Cambodia - Health Sector Support Project : environmental assessment

E631 n- } September 2002 Draft Report Environmental Review Cambodia Health Sector Support Project PREPARED FOR PREPARED BY The World Bank, ]VS consultants Washington D.C. ESnlt \ Vancouver, BC, Canada FiLn: E COPX92  CAMBODIA HEALTH SECTOR SUPPORT PROJECT DRAFT ENVIRONMENTAL REVIEW REPORT Prepared for East Asia Human Development Sector Unit The World Bank 1818 H Street N.W. Washington, D.C., USA 20433 Prepared by EVS Environment Consultants 195 Pemberton Avenue North Vancouver, BC Canada V7P 2R4 EVS Project No. 05/1112-01 2  TABLE OF CONTENTS TABLE OF CONTENTS ................................................... 3 ABBREVIATIONS AND ACRONYMS .................. ................................. 4 EXECUTIVE SUMMARY ................................................... 5 1. INTRODUCTION---------------------------------------------------------------------------------10 1.1 Project Description ................................................ 10 1.2 Project Boundaries ................................................ 11 2. LEGISLATIVE AND INSTITUTIONAL------------------------------------------------------13 2.1 Environmental Assessment ................................................ 14 2.2 Pollution Control ................................................ 15 2.3 Pesticide Use ................................................ 17 3. ASSESSMENT METHODOLOGY-----------------------------------------------------------18 3.1 Assessment Scope and Content ....................................... 18 3.2 Assessment Procedures ...................... .......................... 19 3.2.1 Civil Works ................................................ 19 3.2.2 Disease Prevention and Control Programs .......................... ............ 20 4. PROJECT-RELATED ENVIRONMENTAL ISSUES ------------------------------------22 4.1 Civil Works ................................................ 22 4.1.1 Health Care Facility Construction and Rehabilitation ........................ 22 4.1.2 Laboratory Construction ................. ............................... 23 4.1.3 Drinking Water Quality ................ ................................ 25 4.1.4 Health Care Waste ................................................ 28 4.1.5 Wastewater ................................................ 31 4.1.6 Tuberculosis and HIV/AIDS ...................... .......................... 32 4.2 Malaria and Dengue Vector Control ..................................... 32 4.2.1 Pesticide Use ................................................ 32 4.2.2 Human Health Risks ................................................ 33 4.2.3 Environmental Risks ................................................ 34 5. ENVIRONMENTAL MITIGATION MEASURES ----------------------------------------36 5.1 Environmental Management Plan ...................................... 36 5.1.1 Health Care Facility Construction and Rehabilitation ........................ 36 5.1.2 Laboratory Construction ................. ............................... 37 5.1.3 Asbestos ................................................ 37 5.1.4 Drinking Water Quality ................ ................................ 38 5.1.5 Health Care Waste Management ........................................... 39 5.2 Pesticide Management and Monitoring Plan ............................................... 41 5.2.1 Malaria ........................................... 41 5.2.2 Dengue ........................................... 42 REFERENCES ........................................... 44 ANNEX I - SUMMARY OF ENVIRONMENTAL ISSUES ....................................... 46 ANNEX 2 - LIST OF CONTACTS ........................................... 52 3  ABBREVIATIONS AND ACRONYMS CENAT National Center for Tuberculosis and Leprosy Control CNM National Center for Parasitology, Entomology and Malaria Control EIA Environmental Impact Assessment EA Environmental Assessment EC European Commission EMP Environmental Management Plan EPI Extended Program of Immunizations ER Environmental Review EVS EVS Environment Consultants HCF Health Care Facilities HCW Health Care Waste HCWM Health Care Waste Management HSSP Health Sector Support Project IEE Initial Environmental Evaluation ISDS Integrated Safeguards Data Sheet ITN Insecticide Treated Nets JICA Japan International Cooperation Agency MAFF Ministry of Agriculture, Forestry and Fishery MIME Ministry of Industry, Mines and Energy MoE Ministry of Environment MoH Ministry of Health NCHADS National Center for HIV/AIDS, Dermatology and STI NEAP National Environmental Action Plan NGO Non Government Organization NLDQC National Laboratory for Drug Quality Control OD Operational District PAD Project Appraisal Document PEO Provincial/Urban Environmental Office PHD Provincial Health Department PMMP Pesticide Management and Monitoring Plan POP Persistent Organic Pollutants PVC Polyvinyl chloride SFKC Social Fund of the Kingdom of Cambodia STD Sexually Transmitted Disease STI Sexually Transmitted Infections UNICEF United Nations Children's Fund WHO World Health Organization WHOPES World Health Organization Pesticide Evaluation Scheme WWTP Wastewater Treatment Plant 4  EXECUTIVE SUMMARY 1. This report documents the findings of an environmental review (ER) completed for the World Bank Cambodia Health Sector Support Project (HSSP). The ER complies with the Bank's environmental review policy and procedures and environmental assessment guidelines. In addition, the ER references Cambodia's environmental laws, regulations, policies and other relevant legislation to ensure that applicable environmental assessment requirements are fully addressed in project implementation. 2. The HSSP project is classified as a Category B activity where limited environmental analysis is considered appropriate to address specific environmental issues. Potential environmental and human heal6i impacts of the project examined in completing the ER were: construction and rehabilitation of health care facilities (HCF) focusing on civil works and related HCF operational issues such as drinking water supply; health care waste management (HCWM) practices; and pesticide use in malaria and dengue vector control programs. Environmental issues relevant to these HSSP activities are detailed and recommendations made as to appropriate mitigation measures and monitoring programs with a view to guiding project design and incorporating appropriate management plans during HSSP implementation. 3. Extensive consultation was sought with the Ministry of Health (MoH), Ministry of Environment, provincial health authorities, and national and international organizations involved in the provision of health care in Cambodia in completing the ER to ensure that potential project impacts were fully understood and appropriate conclusions and recommendations were reached. Particular attention was given to obtaining inputs from targeted provinces and technical programs expected to be involved in HSSP delivery. Health Care Facility Construction and Rehabilitation 4. Review of building locations and preliminary design specifications for HCF to be constructed and rehabilitated at the provincial and district level as part of the HSSP indicates that hospitals and health center civil works does not pose any serious environmental concerns and as such will not trigger assessment under Cambodia's environmental impact assessment (EIA) guidelines. Notwithstanding, it is recommended that best environmental and occupational health practices be followed during construction and rehabilitation to minimize or avoid any potential minor adverse impacts. Laboratory Construction 5. The new National Laboratory for Drug Quality Control (NLDQC) in Phnom Penh is expected to trigger additional assessment under Cambodian EIA 5  requirements. Anticipated construction-related environmental impacts of the new laboratory are expected to be minimal as the site selected is situated in an existing built urban area of the city. Adjacent land uses are multi-storey residential and institutional. No environmentally sensitive areas were identified in the project vicinity. Recommendations are made as to assessment issues to be addressed during both construction and operational phases. Construction mitigation measures encompass: occupational health and safety during demolition; nuisance to neighbors, dust and noise emissions; and proper disposal of demolition materials to landfills. It is recognized that greater emphasis should be given to operational laboratory practices in satisfying assessment requirements. These include: air emissions containing pollutants harmful to the environment; laboratory wastewater disposal practices; and disposal of hazardous laboratory wastes. Waste generated by the new NLDQC present special disposal concerns that will need to be considered. It is recommended that best availab(e disposal options be explored in determining appropriate hazardous waste handling practices. Drinking Water Quality 6. Ensuring the safe supply of drinking water to HCF as part of the HSSP is of paramount concern. In completing the ER, the safety of drinking water sources available to HCF was examined. Particular attention was given to potential risks associated with naturally occurring arsenic in groundwater and microbial water quality. Both surface and groundwater are used as sources of drinking water in Cambodia. Although surface water quality in generally very high and is the preferred source of drinking water, an estimated 50% of the country's population currently uses groundwater. Available water quality monitoring data indicates that chemical water quality, particularly for surface waters, is generally very good in Cambodia but that groundwater in certain areas of the country contains levels of chemicals that could pose problems for human health. The most important of these chemicals is arsenic - which has been found to exceed the World Health Organization (WHO) recommended limit of 10 pg/l in some provinces targeted by the HSSP. Water quality data also indicates that microbial water quality is a serious concern for untreated surface waters and shallow groundwater obtained from open wells. Microbial water quality is widely recognized as representing the most serious human health threat in Cambodia with infectious diseases or parasites being the most common and widespread health risk associated with drinking water. 