every day , more than 5 times a week or on alternate days. Some also reported that the collector never comes until called. 6.89% reported it to be infrequent as there was no standard frequency of biomedical waste collection.

On further enquiry we also noticed that there was no extra cost involved in calling the collectors more frequently although one of them stated that an additional charge is applicable if the collector is called more frequently. Why the stark contrast in findings? Why is there no standard prescribed frequency for biomedical waste collection? Why a significant percentage of biomedical waste collection happening only once a week when it clearly has several demerits and health hazards? As mentioned by our interviewed dentists, when the bag is full it's tied and stored in the clinic until disposal. One of the dentists even dumps the waste with the municipal solid waste since the collector fails to turn up despite repeated calls. This is extremely disheartening as it reflects lack of responsibilities on the part of a dentist as well. However, the question remains; if the collection of biomedical waste is so infrequent the what is the dentist expected to do? Why are the dentists not holding the companies accountable for the caused inconvenience of storing the medical waste in the clinics? While observing the color of the bags, we also took a look at the barcodes provided to the clinics. Considering the guidelines of the barcode system given by MoEF& Co, the private dental clinic we visited in Mumbai and Navi Mumbai, we observed and asked questions about the barcode system and how it is followed. Hereâ&#x20AC;&#x2122;s what we found, most of the clinics had the barcode provided by the CBWTFs, except for the clinics not registered with any CBWTFs. A few dentists said that they had the barcode and paid for the service but could not show the barcode at that moment. Following is a picture of barcode given to a clinic by a Common Bio-medical Waste Treatment Facility (CBWTFs)

Photo showing a barcode taken at a certain clinic falling in the area of Ramky for waste management.

For a clear view on the system followed, we interviewed a personnel from Ramky in order to understand it better, he told us that the waste is tracked from the plant and on asking if it's really tracked the personnel replied yes it is tracked.

Discussion We have studied three themes in detail â&#x20AC;&#x201C; Guidelines for BMW disposal , actual condition, and accessibility . Several sub-themes emerged which have also been incorporated in the respective chapters. First off, we noticed that there were dentists who had not registered with BMW companies. We have noted few reasons for not registering of which the most evident was the outlook of the dentist towards waste. The second was the cost factor. The reasons for not registering was space, outlook, cost and frequency of collection. Most of the dentists who had registered were provided with red bags. In addition , all the dentists registered with Envoclean were provided with red bags but a few were provided with yellow and blue bags. Being aware of the BMW protocol plays a key role in the segregation of waste. Some of them did not know the exact type of waste which goes into each bag. A dentist also claimed that latex gloves should not be put into red bags and hence he used black bags for the same. On observation it was found that many dentists who claimed having all 3 coloured bags were found to be in the possession of only a single coloured bag. Also it was found that dentists who claimed having two coloured bags didnâ&#x20AC;&#x2122;t have any. Most of the dentists did not have space as an issue and were willing to keep separate dustbins for waste segregation; however several of them were not willing to work around the space issue for segregation of BMW. The frequency of waste collection varied from the collector visiting the clinic from once a week to 3 times a week. The most prominent frequency was once a week. However it was also noticed that they do not come and hence they were called periodically. Although it was concluded that nothing extra has to be paid to the collector however one dentist opined that he had to pay extra for increased frequency of collection. Majority of the dentists found the cost to be manageable however a few of them found cost as a major roadblock. One of the dentists observed the collector disposing the segregated waste into a common black bag which dissuaded him from continuing his segregation protocol. One was also disappointed about the size specification of the plastic bag and was concerned about the air borne infection hazards since the waste had to be stored in the clinic for a week till it was collected. One of them was also concerned about the frequency of waste collection during the monsoon season. Less patient flow was a demotivating factor to follow the segregation protocol. A dentist found it difficult to follow the proper protocol as no clear guidelines were given by the government. Most commonly we noted that gloves and cotton were disposed in the yellow coloured bag. Few of them also disposed them with other biomedical waste in the red bag.

