Waste Management Practices in Istanbul and Houston

Not a Simple Act: Comparison of Waste Management Practices in Istanbul and Houston & Reuse in Developing Countries Derek Brown 4/27/15

Created for Global Urban Lab Rice University: School of Social Sciences

Executive Summary The medical industry is one of the largest producers of waste annually, and many of this waste are handled unregulated by hospitals. Although now more than ever there are organizations companies devoted to improving the care of medical waste produced by healthcare-providing institutions, a significant amount of waste remains funneled into landfills. In a large number of cases, these supplies and equipment are still usable material; they are simply thrown out. Additionally, a large and widening gap exists between developed nations, such as The U.S. and Turkey, and developing nations in the structure and prowess of medical systems. While developed countries often have access to and observe a surplus of supplies and equipment, developing countries face extreme deficits with even basic medical equipment. The goal of this project is to understand where wasted medical supplies go, and to examine whether unused supplies and underused equipment used in cities with developed health care centers, such as Houston and Istanbul, can be recycled and reused in developing nations without equal access to the same level of resources.

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Table of Contents Executive Summary....................................................................................................................................... 1 Introduction .................................................................................................................................................. 3 Methods ....................................................................................................................................................... 3 Research ........................................................................................................................................................ 4 Findings ........................................................................................................................................................ 5 Istanbul ............................................................................................................................................ 6 Medical Waste Policy Background in Turkey ...................................................................... 6 Interviews and Observations .............................................................................................. 8 Houston.......................................................................................................................................... 10 Medical Waste Policy Background in the United States ................................................... 10 Interviews and Observations ............................................................................................ 10 Medical Kits: A Culpirt of the Problem........................................................................................... 12 Comparison of Medical Waste Management in the U.S. and Turkey............................................ 12 Medical Equipment in Developing Countries: Not a Simple Act ................................................... 13 Conclusions and Implications of Research.................................................................................................. 13 Works Cited ................................................................................................................................................. 14

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Report Introduction The medical industry has a huge garbage issue. Hospitals, clinics, and private practices in developed cities with structured medical systems and facilities produce several million pounds of garbage each year. According to 2010 research performed by Practice Greenhealth, an organization collaborating with members within the health care community to increase acts of environmental guardianship, concluded that in the United States of America (U.S.) alone, nearly 5.9 million tons of waste is produced annually (Waste). This estimation is conservative, and has likely seen a significant increase in recent years. Most of this garbage is comprised of medical supplies and equipment, often times functional yet still thrown away and wasted. Although there are several methods, policies, and regulations that health care providers can use to dispose these materials, still large portions of waste generated by hospitals include functional supplies; materials ranging from excess syringes and lightly worn bedding sheets, to surgical instruments and diagnostic machines.

Additionally, several protocols and measures have been taken to ensure materials and equipment remains sterile. This problem has been exacerbated by current shifts towards the use of easily disposable supplies and medical equipment “kits,� according to a physician working at MD Anderson Cancer Center in Houston, Texas (Sahin 2015). This shift has encouraged practitioners to toss supplies that are found in excess, generating a large proportion of the waste hospitals produce. Currently, very few organizations and health care institutions track the purchase of supplies, quantity and quality of existing supplies, and the amount of medical waste produced annually. These inadequacies often lead to a large excess of supplies, and an unknown millions of pounds of waste created. Where do these supplies truly go after hospitals or health care providers throw them away? Landfills and beaches? Soil and water supply? Or are they partly donated to developing nations whom lie at a significant deficit of supplies to treat patients. Better yet, can they be?

The goal of this project is twofold; first, to understand where wasted medical supplies go after they are considered waste and second, to examine whether these unused supplies and underused equipment used in cities with developed health care centers, such as Houston and Istanbul, can be recycled and reused in developing nations with unequal access to such resources.

Methods Literature reviews were a main venue for gathering information and knowledge about the disposal of medical supplies and equipment in a general sense from both the U.S. and Turkey, specifically in Houston and Istanbul. Statistics on waste management policies and processes from each country were analyzed to determine major differences and similarities within each city, and then used in a comparative analysis.

Additionally, online journals and articles were explored to elicit information concerning the impact current medical waste management protocol has on developing nations. Both Figure 1: MRI machine in Açibadem recent and past research was analyzed to determine and Kadikoy Hospital (2015). describe the current practices of health care providers relating to the handling of medical waste. This research is important in addressing the serious issues surrounding the feasibility of delivering medical supplies and equipment to developing regions, and their effects on such nations.

