Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697627015250.pdf (Antigua and Barbuda)
ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) ENVIRONMENTAL AND SOCIAL IMPACT ASSESSMENT ENVIRONMENTAL AND SOCIAL MANAGEMENT PLAN for Removal and Replacement of Incinerator at the Sir Lester Bird Medical Center (formerly Mount St. John’s Medical Centre) REPORT Prepared by Joseph Prosper i ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) TABLE OF CONTENTS Page Abbreviations and Acronyms ……………………………………………….
v List of Tables ………………………………………………………………… vii List of Figures ………………………………………………………………... ix Executive Summary ………………………………………………………… 1.0 INTRODUCTION ……………………………………………………….

1.1 Project Proponent …………………………………………………….. 1 3 3 1.2 Purpose of the Project ………………………………………………… 3 1.3 Purpose of the Environmental and Social Impact Assessment (ESIA) and Environmental and Social Management Plan ………… 1.4 Scope of the ESIA …………………………………………………….. 1.5 Objectives and Criteria of the ESIA ………………………………….
2.0 PROJECT DESCRIPTION …………………………………………… 2.1 Project Description …………………………………………………….

4 4 4 5 5 2.2 Objectives of the Project ……………………………………………….

6 2.3 Analysis of Project Alternatives ……………………………………… 7 3.0 METHODOLOGY ……………………………………………………… 9 4.0 POLICY, LEGISLATIVE AND ADMINISTRATIVE 11 FRAMEWORK ………………………………………………………….
4.1 Legislation ……………………………………………………………… 11 4.2 Agreements, Treaties and Conventions …………………………… 14 ii ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 4.3 National Policies …………………………………………………….

17 5.0 DESCRIPTION OF THE RECEIVING ENVIRONMENT 18 (BASELINE) …………………………………………………………….. 5.1 Environmental Baseline ……………………………………………….

18 5.1.1 Physical Environment ……………………………………………….


18 5.1.2 Physical Infrastructure …………………………………………… 20 5.1.3 Biological Environment …………………………………………… 22 6.0 SOCIO-ECONOMIC AND GENDER BASELINE …………………… 24 6.1 Socio-Economic Baseline ……………………………………………….
24 7.0 ENVIRONMENTAL AND SOCIAL IMPACTS IDENTIFICATION AND MITIGATION MEASURES ………………………………………… 44 7.1 Bio-medical Waste …………………………………………………….. 45 7.2 Risk Assessment ……………………………………………………….. 48 7.2.1 Classification of Impacts …………………………………………… 48 7.2.2 Removal of Incinerator …………………………………………… 49 7.2.3 Installation of New Incinerator …………………………………… 52 7.2.4 Operation of New Incinerator ……………………………………… 53 8.0 ENVIRONMENTAL AND SOCIAL MANAGEMENT AND 66 MONITORING PLAN ………………………………………………….
8.1 Introduction …………………………………………………………….
66 8.2 Summary of Impacts …………………………………………………… 67 8.3 Mitigation ……………………………………………………………….. 69 iii ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 8.4 Management Structure and Responsibilities ………………………….. 70 8.5 Public Consultation and Environmental and Social Disclosure ……… 71 8.6 Grievance Mechanism …………………………………………………… 72 8.7 Environmental Procedures and Site and Activity-Specific Work Plans/Instructions ……………………………………………………….. 8.8 Performance Criteria …………………………………………………… 8.9 Management and Monitoring Plan 8.10 Gender and Inclusivity Action Plan 73 73 75 84 9.0 Conclusion ………………………………………………………………... 88 References Appendix A Questionnaire Appendix B SLBMC Employees by Department (Gender Disaggregated) 89 90 92 Appendix C Management Plan For Decommissioning of Hospital Incinerator 96 at SLBMC (Formerly MSJMC) iv ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) ABBREVIATIONS AND ACRONYMS ABNMWMP Antigua and Barbuda National Medical Waste Management Plan CBD CBH United Nations Convention on Biological Diversity Central Board of Health CEDAW Convention on the Elimination of forms of Discrimination Against Women CGA CPA CSW DAS DoE DGA EPMA FIA HCW Country Gender Assessment Country Poverty Assessment Commission on the Status of Women 2008 Department of Analytical Services Department of the Environment Directorate of Gender Affairs Environmental Protection and Management Act 2015 Freedom of Information Act 2003 Health
 Care Waste HCWM Health Care Waste Management IDB INDC IPCC Inter-American Development Bank Intended Nationally Determined Contributions Intergovernmental Panel on Climate Change LBS Protocol Protocol Concerning Pollution from Land Based Sources and Activities MHWE Ministry of Health, Wellness and the Environment NAP NGO National Adaptation Policy Non-governmental Organisations NSWMA National Solid Waste Management Authority PPA PPE Physical Planning Act 2003 Personal Protective Equipment Rio+20 United Nations Conference on Sustainable Development v ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) SDG Sustainable Development Goals SIRMZP Sustainable Island Resource Management Zoning Plan SLBMC Sir Lester Bird Medical Center formerly Mount St. John’s Medical Center UNFCCC United Nations Framework Convention on Climate Change vi ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) LIST OF TABLES Table A.
Field study dates and times Table 1.

Number of Houses and Residents Table 2.

Number of Physically Challenged, Blind and Deaf Residents Table 3.

Number of Pregnant Persons Table 4.

Retired Persons (%) Table 5.

Full Employed vs Unemployed Table 6.

Number of Desktop Computers Table 7.

Number of Mobile Phones Table 8.

Waste Disposal Methods Table 9.

Bathroom Location Table 10.

Air Conditioning Units Table 11.

Water Supply Table 12.

Number of Bedrooms Table 13.

Number of Cars Owned Table 14.


Land Tenure Table 15.

Marital Status Table 16.

Disease Affecting Residents by Type (%) Table 17.

Number of Residents who have heard the word incinerator.” Table 18.

Education Level Table 19.

Labour Force Characteristics, by Sex, 2018 Table 20.

Total Resident Population by Sex, St. John’s City Page 10 28 28 29 29 30 30 30 31 31 31 31 32 32 32 32 33 34 35 36 36 vii ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Table 21.
Total Resident Population by Sex, St. John’s Rural Table 22.

Key Indicators of Housing Quality: Percentage Total Household Possessing Each Attribute Table 23 .

Classes of Bio-medical Waste`` 37 37 45 Table 24.

Impacts and risk assessment associated with various stages of the 64 project.

Table 25.

Major Impacts Expected from Project Table 26.

Environmental Management and Monitoring Plan Table 27.
Gender Action Plan 68 75 85 viii ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) LIST OF FIGURES Figure 1: Topographic Zones of Antigua (adapted from National Action Plan) Figure 2.

Villages near SLBMC Figure 3: Business Demographics within the Ovals Area on September 22nd, 2022, 5 - 6 p.m.

Figure 4: Business Demographics within the Michaels' Village Area on October 7th & 13th, 2022, 4 - 6 p.m.
Figure 5: Business Demographics for Upper Ottos on September 29th, 2022, 5 - 6 p.m.

Figure 6: Business Demographics for Lower Ottos on October 13th to November 13th, 2022, 1 - 6 p.m.

Figure 7: Business Demographics for the Radio Range Area October 14th to 16th, 2022, 12 – 5:30 p.m.

Figure 8: Distribution of Individuals with Disability Within Michael’s Village, Ovals Village, Ottos Village, And Radio Range Figure 9.
Disease by Type among Males with Michaels Village, Ovals Village, Ottos Village, and Radio Range Figure 10.

Disease by Type among Females with Michaels Village, Ovals Village, Ottos Village, and Radio Range Figure 11.

Number of Females and Males with understanding of the word “Incinerator”.

Figure 12.

Risk Assessment Matrix Figure 13.

Drum used to store ash from the incinerator Figure 14.
Mitigation Principle Page 19 22 25 25 26 27 27 29 33 34 34 48 50 69 ix ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) EXECUTIVE SUMMARY The project is to remove the present incinerator system at the Sir Lester Bird Medical Center (SLBMC) formerly the Mount St. John’s Medical Centre, and replace it with a new incineration unit.

The project is part of the “Strengthening Resilience and Supporting Recovery in Antigua and Barbuda COVID-19 Health Response Project”.
The Caribbean Development Bank (CDB) is the funding agency.

The Physical Planning Act (2003) Section 23 (1), (2) and in Schedule III requires the preparation of an Environmental Impact Assessment report for certain undertakings one of which is an incinerator.

The CDB/IDB requires that developments classified as Category B have an Environmental and Social Impact Assessment and an attendant Environmental and Social Management Plan.
To elucidate baseline environmental and social conditions related the project site, several methods were used including a desk review of pertinent documents, interviews with relevant personnel, site visits and community surveys.

Data gathered included but was not limited to physical attributes, biological environment, socio-economic conditions, archaeology, history and culture, infrastructure and proposed development.
Impact of assessments evidenced no significant negative effects on the physical and biotic environments, no potential impacts on archaeology, history/culture.

No negative health or socio economic impacts are expected which cannot be significantly reduced or eliminated through effective implementation of the monitoring plan.

Potential issues include air pollution, contamination of hospital water supply, fire and occupational health and safety concerns.
Mitigation based on the management plan include the development of bio-medical waste management plan to include protocols and procedures for segregation, storage, handling and transport, treatment and disposal of waste, proper installation and operation of the incinerator, initial and on-going training of staff and collaborative testing 1 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) and monitoring between the SLBMC team, the DOE, Department of Analytical Services and National Solid Waste Management Authority.
2 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 1.0 INTRODUCTION 1.1 Project Proponent The Sir Lester Bird Medical Centre (hereinafter referred to as SLBMC) formerly Mount St. John’s Medical Centre is seeking to procure a replacement incinerator as part of the project titled: “Strengthening Resilience and Supporting Recovery in Antigua and Barbuda COVID-19 Health Response Project”.
The hospital is the only public hospital providing tertiary healthcare for the twin-island state of Antigua and Barbuda.

The source of funding for the project is the Caribbean Development Bank.

1.2 Purpose of the Project The project aims to improve the handling and treatment of bio-medical waste generated by the SLBMC.

Antigua and Barbuda have limited land space and presently most waste, including biomedical waste, is disposed of at the Cook’s sanitary landfill.
The COVID-19 pandemic saw a massive increase in the amount of bio-medical waste generated (MHWE, 2022) especially contaminated personal protective equipment.

This meant that the hospital had to handle and store more waste, sub-contractors had to transport this waste to the landfill and this waste had to be deep buried in appropriately prepared chambers to reduce leaching, scavenging and other activities with potential hazards due to exposure to bio-medical waste.
The present incinerator is no longer operational and interim procedures for dealing with bio-medical waste are not ideal and presents potential risks and hazards associated with handling, storage, transport and disposal.

These risks are to employees of the hospital, subcontractors responsible for transport of the waste, employees at waste disposal sites, scavengers and the general public.
Incineration using a properly functioning incineration unit operated according to international 3 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) standards and best practices, will reduce the volume of waste and minimize potential harm due to its toxicity, infection and injury potential.

The project will see the removal of the present incinerator and its replacement with a new unit to be operated according to international best practices.
The new incinerator will be placed on the site of the old incinerator in a purpose-built room.

The new incinerator will also handle medical waste from other institutions such as the Clarevue Psychiatric Hospital.
1.3 Purpose of the Environmental and Social Impact Assessment (ESIA) and Environmental and Social Management Plan Legal Authority: The Physical Planning Act (2003) Section 23 (1), (2) and in Schedule III requires the preparation of an Environmental Impact Assessment report for certain undertakings one of which is an incinerator.

The CDB/IDB requires that developments classified as Category B have an Environmental and Social Impact Assessment and an attendant Environmental and Social Management Plan.
1.4 Scope of the ESIA Under the Antigua and Barbuda Physical Planning Act 2003, Section 23, Third Schedule, for the procurement of a replacement incinerator as part of the project titled: “Strengthening Resilience and Supporting Recovery in Antigua and Barbuda COVID-19 Health Response Project”, this ESIA pertains to the installation and operation of a replacement incinerator at the Sir Lester Bird Medical Centre and proposes measures that will mitigate risks, along with the development of a monitoring plan.
1.5 Objectives and Criteria of the ESIA Specific objectives are to: 4 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 1.

Assess potential significant environmental and social impacts of the project.

2.

Assess baseline environmental and social conditions as they relate to the proposed location of the work.

3. Review relevant policies, legislation, and regulations framework which have implications for the successful implementation of the proposed work.

4.
4.

Identify receptors of impacts to include air, ecosystems, water bodies.

5.

Identify stakeholders (e.g., Staff, patients, residents, and workers removing old incinerator and replacing and operating the new incinerator) who may be major recipients of impacts.

6.

Identify mitigation strategies for direct and indirect impacts during the removal of the present incinerator, installation of the replacement incinerator and operation of it.

7.
7.

Develop associated mitigation and monitoring measures required for the successful implementation of the proposed project activities.

The format and criteria of the ESIA is based on the revised terms of reference as set out by the Department of the Environment (see Annex 1) and adheres to the Caribbean Development Bank Environmental and Social Review Procedures.
2.0 PROJECT DESCRIPTION 2.1 Project Description and Objectives The task involves the procurement and installation of a replacement incinerator as part of the project titled: “Strengthening Resilience and Supporting Recovery in Antigua and Barbuda COVID-19 Health Response Project.” The project proposes the removal of the present non- 5 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) functioning incinerator system and replacement with Therm-tec G-20 incinerator (see Annex 2 for specifications).
Objectives of the Project The major objectives of the project are to: 1.

Incinerate hospital waste and waste generated from other medical facilities.

2.

To prevent or reduce improper disposal of bio-medical waste 3.

To reduce risk of injury and spread of disease to the general public due to improper disposal and handling of biomedical waste.

4.

To reduce risk of injury and spread of disease to hospital workers and municipal workers who may be required to handle biomedical waste 5.
To prevent scavenging of bio-medical waste 2.2 Benefits and Justification Incineration of medical waste is widely practiced.

It reduces organic waste to inorganic matter which is less combustible and less hazardous.

Effective incineration requires high temperatures (850-1100 °C) to reduce the volume, mass and infection potential of bio-medical waste and is an effective way of dealing with waste that is difficult or impossible to reuse or recycle safely.
Incineration increases waste management efficiency as it reduces the volume of waste to be disposed in landfills, reduces transportation costs and eliminates potential pathogens and toxins.
This became especially important in 2020 to 2021 when the COVID-19 pandemic exponentially increased the volume of personal protective equipment, such as masks, gloves, 6 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) face shields, and other medical waste generated by the hospital.

