Sterile and Sinister: The Ethics of Plastics in Healthcare

Lily Tan
Aug 1
24 min read

Updated: Oct 7

Are single use plastics necessary in healthcare? Does the industry have an obligation to limit its use if it has the ability to compromise patient safety? These are all questions which highlight the issue of plastics in healthcare. Especially with the advent of COVID, where safety of frontline workers and the public heavily depend on disposable personal protective equipment, it is crucial that this issue is studied from a variety of perspectives in addition to the popular and prominent topic of climate change. This paper seeks to answer “whether and to what degree the healthcare industry should be held accountable for their contribution to climate change and the plastic pollution problem,” through the principle of deontology, the values of accountability, responsibility, fairness, along with the principles of nonmaleficence and justice, in order to draw the conclusion that “it is ethical to hold the healthcare industry responsible for their contribution to plastic pollution as it extends to packaging and excess waste from procedures.”

Abstract
History and Rise of Plastics in Society
Advantages of Plastics in Healthcare
COVID and Plastics
Impact of Medical Waste on Plastic (Ocean) Pollution
Effects of Ocean Pollution on Human Health
Regulation Issues
Stakeholders and Considerations
Deontology
A Slippery Slope
Conclusion
Alternatives
Circular Economy

Abstract

"'Single-use plastics are the cleanest, most efficient way’ to facilitate health and hygiene in hospitals" - Gibbens, National Geographic

This quote is taken from a fact sheet by the American Chemistry Council, a plastic trade group. Plastics began revolutionizing healthcare during the mid 20th century, displacing metals through its cheap, durable, easily sealed, sterile and supposedly disposable qualities. Whatever their practical benefits, however, oceans and freshwater supply contaminated by microplastics have negatively impacted human and wildlife health.

Microplastics make their way into ocean life and the food web, where the effects that they have on humans still are not fully identified. In addition to these health risks, the amount of water used to make plastic is excessive, and the greenhouse gasses released during production pose an additional danger. Chemicals used in plastic production have been linked to hormone-related cancers, infertility, and neurodevelopmental disorders; hospitals now are being required to treat people with such disorders. This paper will focus on the healthcare industry as a major contributor to the plastic pollution problem, which has become an even more prominent issue with Coronavirus (COVID). While plastic aids in the industry’s life-saving work, plastic poses a threat to the broader population.

When COVID hit, the world turned to a hyper-hygienic way of life. Rise in single-use plastics within materials to help manage the virus revived and strengthened the demand for plastic and part-plastic products. It is important to evaluate whether and to what degree the healthcare industry should be held accountable for their contribution to climate change and the plastic pollution problem. This question is important to ask even while acknowledging that COVID has likely increased safety concerns about the risk of transmission.

I believe that it is ethical to hold the healthcare industry responsible for their contribution to plastic pollution as it extends to packaging and excess waste from procedures. While biomedical waste must be discarded properly, and certain instruments that are difficult to sterilize, which pose liability risks, should be mandated single-use, cutting down on plastic packaging and excess waste is an essential step that the healthcare industry must take towards becoming more sustainable.

Lastly, worth noting is that the healthcare industry covers a wide range of sectors. This paper largely focuses on various data from hospitals, specifically. However many of the considerations mentioned can be widely applied to other regions within the industry such as hospitals, private practices, clinics and pharmaceutical buildings, ones that continue to use single-use plastic, disposable equipment and packaging.

History and Rise of Plastics in Society

“in product after product, market after market, plastics challenged traditional materials and won, taking the place of steel in cars, paper and glass in packaging, and wood in furniture” - Susan Freinkel, Science History Institute

World War II required plastic production to grow in the United States in order to fuel industrial and military success, which was crucial to the Allied victory. Plastic was incorporated into military equipment such as plane cockpits, insulade radars, and synthetic rubber for tires. The role of plastic in the ability to produce synthetic alternatives rather than limited natural resources was important and production during WWII increased by 300%. Increased trends in plastics continued after the War when Americans were ready to spend. Author Susan Freinkel said “in product after product, market after market, plastics challenged traditional materials and won, taking the place of steel in cars, paper and glass in packaging, and wood in furniture” (Science History Institute, “History and Future of Plastics”). The material’s perceived abundance (inexpensive, safe, sanitary, flexible) in material gave people hope for the future.