The sharps were disposed in a separate container by most of the dentists , few of them had an incinerator in the dental office, in some cases needle was broken with the help of a cutter. Few of them disposed the needle in red or yellow bags after either capping the needle or covering it in between two plastic glasses. Few dentists disposed the sharps containers either into the red bags, glove box or handed it separately to the collector. Most of the dentists were unaware of the barcode system while a few knew about it. A dentist also claims that during collection , the collector scans the barcode which is put on the wall of the clinic every time. Most of them were found to be unaware of the BMC guidelines. Most of them also stored the biomedical waste inside the clinic however a dentist also used a steel drum with a lock outside his clinic for the waste storage. Most of the dentists didnâ&#x20AC;&#x2122;t have any idea as to where the biomedical waste is exactly disposed off. Others claimed that the waste was disposed at Deonar, Bhiwandi, Kanjurmarg, Taloja, Chembur. Most of the dentists havenâ&#x20AC;&#x2122;t witnessed any inspection being conducted. An inspection was conducted 8-9 years ago and the dentists were charged with a fine of Rs.20,000. Another dentist also said that no fine was imposed during the previous inspection. Equal amount of people are aware of the biomedical waste protocols but are not following it and unaware and hence not following it; however, it was found that a few of them are aware of the protocol and are adhering to it. Overall, the waste segregation and disposal situation is precarious in the city. Expert interviews revealed apathy and a lack of accountability. There was no proper system in place for redressal or answering of queries. There has to be a shared responsibility between the dentists, the government, the regulatory bodies and private entities. Only if all the stakeholders work in tandem will there be a tangible solution to this problem.

Gaps and loopholes There is a lack of communication between NMMC, MPCB, Ramky and Envoclean . Nobody was accountable for the differences in cost, frequency of collection and supply of bags. There were vast discrepancies between their answers. Despite repeated attempts of contacting SMS Envoclean, it was not possible to schedule an interview as we couldn't obtain permission to interview them . Cost for subscription and frequency of collection is not being mentioned in the protocol at all. Neither were the experts interviewed aware about it. Is cost of transportation involved in collection of the waste from the place of generation to the disposal plants an influencing factor in determining the frequency of collection? Dentists themselves are not raising a voice against the BMW disposal system of which they are a part. In addition unawareness of protocol is resulting in improper segregation at the dental clinics. Assistants are not trained formally when they are usually the ones disposing the waste. Why is there no barcode system in place to track the waste as displayed on the Envoclean site? Unsure about the credibility of the barcode system as it only tracks whether the waste has been picked up from the clinic and not its location during transit.

Recommendations 1

3 4

8 9

Colour coded bags should be made available in 3 sizes small medium and large. If so the dental clinics who have less patient flow and not much of waste generation can use smaller bags and not keep putting the waste in the same bag until it is filled. Increased frequency of collection of the waste by the waste management facilities, from once a week to daily or at least every alternate days will solve the problem of storage of waste in clinics for a week. It will thus help in solving the space issues some dentist face for storing the waste, prevent odor and any chances of infection. All types of color coded bags to be provided to the dentist and a container for sharps compulsorily. Collection of waste should be preferably done during clinic timings, ensuring safe handling of BMW directly from clinic to personnel from waste management, and preventing any risk incurred by the bags lying outside the clinics. Since cost is a major roadblock for the dentist from registering with the BMW management facility, a forum for negotiations needs to be available about this issue between the dentists and the companies. Training sessions should be provided by BMW waste management facility yearly for the dentists and the assistants, educating them for following desired segregation protocol. DCI should take up responsibility and ensure that colour coding and proper waste management is followed in the dental colleges, this will help in implementation of the segregation of waste in the future practitioners. Regular inspections should be conducted at BMW disposal plants by DCI to ensure their efficacy. Inspections at the dental clinics should also be conducted and fine to be imposed in case of any breach.

Research Advocacy Community events were conducted at the following places as part of our research advocacy drive: â&#x2014;? Indian Dental Association Head Office at Prabhadevi for private dental practitioners â&#x2014;?

MGM Dental College and Hospital, Navi Mumbai for private dental practitioners , dental teachers and interns who will become the future clinicians of this country.

â&#x2014;? To all the private dentists who were interviewed, pamphlets with proper segregation protocol were distributed and explained.

