BADME.

DICINE
THE AUSTRIAN MEDICALWASTE PROJECT IN
THE PHILIPPINES

(A CASE OF TOXIC TECHNOLOGY TRANSFER)

June 2002
 Executive Summary

"I think the economic logic behind dumping a load of toxic waste in the lowest wage country
is impeccable and we should face up to the fact that ... countries such as Africa are vastly
under-polluted."
-from a leaked internal memo of Lawrence Summers in 1991 when he was then Chief
Economist for the World Bank.

In November 1996, the Philippinegovernment negotiated for the purchase of a number of

Liechtenstein/German-made medical waste incinerators from an Austrian technology vendor.
The purchase was funded through an ATS 200,000,000 (500,000,000 PHP) loan
underwritten by Bank Austria AG, one of Austria's biggest banks, and facilitated by the
Austrian Embassy in Manila. The Project, which was initiated by the Department of Health
during the Ramos administration, involved the purchase of medical waste incinerators and
disinfection units for 26 Department of Health-hospitals all over the country.

This report documents the findings of a four-month research (March to June 2002)
conducted by Greenpeace on the Austrian MedicalWaste Project in the Philippines.

The Austrian MedicalWaste Project, which was intended to provide assistance to Philippine
hospitals in the area of medical waste management, is turning out to be an environmental
nightmare as well as a mounting financial liabilityfor the Philippinegovernment. The report
proves that from the moment of conceptualisation to actual implementation, the Projecr has
been attended with glaring irregularities.

When the technology vendors, Vamed and Hoval presented their incinerators to Philippine
authorities, they made it appear they were modem and state-of-the-art units -- ''fully
compliant with the most stringent European legislation'~ Makingdishonest claims to a buyer
whichthe vendors knew did not have the capacityto validatetheir variousclaimsregarding
the supposed safety, efficiency,and pollution control features of their product is practicallya
case of brazen trickery and deception. Inspection and review of the actual incinerators
installed in the recipient hospitals reveal that they are in fact obsolete technology with a
design dating back to the 1950's, with no pollution control devices nor additional features
which improve equipment efficiency and enhance occupational safety. Without any means
to control and address pollutantsof concern,these Austrianincineratorsare definitesources
of toxic air emissions,whichthreaten both publicand environmentalhealth. These same
incineratorswould never be allowedto operate in Austria or in any other country where
stringent regulationsagainst pollutionsources are enforced. Taken in this context, the
Projectis a classiccase of toxictrade or dirtytechnologytransfer involvingthe dumpingof
obsoleteand pollutingtechnologyfroma richto a poorcountry.
It shouldalso be pointedout that BankAustriawhoseloanto the Philippinegovernment
made the Project possible,owns 10% of the shares of the company,which providedthe
technologyfor the Project.The fact that the bank financeda project involvinga company

1From this point onward, the Austrian Medical Waste Project will be referred to in this report as the
Project.

Exea.d:iveSummary
where it owns 10% of the shares raises some ethical questions and possible conflict of
interests. For example, it is not too far fetched to assume that Bank Austria would be
interested in facilitating the sale of Vamed products and technologies or maybe even help
the company in getting rid of its liabilities like obsolete incinerator equipment from units
dismantled elsewhere. Not only would this deal help raise the financial stock of a company
where the bank owns a significant amount of shares, it would also generate earnings for
Bank Austria from interests associated with the debt payments.

Bankrolled by a soft loan, the Project was packaged as a form of development assistance
facilitated by the Austrian Government, which also helped arrange visits to Austria for
Philippine officials during the Ramos Administration to inspect and see for themselves the
modern waste incinerator systems in Vienna. Vienna's incinerators are also often used as
positive case study examples by technology companies in Europe to sell incineration systems
to developing countries like the Philippines. When asked about the Project, the Austrian
Federal Ministryfor Foreign Affairsresponded by saying that the Project is a "contribution to
improving the sanitary situation in hospitals and to the overall development of the
Philippines."2. The Austrian government also vouches for the track record of Vamed which it
said "has been installing hospital waste incinerators in several countries, including the Asian
region (sic)" and that in the case of the Philippines,"the solution offered by Vamed, which
combines incineration and disinfectant devices, must have been the most efficient, safest
(underscoring ours), and comparatively cheapest."

The shameless defence of the Project on the part of the Austrian government flies in the
face of the obvious and potential damages to public and environmental health arising from
the operation of these obsolete incinerators. Knowing that the Austrian incinerators
transferred to the Philippines would never be allowed to operate in Austria itself makes this
case more compelling on account of the double standards employed by the Austrian
Government in defence of the project. Indeed, dumping polluting technologies in the name
of development assistance is comparable to the condemnable practice of dumping
hazardous waste in the guise of trade in poorer countries.

It also glosses over the fact that at the end of the day, local citizens would be shouldering
the costs involvedin the installation, operation and maintenance of these incinerators.

The Project exhibits the hallmarks of a rushed and negotiated deal where vital contractual
issues and technology concerns managed to escape scrutiny. The Department of
Environment and Natural Resources (DENR) for one, defaulted on its mandate when it
granted the Project an exemption from the Environmental Impact Assessment process. In
granting the EIA exemption for the incinerators, the DENR, through its Environmental
Management Bureau (EMB) questionably underestimated the matter of potential toxic
emissions and hazardous ash residues commonly associated with waste incineration, when
these, together with project siting concerns, should have been the dominant and overriding
basis for assessing the environmental acceptability of the Project.

Moreover, the EIA system would have allowed for some form of public participation and
verification to at least check the claims being made by the technology provider during the

2Letter by Austrian State Secretary Benita Ferrero-Waldner, Federal Ministry of Foreign Affairs to
MaritStinus-Remonde, President of Cebu EnvironmentalInitiatives for Development Center (CEIDEC)
dated 27 November 1998.

Executive Summary
time the Project was being negotiated. The Department of Science and Technology (DOST),
which should have been in a positionto reviewthe technologybeing proposed under the
Project,never figuredsignificantlyin the Projectpreparation.
Investigationsinto the actual operationof the Austrianincineratorsin selected government
hospitalsalso reveal gross omissionsin the area of worker safety and in the handlingof
hazardous residues from the incinerationprocess. Greenpeace research has found that
hospitalworkers in charge of operating, maintainingand cleaningthe incineratorshave not
been assigned the proper protectivegear and equipment. Directexposure of incinerator
workers and operators to toxic fumes and hazardouselements present in the ash residues
from the burning process has been documented as a common problem associated with
waste incineration. Moreover,the results of Greenpeace commissionedtests on the ash
residues coming from the Austrian incineratorsshow the presence of toxic metals (lead,
cadmium, chromium, mercury) at levels high enough for the ash to be classified as
hazardous waste in the UnitedStates. Whilehazardousash requires specialhandlingand
containment in specially lined hazardous waste landfills in the United States, in the
Philippinesthis ash is routinelycollectedby waste haulers and dumped indiscriminatelyin
open dumpsites.Some hospitalseven use the ash as a fillingmaterialfor use withinhospital
premises!
The PhilippineCleanAirActof 1999 mandates a ban on all types of waste incineration,and
prescribesa three-year period (fromthe date of effectivityof the Act)for the phase-out of
all existing medical waste incinerators. In the interim period, existing medical waste
incinerators are allowed to burn only pathologicaland infectious wastes. Greenpeace
investigations,however,show that hospitalsequipped with the Austrianincineratorshave
also been burning general unsegregated waste (e.g. cafeteria and office waste) in these
burners, in clear and blatant disregard of the law. This also indicatesthat the capacityof
the installedincineratorsexceeds the smallfractionof infectiouswaste normallygenerated
in hospitals(i.e. about 10% or less of a hospital'stotal waste stream), thereby providingthe
said hospitalswith an extra incentiveto burn their general waste in these incineratorsas
well.
Aside from its environmental impacts, debt repayments for the Austrian Medical Waste
Project represents an annually recurring financial drain for the country's health budget in the
next 12 years, or until 2015. Indeed it is ironic that the very budget intended to secure the
public's well-being is itself being used to fund the pollution of the environment with toxic
substances that pose long-term threats to the health of the people. This state of
schizophrenia is further amplified by the Health department's legislativeagenda to repeal the
incineration ban in the Clean Air Act or allow for an extension of the phase-out period for
existing medical waste incinerators. Instead of preparing for the phasing-in of non-
incineration alternatives for the treatment of infectious waste as prescribed by the Clean Air
Act, the DOHis campaigning to undermine the same national law. Bycontinuing to justify a
bad deal, the DOH lamentably negates its mandate of protecting and upholding public
health.

The controversial Austrian MedicalWaste Project is a sad commentary on the government's

capacity (or incapacity) to guard against bad business deals masquerading as development
projects. The DENRcannot playa significant role, even if it wanted to, for sheer lack of
expertise and technological capacity to effectively monitor the emissions from these

ExeaJtiveSummary
incinerators. It also highlights the failures and fallacies of end-of-pipe pollution measures
like incinerators to address waste problems.

An extension of the phase-out period for existing medical waste incinerators, including those
installed as part of the Project, beyond 2003 goes against the intent of the Clean Air Act.
The availability of appropriate, safe and cheaper non-burn alternatives for the treatment of
infectious medical waste should put to rest all arguments for incineration.Greenpeace
believes that the Philippine government has strong basis to call for the invalidation of the
Project, even at this stage, and therefore have the loan rescinded. The Project was
presented and approved on the strength of deceptive claims made by the technology
providers. Both the Philippine and Austrian governments need to acknowledgethis as a
case of dubiousand dirty technology transfer. Because of the key facilitating role it played
in the adoption of the Project, the Austrian government should now take the initiative of
instituting measures to correct this injustice committed to the Filipinopeople beginning with
moves to support the withdrawal of the Project loan.

Lastly, the report enumerates alternative technology options that may be considered for use
in the Philippines. The Austrian MedicalWaste Project deserves a long hard look because it
is currently the biggest obstacle to the adoption of safe, appropriate, non-burn strategies for
medical waste management in the Philippines.

ExeaJtiveSummary
 I. INTRODUCTION

One of the most alarming threats to human health and environment is the burning of
medical waste, a practice that results in the release of highly toxic pollutants and hazardous
residues threatening both public health and the environment. The Philippine CleanAir Act of
1999 expressly prohibits waste incineration and specifically calls for a 3-year phase-out
period for existing medical waste incinerators and limits their operation in the interim period
only to the burning of pathological and infectious waste. This mandated phase out of
medical waste incinerators under the Clean Air Act must be viewed as a push towards non-
incineration options as well as waste prevention, source segregation, resource recovery,
reuse and recycling.

The United States Environmental Protection Agency (US EPA) has identified incinerators at
medical facilities as the third largest known source of dioxin air emissions in the United
States. Further, the 2001 Stockholm Convention on Persistent Organic Pollutants (POPs) of
which the Philippines is a signatory, has likewise listed all kinds of waste incineration as
major sources of dioxins and furans, two of the twelve chemicals being targeted for eventual
elimination by the same Convention3. Dioxins are. generally regarded as the most toxic
substance known to science with no known safe level of exposure, triggering various health
impacts even at the most minutest of concentrations. Studies have shown that dioxin
causes cancer, affects immune system, causes birth defects, decreases fertility, sets off
reproductive dysfunction, and upsets a range of hormonal processes. The prevention of
further dioxin release into the environment is therefore of crucial importance.

This report will investigatethe controversialschemeinvolvingthe transfer of a numberof

incineratorsfor medical waste from Austria to the Philippines. It will also show that
incinerationis not the solution for managingmedicalwaste and that there are alternative
methodsfor decontaminatingthese infectedmaterials.

3 The other chemicalsbelongingto the initial list of twelvesubstancesbeingtargetedfor ultimate

elimination by the Stockholm Convention are aldrin, dieldrin, DDT, mirex, chlordane, endrin,
heptachlor, hexachlorobenzene,toxaphene, and polychlorinated biphenyls or PCBs.

Introduction 1
 A. Legal Framework: The Clean Air Act

The Philippines established an international precedent lauded by environmentalists

worldwide when it legislated a national ban on waste incineration for all kinds of waste
through the adoptionof the CleanAir Act (CAA)4 of 1999. Subsequently, the Philippine
government introduced the Ecological Solid Waste Management Act of 2000, which
mandates the implementation of front-end waste management strategies like source
separation, composting and recycling. Facilities with existing medical waste incinerators
were given a grace period of three years from the date of effectivity of the CAA5. In the
interim, the use of these units were limited only to the burning of pathological and infectious
wastes and subject to close monitoring by the Environmental Management Bureau (EMB) of
the Department of Environmental and Natural Resources(DENR). After the aforementioned
grace period, facilities that process or treat biomedical wastes are required to utilize
state-of-the-art, environmentally sound, safe, non-burn technologies.

B. GrowinG Global Resistance to Incineration

1. INCINERATION-BANS

The opposition to incineration is growing worldwide. The Philippines set a milestone by

being the first country in the world to put a ban on all types of waste incineration. In
February2002, the Argentinean capital of Buenos Aires banned the toxic menace of medical
waste incineration. Under the new law, medical waste from the city must be disposed of
using alternative, non-polluting technologies. In 2001, the Province of Ontario (Canada)
enacted a hazardous waste plan that includes the phase out of all medical waste incinerators
in hospitals. The largest, most populated, and most industrialized state in Germany, North
RhinejWestphalia, banned municipal solid waste incinerators in 1995. Although no formal
ban is in place, Ireland closed all of its medical waste incinerators in 1999.6 These are only
a few examples of the growing list of countries, states and provinces that have realized that
incineration creates more problems than it actually solves.

Aside from these restrictions against waste incineration, the overall number of medical waste
incinerators is gradually decreasing. An example of this is the United States whose use of
medical waste incinerators tremendously declined since 1988 (Chapter 1. B. 2.).

4 RepublicAct No. 8749: PhilippinesClean AirAct (CAA)of 13 May 1999; CAAsImplementing Rules
and Regulations (IRR) of 7 November 2000.
S Theoretically,
that three-yearphase-outperiodfor existingmedicalwaste incineratorsends in July
2002. However,the CAA'sImplementing Rules and Regulations (IRR) finalized in 2000, prescribes
that said incinerators should be phased out by 17 July 2003.
6 Multinational Resource Center (MRC) and Global Anti-Incinerator Alliance & Global Alliance for
Incinerator Alternatives (GAIA),Upcoming report, Waste Incineration: A Dying Technology, (when
released, the report will be posted on the GAIAwebsite: www.no-burn.org). 2002.

Introduction 2
 2. DECUNE IN MEDICAL WASTE INQNERATORS IN THE UNITED STATES'

Agure 1. Number of medical waste incinerators in the u.s. (1988-2000)

S
tn
8,000
6,200
as f
- -0 6,000
~
~ t!CD 4,000
.-
~
CD
C
.-
:iE
o
-g 2,000
=It o
1988 1994 1996 2002
Year

The chart above shows the decline in medical waste incinerators in use in the United States.
The first two figures are based on earlier estimates; the last two figures are based on
surveys. The number of medical waste incinerators has dropped from 6,200 in 1988 to 764
in 2002 and the total number of incinerators has declined even further since 2002. The US
EPAhas consistently identified medical waste incinerators as a major source of pollutants,
particularly dioxins and mercury. Since hospital incinerators were usually situated in highly
populated areas, the US EPApromulgated stricter and higher emissions standards and other
requirements (annual testing, training and certification of incinerator operators, record-
keeping, inspections, etc.) in 1997. States were given a few years to come up with
implementing rules that were as strict or stricter than the US EPAlimits. Even when the US
EPAregulations were still in draft form and under review, and during the period when States
were still coming up with implementing rules, many hospitals already realized that it would
be too expensive for them to install the pollution control devices needed to meet the new
limits. For this reason, many hospitals decided to close down their incinerators and started
shifting to alternative methods.

It is also significant to note that since June 1996, only four new medical waste incinerators
have been constructed in the United States and one of those four has since closed down.
This figure is much lower than the original United States Environmental Protection Agency
(US EPA) projection of 700 new incinerators that were expected to have been built from.
1995 to 2000 based on past trends.

7 US EPA, Hospital Waste Combustion Study-Data Gathering Phase, December 1988; US EPA, Medical
Waste Incinerators-Background Information for Proposed Standards and Guidelines: Industry Profile
Report for New and Existing Facilities, July 1994; US EPA, Standards of Performance for New
Stationary Sources and Emission Guidelines for Existing Sources: Medical Waste Indnerators, January
1996; US EPA, EPA Report to the Commission for Environmental Cooperation (CEC), November 2000.