Waste was first observed in oceans during the 1960s parallel to an increase in environmental pollution awareness. Slowly, the view of plastic changed from being inexpensive, safe, and flexible to cheap, and flimsy. As growing pollution and concerns increased, the plastic industry promoted recycling as a solution. The public was led to believe that their plastic products could be recycled, and was never told the truth about the complications of recyclability, leading to more plastic being dumped in landfills. The Great Pacific Garbage Patch, a collection of marine debris in the central North Pacific Ocean, emerged as the epitome of the plastic waste problem. Plastic’s reputation further plummeted with knowledge of the looming threat that most plastics posed to human health, specifically with concerns surrounding additives incorporated during manufacturing. Scientists and the public have grown concerned surrounding the evidence of chemicals leaked into human food and water sources (Science History Institute,“History and Future of Plastics”). Bisphenols and phthalates are two that can make the material harder, softer or more flexible depending on the product. However food that touches this plastic, once warmed, can absorb such chemicals (Loria.)

Today, plastics are produced of almost 100% of chemicals that come from oil, natural gas and coal, all of which are non-renewable. It is estimated that plastic energy could use 20% of the total oil in the world. The USA Environmental Protection Agency reported that 114 million tons of carbon dioxide (CO2) equivalent gas are annually released from the 130 plastics manufacturing facilities and related power plants. It takes 22 gallons of water to manufacture 1 pound of plastic, and around 300 million tons of plastic are produced each year.

Many countries do not have infrastructure to prevent plastic pollution such as sanitary landfills, incineration facilities, recycling capacity, circular economy infrastructure (infrastructure consisting of investments in transports, energy, social, communications, water and waste sectors that work to foster an economy valuing sustainability), and proper waste management/disposal systems. Mismanagement leads to ‘plastic leakage’ into rivers and oceans. Illegal/legal trade of plastic waste can be detrimental to ecosystems when management fails to contain the waste (Vanapalli et al). The never ending cycle of plastic, from production to consumption, is supported through exporting waste to countries that have lower energy and labor costs. This in turn devastates communities and ecosystems where these mostly illegal dumpsites lie. Plastic production from the industry and consumption (driven by consumers) have equally great powers in the way plastic has been produced, distributed, and discarded (correctly and incorrectly).

Advantages of Plastics in Healthcare

It is important to establish the reasons why plastic is beneficial and useful in healthcare. Plastics have a specific ratio of strength and weight. Paired with its durability and versatility, it has been an integral material within the healthcare industry; for example, it has been helpful in creating fluid bags, intravenous devices (IVs) and surgical gloves (Parashar et al). Single-use plastics have found their way into various medical tools, equipment and packaging, and are also integrated into surgically implanted equipment such as pacemakers, defibrillators, artificial joints, and limb prosthetics. These devices may help reduce the risk of rejection fractions and formation of scar tissue. Additionally, plastic’s inexpensive nature has allowed for it to be applied in numerous ways. Its convenience regarding disposability is also attractive, especially when looking at the persistence of COVID and the amount of infected waste it creates.

Healthcare facilities have tools constantly contaminated with blood and pathogens that cannot be recycled. Plastic has been able to be designed so that it can be coated with resistant microbes to fight against these bacteria. Applications of plastic within the industry include protective gear, medical tools, equipment and packaging. The majority of operating room (OR) waste stems from surgical supplies, personal protective equipment (PPE), drapes and plastic wrappers. As the number of operations rise, so does the plastic waste.

Interestingly, the increase of OR and hospital waste is partly due to the switch from reusable to single-use plastics in the 1980s, stemming from concerns about blood-borne disease such as AIDS (Gibbens). Because everything in ORs (and within the healthcare industry overall) must be sterile, all of its supplies and equipment must be sealed in either disposable polypropylene wraps, rigid plastic packaging trays, or other materials. However, it is estimated that 90% of this waste is non-hazardous and potentially recyclable; such as surgical gloves/masks, ventilator tubing and indwelling catheters (Parashar et al).

