Indonesia’s Steady Stream of Medical Waste

Medical waste found in the Cisadane River in Tangerang, Indonesia.

This story was supported by the Pulitzer Center

Ade Yunus can still vividly describe how the Cisadane River bank in Cibodas, Tangerang—a satellite city about 20 kilometres west of the Indonesian capital Jakarta—looked a few years back. Mountains of trash were scattered between banyan tendrils and bamboo groves. The grass and moss grew uncontrollably. It was the kind of place where no one dared to tread, not even locals. 

“People jokingly said it was a place where spirits dwelled and mated,” he laughs. “When dusk fell down nobody wanted to go there.”

Yunus graduated from the State Islamic University Syarif Hidayatullah Jakarta with a degree in political science in 2008, but has been an active member of nature clubs since high school. He has always enjoyed hiking and mountaineering, but in 2012 he felt he needed to do something more. One question kept bugging him: “What can nature lovers give back?”

“I thought that if you were a nature lover, you couldn’t truly enjoy the mountains while also littering,” he tells New Naratif. “Nature lovers should do something real [for the environment].”

Ade Yunus, founder of environmental organisation Bank Sampah Sungai Cisadane (Cisadane River Waste Bank) or Banksasuci, stands on a floating boom used to collect waste from the Cisadane River in Tangerang, Indonesia.
Ade Yunus, founder of environmental organisation Bank Sampah Sungai Cisadane (Cisadane River Waste Bank) or Banksasuci, stands on a floating boom used to collect waste from the Cisadane River in Tangerang, Indonesia.

So in 2012, together with locals and only IDR 15,000 (US$1) to buy water and snacks, and a machete, Yunus started clearing the river bank. The team of five people cut the grass and collected the trash for days. They separated the plastic waste and sold it to collectors for recycling in exchange for cash. Based on the grassroots experience, Yunus then founded an environmental organisation with other activists and residents called Bank Sampah Sungai Cisadane (Cisadane River Waste Bank) or Banksasuci to manage the waste flowing into the Cisadane River. 

Before long, the Cisadane River bank in Cibodas was completely transformed. Yunus set up a camping site and playground on a two-hectare plot of land, and people wishing to visit the grounds may enter free of charge. Instead, they only need to bring plastic waste to exchange for entry tickets. 

“It’s no longer a place where spirits dwell,” Yunus says. “It’s now a place where families could enjoy nature.”

A Steady Stream

Cisadane River runs around 130 kilometres from Mount Pangrango and Mount Salak in West Java to the Java Sea. It provides 80 percent of the water supply for people in West Java, Banten and parts of Jakarta. 

The name of the river comes from Sanskrit, meaning “the water of the kingdom’s palace”. It was a sacred site during the Pajajaran Hindu empire from the 11th to 15th century, and during the Dutch colonial occupation it served as an important trading route, giving access to small merchant boats to and from the Java Sea. The colonial government then built a dam in 1927 for irrigation purposes and to create a water supply. 

Soon it was far from being a sacred site. 

“We were very concerned…. Before this, we only found one or two pieces of medical waste. But now, within a day, we could find around 50 different pieces.”

For decades, the Cisadane River has suffered from severe pollution from nearby factories and households. According to government records, there are more than 5,000 factories along the river in Tangerang Regency alone. Between 2014 and 2018, more than 400 factories were found to be dumping their waste into the river. 

Using a 30-metre-long floating containment boom that stretches across the Cisadane River, Yunus and the local community intercept between 300 and 500 kilograms of waste everyday. In May 2020, Yunus started to notice an increase in medical waste being caught in their floating boom. Almost every day, he found various types of medical waste such as hazmat suits, masks, medical gloves, infusion bags, tubes, syringes and needles. 

Some of the medical waste looked new, as if it had been used yesterday. Some looked decades-old. Yunus tells New Naratif that the medical waste was scattered and not found in biohazard containment bags, meaning it originated from various places and was disposed of improperly. “We were very concerned,” Yunus says. “Before this, we only found one or two pieces of medical waste. But now, within a day, we could find around 50 different pieces of medical waste.”

