It was an accident that could have been avoided. While a waste collector was incinerating infectious waste at Connaught Hospital, Sierra Leone’s principal adult referral centre in the capital Freetown, a spark shot out of the intense furnace into his eye and destroyed it.
The worker was not wearing goggles. The only protective equipment he may have worn that day was a fabric overall and kitchen-style rubber gloves. He was unable to continue working and, two years later, former colleagues told hospital staff the man had died. “They said he actually lost his life as a result of the eye injury,” says Mohamed Hashim Rogers, lecturer in microbiology at the College of Medicine and Allied Health Sciences, University of Sierra Leone. “It’s not a well-paid job, and he had lost an eye. Who was going to look after him?”
Between 2018 and 2019, Rogers observed the risks and challenges waste collectors face on Connaught’s wards for DiaDev, a research project investigating diagnostic devices in global health. The results were shocking, but also typical of conditions found across health settings in low- and middle-income countries (LMICs).
Studies across all continents on the dirtier side of healthcare, in particular a 2011 report by NGO Health Care Without Harm (HCWH), show that health settings poorly manage their waste. The workers collecting that waste receive insufficient protections, minimal training, paltry pay and zero respect.
The World Health Organization (WHO) estimates that 15 per cent of health care waste is hazardous and may be infectious, toxic, or radioactive. HCWH’s report highlights how such waste is frequently dumped when waste systems are lacking. This causes water contamination, among other health and environmental hazards, and exposes scavengers to contaminated waste. LMIC health services often burn their waste, releasing toxic chemicals and, potentially, pathogens, into the air. Health workers are trained to manage these risks, but waste collectors’ working conditions are vastly different.
“The staff who clean the hospital and collect the waste may often be at greater risk than medical staff who produce it,” says the HCWH report. “They are usually poorly educated and trained and little attention is paid to their comfort and safety. It is uncommon for them to have vaccinations or proper protective equipment. Disposable latex gloves may 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 must be segregated at source, in particular sharps waste – used syringes – should be discarded in sealed plastic boxes. But LMICs seldom achieve this basic standard. Rogers found Connaught hospital staff often mistakenly mixed waste. As a result, waste handlers had to handpick infectious waste from bags.
“They manually took out urine and blood bags, pierced them, and let that pour out [into a sink],” says Eva Vernooij, a University of Edinburgh research fellow on the DiaDev project. The workers told Vernooij they did not have a designated tap to wash their hands and were expected to buy their own soap. The workers also removed plastics and cardboard to reduce the waste volume, as the incinerator could only hold one bag of waste, while the hospital generated 15 a day.
The workers piled up excess waste outside for municipal waste services to transport to a city dump. Since it was badly segregated, it also contained infectious waste. “You keep it for three or four weeks and it’s going to smell,” says Rogers. “Dogs and rats are coming to feed from that waste.” In desperation, waste collectors burned the surplus in an open pit. They inhaled the infectious smoke, as did patients and their relatives in the hospital nearby. “This is a recipe for illness,” says Rogers.
As well as these hazards, each time a worker reached into a waste bag they risked being stabbed by a used needle. Several workers had taken HIV tests after accidental injuries. The WHO estimates that among 35 million healthcare workers worldwide, about three million receive percutaneous exposures to blood borne pathogens each year, and more than 90 per cent of these cases occur in LMICs. This means about 40 per cent of hepatitis B and C infections and 2.5 per cent of HIV infections in health care workers are attributable to occupational sharps exposures.
HCWH international science and policy coordinator Ruth Stringer says waste workers rarely report such incidents. “They think it’s their fault – that it makes them look bad,” she says.
Research conducted in Bangladesh found waste worker managers did not feel responsible for protecting staff. One manager said: “It is not our duty to take action against their fate.”
For all the risks the workers face in Freetown, they receive 500,000 leones (approximately US$48.75) monthly. Yet the government-funded private company that hires the waste collectors often fails to pay them for months at a time. Despite this, they continue to work, hoping pay day will come.