In both Istanbul and Houston, information was gathered mostly through field study through fieldwork consisting of personal interviews and observations. Six 25-30 minute interviews were 3|Page

conducted to collect data and information. In Istanbul, professionals involved in health care from Koç University School of Nursing, Açibadem Hospital, and Sariyer Mayor’s Office were interviewed.

Additionally, observations of the used medical equipment at Açibadem Hospital were recorded. Figure 1 and Figure 2 illustrate some of the equipment used in this hospital, a private health care institution.

Reaching out to professionals through personal interviews was a chosen method to obtain information not available in the published literature, and was also used to provide historical and cultural context for Istanbul. Personal interviews and observations were also conducted in Houston.

Interviews in Houston also lasted between 25-30 minutes in length, and were performed at Texas Medical Center Executive Offices, Medical Bridges, and Rice University. Onsite observations were also undertaken at Medical Bridges, including examination of the re-engineering facility, equipment storage, and processes taken to donate materials.

These observations provided insights into organizations that attempt to recycle medical equipment.

Figure 2: Re-sterilization Research machine in Açibadem surgical Hospitals in the U.S. comprise merely 2% of all medical operating room (2015). waste generators, yet they generate nearly 77% of the total annual volume of regulated medical waste, which comes to 8,400 lbs./month/hospital (Klangsin 517).

Various factors affect the amount of medical wastes that hospitals produce, such as: hospital size, geographic location, state and local waste social policies, hospital disposal policies (Klangsin 517).

Clinics, laboratories, dentists’ offices, residential care facilities, and hospice care units are all producers of medical waste (Lichtvel 1990). Health-care waste is caused by several factors, including a lack of awareness concerning the hazards surrounding improper disposal of health-care waste, inadequate training in waste management, meager financial and human resources, and absence of policies for environmentally-friendly waste plans ("Waste from Health-care Activities").

High-income countries, such as the U.S. and Turkey, generate about 0.5 kg/bed-day hazardous waste per bed per day according to the World Health Organization (WHO) ("Waste from Health-care Activities”). These numbers are significantly lower than the average range of medical waste in developing countries, which are situated around 1.5-3.9 kg/bed-day (Mato 4). Nevertheless, mid- and low-income countries oftentimes do not separate and record waste into hazardous or non-hazardous waste such that the real quantity of hazardous waste produced by these countries is likely much higher.

Findings from a study performed in Turkey revealed an estimated quantity of medical waste from hospitals of nearly 22 tons/day, which is about 0.63 kg/bed-day (Birpınar 446). Houston, having one of the largest and most advanced medical centers in the world, most likely produces waste coinciding with the 0.5 kg hazardous waste/bed/day calculated by WHO, and most likely even lower than that of waste produced per bed-day in Turkey.

The practices and habits within the health care industry are hard to influence and change.

Environmentalists and government agencies have noticed the problem in medical waste over several decades and have advocated and created policies to reduce the detrimental environmental impact.

However, awareness is only the first step. Hospitals must change their practices relating to producing waste. Health-care related activities serve to protect lives and revitalize wellbeing, but the waste these activities produce may impose a vicious cycle that creates toxic environments and spreads disease.

According to WHO, of the total amount of medical waste created by such health-care activities, 80% is considered general waste comparable to domestic, or household waste ("Waste from Health-care Activities”). The other 20% is considered hazardous waste material that can be infectious, toxic, or 4|Page

potentially radioactive ("Waste from Health-care Activities").

These wastes cover a spectrum of materials including: infectious waste (waste contaminated with blood, diagnostic samples, cultures and stocks, and equipment), sharps (syringes, needles, disposable scalpels), anatomical waste (removed body organs), chemicals, and pharmaceuticals ("Waste from Health-care Activities", “Medical Waste�). WHO has calculated that infectious and anatomic waste account for about 15% of total waste from the health-care industry. Sharps, on the other hand, represent about 1% of medical waste, but largely contribute to disease transmission ("Waste from Health-care Activities"). The fraction of medical waste capable of producing and spreading infectious disease are considered infectious waste (Klangsin 517). Nomenclature and definitions applied to medical waste across countries and even hospitals are neither universal nor consistent. The Center of Disease Control (CDC), The U.S. Environmental Protection Agency (EPA), Joint Commission, and the Agency for Toxic Substances and Disease Registry, all have different interpretations and definitions of medical waste, specifically infectious medical waste (Klangsin 517). The assortment and inconsistent definitions make it especially hard for hospitals, even policy makers to develop protocols and procedures that are adequate. According to guidelines prescribed by the CDC, in order for waste to be considered infectious however it must satisfy four conditions: virulent pathogens, portal of entry, host resistance, and present in sufficiently high dose (Lichtvel 1990). Anywhere between 3-15% of waste is actually considered infectious, for this percentage depends on the definitions, which illustrates the variability in protocol (Klangsin 517).

