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Hazardous Waste Dilemma in the Arab Region An Eye on Environmental Health Ramifications Basel Al-Yousfi
01/08/2010
 Hazardous Wastes are usually defined based on their nature, characteristics and potential adverse impacts on human health and the environment. From a legal point of view, such a definition is derived from one or more of the following intrinsic properties of wastes: Explosive, Flammable, Corrosive, Infectious, Poisonous, Toxic and/or Eco-toxic. Furthermore, taking into consideration the well-known “Precautionary Principle”, any unknown (suspicious) waste is hazardous until proven otherwise, any waste (residue) derived from hazardous waste is hazardous, and a mixture of hazardous (no matter how small) and none hazardous wastes should be deemed hazardous in its entirety.

The Arab Region, as the rest of the globe, is still faced with serious environmental health challenges stemming from our new way of “modern” lifestyle and the prevailing patterns of unsustainable production and consumption; on top of them hazardous waste can be recognized. Among the various types of waste produced by society, particular attention needs to be paid to that proportion which is potentially hazardous.  Poor management of such waste can endanger public health and give rise to public concern16. The problem of Hazardous Wastes Management (HWM) has been recognized seriously worldwide, but first in industrialized countries4. In developing countries, this problem has been severely compounded by other socio-economic and technological predicaments. 
Despite that most of the world governments have already ratified the Basel Convention (BC); the majority of developing countries are still struggling with establishing practical mechanisms to address the pressing problems pertinent to the generation and management of hazardous waste. In numerous instances, there are no complete and/or reliable data on the amounts of hazardous wastes generated, but rather some crude estimates scattered here and there. The national legislations of such countries, although founded based on the BC provisions, are still impeded by severe shortages in infrastructures suitable for HWM, as well as obvious deficits in trained human resources capable of dealing with the various (and often technically complicated) aspects of the problem.
Only few countries in the Arab Region have already constructed secure treatment, storage and disposal facilities (TSDF) for hazardous waste; but the vast majority lacks the technological know-how and financial means to build such sophisticated systems1, 2. In the absence of safe and sound HWM facilities, exacerbated by weak regulatory enforcement as well as inadequate international cooperation (e.g., north-south technology transfer & indigenization), the dilemma of hazardous waste will continue to be a serious developmental and environmental health challenge in the world. 

It is important to point out that nowadays the production and consumption of electrical and electronic devices (e.g., computers, mobile phones, gadget, etc.) are the fastest-growing sectors around the globe. At the same time, technological innovation, intense marketing and consuming attitude provoke a rapid replacement (and often disposal) processes. Every year, 20 to 50 million tones7 of electrical devices and electronic equipment waste (designated as "e-waste") are generated world-wide. Most of these have intrinsically hazardous components and harmful elements causing serious risks to human health and the environment. Iron and steel constitutes about 50% of the E-waste followed by plastics (21%), and non ferrous metals (13%) like copper, aluminum and precious metals like silver, gold, platinum, palladium etc. The presence of elements like lead, mercury, arsenic, cadmium, selenium, hexavalent chromium and flame retardants beyond threshold quantities in E-waste classifies them as hazardous waste12. Most of these e-waste streams end-up in poor societies and underdeveloped countries (including some Arab countries) that lack the means and knowledge to deal with such e-wastes safely or properly. Unfortunately numerous impoverished localities are exploited as a dumping ground for “second-hand” e-items or e-wastes under various scams (many of which are introduced as charities or recycling business opportunities). To add insult to injury, vulnerable groups (e.g., children) are more likely subjugated to their pertinent risk exposures. 

Of a special environmental health concern to WHO is the safe management and disposal of Health Care Wastes (HCW), often referred to as Medical Wastes. Such wastes are naturally classified as hazardous and nonhazardous. Almost 80% are general waste comparable to domestic waste. The remaining approximate 20% of wastes are considered hazardous that may be infectious, toxic and/or radioactive18. Infectious (or bio-hazardous) waste could potentially lead to the spread of infectious disease. Examples of infectious waste include blood, potentially contaminated "sharps" such as needles and scalpels, and body parts. Sharps include used needles, lancets, and other devices capable of penetrating skin. Additionally, medical facilities produce a variety of waste hazardous chemicals, including radioactive materials. While such wastes are normally not infectious, they may be classified as hazardous wastes, and require proper disposal. Poor management of health care waste potentially exposes health care workers, waste handlers, patients and the community at large to infection, toxic effects and injuries, and risks polluting the environment. It is essential that all medical waste residues and discards are segregated at the point of generation, appropriately stored, transported treated and disposed of safely. The Arab Region has just started to pay adequate attention to the proper management of HCW; however, disparity among the “have” and “have not” of member states still prevails.
 
