May 8, 2003

Are people’s fears that disposable syringes are repackaged and sold as new justified or has the issue been blown way out of proportion? Shazman Shariff reports

The stinking garbage dump abounds with hospital waste—syringes, drip bags, blood soaked bandages, filthy cotton balls—all merging with municipal waste, encroaching upon the pavement. Passers by, repelled by the filth, search for cleaner paths to walk on. However, for the astute-looking Khudad, a scavenger, the foul-smelling filth smells of roses as the garbage is his source of livelihood. Everyday Khudad comes to pick things out — including syringes and drip bags — which he later sells. “I have been collecting syringes from dumps for 20 years and sell them to kabaris,” he says, and is unwilling to say more. An old hand at the trade, he sits unperturbed amidst the toxins of a fetid mass of debris. He wipes the used syringes, needles still attached, using whatever cotton he can find from the trash.

It is not solely Khudad’s run of luck that enables him to fetch a large number of syringes from the sprawling trash dump. The area — just outside Civil Hospital Karachi — makes for an excellent location and is combed through by a number of men like Khudad many times a day. Scavengers care little about where this waste comes from. However, it is a different matter altogether for the hospital management, as whatever quantity of syringes and re-useable waste is found here, the hospital’s reputation is dealt a serious blow. It doesn’t help that hospitals are already targeted for unsafe practices and flawed waste management systems.

“It is very easy for the people to accuse the Civil Hospital of malpractice,” said Captain Liaquat Ali, in charge of hospital waste management and also the additional Medical Superintendent. “A single syringe found in the garbage is seen as evidence of the hospital’s sheer negligence. There are countless clinics and dispensaries in the vicinity which are responsible for disposing their waste here.” Captain Liaquat believes that the media’s only concern was to highlight the negative aspects of issues like these and it did little to focus on the hospital’s positive contributions. “When we have got the incinerator why would we throw our garbage on the road?” he asked. “We have written to the KMC to remove the dump from here but there has been no response from them.”

In a country where better health care facilities can only be afforded by the very few, dangerous injection practices have assumed alarming proportions. It is a major cause behind the spread of Hepatitis B and C and HIV. According to the World Health Organization (WHO) unsafe injection usage is the most common cause of HCV infection in developing and transitional countries, causing two million new infections each year and accounting for 42 per cent of cases. Health experts advocate the use of disposable syringes to limit one’s chances of getting infected with pathogens, which enter the body through the re-use of syringes.

However, this precautionary measure has not succeeded in shielding poor patients who still remain exposed to the various risks that accompany the multiple use of a needle. It is only the safe disposal of syringes that can root out the possibilities of its re-use. An effective disposal system is currently not in place because of sheer negligence and an ineffective implementation process, which fails to control the state of waste management at public hospitals and private clinics.

When syringes are disposed of in garbage dumps, scavengers get their hands on them and sell them for a few rupees. The result is that the needles can either end up in a plastic recycling factory or repackaged and resold. Whatever the end result, it is clear that used syringes means big bucks for a few businesses.

Providing details about Civil Hospital’s disposal system, Captain Liaquat Ali said that in accordance with the hospital waste pilot project developed by WHO and Environmental Protection Agency (EPA) three years ago, the hospital’s waste was divided into two categories: non-infectious and infectious (which includes sharp and other waste items). Categorized waste is collected into colour coded bins lined with polythene bags: yellow for sharp objects like syringes, needles, blades, scapula, broken glass and cannulas; red for hazardous and pathological waste dressings, used bandages, cotton, tissues amputated parts and black for non-infectious items like paper bags, boxes and wrappers.

The hospital produces around 500 to 900 kilos of waste every day which is incinerated, reducing it to a heap of harmless ash. Since the incinerator has the capacity to burn 72 kilos at a time, the process takes place four to five times a day. “Earlier, KMC used to collect the garbage and did land filling in far-flung areas but it has now acquired an incinerator as well,” he said.

Highlighting the particular steps the hospital has taken to check the re-use of syringes, Liaquat said that each department has been provided with needle cutters, and nursing staff and paramedics have been trained on the proper disposal of syringes.

Prof. Noshad A. Shaikh, Medical Superintendent of the hospital, expressed his discontent over the disposal system which he believes leaves much room for complaints. “We have a constraint budget to run things here and there might be a leakage in it. We don’t claim to be perfect, but we are trying our best to make things better within the available resources.”

Shaikh provided some statistics, albeit rough, about the hospital which revealed that it received more than 3,000 patients a day, out of which 60 to 70 per cent needed injections more than once. That means its daily consumption of disposable syringes is between 4,000 to 5000. “At Civil Hospital the amount of waste is enormous and we have asked for a larger and more modern incinerator, which costs around 50 to 60 lakh rupees. The hospital also has to burn Lady Dufferin Hospital’s waste and desperately needs the incinerator,” he said.