In recent years, treatment methods have been imposed to reduce the risk of improper disposal of healthcare waste. For all states, using private haulers (61.5%), pouring into municipal sewage (46.6%), and depositing in landfills (41.6%) are the most frequently reported methods of treating medical waste; percentages add up to greater than 100% because hospitals reported more than one method (Klangsin 523). Use of incineration techniques is a popular technique among hospitals and waste management companies as well (Lee 11). Although some incineration procedures of medical waste have proven to be successful at disposing volumes of material, this is a process that releases vast quantities of toxic pollutants into the air that indirectly cause health risks. Medical incinerators can release significantly toxic pollutants to the atmosphere including: carbon monoxide, acid gases, particulate matter, and furans (Lee 17-21, Rutala 38-9, �Waste from Health-care Activities").

Additionally, American health care facilities have continued to dispose of nearly four billion pounds of annually into landfills, making it the second largest contributor to landfills following the food industry (Kwayke 398).

Findings Specific government regulations and policies were researched to track what has lead to current acts of disposal, or misuse of disposal techniques. Additionally, analyses of policies, both current and past, were essential to analyze whether hospitals are abiding such regulations, or performing against such policies. In the following sections, findings from interviews and observations conducted in Turkey and the U.S. are presented in turn.

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Istanbul Medical Waste Policy Background in Turkey As a rapidly developing country with an emerging economy, Turkey is undergoing massive cultural and population shifts that have large affects on the medical and healthcare industries. Turkey has seen increasing incomes and changing demographics in recent years that have resulted in increased access to healthcare services to a wider population of people (Deloitte 2014). Aging population, higher incidence of chronic disease, increased economic welfare, and wider health insurance coverage have all been driving factors behind this dramatic shift in the Turkish heath care system throughout the past decade (Deloitte 2014). Needless to say, the growing population, increased access to care, and the changing face of disease profiles have placed pressure on health care institutions and government officials to improve the overall infrastructure of healthcare in Turkey. According to data from the World Bank, as of 2013 the population of Turkey stood at 74.93 million people (World Bank Group 2015). Figure 3 depicts the population dynamics of Turkey as determined by Deloitte in a 2014 study (Deloitte 2014). Deloitte projects that by the year 2023, the overall population of people in Turkey over the age of 65 to rise by 10%, and by 2075 to rise by 28%. Additionally, as Turkey’s population begins to resemble populations of developed countries, the change in disease profile will cause significant change to the healthcare system. Increased deaths from cardiovascular disease and cancer incidence have already been recorded, and are expected to increase in the future (Deloitte 2014). These driving forces will ultimately change the types of medical supplies and equipment used by health care providers, and most likely to resemble the trends in the amounts and types of waste produced by higher developed countries such as the United States.

There are eighty-one provinces in Turkey, consisting of 3125 municipalities, yet there are merely thirteen sanitary landfills (Tarhan 2004). Of these landfills, only three are composting plants, and three are incineration plants (Tarhan 2004). Incineration is a common used technique to dispose of medical waste in Istanbul, however disposal to landfills are more common (Baltaci 2013). In fact, according to the National Regulations of Waste Management in Turkey, the most common method of disposal of medical wastes is dumping wastes into preexisting municipal storage areas with other types of wastes and without any regulations (Köse 2007). Starting with the construction of the first incineration plant in Istanbul in 1995, medical waste generated by hospitals are transported and disposed of in burning units (Birpınar 446). Since then, waste volume has decreased by 95% according to statistics from ISTAC, an environmental protection and waste management company (İSTAÇ Turkey n.d.). According to the national regulation, wastes generated by healthcare services are classified into four major groups, depicted in Table 1 (Birpınar 446). This regulation classifies how waste should be properly disposed by implementing a colored bag system (Table 1).

There are several efforts and policy structures in place in Turkey focused on proper disposal of medical waste, but the solid waste management systems in Turkey are quite different than those practiced in the United States. A candidate state for admission in to the European Union (EU), Turkey must adopt EU Environmental Directives into national legislation (Alagöz 2006, Birpınar 445). Not until 1991, when the Solid Waste Control Regulation came into effect, were organization and enforcement applied to the management of municipal solid waste (MSW). By definition of this regulation, MSW consists of all waste generated by human activity and categorized as unwanted material, including medical wastes generated from health-related activities (Berkun et. al, 2005, Turan, 2008). This regulation played an integral role in the development of practices for storage, collection, and disposal of solid waste. Additionally, the Medical Waste Control Regulation (TMWCR) of 1993 and the Hazardous Waste Control Regulation created action steps for waste generators based on such principles of reuse, transportation, collection, and disposal methods (Alagöz 2006, Deloitte 2014, Goren 2010). The TMWCR regulation was the basis for improving medical waste practices throughout Turkey with the aim of 6|Page

regulating and establishing legal controls concerning waste management (Alagöz 2006). Until 1994, there were only estimates of MSW generation due to popular use of open dumping and lack of tracking and recording of waste management processes. Now, the Turkish Statistical Institute (TURKSTAT) analyzes and records data concerning MSW management.

