By Zack Fishman
Medill Reports
When a COVID-19 patient is hospitalized at the George Washington University Hospital in Washington, D.C., they receive a lot of attention from healthcare workers. Whether it’s a nurse doing an hourly check-in or a team of doctors responding to a worsening condition, a medical professional enters a patient’s space about 50 to 80 times per day — and nearly every time, they have to wear a new set of personal protective equipment, or PPE. To prevent spread of the novel coronavirus, healthcare workers don disposable masks, gloves, gowns and other equipment from head to toe. When the visit is over, the equipment is thrown away.
GWU Hospital has had more than 1,000 COVID-19 patients come through its doors, according to Nicole Dollison, the COO of GWU Hospital, though fewer have been hospitalized after initial treatment. Yet the number of patients multiplied by the number of their visits equals a lot of required PPE. The hospital has cut down on the number of surgeries and emergency room services since the nation’s capital went into lockdown on April 1, yet it is consuming twice as many N95 masks as usual and three times as many plastic gowns and boot covers.
“Pretty much everything at least doubled, if not tripled, our normal usage,” Dollison says. The hospital has been producing more medical waste as a result, and Dollison expects it to grow even more as Washington begins its first phase of reopening and GWU Hospital restarts its other medical services.
Like many hospitals worldwide, GWU Hospital has been using more PPE to keep employees and patients safe from the highly infectious coronavirus. But nearly all of the safety equipment employed for this purpose — the N95 masks, the gowns, the gloves — are made of non-recyclable plastic, and they will eventually be thrown out. Where they go next is a crucial question for the environment’s well-being.
If any good news has come out of the devastating COVID-19 pandemic, it has come from its modest environmental benefits. Air quality has improved drastically in cities normally covered by smog, global emissions of CO2 may fall as much as 4-7% this year, and cities such as Miami are seeing significant improvements in water quality from less boating traffic. Some see this moment as a chance to make the economy more sustainable, while others are concerned about a post-pandemic surge in pollution levels.
Yet in many ways, the pandemic has worsened a different environmental crisis: plastic pollution. PPE, packaging for takeout food and water bottles have seen a rise in demand during the COVID-19 pandemic, according to Rachel Meidl, a member of Rice University’s Baker Institute.
Hospitals are using dramatically more single-use plastics to reduce the risk of coronavirus transmission, and ordinary people also consume more plastic — by wearing masks and gloves more often, ordering groceries online with plastic shopping bags and buying takeout from struggling local restaurants in Styrofoam containers. When all of this material is thrown in the trash, it will join an exponentially growing flow of plastic into landfills and natural ecosystems, where it will seep chemicals into the earth and harm both animals and humans in ways researchers don’t yet fully understand.
Plastic, a group of malleable polymers that are produced from fossil fuels and can take centuries to decompose, has become a $570 billion-dollar global industry and a cornerstone of everyday living. But when 8 million metric tons of the material already enters the oceans each year, is there a more sustainable way to respond to a pandemic — and maybe fix an unsustainable waste system along the way?
Medical protection and medical waste
When physician Philip Skiba treats potential COVID-19 patients in the emergency room, he goes through a lot of protective gear. Before every patient visit at Advocate Lutheran General Hospital, located in the Chicago suburb of Park Ridge, Illinois, Skiba puts on a pair of gloves, a plastic gown with sleeves that covers his torso, another pair of gloves, an N95 mask, and a face shield over the mask. After interacting with a patient, he discards the gloves and apron in a red biohazard trash bag and cleans the face shield, which he wears to protect his eyes and to allows him to reuse his mask. He repeats this process with each new interaction with five to 20 patients per day. “You’ve got to be very careful because it’s very, very easy to catch,” says Skiba, the Director of Sports Medicine for the Advocate Medical Group. He is on assignment in Lutheran General’s ER during the pandemic.
Skiba wears this large wardrobe of disposable protective equipment to protect himself from contracting COVID-19 or passing it on to other patients, who are given simple medical masks when they visit. Skiba says that doctors wouldn’t wear the plastic gown and an extra pair of gloves with every patient under normal circumstances, so “there’s definitely more waste.”
PPE isn’t the only disposable medical equipment used in larger quantities. Dollison says GWU Hospital has needed more supplies that assist every aspect of treating COVID-19 patients. This includes the stethoscopes thrown away after contact with a contagious person, specialized equipment needed to operate ventilators, and body bags.
Compounded by every doctor and nurse who sees an ER patient in nearly every hospital in the country, it’s no surprise that the United States has been producing more medical waste, which is waste potentially exposed to infectious materials or people. Stericycle, one of the largest companies that handles medical waste disposal, told The Verge in late March that its facilities were managing a higher volume of waste, although it did not say how much more. The National Waste and Recycling Association, which represents more than 700 firms across the nation, asked for a relaxation of regulations around the handling of medical waste to ensure proper management, the Los Angeles Times reported.