COVID and Plastics

“The Covid-19 pandemic is estimated to generate up to 7,200 tons of medical waste every day, much of which is disposable masks” - MIT

COVID created a new obsession with hygiene in regard to reducing the risk of transmission of the virus. This has concurrently led to more relaxed policies surrounding plastic production and consumption. Coronavirus also refocused attention on plastics in society and the healthcare industry. Public safety and protection of front line workers have heavily depended on plastic. PPE such as face masks, gloves, gowns, and face shields, among others, are vital when avoiding contamination and reducing the risk of spreading COVID. Demand for this upfront cheap and easily disposable equipment has immensely contributed to the heightened demand of plastic (single-use) production. PPE and other disposable products made of plastic have been in demand in sectors such as hospitals, quarantine facilities, containment zones and private practices (Parashar et al).

The virus has also increased the demand for plastic-packaged goods through paranoia about transmission of diseases on hard surfaces, and can be seen in more use in online shopping, home delivery services, and the use of disposable utensils. Plastics packaging is light, flexible and durable. This increased demand has led to the reversal of previous bans and restrictions against SUPs in many countries (Parashar et al). Evidence of COVID plastic waste can be seen in places like Hong Kong and the United States. OceanAsia in Hong Kong and similar groups have reported a mass of surgical masks on the coasts of Soko Islands (Vanapalli et al). Surfrider Foundation in the United States, a non-profit environmental organization focusing on the health quality of Earth’s water, found numerous single-use masks, gloves, and other PPE on beaches during cleanups. “The Covid-19 pandemic is estimated to generate up to 7,200 tons of medical waste every day, much of which is disposable masks” (Trafton, MIT). Compared to pre-COVID times, waste has increased within healthcare facilities up to 10 times the amount of what it used to be.

An example of the life cycle (production to often pollution) of a commonly used single-use item during COVID is disposable masks. They are produced with three layers; inner (fibrous material), middle (filter) and outer (nonwoven, water resistant, colored). In general, masks are made from various polymeric materials, which are the same materials used to make other different types of plastic products. “These face masks within the littering surface are washed into water bodies through surface flooding and canals adding to the nearness of a macroplastics then after a microplastics within the oceanic medium,” (Aragaw). The main filtering is made from conventional fabrication fibers; these can be nanofiber/microfiber. The use of these polymeric materials in general have been discovered as a significant source of macro and microplastics pollution in the environment.

Impact of Medical Waste on Plastic (Ocean) Pollution

Plastic waste makes up "'80% of all marine debris found from surface waters to deep-sea sediments" - IUCN

Plastic pollution is an enormous problem affecting the environment, and specifically marine environments. It threatens ocean health, the health of marine species, food/safety quality in humans, human health as a whole, coastal tourism, and is a major contributor to climate change. Around 14 million tons of plastic find its way into oceans each year. Debris, which includes plastic food wrappers, straws, cups, bags, and bottle caps, is the most common type of waste in oceans and makes up “80% of all marine debris found from surface waters to deep-sea sediments” (IUCN). It is present on the shorelines of every continent, with larger amounts found near popular tourist areas and densely populated areas.

The largest sources of plastic waste originates in oceans comes from urban and storm runoff, littering, sewer overflows, industrial activities, construction/illegal dumping, and poor waste disposal/management (IUCN). Solar ultraviolet (UV) radiation, wind, currents and other natural processes erode plastic down to microplastics (plastics less than 5mm long) or nanoplastics (1-1,000 nanometers). In addition, plastic warmed by the sun can release greenhouse gasses. The size of these (5mm-100nm) debris make it a prime candidate for marine life to ingest accidentally. Ingestion is best illustrated by stories of marine species that become entangled and/or suffocate when they encounter plastic in the ocean. Wildlife such as whales, fish and turtles mistake plastic for food and most die of starvation with stomachs full of debris. These plastics cause lacerations, infections, reduced ability to swim and other internal injuries (IUCN). If it does not lead to death, plastics will continue in the food chain, leading to health concerns among other animals, including humans.