According to Dr. Kahraman, a professor in the Department of Environmental Engineering at Middle East Technical University, however, Turkey’s enforcement of waste management legislation and handling of medical waste is not as productive as some studies and statistics might suggest. According to Kahraman, recycling and sanitary disposal practices are generally ignored in Turkey (Tarhan 2004).

Furthermore, there is also widespread and inadequate landfill site selection and operation of such sites, which lead to increased environmental pollution, and added risk of explosions due to stored gases (Tarhan 2004). Financial woes caused by insufficient resources in municipalities, a need for a consistent and regular accounting system between municipalities, and a lack of superior legal institutional responsibility for supervising waste management services all contribute to recurring problems with medical waste management in Turkey (Tarhan 2004). Moreover and perhaps just as important, there is a lack of awareness and information about regulations and policies the Turkish government has created to address these major environmental issues.

Turkey still faces major challenges since current regulation still lacks critical information on medical waste management that is required by EU Environmental Directives. In the meantime, overall consumption continues to increase and outstrip current attempts to change national legislation. This situation has inevitably led to an increase in solid waste production from past years (Birpınar 445-6).

Although Turkey has historically faced many obstacles concerning the management of solid waste, the rise in population and its strong candidacy for membership in the European Union (EU) have spurred the government to reinforce policies and framework around waste management (Alagöz 2006, Goren 2010). According to Turkish waste management policy, medical wastes are the infectious, pathological, and sharp wastes generated during hospital-related or other medical institutional activities (Köse 2007). Currently, large portions of medical wastes are not collected separately, and are often mixed with other types of wastes and disposed in landfills. There are also inconsistent pricing systems imposed by the Local Government councils (Köse 2007). Only a small number of municipalities use shipment vehicles to transport medical wastes. Many medical institutions dispose of these wastes directly, or mix with household wastes (Köse 2007). 2012 TURKSTAT data suggests that out of about seventy thousand tons of medical wastes collected annually, 46% of medical waste collected was disposed of in controlled landfill sites following sterilization, 28% without sterilization; 16% waste disposed of in municipal dumping sites after sterilization, and 1% without; and 8% incinerated (Baltaci 2013, Köse 2007). Furthermore, out of the total medical waste collected from the largest metropolitan cities, only 22% was collected from health care institution in Istanbul, 11% in Ankara, and 8% from İzmir (Baltaci 2013). The remaining 51% of medical waste was not recorded as collected by these institutions, thus waste from these institution could not be accurately tracked.

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Interviews and Observations The structure of the healthcare system of Istanbul is quite different from that of Houston. Its healthcare industry is undergoing several transformations including a growing alignment with established European systems. In Istanbul, there is a notable difference between public and private hospitals and in the patients they treat. Private hospitals are more representative, and treat nearly 20% of the Istanbul population, making up 37% of all hospitals in Turkey, 30% (152 hospitals) of which are located in Istanbul alone (Deloitte 2014).

According to a Professor of Nursing at Koç University School of Nursing, public hospitals serve a majority of the Istanbul population due to costs of care, yet they are “crowded with people,” and resemble public hospitals in developing areas, such as India (Terzioğlu 2015). There have been difficulties gathering information about public hospitals in Istanbul, as well as statistics on the disposal of medical supplies and equipment.

Figure 3: Exterior of Açibadem Kadikoy However, information about private hospitals was Hospital (2015) available through conversations with the Director of Equipment at and Açibadem hospital and with contacts at Koç. Research also found that medical equipment recycling processes are being carried out in Turkey, but there is little consistency between sources on this specific subject matter.

The Açibadem Hospitals group is a private Turkish healthcare institution comprised of 18 hospitals and 12 medical centers. Since 1991, this healthcare group has become one of the leading institutions in Turkey, and has received international attention for the standard and quality of care given to patients.