SOME HEALTH ASPECTS OF HAZARDOUS WASTES 17, 20:

Evidently, given the diverse mixtures of toxic substances and harmful compounds embedded within hazardous wastes, there should be considerable potentials for adverse health exposures to occur throughout the waste management cycle and beyond (e.g., due to fate and transport phenomena). High levels of contamination of air, soil, water and biota can lead to widespread health risks and illnesses prevalence not only on waste management workers, but also on communities living within a proximity to hazardous wastes sites. Increases in risk of adverse health effects (e.g., certain types of cancers, birth defects, and low birth weight) have often been observed near hazardous waste sites. Increased occurrence of self-reported illness symptoms such as headaches, fatigue, sleepiness etc. among communities located nearby waste sites has consistently been depicted. In the Arab Region, it is envisaged that up to 25% of the total burden of diseases is attributable to modifiable environmental risks. A US EPA study, surveying about 600 hazardous wastes sites, has documented significant correlations between hazardous waste sites and excess deaths for cancers of the lung, bladder, esophagus, stomach, large intestine, and rectum for white males; and for cancers of the lung, breast, bladder, stomach, large intestine, and rectum for white females15.

Sound and safe management of hazardous wastes is an important environmental health issue; especially in developing countries where economies and societies are not well-equipped to deal with adverse impacts and dire consequences stemming from risks of exposure to toxic chemicals and wastes21. It is estimated that by the year 2020, nearly one third of the world's chemical production will take place in developing countries and that global output will be 85% higher than it was in 1995. The shift of chemical production to poor countries will likely increase pertinent health and environmental risks imposed on their populations. Figure 1 clearly illustrates the health vulnerability of developing countries in this regard as depicted in the staggering number of fatalities associated with the prevalence of human poisoning (about 1/3 in developed and 2/3 in developing countries) 17,20.
 
The severity of any environmental-health impact depends on the length of exposure, the ‘dose’ or amount of the harmful compound, and vulnerability of the recipient. It is worth re-emphasizing that acute exposures to hazardous wastes can lead to death or serious illness. Chronic exposure is most often a problem in the occupational setting as hazardous waste is not often separated from municipal waste and other wastes streams, particularly among poor scavenging recipients where men, women, and children all work and live in close proximity to dumping fields. Long-term exposures to hazardous wastes (and toxic residues) can increase the risk of developmental and reproductive disorders, immune-system disruption, endocrine disruption, impaired nervous-system function, and development of numerous cancers. Children and other sensitive groups (e.g., pregnant women, smokers…etc.) are at higher risks and much more vulnerable to exposures. Secondary exposure and routing may also occur as toxic elements from hazardous wastes’ injudicious handling and unsecure disposal can infiltrate water sources (and other media: air, soil…etc.), contaminating drinking water and food-chain species (e.g. fish, a key human nutritional source). Such contamination can lead to a wide range of secondary public health impacts. Figure 28 depicts some of the potential routs of secondary exposures to hazardous wastes.
 
One approach to systematically study the environmental health impacts of hazardous wastes is to apply the Risk Assessment (RA) methodology. RA is a probabilistic assessment of dose-response relationship, taking into consideration the fate and transport of constituents, routes of transfer, pathways of exposure, as well as the potential recipient population(s). The assessment of risk can be outlined in five major steps: hazard identification, dose-response assessment, exposure assessment, risk characterization, and risk management (i.e., what level of risk is acceptable?). This approach is a useful tool for integrating effects over several media (air, water, soil and biota). However, uncertainties always exist in measuring or estimating risks, especially for relatively lower dosages but higher exposure frequencies. Also, extrapolation schemes from animal studies and epidemic investigations are at best debatable. Distinction should be drawn between acute and chronic risks.
It might be also of benefit to hint about the potential aggravating impacts anticipated from the climate change phenomenon. Global warming, heat waves, floods and droughts, etc. should have imminent adverse implications not only on the best environmental health practices with regard to hazardous waste management, but also on the potentially exacerbated exposure scenarios, pathways, effects and risks associated with hazardous wastes.
It is forecasted that in 2050 the number of new cancer cases worldwide will reach 27 million per year, as the estimated number of new cases of cancer each year is expected to rise from 11 million in 2002 to 16 million by 2020. Cancer kills 15.7% of population worldwide. The growing cancer burden includes global increases of incidence of about 1% each year. This increase in incidence takes into account a projected population increase of 38% in developing countries between 2008 and 203019. Furthermore, the annual mortality rate from various cancers in 2050 will be about 17 million, of which 50-75% will prevail in developing nations (in developing countries, 80% of people with cancer already have late-stage incurable tumors by the time they are diagnosed) 19. In our Region, cancer ranks as the fourth leading cause of death. Although the incidence of cancer is still below that in developed countries, the Region is expected to experience the highest increase among all other geographic regions in the coming two decades. This escalating trend can be attributed to many factors including population ageing and exposure to risk factors, such as smoking, unhealthy diet and physical inactivity and not the least environmental pollution19.
 
