t a strip mall in midtown Anchorage, a woman is getting inked with her first tattoo. Nearby, someone uses a midday lunch break for a teeth cleaning. Across town, a trembling puppy gets its first immunization shots, while just down the road, someone receives life-saving chemotherapy.

Each experience produces medical waste—tubing, gauze, needles, and more—all of which must be treated and disposed of in a precise, safe manner.

Many large medical hospitals and facilities handle their own waste. For smaller medical offices, veterinarians, tattoo parlors, Botox clinics, dentists, rural providers, and others, medical waste disposal is a niche industry composed of three licensed businesses in Alaska: Entech and Alaska Medical Waste are headquartered in Anchorage, and Safety Waste Incineration is based in Wasilla.

One thing all three have in common is strict regulation.

“There are numerous agencies involved, from the transportation side of medical waste to the processing of the waste itself to incineration and air quality,” says Jonathan Fries, site manager for Entech. “This is different from handling normal garbage for sure. There is a lot of paperwork. You’re limited to what you can do with the waste and how it has to be handled. Compliance-wise, we want to make sure we’re 100 percent doing it the right way.”

The three Alaska-based licensed facilities submit regular reports to the Alaska Department of Environmental Conservation (DEC). The department only regulates medical waste treatment facilities that are not contained within a hospital, medical office, laboratory, or other medical or research institution. Because many of the state’s largest healthcare facilities, such as Providence and Alaska Regional hospitals, process their own waste, the total volume of medical waste produced annually in Alaska is impossible to quantify, says Kaylie Holland, Southcentral and Western Facilities Regional Manager for the Solid Waste Program at DEC.

The three DEC-regulated facilities can report annual waste amounts either in volume in gallons or weight in tons, Holland says. In 2021, the three companies reported receiving, treating, and disposing of 211,017 pounds and about 1.3 million gallons of medical waste.

Entech is the largest of the three and has been around the longest. Founded in the ‘90s, the company was purchased by Waste Connections, a larger waste management company, in 2012.

“We operate the majority of the time in the Anchorage area, but we do cover the entire state—everywhere from the North Slope to Juneau, Sitka, all over,” says Fries. “We do pickups at hospitals and clinics. We do everything from dentist offices to tattoo parlors to veterinary clinics. For the most part, we’re talking about anything that came into contact with patients: blood, tissue, and any byproducts of medical procedures.”

State statute defines medical waste as “laboratory waste consisting of discarded cultures and stocks of infectious agents and associated microbiologicals; pathological wastes; selected isolation waste; used and unused discarded sharps; animal waste; human blood or blood products; and other wastes defined” as regulated waste.

This includes any “foreign garbage,” Fries says. “Any food-related trash that comes into Alaska on a ship or plane is processed just like medical waste—so the food from an inbound China plane, or a foreign cruise ship. The ham sandwich that comes from Japan gets treated with the needles from the local clinic.”

On a recent weekday, the Entech facility in South Anchorage was bustling with a usual day’s workload. Workers wore high-vis neon vests and puncture-proof gloves. An Entech truck arrived after conducting pickups, packed with red plastic totes weighing about twenty pounds each, labeled with biohazard warnings and “UN3291”—the US Department of Transportation coding for the waste within.

The totes’ contents were loaded into giant wheeled bins and moved via forklift into an autoclave unit.

The autoclave “is basically a huge Instant Pot,” Fries says, and it does resemble that, if an Instant Pot was the size of a large van.

“The autoclave basically steam-cooks and sterilizes the waste,” Fries says. “People think we burn everything, and I think they’d be surprised to find that, with a majority of medical waste, we are not allowed to burn; we have to autoclave.”

Facilities have a time limit for how long they can keep waste on site, and there are set times when treated waste can be delivered to specific landfills. At landfills, medical waste has its own disposal area and is immediately buried by a bulldozer.

“Staff are specially trained to manage it,” Fries says, “and regular people will never come into contact with it.”

There are two autoclaves in Entech’s big bay garage, but the older one, dating back to 1984, is rarely used these days. It ran on a gravity sterilization cycle, which meant steam was pumped in, displacing ambient air. Someone would have to monitor it throughout the waste cooking process and manually release steam to adjust as needed.

The newer version—Fries’ “Instant Pot”—is more hands-off and efficient, using vacuum sterilization: it dynamically removes ambient air from the chamber, allowing steam into areas it would otherwise have difficulty penetrating, for an overall more reliable sterilization process with shorter cycle times.

“You can push the button and walk away,” Fries says. “It’s way more efficient and way fancier.”

Not all medical waste is steam cooked: waste related to chemotherapy or pathology must be incinerated. At Entech, two incinerators sit on concrete pads outside, able to burn these products, which arrive in their own special, yellow sharps bins. One incinerator is older and rarely used, while a newer, shinier version offers more dependability.

Normally, the autoclave and incinerator run four days a week, and “when it’s busy enough, we can cook five days a week,” says Fries, who started out as a worker on the more traditional side of the garbage industry before moving over to Entech.

Tony Cange, owner of Alaska Medical Waste, entered the medical waste industry because he saw opportunity. With a background in government contracting, Cange was working for a Native corporation and saw a bid for processing large medical waste volumes.

“All these bids are public record, so I started looking at other bids—JBER, Eielson, the VA, all these bids I could get data from,” Cange says. “I realized this was a big market here in Anchorage and one only served by two other businesses at the time.”

Cange truly started from scratch: his first client was his own dentist.

“It wasn’t an overnight success,” he says. “It took several years to build that client base. We’ve grown exponentially year over year. In one year, we had 100 customers. It took two years to get the other 100. Then, volume-wise, we’ve gone from 2019 when we processed 45,000 pounds of waste to 2021, the latest year we have data, when we processed 211,000 pounds of medical waste. For 2022, we’ve already passed what we did last year in terms of volume.”

Alaska Medical Waste has about 20 percent of the market share today. Clients include Anchorage-area clinics and surgery centers, rural clinics, and a VA hospital. COVID-19 testing facilities needed waste support, which offset any short-term business upsets when other medical-related businesses closed during the pandemic.

“Anything that has potential for being infected with some sort of infectious disease needs to be treated,” Cange explains. “Dialysis clinics, veterinary clinics, if you’ve gotten Botox—there are so many businesses that are impacted, and it affects just about everybody.”

Cange says the industry’s heavy regulation environment tends to limit competition and startups. There are specific employee training requirements and many evolving rules around how waste is transported, stored, steam-bathed, disposed of, and more, he says.

“What customers don’t see is the regulatory side of things and all the training and safety we undertake,” Cange says. “There’s so much that goes on behind the scenes. The businesses have to go through so much to get a permit and keep a permit.”

Looking forward, Cange still sees opportunity to build more clientele. Anecdotally, he’s seeing more business supporting surgery centers. The anti-aging industry is also growing in Alaska.

One thing he’s learned is that on any given day, there’s no shortage of tissue, tubing, needles, and more that need to be safely disposed of from all corners of Alaska.

“I see this industry being recession proof,” he says. “Everybody needs to go to the dentist. Everybody needs to go to the doctor. And the trash does not stop. The trash has to get picked up, and it just keeps coming.”