Introduction 3
 II. THE PROBLEMS WITH MEDICAL WASTE INCINERATION

A. Air emissions: Leadina source of dioxins & mercury

Infection is essentially a biological problem, which disinfection systems seek to neutralize by

killing the pathogens present in the host material. While burning appears to be an effective
method for killing disease-carrying microorganisms present in infectious waste, the fact that
it also destroys the materials on which the pathogens are sitting on makes it an overkill of a
solution that could lead to more serious problems. Hospital waste contains a lot of
chlorinated plastics like polyvinylchloride (PVC) used in product packaging and in many
disposable medical products. When materials containing chlorine are incinerated, a host of
extremely toxic fumes and pollutants such as dioxins and furans are created. Thus,
incineration converts the simple biological problem of infection into a complex and
life-threatening chemical problem that is costly to manage and difficult to contain.

"The credo, first, do no harm, found in some translationsof the Hippocraticoath, is an

essentialgUideto behaviorin healthcare."sIncineratingmedicalwastecontradictsthis basic
principle of healthcare. In many places,incineratorshave been identified as the most
significant source of dioxin emissionsinto the air. For example, in 1994, the US EPA
identified medical and municipalwaste incineratorsas the largest sourcesof dioxin air
emissions,responsiblefor about84% of the total dioxinair emissionsin the UnitedStates.9

DIOXINS AND FURANSare unwanted byproducts of industrial processes such as incineration.

They are very stable and once emitted into the environment, their longevity allows them to
be transported vast distances along air and ocean currents so they are widely dispersed in
the environment. They are fat soluble, which allow them to accumulate in the bodies of
living things. Their bioaccumulative characteristic causes these chemicals to become more
concentrated as they move up the food chain. Humans are exposed to dioxins almost
exclusively through the food they eat, especially meat, fish and dairy products. And these
chemicals generally have a high chronic toxicity (meaning that they can cause long-term
health effects after exposure to extremely low doses), which can express itself in a variety of
dysfunctions.

Onsite medical waste incinerators are typically small and inefficient. Because of their size,
they tend to burn waste in several batches, increasing the number of start-up and cool down
periods during which dioxin formation is greatest.

Aside from dioxins, another contaminant of concern from medical incinerators is mercury.
Mercury is released from medical waste burners when mercury containing materials like
broken thermometers and other hospital equipment are burned.

In addition to dioxins, furans, and mercury, medical waste incinerators also release into the
air large amounts of other air pollutants such as lead, arsenic, cadmium, particulate matter,
acid-forming gases, and carbon monoxide; see Table 1.

8 Health Care Without Harm, The Campaignerfor environmentally responsible health care.
9 US EPA,Draft Dioxin Reassessment,Part I, Volume II, Chapter 1, p. 18.

The problems with medical waste incineration 4

Table 1. Pollutants from Medical Waste Incinerators
POLLUTANT EXAMPLES / NOTES
Dioxins and furans 2,3,7,8-tetrachloroclibenzo-p-dioxin (TCDD)
Other organic compounds benzene, carbon tetrachloride, chlorophenols,
trichloroethylene, toluene, xylenes, trichloro-
trifluoroethane, polycyclic aromatic
hydrocarbons, vinyl chloride
Heavy metals arsenic, cadmium, chromium, copper,
mercury, manganese, nickel, lead
Acid gases hydrogen chloride, hydrogen fluoride, sulfur
dioxides, nitrogen oxides
Carbon monoxide a common product of incomplete combustion
Pathogens (found in the residues and exhaust of
incinerators operating in conditions of poor
combustion
Particulate matter fly ash

B. Incinerators are exoensive

Aside from their environmental problems, incinerators are extremely expensive to install and
run. Annual operating budgets are high and the cost of the proper disposal of toxic ash
must also be taken into consideration. Ash produced by incineration is often considered
hazardous waste in industrialized countries requiring careful containment and disposal in
specially designated landfills for hazardous waste.

Incinerator proponents normally promote and market their technologies using the tags
"modem" and/or "state-of-the-art'~ For that matter, no incinerator salesman would admit to
selling obsolete or dated technologies. While state-of-the-art incinerators with expensive
pollution control equipment exist, the costs of operating, maintaining and monitoring them
are prohibitively expensive, particularly for developing countries.

Moreover, advances in one country do not always mean other countries will have accessto
the same technology. The differences in the regulatory capacity and infrastructure between
industrialized and industrializing countries could lead to the application of double and
misleading standards on the part of incinerator proponents. Since developing countries
more often than not, lack the technical capacity to check claims made by technology
promoters about the performance and safety of their products, this frequently results in the
uncritical acceptance and endorsement of questionable technologies.

Monitoring incinerators for emissions of concern, such as dioxins and furans, is a constant
challenge faced by incinerator operators and regulators worldwide. There is currently no
technology that can monitor dioxin emissions from an incinerator on a continuous basis.
Tests to measure dioxins and furans from incinerators in so-called trial burns are also very
expensive, making this almost an impossible task for regulatory agencies in the developing
countries. In the Philippines, for example, the Department of Environment and Natural
Resources has admitted that it does not have the financial or the technical capacity to
monitor facilities for these problematic emissions. In the absence of an effective regulatory

The problems with medical waste incineration 5

and monitoring infrastructure, it is not difficult to guess what kind of protection the public
can expect against the health and environmental threats coming from these incinerators.

c. Ash hazards

Fly ash, or ash that is carried by the air and exhaust gases up the incinerator stack, contains
heavy metals, dioxins, furans, and other toxic chemicals that condense on the surface of the
ash. Even when the fly ash is removed from the exhaust stream by pollution control devices
like baghouse filters, the toxic materials remain concentrated in the filter cake. Bottom ash,
or ash remaining at the bottom of an incinerator after burndown, can be extremely toxic
containing concentrated amounts of heavy metals that may leach out, as well as dioxins and
furans.

The better the pollution-trappingdevicein an incinerator,the moretoxicthe ash. Indeed, a

hundred times more dioxin may leave an incinerationfacilityin ash, than from the air
emissions.

Disposalof toxic ash in an environmentallysound manner is problematicand expensive.

Even if handled properly,ash makes incinerationprohibitivelyexpensive for all but the
wealthiest communities. If handled improperly,it poses short- and long-term health and
environmentaldangers. Buryingthis ash in a landfillequippedwitha plasticlinerto prevent
leachingintogroundwateris not a solutioneither because all landfilllinerseventuallyleak.
Researchhas also shownthat pathogenscouldbe releasedin the stack and/or ash residueif
incineratorsare not operated under good combustionconditions.1o
Table 2 below shows that significant portions of the dioxin found in incinerators can be
found in the residue, or slag. The table also shows that cake or ash in the fabric filter is
hazardous because almost 3/4of the dioxin remains in the ashes caught by the filter.

Table2. Dioxin in a Full-ScaleIncinerator!

OUTPUT %
Slag 22
Boilerash 3.3
Fabric filter ash 72.1
Sludge 1.9
Stack gas 1.3

D. Health imDacts

The emissions from incinerators have serious adverse consequences on worker safety, public
health, and the environment. Dioxins at very low concentrations, for example, have been
linked to cancer, immune system disorders, diabetes, birth defects, and other health effects.

l°Barbeito M. and Shapiro M., Joumal of Medical Primatology, 6:264-273,1977; S. Klafka and M.
Tierney, Proceedings: National Workshops on Hospital Waste Incineration and Hospital Sterilization,
EPA-450j4-89-002, U.S. Environmental Protection Agency, January 1989.
11 Giuglianoet al., Chemosphere43,743 (2001).

The problems with medical waste incineration 6

On May23rd of 2002,the U.S. Environmental Protection Agency released the Toxic Release
Inventory (TRI) informationfor 2000. "ACcordingto the EPA,the average adult already has
enough dioxin in their bodies today to cause adverse health effects - one more gram of the
most toxic form of dioxin released into the environment and into our food supply is too
much. There is no margin of safety for exposures to dioxin."... "Dioxin is one of the most
toxic chemicals known. One gram of dioxin is enough to exceed the acceptable daily intake
(set by the World Health Organization or WHO) for between 10 to 40 million people for one
year. The EPA reported that 99,814 grams of dioxin were released in the U.S. into the
environment. The data released by the EPA is only a fraction of the dioxin that is being
released into the environment every day."... ''TRI does not include a number of dioxin
sources, including the three largest sources: municipal waste incineration, backyard bum
barrels and medical waste incineration.,,12

Mercurv is associated with nervous system disorders affecting developing foetuses and small
children in particular. Leadat low concentrationscan causeanemia and reducedIQ in
children. Chronic exposure to cadmium has been associated with progressive lung diseases,
heart disease, anemia, and other health problems, including lung cancer. Chronic exposure
to carbon monoxide at low concentrations may aggravate heart conditions. Acid cases react
in the atmosphere to form acid rain contributing to the environmental degradation of forests,
lakes, and streams. Hvdroaen chloride. which is formed when chlorinated plastics
commonly found in medical waste are incinerated, readily forms hydrochloric acid in contact
with moisture and is corrosive and toxic to plants.

Many studies done on the emissions from incinerators show adverse impacts on human
health. A summary of epidemiological studies from 1988 to 1998, showing serious health
effects among waste incineration workers and community residents living near incinerators,
is presented in Table 3 in chronological order. The epidemiological studies show significant
associations between exposure to incinerator emissions and lung cancer, laryngeal cancer,
ischemic heart disease, urinary mutagens and promutagens, as well as elevated blood levels
of various toxic organic compounds and heavy metals.

12 Green Delaware, Media release Green Delaware, Global Anti-Incinerator Alliance and Global Alliance
for Incinerator Alternatives mailing list, May24,2002.

The problems with medical waste incineration 7

Table 3. Summary of Epidemiological Studies on Adverse Health Effects Associated with Incineration
STUDY SUBJECTS
Residents from 7 to 64
years old livingwithin 5
km of an incinerator and
the incinerator workers
Residents livingwithin 10
km of an incinerator,
refinery, and waste
disposal site
532 males working at two
incinerators from 1962-
1992
Residents livingaround an
incinerator and other
pollutionsources
People livingwithin 7.5
km of 72 incinerators
10 workers at an old
incinerator, 11 workers at
a new incinerator
122 workers at an
industrial incinerator
53 incinerator workers
37 workers at four
incinerator facilities
56 workers at three
incinerators
86 incinerator workers
104 workers at seven
incinerator facilities
176 incinerator workers
employed for more than a
year from 1920-1985
Residents exposed to an
incinerator
The problems with medical waste incineration
CONCLUSIONSREGARDINGADVERSE REFERENCE
HEALTHEFFECTS
Levelsof mercury in hair increased with P. Kurttioet al., Arch.
closer proximityto the incinerator during a Environ. Health, 48, 243-
10 year period 245 (1998).
Significantincrease in laryngeal cancer in P. Michelozziet al.,
men livingwith closer proximityto the Occup. Environ. Med., 55,
incinerator and other pollutionsources 611-615 (1998).
Significantlyhigher gastric cancer mortality E. Rapitiet al., Am. J. Ind.
Medicine,31, 659-661
(1997).
Significantincrease in lung cancer related A. Biggeriet aJ. Environ.
specificallyto the incinerator Health Perspect, 104,
750-754 (1996),
Risksof all cancers and specificallyof P. Elliottet al., Br. J.
stomach, colorectal, liver, and lung cancer Cancer, 73, 702-710
increased with closer proximityto (1996).
incinerators
Significantlyhigher blood levels of dioxins A. Schecter et aJ., Occup.
and furans among workers at the old Environ. Medicine, 52,
incinerator 385-387 (1995).
Higher levels of toluene, lead and cadmium R. Wrbitzkyet al., Int
in the blood, and higher levels of Arch. Occup. Environ.
tetrachlorophenols and arsenic in urine Health, 68, 13-21 (1995).
amona incinerator workers
Significantlyhigher blood and urine levels J. Angerer et al., Int
of hexachlorobenzene, 2,4/2,5- Arch. Occup. Environ.
dichlorophenols, 2,4,5-trichlorophenols, and Health, 64, 266-273
hydroxYpyrene (1992).
Significantlyhigher prevalence of urinary X.F. Ma et al., 1. Toxicol
mutagen/promutagen levels Environ. Health, 37, 483-
494 (1992),
Significantlyhigher levels of lead and R. Malkinet aI., Environ.
erythrocyte protoporphyrin in the blood Res., 59,265-270 (1992).
Highprevalence of hypertension and E.A.Bresnitz et aI., Am. J.
related proteinuria Ind. Medicine,22, 363-
378 (1992).
Significantlyhigher prevalence of urinary J.M. Scarlett et aI., J.
mutagen and promutagen levels Toxicol Environ. Health,
31, 11-27 (1990).
Excessive deaths from lung cancer and P. Gustavsson, Am. J. Ind.
ischemic heart disease among workers Medicine, 15, 129-137
employed for at least 1 year; significant (1989).
increase in deaths from ischemic heart
disease among workers employed for more
than 30 years or followed up for more than
40 years
Reproductive effect: frequency of twinning O.L. Uoyd et aI., Br. J.
increased in areas at most risk from Ind. Medicine, 45, 556-
incinerator emissions 560 (1988).
8
 III. MEDICAL WASTE PROBLEMS IN THE PHILIPPINES

A. Lawsand reaulations

The following lawsand regulationshavebeenidentifiedas pertinentto the managementof

healthcarewastesin the Philippines.

. Presidential Decree (P.O.) No. 1151- Philippine Environmental Policy

Section 4. Environmental Impact Statements.
. P.O. No. 1152 - Philippine Environment Code, covers waste management and
methods for solid and liquid waste disposal.
. P.O. No. 856 - Code on Sanitation of the Philippines, deals with refuse disposal,
nuisances and offensive trades and occupations, and disposal of dead persons.
. P.O. No. 600 - Prevention and Control of Marine Pollution, addressesdeposition of
refuse in navigable water and prohibits against discharge of oil and other harmful
substances.
. RepublicAct (R.A.)No.3931- knownasthe PollutionControllaw.
. Common Wealth Act 383 - provides for penalties for disposing of refuse, wastewater
and other materials into rivers.
. P.O. No. 825 - provides penalties for improper disposal of garbage and for other
purposes.
. R.A. No. 6969 - an act to control Toxic Substancesand Hazardousand Nuclear
Wastes, covers management of all unregulated chemical substances.
. R.A. No. 8749 - an act providing for a comprehensive air pollution control policy and
for other purposes (Clean Air Act).
. R.A. No. 9003 - an act providing for an ecological solid waste management program
and for other purposes (Solid Waste ManagementAct).

At the regional level, the management of hospital wastes is governed by the Metro Manila
Council's Ordinance No. 16, S. 1991, which was later amended by Metro Manila
Development Authority (MMDA) Regulation No. 98-008." 13

B. Waste Cateaories

The Environmental Health Service of the Department of Health drew up a Manual on

Hospital Waste Management in 1992 which classifies waste coming from hospitals into eight
main categories:14

1. General waste includes domestic-type waste, packaging materials,

non-infectious animal bedding, wastewater from laundries and other
substances that do not pose a special handling problem or hazard to
human health or the environment. General waste can be divided into

13 DiazLuis,Dr. consultantof the WorldHealthOrganization(WHO),in coordinationwith the

Technical Working Group (TWG) on Hospital Waste Management and the Department of Health
(DOH), Evaluation and recommendation report on hospital waste disposal practices in the Philippines,
February 2001.
14 Department of Health, Manual on Hospital Waste Management, Manila, 1992.

Medical waste problems in the Philippines 9

 wet (ex. kitchen and canteen waste), and leftover foods and dry waste
(ex. packaging and other debris).

2. Pathological waste consists of tissues, organs, body parts from

surgical operations, biopsies and autopsies, human foetuses and
animal carcasses; and most blood and body fluids.

3. Radioactive waste is generated from nuclear medicine sections,

diagnostic and therapeutic procedures and the paraphernalia used.
This is in the form of solid, liquid and gas contaminated with
radionuclides.

4. Chemical waste comprises discarded solid, liquid and gaseous

chemicals,for example from diagnosticand experimentalwork, and
cleaning, housekeepingand disinfectingprocedures. Chemicalwaste
may be hazardousor non-hazardous.

5. (Potentially) infectious waste are cultures and stocksof infectious

agents from laboratorywork, waste from surgery and autopsies on
patients with infectious diseases, waste from infected patients in
isolationwards, materials such as cotton swabs, tubing and filters,
disposabletowels,gownsand aprons, glovesand laboratorycoats.

6. Sharps include needles, syringes, scalpels, saws, blades, broken glass,

nails, and other items that can cut or puncture.

7. Pharmaceutical waste includes pharmaceutical products, drugs and

chemicals that have been returned from wards, have been spilled, are
outdated or contaminated, or are to be discarded because they are no
longer required.