An aerial view of a waste landslide at the Cipeucang landfill in South Tangerang, Indonesia.
An aerial view of a waste landslide at the Cipeucang landfill in South Tangerang, Indonesia.

After being sorted, the collected medical waste is burned in an incinerator with a capacity of one ton per day which can generate heat of 800 degrees Celsius. While medical waste has economic value if sold to garbage collectors, Yunus can’t risk it. “Can you imagine if a used needle pierced your skin?” he asks. “We never know the contamination risks. It’s very dangerous.”

Yunus later found out that the medical waste originated from the Cipeucang landfill in South Tangerang, about 18 km south of the Banksasuci headquarters. Two landslides occurred at the landfill in just over a year. The first was in April 2019, and more recently a larger landslide occurred in May 2020, sending hundreds of tons of waste—including greater amounts of medical waste—straight into the Cisadane River. There was so much that Yunus’ floating containment boom could not hold the stream of waste and was dragged 1 kilometre from its original placement. 

The South Tangerang Administration built 400-metre embankment walls surrounding the landfill at a cost of IDR 24 billion (US$1.6 million) in December 2019. But it was not enough to contain the waste, raising concern over corruption. On 3 June, activists from Relawan Hijau Hitam (Black Green Volunteers) filed a lawsuit against the South Tangerang Environment Agency to the Indonesian Corruption Eradication Commission (KPK). The agency was accused of embezzling IDR500 million (US$30,000) of state funds meant to build the Cipeucang landfill embankment walls. 

“I have warned the local government that the landfill is far from feasible,” says Yunus. “I wasn’t very surprised that a landslide occurred because the embankment walls are improperly built, and built near the Cisadane River. What surprised me is that the government seems to handle medical waste improperly.”

“A Ticking Time Bomb”

Cipeucang is a 2.5-hectare landfill that can handle 2,500 tons of waste per day. It was established in 2012 to accommodate waste from around Tangerang. Since 2018, environmental activists have said the landfill was overloaded, with piles of trash as high as 16 metres. The South Tangerang Administration planned to relocate the dumping operation to Nambo, Bogor, West Java, but this has yet to be realised. 

Environmental activists have protested against the Cipeucang landfill since day one, as it is located near housing complexes and just a few metres away from the Cisadane River. The foul smell emanating from the site has been reported as far as 6 kilometres away. 

Sujadi, a local resident whose house is just 100 metres from the landfill, frequently suffers from headaches which he attributes to the stench of the landfill, especially after it rains or when the Cipeucang operators bulldoze the waste. 

“Years back I thought we would get used to [the smell],” explains Sujadi, who has lived near Cipeucang since the 1980s. “Turns out I was wrong. When it reeks we just can’t breathe, even when we try closing the door and windows. But we have no choice because we can’t just move out.”

But it is not just a matter of the foul odour. 

“When it reeks we just can’t breathe, even when we try closing the door and windows. But we have no choice because we can’t just move out.”

Dwi Sawung, an environmental campaigner with the Indonesian Forum for the Environment (Walhi), says Cipeucang landfill is “a ticking time bomb”, since it does not have a proper environmental impact analysis report (Amdal) and has poor infrastructure. 

The landfill does not have treatment facilities, such as incinerators, so it is pretty much a run-and-dump operation, says Sawung. It does not have a geomembrane—a low permeability synthetic membrane liner or barrier between the waste and the underlying geology used to control water migration. The use of a geomembrane is mandatory in the United States, Europe and Australia. 

This means that waste produces leachate in a landfill without a geomembrane, and the leachate, which is hazardous, can contaminate the groundwater. It is produced when water flows downward through piles of waste in a landfill, which eventually picks up dissolved materials from the decomposing waste. It contains various toxic pollutants such as heavy metals, inorganic components and acids. 

Since the Cipeucang landfill does not use a geomembrane, chances are the leachate would flow directly into the Cisadane River, Sawung says. 

Worse yet, Cipeucang landfill also does not have a proper methane gas management system, and every landfill produces methane gas as a natural byproduct of the decomposition of organic material. 