Touching on the issue of re-packaged syringes, Prof. Shaikh suggested there should be some system of checks and balances concerning some companies’ heinous practices. “The government should authorize reputed agencies to make syringes. Small clinics and hospitals should be provided with incinerators and a strict system of waste disposal should be enforced at these places. In the absence of it, their only option is to throw waste into garbage dumps.”

Captain Liaquat accompanied me to the various blocks of the hospital, to show how the system has been implemented. After a brief hunt, colour coded bins were located in the medical ward. Lying in a corner, two of the three (the third one could not be found) were defaced with paan stains. They had almost lost their original colour, making it difficult to differentiate between the infectious or non-infectious waste bins. One look inside the bins revealed that un-segregated waste was dumped into the bins, meaning that it too had become targets of misuse and neglect.

“It is emptied every day by the sweeper who takes away the bag and puts in a new one,” said the head nurse, trying to cover up the obvious state of negligence. When she was asked to show the needle cutter, she brought one which didn’t work. “You know, we are trying to increase their level of awareness,” said Captain Liaquat, after mildly reprimanding the nurse for not reporting the fault. He pointed at the instruction board hung on the wall, which clearly stated the proper use of the bins, in Urdu and English — a step taken to spread awareness amongst patients and staff.

Giving assurance that his department follows safe injection practice and disposal system, Dr Tariq Kamal Ayubi, Incharge Emergency, said, “We make sure that sharp objects are disposed of properly but we don’t know if some sweeper cheats on us. We receive some 600 patients every day and it is here that syringes are used in bulk. I am positive that our nurses don’t reuse any syringes.” The same opinion was expressed by others at the hospital, which if taken at face value sounded plausible.

However, how does one explain the fact that used syringes were found at the nurses’ counter in an unlabelled box, along side new syringes? When asked why the needles were not cut, a nurse said she would attend to it when she had some free time. This leaves room for doubt over the training that was imparted to paramedic staff and nurses over the proper disposal of syringes. This also gave some weight to the theory that sweepers would have ample opportunity to access them.

The fact that the management of Civil Hospital is trying to change things is somewhat visible. This was clear in the storeroom where one could see brand new bins and bags along with needle cutters and instruction boards for future use. “We have resolved to improve the situation and it will take some time to spread total awareness,” said Captain Liaquat. Due to the hospital’s limited budget, which at times makes it impossible for them to make ends meet, management has introduced a parchi fee system. “We charge one rupee from the patients at OPDs and this money, which amounts to about 3000 rupees daily, goes towards the hospital’s waste management.”

Inside the Sindh Institute of Urology and Transplantation (SIUT), situated in the area of the Civil Hospital, one can feel the obvious difference. Dr Adeeb Rizvi, one of the institute’s founders, is very vocal on the issue of waste management. He said it is imperative for hospitals and clinics to cut down the chance of needle re-use by destroying the needle and incinerating the remaining portion.

Back at Civil Hospital, one could not escape the harsh realities that mar the reputation of government hospitals and gamble with the lives of thousands of needy patients who cannot seek healthcare elsewhere. Inundated with a plethora of problems, the hospital’s shabbiness makes it hard to believe that things are done as meticulously as planned and portrayed, leaving little room for negligence on the part of the staff.

One could not help but get more suspicious of the hospital’s working when a sweeper of Civil was found emptying a heaped garbage trolley clearly marked “CHK” at the nearby garbage dump. It was disconcerting to see that syringes, drip bags and other hazardous items were in it — things meant to be put in the incinerator. When Captain Liaquat was asked to comment on it he preferred not to, saying he had recently taken over and was therefore not in a position to comment.

Apart from the statements fed to the media by official sources as perfect, there are always some stories to the contrary. Sharing his views based on personal experience and observations a doctor said, on condition of anonymity, that while he was employed at Civil Hospital he saw nurses keeping discarded syringes to use after sterilization for the patients who could not afford to buy them. He said that the same procedure was applied to disposable gloves, used to examine different body parts, which were given to sweepers to rewash for later use.

Somewhat similar comments were also expressed by one of the doctors at Abbasi Shaheed Hospital who said that hospital needle cutters were hardly available and syringes were thrown away with needles attached. One can guess where those syringes eventually end up.

The unsafe use of syringes raises valid concern not only because of the hazards associated with their unsafe disposal, but also for criminal misuse, i.e. over-prescription. WHO has found that each year some 16 billion injections are administered in developing countries and, in certain regions of the world, use of injections has completely overtaken the real need, reaching a proportion no longer based on rational medical practice.

In this regard Dr Sharaf Ali Shah, project director at National AIDS Control Programme, said that according to a study, a doctor who runs a clinic in low-income areas like Landhi, Korangi and Lyaari gives injections to all patients who come to his clinic. But the same doctor who goes to his other clinic at night in more affluent areas does not give injections to his patients. It is the level of education and awareness, more noticeable in people from literate classes that spares them from becoming easy victims of the doctors’ follies. Those from low-income areas are duped easily, not only due to a lack of awareness but because of their unshakable faith in the misconception that injections heal rapidly.