Incineration reduces land pollution, odour nuisance and potential groundwater contamination through leaching in landfills.
It reduces the likelihood of scavenging by humans and animals through dangerous medical waste which may lead to the spread of diseases and reduced health among the population.

Incineration in a controlled and efficient manner as opposed to haphazard and poorly controlled burning may reduce fumes and smoke and its constituents.

2.3 Analysis of Project Alternatives 2.3.1 No Project Alternative The present incinerator will remain inoperable.
Biomedical waste will most likely continue to be stored at the hospital under present conditions (in uncovered skips, then transported in unregulated vehicles to the landfill for disposal.

This represents an unacceptable situation with the potential for contamination of ground and surface water due to leaching, leading to injury and infection to all workers and scavengers who may be exposed to biomedical waste and by extension the spread of pathogenic organisms to members of the general public.
Landfills must be properly constructed and operated in order to reduce these hazards.

2.3.2 Alternative Location The Cook’s Sanitary Landfill is the most logical alternative site for a new incinerator.

However, storage, handling and transport of bio-medical waste will remain potential routes for hazard.

It is also likely that any incinerator obtained will be large enough to burn other waste which may mean that a critical volume of waste must be reached before it is operated.
This means prolonged storage of bio-medical waste when international standards require it to be treated within 24 hours of generation and to be treated near the site of generation.

There is 7 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) already a purpose-built room with all necessary infrastructure at the proposed location and no overt site preparation and construction will be required.
2.3.3 Alternative Technologies There are other methods used for the treatment and disposal of bio-medical waste and each of these are described below.

Most methods are either more expensive, less effective or require highly specialized training and qualifications which may present a challenge to obtain.

All the descriptions below are taken from the draft Antigua and Barbuda National Medical Waste Management Plan (ABNMWMP).
i) Low heat Thermal Low-heat thermal processes use thermal energy at elevated temperatures (100ºC and 180ºC) high enough to destroy pathogens, but not sufficient to cause combustion or pyrolysis of waste.

The treatment processes take place in two environments – moist or dry environment.
In the former, steam is used to disinfect waste, commonly performed in an autoclave or other steam- based system; also referred to as a wet thermal process whilst in the latter heat is used without the addition of water or steam.

ii) Chemical Chemical Treatment Processes use chemical disinfectants such as dissolved chlorine dioxide, bleach (sodium hypochlorite), peracetic acid, lime solution, ozone gas, or dry inorganic chemicals.
This process often involves shredding, grinding, or mixing to increase exposure of waste to the chemical agent and the treatment usually results in disinfection rather than sterilization.

For liquid systems, wastes may go through a dewatering stage to remove and recycle the disinfectant.

iii) Irradiation This is a process by which an object is exposed to radiation.

The waste is treated using irradiation from electron beams, Cobalt-60, or ultraviolet sources to destroy pathogens.
The effectiveness of pathogen destruction depends on absorbed dose by mass of waste.

The operator is required to be shielded to prevent occupational exposure.

This method is not commonly used for treating Health Care Waste because of the high investment cost.

iv) Biological Specifically refers to the degradation of organic matter through processes occurring in nature.
Examples include composting, vermiculture (digestion of organic wastes through the actions of 8 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) worms), bio digestion, and natural decomposition through burial of cadavers, tissues and anatomical parts.

In some cases, enzymes may be added to speed up decomposition of organic waste.

Composting and vermiculture methods have been successfully used for placenta and hospital kitchen waste.
v) Mechanical This method generally supplements other treatment methods and includes shredding, grinding, mixing, and compaction which reduce waste volume.

This method is unable to destroy pathogens.


The advantage of this method is that the rate of heat transfer is improved and the waste has more surface area for treatment vi) Inertisation (Stabilisation) This process involves mixing waste with a mixture containing lime, cement and water in order to minimize the risk of toxic substances contained in the waste migrating into surface water or underground water.

The mixture can be transported in liquid state to landfill.
It is a suitable technology for disposing of pharmaceuticals and incineration ashes with a high metal content.

vii) Shredding Shredders cut sharps into small pieces.

This technology requires a worker skilled in the operation and maintenance of heavy-duty, rotating equipment.

Simple shredders can be made from a manually operated grain mill.

Due to the risks involved for workers during the operation, only disinfected needles and syringes should be processed.
viii) Non Incineration Non-incineration technologies are used to disinfect infectious health-care waste, while avoiding the formation and release of dioxins.

Depending on the waste being treated, alternative treatment technologies may also render health-care waste unrecognizable, reduce its volume, eliminate the physical hazards of sharps, decompose pathological or anatomical waste and/or degrade chemotherapeutic waste.
Source: the draft ABNMWMP, 2022 3.0 METHODOLOGY Both primary and secondary data were used for this report.

The data and information were gathered in the ways described below.

Where possible, data was disaggregated by gender.

1.

Desk review of available literature.


This literature included but was not limited to policies such as the final draft of the Antigua and Barbuda National Medical Waste Management Plan, laws such as the Environmental Protection and Management Act and the Physical 9 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Planning Act , regulations, and regional and international treaties including those pertaining to gender.

2.
2.

Interviews with appropriate hospital personnel and pertinent professionals including but not limited to the project proponent’s representative in the person of the Operations Manager at SLBMC, employees of the SLBMC including the Facilities Manager, the current incinerator operator and the General Manager of National Solid Waste Management Authority.

3.
3.

Besides desk review of available reports such as the Antigua And Barbuda Country Gender Scorecard and Population and Housing Census, data for the socio-economic and gender impact assessment was gathered from questionnaires and informal interviews with community members.
Field study dates and times are displayed in Table A.. Questionnaires: Walk-throughs were conducted in communities adjacent to the hospital that were likely to be impacted by the use of the incinerator to conduct face-to-face interviews using the questionnaire as a guide.

The questionnaire formats can be seen in Appendix C. Table A.

Field study dates and times No.
Date Time Thursday 22nd September 2022 Thursday 29th September 2022 Friday 7th October 2022 Thursday 13th October 2022 Friday 14th October 2022 Saturday 15th October 2022 5:00 pm – 6:00 pm 5:00 pm – 6:00 pm 1:00 pm – 6:00 pm 1:00 pm – 6:00 pm 12:00 am – 5:30 pm 12:00 am – 5:30 pm 10 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Sunday 16th October 2022 12:00 am – 5:30 pm Sunday 13th November 2022 Monday 21st November 2022 Tuesday 22nd November 2022 Thursday 24th November 2022 Saturday 26th November 2022 1:00 pm – 6:00 pm 4:00 pm – 5:30 pm 7:00 am – 12 noon 3:30 pm – 5:30 pm 3:30 pm – 5:30 pm 4.
Mapping software and ground truthing to gather data on physical attributes of surrounding areas for example, the number and types of dwellings and types of businesses (see table 1).

5.

Site visits to the SLBMC for reconnaissance and to gather primary and secondary data.

4.0 POLICY, LEGISLATIVE AND ADMINISTRATIVE FRAMEWORK Part of the desk review focused on examination of applicable laws, policies and non- regulatory framework including international treaties and agreements.

These are outlined below.


4.1 Legislation 4.1.1 The Mount St. John’s Medical Centre Act 2009 The Act provides regulations for the establishment of the hospital in 2009 as well as the efficient management, administration and organization of the hospital.

The hospital was renamed the Sir Lester Bird Medical Center by parliamentary decision in May of 2021.
4.1.2 Environmental Protection and Management Act (2015) The Act aims to “provide for sustainable environmental protection and management, to establish effective allocation of administrative responsibilities for environment management, the 11 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) undertaking and coordination of environmental management, and related activities, the incorporation of international treaty obligations with respect to the environment into national and law related matters,” (p.9).
Specific to this project, the Act provides for preventative and remedial measures for mitigation of all forms of environmental degradation.

Further Schedule VIII Section 64 (3) issues air quality criteria and provides guidelines for the calculation of concentration of a substance in a point source discharge to determine if it exceeds the stated concentration and satisfies air quality standards as set out in parts 3 and 4 of the same schedule.
Part 2 of the schedule provides classification of substances, while Parts 3,4 and 5 delineate air quality guidelines, air quality standards and emission standards respectively.

The Act allows for public participation in and transparency of the decision-making process regarding environmental protection.

4.1.3 Physical Planning Act, 2003 This Act controls the development of land, the protection of the natural environment; and building regulations.
It legislates for a National Development plan and Local Area Plans for parts of Antigua and Barbuda.

The Third Schedule of the Physical Planning Act (2003) Section 23 (1) lists matters which require an Environmental Impact Assessment (EIA) and specifically lists incinerators as one such instance.

4.1.4 Freedom of Information Act 2004 The FOI Act gives effect to those parts of the Constitution that grant rights to receive and disseminate information.
It promotes maximum disclosure of information and requests the creation of an Information Officer for every Public Authority.
Important as well for the project is the provision which requires that the Public Authority make available on an annual basis “ the content of all decisions and policies it has adopted which affect the public, along with the reasons 12 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) for them, any authoritative interpretations of them, and any important background material; and (h) any mechanisms or procedures by which members of the public may make representations or otherwise influence the formulation of policy or the exercise of powers by that public authority.” (Freedom of Information Act, 2004) 4.1.5 Childcare and Protection Act 2003 This Act passed in 2004 provides for the establishment of a Child Protection Agency, licensing of childcare agencies, and speaks to other matters relating to the safety, care and protection of children.
The Act defines a child as someone not having reached the age of 18 years or a person who has attained this age but due to a disability is certified as in need of care and protection by the relevant agent.

The act governs the maintenance of standards for childcare facilities which makes it applicable here as there is potential impact on childcare facilities in associated areas.
4.2 Agreements, Treaties and Conventions The following Multilateral Agreements are pertinent to this project: 4.2.1 United Nations Framework Convention on Climate Change (UNFCCC), 1992 This convention, which entered into force in 1994, provides a framework for intergovernmental efforts to deal with climate change and its effects.
The convention allows for the development and implementation of strategies for tackling emissions and the challenges of expected impacts and provides for financial and technical assistance for developing countries.

Each country formulates its Intended Nationally Determined Contributions (INDC) to the UNFCCC.
To ensure equality in addressing the needs of men and women, the UNFCCC aims for 13 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) gender balance in bodies established in conformation with the Convention and the Kyoto Protocol.

This should improve women’s participation and inform more effective climate change policy.
4.2.2 Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW) In 1979, the General Assembly of the United Nations adopted the CEDAW as a tool for the protection of the rights of women.

CEDAW was ratified by Antigua and Barbuda in 1989 and in 1996 signed the Optional Protocol.
The aim of the CEDAW is to ensure that all women are afforded the opportunity to represent governments at the internationally and participate in the work of international organizations; have equal rights to all forms of financing available to men such as bank loans and mortgages.
Additionally women from rural areas have the opportunity to (i) participate in and benefit from rural development; (ii) participate in development planning at all levels; (iii) obtain training, education, and extension services; (iv) have access to agricultural credit and loans, marketing facilities and appropriate technology; and (v) are treated equally in land, agrarian reform, and land resettlement schemes.
4.2.3 Beijing Declaration and Platform for Action from the Fourth World Conference on Women The platform calls for the active involvement of women in environmental decision making at all levels, the integration of gender concerns and perspectives in policies and programs for sustainable development, and the strengthening or establishment of mechanisms at the national, regional, and international levels to assess the impact of development and environmental policies on women.
14 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 4.2.4 Commission on the Status of Women The 52nd session of the Commission on the Status of Women (2008) identified gender perspectives on climate change as its key emerging issue.
The Commission on the Status of Women urged governments to integrate a gender perspective in the design, implementation, monitoring and evaluation, and reporting of national environmental policies, strengthen mechanisms and provide adequate resources to ensure women’s full and equal participation in decision making at all levels on environmental issues, on strategies related to climate change and the lives of women and girls.
4.2.5 United Nations Conference on Sustainable Development (Rio+20) outcome document.

Rio+20 affirms that green economy policies in the context of sustainable development and poverty eradication should enhance the welfare of women, mobilize their full potential and ensure the equal contribution of both women and men.

“The Future We Want” was adopted in Rio de Janeiro in June 2012.
It resolves to unlock the potential of women as drivers of sustainable development, including through the repeal of discriminatory laws and the removal of formal barriers.

It also commits to actively promote the collection, analysis and use of gender sensitive indicators and sex- disaggregated data.

4.2.6 Sustainable Development Goals (SDGs) The SDGs are the heart of the 2030 Agenda for Sustainable Development adopted in 2015 by the United Nations member states.
The goals are formulated to end poverty and other 15 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) deprivations through strategies that improve health and education, tackle inequality and stimulate economic growth, within the context of dealing with climate change and preserving the environment.
The Declaration assures equal rights and opportunities for women and men, promotes gender equality and the empowerment of women (SDGs 5 and 10) as effective ways to combat poverty, hunger and disease.

4.2.7 Lima Climate Change Conference 2014 The outcome of the Lima Work Programme on Gender states that the role of women is key to the response to climate change and needs to be strengthened.
Lima Work Programme on Gender the Parties agreed on a Lima Work Programme on Gender to advance gender balance and promote gender sensitivity in developing and implementing climate policy.

4.2.8 The Stockholm Convention on Persistent Organic Pollutants (Stockholm Convention) The Stockholm Convention on Persistent Organic Pollutants (POPs) is a global treaty which aims to protect human health and the environment from POPs.
These chemicals share the characteristics of remaining in the environment for long years, are widely distributed geographically, can bio-magnify and bio-accumulate and harm the health of humans and animals and negatively affect the environment.

Antigua and Barbuda acceded to the Stockholm Convention in 2003.

4.2.9 The Minamata Convention on Mercury (Minamata Convention) The convention is a treaty that aims to protect human health and environment from the effects of mercury pollution.
The treaty targets human activities that result in mercury pollution and some of these activities are actively carried out in the health sector such as: 16 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 1. the use of mercury in clinical thermometers and blood pressure machines and other detecting devices vaccines that use mercury as preservatives mercury batteries use of mercury-containing products such as dental filings 2.

3.

4.
3.

4.

The convention recommends a reduction in these activities as well as 5.

6.

Safe storage and disposal of all mercury-related products after their removal from the market Phase out or control mercury air emissions from coal-fired power plants, industrial boilers, and cement production.