Açibadem Kadikoy Hospital (Figure 3) is the first and smallest hospital of the Açibadem Healthcare Group network, currently housing about 106 beds. This hospital was visited and the Director of Equipment was interviewed about the processes and the flow of equipment that enters and exits this hospital. This employee spoke only Turkish, and the teaching assistant for the lab translated from Turkish to English. During the tour of the Açibadem hospital, one of the most notable talking points and attractions for patients was the up-to-date diagnostic equipment, most of which was bought from Siemens. Figure 1 and Figure 2 are examples of equipment observed in Açibadem Kadikoy.

Following a tour of the Açibadem Kadikoy facility, the Director of Equipment took some time to provide further information about what policies Açibadem follows concerning getting rid of medical equipment, whether old, dysfunctional, or simply not wanted. Interview questions were designed to gain insight into where exactly this material, equipment, and waste travel after discharge from hospital.

For large medical equipment, such as MRI, X-Ray, and ultrasound machines, all with many components, Açibadem has an elaborate system for disposal (Bilici 2015). In order to request new equipment for purchase, a physician, or department, with a specific machine in mind will propose this purchase to the hospital administrators, whom will then send a proposal to the sellers (Bilici 2015). Açibadem actually tracks all of its equipment, and prior to purchasing any new equipment, there is a team of people who research the productivity and quality of both the new and old equipment to weigh the benefits to the patients and to the overall improvement of the hospital (Bilici 2015). The Açibadem Hospital chains have in place a system of extensive and elaborate research prior to purchasing of equipment. When machines are disposing, Açibadem pays to have a company transport the material to a warehouse off-site, which where it is compartmentalized (Bilici 2015). The usable parts are salvaged, stored, and actually either donated to other domestic hospitals or shipped abroad to developing countries. The director mentioned that Açibadem has connections with physicians and health-care providers in Niger, to whom they 8|Page

frequently donate parts. Dead parts are sold to a metal junkyard. For hazardous and potentially radioactive components that may exist in this machinery, Açibadem pays for an outside company to dispose of that waste properly as well (Bilici 2015). For medical supplies and wastes that are on a smaller scale, for example bandages, sharps, and surgical instruments, Açibadem has a similar disposal system.

From the information obtained during the interview, virtually 0% of usable waste goes to landfills; it was mentioned the perhaps 2-3% of waste from Açibadem end up in landfills (Bilici 2015). According to this interviewee, whatever supplies are still usable Açibadem donates to developing countries.

Similarly, Amerikan Hospital, an older hospital in Istanbul, has policies and practices that mimic Açibadem. Both Amerikan and Açibadem hospitals are private institutions, and according to the Professor at Koç School of Nursing, public hospitals follow very different protocols (Terzioğlu 2015).

According to this interviewee, nearly all of the medical waste in private hospitals is properly disposed, however it could not be confirmed whether medical waste from public hospitals is handled according to national legislation (Terzioğlu 2015). According to statistics observed by TURKSTAT, many hospitals report proper collection and transfer of medical waste. However, a large number of hospitals fail to report and are likely not taking measures to properly dispose of medical waste (Baltaci 2013, Köse 2007). While these efforts seem environmentally friendly and beneficial for developing countries, Amerikan and the Açibadem Hospitals may be two anomalies.

While visiting the Mayor’s Office in Sariyer Municipality in northern Istanbul, the Minister of Healthcare was interviewed and able to provide insight on practices in the municipality he oversees. He spoke only Turkish, and the translator, also a Turkish-native, may have lost some information during translation to English. Regardless, the Minister mentioned that nearly 97% of medical waste that is generated from the Sariyer municipality ends in landfills (Minister of Healthcare 2015). In contrast to information obtained from the literature review and Turkish national survey statistics, there appear to be areas within Istanbul that direct an overwhelming majority of medical waste to landfills along with common household wastes. Whether this waste was regulated or not could not be confirmed by the Minister during the interview.

Açibadem and Amerikan are private hospitals that draw in wealthy, or upper-middle and upper class patients, are facilities that have more resources than a government-run, or public hospitals. Those hospitals are often not as well endowed as private healthcare institutions and thus, do not take consistent measures to properly dispose of, or donate surplus materials to developing countries. In some areas within Turkey, the public hospitals are as ill-equipped and over-crowded as some developing countries. Unfortunately, private hospitals, and personnel from those facilities, were the only people interviewed for this project; public hospitals were contacted, but no responses were received. This was likely due to existing language barriers, time constraints, and limited use of internet, or many other outside factors.

