Clinics of death

By John Njoroge

When children play with healthcare waste, tainted blood, needles

The air is pungent with urine, fecal matter and cow dung. The narrow walkways are littered with garbage and stagnant water with barefoot children running around innocently. Others rummage through the garbage piles for items to sell. One pile is full of used needles, syringes, blood stained bandages, surgical blades, used gloves and numerous blood transfusion tubes, some of which still have blood in them.

You never know whats in there, says one timid-looking boy pointing to the needles. We have learnt where to and not to play. The problem is with these young ones, he adds, as another group of passing children narrowly miss a lone needle hidden in the grass.

This is Kifumbira, a slum in Kamwokya, a suburb of Kampala city. Coupled with poor hygiene and sanitation, overcrowding and crime, the slum faces a new beast irresponsible disposal of medical wastes. This issue is not exclusive to Kifumbira; the suburbs of Kawempe (Jinja Kaloli), Kalerwe, Wandegeya, Bwaise, Ntinda Kisaasi, Kiwatule, Kitintale and Banda are also affected.

In these and other similarly affected places, adults go about their business oblivious of the danger and potential diseases their children routinely flirt with. At the Kitintale market, used needles, bandages and syringes are openly dumped with domestic food waste. Destitute children and lunatics are always rummaging through this dump. Such irresponsibility can spell disaster.

In late November 2009, Ronald Mukasa, 7, fell ill after he stepped on a needle while looking for plastic bottles and scrap metal in a rubbish dump. For two weeks he was unable to walk due to a swollen foot. His mother gave him paracetamol and massaged his foot with warm water. But after he developed an extremely high temperature, inflamed thyroid glands and began losing consciousness, he was rushed to Kamwokya Christian Caring Community Centre, a health centre in the Kamwokya area. Doctors there revived him but Mukasa died a few days later of tetanus while at Mulago Hospital.

We show the Minister for Primary Health, James Kakooza, some photos from Kifumbira.

These are disturbing, shocking, he says as he flips through the images of needles and tubes of blood.

He is standing on the steps of parliament, his green pink-striped suit flapping slightly in the wind as he takes time from fielding phone calls and speaking with MPs to glance through more photos. . The images put him into a sombre mood.

My God, it has come to this! I have never seen anything like this before.

As he shakes his head from side to side in disbelief, he promises to send an inspection team to Kifumbira. But the bigger issue, he keeps repeating, is the bad attitude of the urban population.

The problem is the I dont care attitude of people in Kampala especially, he says, adding that there are hospitals in the rural areas, both government and private, but they do not have a medical waste problem.

However, according to the Commissioner of Clinical Services at the Ministry of Health, Dr. Jacinto Amandwa, the problem goes well beyond attitude. Calmly seated at his office desk, Dr. Amandwa, is suddenly shocked and saddened when he views the pictures. We have really slacked in the last two years in the area of monitoring medical waste disposals especially by private medical units, he says despondently. We need help.

Improper healthcare waste disposal is a countrywide problem. It poses public health risks due to environmental pollution: impaired air quality, storm water contamination of water courses or when people and children rummage through raw waste stockpiles.

Amandwa apportions part of the blame to the Uganda Medical Council, the licensing body for private hospitals in Uganda. He says the council was given strict guidelines not to licence private health units unless they proved they had the ability and capacity to dispose of their medical waste responsibly. But today many are operating without clear medical waste disposal channels.

The disposal of medical waste material is a delicate affair. Medical units generate different kinds of medical wastes including breakables, prickables (needles and surgical bleeds), infectious and highly infectious waste, domestic waste (food stuffs) and human body parts, which include placenta and amputated body parts. Expired drugs are also considered to be medical waste. Once generated, each kind of waste must be disposed of differently while also keeping the costs to the environment in perspective.

A study, the Uganda’s Healthcare Waste management system Plan (HCWMP) of 2007/08- 2009/10) by the Ministry of Health, suggested that, through the National Medical Stores, it should regularly collect and destroy waste that must not be destroyed by individual healthcare facilities: such is waste that may contain heavy metals (lead, mercury) or radioactive materials. The study cited cost and skills limitations but recognised a need for centralised waste incineration in future.

Major hospitals like Mulago National Referral Hospital, St. Francis Hospital, Nsambya and Kibuli have their own incinerators.  The government has an incinerator in Nakasongola that hospitals and clinics that do not have incinerators. The health facilities retain the duty of transporting their waste to collection centres where government contracted companies then pick it up and transport it to Nakasongola or personally take the waste to Nakasongola. We even provide armed escorts for expired drugs to ensure they get to Nakasongola, says Minister Kakooza. Private hospitals can also work together with hospitals with incinerators to dispose of their waste.

We have an understanding with the government health centre in Kisenyi, says Dr. Appolo Ahimbisibwe, a physician at the Kamwokya Christian Caring Community Centre. It has an incinerator where we take our wastes once a month. Since we do not have a theatre, we have no human body parts; we only generate medical waste like needles, tubes, syringes, bandages and gloves. Ahimbisibwe adds that the centre pays Shs.2000 for every kilo of medical waste it transports to Kisenyi. To save on transportation costs, the centre only takes its waste once it accumulates to 100kg.

But an on-the-spot survey of private medical units in Kifumbira-Kamwokya reveals that many private clinics are not willing to pay these additional disposal costs. At Kasee Clinic, one of 12 private medical units within a 200 metre radius, an attendant was initially helpful but suddenly became hostile and closed the doors of the clinic when she was asked about this practice. Life clinic and Nyange clinic also offered very rude responses. We dont want journalists here, one attendant shouted in Luganda before slamming her door.

Most clinics in the low income city suburbs are dingy, unregistered, two-room affairs. Unrecognized by government and the Ministry of Health, these illegal clinics operate without letters from the medical council and many do not have professional people working in them. Others are established by medics who use their qualifications unethically to open their own unregistered clinic. According to Ahimbisibwe, slum dwellings like Kifumbira-Kamwokya are ideal for unregistered private medical centres to operate; there is minimal inspection and the rights of people in these areas are routinely trampled on. These clinics then dispose of their waste by burning it or by paying random, unaccountable individuals to throw it in open dumpsites. You do not expect such people to be responsible, Ahimbisibwe notes in frustration.

Mulago Hospital is a shining example of how medical waste disposal is supposed to work. With three incinerators, Mulago boasts an organised and elaborately systematic method of medical waste management. Walking through the hospital, one notices colour-coded bins at every corridor. Medical wastes are put in the red and yellow bins while domestic waste is put in black and blue bins.

The hospitals incinerators are also environmentally friendly. Their high chimneys displace the fumes and the machines run on diesel fuel. Only breakables and sharp objects like needles and surgical blades are incinerated. Plastic bottles are recycled, domestic waste is collected by Kampala City Council (KCC) and human body parts are taken to the KCC mortuary grounds in Bukasa, another city suburb, for burial.

But for the residents of Kifumbira-Kamwokya, just two kilometres away, Mulago’s organisation offers little comfort. Not only must slum dwellers continue living among the dangerous waste, but when they get sick the only health facilities they can often afford are those that routinely pollute and potentially put their lives in danger.