Continued Medical Waste Exposure of Recyclable Collectors Despite Dumpsite Closures in Brazil

Background. Brasilia, the capital of Brazil, currently has the largest dumpsite of the Americas at Estrutural, with over 30 million tons of waste accumulated. Recyclable waste collectors are a group of workers who, in addition to having a low socioeconomic status and residing in vulnerable areas, work sorting garbage in inadequate and unsanitary areas. This profession puts individuals at risk, resulting in death, mutilation, and disease for workers. Objectives. The aim of this study was to understand the effects of waste on recyclable collectors, along with their perceptions of associated risks. Methods. A qualitative study was conducted, using interviews with 34 participants at Estrutural. Results. Collectors were exposed to several hazards, including biological, physical, and more extreme hazards (e.g. being run over by waste trucks). Personal protective equipment was not adequately used, exposing recyclable collectors to injury. Accidents included cuts, burns, skin lesions, eyes lesions, and arm, leg, head, feet, and hand injuries and amputations. Often, homecare remedies and collected medical waste (e.g. pain killers) were used on these injuries instead of seeking out proper medical care. Conclusions. Recyclable collectors were aware of occupational hazards, but lacked education on the risks and consequences associated with exposure to medical hazards. Moreover, Brazil recently formally closed all dumpsites, complicating this issue. The findings of the present study confirm the need to address these hazards to provide a safe working environment for waste pickers. Participant Consent. Obtained Ethics Approval. This study was approved by the Research and Ethics Committee of the Health School of Brasília University under Opinion n. 1.517.670/2016. Competing Interests. The authors declare no competing financial interests.