Antigua and Barbuda has been a party to the Minamata Convention since 2016.

4.3 National Policies 4.3.1 Sustainable Island Resource Management Zoning Plan (SIRMZP 2012).
The Physical Planning Act of 2003 describes the intention for a Development Plan for any part of Antigua and Barbuda.

The SIRMZP was commissioned with this in mind and approved in 2012.
4.3.2 National Poverty Strategy 2011-2015 has as one of its strategies, “Building Resilience through Environmental Sustainability – by making disaster risk reduction a feature of the planning process in the light of the high environmental risks that the country faces from hurricanes, earthquakes, and now sea rise, as a result of global warming.

“ 4.3.3 National Biodiversity Strategy and Action Plan.
Target 8 of the action plan calls for a 20% reduction of the pollution in demonstration areas, including from excess nutrients, bringing it to levels that are not detrimental to ecosystem function and biodiversity.

4.3.4 Draft National Medical Waste Management Plan 17 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) The plan is in its final draft and has not yet been adopted but is expected to be short.
The plan was formulated in the absence of overarching policy and legislation for the management of medical waste in Antigua and Barbuda.
The plan has five priorities: Develop and/or review oversight committee, policies, regulations, guidelines, standards and monitoring and evaluation (M and E) systems, improve infrastructure and equipment, increase capacity building, training,, and community awareness, ensure that there are adequate resources for HCWM, Promote best practices in HCWM (especially for the private sector and households) 5.0 DESCRIPTION OF THE RECEIVING ENVIRONMENT (BASELINE) 5.1 Environmental Baseline 5.1.1 Physical Environment Geologically Antigua has 3 distinct regions: a volcanic region in the south and southwest, the central plain and the limestone region which occupies the north and eastern third of the island.
The central region is a diagonal which extends from between Ferris Point and Corbinson Point in the northwest, across the centre of the island, to between Shirley Heights and Willoughby Bay in the south east.

It is approximately 5 kilometers wide and the hospital is situated in the north western third of the belt.

Topography Sir Lester Bird Medical Center is situated on a landform with a distinctly conical shape.

The height is 37.49 metres (123) feet above sea level using a GARMIN GPS 12XL.
The hill has a circular base and smooth sides with a gradient of 32 degrees.

18 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Soil The geology forms part of the clayey central region of the island (see Figure 1).

The soil is of the Ottos Suite.

It was developed over, thin, superficial deposits of Pleistocene clay and over sedimentary tuffs.
The parent material consists of dull brown, very heavy clay that has been derived from the erosion of the rocks of the sedimentary tuff formations.

These are hard to work, heavy clays with impeded drainage, and near neutral pH (Cooper & Bowen, 2001).

They frequently contained layers of weathered chert stones and boulders.

Figure 1: Topographic Zones of Antigua (adapted from National Action Plan) Hydrology The drainage pattern for Sir Lester Bird Medical Centre is radial.
Rainfall develops around a central elevated point where the rainwater radiates outwards from a central high point.

The tributaries from a summit follow the slope downwards and drain down in all directions.

19 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Air and Climate The islands of Antigua and Barbuda are subject to northeasterly Trade Winds and so experience fairly steady winds ranging from the northeast to the southeast.
Monthly average wind speeds are 17 to 26 km/hour, with the lowest speeds from September to November.

(Cooper & Bowen, 2001).

The wind experienced at any given place is dependent on factors such as topography.

Wind is predominantly from the east and northeast but may change due to atmospheric conditions.

Other climactic features of Antigua are year round high temperatures, and a defined wet and dry season.

The temperature extremes of 34 °C and 15°C have been recorded but the average is 29°C.
The traditional dry season is from January to March-April when less than 20% of rainfall takes place.

The height of the wet season is from August to November.

The frequency of storms increases as the wet season advances until it reaches a peak in August September.

The wet season occurs through May to November, during which the island receives around 150 ‐ 250 mm per month.
Antigua and Barbuda also lies in the heart of the Atlantic hurricane belt, where cyclones and hurricanes occur throughout August, September and October.

However rainfall is variable and fairly unpredictable.

Up to November 2020, Antigua was enduring the most severe drought on record there being an accumulated deficit of an entire year’s worth of rainfall since the beginning of the drought in 2013.
The last 32 months (July 2013 to February 2016) have been the driest ever for that period on record and the drought has continued into 2022.

The implications of this was continued heavy reliance on potable water generated by desalting or reverse osmosis.

Communities in Antigua including the watershed, therefore had to rely on intermittent water supply from the government or personal storage arrangements such as tanks and cisterns.
5.1.2 Physical Infrastructure 20 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) The Sir Lester Bird Medical Center formally known as the Mount St. John Medical center is a 185-bed hospital, and the only public hospital on the island of Antigua.

It officially opened in 2009 and offers primary care to advanced critical care.

There are approximately 700 staff including about 200 medical personnel.
The main building has 4 floors which house the wards, laboratories, radiology administration and other departments.

The facilities annex is connected to the main hospital building by a covered walkway.

This annex houses the laundry beneath which is the hospital’s water supply.

There are offices on the upper floors.

The sewage treatment facility is located to the south of the facilities annex.

The generator is also part of the same annex.


The incinerator room is an adjunct of the facilities annex and is purpose-built.

Three of its 4 walls have thick steel mesh providing ventilation.

There has been one main operator since its use began in 2009.

Outside the room, there is a large garbage skip into which bio-hazardous waste is dumped.

At present the skip is carried to the sanitary landfill when it is full, which may take 2 days to 1 week.
Built Environment The hospital is located on the summit of a hill to the southeast of the city.

The hill slopes down to the southern edge of town and to four villages.

Ovals is generally west, Michael’s Village and Ottos to the southwest and Radio Range to the south and south east (see Figure 2).

The main portion of the city of St. John’s lies to the north northwest.

Directly east of the hospital is a Catholic church then open land.

Directly north is the Cancer Treatment Center.


There is a frequently used recreational field northeast of the hospital’s hill and a major bus station.

Hospital road is a major thoroughfare as it provides a route to the hospital and a by-pass from the busy Queen Elizabeth highway to the busy Independence Drive.

21 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Figure 2.
Villages near SLBMC Key 5.1.3 Biological Environment The SLBMC is an already established structure which occupies land that previously housed a hotel.

Therefore the original biological environment has already been altered.

The proposed site is within the boundaries of the St. John’s City limits.

All the land within a 10 km area has had all original vegetation removed.

It has been replaced by business and residential buildings and infrastructure such as roads or has been taken over by generic scrub.
There are no national parks or biosphere reserves within the study area.

There is a stand of mangroves about 700 m west north west of the SLBMC near the Nevis Street dock.

No reports were found of any 22 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) rare or endangered or endemic or /threatened fauna or flora in the study area and none were observed during fieldwork.
Vegetation The southeastern, southwestern, western, northern and northeastern slopes are sporadically covered with thorny Acacia, and Prosopis species; Antigua Hay grass (Dichanthium aristsatum), Seymour grass (Bothriocloa pertusa); Bambatsi grass (Panicum colbratum); Pangola grasses; Guinea grass (Panicum maximum); Coralita (Antigonon leptopus); Leucas martini – earthaginensis; and Cassytha filiformis.

The eastern slopes display grass and a variety of Bouganvilla.
Mammals Observed were the black rat, brown rat, and Mongoose.

The bat’s species include Brachyphylla cavernarum, Natulus stramineus, and Molassus molossus Reptiles The reptiles observed were Amieva griswoldi, Annolis bimaculatus leachi, and Anolis wattsi wattsi, the Gecko (Sphaerodactylus elegantulus).
Birds The birds observed were Lesser Antillean Bullfinch (Laxigilla noctis) , Bananaquit (Coereba flaveola); White Crowned Pigeon (Columba leucocephala); Zenadia Dove (Zenaida aurita); Common Ground Dove (Columbina passerina), Antillean Crested Humming Bird (Orthorhyncus cristatus); Green Throated Carib (Eulampis holosericeus); Gray Kingbird (Tyrannus dominicensis); Caribbean Elaenia (Elaenia martinica); Carib Grackle (Quyiscalus lugubris); Black Faced Grassquit (Tiaris bicolor) 23 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Arthropods A wide variety were observed.
These include butterflies (Sulphur, West Indian Buckeye, Monarch, White Peacock), dragonflies, walking sticks, wasps, bees, ants, centipedes and land hermit crabs.
6.0 SOCIO-ECONOMIC AND GENDER BASELINE 6.1 Socio-Economic Baseline 6.1.1 Distribution of Businesses The graphs below represent the business demographics for the four main villages in Antigua and Barbuda surrounding the Sir Lester Bird Medical Centre that could be directly affected by an established incinerator – Ovals, Ottos, Michaels’ Village and Radio Range.

Educational Institutions refer to daycare institutions, all levels of schools and tutoring facilities.
Private services are companies that provide a service to the public, such as, car wash, mechanics, medical practitioners, private clinics, law firms, barbers, and beauty salons, etc., whereas private merchandising are all retail-based business operations.

Government services/complexes are those provided by the government, such as sports complexes, standpipes, gutters, clinics, government buildings, etc.
Private institutions comprise places of general use by the public, such as, churches, radio stations, cinemas, etc.

24 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Apartment s 2% Education al Institution s 2% Private Services 33% Vacant Houses 36% Private Institution s 1% Private merchandi sing 23% Governme nt Services/ Complexe s 3% Source: Author’s Field Notes Figure 3: Business Demographics within the Ovals Area on September 22nd, 2022, 5 - 6 p.m.
Trend: In Ovals Village majority of the businesses are from private services (33%) and Private merchandising (23%).

Within the closely packed area 36% of the houses are vacant.

Educational Institutions Private Services Government Services/Comp lexes Private merchandising 15% 13% 32% 39% 1% Source: Author’s Field Notes Figure 4: Business Demographics within the Michaels' Village Area on October 7th & 13th, 2022, 4 - 6 p.m.
Trend: In Michaels Village majority of the businesses like the Ovals village are from private services (39%) and private merchandising (32%).

Within this area, only 15% are vacant houses, while 13% are education practices.
25 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) s c i h p a r g o m e D s s e n i s u B Apartments Vacant Houses Private merchandising Private Services Educational Institutions 0 2 4 6 8 10 12 14 16 18 20 22 Total Number of Business Source: Author’s Field Notes Figure 5: Business Demographics for Upper Ottos on September 29th, 2022, 5 - 6 p.m.

Trend: The business demographic within Upper Ottos is mostly private merchandising (15 businesses).
There are seven private services.

And only two educational institutions.

There are over twenty vacant houses within this village.

26 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Vacant Houses 9% Educational Institutions 3% Private Institutions 5% Private merchandisin g 14% Private Services 69% Source: Author’s Field Notes Figure 6: Business Demographics for Lower Ottos on October 13th to November 13th, 2022, 1 - 6 p.m.
Trend: In Lower Ottos, 69% are private service operators, significantly higher than upper Ottos.

Private merchandising stands at 14% and vacant housing at a low 9%.
Educational Institutions 15% 15% Private Services 10% 6% 8% 46% Private merchandising Private Institutions Vacant Houses Apartments Source: Author’s Field Notes Figure 7: Business Demographics for the Radio Range Area October 14th to 16th, 2022, 12 – 5:30 p.m. 27 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Trend: Radio Range also has a large demographic of private services, but they are also many apartment complexes (15%) and significant educational institutions (15%).
Only 10% of the houses are vacant.

6.1.2 Social Demographics The following section details social parameters gathered from field work including vulnerable populations such as the differently abled, amenities, employment and education.

Table 1: Number of Houses and Residents Spoken to.

Village Michaels Village Ovals Ottos Radio Range No.

of houses 148 280 411 188 No.
of residents 222 530 1315 282 Source: Author’s Field Notes (November 2022) Table 2: Number of Physically Challenged, Blind and Deaf Residents Village Michaels Village Ovals Ottos Radio Range Physically challenged 2 6 10 3 Blind Deaf 1 5 8 2 0 5 9 4 Source: Author’s Field Notes (November 2022) 28 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Radio Range Ottos Ovals Michaels Village 0 2 4 6 8 10 12 Number of Deaf Number of blind Physically challenged Source: Author’s Field Notes Figure 8: Distribution of Individuals with Disability Within Michael’s Village, Ovals Village, Ottos Village, And Radio Range.
Table 3: Number of Pregnant Persons Michaels village Ovals Ottos Radio Range 6 19 36 6 Source: Author’s Field Notes (November 2022) Table 4.

Retired Persons Female Male Total Village Michaels Village 39 57 Ovals 123 Ottos 29 Radio Range 248 Total 40 60 92 25 217 79 117 215 54 465 Source: Author’s Field Notes (November 2022) 29 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Table 5.
Full Employed vs Unemployed Village Female Male Female Male Employed Employed Unemployed Unemployed 15 94 106 Michael Village Ovals Ottos Radio Range Source: Author’s Field Notes (November 2022) 130 589 139 275 590 137 83 102 2 7 42 26 0 Table 6.

Number of Desktop Computers Number 0 1 2 3 4 Michaels Village 180 36 15 3 0 Ovals Ottos Radio Range 140 102 36 0 0 185 156 49 12 0 12 110 40 15 2 Source: Author’s Field Notes (November 2022) Table 7.
Number of Mobile Phones Ovals Ottos Radio Range Number 0 1 2 3 Michaels Village 0 192 52 0 10 390 90 0 0 Source: Author’s Field Notes (November 2022) 0 4 140 923 230 0 0 0 160 107 8 0 30 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Table 8.
Waste Disposal Methods Method Public garbage trucks Private garbage trucks Dumping on land Burning Michaels Village 220 0 0 0 Ovals Ottos Radio Range 519 1284 282 1 1 0 1 1 0 5 0 0 Source: Author’s Field Notes (November 2022) Table 9.

Bathroom Location Location Ovals Ottos Inside dwelling Not inside dwelling No Bathroom Michaels Village 219 0 518 6 Radio Range 282 0 0 1284 15 10 2 Source: Author’s Field Notes (November 2022) 0 Table 10.

Air Conditioning Units No.


of Units Michaels Village 140 2 0 0 0 0 1 2 3 4 Ovals Ottos 262 6 2 0 0 397 2 2 2 0 Radio Range 253 3 3 1 0 Source: Author’s Field Notes (November 2022) Table 11.
Water Supply Source Public Standpipe Public piped dwelling Public piped in yard Cistern / tank No response Michaels Village 2 Ovals Ottos Radio Range 0 10 4 198 494 1252 265 3 1 2 30 1 43 5 2 15 Source: Author’s Field Notes (November 2022) 31 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Table 12.