Knowing that about 40% of cancers are preventable (through avoiding or reducing exposure to risk factors, or by modifying the risk factors themselves) and 40% can be cured if detected early19; and recognizing that most hazardous wastes are composed of carcinogenic materials, the sound and integrated management of hazardous wastes is a must environmental health preventive strategy. Policies to improve regulation and control of hazardous waste handling and disposal; environmental health care systems to identify, prevent, treat, and monitor cases of exposures; and educational materials and advocacy tools to inform the public as well as waste-management and health-care workers about health risks and best practices all are profoundly important components of hazardous wastes management.
 
The risks emanating from health care waste are also of great concerns; since they are potentially affecting patients, medical staff, support services personnel, waste management workers and the public at large22. HCW is a reservoir of potentially harmful micro-organisms which can infect hospital patients, health care workers and the general public. Other potential infectious risks include the occasional spread of resistant micro-organisms from health-care establishments into the environment. These latter risks have so far been only scantily investigated18. Wastes and their by-products can also cause injuries, for example radiation burns or sharps-inflicted harms; poisoning and pollution, whether through the release of pharmaceutical products, in particular, antibiotics and cytotoxic drugs, through the wastewater or by toxic elements or compounds such as mercury or dioxins and furans. Finally, it is of paramount importance to pinpoint the tremendous risks associated with dumping HCW in open areas; a common practice in our region that can have major adverse effects on the population (especially on scavengers). The so called “recycling” practices that have been reported, namely, the reuse of syringes is certainly the most serious health problem in a number of developing countries.
 
HAZARDOUS WASTES MANAGEMENT IN THE ARAB REGION1:
Until recently, countries of the Arab Region have underestimated the problems and impacts caused by the generation of hazard waste. Several countries classify all wastes generated from industry as industrial waste whether hazardous or not. Others have fallen victims to illegal trafficking and dumping of hazardous wastes, where several shipments of toxic (and radioactive) wastes are allegedly entered the region for disposal (e.g., Somalia). Nevertheless, most of our states have already ratified the Basel Convention (BC) for the Control of Trans-boundary Movement of Hazardous Wastes.
As industrial developments and urban expansions proliferate in the Arab Region, the rates of hazardous waste generation will continue to rise. Chemical and petrochemical industries are the main contributor to hazardous waste generation; however, other industries and facilities are also contributing (e.g., mineral and metal processing, health care facilities and laboratories…etc.). Small and medium size enterprises (SMEs), such as electroplating shops, tanneries, auto-repair garages, have also their significant share in generating hazardous waste. Municipal wastes always contain certain portions of hazardous wastes (e.g., chemical solvents, paints, cleaning products, pharmaceutical substances, and batteries). Unfortunately, there are no comprehensive databases reflecting accurately the amounts and types of hazardous (and other) wastes generated in the Arab Region, but rather rough predictions based on some correlations with the Gross Domestic Product (GDP), with few exceptions of countries that perform and report their hazardous and sectoral wastes inventories (see Table 1) 6.  
Persistent Organic Pollutants known as (POPs) including obsolete pesticides present a special a challenge to developing Arab countries, as they typically lack the capacity to identify and respond to sources of releases of POPs9 to the air (e.g., dioxins and furans), water and soil (e.g., PCBs). Under some assistance programs (let alone smuggling); few Arab states had been victims of shipments of toxic chemicals from industrialized countries (e.g., herbicides and pesticides). These rapidly transform to hazardous waste streams that require special management care, a commodity which is lacking in the region. A study by FAO in the mid nineties estimated 7 thousand tons of obsolete pesticides present in 15 Arab countries, most have been rid off but more are expected to have accumulated nonetheless. 