The U.S. isn’t the only nation facing the pressure of mounting medical waste. In Wuhan, China, where the coronavirus first broke out, the city had to build a new medical waste plant to handle a peak of nearly 270 tons of medical waste each day, a nearly six-fold increase from the pre-pandemic average of 44 tons per day. Wuhan and 27 other Chinese cities struggled to manage the burden of medical waste during the pandemic, according to the South China Morning Post.
CDC guidelines state medical waste exposed to COVID-19 can be treated the same as other medical waste, so its disposal follows the same path. In hospitals, the PPE of healthcare workers is disposed of in red biohazard bags, where they may join other medical waste such as bandages, specimen cups and examination table paper. In the U.S., 90% of medical waste is autoclaved, or placed in a large machine that uses steam heated to 300°F to sterilize the waste before it is brought to a landfill. The other 10% is incinerated and converted into energy. More than 90% of medical waste was incinerated in the U.S. until 1997, when the EPA passed stringent air pollution standards that targeted the toxic emissions that come from incineration.
Although it is treated the same as other medical waste, the waste from COVID-19 treatment adds strain to the medical waste system and creates more plastic that will sit in a landfill or escape into the environment.
More worries, more waste
In early April, Mark Benfield was walking through his neighborhood in Baton Rouge, Louisiana, when he noticed a new trend: Masks, gloves and wipes were starting to litter the ground in a way he’s never seen before.
“I’m pretty familiar with the normal kinds of things that get washed in and that we see on the streets,” Benfield says. “Water bottles, styrofoam containers, bottle caps — the usual kinds of macroplastic waste.”
Benfield knows Baton Rouge’s litter better than most. He researches plastic pollution and marine biology as a professor in Louisiana State University’s College of the Coast & Environment, and he often monitors the city’s stormwater drains with a drone and doesn’t normally see such large amounts of PPE.
Out of curiosity, Benfield began taking photographs of discarded medical equipment in his neighborhood and graphed them on Google Earth to look for changes over time. He soon found that the medical waste was increasing on Baton Rouge’s sidewalks and even in the wastewater. The LSU professor went on to expand his backyard exploration to proper scientific research, recruiting 20 volunteers to take pictures of littered medical waste in as many cities, including New Orleans, New York City, Hong Kong and Shenzhen in China. Although his data will ultimately provide anecdotal evidence and not a comprehensive survey of these cities, it has nevertheless revealed growing numbers of discarded PPE in many locations.
“There was a lot more than I expected, and these were clearly items that were associated with the pandemic,” Benfield said. “They weren’t things that we’ve seen in the past.”
In addition to hospital personnel, everyday people are another significant source of medical and other plastic waste during the pandemic. Between major changes to daily life under strict stay-at-home orders and efforts to avoid infection, people’s behaviors have greatly changed in a way that leads to consuming more single-use plastics. The proportion of Americans who had worn a mask in public grew from 17% to 63% through the month of April, according to a YouGov survey, and a more recent survey conducted by the Democracy Fund + UCLA Nationscape Project found that the figure jumped to 84% in the second week of May. This huge demand for protective items has been high enough to cause products like masks, gloves, disinfectant wipes and hand sanitizers — many of which, but not all, are made of or packaged with plastic — to be repeatedly out of stock.
This increase can also be seen in non-medical plastic items. In mid-March, not long after stay-at-home orders began going into effect in the U.S., more than 52% of Americans said they ordered groceries online, more than double the amount two years ago, according to the U.S. Online Grocery Survey 2020. Because reusable bags can’t be used with groceries delivered to the front door, customers must use paper or plastic disposable bags instead.
Benfield suggests that behavioral patterns may also explain the trends in PPE littering he’s seen so far. According to his data, people are more likely to litter in areas already populated by older litter, and cities with more trash bins may experience less litter — though New York City seems to have plenty of bins yet sees the most discarded waste of any city Benfield has surveyed.
“My colleague in Turkey was all worried that she was going to be the worst data point on the table. I said no, don’t worry, there’s Brooklyn,” he says with a laugh. For people who carry disposable gloves or masks outdoors, Benfield recommends bringing along a small plastic bag to store them in until they can be thrown out at home. His advice does require an additional piece of plastic, but it’s a trade-off for keeping the outdoors cleaner.
Because many kinds of PPE are made of plastic and related polymers, they break down and affect natural ecosystems in a way similar to traditional plastic waste, Benfield says. So besides its potential infection risk, the increased medical waste released into the environment is primarily an aggravation of the preexisting problem of plastic pollution.