7. To address any concerns relating to HCF water supply, it is recommended that a water quality monitoring program be undertaken as part of HSSP implementation to confirm that existing and intended water supply to HCF meets WHO guideline values - particularly for microbial quality and arsenic content. Recognizing that the human health threat from bacteriologically unsafe drinking water is by far the most important water quality issue in Cambodia at the present time, emphasis is given in the ER to prescribing mitigative measures to ensure the microbial water quality of drinking water supplied to HCF. Additional, mitigation and 6  remedial measures are outlined for situations where elevated arsenic levels are found in drinking water sources. Health Care Waste Management 8. Activities undertaken to improve health services will inevitably create waste that is potentially hazardous. Health care wastes are typically more hazardous that other types of wastes and are of concern in assessing planned health care improvement activities. Exposure to hazardous health care waste (HCW) can result in disease or injury to: medical doctors and nurses; auxiliary and maintenance staff; patients and visitors; and workers at waste disposal facilities. To address these concerns, it is essential to put in place safe and reliable methods for handling and proper disposal of medical waste. 9. Generally accepted strategies for HCWM encompass: waste minimization, recycling, and reuse; ensuring proper handling, storage and transportation; and treatment of waste by safe and environmentally sound methods. To ensure that best practices are promoted as part of the HSSP, specific recommendations are made for: * Adoption of strict waste segregation practices by HCF to ensure that wastes are properly identified and separated and that different waste streams are handled and correctly disposed of. * Expanded use of incineration to ensure proper treatment of wastes generated by HCF that cannot be recycled, reused or safely disposed of in landfills; emphasis is given to the importance of proper incineration practices to ensure that any environmental concerns are addressed. * Land filling of wastes in sanitary or engineered landfills or controlled disposal of health care wastes that cannot be safely incinerated as an acceptable disposal option if proper precautions are taken to minimize potential exposure to infectious wastes. 10. Wastewater from HCF represents a sub-category of HCW that should be addressed in planning construction and rehabilitation as part of the HSSP. Although wastewater from HCF is typically of a similar quality to urban wastewater it may also contain potentially hazardous components of concern from a human health perspective. Typically sewage discharged from HCF is greatly diluted and, as such, no significant health risks should be expected if effluents are treated in municipal wastewater treatment plants. In more remote locations where it is not feasible to connect to municipal systems then appropriate precautions must be taken to avoid health risks associated with discharge of untreated or inadequately treated sewage to the natural environment. It is recommended that, where possible, HCF should be connected to municipal systems. Where there are no sewage systems, technically sound on-site sanitation should be provided. 7  11. Comprehensive guidelines have already been developed by the MoH to address both waste management and hygiene issues at HCF. The guidelines incorporate best HCWM practices and are intended for practical application at HCF with limited available financial and technical resources. Additional guidelines on injection safety have also been developed by the MoH to provide specific guidance to HCF on the distribution, use, collection and safe destruction of disposable syringes and safety boxes. Taken together, both sets of guidelines provide an excellent basis for HCWM in HCF targeted by the HSSP. 12. Notwithstanding the availability of HCWM guidelines, it is recommended that capacity building be provided to improve site-specific waste management practices at HCF. Training in best HCW handling and disposal practices is expected to create more awareness of HCWM issues and foster responsibility among HCF staff in an effort to prevent occupatiAal exposure to HCW and related health hazards. Provisions should be made in HSSP implementation to ensure that adequate waste handling and disposal infrastructure and management systems are put into place at HCF. Malaria and Dengue Vector Control Programs 13. All products intended for use in vector control programs to be funded under the HSSP have successfully passed WHO's Pesticide Evaluation Scheme (WHOPES). Chemicals currently recommended by WHO are considered to pose a very low risk to humans if used correctly. Of the WHO recommended insecticides for malaria control, Deltamethrin, the chemical selected for the HSSP, is considered one of the least toxic and highly unlikely to cause adverse effects at concentrations normally used. Results of human health risk assessments indicate that normal exposure to this insecticide poses little or no hazard. Similarly, the larvicide Temperos, to be used in dengue vector control as part of the HSSP, has a very low toxicity to humans. The Temperos formulation to be used in the HSSP (i.e., 1% sand granules) is thought to present a negligible risk to humans. 14. The toxicity of the insecticides/larvicides intended for use in HSSP malaria and dengue vector control programs to non-target species varies widely. Laboratory and field test results indicate that Deltamethrin is only slightly toxic to birds but is moderately to very highly toxic to fish and other aquatic organisms. Temperos has been shown to be highly toxic to some bird species but moderately toxic to others. It is considered highly toxic to bees and moderately to highly toxic to fish. Both Deltamethrin and Temperos have been shown to be very highly toxic to aquatic invertebrates. Environmental risks to non-target species, particularly aquatic organisms, can result from the unintentional release of these chemicals through improper handling or disposal. Although Deltamethrin and Temperos are highly toxic to aquatic organisms, under normal circumstances only small amounts of these pesticides are likely to be released into ponds, streams and rivers. Of the two chemicals, Deltamethrine is more likely to enter the natural environment as a result of washing of insecticide treated nets in streams and ponds. No scenarios 8  were identified where Temperos might be released unintentionally to the natural environment. 15. Recognizing that all pesticides are toxic to some degree, it is paramount to ensure that proper care and handling practices form an integral part of any program involving their use. To this end, appropriate mitigation measures and best management practices are recommended with a view to minimizing or avoiding any potential adverse human health or environmental effects associated with the use of insecticides/larvicides in malaria and dengue programs to be undertaken as part of the HSSP. Guidelines and training materials already developed for vector control programs in Cambodia represent best available practices and provide adequate safeguards. Recommended enhancements are intended to build upon existing safeguards including: elaboration of guidelines covering safe transport and storage of chemicals; strengthening occupational health guidelines to better address chemical-handling risks; additional training for health workers and compliance monitoring to ensure adherence to guidelines; and extension of training to local communities to more explicitly address environmental risks. 9  1. INTRODUCTION 16. EVS Environment Consultants (EVS) were tasked with undertaking an environmental review (ER) of the planned World Bank Cambodia Health Sector Support Project (HSSP). The ER complies with the Bank's environmental review policy, procedures and environmental assessment guidelines. In addition, the ER documents Cambodia's environmental laws, regulations, policies and other relevant legislation to ensure that applicable environmental assessment requirements are fully addressed in project implementation. 