To demonstrate disparity between various Arab member states in the region, Jordan for example (a non-oil producing country with population of about 6 millions) reported in 2005 to BC a generation of 17,000 tons of hazardous waste, Tunisia on the other hand (a non-oil producing country with population of about 10 millions) reported a generation of 71,000 tons of hazardous waste, while Oman (an oil &  gas producing country with population of about 3 millions) reported in the same year a generation of 242,000 tons of hazardous waste3. In several cases, the estimated hazardous wastes amounts per capita are anticipated to be comparable to those produced by industrialized countries. There are still countries in the Arab Region that depend on uncontrolled dumping and opened burning as the only means of ultimate disposal. Treatment, storage and disposal facilities (TSDF) of hazardous wastes are quite scarce in the Region (e.g., some TSDF exist in GCC countries), and when they exist are inadequate to handle the large quantities of waste produced in the Arab Region as a whole1. In a nutshell, hazardous wastes have will continue to cause major health, environmental and developmental challenges for the Region.
 
It is of importance also to capture on the radar screen the health care waste management problem in the region. Notwithstanding, several success stories in relatively developed Arab states, the overall situation of HCW in the Region is still far from being characterized as sound, safe and integrated management. New laws and national regulations have been established in this regard; nonetheless, with variable enforcement mechanisms and end results. The number of health care facilities in the Arab Region can be approximated at 3685 hospitals, 25000 primary health care centers and about 5000 Pharmacies.  The generation quantity of hazardous health care (medical) waste is estimated at about 330 thousand tons per year, at a rate varying from 0.2 to 1.9 Kg/bed/day or from 0.08 to 0.75 Kg/patient/day14. These hazardous HCW quantities are either handled locally or in about 445 centralized treatment and disposal facilities, ranging from old combusting practices to more advanced incineration and autoclave technologies14. In few LDC Arab states and localities, some medical wastes (including their hazardous portions) unfortunately are still intermingled with general municipal waste streams, to be subjected occasionally thereafter to open dumping and/or uncontrolled burning. Vulnerable groups, such as poor municipality workers and scavengers, are particularly exposed to sever risks, let alone the environment.

Although there are no reliable statistics pertinent to the imminent e-wastes problem in the region, one should know that the prevalence of ICT in the Arab region although leaping is still below that of international average. From 2002 to 2007 internet subscriber rate rose by factor four in the Arab Region, and mobile phone subscribers rose over 56% in the last five years12. Consequently, there is a huge growth potential in the e-waste streams, and consequently challenges and entrepreneurial opportunities.  So far, e-waste recycling in the Arab Region is still at infancy and made by the informal sector, where very few basic precautionary measures are applied to protect workers’ health and/or the environment12. 
As the Arab Region is and has been greatly vulnerable to military operations and conflicts (perhaps ranking number 1 in the world), one cannot but to pinpoint to the dilemma of hazardous wastes of military origins. A case in point is the situation Occupied Palestinian Territories and Iraq, where such a predicament is still looming 10, 13.

In armed conflicts, hazardous waste can be generated either by the weapons used (e.g. Depleted Uranium, and the Tungsten in the Dense Inert Metal Explosive (DIME)) (and/) or from the materials built-in and/or stored in a structure that is damaged by the war (e.g., asbestos, chemicals stored in warehouses). Gaza for example has a significant legacy of such contaminated and ruined sites due to recent military bombardments13. Some sites have major problems with hazardous waste components as well as with contaminated natural media (e.g., soil, water…etc.). Each site has to be assessed separately in a systematic manner so as to identify specific contamination issues, exposures scenarios and corrective actions. In Iraq and in Lebanon, military targeting of industrial sites (e.g., Al-Qadissiya Site in Iraq and El-Jieh PowerStation in Lebanon)10,11 produced acute terrestrial and/or marine   chemical contamination in the medium- and long-terms. On the other hand, associated secondary explosions, chemical releases and fires due to the bombardments have resulted in high levels of air pollution in the short term. If not properly remediated, such sites represent a severe risk to human health, specifically to site workers, trespassers as well as neighboring communities.
 
