Safe and sustainable waste management of self care productsBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1298 (Published 01 April 2019) Cite this as: BMJ 2019;365:l1298
- Ash Pachauri, director1,
- Prerna Shah, honorary researcher and environmentalist2,
- Bethanie C Almroth, senior lecturer3,
- Norma P M Sevilla, professor4,
- Manjulaa Narasimhan, scientist5
- 1Center for Human Progress, Ashburn, Virginia 20148, USA
- 2Protect our Planet (POP) Movement, G-1, Jangpura Extension, New Delhi, India
- 3Department of Biological and Environmental Sciences, University of Gothenburg, Gothenburg, Sweden
- 4Interdisciplinary Center for Research and Studies on Environment and Development, National Polytechnic Institute, Mexico City, Mexico
- 5World Health Organization, including UNDP/UNFPA/Unicef/WHO/World Bank Special Programme (HRP), Geneva, Switzerland
- Correspondence to: A Pachauri
The global growth rate of self care medical devices is estimated to rise from $10.5bn (£8bn, €9.2bn) in 2013 to $16.8bn in 2019—a compound annual growth rate of 7.0%.1 This increase directly correlates with the level of disposables entering the waste stream. Additionally, over half of the world’s population is now at risk from occupational, environmental, or public health threats due to improper management of healthcare waste.2 Waste management of products used for self care is largely unregulated and evidence is limited.
The World Health Organization defines self care as the “ability of individuals, families, and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a healthcare provider.”3 Self care products include a variety of sexual and reproductive health commodities such as condoms, tampons, sanitary pads, and self administered injectables. An analysis of these commodities shows the magnitude of waste management challenges facing individuals, communities, and governments worldwide.
Magnitude of the problem
The magnitude of waste arising from self care products depends on the amount of user generated and segregated waste and the quality of treatment and disposal by the wider waste management system. In the case of condoms, most for men and some for women are made of rubber latex, which is biodegradable, except in water.4 Some condoms contain polyurethane, which is non-biodegradable.4 Their primary and secondary packaging also adds to the waste burden. An estimated five billion packets of condoms are sold annually,56 which contribute to beach litter, blockage of sewage systems, and breeding of vectors.7 In 2013, during the New Jersey beach clean-up, volunteers removed 744 condoms or rubber bands, 511 gloves, and 3102 tampon applicators.8
Condoms are a critical, cost effective method of contraception when used correctly. Their continued availability remains important for reducing mortality and morbidity, but social marketing interventions hardly mention proper disposal, although they have the potential to do so.
Women who have access to menstrual hygiene products might use up to 10 000-12 000 during their lifetime.9 Sanitary pads consist of up to 90% plastic and take around 500-800 years to biodegrade.9 One sanitary pad may contain as much plastic as four supermarket bags.10 This causes problems for waste management worldwide. In 2016, the British Marine Conservation Society found 20 sanitary items per 100 metres of shoreline.11 The Menstrual Health Alliance estimates that 9000 tons of sanitary waste are generated annually in India.12 Typically, this is disposed of with household waste. Disposal is often improperly managed by local authorities, with sanitary products ending up in the oceans and waterways.12
For many women and girls, disposable sanitary pads and tampons remain inaccessible or unaffordable.13 Menstrual Hygiene Day, initiated by the German based non-governmental organisation WASH United, builds awareness, particularly through social media, about the fundamental role of good menstrual hygiene in enabling women and girls to reach their full potential.13 The initiative catalyses a global movement to promote safe disposal of these items through reduction, segregation, and treatment.14
The transmission rates of bloodborne viruses from patient to healthcare worker are up to 30% for hepatitis B (HBV), 1-3% for hepatitis C (HCV), and 0.3% for HIV due to improperly disposed sharps. These numbers may not result from inoculation of fresh blood as the viruses survive outside the body for varying lengths of time, from four days to three weeks.1516 In 2010, unsafe injections from re-use were responsible for 33 800 new HIV, 1.7 million HBV, and 315 000 HCV infections globally.17 A study of 141 rubbish collectors in Karachi reported the prevalence of HBV as 18.8%, HCV 8.5%, and HIV 0.85%,18 with baseline prevalence rates of 2.5%, 5%, and 0.1%, respectively, among adult populations in Pakistan.1920 In the same study it was found that 54% of them had had more them one needlestick injury. Self injection of contraceptives is expected to be increasingly available. This requires cross-sectoral partnerships and guidance for better manufacturing, distribution, and disposal of sharps.