Introduction
There are approximately 15 million people engaged in waste collection worldwide. 1 In low-and middleincome countries, recyclable collectors represent 1% of the urban workforce. 1,2 Data from two Latin American countries suggest that recyclable collectors account for 0.6% of the urban informal employment in Lima, Peru and 0.5% in Brazil. 2 Although not recognized as a profession or as part of the waste management system in many countries, informal waste collection serves as a sustainable income generating activity that offers a livelihood for waste pickers and their families. 3-5 Informal recyclable waste collection accounts for a significant percentage of urban employment in Brazil. The situation in Brazil provides insight into issues of waste management and recyclable waste collection for a number of reasons. First, Brazil is the only country that systematically collects statistical data on recyclable collectors because it formally legalized informal waste collection as a profession. 6 'Recyclable material collector' is a profession recognized by the Brazilian Ministry of Labor and Employment, which is tasked with guaranteeing the right to a safe environment for working individuals. 7, 8 Second, in 2010, the government created a strategy to dismantle dump sites. 5, 9 The aim was to decrease negative outcomes related to unsafe waste gathering techniques. However, even though many sites are now officially closed, they continue to be worked in an informal fashion, contributing to continued adverse health effects for workers. 5 The final reason Brazil's Research waste management is important is because Brasilia, the capital of Brazil, currently has the largest dumpsite in the Americas, Estrutural. According to the Brazilian Association of Public Sanitation and Special Residue Companies, approximately 30 million tons of garbage have accumulated in the dumpsite of Estrutural. Since the mid 1960's, this site has received all solid waste produced in all the Federal District; per data provided by the technical directory of the Sanitation Department in 2014, this amount translates to about 860 000 tons of waste annually. 10 Thus, despite the national policy on solid waste, the governance enforcing dumpsites closures in Brazil, many of these dumpsites continue to operate informally, including Estrutural, which was 'closed' at the end of 2017. 10 The Brazilian national policy on solid waste has drawn more visibility to the recycling sector, allowing the creation of cooperatives and associations, and several programs for the recovery of recyclable waste. 11 This situation can promote awareness and decrease adverse effects in affected populations; however, the working and living conditions of informal waste collectors have not actually improved, with the great majority operating without technical guidance from the local government and basic benefits of employment, and being poorly compensated for recovered materials. 12 In fact, only 5% of waste collectors in Brazil have contracts and income above the national minimum average. 12 In the Federal District dumpsite, there are about 1500 recyclable collectors who are part of six associations for recyclable materials, although it is estimated that 230 000 people work as recyclable collectors (of all types of waste) in Brazil. 13 Although some progress has occurred, there is still a need to improve the health and working conditions of recyclable collectors in Brazil by strengthening health and safety standards. 14 Recyclable collectors in the informal sector experience increased occupational health risks due to direct contact with waste, manual handling, and lack of personal protective equipment (PPE). 4,5 Waste collection is linked to adverse health effects, including injuries (e.g. cuts), hearing loss, musculoskeletal disorders, respiratory diseases (e.g. bronchitis, pneumonia, allergies), skin diseases (e.g. dermatitis, sun burn), communicable diseases (e.g. HIV/ AIDS, sexually transmitted infections, hepatitis B and C), waterborne diseases (e.g. dengue, leptospirosis, diarrhea), and psychological disorders (e.g. depression, stress, anxiety). 5,14, 15 One of the key contributors to this increased occupational risk is exposure to medical waste. [16][17][18][19] Contact with medical waste improperly disposed of by the healthcare industry can result in exposure to biological, chemical, radioactive and sharp objects. 20- 22 Among the most common objects responsible for these accidents are syringes, needles, glasses, spikes, and objects that cause cuts and injuries. In Brazil, despite the mandatory implementation of the medical waste management plan in health-care settings, very few establishments currently comply with internal and external regulations for medical waste management. 23 This lack of universal compliance with the medical waste management plan has resulted in 12.5% of medical waste being disposed in dump sites and mixed together with other types of waste. 23 Consequently, this may be a cause of occupational accidents and diseases among informal waste collectors, who are at a higher risk (compared to the general population) of encountering inadequately disposed medical waste. 24 Recyclable collectors are at risk of exposure either directly (e.g. syringe puncturing skin) or indirectly (e.g. environmental, occupational, and food factors). 25 Previous research studies conducted in the recycling sector in Brazil have not typically focused on the perceptions of the risks and hazards of waste pickers regarding work in unregulated dumpsites and landfills. Since Brazil has recently officially closed all open-air dump sites, research could be used to better understand the health and safety risks associated with waste collection in these newly informal sites. This information may be essential to tailor the national policy on solid waste to incorporate the management of medical waste and integrate all groups of informal recyclable collectors, as well as to ensure adequate occupational health and safety standards in this work setting and improve the efficiency of waste collection methods in Brazil. Thus, the objective of this qualitative study was to understand recyclable collectors' risks, opinions, and perceptions regarding occupational hazards, with a focus on medical waste in the Federal District in Brazil. Zolnikov  In this area, recyclable collectors have historically gathered recyclable materials to sell to recycling companies for profit. As such, the recyclable collectors are exposed to a variety of garbage, as they sift through waste in search of recyclable goods. Semistructured interviews of recyclable collectors were used to understand the types of hazards associated with this recyclable waste collection.
Qualitative methods were used in this study. Qualitative methods are an important tool for researchers who are seeking to understand deeper cultural implications including multiple participant perspectives in varying contexts. 26 A phenomenological study was specifically used, which seeks to understand the experiences of participants. The expectation was that by interviewing participants and teasing apart complexities amongst self, others, culture, and environment, a greater understanding of the perspectives of waste pickers regarding occupational health hazards would be uncovered.
In general, qualitative research must provide measures to ensure validity of the research. In this case, the researchers established trustworthiness through credibility, multiple participant perspectives, peer debriefing and review, reflexive journaling, and field notes. The interviews were conducted on an individual basis, which sought to provide a greater bond and trust between the researcher and the interviewee, who were from the same city and communicated in the native language of Portuguese.
Questions focused on experiences with waste picking, safety, access to treatment, and ideas for improvement in the sector. Multiple participant perspectives were sought and females and males of various ages were all included in the interview process. Peer debriefing and review occurred before and after the development of interview questions and analysis of answers. Reflexive journaling and field notes occurred in the field diary, which was used to report on questions related to field immersion and impressions of each visited location. Suprasegmental features such as pauses and silences were identified with a "+" in parentheses, vowel elongation was represented by colon; these behavioral aspects can improve the analysis of critical discourse. Nonverbal resources, such as laughter, were also provided in the transcripts and were represented by double parentheses that were used to insert a comment on something that occurred during speech.
All interviews were recorded, transcribed, and later analyzed. Codes were manually generated based on the conceptual framework of a phenomenological study as described by Moustakas and from the research questions. 27 Codes allowed the researcher to provide direct and indirect information, such as descriptions and quotes, to support themes and patterns. Codes were generated and made into a codebook; some examples of codes included "safety, " "medical waste, " and "treatment. " These characteristics were reviewed for themes and patterns to help understand the experiences of the subject, as well as perceptions and other phenomena. Themes were then generated from the codebook; these themes represented information supporting the experiences of waste pickers sorting through medical waste in open air dumps. Themes were then re-analyzed and verified by the research team.