8. Pressurized Containers include those used for demonstration or

instructionaland other purposes, containinginnocuousor inert gas,
and aerosol cans that may explode if incinerated or accidentally
punctured.

The MMDA'sregulation requires that the different types of waste have to be collected in
color-coded waste bags, bins, or cans to distinguish them from each other for safety reasons
and uniformity.IS

. Blackfor non-infectious dry waste, or non-biodegradablejnon-compostable waste.

. Green for non-infectious wet waste or biodegradablejcompostable waste.
. Yellow for (potentially) infectious and pathological waste, and sharps that have to be
contained in puncture-proof container covered with a thick solution of lime. (Yellow
with black band for chemical waste).
. Orange with trefoil sign for radioactive waste.

15 Metro ManilaOrdinance No. 16, series of 1991, amended by Metro ManilaDevelopment Authority
(MMDA)Regulation No. 98-008 - Regulating the management, collection and disposal of hospital
waste and those of similar institutions in Metropolitan Manila.

Medicalwaste problems in the Philippines 10

 . Red16for sharps and pressurized containers.

C. How much medical waste is Droduced?

Accordingto a February2001 report commissionedby the Departmentof Healthto evaluate

current waste disposal practices of health care facilities in Metro Manila,the MMDA
estimates that as of June 2002 there are approximately3,730 health care facilitiesin the
metropolis (of which 1,509 are hospitals and clinics).17 These facilities generate an
estimated total of 60 tons of waste each day out of which 9 tons could be considered
infectious.

In 1997, the Department of Health citing a study conducted by the Japanese International
Cooperation Agency (JICA) said that as of March 1997, there were 1,700 hospitals
nationwide, 1,111 of which are private and 589 government controlled. 18 These 1,700
hospitals in the country generate about 6 tons of infectious waste daily and health centers
and stations generate another 1.4 tons/day. Out of the 7.4 tons generated per day, 50%
goes to medical waste incinerators while the other half are disposed of by other means.

Records from the National Solid Waste Management Committee (NSWMC)show that there
are 42 existing hospital waste incinerators in the country, 25 of which are operating within
the premises of government-run hospitals. 19

D. Current waste manaGement Dractices

According to the DOH Manual on Hospital Waste Management, trash in black and green
bags may be disposed of through city and municipal collection and disposal systems while
yellow trash bags should be disposed of through the hospital's incineration system.

In 1996, the Health Operations Center of the Metro Manila Development Authority found
during its inspections that 40 hospitals were violating waste disposal regulations, specifically
MMDAOrdinanceNo. 16 whichrequires hospitalsand other medicalinstitutionsto use four
color-coded trash bags to dispose of their wastes. Hospitals with no incinerators were found
putting their infectious waste in the black and green bags to avoid the trouble of sending
and paying for the disposal of their waste at the Integrated Waste Management medical
waste incinerator in Calamba, Laguna.

16 Red is an additional color-code of the DOH Manual on Hospital Waste Management (not in MMO
No.16).
17 Report done by World Health Organization (WHO)-consultant, Dr. Luis Diaz, in coordination with
the Technical WorkingGroup on Hospital Waste Management and the Department of Health,
February 2001.
18 Slideshow presentation on Health Care Waste Management, A vital component of environmental

health protection, Department of Health, Philippines (Source for data in the slideshow: 1997 MMDA-
Japan International Cooperation Agency (JICA) study report).
19 Junilyn Silvestre, Philippine Hospital Waste Management Situationer, Greenpeace Southeast Asia.

Medicalwaste problems in the Philippines 11

The recent DOHcommissioned report came up with the followingfindings:20

. Treatment and disposal: some hospitals pre-treat liquid and solid waste prior to
disposal using chemical disinfectants. Some hospitals (the majority of the visited
hospitals) use onsite incineration for the management of their infectious wastes and
others contract the services to private entities in Metro Manila. At present, there are
two types of privately owned plants providing disposal services to hospitals in Manila:
one incinerator and one microwave. The facilities charge approximately 40 Pesos
per kg of infectious waste collected and treated. In the case where onsite
incinerators are used, the ashes are typicallydisposed in pits dug within the premises
of the facility.
. The majority of the institutions visited have established a waste management
committee but the committee is not active and does not meet on a regular basis.
. Most of the institutions practice segregation and follow color-coding procedures for
the management of their wastes. However, according to those responsible for waste
management, some members of the staff are not conscientious about proper
segregation.
. Someof the institutionssell food residuesto pig growers. In addition,some of the
institutions practice recyclingand sell the recyclable materials.
. Some of the incinerators are old and lack any type of air pollution device.

20 Report done by World Health Organization (WHO)-consultant, Dr. Luis Diaz, in coordination with
the Technical WorkingGroup on Hospital Waste Management and the Department of Health,
February 2001.

Medicalwaste problems in the Philippines 12

 IV. DIRTY TECHNOLOGY TRANSFER

A. The" Austrian Proiect"

IN November 1996, the Philippine Government bought, through the Department of Health
(DOH) 26 medical waste incinerators from the Austrian corporation Vamed Engineering21.
Vamed, the technology provider, is a company that specializes in the implementation of
hospital infrastructure projects. The incinerators were part of a project, known as the
"Austrian Project - for the establishment of waste disposal facilities and upgrading of the
medical equipment standard in DOH-hospitals,,22,which also included disinfection units and
medical equipment. The Project was financed through a loan agreement (signed in March
31, 1997) concluded between Bank Austria AG and the Philippine Department of Finance.
The Austrian Embassy endorsed the agreement. The incinerators were installed in 26 of the
71 DOH-hospitalsin 1997-1998.23

Accordingto Vamed, the "overall goal of the Project is to increase the value of human capital
and quality of life by improving the access to quality health service in DOH-hospitals and
further to promote the Healthy Environmental Program for Better Ufe.,,24

B. Incinerators and disinfection units

The incineratorswere supplied by Vamedand manufactured by a company called Hoval.

There were two types of incinerators:22 of the 26 incineratorshave a capacity of 300
kg/day (referred to as CV1),the other 4 incineratorscan handle 500 kg/day(referred to as
CV2). Accordingto the plates on the incineratorsthey were manufactured in 1997 and
1998. The incineratorsdo not have pollutioncontroldevices;this importantfeature was not
specifiedin the contract.
However,the incinerators were presented and sold by the promoter as pollution-free
equipment"complyingfully with currentenvironmentalprotectionregulations,25as wellas
"the most stringent EmissionLegislationsin Europe(StandardRegulations)... and current
international Environmental Protection Regulations,26. Furthermore, the units were
described as having "exceedingly low dust emissions in comparison with conventional
incinerato,-st27, "a soot-free combustiorf,28, "a virtually ideal incineration... with smoke free

21 VamedEngineeringhereinafterreferredto as Vamed.
22 Vamed, Austrian Project offer, February 6, 1996.
23 Based on an interview with Eng. Rosemarie Tuason, Department of Health, Infrastructure and
Equipment Division.
24 Vamed Engineering, Austrian Project, February 1996.
25 Vamed Engineering, Austrian Project: Waste Management Component (Environmental Impact

Assessment), October 2, 1996,.

26 Gutierrez RicardoC. of the Philippineaffiliate of Vamed Engineering, Officialresponse to the
National Center for Health FacilityDevelopment's request for information,August 22, 2001.
27 Vamed Engineering, Austrian Project: WasteManagement Component (Environmental Impact
Assessment), October 2,1996.
28 Gutierrez RicardoC. of the Philippineaffiliate of Vamed Engineering, Officialresponse to the
National Center for Health FacilityDevelopment's request for information, August 22, 2001.

Dirtytechnology transfer 13
operation and uncontaminated gas emission, virtually independent of the waste
composition." 29

Aside from the 26 incinerators, 36 disinfection units, referred to as Medister 60 (14 units)
and Medister 160 (22 units), were also included in the Project. The disinfection units called
METEKAMedister 60 and 160 respectively are based on microwave technology. The
Medister 60 can treat about 80 kg of infectious waste in an 8-hour shift; the Medister 160
can disinfect 160 kg of waste per 8-hour shift.

The incinerators and disinfection units were distributed to different government hospitals
nationwide. Annex 2 contains a list of the recipient hospitals of the abovementioned Hoval
incinerators. Allthe hospitals that received such an incinerator also got a disinfection unit,
except for the Teofilo Sison Memorial Medical Center and the Hilarion Ramiro Memorial
Hospital.

C. Proiect Historv

The Departmentof Healthwas the initiatorof the Project. It was conceivedat the end of
1995 during whichtime "the Departmentof Healthwas drawinga lot of criticismfrom the
media and the publicregardingthe improperdisposal of hospitalwaste by DOH-retained
hospitalsin MetroManila. The Projectwas set up to address the problemof solidwaste
disposaland to minimizeor reduce the risks associated with the handlingof medicaland
infectiouswastes.,,30 Officialsof the Departmentof Health and the medical community
wanted an easy solution to the infectious waste problem and incinerationappeared to
providethat convenientway out.
The National Economic and Development Authority (NEDA)approved the Project proposal in
November 1996. It should be pointed out though that medical waste disposal was just one
of the components of the entire Project. The other major component was the provision of
various medical equipment for use in government hospitals. The loan agreement, which
made the Project possible, was endorsed by the Austrian embassy and was signed by the
PhilippineDepartment of Finance in March 1997.

The Presidential Task Force on Waste Management, then operating under the Department of
Environment and Natural Resources (DENR),gave the green light to the Project on the basis
of the emission data provided by Hoval. The DENRapproval for the Project also meant that
the emission data provided by Hoval complied with the DENRstandards. (Department
AdministrativeOrder No. 14: AirQuality Standards and Rules and Regulations).31

D. Terms of the deal

The contract contains a 12 month-warranty,which meant that Vamed is obligated to

maintainthe units for that period. Accordingto the contract, Vamedis responsiblefor the

29 Vamed Engineering, Austrian Project: Waste Management Component (Environmental Impact

Assessment), October 2,1996.
Vamed Engineering, Backgrounder for DOH Project: Supply of Waste Disposal Facilities and
30

Upgrading of Medical Equipment in DOH hospitals, August 22, 2001.

31 Ibid.

Dirtytechnology transfer 14
(pre-) installationof the incineratorsand for the provisionof trainings for staff that will
operate and maintain the incinerators. Bank Austria provided 100% financingfor the
Project,as a loanto be paidfor bythe Philippinegovernment.
The total cost of the Projectwas AustrianSchilling199,860,000ATSor about 503,647,200
PhilippinePeso (PHP)or more than half a billionpesos in 1996 (1 ATS=2.52PHP). Aside
from the costs of the various medicaland waste disposal equipment, this amount also
includedthe costs of freight, insurance, project management, training and maintenance.
The fact that the Projectwas financedby BankAustriain AustrianSchillingmeant that the
loan had to be paidfor by the Philippinegovernmentin the same currency.
Since the time the Project was approved, the value of the Philippine Peso versus the
Austrian Schilling and other stronger foreign currencies has dropped considerably. The
exchange rate at the time the contract was signed was 1 ATS = 2.52 PHp32,while the
current exchange rate as of July 2002 is 1 EUR= 47.55090 PHp33. This means that at
current rates, and with the Philippinegovernment paying for the loan using foreign currency
(now Euro), the government's debt for the Project would have increased by almost 200
MillionPesos.

Repayment of the loan starts five years after the signing of the credit agreemenf4, with an
interest rate of 4% per annum. The repayment has to be done in 24 equal, semi-annual
instalments. This means that the loan has to be paid off by 2015 (March 2014). Annex 4
contains a table of the contract prices for the Austria Project in ATS(EURor Euro) including
conversions to pesos. (Please refer to Annex 4)

The cost of the Waste Disposal Component of the Project is Austrian Schilling (ATS)
95,904,076 or 241.678 MillionPesos in 1996. Out of this amount, the total cost of just the
26 Hoval incinerators was pegged at 133,208,662 PHPin 1996. At current rates and by the
time the Philippinegovernment starts paying for the loan, the cost of the incinerators would
have already increased to 182,660,998 PHP.

E. The sUDDlier:Vamed

Vamed, the supplier, is a very well known company, which is based in Vienna, Austria. It
used to be state-owned before it was sold to Fresenius, a big German hospital builder and
operator. Vamed does "consulting, engineering, project development, contracting and
management of medical care projects'~.. "Vamed AG is one of the holdings of the Vamed-
Group'~ "Vamed AG shares are held by Fresenius AG (77 %), OIAG-Austrian,a STATE-
OWNEDIndustrialGroup(13%), and BankAustria(10 %) ,,35whichprovidedthe financing
for the Project. Bank Austria is one of the biggest banks of Austria. The fact that
the bank financed a project involving a company where it owns 100/0 of the
shares raises ethical questions and possible conflict of interests.

32 As of February 1996.
33 Since 2002, EUmember countries includingAustria have shifted to the use of the Euro.
1 ATS=0.07267 EUR
34 Since the credit agreement was signed in 1997, loan payments are expected to commence in 2002.
35 Vamed Engineering, website: www.vamed.co.at/vagruppe.htm.

Dirty technology transfer 15

 F. The incinerator manufacturer: Hoval

The official base of the Hoval group is in Vadez, Liechtenstein. They have offices in
Switzerland, Germany, Italy, France, England, Poland and Austria. Hoval sells heating
technology, steam boilers, waste disposal technology, high-level ventilation and heat
recovery technology. The incinerators they sell have "capacities ranging from 200kg/day up
to 10,000 kg/day'~36 The incinerators sold to the Philippineswere called MultiZon. Hoval's
representative in the Philippines, which is also exclusively authorized to do repairs on the
incinerators, is a Metro Manilabased company called Food Service Equipment.

G. Monitorina

Before the deal was closed, Vamed supplied a document to the Philippine government,
which stated that the emission values of its incinerators complied with Philippineemission
standards, and that those values were guaranteed by Hoval, the manufacturer. After the
contract was signed, Vamed conducted emission measurements at the East Avenue Medical
Center as part of the training sessions it conducted for the DOHin May1998. The results of
these tests showed that the incinerator's emission levels were in compliance with the local
DENRstandards.

However,their own test results showed carbon monoxide levels of 88 mg/m3 which
exceeded the upper limit of their guaranteed value of 50 mg/m3 as well as U.S. and
Europeanstandards. There were no tests conductedon the ash residues, only on the air
emissions and these were only limitedto parameters for carbon monoxide(CO), carbon
dioxide(C~), sulfurdioxide(502), oxygen(02) and nitrogendioxide(NOx).
And even in cases when emission testing was done for basic pollutants (e.g. sulfur dioxide,
nitrogen dioxide and carbon dioxide) specified in the Clean Air Act, the results showed that
the incinerator concerned failed basic standards for sulfur dioxide emissions37,belying claims
by Vamed/Hovalthat their burners conformed with European standards.

Furthermore, the government sponsored. test done by a company called GMSandoval, Inc
(GMSI)on the PhilippineOrthopedic Center incinerator was not even conducted at maximum
burning capacity or at representative operating conditions as generally required by
regulations (e.g., Compliance and Performance Testing section, Standards of Performance
for Hospital/Medical/Infectious Waste Incinerators, US EPA, 1997). The rated waste
capacity for the CV2 incinerator at PhilippineOrthopedic Center is 50-70 kg/hr and since at
least two loads are incinerated a day, with each load weighing 300 to 400 kg, according to
the hospital engineer, the incinerator operates around the maximum capacity. However, the
actual waste capacity during the GMSI tests was 20-30 kg/hr, well below the normal
operating conditions and the maximum capacity. If the tests were conducted using the
incinerators' maximum rated capacity or at representative operating conditions, the emission
results would have shown higher levels of sulfur dioxide and other pollutants.

36 Hoval,website: www.hoval.com.
37 The tests weredone by a companycalledGMSandoval,Inc. (GMSI)whichwas commissionedby
the DENRto do the measurements in October of 2001 on the incinerator installed at the Philippine
Orthopedic Center. The test results showed that the emission concentrations of Sulfur Dioxide(1,661
mg{Ncm)exceeded the standard set by the Clean AirAct [(DAO2000-81) 502 ExistingSources, Fuel
Burning Equipment: 1,500 mg{Ncm].

Dirty technology transfer 16

Except for these insufficient emission tests, no emissions monitoring has been done by the
government on the installed units on a regular basis.

The DENR does not have the equipment to test incinerators for emissions of concern,
particularly dioxins and furans. Even the equipment available for testing other emissions is
unsuitable for testing in medical waste incinerators because they are reportedly unable to
handle temperatures above 600°C8. Medical waste incinerators theoretically should operate
at a temperatureof 1000°C. Due to lack of monitoring capacityand unsuitabletesting
equipment, not to mention the high costs of sampling and analysis for problematic
emissions, the concerned Philippine government agencies have no way of counter-checking
the claims and data supplied by Vamed and Hoval regarding the environmental performance
of these waste burners.