Appendix Consent Form For Interview DATE: Name of interviewer (Youth Fellow of Girls For Change): Name of interviewee: Topic: Evaluation of Bio Medical Waste segregation, disposal & management system in private dental clinics. To, Whomsoever it may concern, We the fellows of Pukar’s Youth Research Fellowship Program, associated with Tata Institute of Social Sciences are conducting a research on segregation of Bio Medical Waste in private dental clinics and its disposal and management. We would like to ask you a few questions regarding the waste disposal system in your clinic. In order to not misinterpret or miss any information, we will also be taking ● ●

an audio recording of the interview and pictures of the waste disposal area. Kindly let us know if you have any objections to any of the above. All identification information will be kept confidential and collected information will be documented anonymously for our research purpose.

Name & sign of Interviewee for consent

Interview questions to dentists Interview questions to dentists 1.Personal information -name -area -qualification 2. Number of years youâ&#x20AC;&#x2122;ve been practicing? 3. Do you follow any protocol for biomedical waste disposal ? If yes 3.1 What is the protocol that you follow for biomedical waste disposal? 3.2 Do you know the color coding? 3.3 No. Of dustbins used? 3.4 What is the maximum type of biomedical waste generated in your clinic and in which dustbin does it go in? If no 3.1 Do you know about the color coding? 3.2 How do you dispose it?

4 .How does the suction waste gets disposed? 5. Any different protocol for HIV/HBV patients? 6. What are the roadblocks do you face while disposing the biomedical waste? 7. How often does a biomedical waste handler come to collect the biomedical waste? 8. Do you have to pay extra for the collector to come more frequently?

9. Where do you store the biomedical waste until disposed? 10. Are your assistants trained to handle biomedical waste disposal? 11. Are there any mandatory biomedical waste disposal guidelines given by BMC in private clinics? 12. Who is the contractor for collecting the biomedical waste ? (Name? Contact number?) 13. Barcode for biomedical waste? 14. Where is the biomedical waste dumped? 15. Any inspection is held by BMC/NMMC to check the biomedical waste management is your clinic? 16. Do you use amalgam? If yes where do you dispose it? 17. Why do you not use color coded bags? 18. What initiative should be taken by a dentist to incorporate BMW disposal into private practice more seriously? 19. Puncture proof container for sharps? If no, how do you dispose it? 20. Is space an issue for waste management?

Dental Assistant Counter Interview Questionnaire 1. Are you aware about the colour coded bags for waste disposal?

2. Is the protocol for waste disposal followed in your clinic?

3. Are you aware about which kind of waste should be dumped in which colour bag?

4. Have you encountered any problems while handling the waste?

5. Is the waste stored inside the clinic until disposal?

6. Have you received any training for medical waste disposal/handling?

7. Have you got yourself or the people handling the waste in this clinic checked for blood transmitted diseases? (HIV or hepatitis B).

8. How is the fluid sucked from the oral cavity disposed?

Questionnaire For Biomedical Waste Officer (BMC/NMMC) 1) What is the Biomedical waste disposal process followed? 2) Is it mandatory to have a tender for Biomedical waste disposal? 3) If thereâ&#x20AC;&#x2122;s no tender, how does BMC/NMMC maintain the biomedical waste disposal? 4) What is the selection criteria for selection of tender? 5) Do you have any inspection process for the contractor who gets the tender? 6) How much does the BMC charge for the biomedical waste disposal? 7) Are there any safety guidelines for the workers handling or collecting biomedical waste? 8) Does the contractor only treat the biomedical waste or also dispose it? Interview - Contractor Introductory Protocol To facilitate our note-taking, we would like to audio tape our conversations today. Please sign the consent form. For your information, only researchers on the project will be privy to the tapes which will be eventually destroyed after they are transcribed. In addition, you must sign a form devised to meet our human subject requirements. Essentially, this document states that: (1) all information will be held confidential, (2) your participation is voluntary and you may stop at any time if you feel uncomfortable, and (3) we do not intend to inflict any harm. Thank you for your agreeing to participate. We have planned this interview to last no longer than one hour. During this time, we have several questions that we would like to cover. Introduction You have been selected to speak with us today because you have been identified as someone who has a great deal to share about biomedical waste management system . Our research project as a whole focuses on BMW segregation practiced in dental clinics, with particular interest in understanding how the government bodies and contractors are engaged in this activity, how they assess the biomedical waste management process, and whether any changes can be suggested to make the process more safe and effective . Our study does not aim to evaluate your techniques or experiences. Rather, we are trying to learn more about BMW management practices and that help improve segregation of waste in clinics . 59