Results
A total of 28 females and 6 males (n=34) were interviewed by the Brazilian research team (e.g. principal investigator, additional researchers, and graduate school students). The participants were garbage collectors who actively worked at the dumpsite. A convenience sample was taken, although more females were interviewed because the sector is comprised of a greater number of women waste pickers. Most waste pickers were between the ages of 30 to 39 years old (41%). Total time spent working as a waste picker ranged from 7 months to 40 years; work hours averaged 8 hours per day at 6 days per week. In general, most participants had low education levels (32% were illiterate) and did not obtain a formal education (49% received an elementary education and 17.5% went to high school). Most waste pickers racially identified as "parda" (63%), which is mixed Black and White, with 25% identifying as Black and 11% identifying as White.
Through these interviews, substantial information was gathered to provide an accurate description of recyclable collectors' exposures to hazardous medical waste. Furthermore, participants' answers were similar for each question and did not Research introduce any additional information, confirming saturation of the study questions. 27 The participants' answers highlighted environmental exposures that collectors were often faced with while working at the waste site. Key concepts that developed and arose during the research analysis became the main themes; these themes focused mainly on continued exposures and hazards in an industry that has effectively become illegal in Brazil (Supplemental Material). This information suggests that both major and minor hazards are likely to continue despite waste site closures.

Physical and biological exposures
Occupational accidents experienced by recyclable collectors typically occur because of the hazardous nature of the work environment. Interviews detailed many accidents with sharp objects. These accidents occur because medical waste often contains syringes, scalpels, and needles. Syringes appeared to be the most common physical exposure for recyclable collectors.
"I've been punctured here several times-not just once. Here, everyone gets punctured…" (Participant E-28) Some participants spoke about the presence of syringes with the needle attached without the protective cover, not only in medical waste, but in general trash as well. In general, this was found to be common practice in hospitals, as employees and patients alike mistakenly mix biological, chemical, and common waste together. Recyclable collectors were also exposed to biological waste such as body parts, urine, blood and serum. "I've found medications and even pieces of people, in fact this is common here." (Participant E-1) Other participants confirmed these biological exposures and provide more detail on the types of waste. "… I have also seen colleagues get contaminated with blood bags and tubes of serum." (Participant E-12). Other participants provided information on occupational biological waste exposures. In the present study, PPE was reportedly used by most of the participants. However, the equipment was inadequate and did not protect them from the danger of contact with sharp objects. Participants reported using rubber gloves which are not suitable for the risks to which the recyclable collectors were exposed because "they tear easily" (Participant E-30). The specific type of gloves was not described, so that information is not provided. Another solution to avoiding needle pricks was to throw the needles "into the bushes" and at least avoid personally stepping on them.
"Sometimes the needles are facing upwards and it is the worse, because it sticks in the foot of the colleagues. " (Participant E-11)

Use of collected medical waste
Some collectors gathered or saw other workers gathering medicine from waste for personal use or to sell. These medications included diabetes medication, inflammation or pain pills, vaginal ointment, and cancer medication. One reason mentioned for using these drugs was "out of necessity" (Participant E-34