Houston Medical Waste Policy Background in the U.S. In the U.S., there have been several policies formulated to enforce proper disposal of medical waste. The Medical Waste Tracking Act passed in 1988 set short-term standards for federal government regulations of medical waste in four states and Puerto Rico (U.S. Congress 1988). Section 3 of this act actually defines medical waste as “any solid waste that is generated in the diagnosis, treatment, or immunization of human being or animals, in research pertaining thereto, to in the production or testing of biological,” (Lichtvel 1990). Medical waste, infectious waste, and regulated medical waste are each subsets of hospital waste (Klangsin 517). In 1991, when the Act expired, states were given autonomy over laws and regulations concerning the disposal of medical waste.

In Texas, statewide policies and regulations were considered in 2006 under the advocacy of the Texas Commission on Environmental Quality. This is a regulatory guide to assist those generating 9|Page

medical waste, so health-care providers and facilities, as well as transporters of unwanted medical waste, and operators of medical waste treatment facilities (Texas 1-5). According to Texas policy, medical waste is defined as “regulated medical waste,” and “special waste,” which includes only untreated medical waste (Texas 1-2). Specifically, special waste would include any waste directly coming from animals that have been exposed to pathogens, blood contaminants, pathological waste, or sharps.

Generators of medical waste, according to TCEQ policy, are required to properly package, label, and weigh equipment for off-site treatment. Additionally, generators are required to obtain a receipt as well as keep records of all shipments of untreated medical waste for at least three years following the date of shipment; these records must be kept available for potential inspection by the TCEQ (Texas 3).

Mainly, Texas policy for generators of medical waste requires parties to notify the TCEQ of operations and maintain records of such efforts. Whether TCEQ are notifies of operations, or if consistent records are indeed kept by health care administrators is unknown.

The Texas Administrative Code (tit. 30 §330.1207), lists rules for which generators of medical waste should be familiar with including methods used to classify medical waste, and requirements for shipment of untreated wastes when it leaves the hospital or health-care facility, and concerns proper marking and classifications of such waste. These policies lay out clear guidelines for facilities to abide by, but the enforcement and maintenance of such policies can only be measured by the percentage of medical waste improperly handled and disposed of; a problem that is very much still apparent within the scope of current health-care disposal practices.

Interviews and Observations It is estimated that nearly $200 million worth of prepared materials are disposed unused in the U.S. (Rosenblatt 400). Especially in the surgical field in the U.S., unused medical supplies are disposed a regulated medical wastes simply because there is a hospital surplus, and the supply has become unsterile. Nationwide, the disposal of usable materials results in being one of the most costly expenditures in the health care industry (Rosenblatt 400-401). Yet, little action has been carried out to determine the true extent to how much medical supply loss is generated and what kinds of surgical supplies are most frequently wasted. Turkey is no stranger to this act of disposing usable medical supplies as well. Specifically in private hospitals institutions, there are large surplus of medical supplies that are circulated into the process of improper disposal. With several millions of dollars of medical supplies wasted every year by developed countries, and viewed against nations facing severe deficits and shortages in the amount of medical supplies and resources available for treatment, it is unsettling and startling.

An interview with the Senior Vice President of Shared Services in the Texas Medical Center (TMC) supplied knowledge of medical waste generation and donation policies within the greater scope of the Texas Medical Center in Houston. He mentioned that even within the medical center, there are large and drastic differences existing on a spectrum between procedures, policies, and practices among different hospitals and on how they approach medical wastes (Stokes 2015). MD Anderson he said for example, is on the far positive side of the spectrum of potential practices; it is an anomaly much like what was seen within the practices in the Açibadem Kadikoy hospital. Currently, there are no consistent measures taken out to track and monitor the amount or number of medical supplies a hospital within the TMC, thus a hospital seeing a large surplus of supplies is a common occurrence (Stokes 2015). So what happens with the surplus supplies? The question, “When new supplies, for example, plastic tubing are ordered, where do the old ones go if there is not enough storage space?” was asked specifically during the interview. The interviewee’s response was that the surplus materials are likely sitting in a warehouse not being used, rather than most of the waste going to landfill. Although he himself could not confidently confirm, he had a strong assumption; it seemed “pretty likely,” (Stokes 2015). These warehouses are dotted around the Houston metropolitan area filled with equipment that is hardly 10 | P a g e

regulated and hardly ever tapped into for supplies. These warehouse essentially serve as little more than hidden landfills and dumping sites for excess supplies and equipment found in surplus in hospitals and other health care facilities. Although he was not entirely confident on the percentage of waste filtering into landfills, he mentioned it being a low percentage (Stokes 2015). Secondly, he mentioned that donations were widely common among hospitals in Houston and in the TMC, Medical Bridges being a major recipient (Stokes 2015).

Only in the last few decades has the medical industry in Houston begun grasping the core and the true repercussions of this medical waste problem. The amount of waste health-care facilities generate, and efforts made decrease amounts are aimed at understanding the potential resourcefulness and usability of materials, any materials, in developing nations several organizations and philanthropic efforts have arisen to help bridge the gap between the surplus in medical supplies.

