It was an accident that could have been avoided. As a waste collector incinerates infectious waste at Connaught Hospital, Sierra Leone’s main adult referral center in the capital Freetown, a spark burst from the intense furnace in his eye and destroyed it.
The worker was not wearing glasses. The only protective gear he could wear that day was a cloth jumpsuit and kitchen-style rubber gloves. He was unable to continue working, and two years later former colleagues told hospital staff that the man had died. “They said he actually lost his life as a result of an eye injury,” said Mohamed Hashim Rogers, professor of microbiology at the University’s College of Medicine and Allied Health Sciences. from Sierra Leone. “It’s not a well-paying job and he had lost an eye. Who was going to take care of him?
Between 2018 and 2019, Rogers observed the risks and challenges faced by waste collectors in Connaught neighborhoods to DiaDev, a research project studying diagnostic devices in global health. The results were shocking, but also typical of the conditions encountered in health facilities in low- and middle-income countries (LMICs).
Studies across all continents on the dirtiest side of healthcare, in particular a 2011 report by the NGO Health Care Without Harm (HCWH), show that healthcare establishments mismanage their waste. The workers who collect this waste receive insufficient protection, minimal training, derisory wages and no respect.
The World Health Organization (WHO) estimates that 15% of healthcare waste is dangerous and may be infectious, toxic or radioactive. The HCWH report highlights how this waste is frequently thrown away when waste management systems fail. This causes water contamination, among other health and environmental hazards, and exposes scavengers to contaminated waste. The health services of LMICs often burn their waste, releasing toxic chemicals and, potentially, pathogens into the air. Health workers are trained to manage these risks, but the working conditions of garbage collectors are very different.
“Staff who clean the hospital and collect waste can often be at greater risk than the medical staff who produce it,” says the HCWH report. “They are generally poorly educated and trained and little attention is paid to their comfort and safety. They rarely have vaccines or appropriate protective equipment. Disposable latex gloves can be provided, but they are thin and offer little protection. In warmer climates, the majority of cleaners will only wear sandals. “
“A recipe for illness”
Medical waste should be sorted at the source, especially sharps waste – used syringes – should be discarded in sealed plastic boxes. But PRFIs rarely meet this basic standard. Rogers discovered that the staff at Connaught Hospital often mistakenly mixed the garbage. As a result, waste managers had to hand sort infectious waste into the bags.
“They manually removed the urine and the blood bags, pierced them and let them drain. [into a sink]”said Eva Vernooij, a researcher at the University of Edinburgh on the DiaDev project. The workers told Vernooij that they did not have a designated tap for washing their hands and that they had to buy their own soap. Workers also removed plastic and cardboard to reduce the volume of waste, as the incinerator could only hold one bag of waste, while the hospital generated 15 a day.
Workers stacked excess waste outside for municipal waste services to transport to a municipal landfill. As it was poorly separated, it also contained infectious waste. “You keep it on for three or four weeks and it’ll smell,” says Rogers. “Dogs and rats come to feed on this waste. In desperation, the waste collectors burned the surplus in an open pit. They inhaled the infectious smoke, as did the patients and their relatives at the nearby hospital. “It’s a recipe for disease,” says Rogers.
In addition to these dangers, every time a worker reached into a garbage bag, he risked being stabbed by a used needle. Several workers had been tested for HIV after accidental injuries. the WHO estimates that among 35 million healthcare workers worldwide, approximately three million experience percutaneous exposure to blood-borne pathogens each year, and over 90% of these cases occur in LMICs. This means that about 40 percent of hepatitis B and C infections and 2.5 percent of HIV infections among healthcare workers are attributable to occupational exposures to sharp objects.
HCWH’s international science and policy coordinator Ruth Stinger says waste workers rarely report such incidents. “They think it’s their fault – that it makes them look bad,” she said.
Research in Bangladesh found that managers of waste workers did not feel responsible for protecting staff. One official said: “It is not our duty to take action against their plight. “
For all the risks workers face in Freetown, they receive 500,000 leones (about 48.75 USD) per month. Yet the private, government-funded company that hires the waste collectors often fails to pay them for months at a time. Despite this, they continue to work, hoping that payday will come.
