ADVANCING ENVIRONMENTAL HEALTH AND JUSTICE: A CALL FOR ASSESSMENT AND OVERSIGHT OF HEALTHCARE WASTE APHA POLICY STATEMENT NUMBER 20224, ADOPTED NOVEMBER 2022.

• Author: Canate, Tiffany

1. RATIONALE FOR CONSIDERATION 149 II. PROBLEM STATEMENT 150 A. Healthcare Waste Management Standards, Regulation, & Guidance 152 B. Producing and Managing Single-Use and Medical Waste Plastics 156 C. Assessing Healthcare Waste-Streams and Public Health Impacts as a Matter of Environmental Racism 158 III. EVIDENCE-BASED STRATEGIES TO ADDRESS THE PROBLEM 160 IV. OPPOSING ARGUMENTS AND EVIDENCE 164 V. CONCLUSION: ACTION STEPS 166 I. RATIONALE FOR CONSIDERATION

   The American Public Health Association (APHA) Joint Policy Committee and staff have not identified this topic as a policy statement gap for the current year. The last policy statement drafted to explicitly address waste as a public health issue was in 1986 (8911: Resource and Solid Waste Management) and is now archived. (2) APHA recently approved policy statements related to structural racism (LB20-04) (although now expired) and environmental justice (20197) that provide a foundation for this statement on healthcare waste as a public health issue. (3) Recent statements related to COVID-19 are relevant (for example, 20218), as the COVID-19 pandemic has illuminated the scale and implications of our healthcare waste stream. (4) Finally, this proposed statement expands upon the U.S. Call to Action on Climate, Health, and Equity: A Policy Action Agenda, to which APHA is a signatory. (5) That statement calls for the current federal administration to strengthen U.S. health systems "to protect and promote health ... in the era of climate change," but with no mention of healthcare waste. (6) None of these statements combine the issues of environmental justice and healthcare waste management with clear evidence and actionable steps needed to address this longoverlooked issue as a matter of health equity. This proposed Policy Statement is responsive to environmental justice leaders calling on public health leaders to address this long-standing issue that has worsened since the COVID-19 pandemic. (7)

2. PROBLEM STATEMENT

   Healthcare waste refers to all waste related to medical procedures-including waste generated within healthcare facilities--laboratories, research centers, homes, communities, veterinary healthcare settings, and other minor sources. (8) This may entail waste from healthcare-related food systems, medical waste plastics (MWPs), pharmaceutical, chemical, radiological or infectious agents, personal protective equipment (PPE), and human or animal tissues and remains, among other types. (9) In sum, the U.S. healthcare industry generates more than five million tons of waste each year, (10) with over five billion pounds (or about half) attributable to the nation's nearly 6,100 private and public hospitals. (11)

   Moreover, the healthcare sector is responsible for 8.5% of greenhouse gas emissions, which causes worsening health disparities. (12) Beginning in 2020, the COVID-19 pandemic globally accelerated the production of most types of healthcare waste due to increased demands on the system from testing, vaccination, and treatment, as well as the increase of single-use MWPs with early concerns of SARS-CoV-2 (13) transmission and infection. (14) Federal U.S. policy does not define "regulated medical waste" (RMW) but the healthcare industry generally considers it to be "the portion of the waste stream that may be contaminated by blood, body fluids or other potentially infectious materials, thus posing a significant risk of transmitting infection." (15) This includes microbiological laboratory waste, pathological and anatomical waste, blood specimens and products, and other body-fluid specimens, as well as vaccine sharps and vials. Approximately 75-90% of healthcare waste is non-hazardous, whereas 10-25% is infectious, toxic, or radioactive and considered RMW in the United States. (16) In the United States, the healthcare industry typically autoclaves (that is, sterilizes with steam) 20-37% or incinerates 49-60% of RMW, and only sometimes processes it with other technologies, 4-5%. (17) Large healthcare facilities treat much of their RMW on-site, but most rely on other companies to take it off-site. (18) Notably, off-site companies like Stericycle, the largest medical waste incinerator company in the world, also create public health concerns through treating RMW and spreading dangerous fine particle matter, which harms nearby vulnerable communities. (19) By the end of 2021, RMW had increased at unprecedented rates--with more than eight billion SARS-CoV-2 vaccine doses given globally--resulting in an additional 144,000 tons of RMW from glass vials, syringes, needles, and safety boxes. (20) RMW includes bodily remains as well. (21) In 2020, at the onset of the pandemic, with an overwhelming number of lives lost to SARS-CoV-2, management of RMW entailed disaster morgues and mass graves in the United States and across the planet. (22)