Medical Bridges is a non-profit medical surplus recovery organization (MSRO) aimed to bridge this healthcare gap between developed and developing nations by gathering medical supplies and equipment and redistribute these materials to organizations in the developing world. The Director of Operations (D.O) at Medical Bridges focuses on the procurement of surplus medical supply product donations gave first-hand insight on what a non-profit such as Medical Bridges does. According to the D.O., in the U.S. alone, about nine billion pounds of medical surplus goes to waste every year (Judkins 2015). Although a large portion of that waste does end up in landfills, a portion of that is stored in warehouses, and a portion are donated to organizations such as Medical Bridges, or sold (Judkins 2015).

In the scope of the MSRO, a major barrier to the flow of supplies and equipment through their service are these outsourced, second-hand sellers that operate much like eBay (Judkins 2015). Healthcare facilities sell companies their wasted, but still useful equipment, in which then these companies resell or auction those others whom repurpose or then resell the material. An even bigger barrier for hospitals is that it takes time, resources, and connections to donate, whereas resale shops are often found online and have completely electronic processes. Needless to say, Medical Bridges have formed extensive connections with healthcare facilities within Houston, and receive thousands of pounds of equipment every fiscal year.

The interviewee argued that hospitals currently run and thrive off of a system of surplus.

Hospitals, in normal operation tendencies, buy supplies that are found in abundance without knowing that such supplies already exist. This could partly be attributed to faulty communication between hospital staff and inadequate tracking and documentation of supplies across departments within hospital systems, or several other factors depending on the specific hospital and resources available.

Currently medical equipment consumers are much more likely to buy additional equipment before checking to see what already exists. The system of surplus that hospitals use to operate is particularly counterproductive in terms of generating medical waste (Judkins 2015). Following the interview, the Medical Bridges facility was toured and observed. Currently, the facility holds over 3500 parts to review and donate to partner countries. They receive supplies (syringes, bandages, tubing), equipment (nebulizers, x-ray, incubators), and furniture (beds, tables, dressers). Medical Bridges is not a lone ranger in the medical industry; there are several similarly based non-profits spotted throughout the state of Texas, and nationwide. In Turkey even, there are similar efforts as well, such as the Turkish Red Crescent.

Similar differences between private and public hospitals were observed in Houston, although these differences are not as marked as those seen in Turkey. Private and well-resourced hospitals, such as MD Anderson Cancer Center, have elaborate and well-defined processes of disposing medical waste, larger machines and smaller medical supplies included, much like what was observed in the private hospitals in Istanbul. According to an interview conducted with a Pathologist at MD Anderson, employees ensure to recycle as many materials as possible, and that their equipment is properly disposed of by hiring an outside company with which to ensure safe and environmentally-friendly 11 | P a g e

disposal (Sahin 2015). Needless to say, there are still venues for equipment to be wasted, most notably in the surgical and diagnostic setting. Although several healthcare facilities in the U.S. practice proper handling and disposal procedures for medical waste, many still do not. Even within hospitals that exhibit proper waste disposal behavior, such as MD Anderson, it is not simply the appropriate practice that affects the amount of waste generated, but also on the types of materials, supplies, and equipment purchased.

Medical Kits: A Culprit of the Problem Some hospitals are seeing an increase in pre-packaged medical supplies, or “kits,” as they are called (Sahin 2015). Medical kits have proven to be quite useful in recent years. Many equipment and instruments often come in pre-packaged kits, which provides easier means of transportation, storage within facilities, and provide accurate aid for routine and emergency medical situations (Medical Kits & Equipment, Sahin 2015). However, the equipment or instruments in these kits is used for the precise procedure at-hand, whatever that procedure may be. After the kit is open however, the instruments become unsterile. Thereafter, physicians are more likely to simply throw away perfectly good, yet unneeded medical supplies. It costs money to re-sterilize equipment and instruments, and it is seemingly less costly and timesaving to toss the extraneous material. However, a large proportion of materials in such kits are wasted due to several reasons. Even if such materials are re-sterilized, there are identical kits with the same materials present, which create a surplus of materials that continue to add up. Houston, housing one of the largest medical centers in the world, definitely makes a large footprint on this number. However, greater than 25% of U.S. hospitals are utilizing reprocessing as a mean for decreasing the tons of medical waste generated per year (Kwakye 2).

