Coming round to recyclingBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b609 (Published 11 March 2009) Cite this as: BMJ 2009;338:b609
All rapid responses
Clinicians might decrease the environmental impact of medical
practice by drinking tea from china cups. Sounds far fetched?
Not according to Dr. White and Mr. Hutchins, who in their article dish out
this and plenty of similarly original advice. They however do not adhere
to one of their own suggestions (to save paper): extra pages are
required so we can be treated to two(!) pictures of a box full of Petri
dishes and one of a yellow bag.
From my point of view as an anaesthetist, I was especially interested
which disposables would Dr. White dispose with (sorry for the pun) and
which packaging he would simplify.
As someone who started practicing during the non disposable era, I am more
than convinced that the introduction of plastic single use items must have
been one of the biggest contributions to the quality and safety of
anaesthesia. I shall give just two examples: Ventilator tubing used to be
manufactured from heavy black rubber. Thus ventilator (or spontaneous
breathing circuits) disconnections were a constant hazard and did occur
not infrequently - sometimes with disastrous consequences. Endotracheal
tubes were manufactured from red rubber – a nasty irritating compound.
These tubes constantly kinked, obstructed and their cuffs leaked.
I have also spent six months working as an Anaesthetic Assistant and thus
had the “pleasure” of cleaning masks, airways, endotracheal tubes etc.
using various toxic solutions – not an enviable task.
As for the packaging - Dr. White’s article is misleading. Virtually all
packaging of anaesthetic disposables is single layer. Where it is double,
like spinal or epidural packs, then the inner layer serves as cover for a
trolley. Recycling of packaging is impracticable as it consists of both
plastic and paper and cannot be viably separated. Anyway packaging gets
frequently contaminated as it serves as a receptacle for equipment.
Are we supposed to do some form of sorting during our clinical work? Shall
we have one box for syringes; one box for “true” sharps; several boxes for
glass according to its colour etc. (the list seems to be endless)? All
this to achieve (at best) the savings of £ 40 (the top price for a ton of
waste paper) per year per theatre?
Perhaps next time the BMJ publishes yet another environmental article, the
editors should ask the authors also to declare their carbon footprint.
Competing interests: No competing interests
Despite opportunities to reduce the heavy environmental footprint of
the NHS, progress so far has been limited. Reduction in consumption and
elimination of waste can afford substantial savings though successes have
so far been limited. The separate collection of recyclables including
food, paper and cardboard, glass and some metals is of proven value though
the logistics may be troublesome. In clinical areas, errors of segregation
may result in hazardous items being disposed into an inappropriate
container, or of confidential documents discarded without attention to the
necessary data security.
Hutchins and White discount the possibility for recycling of clinical
wastes and imply that these wastes must be considered ‘lost’ to resource
recovery.1 Though not yet widespread, this waste fraction can be processed
for recycling after treatment to render it safe using non-incineration
treatments such as commercial autoclave processing. Valuable high grade
metals from single-use instruments can be recovered using magnetic
extraction. Other separation techniques permit recovery of hard plastics,
while the high calorific value of the treatment residues allows use as a
fuel for cement kiln operation.
Though current regulatory pressures seeks to frustrate recycling
initiatives and divert clinical wastes directly to landfill or to high
temperature incineration with no obligation to energy recovery, post-
processing recovery rates up to 60% make a valuable contribution to
environmental protection without the need for ever more onerous source
segregation that are generally troubled by space and time constraints, by
segregation errors, and by the vastly increased manpower and logistics
costs. With clinical waste production across the UK exceeding 1,400 tonnes
per annum, technologies that enable resource recovery from clinical
wastes, and biogas production from vast quantities of sanitary and
offensive waste fractions that are separately collected, offer an
invaluable environmental advantage that as yet to be fully realised.
Scally is correct is his assertion that NHS procurement must ensure
that decisions are informed by awareness of material and packaging
composition as key determinants in recovery and recycling.2 Indeed, this
approach forms part of the WHO strategy for healthcare waste management
that includes, for example, the production of all syringe components made
of the same plastic to facilitate recycling.3 Inevitably, this would carry
a heavy financial burden for manufacturers who may be unwilling to fund
the redesign and re-approval of their products. However, there are already
green shoots appearing from the treatment of NHS wastes teams, though
these may be hidden to most healthcare professionals. Regulators should
applaud and support developments in recycling from clinical wastes, though
presently the approach is largely obstructive and sits uncomfortably with
a substantial weight of published and technical evidence. In their part,
NHS waste producers can make their contribution to resource recovery of
metals and mixed plastics from clinical wastes by thoughtful selection of
their waste disposal options to ensure that valuable environmental
resources are not lost to incineration, or consigned to landfill disposal.
1. Hutchins DCJ, White SM. Coming round to recycling. BMJ
2. Scally G. Environmental waste in health care. BMJ 2009;338:b1129
3. World Health Organization. Policy paper – Safe health-care waste
management. Accessible from
(accessed 27 March 2009)
18 South Road
London W5 4RY
Competing interests: No competing interests