Number of Bedrooms No.


of Bedrooms 0 1 2 3 4 Source: Author’s Field Notes (November 2022) Michaels Village 0 0 63 48 6 Ovals Ottos 0 0 199 69 8 0 0 178 226 2 Radio Range 0 0 47 203 25 Table 13.

Number of Cars Owned No.

of Cars 0 1 2 3 Michaels Village 16 192 0 0 Ovals Ottos 345 159 12 0 1106 176 3 0 Radio Range 10 256 10 2 Source: Author’s Field Notes (November 2022) Table 14.
Land Tenure Michaels Village 84 60 0 Ovals Ottos 86 180 6 165 230 12 Radio Range 123 60 2 Owned Rented Squatter Source: Author’s Field Notes (November 2022) Table 15.

Marital Status Status Never married Married Divorced Widowed Legally separated Michaels Village 127 69 15 4 2 Ovals Ottos 240 203 39 12 24 800 413 48 10 15 Radio Range 80 151 30 12 2 Source: Author’s Field Notes (November 2022) 32 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Table 16.
Disease Affecting Residents by Type (%) Michael V Ovals Ottos Radio Range Male Female Male Female Male Female Male Female Cancer Diabetes Glaucoma Heart Disease 10 19 7 12 15 22 6 16 Hypertension 18 13 Stroke Sickle Cell Kidney disease Asthma Allergies Source: Author’s Field Notes (November 2022) 60 50 40 30 20 10 0 Michael Ovals Ottos Radio Range Source: Author’s Field Notes Figure 9.
Disease by Type among Males with Michaels Village, Ovals Village, Ottos Village, and Radio Range 33 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 70 60 50 40 30 20 10 0 Michael Ovals Ottos Radio Range Source: Author’s Field Notes Figure 10.

Disease by Type among Females with Michaels Village, Ovals Village, Ottos Village, and Radio Range Table 17.
Number of Residents who have heard the word ‘incinerator.’ Village Females Michaels V Ovals Ottos Radio Range Yes 22 19 8 10 No 97 210 300 118 Source: Author’s Field Notes (November 2022) Males Yes 15 17 10 12 No 80 226 280 90 34 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 350 300 250 200 150 100 50 0 Yes No Yes No Females Males Michaels Ovals Ottos Radio Range Source: Author’s Field Notes (November 2022) Figure 11.
Number of Females and Males with understanding of the word “Incinerator”.

Table 18.
Table 18.

Education Level Level Michael Ovals Ottos Radio Range Primary Secondary A ‘Level Business Engineering Hospitality ABICE ABIIT Nursing University None Village Source: Author’s Field Notes (November 2022) 35 123 30 18 12 10 2 18 12 20 2 35 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Table 19.
Labour Force Characteristics, by Sex, 2018 Source: Statistics Division, Ministry of Finance and Corporate Governance, Labour Force Survey, 2018.

Table 20.

Total Resident Population by Sex, St. John’s City Females Males Total 12,439 11,555 23,994 Source: Statistics Division, Ministry of Finance and Corporate Governance, Labour Force Survey, 2018.

Table 21.
Table 21.

Total Resident Population by Sex, St. John’s Rural Females Males Total 17,015 15,727 32,742 Source: Statistics Division, Ministry of Finance and Corporate Governance, Labour Force Survey, 2018.

Housing The 2011 Population Census of Antigua and Barbuda posed eight main questions concerning housing and households, and the data derived from these forms the basis for the initial analysis presented here.
The eight variables covered the type of dwelling, type of tenure, water supply, 36 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) toilet facilities, date of construction, materials of outer walls, number of rooms, type of lighting, and the fuel used for cooking.

The individual variables were selected as being broadly diagnostic of housing conditions in Michaels Village, Ovals, Ottos and Radio Range.
Table 22 shows the Housing Characteristics for Michaels Village, Ovals, Ottos, and Radio Range These were defined as follows: 1.

2.

3.

4.

5.

6.

7.

8.


Water supply: % of houses using public standpipe Type of Human waste disposal system: %Pit Latrine toilet Type of tenure: % of houses owner occupied Age: % of houses built before 1960 Materials: % of houses built entirely of wood Toilet Type: % of houses making use of pit latrines Lighting Fuel: % of houses using electricity Cooking gas: % of houses using bottled gas Table 22.

Key Indicators of Housing Quality 2022: Percentage Total Household Possessing Each Attribute.
Michaels Village Ovals Ottos Radio Range % 48.19 60.36 22.07 0 # houses 71 % 38.6 # houses 106 % 37.6 # houses 154 % 46.78 # houses Built before 1960 Constructed of Wood Constructed of concrete Pit latrine toilet Flush toilet (water closet type) Owner occupied Electrical lighting Gas for cooking 37 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 136 86.7 92.3 Water piped into yard Owned structure not the land Source: Author’s Field Notes (November 2022) 43.77 45.0 66 240 91.78 377 97.8 183 122 39.16 160 19.28 36 Attitudes Towards Incinerators Based on the questionnaire responses and informal conversations with the person in the Micheals Village, Ovals, Ottos, and Radio Range, there is diminished trust in the institution responsible for the management of the potentially hazardous facility.
The consultant found that the residents exhibited a lack of trust in Sir Lester Bird Medical Centre personnel which operates the medical waste facility and the relevant government agencies that regulate the facility was the primary source of concern.

Several reasons for people’s distrust or lack of trust are possible.

Some of the explanations offered are the people controlling or authorizing and regulating the incinerator.
It seems that suspicions arise if track records are flawed or if it is sensed that facility advocates and regulators do not share one’s own goals for their community.

Apart from whether facility operators and regulators are regarded as honest, competent, and well-intended, scientific uncertainties can contribute to a lack of trust.

The first question residents asked was, “Is this really needed”?
The consultant advises that if its promoters cannot convincingly demonstrate a pressing need for a new incinerator, people who are skeptical of the need or are otherwise opposed to it, will be disinclined to negotiate on other issues about it.

In addition to having a perceived un-favourable or adverse effect on the economic, physical, and mental well-being of individual people in the surrounding area, an existing incineration facility can affect the area’s social fabric.
Some changes may be precipitated by economic factors, but others may be structural, that is, they may concern the formal and informal relationships of groups and individuals in the area.

If individual health and 38 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) wellbeing, property values, and quality of life in the communities are substantially affected by the medical waste incinerator, the neighbourhood’s character may begin to change.
The literature suggests that for decades incineration was the method of choice for the treatment of infectious wastes.

The literature posits that the process of medical waste incineration poses a significant threat to public health if not carried out and regulated properly.

The influence on health is the higher incidence of cancer and respiratory symptoms; other likely effects are congenital abnormalities, hormone defects, and an increase in the sex ratio.
The 4 communities in this study already have notable instances of these diseases (see Table 16, Figures 9 and 10).

In addition to possible physical health effects, a medical waste incineration facility may have other effects on individuals, groups, or the entire population of Ovals, Michaels Village, Ottos, and radio Range.

The effects may be psychological (such as stress and stigma), economic (such as job creation or decrease in property values), or social (such as community fractionalization or unity).
Desktop research reveals that there is little rigorous information on the impacts of medical waste incineration.

The residents of the surrounding area’s concerns need to be heard and understood.

Conflicts can increase the time and expense of conducting medical waste incineration which might be potentially beneficial to Antigua and Barbuda.

Opposition to the incinerator can indicate that important concerns are not being addressed adequately.
Perhaps much public opposition to medical waste incineration might be due to a lack of understanding of the relative health risks posed by incineration in comparison with other waste management methods.

But health is not the only issue and the differences between the expert and public perceptions are not due merely to differences in information and understanding, they can also be due to differences in social values.
It seems that the residents’ perceptions are often extraordinarily resistant to 39 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) change, in part because they reflect underlying values.

Efforts that ignore or try to change these perceptions radically are likely to fail.

Risk communication should accept as legitimate the perception and concerns of various members of the public and involve them in consultative, participatory processes.
Not only do members of the public have a right and responsibility to be involved in the assessment and management of hazards in their communities, but such involvement might result in improved assessments and management strategies.

Developing effective participatory programs is very difficult, but some general principles are beginning to emerge.

The process of public involvement should be open, inclusive, and substantive, and members of the public in an affected area should be involved early and often.
Major concerns are likely to include issues of safety, compensation, and local oversight and control.

Satisfying the public’s need for information on incineration safety requires continual assessment and demonstration of regulatory compliance with existing standards.

Results of the questionnaire administered to the residents of the Ovals, Michaels village, Ottos, and Radio Range.

The questions asked were: 1.

Do you welcome an incinerator at the hospital?

2.


List potential positive impacts of having and using an incinerator.

3.

What issue (s) should be considered in operating an incinerator?

4.

Do you foresee any negative impact of using an incinerator?

5.

Are there any materials you think should not be incinerated at the hospital which you think might cause ill health or raise environmental concerns or other risks to people?

6.

Any additional comments Summary of responses from the questionnaire A.
Gender ✓ 50.8% Females; 49.2 % Males 40 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) B.
Age Range ✓ 18 – 23 years – (22.5%) ✓ 24 – 29 years – (12.3%) ✓ 30 – 35 years – (13.9%) ✓ 36 – 41 years – (7.7%) ✓ 24 – 47 years – (11.9) ✓ 48 – 52 years – (9.2%) ✓ 53 – 59 years – (12.3%) ✓ 60+ years – (12.3%) C. Education attainment ✓ Primary (26.1%) ✓ Secondary (44.7%) ✓ Tertiary (22.5%) ✓ Other (4.7%) D. Marital Status ✓ Single (75.3%) ✓ Married (24.7%) E. Employment status ✓ Full (67.7%) ✓ Part-time (6.1%) ✓ Seasonal (9.2%) ✓ Unemployed (17.0%) 1.

Do you welcome an incinerator at the hospital?


✓ 83% of respondents were negative; 17% were positive 2.

List potential positive impacts of having and using an incinerator.

✓ All the respondents said there were no positives 3.

What issue (s) should be considered in operating an incinerator?

✓ Fear of the smell ✓ Air pollution ✓ Toxic substances ✓ Hazardous waste ✓ Affect children in communities ✓ Safety of the communities ✓ Injuries 4.

Do you foresee any negative impact of using an incinerator?
41 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) ✓ 86% of respondents said there was a negative impact.

14% did not see any negatives 5.

Are there any materials you think should not be incinerated at the hospital which you think might cause ill health or raise environmental concerns or other risks to people?
✓ Human body parts ✓ Vaccines ✓ Expired goods ✓ Plastics ✓ Chemical waste ✓ No burning at all ✓ Biological waste Gender Analysis Gender inequality can lead to differentiated vulnerability for men and women, boys and girls.

A thorough understanding and appreciation of the distinct roles and contributions of each gender will increase recognition of their peculiar needs and interests.

This will ensure assessment of impacts and choice and design of mitigating measures are effective in reducing vulnerability.
Data collection for this project has been constrained by time and the size of the project.

Besides time-limited field surveys, the main sources of information concerning gender are reports such as the Country Gender Assessment 2015 and the Antigua and Barbuda Workforce Survey 2018.

Many sources are dated and lack important data and indicators.

Although both boys and men may be affected by the project, the burden of negative outcomes may be borne more by women than men.
This may be ascribed to biological differences, but much of it is due to the social, institutional and legal context, which reinforces differences in women and men.

The differences are apparent in the productive and social- reproductive roles and responsibilities, differential access to productive resources, including land, credit and employment, and women’s limited participation in political decision-making both at the community and governmental levels.
Females are a significantly larger proportion of every department of the hospital save the Board of Directors (54.5% male), Building and 42 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Grounds (100% male), M.I.S.

(Management Information Systems, 66.7% male), Transport (100% male), Orthopaedics Tech (100% male) (source SLBMC, 2022).

See Appendix B for more details.

Females constitute 75% of hospital staff.


This state of affairs is probably due to the traditional roles of women as the givers of healthcare especially as nurses, nurses aides, cleaners.

Women also traditionally bear the brunt of childcare and care for the elderly and infirm.

The Board has slightly more males which means reduced decision and policy making agency for women.
Women physicians outnumber male physicians by a significant margin (59% female, 41% male) and this may translate into greater power for women.

The gender differences in employment statistics for the hospital is not reflective of the country situation.

According to statistics from the Antigua and Barbuda Labour Force Survey 2018 (Statistics Division, 2020), the labour market population is 51, 931 (56% of the population) and there is a 72.1% participation rate.
Labour force participation was higher among men (76.1%) than women (68.9%) although more women were employed.

The employment to population ratio was higher for men (70.5%) than for women (62.1%).

Unemployment was higher for women (9.9%).

Unemployment was four times as high in the 15-24 years age group, than in the 25-54 years group, probably because many of these persons are still at schools.
In the communities surveyed, the number of employed males generally outnumbered employed females except in Michael’s Village (see Table 5), among those surveyed.

For the country, senior males are more likely to remain active in the workforce than senior women which may account for there being slightly more retired females than males among those surveyed (see Table 4).
There was a country dependency ratio of 44.3% (Statistics Division, 2020), meaning that each 100 employed persons supports on 44 persons from the dependent younger (0-15 years) and older (65 years and older) age groups.

Besides financial dependency, consideration 43 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) must also be given to the undocumented contribution through reproductive roles such as work in the household, raising children, cooking and cleaning.
Men do also perform these tasks as well as productive roles.

Culture and tradition mean that reproductive roles most often fall to women although there are men who also perform them.

Since the hospital’s employees are predominantly female, it is a reasonable conclusion that both productive and reproductive roles will be affected in large part by any potentially negative aspects of the project.
7.0 ENVIRONMENTAL AND SOCIAL IMPACTS IDENTIFICATION AND MITIGATION MEASURES WHO (2018) identified the most common issues associated with health care wastes.

These were lack of awareness, about health hazards, absent or inadequate waste management and disposal systems and inadequate human and financial resources.
Improperly managed bio- medical waste has the potential to increase risk to humans, especially those employed in health care, patients, communities surrounding the health care facility, workers at disposal sites and waste contractors.