Discussion
Recyclable collectors are a group of individuals who make a living by sorting through waste to find recyclable goods, which are then traded in for money. The waste presents many occupational hazards (e.g. needle sticks), and exposures occur when sifting through garbage. Previous research has reviewed health outcomes among collectors, but has primarily focused on solutions to prevent these hazards, such as PPE, instead of determining occupational exposures. 34, 35 The present qualitative research study sought to understand the hazards, medical exposures, risks, and treatment choices directly from waste pickers.
In addition, since this site was officially closed in late 2017, it is important to highlight the working conditions of a population that is not currently supported by national workforce governmental standards or treated as a recognized working class. Participant responses provide further insight on specific occupational exposures that continue to be threats for recyclable collectors, ways in which workers address these hazards, barriers to accessing healthcare or treatment, and suggestions for improving work conditions (Figure 1). Since this type of work continues despite governmental shutdowns of sites, it is imperative that other organizations (e.g. academic, nonprofit, etc.) work to create safer work environments for waste collectors. Recyclable collectors are a population that is particularly vulnerable to occupational and environmental hazards, and are therefore susceptible to accidents and the effects of work site exposures. 36 This research identified key information on the type of hazards that collectors may be exposed to, especially regarding medical waste and wounds from syringes. Hazards primarily included pricks from needles and syringes. These pricks can cause exposure to a variety of biological hazards (e.g. HIV/AIDS). 37-39 There are multiple reasons for these exposures, including worker complacency, as well as inadequate disposal of medical waste in common garbage, that put collectors at risk. This information confirms the need for solutions to mitigate these types of exposure.
One important mitigation step is the use of PPE. However, the use of such equipment does not completely prevent the occurrence of accidents, it only minimizes direct contact of Research collectors with hazardous waste. In an earlier study conducted in the Federal District, it was found that the frequency of occupational accidents was higher among those who reported using some type of PPE, and one reasonable explanation could be due to the quality of the equipment (e.g. old disposable gloves) used by collectors. 40 Most recyclable collectors reported using some type of PPE, but others gave reasons for not using this equipment, such as the fragility of gloves against contact with sharp objects, difficulty of handling waste materials, the high cost of appropriate gloves, and limited provision of equipment by the government.

Conclusions
Informal waste management in Brazil has officially come to an end with the formal closing of all dumpsites throughout the country. The Brazilian government has created formal working spaces for garbage sorting and distributes PPE (e.g. gloves). Unfortunately, despite these actions, recyclable waste collectors continue to work and face occupational hazards associated with their informal occupations. One major hazard encountered by recyclable collectors is encountering sharp objects while sorting. These sharp objects, typically from medical waste, can result in physical injury and biological exposures. Waste collectors are at risk due to improper waste disposal at healthcare facilities, a need to work quickly to avoid other more serious hazards (e.g. being run-over by dump trucks), complacency or poor education on the use of proper PPE, and lack of acknowledgement of the profession by government officials and healthcare workers (e.g. physicians).
The results of the present study confirm the barriers surrounding recyclable collectors to seeking treatment for injuries associated with garbage sifting. Recyclable collectors often face social stigmatization and are frequently overlooked by policy measures to improve the working conditions and livelihood of this population.
Measures to mitigate these occupational exposures include providing proper PPE, improving access to healthcare, increased education on workplace hazards (e.g. biological risks), and government support for upholding occupational health and safety standards in this work setting. Unfortunately, it is unlikely that there will be increased government support in this setting, as many of these sites are now illegal or officially "closed" in Brazil. As is apparent by the continued work of recyclable collectors, these closures do not impede workers from continuing using these sites, as it remains one of the only livelihood options for many people. 1 To change this scenario, workers must become organized and demand governmental support and social protection. However, because recyclable waste collectors have not historically demanded these rights, the government should be aware of the benefits than can occur from formalization or legalization of recycling activities. Legalizing and regulating recyclable waste collection can aid in reducing poverty through maintained jobs, decreased costs of recycling for municipalities, and conserved and protected natural resources. 1 Other areas that can aid in creating changes in this space include organizational support. For example, Women in Informal Employment: Globalizing and Organizing is a network comprised of individuals and institutions that use data and research to provide services or shape policies to help empower workers in informal industries. This organization has worked with waste pickers in Brazil to create frameworks for hiring waste pickers outside of informal employment, negotiated with policymakers and municipalities on improving waste pickers income and quality of life, and other areas of change. 13 Addressing issues faced by waste pickers can improve many aspects of their lives. Ultimately, these findings demonstrate that it is of utmost importance to create a safe working environment for recyclable collectors worldwide to address these occupational hazards and to foster fair labor standards.