Harsh treatment and stigmatisation
All waste workers, not just those collecting medical waste, experience harsh treatment and are often stigmatised, says global public sector workers union Public Services International’s local and regional government officer Daria Cibrario. “Waste is not usually valued as a resource by our societies. It is rather seen as something filthy, sometimes stinky and contaminated,” she says. “Our societies often prefer not to see it.”
Stigmatisation is connected to the fact that waste workers are often racialised, migrant and marginalised workers from the poorest socio-economic groups, or castes in some countries. In India, it is commonly members of the Dalit caste, the ‘untouchables’, who conduct sanitation work. Waste collectors also tend to have had limited access to formal education or professional training, and when they come from foreign countries, they may not be fluent in local languages.
Cibrario points out that globally waste as a public service is “terribly underfunded”. She says one reason for this in LMICs is because there is little devolution of power from national to local government. However, while managing waste requires local oversight, only central government in such countries can meet the high level of investment required to build safe systems, such as adequate dumps and incinerators.
When a government does fund local authorities to manage waste, they rarely include enough to provide ample staffing levels and equipment, says Cibrario.
She gives the example of Tunisia, where the central government devolved waste services to municipalities following the country’s 2011 revolution. “Adequate funding for the service did not follow,” she says. “Infrastructures were not upgraded to make it possible for the local governments to run effective waste management systems.” As a result, in 2019 more than 2,000 municipal waste management workers demonstrated, demanding safer conditions and recognition for the public health role they perform.
Trade union membership was key for Tunisian waste workers to call for recognition and decent working conditions. Cibrario says in countries where waste management is organised by municipal service trade unions, waste workers can represent some of the strongest union divisions, as in South Africa. However, where there are overwhelming levels of informal and precarious work, or where restrictions on the right to organise exist, such as in India, it can be harder for workers to unionise.
Waste pickers are directly impacted by poorly managed clinical waste. When badly segregated rubbish is discarded on open dumps, waste pickers and recyclers who derive a livelihood from refuse are exposed to needlestick injuries, pathogens or potentially radioactive substances. A 2013 WIEGO (Women in Informal Employment: Globalizing and Organizing) study of waste pickers on a dumpsite in Nakuru, Kenya found they encountered syringes, blood, cotton pads and medicines. Research from 2019 by the University of Brasilia at the Brazil’s Estrutural Open Garbage Dump found sharp objects including syringes caused 90 per cent of accidents among waste pickers.
As a result of the Covid-19 pandemic, the amount of medical waste has increased by as much as 40 per cent, according to a World Bank Group estimate.
Used facemasks, gloves, testing kits and sharps waste from vaccinations have added to the risks waste collectors face. According to research by WIEGO, 61 per cent of informal workers globally, including waste pickers, have reported increased occupational health risks.
“What the pandemic does is exacerbate what was already there – it has added an extra layer of vulnerability,” says WIEGO waste specialist Sonia Dias. Her organisation has studied how the pandemic has increased global stigmatisation of waste collectors. A waste picker in Durban, South Africa reported: “They think [waste pickers] are the one who will infect them with Covid-19.”
Waste collectors have often also been last on 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 receiving vaccinations despite working throughout the pandemic. In some places, Covid-19 has shed a light on waste collectors and earned them recognition. For example, in 2020, Colombia’s national government recognised waste pickers as an essential service. However, WIEGO research associate Ana Carolina Orgando says this is likely to be short-lived. “While there might be a recognition of the role that waste pickers play in urban systems now, it doesn’t necessarily mean it’s actually translating into effective and inclusive policies,” she says.
Back in Freetown, Rogers says much needs to change to improve the hospital waste worker’s situation. He wants more protective equipment, a larger incinerator, and higher salaries. But importantly, he says the workers need respect. “How do we [make people value them] to ensure [these workers] feel valued for what they are doing?” he asks. “They should be very proud of coming into the wards, and when they come in, people should give them the time to do their bit.”
“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 are improving health.”
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