17. This ER assesses potential environmental and human health impacts of the planned project, particularly with regard to: (a) construction and rehabilitation of health care facilities (HCF) focusing on operational health care waste management (HCWM) practices, incinerator use, arsenic in groundwater, and extraction of asbestos when present during civil works; and (b) pesticide use in malaria and dengue vector control programs. Environmental issues relevant to these HSSP activities are detailed in the body of the report. Recommendations are made as to appropriate mitigation measures and monitoring programs with a view to guiding project design and incorporating appropriate management plans during HSSP implementation. Specific questions on environmental issues included in the Project Appraisal Document (PAD) and Integrated Safeguards Data Sheet (ISDS) are addressed in Annex 1. 1.1 PROJECT DESCRIPTION 18. The planned HSSP is intended to contribute to the improvement of the health status of the Cambodian population through: (a) supporting the government's health sector reform process and the strengthening the sector's capacity to manage resources efficiently; and (b) improving the health system's ability to provide quality services. Main components of the project are: Component I - Improved delivery of health services aims at increasing the accessibility, quality and affordability of primary health care and first referral services through financing of civil works, medical equipment, support for a hospital maintenance system, pharmaceuticals, a quality assurance program, contracting of health services to non government organizations (NGO), support for specific schemes to protect the poor, and training for program implementation. Component 2- Support to programs addressing public health priorities aims at strengthening infection disease control epidemics and improving the overall nutritional focus on the poor, children and mothers. Sub-components include malaria, dengue, tuberculosis, HIV/AIDS and STD, nutrition, and safe motherhood. 10  Component 3 - Strengthening institutional capacity aims at strengthening Ministry of Health (MoH) management capacities, strengthening health administration at decentralized levels, and developing human resources. Specific activities will include implementation of sector reform measures, capacity building in health services planning and management, provision of training, and development of monitoring and evaluation indicators. 1.2 PROJECT BOUNDARIES 19. Component 1 of the HSSP - involving rehabilitation of HCF will be undertaken in a total of twelve Cambodian provinces, namely: (1) Banteay Mean Chey; (2) Bat Dambang; (3) Kampong Spueu; (4) Kampong Thum; (5) Kampot; (6) Kracheh; (7) Krong Kaeb; (8) Krong Pailin; (9) Otdar Mean Chey; (10) Pousat; (11) Preah Vihear; and (12) Stueng Traeng. 20. The HCF to be targeted in each province under this component will be finalized during the project preparation stage. The initial phase of the HSSP will focus on health facilities being direly in need of rehabilitation works, and on the basis of utilization rates, numbers of inhabitants in the catchment area, distance to a public or private facility and availability of health providers in the facility. Health facilities eligible for funding under this component will include provincial hospitals, district first referral hospitals, health centers and pharmacies. 21. At time of writing, HCF to be constructed and rehabilitated under Component 1 are being prioritized based on poverty levels, available facilities and missing facilities in operational districts (OD) of the provinces targeted by the project. Over the five-year project implementation period, it is anticipated that civil works will include rehabilitation and extension of sixteen existing Referral or Provincial hospitals, the construction of twenty-four Health Centers and the rehabilitation/extension of forty-six existing Health Centers. The project will also provide for the construction of six District Offices and ten Pharmacies. In addition, under the Accessibility and Quality of Health Services sub-component, the project will finance the construction of a new building for the National Drug Quality Control Laboratory (NDQCL). 22. Implementation of activities to be undertaken under Component 2 comprising infectious disease control programs (i.e., dengue, HIV/AIDS, tuberculosis and malaria), nutrition and safe motherhood will be delivered in all provinces covered by the HSSP. Minimal activities are planned in the predominantly urbanized provinces of Kandal, Phnom Penh, and Siem Reab. The scope and extent of implementation strategies will vary among programs as follows: * Malaria vector control support for the MoH's National Malaria Control Program including procurement of environmentally safe chemicals for use in their insecticide treated bed-net and hammock-net activities in areas of high transmission risk. 11  * Logistical and training support for dengue vector control activities to be executed by the World Health Organization (WHO). * Technical assistance and management, training, procurement and minor civil works (i.e., excluding HCF rehabilitation) support for the MoH's Tuberculosis Program at the district and provincial levels. * Procurement support for HIV/AIDS programs at the provincial level. * Capacity building support to improve capacity to deliver nutrition services at the national level and at provincial, district, and health center levels. * Supporting the MoH strategy to reduce maternal mortality through infrastructure improvement, procurement support, and training. 23. Capacity building for health sector refornr under Component 3 of the HSSP will involve strengthening of MoH management and institutional capacity and development of human resources at the central, provincial and OD level. 12  2. LEGISLATIVE AND INSTITUTIONAL 24. This section provides an overview of applicable legislation, and institutional arrangements pertaining to environmental protection and management in Cambodia. Particular attention is given to legal and administrative requirements that must be addressed in completing in assessing potential environmental and human health impacts of HSSP activities. 25. The Law on Environmental Protection and Natural Resource Management (1996) provides for: (i) protection and promotion of environmental quality and public health through the prevention, reduction and contpol of pollution; (ii) assessment of environmental impacts of all projects subject to g6vernment decision; (iii) rational and sustainable conservation, development, management and use of natural resources; and (iv) public participation in environmental protection and natural resource management. Responsibility for enforcing the law is under the Ministry of Environment (MoE) either by themselves or in collaboration with other concerned ministries and institutions. Pursuant to this law, national and regional environmental plans were to be prepared and sub-decrees promulgated to enforce specific provisions of the law. 26. Cambodia's environmental policy and strategic framework for environmental management is detailed in the 1998 National Environmental Action Plan (NEAP) (MoE, 1998). The NEAP predominantly focuses on forestry, fisheries, agriculture, biodiversity and protected areas and energy development but also contains policy guidance on urban waste management including disposal of solid wastes, special wastes and wastewater. 27. A key issue highlighted for the topic of solid waste concerns "disposal of hazardous industrial waste, medical waste and other toxic waste into open landfills or illegal vacant lots, swamps, waterways, and drainage canals, creates major public health and environmental problems." The NEAP notes that Cambodia lacks the capacity to properly dispose of special waste including medical wastes containing pathological wastes, syringes and bandages which are commonly disposed of in open landfills. 28. Strategies outlined in the NEAP to improve waste management include upgrading of existing landfills and construction of new sanitary landfills to ensure that they meet adequate environmental and public health standards. The NEAP highlights the desirability of constructing a pilot medical waste disposal facility in Phnom Penh and provision of training to medical personnel in ensuring proper handling of hazardous medical waste. It was noted that proper disposal would minimize the risk of exposing the public to the adverse health and environmental hazards associated with inappropriate disposal of medical waste. 13  29. Implementation of the strategies outlined in the NEAP was to be in two phases: Phase I (years 1-2) covering the development of an effective policy and regulatory framework on environmental and sanitation standards; and Phase II (years 3-5) covering improving the disposal of solid waste to minimize adverse public health and environmental impacts. 30. Specific sub-decrees that were subsequently promulgated to effect provisions of the Law on Environmental Protection and Natural Resource Management relating to environmental assessment and pollution control are detailed in the follow sections. Corresponding management initiatives taken by the MoE in responding to priority issues identified in the NEAP are also described. 