Effects of Ocean Pollution on Human Health

“These face masks within the littering surface are washed into water bodies through surface flooding and canals adding to the nearness of a macroplastics then after a microplastics within the oceanic medium” - Tadele Assefa Aragaw

Microplastics have found their way into numerous places across the world, such as tap water, salt and into the world’s oceans (including the Arctic). Several chemicals used to produce plastics are carcinogenic and pose a threat to the body’s endocrine system, causing developmental, reproductive, neurological and immune disorders in both humans/wildlife. Scientists are still unclear in their research if microplastics found in the human placenta is currently a widespread problem and of big concern. Contaminants have also grown on surfaces of plastics while being exposed to seawater for too long. Marine organisms ingest this debris, which enter into digestive systems and pollute the food web over time. Transfer of contaminants between marine organisms and humans through seafood consumption has been seen as hazardous to health (IUCN).

Regulation Issues

Waste Management Issues

Plastic management pre-pandemic was already insufficient. Infrastructure for management was generally built for an average amount of plastic and composition material, yet pre-pandemic waste and disposal of plastic was already greater than could be handled by existing infrastructure. COVID has created an enormous increase in waste generation and complex composition material, and will very likely overburden infrastructures and disrupt everyday operations. Challenges in management of plastic during the pandemic within the system include source identification, segregation, collection/transportation, and treatment/disposal. Different international organizations (World Health Organization, United Nations International Children’s Emergency Fund, United Nations Environment Programme, etc.) have currently created specific guidelines and advisories to manage the COVID biomedical waste containing plastic (Parashar et al).

Most of these guidelines and advisories focus on hygiene routines, use of PPE, segregation, collection, storage, transportation and proper treatment/disposal of potentially contaminated materials. Despite these guidelines, some Asian nations do not follow standard procedures for handling waste which leads to an accumulation of COVID-19 infected plastic waste within communities; developing countries (Cambodia, India, Vietnam etc) have reported to be dumping infected biomedical waste in open landfills (Parashar et al).

Current management techniques are mechanical recycling (16%) , incineration (25%) and landfilling (40%). The remaining waste has leaked into the environment from mismanagement (19%) (Vanapalli et al). Recycling has widely declined during the pandemic as seen in states within the US suspending/downsizing municipality-run recycling programs as more workers became sick and operational changes prevented growth. Disruption in programs has increased in countries like Kenya, Indonesia and Haiti due to severe budget cuts (Parashar et al).

Despite landfilling being a common method of plastic disposal within waste management, unscientific landfilling and indiscriminate dumping are common among the developing world. Landfills and dumpsites could reach their capacity, have leakage, mismanaged plastic waste, and leached toxic chemicals. Increased demand and production of SUP PPE causes disasters when improperly discarded and littered, finding its way into oceans and eventually land-based waterways. This cycle of increased demand for plastics, leading to inappropriate disposal, has been further exacerbated due to recent flooding in many South Asian countries like Bangladesh, Nepal, Bhutan, and India.

Plastic Production Issues

Unlike 90 other countries, the US has not established regulations on single use plastics (Seo). Though awareness has risen, the federal government has left individual cities, counties and states to decide whether and how plastics should be regulated. Plummeting oil/petroleum prices in January of 2020 (likely from reduced transportation during pandemic) created a decrease in the cost of plastic manufacturing, leading to increased manufacturing of SUPs and forced its industries to choose between recycling and production of plastics.

Access and Consumption Issues

With an increase in SUPs, policies regulating these plastics have risen (national and sub-national levels). Over 60 countries introduced bans/levies to try and deter SUP waste during the past 4-5 years (PRI). Concerns of cross-contamination through reusable plastic bags and containers is an idea planted and supported by manufacturers. Countries such as the USA, Portugal and Canada have paused their ban of SUPs during COVID; the US planned to ban plastic straws, takeout containers and single-use plastic bags in order to fight pollution from SUPS. COVID halted this and can be seen specifically in the delayed enforcement of the state-wide plastic bag ban in New York as of May 2020 (Parashar). The statewide ban on single-use bags (fines with a few exceptions) finally went into effect during October of 2020 (Kim). Starting May 4, 2022, “single-use plastic bags will be banned in all New Jersey stores, and paper bags will be banned in grocery stores" (nj.com).