Unfortunately, as the direct military operations and hostilities curtail, the hazardous waste situations may not necessarily ease off or improve (sometime they worsen). Recently in Iraq, it was discovered that private contractors employed by the American forces have dispose of the military wastes generated at about 500 bases unlawfully into the Iraqi environment. A 2009 Pentagon document estimated 5,000 tons of hazardous wastes are so far produced by the American troops In Iraq5 (how much of which has been illegally deposited in Iraqis still to be known). This huge hazardous waste legacy which should have been shipped back to the USA for proper treatment and disposal (in accordance with the international law), may have ultimately ended up not only in Iraq ecosystem but within an easy reach of children, and occasionally in close proximity to irrigated farmlands5. Even with concerted remediation and cleanup efforts in the future, irreversible environmental health damages may have already been done chronically for several generations to come. Worth-mentioning, that there are notable and rising claims in various geographical areas in Iraq of increasing rates of cancer cases, birth defects, and illnesses linked to chemicals exposure5. 

SUMMARY & CONCLUSIONS:

The problem of HWM in most countries of the Arab Region is in a dire need for immediate solutions, technically financially and indeed politically. In the absence of dedicated facilities to handle hazardous waste, there is a real concern that such waste will be disposed of with non-hazardous waste, thereby contaminating landfills, soil, water, air and biota, and exposing public health to great environmental risks. To meet such environmental health challenges and overcome the hazardous waste dilemma, the following recommendations provide a comprehensive approach towards reducing health and environmental risks in the Region:
  1. Promote an integrated hazardous waste management strategy in the Arab Region through coordination and cooperation between member states and encourage bilateral agreements on import/export of hazardous waste within the context of the Basel Convention (BC) and other relevant legal instruments.
  2. Encourage Arab Member States to establish integrated systems and facilities for hazardous substances and waste management, as appropriate, and introduce the concepts of risk assessment and management as well as life cycle assessment (LCA) in tracking chemicals and waste (i.e., “Cradle-To-Cradle” approach).
  3. Catalyze national and regional strategies and enforcement policies to establish sound and safe tracking and management systems of specific categories of hazardous waste components, including health care waste, e-waste, obsolete pesticides…etc.
  4. Campaign for the initiation and establishment of internationally-backed reliable systems and funding means, based on the “ Polluter Pays” principle, to handle military operations and conflict wastes, including remedial corrective actions and compensation  mechanisms.
  5. Advocate founding a regional networking mechanism for registration, information dissemination and expertise exchange in coordination with pertinent regional organizations and Arab experts. 
  6. Support the development of a regional waste exchange program, linking waste producers with those industries (existing or upcoming) that would reuse/recycle the waste in their production processes, in accordance with the provisions of the Basel Convention. 
  7. Promote the implementation of Cleaner Production and Sustainable Consumption (CP & SC) Strategies in the Arab Region, and encourage the establishment of National Cleaner Production Centers (NCPC) as well as launch pilot demonstration projects as a means of achieving environmentally sound management of chemicals and wastes with focus on avoidance and minimization.
  8. Encourage industry (and local communities) in the Arab Region to participate in voluntary initiatives, in the areas of Pollution Prevention and Corporate Social and Environmental Responsibility.
  9. Urge Arab countries to sign (ratify/accede) all pertinent Multilateral Environmental Agreements and conventions (MEAs), such as the Rotterdam and Stockholm Conventions…etc, and adopt the Strategic Approach for International Chemicals Management (SAICM) framework on national levels.
  10. Implement awareness, training and capacity building programmes and campaigns throughout the Arab Region on HWM.
Integrated HWM approach and hierarchy “Cradle-to-Grave”, although efficient in reducing adverse environmental health impacts in the Arab Region, are no longer sufficient in dealing with the escalating masses and complicated characteristics of wastes in general and hazardous wastes in particular. While the hierarchal approach encompasses most reasonable waste management solutions, the preventive strategy of“Cradle-to-Cradle” or zero-waste is the future direction sought in terms of modern integrated HWM. Zero Waste focuses on converting refuse to raw materials and aims to prevent waste by design rather than manage it after the fact. Accordingly, the best HWM option is avoid (or minimize) generating wastes in the first place16; and the best waste management technology to be selected is the design which returns a product to industry at the end of its useful life as raw materials to make equally valuable new products.
The environmental health risks and impacts stemming from hazardous wastes are common to all Arab countries, since the potentially health-threatening components within each waste type are similar. However, the actual risks posed vary widely between countries and communities, as they can be greatly reduced by good operational practices, storage methods, personal hygiene, enforcement of regulations and quality of management, as well as levels of income8. Interdisciplinary research initiatives are needed to improve levels of knowledge on risks imposed to human health from hazardous waste sites. These should incorporate short- and long-term epidemiologic and toxicological studies on specific groups, exposures scenarios to individual chemicals and chemical mixtures; and include transformation, fate and transport, as well as the synergistic and antagonistic effects. Moreover, research must also take into considerations other pertinent factors such as the risk assessment and management approach, risk perception, and socioeconomic and sociologic determinants of health (e.g., poverty, education, malnutrition…etc.). Finally, sound HWM (including HCW management, treatment and disposal options) should first and foremost protect the public health and the population, and minimize indirect impacts from environmental exposures to potential hazardous risks.
 