2.1 ENVIRONMENTAL ASSESSMENT 31. The Sub-decree on Environmental Impact Assessment Process (1999) provides for assessment of potential environmental effects associated with every proposed and ongoing project and activity by either private, joint venture or state government and ministry institutions. Responsibility for review and approval of proposed projects is under the MoE's Department of Environmental Impact Assessment Review. The MoE is responsible for: (i) scrutinizing and reviewing EIA reports prepared by project proponents in collaboration with other concerning ministries; and (ii) follow up, monitor and taking appropriate measures to ensure that the project proponent adheres to the environmental management plan (EMP) conditions specified on project approval. If proposed projects or activities are to take place at the provincial level, the sub-decree requires that project proponents consult with the relevant Provincial/Urban Environmental Office (PEO). For purposes of the HSSP it will be necessary to consult with the provincial MoE authorities to discuss potential site-specific environmental concerns and assessment requirements - building renovations are not normally subject to assessment but the PEO must review construction plans and permits prior to construction proceeding. 32. An annex of the sub-decree lists projects that are subject to an initial environmental evaluation (IEE) or full EIA. In completing the ER, a clarification was sought from the MoE as to whether hospitals and hospital operations are subject to environmental assessment under this sub-decree. They advised that size and threshold triggers apply to infrastructure projects - new hospital buildings > 12m in height or with a floor space > 8,000 m2 will trigger an IEE or EIA. 33. Draft Guidelines for Conducting Environmental Impact Assessment (EIA) Report have been prepared by the MoE to provide a standardized reporting template for project proponents. Specific guidance is provided on the scope and content of an IEE or EIA report including: (i) description of environmental resources at risk; (ii) public participation; (iii) analysis of environmental impacts; (iv) mitigation measures; (v) environmental management plan (EMP); and (vi) institutional capacity. 14  2.2 POLLUTION CONTROL 34. The Sub-decree on Solid Waste Management (1999) is intended to regulate solid waste management in a proper technical manner and safe way to ensure the protection of human health and the conservation of biodiversity. This sub-decree applies to all activities related to disposal, storage, collection, transport, dumping of garbage and hazardous waste. 'Solid waste' refers to hard objects, hard subjects, and products or refuse which are intended or required to be disposed of. 'Hazardous waste' is further defined as: radioactive substances, explosive substances, toxic substances, inflammable substances, pathogenic substances, irritating substances, corrosive substances, oxidizing substances, or other chemical substances which may pose a da(ger to human health and the environment. Specific articles dealing with hazardous waste management include: * MoE shall establish guidelines for the management of hazardous waste to ensure their safe management. * MoE shall stipulate quantities of toxins or hazardous substances in hazardous waste that can be disposed of. * The owner of hazardous waste is responsible for safe temporary storage of their waste. * The owner of hazardous waste shall submit quarterly reports to MoE specifying type and quantity of waste, temporary storage method, and treatment or elimination method. * Storage, transportation and disposal of hazardous waste is to be separate from household wastes. * Owners of landfills receiving hazardous waste shall report quarterly to MoE specifying type and quantity of waste, sources, handling and processing. 35. Hospitals and health clinics are specifically required under the sub-decree to report to the MoE on types and quantities of hazardous waste generated, and storage, treatment and disposal methods. No specific requirements or guidance on actual treatment methods are provided in the sub-decree. 36. The MoE have advised that actual enforcement of provisions of this sub- decree has been limited to date; reflecting the lack of appropriate facilities for handling hospital waste in Cambodia. Although the majority of hospitals are currently employing incineration to treat selected hospital wastes, plastic wastes continue to be disposed to open landfills. The MoE are currently drafting guidelines for handling of hospital wastes. They have already completed a survey of waste streams generated by urban hospitals in Phnom Penh and are seeking inputs from hospitals on practical and affordable management practices. The MoE are still examining the issue of incinerator use by hospitals and identified environmental concerns - primarily air pollution and Cambodia's obligations under international 15  conventions on climate change and persistent organic pollutants (POPs) - relating to the use of incineration as the preferred treatment method. Recognizing the concerns of the MoE regarding incinerator use, additional consultation should be sought with the Ministry concerning the possible expanded use of small incinerators in rehabilitated and new HCF under the HSSP. 37. The Sub-decree on Pharmaceutical Management (1996) applies to HSSP activities involving purchase and distribution of drugs in HCF. This sub-decree encompasses prescription of drugs at pharmacies, private clinics and public health units and is intended to closely track usage of drugs, particularly restricted substances such as opiates. Provisions of the sub-decree apply to all aspects of drug procurement, storage, handling and disposal. Actual disposal of expired drugs is covered by the Sub-decree on Solid Waste Management. 38. The Sub-decree on Water Pollution Control (1999) provides for water pollution control through prevention and reduction of water pollution in public waters to ensure the protection of human health and conservation of biodiversity. The sub-decree is broadly defined to include surface waters - canal systems, streams, rivers, ponds, lakes, and the sea - and groundwater. Specific articles dealing with pollution include: * Defining 'pollution sources' as any premise or facility from which wastewater, solid waste, sewage, pollutants or hazardous substances are directly or indirectly discharged into water areas or drainage systems. * Defining 'pollution' as any substance that can cause any physical, chemical or biological change in receiving water characteristics. * 'Hazardous substances' are further defined as any substance that endangers living organisms or adversely impacts or damages the environment. * Discharge of potentially polluting substances are subject to effluent discharge standards enforced by the MoE. 39. Of relevance to the HSSP, this sub-decree encompasses solid wastes and garbage and provides that the storage and disposal of solid wastes or any garbage and hazardous wastes that lead to pollution of water be prohibited. Hospitals and clinics are specifically listed as pollution sources required to have secured permission from the MoE before discharging. 40. In responding to specific HCWM issues of concern in Cambodia, the MoH have developed comprehensive Waste Management Guidelines covering all aspects of waste management and hygiene at HCF. In addition, the MoH have promulgated a National Policy for the Safety of Injections and a corresponding Strategic Plan of Action to address safety issues relating to an extended program of immunizations (EPI) initiative being carried out countrywide. Detailed Injection Safety Guidelines for Referral Hospitals have also been developed to provide guidance to health care workers on the safe distribution, use, collection, and destruction of disposal syringes and safety boxes. 16  2.3 PESTICIDE USE 41. Although mention is given to pesticides in the fisheries section of the NEAP, no specific strategies or guidelines are outlined other than identifying the need to strengthen existing laws by including national standards to regulate the import or manufacture, sale or application of agro-chemicals such as fertilizers, pesticides, and herbicides. A recommendation is made to ban the import and/or use of extremely hazardous pesticides to prevent harm to ecologically sensitive fish habitats. 42. In completing the ER, clarification was sought from the MoE as to whether provisions of the Sub-decree on Standard and Mahacement of Agricultural Materials (1998) might apply to the HSSP. They advised that this sub-decree was promulgated by the Ministry of Agriculture, Forestry and Fishery (MAFF) and is intended to regulate the use of agricultural materials such as agricultural pesticides and therefore does not cover chemicals typically used as part of malaria and dengue vector control programs. 43. At present there are no specific policies or guidelines regarding safe handling and use of pesticides intended for use in public health programs in Cambodia. The MoE are currently drafting a new Law on Hazardous Substance Control that will include provisions for the safe handling and use of pesticides used in public health programs; this law will likely come into effect by 2004. 