There are also potential threats to the environment such as contamination and pollution.
The main objective of the installation of a new incinerator at the SLBMC is to efficiently and safely destroy or otherwise render less harmful and bulky, biomedical waste generated during normal hospital operation and to enable the hospital to deal with larger volumes of waste in cases such as a pandemic.

A short familiarization with the meaning and categorization of biomedical waste is appropriate before a discussion on possible impacts of the project.
7.1 Bio-medical Waste 44 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Bio-medical waste refers to liquid or solid waste created during diagnosis, treatment or vaccination of humans (Hirani et al., 2014).

Biomedical waste can be largely categorized as hazardous or non-hazardous based on its potential impact on human and environmental well- being.
Hospitals are a major source of biomedical waste as the generation of this waste is regular and in large quantities.

Most hospital waste is non-hazardous having similar characteristics to ordinary domestic waste but approximately 15% of hospital waste may be hazardous (WHO, 2018) due to toxicity and infectivity.

The major classes of bio-medical waste can be seen in Table 23.

Table 23 .
Table 23 .

Classes of Bio-medical Waste CLASS OF BIO-MEDICAL WASTE Infectious waste Pathological waste Chemical waste Cytotoxic waste Radioactive waste Pharmaceutical waste DESCRIPTION Waste contaminated with blood and other bodily fluids, cultures and stocks of infectious agents from laboratory work, or waste from patients with infections (e.g.
swabs, bandages) Human tissues, organs or fluids, body parts and contaminated animal carcasses, sharps waste syringes, needles, disposable scalpels and blades, etc.

Solvents and reagents used for laboratory preparations, disinfectants, sterility and heavy metals contained in medical devices (e.g.

mercury in broken thermometers) and batteries; Waste containing substances with genotoxic properties (i.e.
highly hazardous substances that are, mutagenic, teratogenic or carcinogenic), such as cytotoxic drugs used in cancer treatment and their metabolites; Products contaminated by radionuclides including radioactive diagnostic material or radio therapeutic materials; Expired, unused and contaminated drugs and vaccines; Non-hazardous or general waste Adapted from Healthcare Waste, (WHO, 2018) https://www.who.int/news-room/fact-sheets/detail/health-care-waste Waste that does not pose any particular biological, chemical, radioactive or physical hazard.
There are adverse health conditions related to exposure to bio-medical waste and its by-products.

These include: • Injuries inflicted by sharps such as scalpels, broken class and needles; 45 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) • Exposure to toxic pharmaceutical products, for example, antibiotics and cytotoxic drugs, and exposure to substances such as mercury or dioxins.
This may occur during handling or incineration of bio-medical waste; • Chemical burns arising from handling waste as well as disinfection, sterilization or waste treatment activities; • Air pollution that may occur if particulate matter is released during medical waste incineration; thermal injuries occurring with the operation of medical waste incinerators; radiation burns.
inhalation of ash generated from incineration • • • Source: WHO, 2018 POPs are chemicals of global concern because they have the following characteristics: they remain for many years, become distributed widely through natural processes notably air movements, persist in the environment, can bio-magnify and bio-accumulate in ecosystems including through humans, and are toxic to the health of humans and other wildlife (UNEP, 2022).
Unintentional POPs (u-POPs) are generated from thermal processes that involve chlorine and organic matter.

Polychlorinated dibenzo-p-dioxins (PCDD) and dibenzofurans (PCDF) commonly known as dioxins and furans can be produced by medical waste incinerators and other combustion processes including fires in landfills.
Contact with dioxins and furans can result in health impacts such as: o skin disorders, such as chloracne o liver problems 46 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) o impairment of the immune system, the endocrine system and reproductive functions o effects on the developing nervous system and other developmental events o certain types of cancers National Medical Waste Management Plan, 2022 Mitigation aims to identify measures to safeguard communities and the environment from potentially negative effects of an action.
A framework for mitigation considers measures devised to enhance beneficial aspects, minimize, avoid or remedy adverse effects or keep them within an acceptable level.

Avoidance is the preferred choice followed by minimizing of hazards and then by remedial action.

Important factors in this project make mitigation important.
The location of the incinerator as part of a facility that houses patients some of whom may have limited mobility due to health, the location of the hospital near villages, five schools and the densely populated city of St. John’s are also important considerations.
Although difficult to measure with absolute certainty, the hospital environs may host upwards of 500 persons to include in-patients, out- patients attending clinics and using other hospital services such as diagnostics, administrative, medical and other staff and visitors, at any one time.

There are internationally accepted principles that guide effective waste management.

1.
1.

The polluter pays principle: the waste producer is legally and financially responsible for the safe handling of waste and disposal of that waste in an environmentally sound manner and the creation of incentives to reduce the amount of waste generated.

2.
2.

The precautionary principle: notwithstanding the lack of conclusive scientific knowledge about the possible impacts of an action, there is a social responsibility 47 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) to protect society from any potential negative outcomes.

Not implementing cost- effective measures to prevent degradation of the environment should not be based on lack of conclusive evidence of a threat.

3.
3.

The duty of care principle: sound ethics dictate that the person managing or handling waste must exercise the utmost care in doing so.

4.

The proximity principle: hazardous waste should be treated and disposed of as close as possible to its origin or point of production within environmental and technical parameters to minimize transport risks.

5.
5.

The prior informed consent principle: Communities and stakeholders who may be impacted, must be informed of risks and hazards associated with the location and operation of waste treatment and disposal facilities and transport of wastes to and from them.

7.2 Risk Assessment 7.2.1 Classification of Impacts Evaluation of the significance of the impacts was done using a risk assessment matrix (see Figure 12 below).
The risks were identified based firstly on what phase of the project they may occur and then given a risk rating from low to high.

Table 24 shows the classification of identified risks.

48 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Figure 12.
Risk Assessment Matrix Source: TOR for plan application #G28-2021: Replacement of Incinerator for Sir Lester Bird 7.2.2 Removal of Incinerator The incinerator has a single combustion chamber from which a chimney flue exits.
The incinerator flue passes through the roof of its ground floor room, slopes at an approximately 45 degree angle towards the wall of the facilities annex and thence up this wall to pass through the roof overhang and thence atop the building where it projects approximately 46 cm above the building roof.

The incinerator room has open wire mesh forming a large portion of 2 walls to provide ventilation.

The entrance is through a large metal gate which is kept locked.
The incinerator does not appear to be fixed to the floor.

The incinerator operated from its commissioning in 2009.

It is presently heavily rusted and dilapidated.

The existence of any asbestos material as part of the incinerator is unknown.

The incinerator burned a load 4 to 5 times a day when in operation (Bissett, personal com.)

and has been turned on recently.

Waste was placed into the incinerator and the resulting ash removed using a shovel.
The ash residue is 49 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) stored in plastic and half metal drums, left uncovered before being taken to the local landfill.

The incinerator combustion chamber and the chimney flues are likely to contain residue and can be considered contaminated possibly with chemicals such as dioxins and furans (known carcinogens), and heavy metals.
There is a risk of inhalation of this residue or releasing it into the environment during removal and transport of the incinerator.

There is risk of injury from the rusted chimney flues.

Photo credit Joseph Prosper 6 Sep 2022 Figure 13.

Drum used to store ash from the incinerator The incinerator room is presently filled with discarded materials obviously not meant for incineration such as boxes, mattresses, and other debris.
There are many containers containing body parts and ordinary cardboard boxes filled with discarded medical materials.

All these are potential hazards and obstructions to the safe disassembly and removal of the incinerator.

Outside the incinerator room is a garbage skip into which is thrown both medical and general hospital waste.

The skip remains until it is full enough to warrant a call to a sub-contractor to collect it.
The medical waste is stored in appropriate bags and containers but they are amongst ordinary garbage bags containing regular waste.

There is thus a risk of exposure to workers 50 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) disassembling and removing the incinerator.

The volume of debris generated is not expected to pose any challenges with transportation in conventional 20 tonne trucks or in a garbage skip.
There should be no disruption to traffic outside hospital grounds or on roads leading to the Cook’s landfill.

Traditional gender roles may make it unlikely that women will apply for or be hired to be part of this phase of the project as it is considered dangerous work that involves heavy lifting.

Conversely, the extensive involvement of men mean that this gender group will be most likely affected by potential injuries and hazards associated with this job.
Mitigation All the debris from the incinerator room should be removed before decommissioning the incinerator.

The garbage skip should be emptied or moved as well during the process.

All workers must be fitted with appropriate protective equipment.

Decommissioning should proceed with caution.


All old incinerator materials and/or parts should be carefully dismantled in a negative pressure environment, adequately wrapped with fire retardant polythene sheets and transported safely for destruction at the dump.

The residual ash should be vacuumed and removed before decommissioning.

It is most important to minimize or avoid release of incinerator ash to the environment which may contaminate other hospital facilities.
Since the furnace is small and has had minimal use within the last few months, there is not expected to be any significant environmental impact from decommissioning.

The decommissioned incinerator parts should be transported in approved vehicles to the Cook’s landfill immediately after removal and disposed of according to best practices.

Trucks should be covered during transport and cleaned thoroughly after the exercise.
Appendix C has details for the creation of a safe decommissioning environment and disposal of the incinerator.

An integrated gender action plan 51 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) that prescribes against discrimination based on gender should be developed and followed.

See Table 24 for summary.


7.2.3 Installation of New Incinerator The most likely negative impacts from installation of the incinerator are noise pollution (low) and waste generation specifically packaging (medium).

The incinerator may be installed incorrectly due to lack of local expertise.

Women may be excluded from employment due to traditional gender roles and both genders are not expected to suffer extensive negative impacts from this phase of the project.
Other impacts may occur as a result of operation but mitigation to reduce or eliminate them may take place during installation.

Mitigation It is recommended that the project invoke the manufacturer installation, training and maintenance option.

The incinerator should be assembled according to manufacturer’s instructions by appropriately trained workers.

The connections must occur as prescribed in order to allow flow of noxious gases through the machine to ensure operator safety.
The equipment should be installed in a protected and well-ventilated area to allow temperature management and protection from adverse weather conditions.

The area should have adequate water supply for fire emergencies and a well-equipped sprinkler system, with surrounding gutters for runoff.

Waste should be collected in a prearranged area or skip and transported for disposal as soon as possible.

Noise generation is expected to be very small and have little impact on the hospital environs.
A gender action plan that ensures opportunities for training and employment for all genders should be developed and adopted.

It should be noted that the installation of the operator may require 52 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) skill that precludes the imposition of a gender equal policy.

Timely and efficient installation should reduce any noise impact.
7.2.4 Operation of New Incinerator Occupational Health and Safety In general a medical facility poses potential risks to health care workers as it is a source of infectious waste.

Of particular concern are injuries due to handling of infectious waste such as sharps without adequate protective gear, storage of sharps and other waste in containers that are not puncture or leak-proof and management of radioactive waste.
Potential impacts include burns and injuries to workers due to improper handling of waste and improper operation of the incinerator, and improper transportation of incinerator waste.

The residue from incineration may still contain sharps such as needles which although no longer infective, pose a risk of physical injury.

Ash may have elevated levels of still toxic components such as heavy metals and by- products of low incineration temperatures (200 - 450°C) such as doxins and furams (WHO, 2014).
The acceptable WHO tolerable daily intake (TDI) is 0.000000000001 g TEQ/kg/day.

At present both biological and other hazardous medical waste are deposited in an open skip near the incinerator room.

When the skip is full, the facilities personnel contact a sub-contractor who collects the skip and takes it to the landfill where the waste is buried.

The skip may take up to 2 weeks to fill and the waste remains uncovered in the skip for the duration.
This is a protracted period in which hospital employees and visitors may be exposed to potential injury and infection.

It is also aesthetically displeasing.

Records pertaining to the volume of waste generated daily and the exact nature and proportion of waste were not available.

However, it is reasonable to assume that the waste includes the normal components of bio-medical waste as described in Table 1.
Both bio-medical and general hospital waste are stored in the skip even though the bio-medical 53 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) waste is separated into appropriate bio-medical waste containers including bins for sharps and colour-coded bags.

There are adverse health outcomes associated with bio-medical waste.
Injuries due to sharps such as syringes and broken glass implements, toxic exposure to pharmaceuticals such as cytotoxic chemicals and chemical burns are possible.

Incineration of medical waste may be associated with thermal injuries and air pollution.

Incineration of inappropriate materials such as those containing heavy metals or materials with high metal content (such as lead, mercury and cadmium) can lead to the spread of toxic metals in the environment.
As regards gender-specific impacts, traditional roles make it unlikely that women will apply for or be considered for employment in roles specifically related to the operation of the incinerator.

This means a likely disproportionate benefit and risk for men.

Women are more likely to be exposed to the generation and disposal of bio-medical waste at the source due to their traditional roles as nurses, and as cleaners, however the transport of waste will most likely fall to men.
Mitigation The primary strategy for reducing risks to health must be prevention and avoidance.

Thus specific and general risks must be identified and pro-active measures instituted to avoid them.

Therefore, proper protocols and guidelines, such as general operation of the incinerator, burn procedures and maintenance checks must be formulated and followed to facilitate proper operations.

The following is recommended as a minimum: A.


Development of a written gender-responsive Waste Management Plan for the hospital which should be adhered to.

It should be based on the principles of waste management as outlined below.

54 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) There are suggested protocols for the management of bio-medical waste.
The recommended steps in dealing with hospital waste are segregation, storage, handling and transportation and treatment (Chakraborty et al., 2014).

1.

Segregation sorts the waste by storing specific types of waste based on characteristics as this will determine treatment and disposal options.

Some waste may require higher temperatures or longer incineration times.

Segregation should begin at the point of generation.

Waste should be segregated at source by those who generate it.
Segregation should not take place after waste has been placed into their waste containers.

Segregation should ensure that only non-polluting material is sent for incineration.

2.

Waste storage occurs between the point of generation and the point of treatment and disposal.

Attention must be made to containers, their labeling and the place and time of storage.

3.

Handling and transport move the waste from storage to the point of treatment in this case incineration.
Consideration must be given to safe handling and movement to minimize or eliminate any peril to human and environmental health.

Suggestions are designating routes for transport, regular disinfection of conveyances, scheduled times for transport, use of PPE.

4.

Treatment and disposal should occur as near the source of generation of the waste as possible.

Different methods are recommended for different types of waste and some waste may require further treatment after incineration.
Adapted from Chakraborty et al., (2014) 55 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) The present practice of storing the waste in an open skip outside the incinerator room should be discontinued.

