I recently engaged in a discussion on health care waste disposal in low to middle income countries (LMICs) with Mike Friend, a colleague at work, within product development for health technologies to fill gaps in primary health care (PHC). This conversation made me reflect on my own experience with health care waste in the outskirts of Kampala, Uganda.
My very first patient was a plastic bottle, which I treated for pneumonia. It was a Saturday morning of the December school holiday and everyone at home was doing chores. I had completed my task of washing the dishes. I decided to make use of the free time to walk barefoot to a landfill 2 miles away from home. My friends in the neighborhood and I had discovered the landfill the previous day.
The large landfill was about 15, 000 sq. ft with heaps of waste. There was a mix of plastics, rope, soiled linen and cotton, broken medical equipment, needles and syringes of various sizes and colors, and all assortment of medical wastes. Steam was cloudy over the heaps of waste. Flies were hovering around in search for their meal of the day. Rats were all over the place. As a 7-year-old, I didn’t mind at all. I was overjoyed about the chance to perform an injection.
Because of frequent infections with pneumonia and malaria, I had received several injections in the past and I knew all the steps of giving a patient an injection—as well as I knew the back of my hand. I smiled. It felt so good to have the opportunity to practice what I had seen a nurse perform at Dr Ocen’s Donken clinic that was 2 miles from our house where my mother took us for health care whenever we fell sick.
I dipped my bare hands into the heap of mixed waste. I accidentally pricked my fingers as I pulled out a syringe and needle. I was not aware of the possible consequences of a needle stick injury or the actions that should be taken in case one experienced one. At that time (1988), one in every 3 adults had HIV in Uganda. HIV can survive in dried blood at room temperature for up to six days, although the concentrations of virus in dried blood will invariably be low to negligible.
Completely unaware, though, I smiled like the biggest achiever in the universe. I was amazed that I had gotten an effortless opportunity to step into the shoes of the doctor who always treated us. Standing with the syringe I closed my eyes and reminisced about all the steps the nurse took to give patients injections. It always started with selecting the right syringe size from a pile of syringes and needles that had been “sterilized” through boiling. Larger syringes were reserved for adults who required larger volumes of medicines for their body size.
Standing in the landfill, I didn’t pay attention to how the used metal needle I held was old and had been out in the elements. I had not yet received a tetanus booster because the national vaccination guidelines deferred it for girls until an age older than me. I could have gotten infected with Tetanus.
In 1990, tetanus caused 850 non-neonatal deaths in Uganda. In my career, I have seen a few patients with severe forms of the disease. In LMICs, there are limited treatment options. Patients are treated by managing symptoms such as spasms and respiratory distress. The last patient that I saw—who made it—was a 13-year-old girl I saw at St. Joseph’s hospital in Kitgum where I worked as a medical officer. She was referred to Lacor hospital, another missionary hospital where she was admitted in the hospital ICU for about a month. Neil Gupta, a visiting medical student from the U.S who was doing a temporary assignment abroad, accompanied the team when the patient needed immediate transfer to the hospital by ambulance—over 110km and about 2 hours of driving.
As the 7-year-old with my syringe discovery, I scanned for what could serve as my dummy patient. My eyes landed on an empty plastic bottle that once contained saline water. I felt like the “doctor of all cases,” a TV series hero I watched weekly, who had inspired me to become a doctor. I drew water from a muddy puddle. Held the syringe upright and squeezed the plunger to expel air and a few drops of water. I placed the needle in the plastic bottle that lay on the ground and gently injected the contents of the needle into the bottle. I could hear my patient held by an imaginary mother scream from pain. “You have pneumonia,” I said to my patient (the bottle). “You will need 2 more injections. Return for another injection same time tomorrow.”
It began raining heavily. I ran barefoot for about 2 miles to our home in the rain through thick grass and under mango trees. I got home drenching wet. “Where are you coming from?”, my mom asked. “Come in and change your clothes. This cold is very bad for you. You will risk catching pneumonia.” She continued even before I could respond. At that age, I already knew cold weather was a fallacy people associated with pneumonia. When I was dried up and warm, my mom handed me a cup of millet porridge. “Mmmh yummy, ” I said, as I drank from the cup—not even aware how lucky I was to have survived my encounter with discarded, hazardous medical waste.
Nations have made efforts to better manage health care waste, and control and prevent infection. Most infection control technologies were designed for high income countries that are not easy to employ in limited resource settings. Efforts around the world to create appropriate technologies for infection control will protect populations with the risks of infection associated with healthcare-associated processes.