17  3. ASSESSMENT METHODOLOGY 3.1 ASSESSMENT SCOPE AND CONTENT 44. Bank environmental review requirements pertaining to the HSSP are summarized in this section. The following sections provide a synopsis of the procedures that were applied in assessing environmental issues for each of the project components. 45. Environmental review is required for all Bank loans and credits to ensure that environmental issues are identified early in the project cycle. The overall intention of the ER is to demonstrate that potentiab'project-related environmental impacts are well understood and that appropriate mitigation measures are incorporated during the design phase and throughout project implementation. The intensiveness of ER necessary for specific projects is dependent on the nature, magnitude and sensitivity of the environmental issues identified during initial project screening. Environmental review may entail preparation of a full environmental assessment (EA), a more limited environmental analysis, or no further analysis at all. Bank projects are assigned to one of four categories for ER purposes: Category A - EA is normally required as the project may have diverse and significant environmental impacts. Category B - More limited environmental analysis is appropriate, as the project may have specific environmental impacts. Category C - Environmental analysis is normally unnecessary, as the project is unlikely to have significant environmental impacts. Category D - Environmental projects for which separate EAs are not required, as environment is the major focus of project implementation. 46. Following screening of the project by Bank staff to determine the type of ER to be conducted; the HSSP project was classified as a Category B activity where limited environmental analysis was considered appropriate to address specific environmental issues. Particular issues identified for examination in completing the ER were: * Civil works planning and implementation. Particular emphasis was to be given to: (i) ensuring the safety of drinking water supply to new and rehabilitated HCF; and (ii) safe removal of hazardous building materials if present in HCF targeted for rehabilitation. * Solid and liquid waste collection, disposal and management at HCF. Particular attention was to be given to HCWM practices. * Potential health and environmental impacts related to the use of pesticides in malaria and dengue vector control programs. Emphasis was to be given 18  to assessing the safety of all chemicals used and on recommending appropriate occupational health and environmental safeguards. 3.2 ASSESSMENT PROCEDURES 47. Extensive consultation with MoH staff, provincial health departments (PHD) and MoH partners was sought in completing the ER to ensure that potential HSSP impacts were fully understood and appropriate conclusions and recommendations were reached. Particular attention was given to obtaining inputs from technical programs expected to be involved in project delivery. A list of contacts is provided as Annex 2 to this report. 3.2.1 Civil Works 48. Interviews were completed with MoE, MoH, PHD and Social Fund of the Kingdom of Cambodia (SFKC) representatives to identify potential environmental impacts of planned new construction and rehabilitation of HCF. Field visits to referral hospitals in Banteay Mean Chey and Bat Dambang provinces provided an opportunity to review rehabilitation plans and complete a preliminary assessment of site-specific environmental issues. Follow up discussions were completed with the MoH to obtain additional details of the design specifications for new health center and referral hospital construction. Preliminary drawings for the proposed new NLDQC in Phnom Penh were also reviewed with the laboratory Director to determine whether this construction will trigger an assessment under Cambodian EIA requirements and to characterize potential environmental issues to be addressed in completing an assessment. 49. Consultations were also completed with specialists from the NGO Partners for Development, the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) to discuss the issue of drinking water quality at HCF in Cambodia. Results of water quality monitoring programs completed to date by the Japan International Cooperation Agency (JICA), UNICEF and the WHO were reviewed to characterize human health threats related to drinking water used by HCF. Although emphasis was given to determining whether naturally occurring arsenic in groundwater presents a threat to patients, attention was also given to overall drinking water quality (e.g., microbiology). 50. Bank environmental assessment guidelines (World Bank, 1991 a,b) provided the analytical framework for evaluating potential environmental issues relating to planned HSSP civil works activities. Specific aspects considered in analyzing HCF construction and rehabilitation included: * Destruction or degradation of environmentally sensitive areas * Loss of existing land uses * Air pollution 19  * Surface and groundwater pollution * Solid waste pollution (e.g., handling and disposal of hazardous construction materials such as asbestos roof tiles) * Drinking water sources and quality (e.g., arsenic). 51. Health care waste (HCW) generated by new and rehabilitated HCF was considered as a discrete issue in completing the ER. During site visits to referral hospitals in Banteay Mean Chey and Bat Dambang, a Health-Care Waste Management Rapid Assessment Tool developed by the WHO (2002) was applied to compile information on existing HCWM practices. This tool provided a basis for gathering information at HCF visited and in questioning hospital staff. Hospitals visited were intended to be representative of goon and poor HCWM practices at the OD level. Information gathered at each hospital covered: geographical situation and catchment population; health care services provided; staffing levels; types of HCW generated; HCW segregation and handling; HCW storage containers; HCW storage areas; HCW collection and on-site transport; HCM off-site transport; HCW treatment; HCW final disposal; HCWM regulations and guidelines; HCW policy and budget; and sanitation and wastewater. 52. On completion of the field visits, follow up discussions were held with the PHD and MoH to discuss HCWM problems identified and simple, practical actions which should be taken to solve them. 3.2.2 Disease Prevention and Control Programs 53. Interviews were completed with both national and international organizations to review potential environmental impacts associated with the delivery of disease prevention and control programs. Malaria and dengue specialists from the National Center for Parasitology, Entomology and Malaria Control (CNM), the European Commission (EC), and the WHO provided comprehensive inputs concerning the scope and content of vector control programs to be implemented under the HSSP. Particular attention was given to characterizing the way that insecticides are selected and handled in ITN distribution and dengue larviciding programs with a view to determining where there may be scope for improving practices to limit risk of adverse occupational and environmental impacts occurring as a result of using of these insecticides. Specific issues examined were: * Insecticides used, formulation, and dosage * Distribution strategies * Storage, transport and disposal 20  * Information, education and communication * Environmental and human health issues. 54. Additional consultations were completed with the National Center for HIV/AIDS, Dermatology and STI (NCHADS) and the National Center for Tuberculosis and Leprosy Control (CENAT) to characterize the activities to be funded under the HSSP and identify any relevant environmental issues. A visit was completed to the National Tuberculosis Center to view HCWM practices. Emphasis was given to assessing potential environmental issues relating to infectious wastes generated during treatment - handling and disposal of infectious wastes is addressed as part of the HCWM topic. 21  4. PROJECT-RELATED ENVIRONMENTAL ISSUES 4.1 CIVIL WORKS 4.1.1 Health Facility Construction and Rehabilitation 55. At time of writing, building locations and design specifications for HCF to be constructed and rehabilitated at the provincial and OD level as part of the HSSP had not been finalized. Review of the preliminary design models for referral hospitals indicates that hospital construction will not trigger an assessment under the MoE EIA guidelines - new full service referralpospitals (i.e., inpatients, outpatients, surgery, x-ray, laboratory, emergency, ambulance, patient wards, maternity, blood bank, pharmacy, janitorial, kitchens, administration) are expected to have a total floor space of approximately 2,000 m2 which is well within the 8,000 m size threshold for new buildings requiring assessment. Building height is not expected to exceed 6 m; again well within the 12 m height threshold. Similarly, design models for health centers - both outpatients and combined outpatients and inpatients - provide for modest sized buildings with a maximum floor space of 110 m2 and a height not exceeding 6 m. As such, health center construction is not subject to assessment. 