Plastic in the environment
Most single-use plastics, even those that save lives, outlive their intended use and may go on to cause environmental harm. In the last six decades, 8.3 billion metric tons of plastic — 19 trillion pounds — have been produced globally, as reported by National Geographic, and 6.3 billion has become plastic waste. Nine percent of that waste has been recycled, and 12% has been incinerated for energy, a process that releases poisonous fumes such as dioxin. The remainder have gone either to landfills, where they leak toxic chemicals into groundwater, or into the environment, where they entangle and kill animals.
For example, Benfield is concerned how the new medical waste in Baton Rouge will affect the nearby marine ecosystems. “Gloves — texturally and from a morphological perspective — look a lot like a jellyfish,” he says. “It won’t take too long before microbes grow on them and give them a taste and a smell that is pretty similar to actual food, so they’re definitely a hazard for sea turtles, for some fishes, maybe some marine mammals.”
A different, less understood problem emerges as plastic breaks down into microplastics. When plastic items get torn up over time in the environment, they can form pieces less than half a millimeter in length and cause harm to humans and animals alike, says John Scott, a senior chemist at the Illinois Sustainable Technology Center. At the ISTC, a research organization associated with the University of Illinois, Scott studies how microplastics vary in shape, size and material, and his latest research has revealed the plastic fragments present in Wisconsin’s Milwaukee River and in aquifers deep underneath Illinois. Other researchers have found the contaminants throughout nature, from Arctic snow to Hawaiian beaches.
“They are very mobile, and in the environment over time, these things are very persistent and they just keep breaking down into smaller, smaller sizes,” Scott says. “And the smaller the size, the more potential there is for adverse effects in biota that becomes exposed to them.”
Those adverse effects are only beginning to be understood, Scott says, but “we know for sure” that when the stomachs of animals like fish and birds fill with indigestible plastics, they feel less hungry and feed less often, literally starving themselves of nutritional value. Humans also consume tens of thousands of microplastic particles each year from eating, drinking and breathing — approximately the equivalent of a credit card per week. The National Institutes of Health’s website states “there is scientific uncertainty about the hazards of microplastic issues” but cites concern of microplastics and toxins they may absorb causing “adverse health effects” in humans, particularly through seafood.
Plastic pollution is also a possible economic liability on the local level. “Imagine if a beach becomes littered with plastic. Nobody’s going to want to go to it, so right there is a loss,” Scott says. Sport fishing may also become less popular if microplastics disrupt fish populations.
Although he hasn’t studied the relationship between plastic pollution and the COVID-19 pandemic, Scott recognizes the polluting implications of mass-produced PPE. “Everything else takes a backseat to (public health), but the afterthought is, we’re going to be up to our necks in disposable masks pretty soon. What are we going to do with all these things?”
Bags, bans and business
For someone who speaks out against plastic bag use, Beyond Plastics founder Judith Enck sure has a lot of them in her home.
“I have more paper and plastic bags in my kitchen today than I’ve had in literally 20 years — it’s horrifying,” says Enck, a previous EPA regional administrator appointed by former President Barack Obama. She says the build up is because of the pandemic-related lockdown in her state of New York. But rather than laying blame at the feet of consumers, Enck has made recent media appearances to criticize plastic lobbying groups, who she says have been misleading the public about the safety of plastic bags to advocate for plastic bag ban repeals.
Indeed, plastic lobbying groups have said scientific studies have found that reusable bags spread bacteria and viruses in grocery stores and argue that single-use plastics are the most sanitary option during the COVID-19 pandemic. In a letter to the U.S. Department of Health and Human Services, for instance, the Plastics Industry Association asks the department to put out statements supporting the safety of plastic bags and against plastic bag bans.
Although the HHS has not performed the lobbying group’s suggestions, some state governments have recently taken actions to make plastic bags more available for grocery shoppers. For instance, New York and Maine have delayed implementation of plastic bag bans, California temporarily lifted its own ban, and New Hampshire has banned the use of reusable bags in grocery stores. Companies have been enforcing their own rules against reusable containers, such as Starbucks’ ban on customers bringing their own reusable cups, which replace the coffee chain’s own cardboard or plastic cups. “I think this is all contrived by the plastics industry, and they are doing pretty well,” Enck says.
But Enck says that the studies that groups such as the PIA cite don’t support the claim that plastic bags are safer than reusable bags. The letter written by the PIA, which did not respond for comment, referred to three studies published before the COVID-19 outbreak that showed that reusable bags could spread bacteria in grocery stores. But according to Enck, those studies have limited applicability to coronavirus, which is not a bacterium but a virus, and only shows the necessity of washing reusable bags. Furthermore, a study by the U.S. National Institutes of Health found that the coronavirus may even live longer on plastics (2-3 days) than on other materials like cardboard (24 hours). “It’s pretty clear that without much scientific justification, the plastic bag manufacturers are exploiting the crisis,” she says.