38Based on interview with Engineer Carlos G. Bariring, National Center for Health Facility
Development, Department of Health, Infrastructure and Equipment Division.

Dirty technology transfer 17

 \I. FINDINGS
Greenpeace conducted investigations on the Austrian Project beginning March 2002, which
included interviews with key people from the Department of Health, hospital personnel, and
other government agencies concerned, on-site inspections of some of the installed Hoval
incinerators in seven selected government hospitals, and sampling and testing of ash
residues from some of these incinerators.

Site visits and interviews with concerned hospital staff were conducted at the following
hospitals. Hospitals located in Metro Manila were prioritized for practical purposes. Two
hospitals located in the Western Visayas region were also selected because they have been
the subject of community complaints in the past.

. East Avenue MedicalCenter (April 16, 2002);

. RizalMedicalCenter (April 19, 2002);
. PhilippineOrthopedic Center (April22, 2002);
. Research Institute for Tropical Medicine(April25, 2002);
. Batangas Regional Hospital (May3, 2002);
. Western Visayas Regional Hospital (May 6,2002);
. Western Visayas MedicalCenter (May 7, 2002).

The research uncovereda long list of environmentalviolations,scandalous practices and

complaintsabout the pollutioncomingfromthe subject incinerators.

A. Technical Findinas

1. HOVAL CV1 AND CV2 INCINERATORS ARE OBSOLETE TECHNOLOGIES

Some Philippine officials and hospital representatives have claimed that the Hoval
incinerators are state-of-the-art incinerators. The validity of this claim is evaluated in this
section.

a Basic Design
Incinerators are generally categorized according to the basic design of their treatment
chambers. Before the 1950s, incinerators were single-chamber oven-type units that are no
longer acceptable in many countries. Today, the three basic types of designs commonly
used for medical waste incinerators are: multiple chamber, controlled air, and rotary kiln.
Multiplechamber incinerators and controlled air incinerators were developed in the 1950s.
Rotary kiln incinerators were originallydesigned to destroy hazardous waste but began to be
used in the 1990s to treat medical waste.

The chamber design of the Hoval incinerator is of the controlled air type developed in the
1950s. The Hoval incinerator consists of the following:
. A primary chamber where medical waste is burned under starved air conditions.
. A ''thermo-reactor'' or "thermal reactor" where the gases are mixed with air and heated
to about 1000 0c.
. A standard chimney or stack for the exhaust gases.

Findings 18
Photo: Hoval incinerator - Western Visayas Medical Center (WVMC)

The primary chamberhas a start-up burner to

ignite the waste and maintain a minimum
temperature, a water-injection system to
decreasetemperature,and a blower to control
the amount of air in the primary chamber. The
thermo-reactoris merely a small section after
the primary chamberwith a reactorburner and
a louver-typedamperto providecombustionair.
Two sizes of incineratorswere providedto the
Philippines:model CV1with a capacityof 300
kg/dayand modelCV2with a capacityof 500 kg
per day. 39

Photo: Hoval incinerator - WVMC

In 1996, Carl R. Brunner, author of Incinerator

Systems Handbook and Medical Waste
Disposal, described this specific type of
controlled air design typified by the Hoval
incinerator as follows: Today with the medical
waste containing more varied materials many
of these older incineration systems can not
operate effectively they are generally unable
to meet state emissions requirements for new
incinerators.40

Further refinements to the early version of the

controlled air design were made in the 1960s.
There refinements were necessary because,
unlike medical waste in the 1950s, which were
mostly paper, cotton, and other cellulose-type
materials, medical waste became more varied
and included plastics of different kinds. The
refinements included a full secondary chamber of about the same size as the primary
chamber, instead of a small thermal reactor section. These design refinements are NOT
reflected in the Hoval designs sold to the Philippines.

39 Operating Manual, Setting Points 1, Plant Description, Description of Components, and other

documentation, Hoval, November 30, 1993.

40 C.R. Brunner, Medical Waste Disposa~la, Reston, Virginia,1996, page 8-14.

Findings 19
Thus, the Hoval incinerators are an obsolete technology with a basic design
dating back to the 1950s and representing the earliest version of controlled air
technology.

b Residence Time
An important designparameterfor incineratorsis the residencetime (also calledthe dwell
time or retention time). It is a measure of the time that off-gases are exposedto
combustiontemperaturesandturbulent mixingwith air. The residencetime generallyrefers
to the time in the secondarychamber(or in the case of the Hoval,the thermal reactor
section). The higher the residencetime, the greater the extent of destructionof organic
materialand of any microorganismsin the off-gasandthe lowerthe pollutantlevels.

As early as 1977, experiments with incinerators using biological test spores resulted in the
recommendation of a minimum residence time of 2 seconds to assume total destruction of
all pathogens.41 By the mid-1990s, however, most regulations required that the secondary
chamber temperature be maintained between 871 to 1093 °C and a residence time of at
least 1 second.42

In the research commissioned by the U.S. Environmental Protection Agency (US EPA) in
preparation for their medical waste incinerator regulations of 1997, the secondarychamber
residence time was identified as the single most important factor in combustion control for
achieving low emission levels. The studies noted that medical waste incinerator
manufacturers had focused on secondary chamber residence time as the key component of
their redesign efforts to meet emission limits. The Midwest Research Institute, which
conducted the study for US EPA,found that new incinerators built in the U.S. from around
1993 already had residence times of 2 seconds, while those built before that period were
designed with 1-second residence times.43 Basedon their studies, US EPAdetermined that
the cost of complying with their new incinerator regulations would include retrofitting the
secondary chamber of all incinerators to achieve a 2-second residence time in order to meet
the minimum requirements for good combustion.44

To summarize, studies as early as 1977 recommended a residence time of 2 seconds for

medical waste incinerators. By the 1990s, most regulations required a residence time of at
least 1 second. However, new incinerators built in the U.s. during the early 1990s were
already designed for a residence time of 2 seconds. Studies conducted in 1996 for the US
EPAcharacterized the minimum requirements for good combustion as a 2-second residence
time. Accordingto the technical specificationsunder Descriptionof Componentsin the

41 M. Barbeito and M. Shapiro, Microbiological Safety Evaluation of a Solid and Uquid Pathological
Incinerator, Journal of Medical Primatology, 6:264-273, 1977; Hospital Medical Waste Incinerator
Operation and Maintenance, U.S. Environmental Protection Agency, Office of Air Quality Planning and
Standards, March 1989.
42C.R. Brunner, loc. cit
43 Charles Hester, PM, CO, and CDD/CDF Average Emission Rates and Achievable Emission Levels for
Medical Waste Incinerators with Combustion Controls, memorandum to the U.S. Environmental
Protection Agency, Midwest Research Institute, Cary, North Carolina, May 20, 1996, page2.
BrianHardeeand KatieHanks,CostImpactsof RegulatoryOptionsfor Newand ExistingMedical
44
Waste Incinerators (MWI's), memorandum to the U.S. Environmental Protection Agency, Midwest
ResearchInstitute, Cary, North Carolina, May 20, 1996, pages 3-4.

Findings 20
Hovaldocuments, the Hovalincineratorshave a residencetime of only 0.5 seconds. This
meansthat the HovalincineratorsalsoCANNOTmeetthe currentEuropeanDirectiveon the
incinerationof medicalwastethat requiresa 2-secondresidencetime.

Thus, the Hoval incinerators fail to meet the minimum standard of a 1-second
residence time and obviously do not meet the higher standard of a 2-second
residence time found in new incinerators built since the early 19905.

c Air Pollution Control

Because medical waste incinerators emit a wide range of pollutants, which are harmful to
public health and the environment, incinerators require air pollution control devices to
reduce emission levels. The devices are added on to the incinerator before the exhaust gas
leaves the stack. Many types of pollution control equipment are used alone or in
combination, including wet or dry scrubbers with or without a neutralizing alkali (such as
lime or sodium hydroxide), fabric filters (baghouse filters), cyclone separators, electrostatic
precipitators, and other devices of varying levels of efficiency. Perhapsthe most common air
pollution control device is the wet scrubber, of which many kinds are in common use such as
venturi, packed-bed, spray tower, and impingement tray scrubbers.

A rapid quench system is also helpful to quickly reduce the temperature of the exhaust gas
below the temperature range at which dioxins and furans are formed. Dioxins and furans
are formed between 250 to 450°C. Hence, the formation of dioxins and furans generally
takes place in the post-combustion zone after the thermal reactor, that is, in the section
where the exhaust gas begins to cool. The section between the thermal reactor (or
secondary chamber) and the air pollution control device is where a quench section is added.

In preparing its regulations in 1996, the US EPAdetermined that in order for incinerators to
meet the regulatory emission limits, they would need at least wet scrubbers (typically
venturi scrubber/packed bed systems), dry injection/fabric filter systems (typically activated
carbon injection plus baghouse filter), or comparable air pollution control devices.45

Air pollution control devices to minimize pollutant emissions from incinerators are required
by regulations in many countries. Also the Metropolitan Manila Development Authority.
(MMDA) Ordinance No. 16 of 1991 (amended by MMO No. 98-008) regulating the
management, collection and disposalof hospital waste and those of similar institutions in
Metro Manila specifies that a hospital incinerator system has "to be provided with a smoke
or exhaust air scrubber'~ Airscrubbers are regarded as an essential part of an incinerator.
Hoval merely listedflue gas cleaningas "options"to remove "noxiousgases (HCI,SOx, HF
and so on), dust, aerosols and finest dusts, and dioxins." These cleaning devices were not
part of the incinerators installed in the Philippines. At a Hoval workshop/seminar
on May 25-
27, 1998, a participant asked what kind of scrubber should be selected for the incinerators.
The Hoval representativerespondedthat a wet scrubber with a quench system and a
neutralizingalkali or baseshouldbe used,or a dry baghousefilter usinga neutralizinglime
and a quench system. However, despite the fact that the Hoval representative

Brian Strong, Determination of Maximum Achievable Control Technology (HACT) Floor for New
45
Medical WasteIncinerators, memorandum to the U.S. Environmental Protection Agency, Midwest
ResearchInstitute,Cary,NorthCarolina,March20, 1996, pages 2-4.

Findings 21
recommended these air pollution control devices to minimize the release of toxic pollutants
from the stack, no such devices were supplied with the incinerators.

It must be mentioned that pollution control devices are the most expensive part of an
incinerator. For example the price of a (dry) flue gas cleaning system for a CV1incinerator
is about 150,000 USD(roughly equivalent to 7,500,000 PHP)while that for a CV2unit would
cost about 168,000 USD (roughly equivalent to 8,400,000 PHP). Note that the costs of
pollution control are even higher than the actual cost of each incinerator.
The Hoval incinerators have no air pollution control devices added on to the
incinerator.

d Stack Height
It is essential that an incineratorhas a tall stack or chimneyso that pollutantgases are
dilutedand dispersedin the atmospherethereby reducingtheir concentrations. Atall stack
also decreases the danger of toxic pollutants at high concentrations entering nearby
buildings or homes through windows, doors, and air intakes of ventilation and air
conditioningsystems. In order to accommodatetall stacks and the necessary add-on air
pollutioncontroldevices, modern incineratorstacks are generallymountedon a foundation
separate from the incineratorand supported by cables (guy wires) along the length of the
stack.

According to "good engineering practice" criteria, the height of a medical waste incinerator
stack should be 2.5 times higher than the height of nearby structures. In order to reduce
the concentration of pollutants, incinerator stacks can be over 30 meters high.46

Accordingto Hovaldocuments, the stack height of the CV2incinerator is a fixed 9.9 meters.
Among the incinerators installed in the Philippines, some of the incinerator stacks are barely
above nearby structures.

Several of the Hoval incinerators in the Philippines do not meet stack height
criteria necessary to reduce the concentrations of toxic pollutants on the ground.

e Additional Features
In addition to add-on air pollution control devices, other features can be found in
state-of-the-art incinerators. These includeautomatic charging system for semi-batch or
continuousoperation. Examplesincludehopper-ramor auger feeders withair locks. These
charging systems are designed to prevent surplus air from being drawn into the primary
chamberthereby minimizingextreme transient conditionsduringwhichexcess pollutantsare
generated. Some incinerators may have stoking systems to expose new surfaces and
promotecompletecombustion. Manyincineratorshave automaticash removalsystemswith
wet ash sumps designed so that air leakage into the incinerator is prevented. These
systems minimizethe risks associatedwith hot ash. Sincedry ash is easilyspread through
the air during manual ash removal,these systems also reduce the exposure of workers

46 C.R. Brunner, loe. eit, page 9-48.

Findings 22
airborne ash that may contain heavy metals, dioxins, furans and other toxic organic
compounds.

The Hoval incineratorsdo not have any of these additional features that. improve
the combustionprocessand enhanceoccupationalsafety.

f Conclusion
Based on this assessment, the Hoval CVl and CV2 incinerators in the Philippines
were not state-of-the-art incinerators at the time of their purchase in 1996.

2. HOVALINCINERATOREMISSIONS EXCEEDINTERNATIONALUMITS

Hoval claims that their incinerators are "environmentally acceptable" and guarantee a range
of emission values that their incinerators can meet. They claim their design complies with
the most stringent emission limits in Europe. They provide emission test results conducted
by Hoval and Vamed Engineering in May 1998 on the East Avenue MedicalCenter incinerator
as well as test results from incinerators in Austria conducted by TUV,a technical institute. In
this section, the emission characteristics of the Hoval incinerators are evaluated.

Annex 3 compares selected parameters from various test results provided by Hovaland
GMSIwith Philippine,U.S. and European standards. (In all cases, units have been
convertedto milligramsper cubic meter except for dioxinsand furans, whichare generally
reportedas nanogramsper cubicmeter; see also note below.)
Test results for incinerators in the Philippinesshow that some emissions exceed even Hoval's
guaranteed range of emissions for carbon monoxide and sulfur dioxide, and exceed
Philippine limits for sulfur dioxide. Hoval provided test results for hospitals in Austria; one
test result exceeds Hoval's guaranteed range for hydrogen chloride. When compared to US
EPA'semission limits for incinerators promulgated in 1997, the test results for incinerators in
the Philippinesand Austriaas wellas the upperlimitof Hoval's guaranteedrangeexceed
U.S. limits for particulate matter, carbon monoxide, sulfur dioxide, hydrogen chloride, and
dioxins and furans. When compared to the current, more stringent European Union
standards for incinerator emissions, the minimum value that Hoval can guarantee already
exceeds the limits on total dust, hydrogen chloride, sulfur dioxide, dioxins and furans. This
European Union directive also requires continuous measurements of nitrogen dioxide,
carbon monoxide, total dust, total organic carbon, hydrogen chloride, hydrogen fluoride, and
sulfur dioxide; the Hovalis not equipped to do continuous monitoring of these pollutants.

Since there is no pollution control device in the Hoval, its emission will most
likely exceed the limits on mercury ~nd other metals if those metals are present
in the waste. In other words, because of the poor emission characteristics of
Hoval incinerators,they would be in violation of u.S. a.,d Europeanstandards as
well as Philippinestandards in the caseof sulfur dioxide.

Findings 23
 B. Other Findings

1. VERYRUSTYAND COVEREDWITH SOOT, CRACKS IN THE REFRACTORY

Our investigations showed that most of

the incinerators in question are already in
a very rusty state, covered with soot and
often have cracks in the refractory
material. The photos speak for
themselves.

Photos: Incinerator chamber and

stack (Western WsayasMedical ---
Center)

According to Hoval, the refractory material for the incinerators has a lifetime of ten years.
This means that the incinerators installed in 1998 would already require replacement of the
refractory material under the best conditions by 2008. Since the repayment of the loan ends
in 2014, the already replaced refractory material would have already worn-out for the
second time and would need a new replacement. Depending on usage and the nature of
the waste treated, the refractories may even have to be replaced sooner (e.g., waste with a
lot of chlorinated plastics release hydrogen chloride which degrades the refractories faster;
heating up the incinerator quickly also. degrades refractories faster). Refractories are a
major cost item with incineration. This fact underscores the escalating nature of the costs
associated with the maintenance, repair and operation of incinerators.

Rndings 24
 2. ExEMPTION FROM THEENVIRONMENTAL IMPACT ASSESSMENT LAw

In April 1997, the Environmental Management Bureau (EMB)exempted the incinerators

under the Austrian Project from the Environmental Impact Statement (EIS) system. The
exemption was made on the basis of the erroneous assumption that the in-house installation
of the mini-incinerators will not involve site development or any major infrastructure work.
The EMBadded that the acquisition and installation of incinerators would improve the
present waste disposal systems of recipient hospitals. Clearly,in granting the EIAexemption
for these incinerators, the EMS ignored the matter of potential toxic emissions and
hazardous ash residues, commonly associated with waste incineration, when these in fact
should have been the dominant and overriding basis for assessing if a project were
environmentally critical or not.