56. Although environmental assessment is not required for HCF construction and rehabilitation, best practices should be followed to preempt any potential human health and environmental impacts. Particular attention should be given the proper handling and disposal of hazardous building materials such as asbestos that may be present at facilities undergoing rehabilitation. 57. Asbestos - a fibre mined in several countries - has been widely used worldwide as a construction material and insulator because of its strength, durability and heat resistance characteristics. In recent years, evidence on the adverse health effects of exposure to asbestos has been mounting globally leading to urgent calls to cease production of the most-harmful asbestos types, limit the use of less-harmful asbestos (e.g., discontinued spraying of asbestos), and to impose strict exposure standards for workers handing raw asbestos and asbestos- containing products. Occupational exposure to asbestos by inhalation can cause asbestosis (scarring of the lung tissue), lung cancer, and mesothelioma (cancer of the lung's lining). In developed countries, occupational asbestos exposure is thought to have peaked in the 1970's but the effects of exposure continue to manifest themselves today with an estimated 30,000 new asbestos-related cancers being diagnosed every year. 58. The surge of asbestos use in developing countries as they increasingly industrialize has raised concerns of a second epidemic of asbestos-related cancer deaths over the next three decades. Although the use of asbestos has fallen in developed countries, it has climbed dramatically in developing countries in the past 22  twenty years. For example, asbestos consumption in Thailand rose from 21,271 metric tons in 1970 to 164,000 metric tons in 1994. In Thailand, asbestos is used extensively in the manufacture of construction materials such as roofing, flat sheets for wall and water pipes - these fibre cement products typically contain 13% asbestos by weight. Demand for asbestos building materials is expected to remain high in developing countries due the their low cost compared to alternatives such as polyvinyl chloride (PVC) plastics and galvanized metal. 59. Occupational health risks posed by asbestos in Cambodia are difficult to quantify because of limited information concerning the use of asbestos building materials. Consultations with the SFKC, who are responsible for government civil works in Cambodia, suggest that asbestos may be a problem in existing building containing fibre cement products. While clay roofing tiles are the preferred roofing material used in provincial and district HCF, fibrescontaining ceiling sheeting is a commonly used building material in Cambodia. Since 2000, the SFKC have specified that asbestos-fibre concrete building materials are no longer permissible - construction is closely supervised to ensure that contractors do not use cheap asbestos materials manufactured in Thailand. 4.1.2 Laboratory Construction 60. Review of preliminary drawings for the planned new NLDQC in Phnom Penh indicates that the laboratory will trigger an assessment under Cambodian EIA requirements. Although the total planned building floor space of approximately 2,000 m2 falls within the size threshold, the approximately 20 m height of the building, necessary to fit the laboratory within the available confined site, exceeds the 12m height threshold. Discussions should be initiated with the MoE at the earliest possible time once final preliminary drawings have been prepared. Review of architectural and engineering specifications by the MoE will ensure that environmental considerations are properly addressed at the planning and design stage. 61. The new NLDQC laboratory is situated in an existing built urban area of the city and will occupy a site that currently contains two derelict concrete buildings - the existing structures on the site are a MoH warehouse and the old Epidemiology Institute buildings. These structures will be demolished. Adjacent land uses are multi-storey residential and institutional. No environmentally sensitive areas were identified during a site visit. 62. Although minimal construction phase impacts are considered likely, attention should be given to: * Occupational health and safety during demolition (e.g., caution should be taken when handling hazardous building materials such as friable asbestos) * Nuisance to neighbors from increased construction vehicular traffic, dust and noise emissions 23  * Disposal of demolition materials to landfills * Surface water run-off from the construction site. 63. It is expected that greater emphasis will need to be given to operational laboratory practices in completing an IEE or EIA. Recommended guidelines for assessing laboratory operations (U.S. EPA, 2000) provide a useful analytical framework for assessing the planned NLDQC laboratory. Key issues that should be considered are: Air Emissions - Steps should be taken to minimize emissions from the new laboratory because even small amounts of pollutants can be harmful to the environment. Air emissions are also a potential occupational health issue. In order to understand the risk posed by air emissions it v11 be necessary to identify air emissions sources in the laboratory (e.g., fume hoods, stacks, vents) and to quantify actual and potential emission levels. Emphasis should be given to identifying the most air volatile and commonly used chemicals, such as organic solvents, as well as any especially hazardous or stringently regulated chemicals. Water Discharges - Proper disposal of wastewater is essential to ensure that environmental problems do not occur as a result of laboratory operations. Careful control and disposal of chemical wastes via sewer systems is desirable because it minimizes wastes sent off-site but precautions must be taken to ensure that chemicals are not improperly disposed of down sink drains. To completely understand and effectively manage wastewater, it will be necessary: to inventory wastewater discharges; evaluate programs and practices for preventing, controlling, and minimizing wastewater; and review existing operating and maintenance procedures for wastewater collection and treatment as part of an environmental assessment with a view to affecting improvements. Hazardous Wastes - Managing the generation and disposal of hazardous wastes is one of the most difficult challenges for laboratories. Common issues to address include classification, storage, labeling, emergency preparedness, and treatment and disposal of laboratory wastes as well as identifying opportunities to minimize its generation. It is common for laboratories to generate waste streams that contain a combination of chemical, biological, or radioactive substances necessitating that appropriate treatment technologies give priority to constituents that pose the greatest hazard. Best management practices for laboratories that generate hazardous waste depend on how much waste they generate and accumulate in a certain time period. For this reason, it will be necessary to make an initial determination of the quantity and composition of hazardous waste expected to be generated by the new NLDQC laboratory. Once hazardous waste projections are available, the laboratory can then develop waste handling and storage practices and procedures based on applicable requirements and regulations. Finally, laboratories must consider transportation and disposal procedures. If on-site treatment is not appropriate, then the laboratory must transfer its hazardous waste to a regulated disposal or recycling facility. 24  4.1.3 Drinking Water Quality 64. Considerations relating to ensuring the supply of safe drinking water to new and rehabilitated HCF are outlined in this section. Particular attention is given to potential risks associated with arsenic in groundwater and microbial water quality. Arsenic 65. The potential for naturally occurring arsenic to appear in groundwater was identified as a concern in connection with provision of safe water supply to HCF. In recent years, it has become increasingly apparent that drinking water guidelines are quite frequently exceeded in available water sources worldwide. Arsenic is now recognized as one of the most serious inorganic Aontaminants in drinking water on a global basis (UN/WHO, 2001). The most serious groundwater problem identified to date has been in Bangladesh where very high arsenic levels in groundwater affects drinking water wells. The heavy reliance on groundwater for public drinking water supply in Bangladesh has resulted in an estimated 40 million people having been exposure to high arsenic levels. Consumption of elevated levels of arsenic in drinking water over long periods of time has been associated with a variety of human health problems including skin disorders and respiratory, cardiovascular, immune, reproductive, gastrointestinal and nervous system ailments. 