   Overall, healthcare waste poses many threats to public health, including from excessive production and disposal of petroleum-based, single-use MWPs, unsustainable waste management practices that contribute to climate change (for example, failure to adequately segregate RMW from non-hazardous waste), and inequities associated with transport and siting of healthcare waste that disproportionately harm communities of color and low-income communities. This includes both urban and rural populations globally, from the frontline and all throughout the waste stream. Of course, the exposure scenarios and environmental risk factors for these related issues vary greatly, and the United States needs multiple, coordinated policy solutions to improve oversight towards health equity. To begin, this Policy Statement focuses on common types of healthcare waste, including single use and MWPs and RMW from U.S. hospital settings, that contribute to notable health inequities downstream. (23)

   1. Healthcare Waste Management Standards, Regulations, & Guidance

      In the United States, a variety of agencies have responsibilities for healthcare waste management:

      * The Environmental Protection Agency (EPA) oversees waste management through the Resource Conservation and Recovery Act (RCRA), (24) which gives a legal framework for management of both hazardous and non-hazardous solid waste. Much of the general healthcare waste stream makes its way to RCRA-managed waste facilities. (25)

      * The Occupational Safety and Health Administration (OSHA) and Centers for Disease Control and Prevention (CDC) provide rules and guidance for discarding RMW, and facilities that generate this type of waste are required to have a medical waste management plan to prevent infection. (26) OSHA has additional responsibilities over workplace safety for those managing waste. (27) The CDC is responsible for infectious disease management of waste. (28) The Department of Transportation (DOT), Department of Veterans Affairs, Department of Agriculture (USDA), Federal Emergency Management Agency (FEMA), and other agencies have their own regulations or guidelines that point to CDC and OSHA rules. (29)

      * Also, along with the CDC, OSHA, USDA, and FEMA, DOT enforces Hazardous Materials Regulations (30) with requirements for transport of RMW, as workers and communities may be at risk if problems occur in transit. Motivated by cases of Ebola in the United States between 2014 and 2015, DOT developed stronger protections for 'Category A' materials which DOT defined as those "known or reasonably expected to contain a pathogen that is in a form capable of causing permanent disability or life-threatening or fatal disease in otherwise healthy humans or animals who are exposed to it." (31)

      These and many other federal protections are in place, and Congress and the agencies designed them primarily to reduce transmission of infection through worker protection.

      Ultimately, there are no federal regulations for tracking healthcare waste, which complicates identifying which, and how much, healthcare industries disproportionately burden communities with any associated environmental exposures. The Medical Waste Tracking Act of 1988 (MWTA) (32) followed RCRA's "cradle-to-grave" approach to . waste regulation, where EPA specifically tracked RMW from generation to disposal. (33) Motivated by several incidents of healthcare waste washing ashore in waterways and oceans in the late 1980's, it mandated enforceable standards (that is, standards with penalties) for separating, packing, storing, and labeling RMW with recordkeeping of amounts and types of RMW. (34) However, EPA implemented the MWTA in only a handful of states and it expired after two years. (35)

      In 1990, Congress commissioned a report by the Government Accountability Office (GAO) to assess selected states' infectious medical waste regulatory programs and the status of EPA's implementation of the MWTA. (36) The report yielded six recommendations for EPA to reconsider various health waste management practices, and it considered five of the six recommendations "closed and not implemented," stating, "EPA does not anticipate having a regulatory role in medical waste management[,]" without indicating which agencies should have this responsibility. (37)

      EPA addressed one of the 1990 GAO recommendations by developing the Clean Air Act's Hospital Medical Infectious Waste Incinerator (HMIWI) standards. (38) Through the HMIWI standards, EPA considers impacts for communities where the healthcare industry incinerates waste by regulating emissions. (39) The healthcare industry incinerated more than 90% of U.S. healthcare waste prior to the implementation of these standards in 1997, (40) a process which may contribute to ambient air pollution as a major source of "dioxins, furans, and particulate matter." (41)

      Most states have developed laws pertaining to RMW (some patterned after the MWTA), and these vary in their stringency, definitions of RMW, and requirements. For example, while some states require registration for medical waste generators, most states do not. (42)...