Comparison of Medical Waste Management in U.S. and Turkey Both in the U.S. and Turkey, Houston and Istanbul, policies have framed detailed procedures the proper disposal of medical wastes. However, several factors lead to improper placement of hazardous materials in landfills. Policies lay out and set rules for health-care providers to abide by when disposing wastes, yet there is little regulatory enforcement behind such policies for facilities in both Turkey and the U.S. Moreover, and perhaps a bigger problem, there is a miscommunication between policy makers and providers of health care concerning proper disposal. Hospitals both in the U.S. and Turkey operate on a system of surplus, in which supplies and materials are continually purchased despite having an endowed stock of the exact or similar supplies. Simply, even though the policies are drafted, passed, and in effect, there is a lack of awareness of where and how to properly dispose of medical wastes. Whether a majority of material deemed medical waste is completely inoperative, or if the waste consist of usable materials (beddings, sharps, and instruments, etc.) simply found in surplus and in operable condition.

Within the masses of wastes generated by health-care activities, facilities, and institutions, how much of that ‘waste’ are usable goods? What proportions of supplies are simply thrown out because new equipment has misplaced old, or because consumers over order bandages or bedding sheets?

Medical Equipment in Developing Nations: Not A Simple Act The title of a 2008 NBC News article, 10 million children die from a lack of health care, speaks clearly of the issue developing nations face. More than 200 million children under the age of 5 do not have access to basic medical care, leading to the daunting number of annual child mortality rates in developing regions. Fast forward seven years to the present, this number is likely much higher, and broadening this population to all age groups, an even higher estimation.

The act of donating medical equipment and supplies to developing countries is an act easier said than done. There are several barriers that may pose as hindrances for successful use in such regions.

Medical equipment donations, indeed, have the power to enable hospitals in developing countries to 12 | P a g e

have access to advanced and much-needed technology (Jones 2013). However, there are legitimate and growing concerns that these donations are creating more impairments than benefits (Courage 2012).

According to a published online report in 2012, an estimated 40% of medical equipment is out of service in developing countries (Howitt 3). Likewise, WHO has calculated that nearly 80% of medical equipment is donated or funded through foreign services, and only 10-30% of those donations are implemented to an operable state (Medical device donations 2011). According to Howitt, there are three fundamental barriers that prevent technology from making a greater contribution to global health in developing countries: availability, accessibility, and acceptability (11). Technological equipment that is donated must be able for use in a resource-poor setting, one without sufficient supply of energy, human resources access, and usability (Howitt 11). Many resources and equipment used in developed countries are designed for environments with access to sufficient energy supply and large numbers of trained health care providers, and when these types of equipment are donated to countries without these fundamental resources, problems arise, and equipment virtually becomes trash (Courage 2012).

Needless to say, when large amounts of medical waste are produced annually by developed countries such as the U.S. and Turkey, in cities such as Houston and Istanbul, how can hospitals or healthcare-focused organizations better mobilize efforts to bridge gaps between access to medical care in developed and developing countries? Through research and interviews, observations and conclusions suggest that if regulations are upheld and organization such as Medical Bridges gain more support, hospitals in both locations can develop abilities to filter out usable yet unneeded supplies and equipment and better support implementation to developing countries.

Conclusions and Implications of Research The inequalities existing in access to health care for populations in developing nations and populations in developed nations are wide and only increasing. Several countries with established medical industries and resources are active in donating to developing regions, but the act of donating is not enough to supplement disparities.

The U.S. and Turkey, specifically Houston and Istanbul, were studied to determine how much medical supplies and equipment are generated as waste, and whether such wastes are supplies that are still usable. Additionally, research was aimed to determine whether organization and hospitals had incentives to support the donation of what are usable wastes into developing countries. The problem of waste generation within the health care industry has been long standing, yet perceived as stable. Such that, health care providers are not considering the environmental footprint supplies leave once thrown away, especially when such supplies are usable. Usable or not, healthcare institutions fail to consistently monitor and report to environmental agencies where medical waste from facilities travels. With additional awareness of regulations and sufficient training of health care providers, this can be changed; amounts of medical wastes in landfills can be decreased, and amount of usable supplies filtered into developing countries increased.

The act of throwing away medical equipment improperly is a simple act, a seemingly unmeasurable operation. Yet, if health care providers are empowered to become more aware of their actions, develop and enforce proper disposal of medical waste, maybe, just maybe people would start to notice the large quantity of medical supplies and equipment that are being misused and underused.

Change is not simple under any circumstance, but if hopes of decreasing the amount of usable medical material in landfills and increasing the amount of usable material sent and donated to developing countries are to be fulfilled, change must happen. The medical supplies and equipment we waste may save the lives of those who are denied such privilege and such resources; ambitious it might be, yet a simple realization.

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