Harsh treatments and stigma
All waste workers, not just those who collect medical waste, endure harsh treatment and are often stigmatized, says Daria Cibrario, head of local and regional governments for the global union of public sector workers. “Waste is generally not valued as a resource by our societies. Rather, it’s seen as something dirty, sometimes smelly and contaminated, ”she says. “Our societies often prefer not to see it. “
The stigma is linked to the fact that waste workers are often racialized, migrant and marginalized workers from the poorest socio-economic groups, or castes in some countries. In India, it is generally members of the Dalit caste, the “untouchables”, who carry out the sanitation work. Waste collectors also tend to have limited access to formal education or vocational training, and when coming from foreign countries, they may not be fluent in local languages.
Cibrario points out that on a global scale, waste as a public service is “terribly underfunded”. She says one of the reasons for this in LMICs is that there is little transfer of power from national government to local government. However, while waste management requires local oversight, only the central government of these countries can achieve the high level of investment required to build safe systems, such as adequate landfills and incinerators.
When a government funds local authorities to manage waste, they rarely include enough staff and equipment, Cibrario explains.
She gives the example of Tunisia, where the central government delegated waste management services to municipalities following the 2011 revolution. “Adequate funding for the service has not followed,” she said. “The infrastructure has not been modernized to allow local governments to put in place effective waste management systems. »As a result, in 2019 over 2,000 municipal waste management workers demonstrated, demanding safer conditions and recognition of the public health role they fulfill.
Union membership was essential for Tunisian waste workers to demand recognition and decent working conditions. Cibrario says that in countries where waste management is organized by municipal service unions, waste workers can represent some of the strongest union divisions, such as in South Africa. However, where there are overwhelming levels of informal and precarious work, or where restrictions on the right to organize exist, such as in India, it may be more difficult for workers to organize.
Waste pickers are directly impacted by poorly managed clinical waste. When improperly sorted waste is dumped in open landfills, the waste pickers and recyclers who make a living from the waste are exposed to needlestick injuries, pathogens or potentially radioactive substances. A WIEGO study (Women in informal employment: globalization and organization) 2013 Garbage collectors at a landfill in Nakuru, Kenya, discovered they had found syringes, blood, cottons and medicine. Research of 2019 by the University of Brasilia At the Estrutural landfill in Brazil, sharp objects, including syringes, were responsible for 90% of accidents among waste pickers.
As a result of the Covid-19 pandemic, the amount of medical waste has increased by almost 40%, according to a World Bank Group estimate.
Face masks, gloves, test kits, and used sharps and sharps waste from vaccinations have added to the risks that waste collectors face. According to search by WIEGO, 61 percent of informal workers globally, including waste pickers, reported increased occupational health risks.
“What the pandemic does is exacerbate what was already there – it added an extra layer of vulnerability,” says Sonia Dias, waste specialist at WIEGO. His organization has studied how the pandemic has increased the global stigma against waste collectors. A garbage collector in Durban, South Africa, said: “They think [waste pickers] are the ones who will infect them with Covid-19. “
Waste pickers were also often the last on the Covid-19 vaccination lists, despite providing a public service. As recently as June 2021, road sweepers in São Paulo, Brazil, went on strike after not being vaccinated despite their work throughout the pandemic. In some places, the Covid-19 has shed light on waste pickers and earned them recognition. For example, in 2020, the Colombian national government waste pickers recognized as an essential service. However, Ana Carolina Orgando, research associate at WIEGO, says it will likely be short-lived. “While there may be a recognition of the role that waste pickers currently play in urban systems, this does not necessarily mean that this actually translates into effective and inclusive policies,” she says.
Back in Freetown, Rogers says a lot needs to change to improve the situation for the hospital waste worker. He wants more protective gear, a bigger incinerator and higher wages. Most importantly, he says workers need respect. ” How can we [make people value them] make sure [these workers] feel valued for what they do? he asks. “They should be very proud to come into the ward, and when they come in people should give them time to do their part. “
“In this part of the world, we have financial challenges,” he adds. “But at the end of the day, if you do the right thing, you improve your health.”