The skip should be covered or placed inside an appropriately prepared and ventilated structure so as to minimize exposure to the elements and pests such as flies and rats.

Hazardous biomedical waste should be separated from general hospital waste.
The waste should be transported from the source to storage or incineration in appropriate, designated, leak and puncture proof conveyances (trolleys and wheelbarrows).

The waste should be secured from unauthorized personnel.

The waste should be evacuated regularly (daily is ideal).

Prominently display signage using gender-sensitive language, outlining procedures.

B.

Training is an important component of mitigation and the following is recommended: 6.
Initial and continuous gender-responsive training of all hospital staff in proper procedures for dealing with waste especially hazardous bio-medical waste.

Training should encompass everything from segregation all the way through to disposal of waste.

7.
7.

Initial and continuous gender-responsive training of incinerator operators and assistants to include technical instruction in operating the incinerator as well as general training in the hospital’s waste management procedures, occupational health and safety, fire prevention and first aid.
C. Proper Operation and Maintenance of Incinerator The incinerator model should meet the standard below: Capable of reducing waste to ashes (95%) reduced into ashes) • Primary and secondary chambers • • Use fuel burners • Emission conform to national and international standards 56 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Recommended minimum operating procedures: the area around the incinerator must be cleaned • operators should wear appropriate PPE • • weigh, record and maintain records for the HCW to be incinerated • all needed tools and equipment should be readily available before and during operation.
• ashes from previous day’s combustion process should be removed before operation • warm up the incinerator with dry waste • Monitor temperature • the incinerator should be allowed to cool down sufficiently (5 hours) before removing ash.

• appropriate PPEs should be worn when removing the ash.

Do not handle the ash or other solids with bare hands.

• Use a shovel or rake to remove ash and other non-burnable waste • Do not allow the ash to remain for long periods of time (more than 2 days).
• Sweep the around the incinerator to remove non-combustible waste such as needles.

In addition: 1.

2.

3.

Incinerator to be operated only by authorized trained personnel.

Invoke the manufacturer installation, training and maintenance option Training to include appropriate operating temperatures, appropriate and inappropriate materials to be incinerated.

4.

Schedule regular maintenance and safety checks based on manufacturer’s instructions.

5.

6.
5.

6.

Keep detailed records of maintenance and safety checks.

Create and maintain records of the daily operation of the incinerator to include volume and type of waste incinerated, temperatures used and a record of any incidents or observations which may affect the operation of the incinerator.

7.

Prominently displayed signage outlining procedures, dos and don’ts.

57 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 8.
Regular testing of incinerator residue and other emissions.

D. Procedures for Accidents 1.

All at-risk workers, both incinerator workers and general staff, must be provided with adequate and effective personal, protective gear to include as needed: heavy puncture -resistant gloves, aprons or overalls, boots or protective footgear with puncture resistant soles and toes, face shields and respirators, all according to international safety standards and guidelines.
Staff should be trained in their proper use and be required to use them.

2.

Develop written protocols for dealing with accidents and injuries to include burns.

3.

4.

Create and maintain records of accidents and incidents.

Prominently display signage outlining procedures.

E. Require that all health workers and incinerator staff receive preventative vaccines such as for Hepatitis B and Tetanus.

Institute and require medical surveillance of workers.
Require twice yearly health checks for incinerator staff.

Land Improper storage of bio-medical waste before incineration may negatively impact soil quality.

Ash and other residue generated as a result of incineration may also impact soil quality.

This impact is expected to be low however.

Mitigation 58 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Adequate storage facilities and disposal mechanisms will reduce or eliminate impact on land environment.
Incineration ash should be stored in appropriate water proof containers which are sealed to prevent escape of ash into the environment.

This ash should be collected by an authorized sub-contractor approved by the NSWMA.

A waste management plan detailing protocols and procedures for waste management should be developed, staff trained and its use strictly adhered to.
Besides storage and handling, the plan should detail what substances can and cannot be placed in the incinerator and minimum operating temperatures (850-1100 °C).

Noise There may be a small amount of noise associated with the operation of the incinerator but this is not expected to impact the hospital and its environs in any negative way.

The hospital is air conditioned and the main building is sufficiently far away that noise-sensitive processes are unlikely to be affected.
Mitigation Hand tools or small powered tools can be used.

Decommissioning and removal should occur in as minimum time as is efficient and safe.

Air Flue gases are a potential threat to persons who live or work near the incinerator.
Poorly controlled emissions, due to inappropriate maintenance and operation of the incinerator, for example temperatures that are too low or the attempted incineration of certain materials such as PVC or materials containing heavy metals may result in air pollution from respirable ash, furans and dioxins.

In particular low operating temperatures may result in incomplete combustion of material and some gases.
The easterly prevailing winds create the possibility of this pollution 59 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) being carried towards the Radio Range and beyond.

Occasional changes in wind direction may carry these pollutants towards the main hospital building, to the villages beyond and to St. John’s City.
Health risks are associated with respiratory and cardiovascular morbidity and mortality due to particulates, immune and neurological systems, kidneys and lungs due to volatile metals such as mercury and other effects such as cancers due to dioxins and furans (WHO, 2014).

Mitigation It is recommended that the project invoke the manufacturer installation, training and maintenance option.

Chimney and stack installation should be done according to best practices to maximise reduction of waste material.
Adequate and ongoing training for incinerator operation as described above is essential.

The incinerator and its parts including the chimney stack should be monitored and inspected regularly.

The air quality around the hospital should be monitored both when the incinerator is operating and when it is not.

There should also be examination and testing of incinerator residue in collaboration with the Department of Analytical Services and overseen by the Central Board of Health.
A waste management plan detailing protocols and procedures for waste management should be developed, staff trained and its use strictly adhered to.

Besides storage and handling, the plan should detail what substances can and cannot be placed in the incinerator and minimum operating temperatures (850-1100 °C).

Fire The operation of an incinerator carries the inherent risk of fire.

The results could be catastrophic with disastrous life and financial impacts.
As the only public tertiary healthcare facility, the impact of a fire can have devastating domino effects on the health of the general population and the finances of the government.

Hospitals are especially vulnerable as they have patients many of whom may not be ambulatory due to health or the treatments required (e.g.

60 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) those in intensive care or on ventilators).
Note that the risk of fire is present in many places in a hospital such as laboratories, and due to electrical faults.

A fire at the hospital will pollute the air with smoke potentially containing hazardous compounds.

This smoke will likely spread to the west of the hospital towards St. John’s City and nearby villages.

The reproductive and productive roles of both men and women will be affected.

Women, as the more represented gender among the employees, may suffer a disproportionately larger impact.
Mitigation The best approach is avoidance.

It is recommended that the project invoke the manufacturer installation, training and maintenance option to reduce the likelihood of fires due to the operation of the incinerator.

A written fire prevention and emergency management plan should be developed and put in place.

If there is already such a plan then it should be reviewed periodically and specifically include measures for fire originating from the incinerator.
These measures will target the confinement of the fire to the incinerator room as much as is practicable.

The fire prevention and emergency plan should include the following elements as a minimum: a.

Provide fire extinguishers/fire blankets, charged hoses, sand buckets and other necessary equipment of an appropriate number and placement including the incinerator room, adjacent rooms and throughout the hospital.

Fire extinguishers and hoses should be checked and maintained in working order.

b.
b.

Adequate working sprinkler system that is regularly checked and maintained.

c. Key healthcare staff and incinerator staff as well as facilities workers should have basic training in fire control; d. Fire emergency telephone numbers should be displayed in communal areas; e. Undertake fire drills at healthcare facility, at a minimum once a quarter.

61 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) f. Adequate training of operators.
Contamination of Hospital Water Supply Since the water storage containers for the hospital are beneath the facilities building where the incinerator room is located, the potential exists for contamination of this water supply.

This can be potentially devastating resulting in widespread illness.

Mitigation Avoidance is best.

The water storage tanks must be sealed completely from the incinerator room and the area in which bio-medical waste and incinerated material such as ash are stored.
There should be regular testing of the hospital’s water supply to ensure that it remains potable.

Social Resistance There is a general negative perception of the use of the hospital incinerator.

Residents in nearby villages perceive potential harm in the operation of the incinerator with different questions revealing a high expectation of negative outcomes.
This most likely reflects lack of accurate knowledge and awareness about how incinerators function and can be beneficial compared to other means of dealing with healthcare waste.

Most persons had never heard the word incinerator and were unaware that one had operated at the hospital since 2009.
Although the new incinerator can operate without public support, it is unethical and counter-productive to ignore the concerns of those which may be directly or indirectly affected by the operation of potentially hazardous equipment.

Mitigation 62 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Develop a gender-responsive public relations and communications strategy to inform and educate communities, including hospital employees about the project.
Focus should be on an honest and accurate presentation of information about the incinerator’s operation, including any potential negative impacts and proposed mitigation.

The strategy must consider that the issue of medical waste is sensitive and elicits negative reactions from people due to fear of health hazards and the visual impacts of anatomical waste (WHO, 2014).

The strategy should use established, social media platforms, local television and radio stations.
The education and training of staff should be gender-responsive, use gender sensitive language.

There is a higher proportion of females than males in 33 of the 37 departments of the hospital.

The exceptions are Board of Directors, Building and Grounds, M.I.S.

and Transport.

Therefore training must consider traditional gender roles such as child care being a predominantly female role, in decisions about scheduling and duration of training and education sessions.

Table 24.
Table 24.

Impacts and risk assessment associated with various stages of the project.

Impact Risk Significance Mitigation Residual Risk Decommissioning and removal of present incinerator Medium 1.

Air pollution from residual ash 2.
Exposure of workers to hazardous waste Injury due to obstructions Medium Medium Vacuuming and creation of negative pressure environment, covered transport to landfill Removal/emptying of skip before decommissioning Removal of debris/obstruction before decommissioning Very low Eliminated Eliminated 63 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Serious Integrated Gender Plan Low Exclusion of women from work opportunities Disruption to traffic Low Aesthetics Very low Installation of new incinerator Medium Generation of solid waste which may pollute the land Noise pollution Very low Women excluded from employment Incorrect installation of incinerator Serious Low Serious Operation of the Incinerator Infection and injury due to exposure to bio-medical waste or operation of incinerator Very low Very low Move after 8:30 am when traffic has reduced No impact as incinerator room not normally traversed by public Collection and immediate removal Very low Quick and efficient installation Gender Action Plan Very low Low Eliminated Very low Invoke manufacturer installation, training and maintenance option Waste Management Plan It is recommended that the project invoke the manufacturer installation, training and maintenance option Training (incinerator operators and other hospital staff in waste management Training of incinerator operators in proper operation of incinerator.
Adequate storage Proper installation of incinerator.
Regular maintenance checks Protocols for accidents Vaccines 64 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Poor aesthetics of waste storage Medium Air pollution from ash, smoke, possibly dioxins and furans Medium Land pollution Medium Fire hazard High Noise pollution Very low Water contamination Low Accumulation of bio- medical waste due to incinerator failure Low Negative public perception Women excluded from employment High Serious Regular health checks.
Prominently displayed signs.

Record keeping Waste management plan: storage out of sight or covering of skip Training of incinerator operators in proper operation of incinerator.

Maintenance checks Air quality monitoring Residue testing Operation of incinerator at temperatures between 850°C to 1100°C.

Waste management plan: proper storage and transport of waste Fire Prevention and Emergency plan Prominently displayed signs outlining procedures and emergency numbers.

Use hand tools or small powered tools.


Keep time period at a minimum.

Proper storage Water testing Training of incinerator operators in proper operation of incinerator.

Maintenance checks Public Education Campaign Integrated Gender Action Plan Very low Very low Very low Low Very low Very low Low Low Low 65 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) High Serious Medium Low Very low Eliminated Key for Risk Categorization.
Positive Impacts There are few extra employment opportunities associated with the operation of the incinerator as there is already staff fulfilling this role.

Employment opportunities may exist in the following spheres: a. Decommissioning of the incinerator: may be subcontracted and the subcontractor may need to hire personnel but this will be a one-time instance b.

Installation of the incinerator- extra staff may be needed to assist with the installation but this is not expected to be a large number.
c. Operation and maintenance of the incinerator: besides the present single operator, a second person should be hired for data collection and record-keeping d. Training in gender awareness and the incorporation of gender analysis into existing hospital procedures such as waste management and fire prevention plans.

8.0 ENVIRONMENTAL AND SOCIAL MANAGEMENT AND MONITORING PLAN 8.1 Introduction According to the draft ABNMWMP (2022), there are gaps in the management of bio- medical waste in Antigua and Barbuda.
The gaps concern segregation practices, waste storage, training of staff, availability of equipment and supplies, and disposal.

Waste is transported in open tray and other types of vehicles by sub-contractors who utilize them for other purposes.

There is inadequate monitoring of medical waste management activities and ambiguity as to which Government department is responsible.

The ABNMWMP aims to fill this gap and so some recommendations are based on it.
8.2 Summary of Impacts: Positive impacts from the project may include: 66 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 1. reduction in the volume and infectious potential of bio- medical waste 2.

3. review of the present waste management plan reduction in air pollution from improperly functioning incinerator 4. some employment opportunities The major negative impacts which may result from this project are summarized in the table below.
The largest concern is with the exposure of hospital workers and subcontractors to hazardous bio-medical waste, possible air pollution including the generation of POPs, and fire hazards.

Gender-specific impacts revolve mainly around the exclusion of females from employment in this sector due to traditional roles.

Social impacts are expected to be minimal.

Table 25.
Major Impacts Expected from Project Impact Category Risk Significance Decommissioning and removal of present incinerator Air pollution from residual ash Environmental Medium Exposure of workers to hazardous waste Social Injury due to obstructions Exclusion of women from employment opportunities Disruption to traffic Aesthetics Installation of New Incinerator Social Social Social Social Medium Medium Serious Low Very low 67 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Generation of solid waste which may pollute the land Environmental Medium Noise pollution Environmental Very low Women excluded from employment Social Serious Operation of the Incinerator Infection and injury due to exposure to bio- medical waste or operation of incinerator Social Serious Poor aesthetics of waste storage Social Medium Air pollution from ash, smoke, possibly dioxins and furans Environmental Medium Land pollution Fire hazard Noise pollution Environmental Medium Environmental Social Environmental High Very low Water contamination Environmental Low Accumulation of bio-medical waste due to incinerator failure Environmental Low Negative public perception Women excluded from employment Social Social Low Serious 8.3 Mitigation The mitigation principle to be applied in reducing any negative project impacts is illustrated in figure below.
68 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Avoidance Minimisation Compensation Figure 14.