The EIAlaw requires the conduct of an EnvironmentalImpact Study for every proposed
project and undertakingthat significantlyaffects the quality of the environment47.This
includesidentifyingall possibleimpactsthe project may have on the environmentand the
identificationof mitigatingmeasures to address these impacts. PresidentialDecreeNo.1586
or the SA law covers infrastructureprojects that are environmentallycriticalfor a given
area. This, obviously,should includeincinerationfacilitiesdue to the toxicfumes they emit
and the hazardousresiduesthey create.
As indicated earlier in this report, medical waste incinerators are notorious for being top
sources of mercury and dioxin emissions. A hospital's waste stream typically includes large
amounts of chlorinated plastic waste like PVC plastics which when burned gives rise to
dioxins.

In addition, the amendment (No. 98-008) to MMDAOrdinance No. 16 of 1991 states that
hospital incinerator systems "should pass the standard requirements set by DENRprior to
the issuance of an Environmental Compliance Certificate (ECC)'~ Yet, these concerns were
obviously sidestepped if not totally ignored in the EMB'sdecision. Furthermore, most if not
all of the Austrian incinerators operate in hospitals located in the middle of residential areas.

While Vamed provided the government emission data for the tests it conducted at the East
Avenue MedicalCenter, the DENRwas unable to verify or countercheck these data due to
the lack of proper equipment and the high costs of sampling and analysis. This also implies
that the decision to exempt these incinerators from the EIS was based solely on data and
,literature provided by the manufacturer.

Since monitoring for dioxins and furans is very expensive, the Philippinegovernment cannot
afford to buy the equipment to test for these most toxic by-products of medical waste
incineration. Even the testing equipment it has for other pollutants like heavy metals seem
to be of little use. For instance, when the Department of Environment and Natural
Resources (DENR)tried to conduct emissions tests in 1998-1999 at the Western Visayas
MedicalCenter, its testing equipment could only sustain a maximum heat of 600°C. Since
medical waste incinerators reach much higher temperatures than that, the government has
practicallyno ability and capacity to test the environmental performance of these units.

47 Presidential Decree No. 1568: Establishing an EnvironmentalImpact Statement system, including

other environmentalmanagementrelatedmeasuresand for other purposes.

Findings 25
 3. INCINERATION OF NON~SEGREGATED WASTE

The Clean Air Act (CM) states that in the interim

period, pending the phase-out of all medical waste
incinerators in the country, only infectious and
pathological waste may be incinerated in existing
units. In accordance with the color codes provided
by the Metro Manila Development Authority
(MMDA), these two waste types are supposed to be
collected in yellow bags. While the investigation
showed that most hospitals visited incinerated only
the yellow-bagged waste, closer inspection of the
bags showed that they contained general waste like
soft drink cans, fast food packaging, empty plastic
water bottles, kitchen waste, and office waste. This
means that non-infectious waste materials, including
general hospital waste were also being burned in
clear violation of the CM.

Photos: Unsegregated waste - Right. East A venue

Medical Center; Bottom: Philippine Orthopedic
Center

Furthermore, an engineer in charge

of the incinerator at Western
Visayas Medical Center in Iloilo
admitted that the hospital
incinerated almost all of their waste
except for aluminium cans, kitchen
waste, needles, sharps and
thermometers. This incinerator is
no longer operational because of
high costs for replacing the broken
incinerator parts together with the
high operational costs of the
incinerator. In the Batangas
Regional Hospital, green (non-infectious wet waste) and black (non-infectious dry waste)
bags were incinerated in their entirety. In some cases, general waste is burned when there
is not enough yellow bag waste. This also indicates that these incinerators are too big for
the small fraction of infectious waste being generated in each hospital, and this overcapacity
is giving hospitals an incentive to burn their general waste as well. Syringes and sharps are
also incinerated in most of the hospitals.

According to a July 2001 article written by Miriam V. Torrecampo for the Medical Observer
the incinerator inside the DOH compound itself is burning unsegregated waste. The article
mentions that a source familiar with the incinerator's operations admitted that the
incinerator, which is managed by the Jose Reyes Memorial Medical Center, was emitting
dark, thick smoke, especially when syringes and plastic materials were being burned. The
Metro Manila Development Authority (MMDA) then collects the ashes from the incinerator,

Findings 26
which contain incombustible vials, needles, and metal, amongst other waste, most likelyfor
disposal in a landfill or dumpsite.48

4. INADEOUATE OPERATOR TRAINING

Trainingis so essential for the proper operationof an incineratorthat it is a requirementin

many regulations. An operator should be familiarwith combustion principles,the basic
incinerator design, incinerator operation including an understanding of the controls,
inspections and maintenance, environmentalissues, occupationalsafety issues, relevant
regulations,and responsesto typicalincineratorproblemsand contingencies.
Interviews with hospital personnel revealed that hospital staff currently operating the
incineratorswere not the same persons who receivedthe training given by Hoval/Vamed.
Nor did they receive other training on how to operate the incinerators,relyingmerely on
instructionsfrom their supervisors. In some hospitals such as the East Avenue Medical
Center, a janitor is tasked with operating the incinerator,instead of an engineer who
understandsthe delicateoperationsof the incinerationprocess.
As part of this investigation,Greenpeaceasked several hospitalincineratoroperators and
engineers, includingthose who took part in the Hovaltraining workshop in 1998, some
gauge questions to assess their understanding of the incinerationprocess (e.g. what if
smoke from the incinerator became black or white or if white smoke appeared some
distance from the stack or if a large percentage of the waste residue remained
unburned?).49 These questions were asked to gauge the operator's understandingof the
incinerationprocess and his or her abilityto recognizeand respond to problemsthat are
relevantto environmentalprotection. Exceptfor one engineer,the other respondentsgave
vague or incorrectanswers or could not understand the questions at all. Their responses
suggest that the trainingprovidedto the operatorswas inadequate.

The training given by HovalNamed looked more like a brainwashing session to downplay the
dangers associated with incinerators. The Question (Q) and Answer (A) overview from the
Hoval workshop/seminar of 25-27 May 1998 contained the following statements (our
comments in Italics):
. (Q) Is ash dangerous?
(A) No ash is absolutely sterile.

Not a/l incinerator ash can be assumed to be sterile. During poor operating conditions,
pathogens have been shown to survive in the ash residue after the incineration process
(5. Klafka and M. Tierney, "Pathogen Survival at Hospital/Infectious Waste Incinerators, "
Proceedings: National Workshops on Hospital Waste Incineration and Hospital Sterilization,

48 MiriamV. Torrecampo, Medical ObselVer, Volume 10, Number7, SpecialReport:A burning

problem, July 2001.
49These questions were taken from the US EPA'sincinerator operator training course based
on real problems that incinerators face as a result of transient conditions, problems in
operation, control system faults, failures of specific components, the need for maintenance,
and other causes. ("Hospital Incinerator Operator Training Course: VolumeI, U.S.
Environmental Protection Agency, Research Triangle Park, North Carolina, March 1989)

Findings 27
EPA Office of Air Quality Planning and Standards, EPA-450/4-89-002, January 1989).
Another US EPAreport warned that if proper operating conditions are not met, incinerators
could release pathogens through the residues (Hospital MedicalWaste Incinerator Operation
and Maintenance, u.s. Environmental Protection Agency, Office of Air Quality Planning and
Standards, March 1989). More importantly, ashes can be toxic since they often contain
leachable toxic metals, dioxins, furans, and other organic contaminants. Tests conducted by
Greenpeace on ash from some of these incinerators prove that they contain heavy metals
like lead, cadmium, chromium and even mercury in excessive quantities.
. (Q) Dioxinin ash and fly ash and after-flue gas absorber expected?
(A) The dioxin content from incineration comes is in very small concentrations and
are therefore not a risk to humans and the environment.

Dioxins are found in significant amounts in the air emissions of medical waste incinerators as
well as in the ash, and the risk to human health is well documented. The USEPAhas
determined that medical waste incinerators are a major source of dioxins in the
environment It is also the reason why the Stockholm Convention on Persistent Organic
Pollutants specifically targets dioxins from medical waste incinerators. Even incinerators
with air pollution control devices such as absorbers can emit significant levels of dioxins
depending on their efficiencies and whether they are operated properly. Recent studies
have shown that in some cases the amounts of dioxins in the ash are even greater than
those found in the fly ash (Giugliano et al, Chemosphere 46, 1321 (2002». Furthermore,
the above question clearly states "AFTERflue gas absorber'; which the Hoval incinerators
don't even have in the first place.
. (Q) What are the disadvantages of the HF-disinfectionprocess used before
incineration?
(A) Noorganic matter is destroyed.

The HF-disinfection (microwave) process kills the organic matter that is of real concern,
namely, pathogenic microorganisms in the waste. Microwave technology has the advantage
of not generating high levels of toxic pollutants as incineration does. The Hoval
representative was apparently referring to organic material such as plastics. Ironically,
destroying organic compounds like chlorinated plastics through burning is exactly what
cause toxic fumes like dioxins, furans, and hydrogen chloride to be released.
. (Q) Which scrubber type should be chosen?
(A) Wet basic absorber with quenchero or dry bag house filter with quencher and
lime milk.

Hoval's answer shows that they knew that the incinerators needed scrubbers and/or
baghouse filters with a base (lime) and quench section but these features were not included
in the design of the incinerators they transferred to the Philippines.

soQuencher:State-of-the-artincineratorsuse quenchers,whichare devicesto rapidlyreducethe

temperatureof the exhaust gas. Bydoingso, you minimizethe amountof dioxinsand furansthat are
formed.

Findings 28
. (Q) WillHCInot cause acid rain?
(A) Yes, but the concentration willnot pose a risk to humans and the environment.
. (Q) Howcan we reduce ozone-depleting byproducts of combustion (PVC?)?
(A) HCIis heavier than air and therefore no HCIwillbe released into the atmosphere.

These answers are misleading. Hoval's answer is only true for the upper atmosphere,
namely, the stratosphere where ozone is found which is around 15 km above the earth's
surface. What is misleading is that HCIWILLbe released to the lower atmosphere, namely
the troposphere where it is an air pollutant HCIis heavier than air. But when it first comes
out of the incinerator stack, HCIgas is hot and lighter than the surrounding cool air. It is
only when HCIgas cools down to around 220 F that it becomes heavier and begins to sink
until it reaches ground level where people can breathe it or where it can corrode metals and
cause leaf burns and internal damage to plants and trees. If the air is vel}' humid, the HCI
gas forms hydrochloric acid, which is also toxic and damaging to the -environment One
often finds corrosion on metal surfaces in areas along the common direct path of the
exhaust plumes from medical waste incinerators. Since these concentrations are high
enough to cause corrosion and since HCI is associated with the presence of dioxins and
furans, it is likely that humans exposed to the exhaust acid gas would be at risk.

5. No WORKERSAFETY

Photo: Ash removal without protective gear - East A venue Medical Center
Former DOH Secretary Alberto
Romualdez Jr. once said that: "infected
or contaminated medical waste may put
the health of people exposed to them in
danger'~ The ostensible purpose of
incinerating infectious waste is to kill
the pathogens present in the host
matter in order to prevent the spread of
diseases, yet incinerator operators and
personnel assigned to handle this kind
of waste are rarely, if ever, assigned the
proper protective gear. Moreover, the
personnel assigned to manually remove
the toxic ashes and clean the incinerator
do not wear any protective gear or
clothing such as gloves, masks, or
biohazard suits.

6. IMPROPER HANDUNG AND DISPOSAL OF AsH REsrDUES

The incineratorash, which should be treated as toxic waste, is manuallyremoved with a

shoveland is often first stored a few meters fromthe incineratoron an uncoveredpile. It is
eventuallytransferredto blackbags for generalwaste or rice bags for collection-laterby the
city collectorwho then takes them to a dumpsite. In some cases, they are simplythrown

Findings 29
 into an open pit or dumped within hospital
premises, as is the case with the Research
Institute for Tropical Medicine(RITM). One
of the engineers of RITMeven said that
"the ashes can be used as fertilizer'~clearly
. underscoringtheir ignoranceas regardsthe
potential toxicity of the ash.

Photo: ash dumping - RITM

Greenpeace took ash samples from four incinerators as part of the on-site investigations.
These incinerators were located in the following hospitals; East Avenue MedicalCenter,
Batangas Regional Hospital, Research Institute for Tropical Medicineand Philippine
Orthopedic Center. The samples were sent to the PhilippineInstitute of Pure and Applied
Chemistry (PIPAC)and tested51 for the followingcomponents: Lead (Pb), Cadmium (Cd),
Mercury (Hg) and Chromium (Cr). In Philippinelaw, no special standards for incinerator
ashes are prescribed. Since the ashes are treated as normal waste to be dumped, landfilled
or put in an ash pit, the test results of the ashes are compared in Table 4 with background
concentrations in soil (Alloway1990) and US EPA'stoxicity characteristic leachate procedure
(TCLP).

Table 4. Concentrations in mg/kg or Jlg/g of Lead, Chromium, Cadmium and Mercury In the
ash samples of four Hovallnclnerators In the Philippines
Pb Cr Cd Ha

PhilippineOrthopedicCenter 460 65 7.3 N.D*.

ResearchInstitutefor TropicalMedicine 440 66 2.8 N.D*.
BatangasRegionalHospital 210 53 1.6 N.D*.
EastAvenueMedicalCenter 490 124 5.5 0.4

Background concentrations in soil 10-30 <1-100 0.01-2.0 0.02-0.625

(Alloway 1990)
TCLP-limits 5 5 1 0.2

Note: ND* = None Detected. Minimum detectable amount is 0.4 ~g/g.

The test results show significantlevels of lead, chromium, and cadmium in three ash
samples, plus mercury in a fourth sample. The lead levels in all four samples are high.
Because a different test method was used, one cannot state conclusivelythat the ash
samplesfail USEPA'stoxicitycharacteristicleachateprocedure(TCLP)test and are therefore
hazardous waste. Howeverthe PIPACtests are similarto another EPAmethod used for
preliminarydeterminations. If the test results in ~g/g are 20 times or higher than the
correspondingTCLPlimits, the samples are likelyto be hazardous and must be tested
further. Compared to the TCLP-limits,the lead samples are almost 100 times higher,

Analyttcalmethods: 1. Ashing&Add Digestion/AtomicAbsorption; Spectrophotometry for Lead,

51
Chromium& Cadmium. 2. Add Digestion/Cold-VaporAtomicAbsorption; Spectrophotometry for
Mercury.

Findings 30
chromium is 10 to more than 20 times higher,
cadmium is 5 to 7 times higher, and mercury is
twice the correspondingTCLPlimit. Giventhese
results, the ash would most likely fail TCLPand
would likely be classifiedas hazardouswaste in
the UnitedStates.

7. UNBURNED WASTE

As one can see from the photoon the right (East

AvenueMedicalCenter) a lot of unburnedwaste
like glass bottles and tubes, needles,aluminum
soft drink cans remains after incineration. The
presence of unburned waste is a sign of an
inefficient burning process. When burning is
inefficient, the potential for creating dioxins and
furans, which are products of incomplete
combustion,is extremelyhigh.
Photo: Unburned waste (EAMC)

8. COMMUNrTYCOMPLAINTS

. Mrs. Diana D. Magbanua lives with her family some 15 meters across the incinerator of
the Western VisayasMedicalCenter (WVMC)in Iloilo where she also works as the
hospital'sRecordsOfficer. She claimsthat the incineratorstarted emitting"thick, dark
smoke" (of which she has video evidence) less than a year after the facility was
established. Mostof the time the incineratorwould start burning from 11:00 pm until
around 5:00 or 6:00 am. She claimsthat her family has been sufferingfrom chronic
respiratory illnessessince the incineratorstarted operating; and that when it ceased
operating,their coughingandrespiratoryproblemswererelieved. The incineratorstands
in a thickly populated area. 52

The fact that WVMC incinerator'schimney was low also meant that pollutants were
dispersed in the immediate surroundings. For example, Mrs. Magbanua has videotape
from the neonatal ward where one could see the ashes from the incinerator of Western
Visayas MedicalCenter wafting into the room.

Mrs. Magbanua has filed several complaints to both government and hospital authorities
even if most of them were ignored initially. She then sent a letter of complaint
accompanied by a copy of a petition signed by 152 people (patients, doctors, hospital
staff and people living in the immediate vicinity of the incinerator) to Senator Loren
Legarda who replied that the matter would be endorsed to the Secretary of the DENR.

52Sorza Rexel J., Couple complains of noxious odor from incinerator,The Visayas Examiner,June 15,
2001, pages 1 and 4.