Implications of unregulated waste from self care products
Unregulated, and even regulated, improper waste disposal is not unique to self care products. Inappropriate waste burial may cause leaching of toxins and microorganisms into waterways,21 incineration increases greenhouse gas emissions, and dioxins and furans have been associated with a wide range of human health problems.21 Plastics, commonly used for packaging, break down into microscopic fragments (microplastics),22 which are being ingested by people worldwide. However, little is known about their effect on human health and ecology.22
Access to good quality products when needed forms part of the right to healthcare. As we reduce dependence on hospitals and enhance our reliance on community based systems, and self management, waste disposal of self care products will rise substantially. This adds a sense of urgency, as the need for such products is sometimes coupled with unregulated waste management. Economic and social inequities exacerbate the problem, with the poorest, most vulnerable populations in low and middle income countries at highest risk of adverse health and environmental effects. Evidence suggests that although per capita waste generation is highest in the developed world, these countries have better waste management practices that mitigate potential adverse health effects.23
Global practices of dealing with self care waste
Many countries have schemes for safe disposal of certain self care products outside healthcare facilities. These include drop-off container collection sites, residential special waste pickup services, mail back programmes, unused medicine take back and disposal options, syringe exchange programmes, and home needle destruction devices.24 However, such opportunities are not universal and there is resistance to the collection of home medical waste in municipalities because its classification (as home or industrial waste), and hence management, is unclear.25
For large quantities of condoms, shredding or compacting is a recommended method of disposal,4 eliminating the risk of scavenging and condom reuse. However, condoms are difficult to shred,4 and anaerobic degradation (due to compacting or burial) of plastic and rubber produces carbon dioxide and methane,4 both of which are major greenhouse gases. Some condom manufacturers are obtaining latex directly from rubber trees,6 packaging in recycled paper boxes, and printing directions with vegetable ink.6 Such products are easily available online and cost between $1 and $1.5 a piece.26 Others have begun producing menstrual products using sustainable materials (eg, wood pulp replacing plastic fillers in sanitary pads) and reusable products (eg, menstrual cups),27 thus dealing with equity and environmental considerations. Some of these are 100% biodegradable and 43% cheaper than the average retail price.28
Life cycle analysis and associated accountability
Disposal of a product is one of many costs incurred during its life cycle. Accountability can be ascertained by examining each stakeholder’s role in key stages of a product’s manufacture, procurement, distribution, and use. For instance, United Nations Population Fund’s (UNPFA) replicable green procurement strategy involved collaboration with donors, governments, beneficiaries, and suppliers. It clearly communicated details of the plan, thus leading to savings of 7.8 metric tons of CO2, 11.8 million kg of solid waste, and 587 598 m3 of water in 2010.29 Similarly, a study evaluating the effect of syringe acquisition on syringe disposal indicated that HIV positive injection drug users who obtain syringes from a safe source are more likely to dispose of them safely.30
Consumers are beginning to play an active part in making decisions about their health.31 It is therefore necessary to develop a system that provides them with critical information, and sets a strong precedent for greener supply chains, reducing both the amount of waste and the cost of disposal. Some companies, however, seem to potentially mislead consumers by replacing restricted materials with little known and legally permissible materials that may have similar physiological effects (eg, replacement of bisphenol A with bisphenol S or bisphenol F32). Users and policy makers responsible for regulation of chemical usage require access to this information and the ability to evaluate it.
Facilitating holistic self care waste management through cross-sectoral partnerships
A robust self care system will depend on cross sectoral partnerships which create healthy communities, towns, and cities.33 UNFPA’s green procurement strategy is an example of collaborative action that included donors, governments, suppliers, and beneficiaries.29 While building on existing systems, care must be taken to consider the broader effect of establishing more formal waste management. Thus, for example, the livelihoods and occupational safety of waste handlers in the informal sectors must be considered.34
Based on analysis of reports from the fields of healthcare waste management,213536 sustainability and the environment,22 and waste management from home care and non-medical settings,373839 actions in specific sectors can be developed that lead to better waste management of self care products:
Governments— The importance of integrated solid waste management by city governments based on the 3Rs—reduce, reuse, and recycle—is well recognised as the basis of sustainable development.40 National governments could also improve their waste management. Targeted budgets could be developed to build and maintain cleaner technologies,41 and policies that include environmental or health externalities in product pricing.