Mitigation Principles Adverse impacts should be avoided as the first strategy of mitigation and preventative measures should be sought automatically.

Once these avenues are exhausted, the second strategy is to minimize or reduce adverse impacts to as low a level as possible.

Compensation for adverse, unavoidable impacts is the third level of mitigation.
The recommendation is the polluter pays principle where compensation for negative outcomes proven related to this project’s activities should be borne by the SLBMC.

There are internationally accepted principles that guide effective waste management and will be applied here.

a.
a.

The polluter pays principle: the waste producer is legally and financially responsible for the safe handling of waste and disposal of that waste in an environmentally sound manner and the creation of incentives to reduce the amount of waste generated.

b.

The precautionary principle: notwithstanding the lack of conclusive scientific knowledge about the possible impacts of an action, there is a social responsibility to protect society from any potential negative outcomes.
Not implementing cost- effective measures to prevent degradation of the environment should not be based on lack of conclusive evidence of a threat.

69 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) c. The duty of care principle: sound ethics dictate that the person managing or handling waste must exercise the utmost care in doing so.
d. The proximity principle: hazardous waste should be treated and disposed of as close as possible to its origin or point of production within environmental and technical parameters to minimize transport risks.

e. The prior informed consent principle: Communities and stakeholder who may be impacted, must be informed of risks and hazards associated with the location and operation of waste treatment and disposal facilities and transport of wastes to and from them.
8.4 Management Structure and Responsibilities The SLBMC as the implementing and executing agency has ultimate responsibility for the project.

It is responsible for: 1. the implementation of the environmental and social management plan.

2. the provision of guidance or contracting persons to provide guidance in following the mitigating measures while the activities of the project are being carried out.

3. environmental monitoring and reporting.


4. ensuring compliance with the ESMP and the GIAP by any contractors or site supervisors.

5. where unforeseen factors occur, reviewing and updating the ESMP to minimize any environmental or social impacts.

6. organizing and hosting public or other forms of consultation with stakeholders as needed during project execution.
70 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) The site supervisor may be the contractor supervising or performing the activities of the project or the SLBMC or one of its agents such as the project manager, that are on-site to observe the project activity.

The site supervisor is responsible for: 1. ensuring that the tenets of the ESMP are implemented and adhered to during operations.
2. recording and reporting to the SLBMC administration or Board any contravention or non- compliance as they occur and any factors which may have led to it.

3. completing a compliance report.

4. recording and reporting any complaints that are made with respect to the activities of the project.

5. recording and reporting as soon as possible, any incident that causes or has the potential to cause material or serious environmental harm.
8.5 Public Consultation and Environmental and Social Disclosure Public consultation and disclosure is to be an integral part of the project implementation.

Following the guidelines outlined below and in accordance with DOE policies, the contents of the ESIA shall be made available to the public and the public will have the opportunity to express their opinions on the contents of the ESIA or on any part of the project that may affect them.
8.6 Grievance Mechanism Since the SLBMC will be fulfilling the terms of the ESIA and ESMP in conjunction with the Department of Environment (DOE), their established Complaints Procedure is included as part of the Grievance Mechanism for this project.

Complaints pertaining to project activities will be directed to designated personnel at SLBMC.
Affected persons can submit complaints related to the activities of the project to 71 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 1. the SLBMC or 2. the DOE via the following channels: • On the DoE’s website: • http://www.environmentdivision.info/submit_a_complaint_en_365cms.htm • Filling out the form and emailing it to antiguaenvironmentdivision@gmail.com • In writing to: Director, Department of Environment, Ministry of Health and the • Environment, #1 Victoria Park Botanical Garden, P.O.
Box W693, St. John's Antigua • By email: antiguaenvironmentdivision@gmail.com • By Phone: Monday to Thursday: 8am to 2pm, Fridays: 8 am to 12 pm, by calling: (268) 462 4625; (268) 562-2568; (268) 460-7278 When a complaint is communicated, the following information is recorded: • The nature of the problem • The location of the problem • When the problem occurred (date and time) • Who or what is the perceived source of the problem • Any information or evidence you may have—particularly eyewitness information, • documents or photographs, a videotape, or a water or soil sample (the • information or evidence must be credible and relate directly to the incident being • reported).
• The contact information of the complainant The Department will produce a report of its findings and recommendations and action if necessary.

Complainants may request for a copy of the reports related to the complaint, as per the 72 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Freedom of Information Act.

Once the Department has completed its investigations, the Department will notify the complainant, either verbally or in writing, about the results.
A complaints register should be kept and updated throughout the life of the project.

The SLBMC is ultimately responsible for recording and dealing with complaints.

8.7 Environmental Procedures and Site and Activity-Specific Work Plans/Instructions The SLBMC in consultation with the contractor or site supervisor will devise a site or activity-specific description and checklist for all activities to ensure the minimizing of any environmental hazards.
The contractor or site supervisor is required to follow and complete the checklist on a daily or weekly basis and submit it to the SLBMC administration for revision.

The SLBMC will follow-up and make necessary adjustments.

8.8 Performance Criteria There are a set of minimum criteria based on environmental and social indicators which should be met.

These criteria are described below, followed by a table detailing the management plans.

Performance Criteria/Standard 1.

Reduction of air pollution hazard.


2.

Reduction of land pollution hazard.

3.

Reduction or elimination of sickness or injury due to exposure to bio-medical waste.

4.

Gender neutral participation of men and women in all aspects of the project; participation and involvement of vulnerable populations.

The education and training of staff should consider that females significantly outnumber males in 33 of the 37 departments of the hospital.
The exceptions are Board of Directors, Building and Grounds, M.I.S.

and Transport.

Therefore training must consider traditional gender roles such as 73 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) child care being a predominantly female role, in decisions about scheduling and duration of training and education sessions.
74 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 8.9 Management and Monitoring Plan Table 26.Management and Monitoring Plan Mitigation Table 26.

Environmental Management and Monitoring Plan esired Outcomes Monitoring: Performance Indicators/Targets or Acceptance Criteria Time Responsibility Cost United States dollars Decommissioning and removal of incinerator Reduction of air pollution from residual ash during dismantling and transport to landfill.
Before and during dismantling of incinerator.

Decommissioning plan including: HEPA filter vacuuming, creation of negative pressure environment, wet wiping Air pressure monitor with alarm.

Sub-contractor $ 5000 Covered transport to landfill Removal/emptying of skip before decommissioning During transport to landfill During dismantling of incinerator.
Empty skip or skip in different location so workers do not come in contact with waste Site supervisor $ 200 Reduction of exposure of workers to hazardous waste stored near incinerator room entrance.

75 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Mitigation Monitoring: Performance Indicators/Targets or Acceptance Criteria Time Responsibility Cost United States dollars Table 26.
Environmental Management and Monitoring Plan esired Outcomes Reduction of injury due to obstructions Equitable access of all genders to employment Removal of debris/obstruction before decommissioning Gender Action Plan Reduced disruption to traffic Move after 8:30 am when traffic has reduced Improved aesthetic Equitable access of all genders to employment No impact as incinerator room not normally traversed by public Gender Action Plan Cleared incinerator room and immediate environs outside room.
Employment opportunities offered to genders equitably.

No disruption in traffic due to transport of incinerator parts.

No unsightly aesthetics.

During dismantling of incinerator.

Before dismantling of incinerator.

During transport of old incinerator.

During dismantling of incinerator Site supervisor $ 200 NA Site supervisor NA Site supervisor NA Employment opportunities offered to genders equitably.
Before installation Site supervisor Subcontractor NA Installation of new incinerator No accumulation of Reduced solid waste outside generation of designated area.

No solid waste solid waste visible which may pollute the land Collection and immediate removal of packaging and other waste.

Site supervisor Subcontractor During installation 76 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Table 26.
Environmental Management and Monitoring Plan esired Outcomes Reduced noise pollution Equitable access of all genders to employment Properly functioning incinerator Mitigation Quick and efficient installation.

Use of hand held tools.

Gender Action Plan Invoke the manufacturer installation, training and maintenance option Monitoring: Performance Indicators/Targets or Acceptance Criteria for more than a day.

No complaints of noise from patients, staff or visitors.
Employment opportunities offered to genders equitably.

Correct functioning of incinerator Time Responsibility Cost United States dollars During installation Site supervisor Subcontractor NA Before installation Site supervisor Subcontractor NA Before installation SLBMC administrator Operation of new incinerator Reduced infection and injury due to exposure to bio- medical waste Throughout duration of operation of the incinerator.

Facilities manager/ incinerator operations supervisor.
Waste Management Plan Written plan presented.

$ 2000 Training (incinerator operators and Certification.

No infections or injury due to possible Before and intermittently SLBMC administrator.

$ 5000 77 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Mitigation Table 26.
Environmental Management and Monitoring Plan esired Outcomes other hospital staff in waste management Adequate storage Reduced infections or injury from operation of incinerator Training of incinerator operators in proper operation of incinerator.

Invoke manufacturer training option Proper installation of incinerator.

Monitoring: Performance Indicators/Targets or Acceptance Criteria exposure to bio- medical waste.

Bio-medical waste segregated into appropriate containers and separated from general waste.
Covered skips or waste stored out of sight in appropriate room.

Certification.

No infections or injury from operation of incinerator.

Time Responsibility Cost United States dollars during operation of the incinerator.

Before and during operation of the incinerator.

Before and during operation of the incinerator.

Facilities manager/ incinerator operations supervisor.

SLBMC administrator.

$ 3000 ^ Certified inspection by appropriate professional.

Before operation commences.

SLBMC administrator.


78 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Mitigation Table 26.

Environmental Management and Monitoring Plan esired Outcomes Monitoring: Performance Indicators/Targets or Acceptance Criteria Time Responsibility Cost United States dollars Regular maintenance checks.

Protocols for accidents Vaccines Regular health checks.

Written records.

No infections or injury from operation of incinerator.
Written records Written records Prominently displayed signs.

Record keeping Signs $ 4000 Facilities manager/ incinerator operations supervisor.

SLBMC administrator.

SLBMC administrator.

$ 500 $ 1000 Facilities manager/ incinerator operations supervisor During operation of incinerator.

Before operation of incinerator commences.

Before operation of incinerator commences or before worker allowed to work.

Before operation commences and remain displayed during operation.
79 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Table 26.

Environmental Management and Monitoring Plan esired Outcomes Improved aesthetics of waste storage Reduced air pollution from ash, smoke, possibly dioxins and furans Mitigation Waste management plan: storage out of sight or covering of skip Training of incinerator operators in proper operation of incinerator.
Monitoring: Performance Indicators/Targets or Acceptance Criteria Written plan Certification.

Air quality within acceptable standards.

Maintenance checks Written records.

Time Responsibility Cost United States dollars Before and during operation of incinerator.

Before and intermittently during operation of incinerator.

SLBMC administrator.

SLBMC administrator in conjunction with DAS.

Included in ^ above At regular intervals based on international best practices.
Facilities manager/ incinerator operations supervisor Air quality monitoring Records showing air quality within acceptable standards.

Residue testing Operation of incinerator at Records showing residue components within At regular intervals based on international best practices.

At regular intervals based on SLBMC administration in conjunction with DAS.

$2000 SLBMC administrator in $2000 80 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Mitigation Table 26.
Environmental Management and Monitoring Plan esired Outcomes Monitoring: Performance Indicators/Targets or Acceptance Criteria Time Responsibility Cost United States dollars temperatures between 850°C to 1100°C acceptable international standards.

international best practices conjunction with DAS.

Elimination of land pollution Waste management plan.

Written plan presented.

Proper storage and transport of waste Waste stored and transported appropriately.

No land pollution.
No land pollution.

Before operation of incinerator.

During operation of incinerator Reduction or elimination of fire hazard Fire Prevention and Emergency plan.

Written plan presented.

Adherence to procedures e.g.

Regular fire drills (every quarter) and practice sessions.

Before operation of incinerator.

Before and during operation of incinerator.

SLBMC administrator NA Facilities manager/ incinerator operations supervisor SLBMC administrator.
Prominently displayed signs Before and during SLBMC administrator.

$2000 81 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Mitigation Table 26.

Environmental Management and Monitoring Plan esired Outcomes Monitoring: Performance Indicators/Targets or Acceptance Criteria Time Responsibility Cost United States dollars outlining procedures and emergency numbers.

Trained staff.

Implementation of Fire Emergency Plan.

Use hand tools or small powered tools.


Keep time period at a minimum.

Proper storage of waste.

Water testing.

Signs using gender- sensitive language displayed.

operation of incinerator.

Trained staff No complaints of noise.

Before and during operation of incinerator For fire emergencies.

During operation of incinerator.

Records showing acceptable water quality.

During operation of incinerator.


Reduced noise pollution Prevention of water contamination Prevention of accumulation of Training of incinerator Certification.

Emergency use.

$2000 $ 2000 Facilities manager/ incinerator operations supervisor Facilities manager/ incinerator operations supervisor in collaboration with CBH and DAS Facilities manager/ 82 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Table 26.
Environmental Management and Monitoring Plan esired Outcomes bio-medical waste due to incinerator failure Equitable access of all genders to employment Mitigation operators in proper operation of incinerator.

Maintenance checks.

Revert to deep burying at Cook’s landfill or use autoclave if commissioned.

Gender and Inclusivity Action Plan Negative public perception Education Campaign Monitoring: Performance Indicators/Targets or Acceptance Criteria Maintenance records.
Time Responsibility Cost United States dollars incinerator operations supervisor Employment opportunities offered to genders equitably.

Increase in positive perception evidenced by survey results.
Before installation Site supervisor Subcontractor NA Before operation of incinerator SLBMC administrator $8,000 83 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 8.10 Gender and Inclusivity Action Plan A gender action plan (GAP) is project specific document addressing the gender-based constraints and opportunities peculiar to that project.

It is informed by the social and gender impact and analysis carried out in relation to the project.
Since considerations related to gender means the identification of vulnerabilities, other vulnerable groups will also be considered as part of this management plan.

The major gender- based and inclusivity constraints identified for this project are outlined briefly below.

1.

Traditional roles expect that decommissioning, installation and operation of an incinerator is man’s work and women may not apply or be considered for any job opportunities.

2.
2.

