Healthcare waste and circular economy principles: It is time to improve!

As we approach the 2030 Agenda for the Sustainable Development Goals (SDG) proposed by the United Nations in collaboration with 191 countries, the importance of the established goals – and the necessity of commitment to them – has become increasingly urgent (United Nations, 2015). To address environmental commitments, several key efforts can be emphasized, such as ensuring sustainable consumption and production patterns, promoting the development of innovative industries and encouraging the use of clean energy. These initiatives aim to mitigate climate change and natural disasters while fostering economic and social progress (Sachs, 2015). Other highlighted terms in the SDG are the access to quality essential health-care services and combatting of epidemic diseases worldwide. This challenge has been further intensified by the onset of the COVID-19 pandemic, which has amassed more than 765 million cases since its inception in 2023 (World Health Organization (WHO), 2023). This has led to heightened demands on hospitals, clinics and laboratory institutions. Demonstrating the relevance of these topics for the maintenance of human life and the environment, the question now posed within the environmental science community is: “are healthcare and sustainable development effectively working together?”

Healthcare waste (HCW) encompasses residues resulting from diagnostic, treatment and research procedures, which can be classified into infectious, pathological, sharps, chemical, pharmaceutical, radioactive and non-hazardous or general (WHO, 2022). The institutions that produce these types of waste are diverse, ranging from hospitals, laboratories and pharmacies to research institutions, dental and veterinary clinics, nursing homes, etc. According to estimates, approximately 15% of the total HCW generated in these facilities is considered hazardous due to biological, chemical or radioactive contamination (WHO, 2022). During the 1980s and 1990s, accidents and scandals involving hazardous waste heightened awareness of the need for separate treatment and final disposal for them. This led to the creation of national and regional guidelines, as well as international agreements like the Basel Convention, which established rules for the transboundary movement of hazardous waste between countries (Borowy, 2020; Yang, 2020). First-world countries have made significant efforts to comply with these guidelines, but there are numerous reports in the literature of overproduction of their HCW (Mol et al., 2022). In contrast, developing countries face issues such as improper segregation, disposal and uncontrolled combustion due to limited financial resources and regulatory structures. Such realities have made HCW a challenge for sustainable development on a global scale (Borowy, 2020).

Considering the highlighted problems and the current management system of HCW, the healthcare sector has come under pressure to devise strategies to reduce its environmental impact, thus complying with regulation and enabling its integration into the circular economy (CE) actions. One definition of the CE concept describes it as a regenerative system that minimizes the consumption of virgin raw materials, reduces waste generation and optimizes energy usage through actions such as closing, slowing and narrowing production chains (Geissdoerfer et al., 2017). In the healthcare field, applying CE principles presents a significant paradigm shift, particularly considering biosecurity concerns surrounding waste management in this sector. Recent studies have described the numerous challenges associated with implementing CE practices in HCW management. These challenges include the complexities inherent to the industry, regulatory constraints, cost and technology requirements, as well as social barriers (Mahjoob et al., 2023). Moreover, there are few comprehensive works that delve into the implementation process of methodologies, providing practical insights into overcoming these challenges (D’Alessandro et al., 2024).

One insight that could contribute to the advancement of research and practical application of CE principles in the healthcare sector is understanding the diversity among establishments that generate HCW. This includes their participation in industrial chains, their cultures, goals and routines. Such understanding enables the initial implementation of the 10Rs of CE – Refuse, Rethink, Reduce, Reuse, Repair, Refurbish, Remanufacture, Repurpose, Recycle and Recover (Kirchherr et al., 2017), considering the subjectivities of each generator, as well as their demands, suppliers and resources.

When it comes to Refuse, Rethink and Reduce, constant evaluation and training of professionals, as well as the routine procedures carried out by them, are essential. This helps to understand how the same activities can be performed with fewer resources (Refuse), that can have their life cycle expanded (Rethink) and do not need more natural resources on their manufacture process compared to others (Reduce). Institutions that commit to maintaining a schedule of review and innovation of their routine procedures, and adopting sustainable purchasing, position themselves ahead in the transition from outdated models to activities that, based on previous analyses, may yield monetary benefits and meet sustainability standards. Some possibilities that can be developed, for example, include increasing the demand of adopting bioplastics composed of organic polymers in secondary packaging for suppliers, adoption of common areas of equipment for lower energy consumption, telemedicine practices, evaluating the wastage of personal protective equipment (PPE) and the adoption of clothing with less plastic and more organic fabric (Materazzo et al., 2022; Memon et al., 2020).

