Discussion

In 2018, the USA generated 292.4 million tons of municipal solid waste, of which 18% was plastic.¹⁰ Pre-COVID-19, USA hospitals comprised 2% of that amount and produced over 5 million tons of waste, of which at least 20% were plastics.Reference Janik-Karpinska, Brancaleoni, Niemcewicz, Wojtas, Foco, Podogrocki and Waste-^{5, 7,} Reference Dehghani, Ahrami, Nabizadeh, Heidarinejad and Zarei^11, Reference McGain, Clark, Williams and Wardlaw¹² It is interesting to note that during the COVID-19 pandemic, single-use plastics, along with cement and steel, became the most widely manufactured substance in the world.Reference Williams and Rangel-Buitrago¹³ The global medical plastics market size in 2023 was estimated at 52.9 billion USD, with the expected growth at a compound annual rate of 7.4% from 2024-2030, with a revenue forecast in 2030 of 87.58 billion USD annually.¹⁴ Considering that plastics are becoming a bigger part of health care trash and US Environmental Protection Agency (EPA) and other government numbers, it is suggested that, in the USA, 1.7 million tons of plastics are part of the 5.9 million tons of nonhazardous medical waste transported to landfills, incinerators, or transferred by ship to other countries.Reference Voudrias^{6, 8, 9, 15}

Today, plastics are ubiquitous in our health care system, from packaging of all supplies to operating room instruments (either plastic originally, or as sterilization protection), procedure labs, and daily protection of employees as single-use PPE. Waste generated by health care facilities has become increasingly recognized as a consequential source of environmental pollution, particularly due to the widespread use of single-use plastic PPE whose components are not recycled. Barriers to recycling hospital plastic waste include the risk of further spreading of infectious diseases and a lack of knowledge regarding appropriate recycling.Reference McGain, Clark, Williams and Wardlaw^12, Reference Azous, Boyll, Swanson, Castel, Maffi and Rebeca¹⁶ In 1 published study, a hospital’s catheterization lab was projected to accumulate 2600 kg of recyclable medical material in a year, which the authors extrapolated for the USA to be 1.36 million kg of recyclable waste, the majority of which is plastic and would be generated annually from catheterization labs alone.^17, Reference Doshi, Savage and Ruggiero¹⁸

As plastics enter the environment as waste, many public health threats are becoming more evident. When discarded, these items are exposed to elements including ultraviolet (UV) radiation and are degraded into microplastics and micro-fibers.Reference Khan, Shah and Hossain¹⁹ These minute plastic beads have been detected in a variety of human tissues and marine and terrestrial wildlife, supporting speculation that the same anatomical and physiological issues affecting marine and terrestrial wildlife are affecting humans as well.Reference Ragusa, Svelato and Santacroce^20‒Reference Leslie, Van Velzen, Brandsma, Vethaak, Garcia-Vallejo and Lamoree²³ Initially, as plastic breaks down, it degrades through mechanical tumbling forces and exposure to ultraviolet radiation; these pieces move through the marine and terrestrial environment, where there are unintended consequences. These include hormonal dysregulation, which may result in low birth rates and birth defects; ingestion, causing physical obstruction of the gastrointestinal system, as well as causing a decrease in nutrient absorption because of the microplastics deposits; and increased free-radicals, which are known to increase cancer risk.Reference Ragusa, Svelato and Santacroce^20, Reference Rahman, Sarkar, Yadav, Achari and Slobodnik²⁴ Other health risks include reproductive or endocrine disruption and behavioral abnormalities in animals, including humans, due to plastic softening additives such as Bisphenol A and Di-2-ethylhexylphthalate during its manufacturing and breakdown.Reference North and Halden²⁵ The negative impacts of plastic waste on health are calculated to affect humans by 314 disability-adjusted life years (DALYs) (1 DALY represents the loss of the equivalent of 1 year of full health) and an overall global effect of a loss of species per year of 0.67.Reference Islam, Safiq, Bodrud-Doza and Mamun^26, Reference Rizan, Reed and Bhutta²⁷ Overall, the impacts of plastics through manufacturing and breakdown on the world are ubiquitous. Effects include water usage and pollution, energy consumption (oil and electricity), greenhouse gas emissions, solid waste burden, and dioxins and heavy metal release through incineration.^15, Reference Hong, Zhan, Yu, Hong and Qi²⁸

In our retrospective review of waste in our hospital during COVID-19, it was originally hypothesized that we would have a noticeable increase in the gross tonnage of non-hazardous waste due to the increased use of PPE (masks, gowns, gloves, and eye protection) by hospital employees. However, during the study period, the average amount sent to the landfill was 100 gross tons/month, which was just shy of pre-pandemic numbers (Figure 2). As we investigated further, it made no sense that gross tonnage would stay about the same even though the amounts of PPE, which included gloves, gowns, and masks purchased, had increased. It could be surmised that because there was both a decrease in patient census in the hospital as well as a decrease in employees working at the hospital, the nonhazardous waste gross tonnage would have been markedly increased if the hospital was operating at full capacity.

Figure 2.

Volume of gloves, masks, and gowns purchased from August 2019-December 2021.

The key is the creation of a hospital economy in which plastic packaging is reduced initially and resource utilization is maximized through purchasing items that may be reused as well as the promotion and implementation of safe recycling practices.Reference Voudrias^6, Reference Rizan, Reed and Bhutta²⁷ Hospitals have a great opportunity to be at the forefront of promoting and improving public health as well as embarking on cost savings measures, some of which are as easy as promoting awareness to increase compliance. Examples include an article in the American Journal of Surgery where operating room staff was unaware that the plastics could be recycled and did not know to put clean plastics in recycling containers that were available in the operating room,Reference Azous, Boyll, Swanson, Castel, Maffi and Rebeca¹⁶ as well as another article which revealed that 90% of “red bag-hazard” hospital waste does not meet the criteria for hazardous waste and is actually nonhazardous plastic waste which does not need special handling and could go into regular trash or into recycling.

As hospitals are more fiscally aware and leery of spending money, one of the other barriers to plastic recycling is a myth that it is not financially beneficial. However, a study examining data from hospitals that have implemented programs to reduce energy use and waste shows that savings could exceed $15 billion USD over 10 years, including recycling and reprocessing of single use plastic devices.Reference Wu and Cerceo³⁰ Additionally, there is a growing research movement and project development exploring biodegradable PPE and the creation of PPE gowns that can withstand laundering 75-100 times in contrast to single-use plastic gowns.Reference Baker, Bromley-Dulfano and Chan^31, Reference Klemeš, Fan, Tan and Jiang³² Other papers have discussed repurposing surgical masks to create sound-dampening material.Reference Maderuelo-Sanz, Acedo-Fuentes, García-Cobos and Sánchez-Delgado³³ Currently, there are already reusable hoods on the market with battery packs that power personal air filters whose face and head covering may be cleaned and even sterilized for continued safe use in the operating room. The key is the creation of a circular economy in which the use of plastics is principally reduced, and resource utilization is maximized through reuse or ensuring safe recycling practices.Reference Voudrias^6, Reference Rizan, Reed and Bhutta²⁷