Widely held view that the inherent danger associated with the decommissioning, installation and operation of an incinerator precludes the application or selection of persons with disabilities for employment.

3.

Poor public perception of the incinerator.

The SLBMC as the implementing and executing agency has ultimate responsibility for the execution of the GAP.

It is responsible for: 1.

2.

3.

4.

5.


6. the implementation of the GAP through the assignment of senior staff or the contracting of a gender expert.

the provision of guidance or contracting persons to provide guidance in following the mitigating measures while the activities of the project are being carried out.

monitoring and reporting.

ensuring compliance with the GAP by any contractors or site supervisors.
where unforeseen factors occur, reviewing and updating the GAP to minimize any environmental or social impacts.

organizing and hosting public or other forms of consultation with stakeholders as needed during project execution.
84 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) The site supervisor may be the contractor supervising or performing the activities of the project or the SLBMC or one of its agents such as the project manager, that are on-site to observe the project activity.

The site supervisor is responsible for: 1.

2.

3.

4.

5. ensuring that the tenets of the GAP are implemented and adhered to during operations.
recording and reporting to the SLBMC administrator any contravention or non-compliance as they occur and any factors which may have led to it.

completing a compliance report.

recording and reporting any complaints that are made with respect to the activities of the project.

recording and reporting as soon as possible, any incident that causes or has the potential to cause material or serious harm In designing the action plan, note was taken of several points.
The installation and operation of an incinerator may require skill that exists mainly in one gender (most likely men) due to traditional roles.

Thus the incinerator manufacturer/company may be unable to ensure equitable representation of genders in personnel.

There are few extra employment opportunities associated with the operation of the incinerator as there is already staff fulfilling this role.
Employment opportunities may exist in the following spheres: a. decommissioning of the incinerator: may be subcontracted and the subcontractor may need to hire personnel but this will be a one-time instance b. installation of the incinerator- extra staff may be needed to assist with the installation but this is not expected to be a large number.
c. operation and maintenance of the incinerator: besides the present single operator, a second person should be hired for data collection and record-keeping d. training in gender awareness and the incorporation of gender analysis into existing hospital procedures such as waste management and fire prevention plans.

Table 27.
Gender Action Plan ACTIVITIES OUTPUTS (WITH INDICATORS TIMEFRAME BUDGET PERSON RESPONSIBLE GENDER ACTION PLAN TARGETS/QUOTAS) OUTCOME 1: Skills-based employment for the decommissioning, installation and operation of the incinerator that considers both men and women Offer job opportunity to both genders At least one woman hired for each phase of project At least one woman hired 6 months NA SLBMC, sub-contractors 85 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 6 months Certification of staff for each phase of project All sub-contractors trained in gender response without prejudice.
OUTCOME 2: Gender-responsive training for both men and women Gender- responsive training for sub- contractors and SLBMC staff Gender- responsive training for operation of the incinerator All incinerator operators trained 6 months $ 1000 SLBMC $3000 SLBMC and manufacturer $5000 SLBMC 6 months All hospital staff trained Gender- responsive training in waste- management for hospital staff Gender- responsive training in fire prevention and reduction for key staff (e.g.
incinerator operators) OUTCOME 3: Men and women within surrounding society and community informed about incinerator 6 months and on-going All key staff trained SLBMC $2000 Certification of staff Sex- disaggregated data on attendance and completion Certification of staff Sex- disaggregated data on attendance and completion Certification of staff Sex- disaggregated data on attendance and completion 86 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Gender- responsive public relations campaign Surrounding communities informed about incinerator Sex- disaggregated data from attitudinal surveys conducted after the campaign 6 months $8000 SLBMC 87 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 9.0 SUMMARY AND CONCLUSION The project goal is the replacement of the present debilitated incinerator unit at the SLBMC with a new unit.
The primary positive outcome is the reduction of the volume, infective and injurious potential of medical waste produced at the facility.

Incineration is a widely used and accepted method of dealing with bio-medical waste.

Negative impacts are mainly the potential for production of harmful air pollutants such as doxins and furans, hazards to workers associated with the collection, storage and treatment of the waste, negative perceptions of incineration by the general public including nearby communities.
Mitigation recommends the development and implementation of waste management plan for the hospital, invocation of the manufacturer installation, training and maintenance option for the installation of the new incinerator, training, public relations, incorporation of gender-sensitive response into present hospital policies.

88 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) References Caribbean Development Bank.
(2014) Environmental and social review procedures.

CBD Chakraborty, S., Veeregowda, B., Gowda, L, Sannegowda, S.N., Tiwari, R., Dhama, K. & Singh, S.V.

(2014).

Biomedical waste management.

Adv.

Anim.

Vet.

Sci.

2 (2): 67 – 72 Hirani, D. P., Villaitramani, K. R., & Kumbhar, S. J.

(2014).

Biomedical waste: an introduction to its management.

International Journal of Innovative Research in Advanced Engineering (IJIRAE), 1(8), 82-87.

Ministry of Health, Wellness and the Environment.

2022.
2022.

Antigua and Barbuda national medical waste management plan (Final draft).

Government of Antigua and Barbuda.

Ministry Of Health, Community Development, Gender, Elderly And Children.

(2017) National standards and procedures for health care waste management.

United Republic of Tanzania Silva, S., & Lopes, A. M. (2017).

Environmental aspects and impacts of a waste incineration plant.

Energy Procedia, 136, 239-244.

Statistics Division, (2020).

Antigua and Barbuda 2018 Labour Force Survey Report.
Government of Antigua and Barduda.

World Health Organization.

(2017).

Safe management of wastes from health-care activities: a summary (No.

WHO/FWC/WSH/17.05).

World Health Organization.

PATH.

(2010).

The Incinerator GuideBook: A Practical Guide for Selecting, Purchasing, Installing, Operating and Maintaining Small – Scale Incinerators in Low re source Settings.

Ver.

1: 1 – 58.
Ver.

1: 1 – 58.

UNEP http://chm.pops.int/theconvention/thepops/tabid/673/default.aspx 89 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Appendix A Questionnaire JOSEPH WRENCH PROSPER OLD PARHAM ROAD ST JOHN’S, ANTIGUA TELEPHONE: 462 - 1163 773 - 1159 ENVIRONMENTAL AND SOCIAL IMPACT ASSESSMENT The purpose of the questionnaire is to get your views on placing and operating an incinerator within the Sir Lester Bird Medical Centre.
The incinerator is expected to handle general and medical waste generated during the operation of the hospital.

1.

Do you welcome an incinerator at the hospital?

Yes No 2.

List potential positive impacts of having and using an incinerator.

____________________________________________________________________________________ 3.

What issue (s) should be considered in operating an incinerator?

_____________________________________________________________________________________ 5.
Do you foresee any negative impact of using an incinerator?

Yes No If yes (list them) _____________________________________________________________________________________ 6.

Are there any materials you think should not be incinerated at the hospital which you think might cause ill health or raise environmental concerns or other risks to people?

__________________________________________________________________________________ 7.
Any additional comments ________________________________________________________________________________ 8.

Gender: male female other 9.

Age range: 18 – 23 24 – 29 30-35 36 – 41 42 – 47 48 – 52 53 – 59 60 + 10.

Highest level of education: primary secondary tertiary other 11.

Marital status: single married other 90 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 12.
Employment status: full part time seasonal unemployed 91 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Appendix B SLBMC Employees by Department (Gender Disaggregated) 92 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Department ADMINISTRATION ADMITTING/PBX BOARD OF DIRECTORS Gender Percentage (%) Female Male Female Male Female Male BUILDING & GROUNDS Male CENTRAL SUPPLY & STERILIZATION CRITICAL CARE NURSE DIALYSIS NURSE DIETARY EDUCATION EMERGENCY ROOM NURSE FINANCE HUMAN RESOURCES Female Male Female Male Female Male Female Female Female Male Female Male Female LABOR/DELIVERY NURSE Female LABORATORY LAUNDRY/LINEN M.I.S.
Female Male Female Male Female Male MATERIELS MANAGEMENT Female 90 10 88.8 1.2 45.5 54.5 100 72.7 27.3 93.8 6.2 92.9 7.1 100 100 89.4 1.6 83.8 16.2 100 100 78.3 21.7 71.4 28.6 33.3 66.7 62.5 93 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) MEDICAL RECORDS MEDICAL UNIT NURSE NURSERY NURSE NURSING MANAGEMENT OPERATING ROOM NURSE ORDERLIES Male Female Male Female Male Female Female Male Female Male Female Male ORTHOPAEDICS TECH Male OUT PATIENT CLINIC NURSE Female PEDIATRICS NURSE PHARMACY PHYSICAL THERAPY PHYSICIANS PUBLIC RELATIONS QUALITY ASSURED RADIOLOGY TECH SURGICAL UNIT NURSE TRANSPORTATION Female Female Male Female Male Female Male Female Female Male Female Female Male WOUND CARE CLINIC NURSE Female NURSING PERSONEL Female Male ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) TOTAL EMPLOYEES Female Male 75.2 24.8 SUMMARY NB: Table represents the male to female ratio per department of the total number of staff employed by the Sir Lester Bird Medical Centre.
Physicians are represented as one (1) department but in practice work within individual Clinical Specialties and Diagnostic Departments.
Data provided by: Sir Lester Bird Medical Centre (formally Mount St. John’s Medical Centre) Director of Operations 95 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Appendix C MANAGEMENT PLAN FOR DECOMMISSIONING OF HOSPITAL INCINERATOR AT SLBMC (FORMERLY MSJMC) Considerations There may be ash and other residue including heavy metals and dioxins and glass shards remaining in the main combustion chamber and flues.
The chamber and chimney and associated ducts systems may therefore be contaminated so must be decommissioned using appropriate procedures to prevent the release of the ash, metals or dioxins into the environment.

A containment approach is recommended.

Decommissioning should be carried out by a competent contractor using appropriately trained personnel.

Ideally ash sampling and analysis should be carried out.

However, once the recommendations are adhered to the risk will be minimal.
Site Preparation and Construction The floor drain in the incinerator room shall be covered with a temporary seal during the decommissioning and demolition works.

The top of the chimney should be sealed with polyethylene sheets at least twenty-four (24) hours before the works commence.

The flue opening on the side connected with the incineration furnace shall be sealed with 2 layers of fire retardant polythene sheets.
Preliminary site decontamination of all debris shall be carried out using High Efficiency Particulate Air (HEPA) vacuum cleaner.

Except the incinerator, all other existing items shall be removed from the incinerator room as far as practicable to avoid obstructing the subsequent work activities.

The walls, floor and ceiling of the incinerator room shall then be lined with 3 layers of fire retardant polythene sheets.
At the entrance to the incinerator room, a 3-chamber decontamination unit shall be constructed for entry and exit from the work area.

The walls of the room shall be used as the boundary for the segregation.

All workers must carry out decontamination procedures in this unit every time they leave the work area.

Warning signs should be put up in conspicuous areas.
The 3-chamber decontamination unit shall comprise a dirty room, a shower room and a clean room of at least 1m x 1m base each with 3 layers of fire retardant polythene sheet where the worker shall carry out decontamination before leaving the work area.

All bagged material shall egress the containment through the decontamination unit after thorough cleaning.

An air mover shall be provided to exhaust air from the work area.
Sufficient air movement shall be maintained to give a minimum of 6 air changes per hour to the work area, and maintain a negative pressure of 0.05-0.15 inches of water within the work area throughout the entire course of the decommissioning works.

A pressure monitor with printout records and audible alarm shall be installed at an easily accessible location to demonstrate that the negative pressure is maintained.

A standby air mover shall be made available for use.
New pre-filters shall be used at the air movers.

Removal 96 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) All workers shall wear full protective equipment, disposable protective coverall (such as Tyvek) (with hood and shoe covers), inner and outer nitrile gloves, rubber boots (or boot covers), and full-face positive pressure respirators equipped with a combination cartridge that filters particulate and removes organic vapour.
The top vertical section of the incinerator flue shall be removed first.

The detached sections of the flue shall be wrapped with 2 layers of fire retardant polythene sheets.

A third layer shall then be wrapped and secured with duct tape.

Decontaminate the outer layer of the wrapped flue sections by wet wiping when passing them out of the containment through the decontamination unit for disposal.

If a flue section is large, it should be left in the contaminant for later removal.
The combustion furnace, upon removal, shall be wrapped with 3 layers of fire retardant polythene sheets.

The outermost layer shall be secured with duct tape.

Workers shall carry out decontamination in the 3-compartment decontamination unit and have the used coveralls, nitrile glove, and rubber boots disposed of as chemical waste in the dirty room.
All wastewater generated within the decontamination unit shall pass through a filtration system for removal of particles down to 5 micron in suspension, before being discharged into the drainage system.

After completion of removal, decontaminate all surfaces, including the wrapped incinerator chambers and flue sections left within the containment, by wet wiping and HEPA vacuum.

Then spray the innermost layer of the fire retardant polythene sheet covering the wall, ceiling and floor with PVA.
Upon drying, peel off this innermost layer of the polythene sheet covering the containment and dispose of as chemical waste.

Repeat the above decontamination procedure for the second innermost layer of fire retardant polythene sheet, including the wrapped incinerator chambers and flue sections left within the containment by wet wiping and HEPA vacuuming.
After spraying with PVA, peel off this second innermost layer of the polythene sheet covering the wall, ceiling and floor and dispose of as chemical waste.

Disposal The dismantled incinerator furnace and flue sections wrapped in polythene sheets shall be disposed of at a designated landfill site.

In addition, cloths which have been used for wet wiping will not be re-used and will be disposed of at the landfill.
A suitably licensed waste carrier will be used to transport the wastes to the designated landfill.

Waste Management Implications As a prudent approach, the polythene sheets wrapped incinerator furnace and flue sections shall be regarded as chemical waste, and shall be placed into appropriate containers such as drums, jerricans, or heavy duty and leak-proof plastic bags and disposed of appropriately.

Labelling and Storage of Chemical Wastes.


Potentially contaminated waste generated from the dismantlement of the containment and decontamination units, and cloth used in wet wrapping, etc.

shall also be disposed of as chemical waste.
97 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Adapted from Parsons Brinkerhoff 98 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Annex 1 99 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 100 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 101 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 102 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 103 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 104 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 105 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 106 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 107 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 108 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 109 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 110 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 111 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) Annex 2 112
 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 113 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 114 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 115 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 116 ESIA and ESMP for Replacement of Incinerator at SLBMC (formerly Mount St. John Medical Center) 117