MEDICAL WASTE IN MONTENEGRO - A LURKING MENACE

The World Health Organisation (WHO) estimates show that some 20 million people are infected each year by hepatitis B, C and HIV due to improper medical waste handling. Montenegro keeps no such records. However, more than a thousand tonnes of such waste is beyond any supervision.

“When my mother died of cancer I didn’t know what to do with the pile of leftover pills. A friend taught me to empty the capsules into a bag and mix them up with a toothpaste. Then I flushed the stuff down the toilet. I didn’t want to hand them over to a pharmacy so they profit from my loss“ said a native of Podgorica who wanted to stay anonymous in the interview with the Montenegrin Investigative Reporting Centre (CIN-CG). He is one of many who owns mini stockpiles of pharmaceutical and other medical waste (expired medications, thermometres, mercury blood pressure gauges and other hazardous materials).

Medical waste can have harmful effects on human lives and on the environment as it causes infections, epidemics, injuries, poisoning of soil and water. Our research showed that the  authorities have failed to adequately inform the public about the proper disposal of all sorts of medical waste. This is corroborated by the Environmental Inspectorate and various non-governmental organisations which recorded cases of medical and communal waste being dumped together. Many in the civil sector complain about the lack of transparency and possible illicit activities.

The hazardous wastes includes pharmaceutical, infectious, chemical, pathoanatomic, cytostatic and sharps wastes. The WHO defines it as human organs and tissues, blood and body fluids, extracts and secretions, medicines, swabs, gauze, bandages, needles, scalpels, lancets and other sharp instruments as well as leftovers from medical, dentist and pharmaceutical providers. All those can cause infections if a person is contaminated by the aforesaid waste. Moreover infectious waste makes up 80% of the hazardous medical waste coming from public health facilities.

The National Waste Management Plan 2015-2020 states that Montenegro generates 2,148 tonnes of waste a year of which 874 tonnes are hazardous and largely infectious. However that refers only to public health facilities while another thousand of tonnes are believed to be generated in private clinics, dentist practices and nursing homes. The Ministry of Health didn’t reply our inquiry on whether it possesses the exact records about the waste in the private sector. Nonetheless the ministry claims that the medical waste from the public sector is not mixed with the communal waste but is properly disposed. Furthermore, some 400 tonnes are treated every year.  

However, certain shortcomings of management are admitted in the National Plan when it comes to storage, control and insufficient staff training which ought to be addressed in the forthcoming period.

Anyway, the state owned Montefarm Company recommends giving public guidelines so that people refrain from dumping medical waste into bins or sewage. Instead they should hand it over to the nearest pharmacy. The company believes that such guidelines should become a law.    

The CIN-CG research reveals that not all pharmacies in Podgorica have the same standard of accepting the waste from their customers. Some storage the waste while others don’t citing various excuses. The Montefarm storage manager Vera Dabanovic explains in the interview with CIN-CG that pharmacies are not allowed to resell the unused medications that people return. She further adds that private pharmacies should abide by the same rule. The stockpiled medications, whether expired or still valid, are kept in temporary depots and subsequently sent back to suppliers. 

Inspectors press charges

Environmental Inspectorate instigated seven infringement procedures in the last three years. Inspectorate General however refused to share the control records saying that their publication would rather cause harm and would be illegal as “the proceedings are not over yet“. However,  the reply from environmental inspection reveals that only one case is still in court while in four cases the courts ordered payment of fines. The two remaining cases ended with acquittals for lack of evidence.

Individuals breaking the Waste Disposal Law risk fines from 30€ to 2,000€ while companies and institution risk paying from 1,000 to 40,000€. The Inspectorate explains that it started proceedings as certain health care providers (six private and one public) mixed medical and communal waste. Nonetheless the inspectors notice that there is a growing number of those who properly handle the hazardous waste. Back in 2017 the inspectors sent instructions on the proper disposal of products containing mercury and further informed that as of 2020 the products won’t be allowed for import. Moreover, the Inspectorate General is set to expand its environmental staff from 8 to 21 (as projected).  

Nikitovic: Some ask for fake receipts

The Ekomedika Ltd. and The Hemosan (in the port city of Bar) take care of most of the hazardous waste. The government issued The Ekomedika and OMPeco consortium 15 year licence in 2011 for treatment of sharps and infectious medical waste. The MANS (Nongovernmental Affirmation Network) objected to the monopoly for violation of tender protocol and law. Nevertheless the public prosecution office replied that “there were no reasonable basis for prosecution“.