According to the Environmental and Energy Study Institute, one ton of methane causes 72 times more warming than one ton of carbon dioxide. Over time, methane gas beneath the mountain of waste piles up, meaning it could be collected in pipes for other beneficial uses. If not, it could cause an explosion.

In February 2005, an explosion that triggered a landslide due to untreated methane gas occurred at Leuwigajah landfill in Cimahi, West Java, killing more than 150 people and destroying hundreds of homes. Leuwigajah is a 25-hectare landfill and receives 3,800 tons of waste per day. The open dumping system has created a 60-metre-high tower of waste.

“It’s just a matter of time until a bigger environmental disaster occurs at Cipeucang,” says the activist Sawung.

Reckless Medical Waste Treatment

The incident at Cipeucang landfill in May underlined two major problems: how Indonesia’s poor waste management and open-dumping systems have serious environmental impacts and how reckless medical waste treatment has yet to be addressed.

Long before the COVID-19 pandemic, improperly disposed of medical waste was an environmental problem in Indonesia. It has been found in almost all landfills across the country. Recently medical waste was found in Sumur Batu and Bantar Gebang landfills in Bekasi, West Java. 

According to Health Ministry regulations, every medical facility should have its own medical waste treatment plants. If the facility can’t afford it, a third-party waste management company should be contracted. However, only 14 waste management companies are regulated by the government: 10 in Java, two in Kalimantan, and one each in Sumatra and Sulawesi. 

Out of 2,889 hospitals across Indonesia only 82 have their own waste treatment facilities such as incinerators and autoclaves, according to the Health Ministry’s Directorate of Environmental Health. Before the pandemic, the Health Ministry estimated that more than 290 tons of medical waste were disposed of per day across Indonesia. During the pandemic, the number is estimated to be five times higher, especially since the government has appointed more than 130 hospitals to handle COVID-19 patients across Indonesia, according to the directorate. 

“Every medical facility should collect all the medical waste using specially designated bags before being treated, either by themselves or by third-party companies. But we have to admit that we can’t monitor how the third-party companies operate.”

The ministry’s director of environmental health, Dr. Imran Agus Nurali, admits that medical waste treatment in Indonesia is far from adequate, especially during the COVID-19 pandemic. Imran says that the Health Ministry does not have the ability to monitor every medical facility, though together with the Environment Ministry they have issued regulations and guidelines on how to manage medical waste. 

“We do have issued regulations,” Imran tells New Naratif. “Every medical facility should collect all the medical waste using specially designated bags before being treated, either by themselves or by third-party companies. But we have to admit that we can’t monitor how the third-party companies operate.”

Overly lax regulation and inadequate monitoring have created loopholes in managing medical waste. Yet even in normal times, most third-party companies operate without proper procedures. 

The chairman of the National Waste Coalition (KPNas), Bagong Suyoto, says the problem lies in the transportation and treatment chains conducted by the third-party companies. “Most permits of third-party companies are highly questionable,” Suyoto says. “The medical waste that should be incinerated is usually sorted out before being sold to recycling companies.”

One waste management company, PT Putra Restu Ibu Abadi (PRIA), based in Mojokerto, East Java, was accused of dumping biohazardous waste in Lakardowo village, Mojokerto in 2017. The hazardous waste allegedly came from Sanglah Hospital in Denpasar, Bali, yet no charges were brought against PT PRIA. Lakardowo residents demanded that the Environment Ministry investigate the case against PT PRIA in 2018. However, the case went dark after an auditory team from the ministry found a lack of evidence of pollution.

In the case of the medical waste at Cipeucang landfill, the head of the South Tangerang Health Agency, Deden Deni, told local news media that all medical facilities within his jurisdiction are under contract with city-owned firm PT Pembangunan Investasi Tangerang Selatan (PT PITS). “Most medical waste from healthcare centres (Puskesmas) are handled by PT PITS,” Deni told Sindonews in June. “Only Tangerang Hospital contracts another third-party.”

“There are many ways in which COVID-19 could spread. We know it can stay for hours on a surface. God knows if there will be a new landfill cluster due to medical waste.”

According to its website, PT PITS was established in 2014 to manage the water supply around South Tangerang and offer services such as waste management and transportation. 