66. Both surface and groundwater are used as sources of drinking water in Cambodia. Although surface water quality in generally very high and is the preferred source of drinking water, an estimated 50% of the country's population currently uses groundwater. A recently completed water quality study indicated that groundwater from certain areas of the country contains levels of arsenic that could pose problems for human health (Feldman, 2001). Arsenic levels measured are summarized by province in Table 1. These values represent the highest or 'worst case' arsenic levels measured for individual wells in each province - spatial variability for arsenic is typically high and it is not unusual to get widely different measurements even for wells located in the same village. Study results reveal that several water sources, in both urban and rural locations, were found to contain arsenic concentrations above WHO's recommended limit of 10 pg/I (WHO, 1993). The highest arsenic concentrations were detected in Kandal Province - wells in Ta Khmau were found to contain between 30 and 90 pg/l. Elevated levels were also detected at sampling locations in Kracheh, Svay Rieng, Kampong Thum and Bat Dambang provinces. 25  Table I Overview of groundwater arsenic levels in Cambodia. Province Arsenic Concentration (pgIl) Banteay Mean Chey <10 Bat. Dambang > 50 Kampong Cham <10 Kampong Chhnang <10 Kampong Speue <10 Kampong Thum 10 - 50 Kampot _ No Data Kandal 0- -50 Kaoh Kong . No Data ! Krachelh > 50 Krong Kaeb No Data Krong Pailin No Data Krong Preah Sihanouk No Data Mondol Kir No Data Otdar Mean Chey No Data Phnom Penh 50 -100 Pousat . . < 10 Preah Vihear: No Data Prey Veaeng < 10 Rotanak Kiri No Data Siem Reab <10 StuengTraeng No Data Svay Rieng 10-50 Takaev < 10 67. It is noted that monitoring of arsenic in groundwater has not yet been completed in all twelve provinces targeted by the HSSP (indicated by shading in Table 1). Feldman's (2001) study covered only thirteen of the twenty-four provinces and municipalities of Cambodia due to budget and time constraints. Follow up sampling completed by the WHO and UNICEF subsequently included Stueng Traeng Province and increased the number of wells sampled - groundwater arsenic in Stueng Traeng was found to exceed 10 pg/l. JICA have also completed extensive sampling of villages in Central and Southern Cambodia. Although these studies augment the spatial coverage of groundwater arsenic surveys in Cambodia some data gaps remain in the HSSP provinces. Specifically, 26  limited or no data is presently available for Kampot, Koah Kong, Krong Kaeb, Krong Pailin, Otdar Mean Chey, and Preah Vihear. Of these provinces, it is likely that low arsenic levels are prevalent in Kampot and Krong Keab (P. Feldman, Personal Communication). The surficial geology of Cambodia is dominated by the Mekong and Tonle Sap river systems. Study results suggest that elevated arsenic levels are closely correlated with alluvial sediments (i.e., river deposits). Lower groundwater arsenic levels have been measured in the southeastern, southwestern, and northeastern provinces where bedrock lies closer to the surface. Extrapolating from available geological and groundwater survey data suggests that groundwater arsenic may be elevated in Krong Pailin and Preah Vihear, with lower levels likely in Otdar Mean Chey (P. Feldman, Personal Communication). 68. There are currently no standards or regulations concerning drinking water quality in Cambodia; although it was learned that,(he Ministry of Industry, Mines and Energy (MIME) are in the process of developing guidelines. In the absence of national guidelines, WHO guidelines values can be used to evaluate the potential human health impacts of drinking water sources. It is important to note that the WHO guidelines are not intended as standards but instead as guidance values in interpreting data. In reviewing survey results, it should be recognized that the WHO's provisional guideline for arsenic of 10 pg/I may not be practical for many developing countries to achieve. For this reason, an action level of 50 pg/l has been proposed by UNICEF in Cambodia. The provisional WHO guideline of 10 pg/l is considered appropriate for a long-term goal but may be overly stringent in the near term given the difficulty of measuring trace arsenic and the expense of treatment at such low levels. Instead an interim standard of 50 pg/I is recommended - this represents the current drinking water standard in most countries. Further, a tiered-system of categorizing risk is suggested where: (i) no actions are necessary when arsenic concentrations are < 10 pg/l; (ii) arsenic concentrations of 10 - 50 pg/l are ranked as a medium priority triggering additional testing to assess the geographical extent of the problem and periodic monitoring to assess temporal changes; and (iii) arsenic concentrations > 50 pg/l are a high priority requiring treatment of affected drinking water or substitution of alternative water sources. Microbial Water Quality 69. Problems posed by bacteriological contamination of drinking water supply continues to be the most important health related concern in Cambodia's water supply sector. Feldman (2001) emphasizes that the human health threat from bacteriologically unsafe drinking water is by far the most important water quality issue in Cambodia at the present time and urges that national attention should continue to focus on this well-documented public health threat. Recognizing this threat, both the WHO and UNICEF have recommended that attention also be given to ensuring microbial water quality of drinking water supplied to HCF under the HSSP. To this end, recommendations contained in Section 5.1 - Environmental Management Plan are intended to ensure the overall quality of drinking water utilized by hospitals and health centers. 27  4.1.4 Health Care Waste 70. Activities undertaken to improve health services will inevitably create waste that is potentially hazardous. Health care wastes are typically more hazardous that other types of wastes and are of concern in assessing proposed health care improvement activities. To address these concerns, it is essential to put in place safe and reliable methods for handling and proper disposal of HCW. 71. Health care waste includes all wastes generated in the delivery of health care services. WHO (1999a) estimates that 75-90% of waste produced by HCF originates from non-risk or general sources (e.g., janitorial, kitchens, administration) and is comparable to domestic waste. The remaliing 10-25% of HCW is classified as hazardous and poses a variety of potential health risks. Categories of HCW, as defined in WHO (1999a), which are considered of most concern in Cambodian HCF are summarized in Table 2. 72. A wide number of persons are potentially at risk from HCW, both inside and outside of HCF. Exposure to hazardous HCW can result in disease or injury to: * Medical doctors, nurses - Occupation health risks to health care workers are numerous and varied with the greatest risk being infection (e.g., HIV/AIDS and hepatitis B and C) through injuries from contaminated sharps. * Auxiliary and maintenance staff - Hospital workers such as janitors are at significant risk of infection or injury due to improper handling of infectious and chemical wastes at HCF. * Patients and visitors - Although risks of exposure to hazardous waste are considered lower than for hospital staff there is a potential for accidental exposure to infectious sharps and chemical waste (e.g., children accompanying families during extended stays at HCF are particularly at risk). * Workers at waste disposal facilities (e.g., incinerators and landfills) - Waste management workers are at significant risk of infection or injury from hazardous wastes; particularly scavengers at open landfills who are either not aware or ignore risks and often do not wear even rudimentary protective clothing. 73. Generally accepted strategies for HCWM encompass: (i) waste minimization, recycling, and reuse; (ii) proper handling, storage and transportation of HCW; and (iii) treatment of waste by safe and environmentally sound methods. These strategies are intended for tiered application - initially focusing on managing waste generation before moving on to actual disposal. Significant reductions in waste generated by HCF can be achieved through source reduction, use of recyclable products, and good management and control practices. 