Health Requirement/Standard Issues

WHO projected 89 million face masks, 76 million gloves, 30 million gowns, and 1.6 million goggles, with 2.9 million hand sanitizers, in order to combat infection during COVID per month in 2020. Standards for infectious waste are defined as materials “generated as a result of medical care or research containing pathogens that have the potential to transmit infectious diseases” (Andeobu et al). Though up to 90% of hospital waste can be recycled, the other 10% is hazardous and “the onset of the current COVID-19 pandemic has created the need for public awareness and the importance of its separation from general waste” (Andeobu et al). WHO guidelines advise incineration of PPE/infectious (plastic) waste in 900-1200 degrees celsius temperatures. Capacity of incinerators needs significant reworking to deal with this pandemic causing a surge in plastic waste/composition processing. There must also be equipment added to control and minimize air pollution. The other 90% of general, non-hazardous waste has potential for recycling and reuse.

Guidance regarding decontamination methods of COVID plastic waste, transportation, operation maintenance, cost, and economics are outlined elsewhere. Once decontaminated, this waste goes to disposal facilities. Disinfection solutions such as chemical sanitation/high-treatment options are also considered to be environmentally possible; this includes scientific sterilization of infected biomedical waste, microwave/radio wave disinfection, and steam disinfection/autoclaving, which can help shrink transmission risk of COVID plastic waste. However, with higher demand and shortages of PPE within countries, decontamination could help reprocess used plastic protective gear such as eye goggles, face shields, and face masks. This use of decontamination could reduce waste (Parashar et al). Given the complexity of the situation, should hospitals and workers be held responsible for their contribution to plastic pollution? If so, what values and ethical considerations complicate this issue?

Stakeholders and Considerations

Accountability and Responsibility: Doctors

"a global pandemic is not the time to burden health-care professionals with another responsibility" The Conversation

Doctors have many duties to their patients, the first being care and treatment. Caring for a patient can look different in a variety of ways, but is changing the healthcare industry’s use of plastics one of them? Some say “a global pandemic is not the time to burden health-care professionals with another responsibility” (The Conversation). Furthermore, they could resist this responsibility while focusing more on their life-saving work. The efficiency of plastic presents itself as being advantageous to doctors and the healthcare industry, whose primary goal is to help as many sick people in need. This mission to help those in need is also why the system as a whole should take interest in the well-being of their patients and know the full impact of plastic pollution on human health.

Nonmaleficence: Doctors

"'Addressing sustainability is not really on our priority list; everything we do is about helping our patients'" Teves, Ngo, BBC

Addressing the environmental impact of healthcare can become fiercely debated. For doctors, the patient always comes first in terms of safety. For Dr. Teves (pseudonym) in the Philippines, “her motivation in saving devices was to provide equipment for patients… addressing sustainability is not really on our priority list; everything we do is about helping our patients’”. Sustainability can also help patients by protecting them from harm that could land them in the hospital, which is an important tool in preventive medicine, or the practice of promoting preventive healthcare to improve patient well-being. Doctors’ concern for their patients safety, whether by using single-use or reusable instruments, both can work under their oath of nonmaleficence, an obligation to not harm their patients. Each option poses different potential short and long-term risks to society.

It is all about looking at assumptions and different perspectives; although healthcare workers stress the need for SUPs to prevent infectious disease from spreading (COVID), only 15% of healthcare waste is classed as hazardous. [Teves’] effort in Singapore to save reusable medical devices from incineration can align care of patients and sustainability. This example stresses the importance of proper disposal techniques, perhaps a more manageable change to make than the elimination of plastics in healthcare.

Patients

"Unlike refusing a straw at a restaurant, it’s difficult to cut down on plastic while strapped unconscious to an operating table" Gibbens, National Geographic

The notion that pushes healthcare workers to reduce their use of SUPs and properly dispose of others, is built on the idea that patients are not often in the position to undertake these choices themselves. “Unlike refusing a straw at a restaurant, it’s difficult to cut down on plastic while strapped unconscious to an operating table” (Gibbens). The Plastic Industry Association and Healthcare Plastics Recycling Council in 2017 led a project and concluded that sorting recyclables in intense hospital environments was “fraught with difficulty and that the economic value was not sufficient in the current climate.” SUPs within the industry sometimes are the result of mandatory rules from the Canadian Ministry of Health; Susan Reader, director of Surgical Services and Allied Health at Rockyview General Hospital, says that the ministry can “dictate what can be reused and not be reused.”