REFERENCES:
  1. Al-Yousfi, A.B., “Management of Hazardous Wastes: A Regional Perspective”, UNEP-ROWA, Bahrain, June 2003.
  2. Al-Yousfi, A.B., “Sound Management of Hazardous Waste- Principles Overview”, Workshop on Integrated Sound Management of Wastes Generated from the Petroleum Sector, Syria, October 2007.
  3. Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and their Disposal, BC, http://www.basel.int/
  4. Organization for Economic Co-Operation and Development, OECD, Environment Directorate, “Workshop on Waste Prevention- Toward Performance Indicators”, Parts 1 & 2 Reports, France, 2001.
  5. Times Newspaper, Oliver August, Articles “America leaves Iraq a toxic legacy of dumped hazardous materials”, and “US military to punish culprits behind toxic waste dumping in Iraq”, June 2010.
  6. United Nations Economic and Social Commission for Western Asia, ESCWA, “Compendium of Environmental Statistics in the ESCWA Region”, http://www.escwa.un.org/, 2007.
  7. United Nations Environment Programme, UNEP/DTIE/IETC, http://www.unep.or.jp
  9. United Nations Environment Programme, Basel Convention, Report “Regional workshop for Arab states on the environmentally sound destruction of POP and contamination of POP containing waste in the context of the Basel Convention and the Stockholm Convention”, 2005
  10. United Nations Environment Programme, Assessment of Environmental “Hot Spots” in Iraq, ISBN 92-807-2650-1, 2005
  11. United Nations Environment Programme, Lebanon Post-Conflict Environmental Assessment, ISBN: 978-92-807-2794-4, 2007
  12. United Nations Environment Programme, the Center for Environment and Development for the Arab Region and Europe (CEDARE) Study on E-Waste Management in the Arab Region, 2008
  13. United Nations Environment Programme, Environmental Assessment of the Gaza Strip Following the Escalation of Hostilities December 2008-January 2009, ISBN: 978-92-807-3041-8, 2009
  14. United Nations Environment Programme, Regional Paper on “Management of Medical Wastes in the Arab Region” in contribution to the Regional CSD18 Report, 2009
  15. United States Environmental Protection Agency, EPA, “Cancer Mortality in U.S. Counties with Hazardous Waste Sites and Ground Water Pollution”, Technical report, PB-90-245952/XAB; EPA--600/J-89/399, 1989.
  16. World Health Organization, WHO, “Hazardous Waste” Report, 1998, http://www.emro.who.int/CEHA/pdf/HazardousWaste.pdf
  17. World Health Organization, WHO,” The World Health Report 2003 – Shaping the Future”, 2003.
  18. World Health Organization, WHO, “Waste from Health-Care Activities” Factsheet No. 253, 2007.
  19. World Health Organization, WHO, “Technical Paper: Strategy for Cancer Prevention and Control in the Eastern Mediterranean Region” EMRO RC 56th, Morocco, 2009.
  20. World Health Organization, WHO, “Agrochemicals, Health and Environment – Directory of Resources”, http://www.who.int/heli/risks/toxics/chemicals/en/index.html
  21. World Bank, WB, “The Impact of Toxic Substances on the Poor in Developing Countries”, Washington, DC, 2002.
  22. World Bank, WB, and World Health Organization, WHO, “Health Care Waste Management – At A Glance”, 2003.
 
 
 
 
 
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