Name Age/Sex 1. How long have you been into biomedical waste management business ? / how long have you been at the current position in the institution ? 2. What is your highest degree ? 3. What are the areas covered under your services ? How many private clinics are included ? How many private clinics do you provide your service to ? 4. How far is the plant situated ? Probes-any difficulties faced during transportation 5.1 Do you provide bags according to the color coding ? (institution/clinics) 5.2 Is the cost of the bag inclusive or exclusive of the amount you charge for collection of the BMW ? 5.3 Which bag is sold / collected the most ? 6. How much do you charge for collection of the BMW ? 7.1 Is there any identification code you follow to track / assess /identity the waste collected from the clinics ? 7.2 Are there any assessment techniques followed ? 7.3 How is the assessment technique useful at the disposal plant ? 8.1 How many employees are involved in the collection of waste ? (total/ per area/one clinic) 8.2 What is the strength of employees at your plant ? 8.3 Is there any training / instructional program being conducted for the employees who are directly exposed to the biomedical waste handling ? 8.4 Are there any risks/health hazards the employees face during collection of BMW ? 8.5 Have any such incidences of exposure being reported to you ? 8.6 How do you ensure safety of your employees ? Probes- ask about waste collector , gloves , masks provided 9. How often is the waste collected ? 10. What is the strategy at this plant followed for disposal of the collected waste ? Probes: Is it working â&#x20AC;&#x201C; why or why not? Purpose, development, administration, recent initiatives 11. What are some of the major challenges your institution faces during collection or disposal of biomedical waste ? Probes: How can the barriers be overcome?

12. Are there any specific New practices for segregation , collection or disposal which you have implemented in your plant ? 13. How do you monitor the overall process ? Are there any visits by the government bodies at the plant anytime ? Thank you so much for taking time out of your busy schedule and arranging a meeting with us . We value the information provided and ensure you of maintaining anonymity . What is the best way to contact you if I need any further assistance related to research (email/contact / time)

References [1] As taken from the Maharashtra pollution Control Board website. http://mpcb.gov.in/biomedical/pdf/BMW_Rules_2016.pdf [2] A study on waste treating technologies used for disinfecting the bio-medical waste in Greater Mumbai. International Journal of Research and Review. (Gupta B.) August 2017, 4(8): 43-49 [3] Awareness of Biomedical Waste Management Among Dental Professionals and Auxiliary Staff in Amritsar, India,Ramandeep et al. [4] A Study: Biomedical Waste Management in India. (Kirti Mishra et. al.). IOSR Journal of Environmental Science, Toxicology and Food Technology. May,2016 10(5): 64-67 [5] Patil AD. Health-care waste management in India.Shekdar AVJ Environ Manage. 2001 Oct; 63(2):211-20 [6] Hindustan times article-18th march, 2018: Maha focuses on small clinics to treat bio-medical waste https://www.hindustantimes.com/mumbai-news/maha-focuses-on-small-clinics-to-treatbio-medical-waste/story-qgk4mjpqXwjqNIXVJSFoiI.html [7] Hindustan times article-18th march, 2018: Maharashtra generates most bio-medical waste in India https://www.hindustantimes.com/mumbai-news/maharashtra-generates-most-biomedical-wastein-india/story-oHGFnSi3DvsaagPLHXnYqM.html [8] Article + video on First Post- Watch: Where all of Mumbaiâ&#x20AC;&#x2122;s medical waste goes https://www.firstpost.com/india/watch-where-all-of-mumbais-medical-waste-goes-3483835.html [9] Article on Times of India- 24th August 2017--Inadequate management of bio-medical waste in Maharashtra: CAG https://timesofindia.indiatimes.com/city/mumbai/inadequate-management-of-bio-medical-wastein-maharashtra-cag/articleshow/60209901.cms [10]Website of SMS Envoclean Pvt. Ltd. http://www.smsmumbaibmw.co.in/ [11] Website of MWML-Mumbai Waste Management Limited. http://www.mumbaiwastemanagement.com/index.htm [12] Draft on Guidelines for Barcode System to be adopted by the Occupier or Operator of a CBWTF for ensuring compliance to the BMWM Rules 2016.

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