It is also important to recognize society as patients and their role as consumers. The healthcare system is supposed to provide safe and quality care to its patients; and as consumers in this country that pay for this service, can it really be expected of them to put their lives at risk for perhaps a more eco-friendly option?

[The Ottawa Hospital] "are saving tens of thousands of dollars a year by moving to disposable fetal monitoring belts" Glauser, Petch, Pendharkar, Healthy Debate

Outbreaks of the virus can sometimes be revealed within weak spots in supplies that are difficult to sterilize, as this occurs, more instruments are mandated as single-use. If an instrument is not 100% sterilized, liability issues can occur. Cost-effective disposable products have presented themselves due to manufacturing technology. Sometimes sterilizing expensive reusable instruments that wear down can be more costly. Ann Mitchell, Clinical Director of Obstetrics and Gynecology, at The Ottawa Hospital, “are saving tens of thousands of dollars a year by moving to disposable fetal monitoring belts” (Healthy Debate).

Image by fernando zhiminaicela from Pixabay

A prime example of disposable materials preventing clinical infection is in implant-based breast reconstruction. Here, bacterial strikethrough of draping and gown material commonly causes infection. A study was conducted to conclude whether the disposable draping system trumped reusable ones in preventing implant-based breast reconstruction infection. From March 2010 through January 2012, 102 randomized women completed the study. 43 patients were in the Reuseable Group and 59 were in the Disposable Group. There were no big differences in patient demographic data, procedural data, or the type of procedure performed between groups. The Reusable Group resulted in 5 infections within 30 days, opposed to no infections within the Disposable. Secondary complications had no dramatic differences. In conclusion, the disposable draping material was successful in better preventing clinical infection within the immediate postoperative period (Showalter et al).

Education: Hospital Staff

"all you needed to do is give the surgeons, the people on the ground, the information they needed to be helpful, and they jumped at the chance" [to reduce plastic and use it more responsibly] Tymianski, National Post

An alternative could be to work on education; doctors, nurses, managers and hospital boards should be taught that the healthcare industry is responsible for a large contribution to climate change, and should seek to reduce that impact. Taking steps to reduce this footprint could then follow. Dr. Michael Tymianski, head of the Toronto Western’s neurosurgery division explained, “all you needed to do is give the surgeons, the people on the ground, the information [and materials] they needed to be helpful, and they jumped at the chance [to reduce plastic and use it more responsibly]." Plastic producers and managers, by working together, could achieve more good than harm. Producers should not feed into public paranoia of viral transmission through non-plastic/SUP packaged goods, which then in turn, overloads management systems after disposal.

According to a 2018 survey of 524 Mayo Clinic staff members, they found that SUPs accounted for 20% of medical waste in US hospitals. 57% of staff were ignorant to which items in ORs were able to be recycled, 39% thought they were already recycled and 48% had “lack of knowledge about recycling.”

Another study by Western University was conducted; staff members were asked to estimate the price of 23 common throw away supplies (range of syringes-tracheostomy tubes). More than 70% couldn’t accurately relay the cost of the real figure. The options available were unknown to surgeons and they were blind to the financial differences.

Fairness: Waste Managers

"It worked for a while when China took it" Howard, Gibbens, National Geographic

Waste managers are another important stakeholder in this discussion, they are the people that are attempting to profit off of the slim circumstances under which plastics can be recycled and reused. Janet Howard of Practice Greenhealth said “It worked for a while when China took it” referring to the problem that arose when China stopped importing 24 kinds of waste from various countries, including the USA, in 2018. Recycling efforts, Howard says, have since gone backwards. Since then, facilities have tossed mixed plastic waste into landfills/incinerators. PVC that ends up in incinerators releases toxic chemicals that impact human health.

Hospitals that attempt to sort their plastic are not producing enough material to appeal to recyclers. The Healthcare Plastics Recycling Council (HPRC) provides toolkits for hospitals looking for recycling networks to join. HPRC’s HospiCycle is a step-by-step guide to help hospitals “navigate the process of activating a plastics recycling program from initial planning and business decisions through program implementation and improvement considerations” (HPRC). In addition to also increasing awareness among manufacturers and giving design guidance on how to improve recyclability, their Healthcare Recycling Vendor Directory is an interactive tool created to “help facilitate geography-specific collaboration between healthcare facilities and recycling vendors interested in their material streams” (HPRC).