Findings 31
 In June 2001the DENRconductedan inspectionof the WVMCincinerator.It was found,
among others, that smoke emission was observed at shade #1 based on the Ringlemann
Charf3. The Ringlemann Chart is a way of measuring "opacity"or the density of smoke
discharge from an incinerator. US EPA requires that new medical waste incinerator
smoke not exceed a 10% opacity at any time. Ringlemann #1 is a less stringent
standard since it is equivalent to a 20% opacity. The Ringlemann chart is only a rough
indication and was developed long time ago as a response to the public not wanting to
see black smoke. The Ringlemann chart is somewhat subjective and can be misleading
because it does not necessarily reflect the true amount of particulate emissions, since
many particulates are too small to be seen by the eye. So even if an incinerator meets
Ringlemann #1, its particulate emissions may be very high. For that reason, the better
standard for particulates is to conduct actual stack sampling and analysis.

The incinerator was operational for about three years until operations stopped in 2001.
Accordingto the hospital engineer, the reason for the incinerator's closure was the high
cost of replacing broken parts as well as the high operational costs. Mrs. Magbanua, on
the other hand, believes that the incinerator was shut down because of their complaints
and the subsequent media attention. This is supported by the findings of Dr. Luis Diaz
who also cites in his report for the Technical Working Group on Hospital Waste
Management that the hospital stopped using the incinerator because they were "forced
by the surrounding community." The health care facility now relies on chemical
disinfection and land disposal for the management of its infectious wastes.
. In a similar case, a family living behind the incinerator of the Western Visavsas Reaional
Hospital in Bacolod that has been living in the area since 1976 told Greenpeace in a
video interview that the incinerator always emits black smoke during operation. They
also complained to the operator about the foul smell but did not bother to make an
official complaint because they are "only squatters'~ Though the incinerator had already
been ordered to shut down, the hospital still operated it for another month.

. For emitting blacksmoke, the RizalMedicalCenter incineratorwas also the subject of

previous complaints from the neighbouring Robina Millsflour factory, the inhabitants of
Barangay Pineda, and even from the hospital's staff 54.

9. BREAKDOWNSAND REPAIRS

In case of breakdowns, a company called Food Service Equipment, exclusivelyauthorized by

Hoval/Vamed,does the repairs. The main problem with breakdowns is that spare parts are
often not available in the Philippines and have to be imported from other countries.
Breakdowns that have occurred in the past involved leaking chamber doors and solenoid
valves for the fuel pump, meltdown of the baffle tube/plate of the start-up burner, cracks,
breaking off of refractory material and traverse cams. 55

53 The way the Ringlemann number is determined is by holding up a Ringlemann chart against the
smokein the backgroundand matchingthe darknessof the smoketo the differentshadingsin the
chart.
54 Interview with Rizal Medical Center incinerator operator.
55 Basedon interviews with engineers of the hospitals visited.

Findings 32
The engineer of East Avenue Medical Center said that the hospital already had 13 incinerator
breakdowns since the first day of operation, with a total repair cost of 532,999 PHP that was
charged to the hospital's account.

The incinerator of the Western Visavas Medical Center, according to the hospital's engineer,
is no longer operational due to the high costs of replacing the broken parts (traverse cam =
35,000 to 40,000 PHP) together with the high operational costs (50,000 PHP/month). The
hospital's limited budget cannot allow for the needed repairs. Worse, community protests
against the incinerator has put the hospital in a bad light.

The Research Institute of Trooical Medicine's engineer said that repairs made by Food
Service Equipment are very expensive; not surprising given the fact that the company has
exclusive rights to provide repairs and spare parts for broken incinerators, they can simply
monopolize the price.

10. UNUSEDDISINFECTION UNITS

All the hospitals that received an incinerator as part of the Project also got a Medister
microwave disinfection unit, except for the Teofilo Sison Memorial Medical Center and the
Hilarion Ramiro Memorial Hospital. Except in a few hospitals, most of these units seem to
have not been used at all. For the few hospitalsthat use them, their practice is to first
disinfect the waste before incinerating it, a procedure that is best described as redundant
and questionable. Since the waste has already been disinfected, there is no longer any need
to incinerate it. The pathogens present in the host material have already been eliminated.

c. Hoval: A DirtYTrack Record Overseas

At the beginning of the 1990s many Hoval incinerators were also installed in the Czech
Republic. According to Econnect, a Czech non-profit organization, the emissions of Hoval
incinerators operating in the Czech Republic have exceeded EU dioxin emission limits
.(0,1 ngTEQ/m3)56up to 149 times. (please seeTable on the next page) 57

The performance of the Hoval incinerators in the CzechRepublic would definitely disqualify
them for use and operation in countries with strict emission standards. Like hazardous
waste, dirty technologieswill alwaysfollow the pathof leastresistance. Countries or places
with low environmental standards and practically non-existent pollution and occupational
health and safety controls become havens for manufacturers and distributors of dirty and
obsolete technologies. By exploiting the lower standards of developing countries like the
Philippines, companies like Hoval are able to profit from the export of technologies that
would have been considered serious liabilities in their places of origin.

56 Releases of dioxins and furans are reported in units of toxic equivalence (TEQ) as compared to the
most toxic type of dioxin, 2,3,7,8-tetrachlorodibenzo-pdioxin (PCDD).
57 Econnect, 1994-1999 emission data of Hoval incinerators operating in the Czech Republic,
website: www.ecn.cz/dioxin/soal men.html.

Findings 33
Table 5. Hoval incinerators in the Czech Republic exceeding EU dioxin emission limit
(1994-1999)
YEAR LOCATION NAME TYPE CAPACITY PCDD/Fs in
MEASUREMENT IYEAR nqTEO/m3

1994 Pardubice Nemocnice Pardubice Hoval GG-14 750 0,516

1994 Strakonice spalovna FEZKO Hoval GG-24 1000 7,44
1995 Praha 1 Typografie Hoval GG 14 6,43
1995 Praha 9 -
Barvy laky Hoval GG 24 660 0,33
1995 -
Praha 4 Krc Spalovna NO Hoval GG-14 700 2,7
1995 Kolin LZ-DRASLOVKA HovalGG-14 540 0,369
1995 Praha 9 Spalovna komunalnmo odpadu HovalGG-14 540 0,21999
1995 Jihlava MOTORPAL, a.s. Jihlava HovalGG-24 900 0,569
1995 Pustmer EKOTERMEX, a.s. VySkov HovalGG-24 350 0,12999
1995 Luze Hamzova detska lecebna Hoval GG-7 350 0,93099
1996 Pardubice Nemocnice Pardubice HovalGG-14 750 11,675
1996 Pardubice Nemocnice Pardubice HovalGG-14 750 11,675
1997 -
Plzen Lochotfn spalovna FN Lochotfn HovalGG-14 1350 1,7
1997 Strakonice spalovna FEZKO HovalGG-24 1000 14,9
1997 Ceske Budejovice Ekologicka spalovna EKOKOMBEK HovalGG-24 1000 11,43
1997 Pustmer EKOTERMEX, a.s. VySkov HovalGG-24 350 0,23999
1997 Luze Hamzova detska lecebna HovalGG-7 350 0,68
1998 Zirovnice spalovna KPZa.s: 2x HovalGG-14 700 0,51
1998 Zirovnice spalovna KPZa.s. 2x HovalGG-14 700 0,13
1998 Znojmo OnsP Hoval GG-14 750 0,008
1998 Otrokovice EKO-RUBBER HovalGG-24 1200 0,133
1998 Breclav -
ALBA SERVIS HovalGG-7 350 0,91
1999 Jihlava MOTORPAL, a.s. Jihlava HovalGG-24 900 0,4
1999 Kolin LZ-DRASLOVKA HovalGG-14 540 0,8
1999 Pardubice Nemocnice Pardubice HovalGG-14 750 11,67
1999 Plzen - Lochotin spalovna FN Lochotin HovalGG-14 1350 9
1999 Uherske Hradiste Nemocnice s poliklinikou HovalGG-7 350 0,7
1999 Praha 5 - Motol Spalovna FNM 2xHovalGG-24 1920 3,43
1999 Brtnice SNAHA HovalGG-14 4,377

58 Metric tones per year.

Findings 34
 VI. A CASE OF DOUBLE STANDARDS

In the 1980s, Austria did not have any emission controls nor proper operating requirements
conditions for its hospital incinerators. Over the years, however, with the onset of better
regulation and stricter standards, many of these incinerators were forced to shut down.
Only those equipped with advanced pollution control technologies capable of meeting strict
Austrian standards remain in operation today. Non-incineration methods for the disposal of
infectious waste likethe use of steam sterilization have also become common in Austria.

In 1998, there were only three municipal waste incinerators operating in the whole of
Austria. Two of these units are located in Vienna where they are expected to comply with
very high standards (e.g. on dioxin). The city of Vienna has closed down all hospital
incinerators operating in the city, and is currently employing a strategy where medical waste
is divided into:

a) recyclable products (paper, glass, metals, some plastics, organic)- brought to

recyclingfacilities;
b) toxic wastes - which are brought to toxic waste incinerators with emissions
complyingwithAustrianI EUstandards, e.g. dioxinsclearlyunder 0,1 ng/m3; and
c) all other wastes - which are brought to the Vienna incinerationplants. It is
especiallyimportantto emphasizethat the hospitalsin Viennahave also taken a lot
of measures to reduce PVC(no packagingand also reductionin products) in their
waste stream.

As of 2002, there are around 5 incinerators for medical waste still working in Austria. They
are located in Baden, St. Veitan der Glaan, Bruckan der Murand Spittal.

The Austrian Federal Waste Law implements the waste strategy of avoidance, recycling, and
disposal, Austria is among the leading European countries as far as recycling is concerned.
"The estimated total waste volume for all 350 hospitals in Austria is 70,000 - 100,000 tons a
year. Around 50% of Austria's waste is recycled (paper, glass, metals, packaging material,
biomedical waste, etc.). 2.5% of Austria's total waste stream is hazardous waste." 59

In 1999, Greenpeace Austriaconducted an inquiry into the operations of Austria'swaste

incinerationplants. Austrian incinerators are often promoted as positive examples for
incinerators from Europe, especially among Southern European and Asian countries.
Vienna'sincineratorsare also often used as case study examplesby technologycompanies
to sell incinerationtechniquesto developingcountries likethe Philippines.Asexpected,the
incinerationplantsin Austriahaveto complywith highenvironmentalstandards(Austrian/EU
standards), they have pollutioncontrol devices and are monitoredfor air pollutantson a
regularbasis and the data are made public.
In November 1998, Mrs. Marit Stinus-Remonde, President of the Cebu Environmental
Initiatives for Development Center (CEIDEC),a Cebu-based environmental group wrote to
the Austrian government to ask why Austria was selling dated on-site medical waste
incinerators in the Philippines, when it already stopped using them back home. Mrs.

59 Muehlberger Manfred, Dipl.-Eng., ETA Umweltmanagement, Wien.

Findings 35
Benita Ferrero-Walder from the Austrian Federal Ministry of Foreign Affairs responded by
saying in a letter to Mrs. Remonde that the Austrian government believes that the Project
was a "contribution to improving the sanitary situation in hospitals and to the overall
developmentof the Philippines."60 The Austriangovernment also vouches for the track
record of Vamed which it said "has been installing hospital waste incinerators in several
countries, including the Asian region (sic)" and that in the case of the Philippines, "the
solution offered by Vamed, which combines incineration and disinfectant devices, must have
been the most efficient, safest (underscoring ours), and comparatively cheapest."

The shameless defence of the Project on the part of the Austrian government flies in the
face of the obvious and potential damages to public and environmental health arising from
the operation of these obsolete incinerators. Knowing that the Austrian incinerators
transferred to the Philippineswould never be allowed to operate in Austria itself makes this
case more compelling on account of the double standards employed by the Austrian
Government in defence of the Project. Indeed, dumping polluting technologies in the name
of development assistance is comparable to the condemnable practice of dumping
hazardous waste in the guise of trade in poorer countries.

It also glosses over the fact that at the end of the day, local citizens would be shouldering
the costs involved in the installation, operation and maintenance of these incinerators.

60 Letter by Austrian State Secretary Benita Ferrero-Waldner, Federal Ministry of Foreign Affairs to
MaritStinus-Remonde, President of Cebu EnvironmentalInitiatives for Development Center (CEIDEC)
dated 27 November 1998.

Findings 36
VII. CONCLUSIONS

People have a right to live in a safe and healthy environment free from the threats of toxic
pollution. This is a fundamental right that governments worldwide must always strive to
secure for their people. When the Philippines legislated the Clean Air Act in 1999 with the
unprecedented national ban on incineration, it was only being consistent and true to a
commitment enshrined in its Constitution to provide a safe and healthy ecology for its
people.

The Philippine incineration ban also sent a signal to the rest of the world that the country
would not be used as dumping ground for controversial technologies like incinerators,
especially given the specific and preferential references both in the Clean Air Act and the
Ecological Waste Management Act for the use of alternative, non-burn techniques and
technologies for dealing with waste.

Unfortunately, instead of learning from the mistakes of other countries and moving forward
with the alternatives, some voices in government still prefer to go with the convenient but
deadly practice of waste incineration. Instead of implementing the laws and fulfilling their
given mandate, government agencies like the Department of Health would rather work to
weaken if not sabotage the intent of these statutes.

The Department of Health has always been a vocal critic of the Clean Air Act becauseof the
ban on incineration. Their current legislative agenda includes a push in Congress to have
the ban amended to accommodate a ten-year extension for the operation of hospital waste
incinerators. The fact that cheaper and safer non-burn alternatives to medical waste
incineration are available should have already ended the argument. (Please see Annex 1 -
Alternatives)

The untenable position of the DOH on the incineration issue could only be attributed to its
continuing defence of the Austrian Project, a project, which this report has already
established, to be disadvantageous to the Philippine government. Through the Project, the
DOH has unfortunately become the conduit for the transfer of obsolete and highly polluting
technology, which pose serious and long-term risks to the environment and human health.
This report provides strong evidence that the technology offered to the Philippines was
misrepresented and portrayed by the technology vendors and providers as modern
equipment, which are fully compliant with stringent regulations in industrialized countries.
Nothing could be further from the truth.

The Philippines received obsolete and dangerous technology from a deal that was presented
as a form of development assistancefacilitated by the Austrian government.

Indeed, it was brazen and mind-boggling for the technology providers to claim that their
incinerators will not emit toxic fumes when they did not even have basic pollution control
devices. Hoval/Vamed's claims that their incinerators were compliant with the highest
European or international standards proved to be nothing but an empty boast intended to
deceive Philippine authorities. Without pollution control devices, even of the most basic
type, it can be assumed that these incinerators would not be allowed to operate in Austria or
any other industrialized European country. These facts make this case of technology
transfer a blatant form of toxic trade.

Conclusionsand Recommendations 37
That the Philippine government still has to pay the loan to an Austrian bank, which made
this toxic technology transfer possible, makes this case even more revolting. In effect, with
this loan package, the Philippine government is financing and subsidizing the poisoning of its
people and their environment.

Already installed and operating, these facilities represent an annually recurring financial and
image liability for the DOH in the next seventeen years (since initial payments for the loan
starts five years from signing and will continue for the next twelve years). The long-term
payment scheme also tends to remove any incentive on the part of the DOHto pursue more
rational, safe and cost effective solutions to the medical waste problem.

Undoubtedly, the Project has placed the DOH in a terrible quandary. The Austrian
incinerator deal is now going up in smoke, especially when the phase-out period for existing
medical waste incinerators ends in July 2003. The DOH must realize that it cannot keep on
pushing for an extension of the phase-out period while at the same time ignoring the
pollution and health hazards of incinerating medical waste. Instead of continuing to justify
an obviously bad deal, the Health Department should start playing a more pro-active role in
the development and phasing-in of the safe alternatives. At the same time, the Philippine
government must assert its rights against dubious forms of development assistance such as
this Austrian Project. It must call for an invalidation of the Project or at least a re-
negotiation of the loan, to remove components of the Project having to do with the
incinerators. In addition, Vamed jHoval should be made to dismantle the incinerators they
had installed in the Philippines as well as pay for the costs of shipping them back to their
place of origin.

Both Austria and the Philippines are signatories to the Rio Declaration adopted during the
United Nations Conference on Environment and Development (UNCED) in 1992. As such,
both States are politically and morally committed to operationalize and implement the
Principles embodied in the Declaration which include the following:

Principle 2: States... have the responsibility to ensure that activities within their
jurisdiction or control do not cause damage to the environment of other States or of areas
beyond the limits of national jurisdiction;

Principle 14: States should effectively cooperate or discourage or prevent the relocation
and transfer to other States of any activities and substances that cause severe
environmental degradation or are found to be harmful to human health; and

Principle 19: States shall provide prior and timely notification and relevant information to
potentially affected States on activities that may have significant adverse transboundary
environmental effects and shall consult with those States at an early stage and in good faith.