Non-governmental organisations—While advocating promotion and use of self care, non-governmental organisations could implement home and community based programmes for waste management. Interventions to change behaviour, which have shown great potential in individual and community waste management practices, may also be introduced. These could educate communities and improve consumer knowledge, attitudes, and practices towards safe and sustainable waste management of self care products.35
Private sector— The concept of a stronger, more circular economy offers the private sector an opportunity to promote the use of safe and efficient materials, reduce waste, and prioritise products with low carbon footprints. This would reduce energy costs, while creating environmental and health benefits.42 The private sector could develop solutions to reduce the volume and toxicity of waste by using regulated materials and alternative, safe packaging. It may also include the social, environmental, and financial analyses used to evaluate performance and create greater value while exploring possibilities of waste collection that is not carried out by the municipality.
Consumers—Education on reducing the volume of waste generated, on waste segregation, recycling practices, and on attitudes towards waste, has been shown to have a positive effect.35 Thus, large scale public awareness could create a change in consumer attitudes.
Donors and development partners—Donors can influence development43 and could set priorities, affect policy, and make financing decisions to ensure sustainable waste management systems for self care products. They may also introduce and monitor such systems and support research needed to identify means for cleaning the environment and improving public health. By collaborating with the private sector and governments, donors might also be able to ensure sustainable waste management as health systems are expanded in developing economies.
Researchers—The importance of research in protecting our planet and promoting public health cannot be denied.44 Recognising the urgency of dealing with self care product waste, researchers should focus on understanding its effect on the environment. They should consider operational solutions, including production and packaging, inventory management, procurement strategies, disposal techniques, and routeing and transportation. Interdisciplinary and transdisciplinary research is required.
Self care will form an important part of healthcare systems as governments strive to achieve universal health coverage by 2030, as part of the sustainable development goals. However, waste management of self care products cannot be neglected, particularly for poor and vulnerable populations. While waste generated by regulated hospitals continues to cause alarm, the problem of uncontrolled self care products waste appears to be quietly growing. This is an urgent call to understand its sustainability implications and facilitate the design of policies and development of programmes to promote sustainable waste management. This is the responsibility of all, and not only of the user. Countries should be supported to develop and adopt routes to sustainable self care waste management that include increasing access and developing methods to protect human and environmental health.
Self care will continue to grow, especially as it is seen as key to reaching universal health coverage by 2030, as part of the sustainable development goals
Research is needed to clearly understand the effect of unregulated waste from self care products on human health and the environment
National policies and regulatory frameworks are urgently required to enable the adoption of safe waste management techniques and the development of efficient production methods
Safe and sustainable self care product waste management necessitates the development of cross sectoral partnerships and action by all players in the system
We are grateful for feedback from a group of committed people who participated in the WHO/Wilton Park expert meeting “Reimagining Global Health: Self-Initiated Interventions and Implications for Healthcare,” 10-12 September 2018. Special thanks to Saroj Pachauri and Shonali Pachauri for their invaluable input.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Contributors and sources: AP is a public health researcher with expertise in social mobilisation and behaviour change communication. PS is an environmentalist whose work focuses on environmental health and behavioural science research. BCA carries out research into the effects of microplastics and chemicals in food chains, as well as chemicals in plastic packaging. NPMS is a researcher with expertise in biological oceanography, marine biochemistry, environmental deterioration, and climate change. MN is a scientist with expertise in sexual and reproductive health and rights, and is leading the WHO normative guidance development on self care. AP and MN conceived the idea for the article. AP and PS wrote the first draft. AP, PS, BCA, NPMS, MN revised the paper. AP is the guarantor. The contents are the responsibility of the authors and do not necessarily reflect the views of WHO.
Provenance and peer review: Commissioned; externally peer reviewed.
This article is part of a series proposed by the UNDP/UNFPA/Unicef/WHO/World Bank Special Programme for Human Reproduction (HRP) and commissioned by The BMJ. The BMJ retained full editorial control over external peer review, editing, and publication of these articles. Open access fees are funded by HRP.
This is an Open Access article distributed under the terms of the Creative Commons Attribution IGO License (https://creativecommons.org/licenses/by-nc/3.0/igo/), which permits use, distribution, and reproduction for non-commercial purposes in any medium, provided the original work is properly cited.