Neither Montenegro nor any of the former Yugoslavia countries has any facility to treat pharmaceutical, chemical (mercury) and nuclear waste. The Hemosan sends the waste mostly to Austria. In the last three years the company has shipped some 100 tonnes of pharmaceutical and 38 tonnes of chemical waste. The Hemosan manager Zoran Nikitovic warns that any medication can be hazardous saying that “the authorities must warn the providers to take care of the leftovers as the price of medication includes its subsequent disposal costs“. He adds that it wouldn’t pay out to construct a treatment facility in Montenegro since “we are a small country... only the filters in the incinerator plant in Vienna cost up to 15 million €“.  

Nikitovic admits that some requested fake receipts even though it was trashed somewhere else. He wouldn’t tell who made such requests. He ended that he would never do it. He further said that the money paid by the government for the waste handling is “close to peanuts“ and that such arrangements in other countries would have been paid in millions.

“Montefarm has no large stockpiles- we are talking about several tonnes and that whole thing is worth 20,000€” he said.

Treatment centres for infectious and sharps waste are founded in Podgorica and Berane. For now there are no plans for expansion as the collection process is bellow the mark.

The Ekomedika collected and treated 416.5 tonnes in 2017. The contract authorises collection, transport, treatment and sterilisation after which the waste can be ranked to a mixed municipal waste which ends up on a sanitary landfill. The consortium is paid 1.85€/kg within the annual cap of 654 tonnes.

There are reasonable basis to investigate environmental crime

The Ozon Environmental Movement conducted morphological analyses in 4 municipal dumps around the country. Medical waste was frequently found in each location in 4 subsequent surveys. The Ozon manager Aleksandar Perovic said in the interview for CIN-CG that the law prohibits the mixing of communal and other wastes and the new lump turns into something hazardous. “To make things worse, there are no accurate data of the generated waste on the national level. That breeds suspicion in various illicit activities and corruption. Hence there are basis to investigate into environmental organised crime“ he points out. Furthermore, other countries in the neighbourhood have similar problems, and “unfortunately, it seems that medical waste management is shrouded with certain secrecy everywhere around. Transparency is something pivotal in this line of work“ he says. He reminds that it’s not uncommon in Montenegro to dump expired medications in burning waste containers. That speaks enough about ignorance and the danger it can cause. “Someone would expect the authorities to get more serious about this and the ordinary people to learn and act. However, all responsibility is on the contractors who are unable to deal with this issue as they should“ concluded Perovic.  

EU: No progress

As Chapter 27 of the EU accession talks is recently opened, the medical waste disposal is considered one of the biggest environmental issues. The European Commission does not mention the medical waste per se in its reports but it states that the waste handling legislature is somewhat in line with the EU and that “no progress has been made“ and that “serious efforts“ are expected in terms of national plan and strategy. Furthermore, local governments should resolve the problem of temporary waste dumps.  

Mercury, lead, arsenic…

Infectious waste includes accessories from microbiological labs, equipment and tools used to collect blood and other liquids.

Chemical waste contains toxic and hazardous chemical solutions. Furthermore the materials with high concentrations of heavy metals are included in the chemical waste, like mercury from broken medical gear, cadmium from batteries, lead, arsenic etc

Sharps waste mainly refers to contaminated needles, lancetas, nozzles and scalpels.

Cytotoxic waste is generated after the use of pharmaceutical products and accessories.

Pharmaceutical waste is generated from all medications including the packaging systems which are sent out of stock either because of expiration dates or improper safeguarding.

Whither the body parts

“Medical waste records are not on the satisfactory level while there is no adequate storage for some six tonnes of pathoanatomic waste“- is reported in the National Action Plan for 2018. Pathoanatomic waste includes body parts, amputations, tissues and organs removed in surgical procedures, placentas...

The government points out that 400 tonnes of treated medical waste refers only to public health institutions while the private sector, pharmacies and nursing homes are not counted in. Moreover the authorities announce waste handling instruction forms and further coaching (which may include recycling operations) in order to improve the situation and respect the critics.

Maja BORICIC