The shamelessdefenceof the Projecton the part of the Austriangovernmentflies in the

face of the obviousand potentialdamagesto publicand environmentalhealtharisingfrom
the operation of these obsolete incinerators. Knowing that the Austrian incinerators
transferredto the Philippineswould neverbe allowedto operatein Austriaitself makesthis
case more compelling on account of the double standardsemployed by the Austrian
Governmentin defenceof the Project. Indeed,dumpingpollutingtechnologiesin the name
of development assistance is comparable to the condemnable practice of dumping
hazardouswastein the guiseof trade in poorercountries.

Conclusionsand Recommendations 38
 Bibliography
Websites

. http://www.greenpeace.org
. http://www.vamed.co.atjvagruppe.htm
. http://www.hoval.com
. http://www.bankaustria.com
. http://www.no-burn.orgjactionkitjaltmedwaste.html
. http://www.ecn.czjdioxin/spaLmen.html.
. http://www.unep.org/unep/rio.htm

Leaislation

. Presidential Decree No. 1151: The Philippine Environmental Policy.

. Presidential Decree No. 1568: Establishing an Environmental Impact Statement system,
including other environmental management related measures and for other purposes.
. Republic Act No.6969: Toxic substancesand Hazardousand Nuclear Wastes Control Act
of 1990.
. Republic Act No. 8749: PhilippinesClean Air Act (CAA) 1999; CAAsImplementing Rules
and Regulations (IRR) of 2000.
. Republic Act No. 9003: The EcologicalSolid Waste ManagementAct of 2000.
. Metro Manila Ordinance No. 16, series of 1991, amended by Metro Manila Development
Authority (MMDA) Regulation No. 98-008 - Regulating the management, collection and
disposal of hospital waste and those of similar institutions in Metropolitan Manila.

Hoval and Vamed documents

. Hoval, Operating Manual, Setting Points 1, Plant Description, Description of Components,

and other documentation, Hoval, November 30, 1993.
. Gutierrez Ricardo C. of the Philippine affiliate of Vamed Engineering,Officialresponseto
the National Center for Health Facility Development's request for information, August 22,
2001.
.
. VamedEngineering,AustrianProject,February1996.
Vamed Engineering, Austrian Project: WasteManagement Component (Environmental
Impact Assessment), October 2, 1996.
. Vamed, AustrianProjectoffer, February6,1996
. Vamed Engineering, Backgrounder for DOHProject: Supply of Waste Disposal Facilities
and Upgrading of Medical Equipment in DOH hospitals, August 22, 2001.
. Vamed Engineering, Technicalproposal for the Austrian Project, February 1996.

DOH and WHO documents

. Abesamis Criselda G., Chairman, DirectorNationalCenterfor HealthFacility

Development (NCHFD), Technical Working Group on Hospital Waste Management,
Meeting with the chiefs of hospital on the preparatory activities before the actual air
emission tests, NCHFD Conference Room, 12 October 2001.

Bibliography
. AbesamisCriselda G., Chairman, Director National Center for Health Facility
Development (NCHFD),Technical WorkingGroup on HospitalWaste Management,
Technical workinggroup meeting: Hospital Waste Management, INFRAConference
Room, 29 May2001.
. BariringCarlos G., Engineer of the Department of Health, Summary on Emission
sampling/testing of incinerators.
. Department of Health, Manual on Hospital Waste Management, Manila, 1992.
. Department of Health, Slideshow presentation on Health Care Waste Management: A
vital component of environmental health protection, Department of Health, Philippines,
Manila.
. Department of Health, Terms of reference for WHOconsultant
. Diaz Luis, Dr. consultant of the World Health Organization (WHO),in coordination with
the Technical WorkingGroup (TWG)on HospitalWaste Management and the
Department of Health (DOH),Evaluation and recommendation report on hospital waste
disposal practices in the Philippines,February 2001.
. PadillaAlexander A., undersecretary, Inform Action Express for Secretary Manuel M.
Dayrit,July 31, 2001.

NewsDaoer and maoazine articles

. Sorza Rexel J., Couple complain of noxious odor from incinerator,The Visayas Examiner,
June 15, 2001, pages 1 and 4.
. Torrecampo MiriamV., MedicalObserver, Volume 10, Number 7, Special report: A
burning problem, July 2001, pages 40-44.

Other information sources

. Barbeito M.and Shapiro M., MicrobiologicalSafety Evaluation of a Solidand Liquid

Pathological Incinerator, Journal of MedicalPrimatology,6:264-273, 1977.
. Brunner c.R., Medical Waste Disposal, ICI, Reston, Virginia,1996, page 8-14.
. CGHEnvironmental Strategies, Inc. of Burlington, Eleven Recommendations for
Improving Medical Waste Management, Vermont, U.S.A,December 1997.
. Econnect, 1994-1999 emission data of Hoval incinerators operating in the Czech
Republic,website: www.ecn.czjdioxin/spaLmen.html.
. GlobalAnti-Incinerator Allianceand GlobalAlliancefor Incinerator Alternatives (GAIA),
Petition, A citizens' appeal to the president: Stop Dioxin Pollution,Phase Out Medical
Waste Incinerators, GAIA,Philippines,June 2002.
. GMSandoval, Inc. (GMSI),test results for the emissions from PhilippineOrthopedic
Center incinerator, source sampling conducted on October 17, 2001.
. Green Delaware, Media release Green Delaware,GlobalAnti-Incinerator Allianceand
GlobalAlliancefor Incinerator Alternatives mailing list, May24,2002.
. Greenpeace International, Greenpeace Southeast Asia Toxics Campaign, ToxicFree Asia
Tour Briefing Paper No.5: Dioxins, Greenpeace International.
. Giugliano et aI., Chemosphere 43, 743 (2001).
. Hanks Katie and Hardee Brian, Cost Impacts of Regulatory Options for New and Existing
Medical Waste Incinerators (MWI's), memorandum to the U.S. Environmental Protection
Agency, MidwestResearch Institute, Cary, North Carolina, May20, 1996, pages 3-4.
. Health Care Without Harm, The Campaigner for environmentally responsible health care.

Bibliography
. Hester Charles, PM,Cq. and CDD/CDFAverage Emission Rates and Achievable Emission
Levels for Medical Waste Incinerators with Combustion Controls,memorandum to the
U.S. Environmental Protection Agency, Midwest Research Institute, Cary, North Carolina,
May20, 1996, page 2.
. KlafkaS. and Tierney M.,"Pathogen Survivalat Hospital/Infectious Waste Incinerators,"
Proceedings: National Workshops on Hospital Waste Incineration and Hospital
Sterilization, EPAOffice of AirQuality Planning and Standards, EPA-450/4-89-002,
January 1989.
. MultinationalResource Center (MRC)and GlobalAnti-Incinerator Alliance& Global
Alliancefor Incinerator Alternatives (GAIA),Upcoming report, Waste Incineration: A
Dying Technology, (when released, the report willbe posted on the GAIAwebsite:
www.no-burn.org). 2002.
. Silvestre Junilyn, Summary of key waste management issues in the country: current and
emerging, medical waste incinerators, Greenpeace Southeast Asia, Philippines.
. Silvestre Junilyn, PhilippineHospital Waste Management Situationer, Greenpeace
Southeast Asia.
. Strong Brian, Determination of Maximum Achievable Control Technology (MACT)Floor
for New Medical Waste Incinerators, memorandum to the U.S. Environmental Protection
Agency, MidwestResearch Institute, Cary, North Carolina, March20, 1996, pages 2-4.
. TUVBayern Landesgesselschaft Osterreich GmbH, Certificate:Emission of Hoval-
Incinerators, May5, 1998.
. U.S. Environmental Protection Agency, Draft DioxinReassessment, Part I, VolumeII,
Chapter 1, p. 18.
. US EPA,EPAReport to the Commission for Environmental Cooperation (CEC),November
2000.
. US EPA,Hospital Incinerator Operator Training Course: Volume I, U.S. Environmental
Protection Agency, Research Triangle Park, North Carolina, March 1989.
. US EPA,HospitalMedical Waste Incinerator Operation and Maintenance, Office of Air
Quality Planning and Standards, March 1989.
. US EPA,Hospital Waste Combustion Study-Data Gathering Phase, December 1988.
. US EPA,Medical Waste Incinerators-Background Information for Proposed Standards
and Guidelines:Industry ProfileReport for New and Existing Facilities,July 1994.
. US EPA,Standards of Performance for New Stationary Sources and Emission Guidelines
for Existing Sources: Medical Waste Incinerators, January 1996.
. Waldner Benita, Letter by Austrian Federal Ministryof Foreign Affairsto MaritStinus-
Remonde, President of Cebu Environmental Initiatives for Development Center
(CEIDEC),November 1998.

Recommended Literature

. AllsopMichelle,Costner Pat, Johnston Paul, Incineration and Human Health: State of

knowledgeof the Impactsof WasteIncineratorson HumanHealth,Greenpeace
Research Laboratories, Universityof Exeter, UK,March2001.
. Emmanuel Jorge, PhD, CHMM,PE, Non-Incineration MedicalWaste Treatment
Technologies, Health Care Without Harm, August 2001.

Bibliography
 Figures &. Tables

Fioures

Figure1. Numberof medicalwasteincineratorsin the u.s. (1988-2000) p. 3

Figure2. Typesof HospitalWaste Annex1

Tables

Table1. Pollutantsfrom MedicalWasteIncinerators p. 5

Table2. Dioxinin a Full-ScaleIncinerator p. 6

Table 3. Summary of Epidemiological Studies on Adverse Health Effects

Associatedwith Incineration p. 8

Table4. Concentrations in mg/kg or pg/g of Lead, Chromium, Cadmium

and Mercury in the ash samples of four Hoval incinerators in the Philippines p. 30

Table5 Hoval incinerators in the CzechRepublic exceeding EU

dioxin emissionlimit (1994-1999) p. 34

Table6. Non-PVCHospitalProducts Annex1

Table 7. Cost Comparison of Small-Scale Incinerator and

Autoclave(50 kg/hr) for on-sitetreatment Annex1

Table 8. Capital Cost Comparisons of Incinerator and

AdvancedAutoclave(50 kg/hr) Annex1

Table9. CostComparisonof Large-ScaleIncineratorandAutoclave Annex1

Figuresand tables
 Abbreviations
ATS AustrianSchilling
BRH BatangasRegionalHospital
CAA CleanAir Act
CEC Commissionfor EnvironmentalCooperation
CEIDEC CebuEnvironmentalInitiativesfor DevelopmentCenter
DENR Departmentof Environmentaland NaturalResources
DOH Departmentof Health
EAMC EastAvenueMedicalCenter
ECC EnvironmentalComplianceCertificate
EIA EnvironmentalImpactAssessment
EIS EnvironmentalImpactStatement
EMB EnvironmentalManagementBureau
EU EuropeanUnion
FSE FoodServiceEquipment
GAIA GlobalAnti-IncineratorAlliance,
GlobalAlliancefor IncineratorAlternatives
GMSI GMSandoval,Inc.
HCWH HealthCareWithout Harm
INC IntergovernmentalNegotiatingCommittee
IRR ImplementingRulesand Regulations
JICA JapanInternationalCooperationAgency
MMA MetropolitanManilaAuthority
MMDA MetroManilaDevelopmentAuthority
MMO MetroManilaOrdinance
MRC MultinationalResourceCenter
MWI MedicalWasteIncinerators
NEDA NationalEconomicand DevelopmentAuthority
NCHED NationalCenterfor HealthDevelopmentFacility
NSWMC NationalSolidWasteManagementCommittee
P PhilippinePeso
PCDD Polychlorodibenzo-p-dioxin
P.D. PresidentialDecree
PE Polyethelyne
PHP PhilippinePeso
PIPAC PhilippineInstitute of Purean AppliedChemistry
POC PhilippineOrthopedicCenter
POPs PersistentOrganicPollutants
PP Polypropylene
PVC Polyvinylchloride
R.A. RepublicAct
RMC RizalMedicalCenter
RITM ResearchInstitute for TropicalMedicine
STP StandardTemperatureand Pressure
TCDD Polychlorinateddibenzo-p-dioxins
TCDF Polychlorinateddibenzofurans
TEQ ToxicEquivalence

Abbreviations
TRI Toxic Release Inventory
TWG Technical Working Group
US EPA United States Environmental Protection Agency
UNCED United Nations Conference on Environment and Development
UNEP United Nations Environmental Programme
WHO World Health Organisation
WVMC Western Visayas Medical Center
WVRH Western Visayas Regional Hospital

Abbreviations
 Annexes

Annex 1: Alternatives

Annex 2: List of DOH hospitals with an Hoval incinerator

Annex 3: Comparison emission data on Hoval incinerators

Annex 4: Costs Hoval incinerators

Annexes
 Annex 1: Alternatives

The most important part of waste management is waste minimization. Preventing the
generation of waste is the first step. Waste reduction in hospitals begins with the purchase
of hospital supplies. Giving preference to reusable items, minimizingpackaging and opting
for PVC-freematerials, can do this.

The second step is reducing the volume and toxicity of the medical waste stream through
waste seareaation. Most wastes, such as paper, cardboard, glass, some plastics and metals,
can be recycled. Recyclinginstead of incinerating does not only prevents the emission of a
wide range of pollutants, it also recovers and saves raw materials. The recovered material
can be reused to make new items instead of depleting already scarce resources.

Figure 2. Types of Hospital Waste'1

In general,eightyfive percentof the total medical
Types of Hospital Waste
waste stream in hospitals consists of a mixture of
discarded paper, plastic, glass, metal and food
waste similar to the same waste coming from
hotels, offices or restaurants, since hospitals also
serve all of these functions. Only ten percent or
less of a typical hospital waste stream is
considered infectious (potentially infectious and
infectious waste) and must be sterilised before
disposal.
85%
The infectious waste can be sterilized with non-
II GeneralNon-Infectious burn disinfection alternatives. There is no need
1m Infectious for incineration; efficient, sensible, affordable and
- ChemicalI Radioactive.
o Hazardous environmentally sound non-burn technologies exist
which are capable of destroying the bacteria and
viruses without attempting to chemically destroy
the materials on which they are sitting.

Because medical waste incinerators are major sources of dioxins some countries have
brought in more stringent regulations. This has resultedin many hospitalsclosingtheir own
on-site incineratorsand shipping waste to a commercialincineratorwith more pollution
controldevices.'~.."This,however,is increasinglyseen as an inadequatesolution.
Increasingly,hospitals in Austria, Germany and Denmark are reducing the amount and
nature of their wastes by switchingto reusablesthat can be sterilised. Substitutionsof PVC
products go hand in hand with programs to prevent waste and to segregate them for
recycling.

CGHEnvironmental Strategies, Inc. of Burlington, Eleven Recommendations for Improving Medical

61
Waste Management, Vermont, U.S.A, December 1997.
 PVC-FREE HOSPITALPRODUCTS

Table 6. Non-PVC Hospital Products

jPvc USE 1ALTERNATIVES I

,
p2 and/or PEcopolymers are recommended. Latex is
IExamination gloves:
of higher quality and is a proven barrier to viruses.
clogs with leather tops in operating rooms; multiple-use
Overshoes: rubber shoes, shoes made of cloth or overshoes made
of PEfor single use e.g. visitors in intensive care
rooms.
cloth alternatives used in low contamination areas, PE
Aprons: ,
coated in operating rooms.
! alternative plastic and rubber use only where necessary,
jMattress covers: washable microfibre - e.g. "Kortex" or "Geritex" more
comfortable to patient.
Wound plasters and
textile materials recommended.
dressings:
;Bedpans: : Stainless steel
!
PEand pp63,sometimes ABSand natural rubber, Glass
ISyringes:
! syringes for blood extraction
!Infusion equipment, bottles, 'INon-PVCinfusion equipment, ego glass for certain uses,
and/or bags with suspension PP,PE,PE/PA,EVAPCCEand PSUas well as multi use
devices, tubings, tubing suspension devices for all common
clamps, stop cocks: infusion receptacles.
EVAand EVAcopolymers, PCCEor PE,In other fields of
Tubing: application, e.g. for respiration, silicon or rubber
! ,-ubings
! PE, PC and PSU, often in combination with several
plastics. Silicon adapters with connecting parts of PE
JStop cocks: and PP
i
iGastric probes: Silicon and PP
Catheters silicon and latex drainage
bottles, collecting 'glass, PE, PE/PP
bags:
Scalpels: (disposable with .
iMetal handles with interchangeable, s'
PVC handles) i .
masks ubber, silicon, latex
Special Case Blood Bags plier with prototype in U.S.A
Packaging ostly PVCfree now. PPBlister.packs

62 PE: Polyethylene
63 PP: Polypropylene
PVCplastic is probably the single most significant source of chlorine in hospital waste
incinerators - the element responsiblefor dioxin generation. An estimated 9.4% of all
infectiouswaste is PVC,and virtually all availablechlorinefed to medicalwaste incinerators
comesfrom PVc.