About reusing materials, especially in medical procedures and clinical analysis, there is a significant preference for disposable objects over adopting decontamination techniques for reusable instruments. This preference is largely due to the perceived cost–benefit and practicality associated with disposable items (Alves et al., 2020). Additionally, the lack of dissemination and knowledge among professionals regarding safety and quality standards related to the reuse of certain materials, coupled with the need to ensure patient safety and/or accuracy in laboratory results, has created a stigma. This stigma, in turn, impedes the progress of studies and practical methods in addressing this issue. Nonetheless, it is essential to understand the particularities of each material and the procedures in which they are used to advance comprehension in this matter. It is important to highlight the relevance of research in this area, like case studies that include the adoption of reusable instruments, such as secondary packing and PPE, in Operating Rooms, as well as the creation of a chemical reuse system connecting different laboratories within a public healthcare institution in Brazil. All these initiatives were implemented with careful consideration of legal, economic and biosafety factors (Barbosa et al., 2020; Harding et al., 2021).

Considering the practices of Repair, Refurbish, Remanufacture and Repurpose several approaches can be adopted. In the case of Repair and Refurbish, it is essential to continually evaluate the cost-effectiveness of low-cost supplies with shorter lifespans compared to the maintenance costs of equipment with longer life cycles (Repair) within the possibility of restoring an old non-functional equipment (Refurbish). Van Straten et al. (2021) applied these principles to stainless steel waste, reintegrating it into the hospital production chain. This approach resulted in significant cost savings on waste management and increased financial gains. Considering these possibilities, preference should be given to suppliers actively researching new design proposals and implementing reverse logistics systems. These systems should focus on incorporating parts in good condition from discarded products into the production of new items with the same function (Remanufacture) or use them to fulfil different roles in other production chains (Repurpose) (Roudbari et al., 2021; Veleva & Bodkin, 2018).

Although considering Recycle, there is a need to not only forward waste already known as recyclable but also reinterpret residues earmarked for landfilling and incineration objects with potential value and applications. A practical example is the transformation of laboratory plastics that were incinerated into filaments for use in 3D printing at a research institution in Brazil (Recycling) (Embrapa, 2019). Such initiative has drawn attention to the issue of residues that may not encounter with hazardous components but are still disposed of according to linear economy principles. This application opens the possibility of establishing new industries based on Recycling materials, thereby developing products that can be reintegrated into the healthcare sector or utilized in other areas. The final R, Recover, represents the last opportunity before final disposal. It focuses on maximizing the energy potential of waste. This includes processes such as composting and biogas production for organic waste, as well as energy recovery from the incineration of biohazardous waste (Dhakal et al., 2015; Khan et al., 2022).

The question that arises amidst so many possibilities is how to establish an effective way to promote the application of CE principles in HCW generating facilities. The answer to this issue may lie in the implementation of an Environmental Management System that goes beyond merely adhering to norms for the secure segregation and disposal of HCW. Rather, it involves a commitment to developing action plans aligned with CE guidelines and actively participating in theoretical and practical applications. This approach aims to develop strategies and management models that can be replicated by institutions operating in the healthcare sector with similar needs and demands. One way to take the first step towards this proposal is to develop contribution indicators for CE that are suitable for healthcare institutions, considering their specific characteristics. By collaborating with representatives from various areas such as environmental, healthcare facilities, suppliers and academic organizations, opportunities that are overlooked in the context of linear economy can be identified. Additionally, actions that can be implemented in the short, medium and long terms can be identified to establish a culture of proactivity and innovation. In doing so, it is anticipated that the stigma associated with the perceived incompatibility between CE and HCW can be overcome, paving the way for meaningful progress in sustainable waste management practices within the healthcare sector.

WM&R has been discussing the CE throughout its existence, and it now opens this crucial space for scientists and professionals to address the identified gaps. The aim is to foster an in-depth debate on how to effectively enable the CE within the realm of healthcare enterprises, promoting a sustainable approach.