During the Cipeucang landfill inauguration ceremony on 21 June 2012, then-PT PITS director Dudung E. Diredja claimed that the landfill “implements sophisticated technology that will not harm the environment so people around the landfill should not be worried” and that it is “an important step toward handling waste in South Tangerang”.

Over the course of its operation, PT PITS says its profits have increased by 300%. 

According to Environment Ministry records made public in April 2020, PT PITS does not have an operational permit to handle biohazardous waste, yet Diredja tells New Naratif that PT PITS has secured operational permits from the ministry and that his company has nothing to do with the medical waste scattered at Cipeucang landfill. 

PT PITS is only responsible for transporting the waste and does not deal with waste treatment, Diredja says. PT PITS contracted the waste management activities to another company named PT Wastec based in Cilegon, Banten, he adds. 

“Of course we have permits [from the ministry], because it’s one of our responsibilities [to handle biohazardous waste],” Diredja tells New Naratif. “We have discussed with the ministry that PT PITS does not dump medical waste at Cipeucang.”

Harmful to Human Health

While the government lifted the large-scale social distancing restrictions (PSBB) in June, allowing businesses in various sectors to open, new daily COVID-19 cases continue to spike with a record high of more than 2,600 cases on 9 July. Indonesia has confirmed over 97,000 cases with more than 4,700 deaths as of 26 July.  

Not only harmful to the environment, in times when the COVID-19 pandemic ravages the country with no end in sight, medical waste poses a great danger to human health in Indonesia. It could also jeopardise the effort to flatten the curve.

Dr. Mahesa Paranadipa from the Indonesian Doctors Association (IDI) tells New Naratif that the dumping of medical waste is not just a crime against the environment, but also an inhumane act. The government, he adds, should punish those responsible for such acts. 

“The regulation states as such,” Paranadipa says. “It is punishable by law and could land you in jail plus billions of rupiahs in fines. So why not investigate and punish people?”

Paranadipa continues that treating waste is a long process that involves many people, from the stages of collection and transportation to the landfill to being picked up by scavengers or waste pickers. If left untreated, the refuse could create a whole new cluster of COVID-19 infection.

“Even treating household waste needs special treatment, let alone medical waste. It needs very special treatment,” he explains. “There are many ways in which COVID-19 could spread. We know it can stay for hours on a surface. God knows if there will be a new landfill cluster due to medical waste.”

Toward the Largest Dumpsite: The Jakarta Bay

In the end, all of the untreated waste in the rivers ends up in Jakarta Bay: the confluence of nine rivers that flow through Greater Jakarta and the Java Sea. 

Scientists at the Indonesian Institute of Sciences (LIPI) estimate that more than 20 tons of waste enter the bay every day. The figure is most likely higher as waste is sometimes trapped beneath the surface water, LIPI oceanographer Muhammad Reza Cordova tells New Naratif. Between March and April this year, Cordova and his team of scientists say they observed medical waste flowing to the Cilincing and Marunda estuaries in North Jakarta for the first time. Using an underwater net to catch the waste at depths of 1.5 metres, Cordova found various types of medical waste that accounted for 16 percent of the total waste captured. 

“We found around 1,600 items of medical waste just within a month,” mostly hazmat suits and masks, Cordova says. “But since the net is just 1.5 metres deep, we suspect the figure may be higher.”

Cilincing is one of the most important coastal areas for fisheries and aquaculture in Jakarta. As many as 8,000 fisherfolk from outside Jakarta—mostly from Indramayu, Tegal and Cirebon—have settled there since the 1970s. 

When New Naratif visits the coastal region in early June,  all types of uncountable consumer plastic waste can be seen floating on the surface of the pitch black brackish water, which flows from the Cakung River into the Cilincing estuary. There are practically no fish around Jakarta Bay, and in order to catch anything fishers have to move further afield around the Thousands Islands—about 40 km north of Jakarta—according to a local fisherman named Maksum. 

“It’s like we have suffered a double blow,” says Maksum, who relocated from Indramayu in the 1990s. “We can’t fish around here and we have to deal with the waste too.”

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