Justice: High-Income vs. Low-Income Countries

High-income countries generate more plastic per person and they have the resources to better manage waste, preventing leaks in the environment. Countries with insufficient waste collection/management create more ocean plastic pollution. Half of all plastic pollution waste comes from the countries; China, Indonesia, Philippines, Vietnam and Thailand. As stated previously, plastic production facilities are commonly found in low-income communities, where pollutants impact their health and daily life. Fund crunches in more developing countries result in disrupted recycling programs (Parashar et al).

Improper waste management in low-income countries, as seen in landfilling systems in developing countries, have caused leakage and leached toxic chemicals into the environment. Production facilities are commonly found in low-income communities, including those of color. Landfills and incinerators serve as the last step of many plastics’ journey. Many of these facilities pollute to a high degree which impacts nearby residents’ health. At the same time, placements of facilities also devalue property (NotComplicated).

The disparity between developed and developing countries, in terms of waste management and pollution, highlights the issue of environmental justice. The underlying idea behind these principles, seeks to close the disproportionate exposure of poorer and communities of color to the negative health and environmental impacts that climate change presents.

‘Polluter pays’ is a phrase associated with climate justice and states that countries creating the pollution should also clean up after themselves. While developed countries have resources to clean up and prevent waste, developing countries are left with no way out. It’s important to question whether these well-off nations have a duty to help those who cannot help themselves.

Access and Expenses

"Single-use disposables are perceived to cost less upfront" Blackwell, National Post

“Single-use disposables are perceived to cost less upfront,” as opposed to those that must be carefully sterilized to prevent infection (Blackwell). In the long term, replacing devices is costly; Canadian neurosurgeons cut costs by $750,000 by cutting use of disposables by 30% within 4 months. Disposable surgical equipment (sutures, clotting glue, scalpels, drapes) can cost thousands of dollars/case and add millions of dollars to acute-care budgets.

"An ENT surgeon who stopped using a single-use, tissue-sealing device that cost $375 and replaced it with a $35 model. He felt the 10 minutes saved by the pricier one could not be justified" Blackwell, National Post

“How you do clinical practice in a sustainable way is going to require every healthcare professional to think about it, ” says Dr. Tymianski. Some doctors are concerned that cheaper supplies could put a small group of patients at greater risk; severing an appendix through loops that cost $18 vs. $300 for detaching it with a surgical stapler. The loop has a 1% greater risk of complication and wipe out costs. “An ENT surgeon who stopped using a single-use, tissue-sealing device that cost $375 and replaced it with a $35 model. He felt the 10 minutes saved by the pricier one could not be justified” (Lemke).

Deontology

"Traditional assessments in the successes or failures in the healthcare system as a whole have yet to factor in the cost of pollution both up and downstream of the industry’s supply chain, from resource extraction to disposal management" Jodi Sherman, Yale School of Medicine

Using the framework of Deontology, hospitals (and the healthcare industry) have a duty to their patients to reduce their use of plastics and contribute to climate change. Though a doctor’s responsibility is to the individual patient, the healthcare industry is not tied to that kind of one-on-one relationship. Yale School of Medicine (Jodi Sherman; associate professor of anaesthesiology) referred to environmental sustainability as an “unappreciated dimension of health quality care.” Jodi Sherman, an associate professor of anaesthesiology at Yale, along with her co-authors said that “traditional assessments in the successes or failures in the healthcare system as a whole have yet to factor in the cost of pollution both up and downstream of the industry’s supply chain, from resource extraction to disposal management.”

A Slippery Slope

The slippery slope of not holding the healthcare industry accountable is more pollution. The BBC explains that “Coronavirus could well become a catalyst, because people may realize that by degrading our environment, we could find that we are getting more and more of these types of diseases.” Healthcare Without Harm believes that care includes addressing factors that make patients sick in the first place, not just the sick people.