28  Table 2 Health care waste characteristics and hazards profile. Classification Characteristics/Associated Hazards Infectious Comprises waste that is suspected to contain pathogens including laboratory cultures, surgery and autopsy wastes from patients with infectious diseases, bodily wastes from patients in infectious disease wards, and miscellaneous waste such as disposable gloves, tubing and towels generated during treatment of infectious patients). Pathogens from infectious waste may enter the human body through puncture of skin cuts, mucous membranes, inhalation or ingestion. Pathological Consists of tissue, organs, body parts, blood and body fluids. Pathological wastes are considered a sub-category of infectious wastes and pose the same hazards. Sharps Describes items that could cause cuts or puncture wounds, including hypodermic needles, scalpel, and broken glass. Because sharps can not only cause cuts and punctures but also infect these wounds if they are contaminated with pathogens, this sub-category of infectious wastes is considered very hazardous. Chemical Consists of discarded solid, liquid and gaseous chemicals with toxic, corrosive, flammable, reactive, and genotoxic properties. Chemicals most commonly used in HCF include formaldehyde, photographic chemicals, heavy metals such as mercury from broken clinical equipment, solvents, organic and inorganic chemicals, and expired, usused or spilt pharmaceuticals. Hazards from chemical and pharmaceutical waste include intoxication as a result of acute or chronic exposure from dermal contact, inhalation or ingestion and contact burns from corrosive or reactive chemicals. Radioactive Includes solid, liquid and gaseous materials contaminated with radio nuclides; produced as a result of procedures such as in- vitro analysis of body tissue and fluid, in-vivo organ imaging and various investigative and therapeutic practices. Because radioactive waste is genotoxic, health workers in handling active sources and contaminated surfaces must take extreme care. 29  Of these measures, waste segregation - careful sorting of waste matter into different categories - is critical to minimization of health care wastes; resulting in significant reduction of hazardous waste that needs to be handled and treated. Although safety concerns necessarily limit opportunities to reuse medical equipment (i.e., aside from items that are intended to be reusable), segregation and subsequent recycling of materials such as plastics, metal, paper and glass is often practical and can represent an income source for HCF. 74. Segregation of HCW is intended to ensure that wastes are properly identified and separated and that different waste streams are handled and disposed of correctly. It typical involves sorting different wastes into color-coded plastic bags or containers at source. Examples of WHO (1 999a) recommended HCW handling practices are: * General HCW (in black bags or containerg) should join the domestic refuse stream for disposal. * Sharps should be collected together into puncture-proof yellow safety boxes and held for high-temperature incineration. * Infectious waste should be deposited in yellow bags and containers marked with the international infectious substance symbol and held for incineration. * Highly infectious material should be placed in marked yellow containers for immediate sterilization by autoclaving and then incinerated. * Large quantities of chemical wastes should be packed in chemical-resistant containers and sent to specialized treatment facilities. Small quantities of chemical waste can be held in leak proof containers and enter the infectious waste stream for incineration. * Waste containing high heavy metal concentrations should be collected separately in brown containers and sent to specialized treatment facilities. * Low-level radioactive waste should be collected to yellow bags or containers for incineration. High-level radioactive waste must be sent to specialized disposal facilities. 75. Incineration is a widely used treatment method for most hazardous waste generated by HCF. Incinerators can range from simply, single-chamber combustion units to sophisticated, high-temperature plants. WHO (1 999a) notes that all types of incinerator, if operated properly, eliminate pathogens from waste and reduce the waste to ash. Used correctly, incineration allows for a very significant reduction of waste volume and weight and is typically selected to treat wastes that cannot be recycled, reused or safely disposed of to landfills. The key to environmentally-safe incineration is proper segregation of waste streams within HCF - inappropriate waste types include large volumes of chemicals, photographic and radioactive wastes, PVC plastics, and waste with a high mercury or cadmium content. Incineration of these wastes causes the release of toxic emissions to the atmosphere if insufficiently high incineration temperatures are attained or in the absence of adequate emission controls. 30  76. Land filling of wastes that cannot be safely incinerated is regarded as an acceptable disposal option if proper precautions are taken to minimize potential exposure to infectious wastes. Disposal of HCW to open landfills is not considered acceptable. Open landfills are characterized by the uncontrolled and scattered deposit of wastes at a site which can lead to groundwater and surface water pollution and a high risk to scavengers working at the landfill. Instead, HCW should only be deposited to sanitary landfills that are designed to prevent contamination of soil, surface water, and groundwater and limit air pollution, odors and direct contact with the public. In the absence of sanitary landfills - which may not be feasible for cost and technical reasons - HCW can be safely disposed of to landfills that provide for controlled dumping; including measures to control leachate release from the site, confined disposal of wastes, and rapid bufial to avoid human or animal contact. 77. Recognizing that sanitary or engineered landfills are unlikely to be available in remote locations, another option is safe burial of HCW on HCF premises. On-site disposal represents an acceptable disposal option only if certain requirements are met as follows: * Restricted access to disposal site by authorized personnel only * Lining of burial site with a material of low permeability such as clay to prevent groundwater pollution * Limit use to hazardous materials which cannot safely be incinerated to maximize the lifetime of a landfill * Proper management of landfill (i.e., layering of HCW with layers of earth) to prevent odors. 4.1.5 Wastewater 78. Wastewater from HCF represents a sub-category of HCW that should be addressed in planning construction and rehabilitation as part of the HSSP. WHO (1999a) notes that although wastewater from HCF is typically of a similar quality to urban wastewater, it may also contain potentially hazardous components. Microbiological pathogens introduced into the wastewater stream by patients being treated for enteric diseases are of most concern. Lesser hazards are posed by small quantities of hazardous chemicals, pharmaceuticals, and other pollutants commonly found in HCF wastewater. Adherence to the hazardous waste segregation practices described in the preceding section provides assurances that chemicals and pharmaceuticals are not entering the wastewater stream. 79. Typically sewage discharged from HCF is greatly diluted and as such no significant health risks should be expected if effluents are treated in municipal wastewater treatment plants (WWTP). In more remote locations where it is not feasible to connect to municipal WWTP then appropriate precautions must be taken 31  to avoid health risks associated with untreated or inadequately treated sewage to the receiving environment (e.g., wetlands or agricultural lands immediately adjacent to a HCF). Where possible, HCF should be connected to municipal systems. Where there are no sewage systems, technically sound on-site sanitation should be provided. Recommended mitigation measures covering wastewater from HCF are elaborated in Section 5.1 - Environmental Management Plan. 4.1.6 Tuberculosis and HIV/AIDS 80. Health care wastes generated during treatment of patients with tuberculosis and HIV/AIDS at HCF can be considered a sub-category of HCW. Tuberculosis outpatient and hospital services to be funded under the HSSP are best addressed in the overall context of proper H6WM at HCF. Safeguards applicable to handling and disposal of highly infectious waste as described in the previous section are therefore applicable. 81. No specific HCWM-related environmental concerns were identified for the HIV/AIDS activity to be funded under the HSSP. Grant funding for HIV/AIDS prevention and treatment in Cambodia will cover the cost of drugs used in sexually transmitted disease (STD) clinics for treatment of sexually transmitted infections (STI) in sex workers and operating costs of the NCHADS 100% condom use program. Drugs to be procured are Cexime, Doxycycline, Clotrimazole and Ciprofloxacin. Procurement and distribution of the drugs to STD clinics is closely supervised by NCHADS. A comprehensive manual exists for STD case management at clinics that contains guidelines on how to organize services and policies for delivery. 4.2 MALARIA AND DENGUE VECTOR CONTROL 4.2.1 Pesticide Use 82. Insecticide and larvicides intended for use in malaria and dengue vector control programs as part of the HSSP are summarized in Table 3. It is noted that all products have successfully passed WHO's Pesticide Evaluation Scheme (WHOPES) (see WHO, 1997 for overview). The WHOPES was set up in 1960 to promote and coordinate the testing and evaluation of pesticides for public health. Products proposed for use are subject to a rigorous four-phase evaluation and testing program that examines the safety, efficiency and operational acceptability of public health pesticides and specifications for quality control. WHOPES reviews and recommendations are based on methodologies developed through extensive consultation with the international community and should be considered authoritative. 32  Table 3 Insecticides/larvicides to be used in vector control programs. Insecticide/Larvicide . . Comments on Intended for Use and Quantity Required Purpose Environmental Specifications Safety Deltamethrin (K- 2,000 liters/year Treatment of One of the Othrine