Still, given the reality that many people don’t wash their tote bags, Enck recommends a “middle ground” approach to grocery shopping in the pandemic: Put groceries in the bags yourself. “We gotta protect the health of these amazing grocery workers who all should be getting raises and combat pay,” she says. “So pack your own groceries. Maybe some people with disabilities can’t do it — most people can. … I talked to a supermarket executive in an email the other day and they’re fine letting their customers do that.”
If ordering online is a necessity, choosing paper bags rather than plastic allows for the option of recycling. “There’s a desperate need for more paper for recycling,” Enck says. “Companies that make cardboard boxes have a shortage, and there’s an increasing demand, especially with online commerce.” This is in contrast with trying to recycle plastic bags, which are often made of low-density polyethylene (recycling No. 4). Depending on the policies of individual recycling services, plastic shopping bags often can’t be thrown in the recycling bin and need to be dropped off at specially designated places to be recycled. Furthermore, the recycled plastic market is in the midst of a slump after China stopped purchasing most of the recycled plastic being produced by the U.S. in 2017.
In her efforts to stave off plastic pollution, Enck says she recognizes that public health should still be policymakers’ first priority. “I’m less worried about delay (in plastic bag ban implementation) because this is such a frantic time, and I actually think their policymakers should be focused on real COVID issues; I don’t want to distract them,” she says. “I want them to deal with more contact tracing and more testing and more access to health care. … The question is how long do the delays last, and do they lead to repeals, because there’s just no science to back up the position that the plastic bag manufacturers are taking.”
Regardless of how plastic bags affect the spread of the coronavirus, the plastics industry holds a bigger stake than allowing cashiers the chance to ask customers, “paper or plastic?” The recent natural gas boom created by the advent of fracking and big investments by international players like China and the U.S. are setting up the plastics industry for a 33% expansion for some products by 2025, according to the Center for International Environmental Law.
However, the recent spin-out of the oil industry caused by the pandemic have persuaded investors like Shell to suspend construction of plastic production facilities. As well, international efforts to ban or limit the use of single-use plastics — which constitute 40% of the plastics industry — could reduce demand for plastic to less than what the industry can produce, according to reporting by Time. By advocating for the retention of plastic bags in grocery stores, groups like PIA are trying to protect their existing markets and have consumers associate their product with cleanliness.
The growth of the plastics industry, in part driven by the rapidly expanding $244 billion plastic packaging industry, is also important to the oil industry, according to reporting by Oil Price. Petrochemicals like plastics make up 14% of global oil use, but they will make up a full 50% of the oil industry’s demand growth by 2050. Faced with the firm resistance from countries trying to clean up their energy sources and switch to renewables, plastics may become an increasingly valuable market for producers of fossil fuels.
A pandemic without plastic?
The first plastic was invented in 1869 as a replacement for ivory in billiard balls, but its mass production only began during and after World War II, when newly invented plastics such as nylon saw widespread use in military products. There was once a time when plastics were revolutionary and replaced many other, less pliable materials; now, with the damage plastic pollution has on the environment, many are wondering whether society can move beyond it.
Plastic use and waste has increased during the pandemic in part because many crucial products are only mass-produced from plastic materials. But Nicole Dollison of the George Washington Hospital has many ideas to reduce medical waste in hospitals, such as purchasing washable gowns rather than disposable ones and sterilizing N95 masks for long-term use.
But a fully sustainable response to a pandemic may require a fully sustainable economy and society, and one theory for reaching that point would ideally address not only plastic pollution but all pollution: the circular economy. Rather than in a linear economy like our own, which uses natural resources to create a product that will eventually turn to waste, a circular economy recycles its wastes into the materials for another product — or produces no waste at all. The World Economic Forum’s Circular Gap Report Initiative rates the world economy as being 8.6% circular, demonstrating a long path to sustainability.
Plastics as they currently exist don’t fit into a circular economy because they consume fossil fuels and leave behind harmful waste, but potential replacements are being developed that can perform similar functions without the environmental harm. Bioplastics can be produced by the sugars in plants, but mass producing plant-based bioplastics may require too much land, according to reporting by National Geographic. Researchers at Tel Aviv University demonstrated that they could make a sustainable plastic-like material from a microorganism living on seaweed, according to EcoWatch; the innovative material doesn’t require large amounts of land and degrades quickly. Any large-scale application could only happen after many years of research, but it’s a step in the right direction to replacing plastics.
Judith Enck, whose organization Beyond Plastics has the stated mission of ending plastic pollution, says she likes working on problems that are “almost impossible to solve, so of course I chose plastics.” Given the size of both the physical plastic pollution and the industry underlying it, her assessment may not be far off. Regardless, she seems to stake out progress by framing the pandemic and its ensuing economic disruption as a turning point away from plastic pollution.
“We can’t let the crisis take our common sense away from us,” she says. “We know we’re in this for a very long time, and the new normal cannot be going back to more single-use disposable plastics.”