Conclusion

An equitable appraisal takes into consideration the pros/cons of plastic during the pandemic and decides that this practice is primarily a polluter; considering the publics' irresponsible behavior, poor attitude and awareness, stress on waste management infrastructure regarding collection, operation and financial constraints, leading to pollution (Parashar et al).

However, it is important to acknowledge that the advent of single-use plastics has made the industry as a whole more efficient and easily sterilized. Eliminating the need to sterilize and reuse devices coming into contact with deadly diseases has created an extra precaution that is crucial to keeping humans safe. The antimicrobial surfaces the single-use devices can be coated with is extremely effective in killing bacteria and eliminating pathogens, even when its surfaces aren’t regularly cleaned.

One of the most popular methods of sterilization is moist heat taking the form of saturated steam. This steam, while being nontoxic and inexpensive, can damage some materials such as; reduction of ability to transmit light associated with laryngoscopes. Sterilization is much more time consuming, compared to a kit of disposable plastic tools that could easily be thrown out and exchanged within minutes or even seconds. Growing populations and overloaded hospitals due to the pandemic rely on its ability to move quickly and efficiently.

Excess Waste in Operating Rooms

Operating rooms are a small part of hospitals, but it is estimated they generate 20-30% of total waste produced. The value of sterilization, here, creates a challenge when it comes to waste management. It was mentioned earlier that up to 85% of hospital waste is nonhazardous solid waste. However, 50-85% of this is disposed of as biohazardous waste rather than solid. As much as 80% of solid waste from a single operation is created before the patient enters. Plastic packaging is a major contributor to waste production because many surgical products are packaged in large, double-wrapped containers. Instead, I believe hospital boards should partner with the industry as a whole to promote greener packaging practices.

“Overage” refers to surgical inventory that is readied for surgery but is not used, and therefore wasted. Many hospitals rely on industry-prepared surgical packs to promote efficiency in the OR. However, these packs usually contain tools not regularly used due to surgeons’ personal preferences surrounding equipment. Still, once outer packaging is opened, all items included are considered as being exposed to the surgical field. These items must now be discarded (Kagoma et al).

Alternatives

Reducing Waste in Operating Rooms

Reforming surgical packs is an easy way to cut down on excess use of SUP surgical supplies. Hospital boards can work with suppliers to identify the specific type and amount of tools they would need for common procedures conducted. This reduces the amount of unused stock that is unnecessarily wasted, saves money, and allows for more storage space in hospitals.

PPE and Other Medical Supplies

With new methods of sterilization on the rise, countering shortages in supplies due to COVID, hospitals are seeking the CDC’s approval to have some disposables decontaminated. In the future, these methods could be sustained to reduce waste while also prioritizing safety. Other materials that are left in a patient's room, unused, are always discarded. Organizations such as Partners for World Health (PWH), collect supplies and equipment in the USA and distribute them to more developing countries (Kaplan).

Sterilization Wrap

Hospitals commonly use blue wrap, made of polypropylene, when wrapping instruments for sterilization. According to Practice Greenhealth, around 255 million pounds are discarded per year by the healthcare industry. Previously, reusable sterilization containers were used, rather than blue wrap which is voluminous and hard to recycle . Janet Howard of Practice Greenhealth stated “we’d rather hospitals go back to reusable sterilization containers rather than recycle the blue wrap”.

Key Performance Indicators

Lastly, key performance indicators (KPIs) are a type of performance measurement that can help hospitals measure and reduce waste. PWH, for example, provides hospitals “with an annual accounting of how many pounds the organization collects, so hospitals can calculate their savings from avoiding disposal fees” (Kaplan). Howard believes that by having hospitals create positions spearheading sustainability, they have the most success. Positions can include waste and/or energy managers.

Circular Economy

Circular economy is defined as an economy that uses a system-focused approach and involves industrial processes and economic activities that are restorative and regenerative by design. Plastics can be good if managed adequately and paired with circular economy strategies regarding reduction and recycle/recovery, which prevents leakage and pollution. Sustainable and safer options, such as scientific decontamination of PPE to be reprocessed and reused, plastic reduction policies, redesigned/innovative products, and independent technology during waste management, can improve the issues of public health without being detrimental to the environment. What is needed is policies that encourage creating sustainable waste management practices and consumer (healthcare systems, administrators, physicians, patient