ALTERNATIVE
DISINFECTION

To disposeof the 10% of infectiouswastethere are severalalternative,dioxin-freemethods

that are cost-comparative. Some of these are: Autoclaving, Advanced Autoclaves,
MicrowaveDisinfection,sometypesof ChemicalDisinfection,and Dry HeatSterilization.

Pyrolysisand gasificationsystemswere deliberatelyexcludedfrom the list of alternatives.

"While they are being promotedas clean, non-burn alternatives,they are still capableof
generatingdioxins,furansandother pollutants,despitemarketingand promotionalclaimsto
the contrary.,164
. Autoclavina

"An estimated 45% of infectious medical equipment from Western hospitals is already
reusedthrough autoclaving. This is donethrough steamsterilisation,whichencouragesthe
reuseor recyclingof medicalequipment. Autoclavesare commerciallyavailablein varying
sizesfrom desktopto industrialunits."

The processinvolvesheatingbagsof medicalwaste between120and 1650degreesCelsius

for 30 to 90 minutes in chambersinto which pressurisedsteam is introduced. The steam
penetration ensures destruction of bacteria and pathogenicmicroorganisms. Waste is
reduced by an estimated 75% of its volume and can either be landfilled directly or
compactedfurther. The autoclavedinfectiouswaste adds to the landfill burden, but the
amount is usuallylessthan 0.2% of the municipalsolidwastestream. Accordingto a recent
survey of hospitals that have installed autoclaves, they are easier to operate than
incinerators.

. AdvancedAutoclaves

Advancedautoclaves basicallyfunction as autoclavesbut they combine steam treatment

with pre-vacuumingor pulsed vacuuming, or various kinds of mechanicalprocessing
(internal mixing, fragmenting, shredding,etc.) before or during steam treatment. Other
may incorporateshredding,drying, and/or compactionafter steamtreatment. The addition
of internal shredding or mixing improves the transfer of heat, lessens the time or
temperatureneededto achievedisinfection,and reduceswaste volume.
. Microwave Disinfection

Microwavingis economicallycompetitive and versatile. Studies in Europe have shown

virtually no emissionssince the device'sinternal heating system is closed. Consequently,
there is no need for pollution control devices. Microwavedisinfection relies on treating
hospitalwastewith moist heatand conventionalmicrowavesat temperaturesof 940°C. The

64Global Anti-Incinerator Alliance& Global Alliance for Incinerator Alternatives, website: www.no-
burn.org; action kit; alternatives; medical waste incineration.
equipment can be installedon- or off-site in stationary or mobile units. The remaining
residuesthat have been reducedby 80% in volumecan be landfilled.
. Chemical Disinfection
Chemicalprocesses employdisinfectantssuch as peraceticacid, or dry inorganicchemicals
such as lime to destroy pathogens. To enhance exposure of the waste to the chemical
agent, chemicalprocesses often involveinternal shredding, grinding,or mixing. Besides
chemicaldisinfectants,there are also encapsulatingcompoundsthat can solidifysharps,
blood,or other bodyfluidswithina solidmatrixpriorto disposal. The use of heated alkaliin
stainless steel tanks is a non-burn alternative for treating tissues, pathologicalwaste,
contaminatedanimal waste, and chemotherapywaste. However,some chemicalsystems,
such as hypochlorite-basedtechnologies,can also release pollutantsin the wastewater.
. Drv Heat Sterilization

Just as circulatinghot-air ovens have been used to sterilizeglassware and other reusable
instruments,the concept of dry heat disinfectionhas been appliedto treatment of medical
waste. In dry heat processes, heat is appliedwithoutadding steam or water. Instead,
the waste is heated by conduction, natural or forced convection, and/or by thermal
radiation. In force convectionheating,air heated by resistanceheaters, is circulatedaround
the waste in the chamber. In some technologies,the hot walls of the chamber heat the
waste through conductionand natural convection. Other technologiesuse radiant heating
by means of infrared or quartz heaters. These non-burn dry heat systems operate at
temperatures below 177 C, i.e., at temperatures in which no burning or combustiontakes
place.
Some cost comoarisons of incinerators and autoclaves with shredder

In general, lowheat technologiessuch as autoclaves,advancedautoclaves,microwaves,and

dry heat systems are the most environmentallyfriendly alternatives. Autoclavesand
advanced autoclavesare the cheapest. Microwavesand dry heat systems tend to be very
expensiveexcept for the smallestunitsthat are only usefulfor clinicsor singledepartments
in a hospital. Autoclavescan be locallymanufacturedand therefore are recommendedas
an alternativeto medicalwaste incinerationin the Philippines.They can also be combined
with post-treatmentshreddingand compactionto reducevolume. The treated waste can be
recoveredor recycled.
Table 7. Cost Comparison of Small-Scale Incinerator and Autoclave (50 kgjhr) for on-site
treatment
COST ITEM INCINERATOR AUTOCLAVE

Baseequipment 150,000 47 000

Installation 22,500 5000
Air PollutionControl 194,500 0
Electricsteam generator 0 16 000
Shredder 0 23,000
Monitoringand testing 16,600 2,400
TOTAL U.S. $ 383,600 U.S. $ 93,400
Incinerator costs based on medical waste incineration review by Seeker (1998) and EPAstudies. Autoclave cost
based on AS 23 model of Mark Costello.

Table 8. Capital Cost Comparisons of Incinerator and Advanced Autoclave (50 kgjhr)
COST ITEM INCINERATOR AUTOCLAVE

Base equipment 150,000 70,000

Installation 22,500 6,500
Cost of pollution control 194,500 0
technology to meet EPA
emission limits for a 50 Ib65fhr
incinerator
Cost of electric steam generator 0 16,000
Cost for monitoring and testing 16,600 2,400
TOTAL $383,600 $94,900
Incinerator costs based on medical waste incineration review by Seeker (1998) and EPAstudies.
Advanced autoclave costs based on information from San-I-Pak, a company that produces this type of
sterilization units.

Table 9. Cost Comparison of Large-Scale Incinerator and Autoclave

COST ITEM 750 Ibfhr INONERATOR 500 Ibfhr AUTOCLAVE

Equipment 750,000 118,000

Air PollutionControl 344,000 --
Automatic Feeder or Tipper 50.000 5,000
Boiler -- 27,000
Shredder -- 115,000
Compactor -- 40,000
Treatment Facility 285,000 207,000
Installation
TOTALCOST $1,429,000 $512,000
Based on 750 Ib/hr incinerator (Symonds), 500 Ib/hr autoclave (Sierra).

Autoclavingis the most profitableinvestment unless there are no regulations at all on

incinerationemissions. Furtherassessment was made of the costs to hospitalsof converting
to autoclaves,includingpayingoff the debt on the originalpurchase of an incinerator. In
this scenario,the conversioncosts of $2.9 milliondollarsare stillcheaper than the annual
operatingcost of incinerationwith mandatoryemissionupgradingat $3.4 milliondollarsper
year.
TECHNOLOGIESIN THEPHIUPPINES

Section A is an indicativelist of technologiesthat may be appropriateto the Philippines,

have possibilitiesand are worthconsideringas non-burnalternativesto incineration.Section
S, on the other hand, is a list of technologiesthat might be less appropriate under our
circumstances.

6S"lb"is short for pounds (from the Latin word "libra"); so SOIb/hr is SOpounds of waste per hour or
about 23 kg/hr.
 Techno/oaies that should be considered in the Phi/iooines

. AWSClinicalWaste (Cleveland, Queensland, Australia);

. Bondtech (Somerset, Kentucky, USA);
. Ecodas (Roubaix, France);
. EnvironmentalTechtonics Corporation (Southampton, Pennsylvania, USA);
. Hydroclave(Kingston, Ontario, Canada);
. MarkCostello (Carson, California,USA);
. Meteka Medister (Burggasse, Austria);
. Pulse Pharma (New Delhi, India);
. San-I-Pak (Tracy, California, USA);
. Sanitec (West Caldwell,New Jersey, USA);
. Sierra Industries (Santa Ana, California, USA);
. Sintion (Graz, Austria);
. Tempico (Madisonville,Louisiana, USA);
. Waste Reduction by Waste Reduction (Indianapolis, Indiana, USA).

An immediate response to comply with the incineration ban is to put into operation all the
existing non-burn disinfection technologies 36 Meteka medister disinfection units, also
enumerated in the above list of technologies that may be useful in the Philippines,were part
of the Austrian Project, and were installed in 35 DOH-hospitals,with one hospital receiving
two units.

Techno/oaies that mav be viable in the Phi/iooines

. Antaeus (Hunt Valley,Maryland, USA);

. Balcan Engineering (Lincolnshire, England, UK);
. Daniels Corporation (Dandenong South, Victoria,Australia);
. Ecolotec (Union Grove, Alabama, USA);
. KCMediWaste(Dallas, Texas, USA);
. LogMed(Kaufering, Austria);
. MachinFabrik (Mumbai, India);
. MatrixTechnology (Cairns, Queensland, Australia);
. Positive Impact Waste Solutions (Pearland, Texas, USA);
. Steridos (Czech Republic);
. Sterile Technology Industries (West Chester, Pennsylvania, USA);
. Steris Ecocycle(Mentor, Ohio, USA);
. SteriTech (Bloomington, Indiana, USA);
. Thermal Waste Technologies (Bethel, Connecticut, USA);
. Tuttnauer (Breda, Netherlands);
. Valides (Munich, Germany).
 Annex 2:
Listof DOHhospitalswith an Hoval incinerator

# Recipient Hospitals Location

CV1 Incinerators

1 Dr. Jose Fabella Memorial Hospital
2 Baguio General Hospital and Medical Center
3 Mariano Marcos Memorial Hospital
4 Ilocos Regional Hospital
5 Teofilo Sison Memorial Medical Center
6 Veterans Regional Hospital
7 Cagayan Valley Regional Hospital
8 Jose B. Lingad Memorial General Hospital
9 Dr. Paulino J. Garcia Memorial Hospital
1013~Q9aS,F-~gi9narrtospi~1
11 Bicol Regional Hospital
12 Albay Provincial Hospital
13 Western Visayas Medieal e:enter
.!1..'N~ro"'.Visq~$.Regional Hospital
15 Celestine Gallares Memorial Hospital
16 Zamboanga City Medical Center
17 Hilarion Ramiro Memorial Hospital
18 Northern Mindanao Medical Center
19 Davao Medical Center
20 Davao Regional Hospital
21 S0tabato R«:2!~nalHOS1Ji~1. . ...
22 Research Institute Trqpical.Medicine
Manila - Lope De Vega St., Sta. Cruz
Baguio City
Ilocos Norte - Batac
La Union - Parian, San Fernando
-
Pangasinan Dagupan
-
Nueva Vizcaya Bayombong
Cagayan - Tuguegarao
Pampanga - Brgy. Dolores, San
Fernando
Nueva.~~Qa - Cabanatuan
Batan.gas:~~qgas
Camarines Sur - C. Pequena, Naga
Albay - Legaspi City
lroiii(;itY..~M8nguriao
N~ros OCtidenfal'-BacoIO<:i
Bohol - Tagbilaran
Zamboanga City - Evangelista St.
Misamis Occidental - Ozamis
Misamis Oriental - Cagayan De Oro City
Davao City - Bajada J. P. Laurel Avenue
Davao Del Norte - Apohom, Tagum
. Maguindanao - Catabato City
,w'AlabangCity .

CV2Incinerators
=<- "-= ."""«'=~
1 East Avenue Medi€al Center ,~uezo~i:Y- ]:ast~VE!hUe., ~

2 RizalMedicalCenter -
Pasig Shaw BOulevard
3 Philippines.Ort:hopecJicCeri~r Quezon City - M. Clara St. Cdr. Banawe
4 Vicente Sotto Sr. Memorial Medical Center Cebu - Cebu City
 Annex 3. Comparison emission data on Hoval incinerators66

- - -i - -i -- -I
- - s
'1"1 00
0 Ch
)c 0 Ch
! i
'is.
Q
N '1"1
Z' EIICh ->-
I!
=
III
'"
J!I

!...
J!I
!
ii
:1:1
'c
...-
J!l8
II J!I't
jt u-
.5'1"1
u'l"l
.5'
.;
:!!.
cu
-u en -=
-U)
....:1:1
-c
III'C
!:c III ....u Co00
Co'
._0 i-=t i i::;)
!:'"
o c :E 0
!:Ch -=i 1) :=0 =PI
:Co en
:c-B
oCh °en .co
:cl! '" :c :c::!. :c- :c- CoN CoZ ::;) Ilol

Dust 50-125 125 100 200 69 mg/m3 10 mg/m3 (std)

(partlculat mg/Nm3 mg/Nm3 mg/m3 mg/Nm3 (dry, std)
e matter)
Carbon 20-50 88 50 500 500 46 mg/m (or 50 mg/m3 (std)
monoxide mg/Nm3 mg/m3 mg/Nm3 mg/Nm3 mg/Nm3 40 ppm)

SultiJr 100-200 1,661 150 145 1,500 144 mg/m;,) 50 mg/m;,)(std)

dioxIde mg/Nm3 mg/Nm3 mg/m3 mg/m3 mg/Nm3 (or 55 ppm)

Hydrogen 100-400 285.0 488.0 66 22 mg/m3 10 mg/m3

chloride mg/Nm3 mg/m3 mg/m3 mg/m3 (15 ppm)

Dioxins & 1.0- 7.378 5.900 2.3 ng/m;,) 0.1 ng/m3 (std,
Furans 10.0 ng/m3 ng/m3 (dry, std) 4-hr ave)
(teq) mg/Nm3

Note: in some cases, it was not clearwhetherthe unitswere definedunder normalor standard conditions(whichin turn are defineddifferentlyin different
countries)but the differencesare small; for examplea normaltemperaturedefinedas 0 °C versus a standard conditiondefinedas 20°C results in a 9%
differencein value.

66 Sources: "Certificate: Emissionof Hoval-Incinerators,"TUVBayern Landesgesselschaft Osterreich GmbH,May5, 1998; Chapter VI "Environmentally
Acceptable" in "Austrian Project-Waste Management Component", Vamed Engineering, October 2, 1996, pages 27-28; test results from GM Sandoval, Inc.
(GMSI) for the emissions from Philippine Orthopedic Center incinerator, source sampling conducted on October 17, 2001.
 Annex 4. Costs Hoval incinerators

CI) CI) g:
teA:' t( =c
II.I
U)
(1)% (I) (l)C ...
::IA. ::1- ::III)
I!!N I!!g: I!!II) .5
CUll)
>N . = > .
cu CI)
CI) g::11.1 A. II te
t( !I: II
A.CI)
=.... fg: .5
w:E: ...
.5 .5t( c....
'-c .-c::)
11.1 'c
I- cu cu
U cu....
. uC . S...
.--
::I
I-
'C I-U) 'C II I-N cu
J!!
1;;
c:a.

j....
-c:a.

.13....
c:a.

as-
-c-
c:a.c
BNA. u
Q.
cu
'C
"4
8 .5 .5f A.
. '!:reiaht and Insurance 7,620,370 19,203,332 553,772 26,332,371
,
Project managemenf7 20,990,640 52,896,413 1,525,390 72,533,658
.., Irrainina 4,834,182 12,182,139 351,300 16,704,631 ,
Maintenance -,
5,954,700 15,005,844 432,728 20,576,608
Related Services 39,399,892 99,287,728 2,863,190 136,147,269
CV1 (22 vnits) 43.989, OOG 110, 852,28C 3,196,681 152,005,041 1,999,50C
CV2 (4 vnitsJ 8,871,58G 22,356,382 644,69 30,655,957 2,217,89t
Incinerators 52,860,58CJ 133,208,662 3,841,378 182,660,998
M 60 A (14 units) 14,082,740 35,488,505 1,023,393 48,663,245 1,005,910
M 160 A (22 units) 28,960,756 72,981,105 2,104,578 100,074,585 1,316,398
Disinfection units 43,043,496 108,469,610 3,127,971 148,737,829
Waste disposal equipment 95,904,076 241,678,272 6,969,349 331,398,827
Medical eauiDment 64,556,032 162,681,201 4,691,287 223,074,912
CONTRACT PRICE 199,860,000 503,647,200 14,523,826 690,621,007

67 Including: (pre-)installation, ...