“We need to spread awareness and remove the misconception from their minds that injections work wonders,” said Dr Shah. Doctors earn more by prescribing injections and refrain from educating the poor patients about alternative oral treatments.

In a society where a majority is blinded by lack of awareness, the quacks can flourish (it is estimated there are 60,000 in Karachi) and wily medical practioners cash in.

Dr Naseem Salahuddin, head of the department of infectious diseases at Liaquat National Hospital and president of Infectious Diseases Society of Pakistan, gave the example of one of her patients, an uneducated middle aged Pathan woman, whose medical history revealed that she had been frequently given injections from a roadside clinic at Landhi where the doctor used the same syringe on many patients. “Rural people should be addressed through the media as these are the people who suffer most and need to be informed,” she said.

When discussing the role of health care organizations like the Pakistan Medical Association (PMA) in eradicating the level of unawareness amongst people, Dr Shershah Syed, its Secretary said the association imparts continued medical education to patients and spreads its message through the media. “This is what the PMA can do. The government should work effectively to control the malpractices and ban quacks who are mostly involved in unsafe practices.”

At JPMC one expected to see things done in a slightly more efficient manner as it comes under the federal government whereas Civil falls under the jurisdiction of the Sindh government. Patients at JPMC don’t have to worry about buying syringes as the hospital provides them for free. “We have got a seven crore budget for medical and surgical items that includes gloves, syringes, blades antibiotics etc,” said Dr Mohammed Azhar Khan, deputy director of the hospital. Regarding the waste management he said that the hospital has introduced colour coded bins in which waste was deposited and regularly sent to the incinerator. With a daily turnover of 5,000 patients, JPMC has the monthly consumption of 35,000 to 40,000 syringes.

A walk around the wards and brief chats with the nurses brought forth the fact that carelessness prevents people from performing efficiently. For example, it takes just seconds to destroy a syringe using a needle cutter but paramedic staff put off the task for another time. A head nurse in her defence said, “It is impossible to do it immediately since this is rush hour.” Her response was enough to substantiate the fact that it is not just unawareness that cripples our system, but carelessness as well. Dr Zafar Iqbal, Assistant Director Paramedics, who was present when this happened, said that nurses don’t receive a fresh stock of syringes unless they return the used ones with needles cut.

“She is here to watch your khamian (faults)” he said to one of the nurses at a medical ward. However, he looked puzzled when he saw used syringes lying open and pre-filled syringes at the counter. After having a word with the nurses about doing away with this dangerous practice, he said, “We’ll now be in trouble since you will write all this in your story.” Perhaps he realized that things were not done as meticulously as they were portrayed in our meeting at the director’s office.

When asked to demonstrate how a needle is cut, one of the nurses on duty at one of the wards, looked perplexed as she tried to put the needle in the needle cutter but was unable to do it correctly. “Your questions have made her nervous,” her colleague said, while helping her discard the syringe.

Other scenes at JPMC cast further doubts on the working methods of the staff, which was told to be well aware of the procedure of waste disposal. Besides a number of cats found roaming around in the corridors, discarded syringes were thrown carelessly in the pan kept under the patients’ beds. This speaks volumes about the state of neglect at the hospital, which employs 329 people in its sanitation department who are responsible for the disposal of hospital waste.

At the site of the incinerator, installed in 1998, a heap of syringes and plastic bags was seen, which as told by the attendant, was collected to be incinerated. To prove how stringently they manage the waste, he showed a register in which was entered a date, time and weight of the waste brought to the spot. “Although we can sell these plastic items to the plastic industry for re-cycling, we don’t,” said Dr Zafar, adding that recycling of the plastic is not harmful as the smoke emitted during the incineration of syringes and other plastic waste.

Syringes are commonly available at medical stores for three to five rupees and one can purchase them without a doctor’s prescription, which is against the rules. Uncontrolled leniency by the concerned authorities has given confidence to the people to mint money and risk the lives of thousands of people, who go to doctors to get a simple vaccination but unknowingly become victims of deadly diseases.

There have been reports that syringes picked up from garbage dumps or directly sneaked out from clinics and hospitals reappear in the market in new packaging. Dr Salahuddin said that she once bought a brand new syringe, which was from a reputed company, but to her shock it had specks of blood inside. “I have still kept its photo to support what I saw,” she said.

Another health care provider, Dr Seemin Jamali, in charge accidents/ emergencies and deputy director JPMC, narrated a similar experience when the new syringe she bought had some particles inside. Even if one buys a fresh syringe one can never be sure if it has come straight from the company or through some scavenger.

Sources say that repackaging of syringes occurs in areas near Shershah, Korangi, Afghan Basti and other areas of Karachi. However, there has never been any attempt to catch the culprits involved. One of the sources said that in Bazatta line, behind JPMC, where the staff of the hospital resides, there is a kachra ghar, a spot where sorting and repacking of syringes is carried out. These repacked syringes are usually sold at cheap rates or land up in the hands of vendors like Sardar. Sardar was found selling syringes at JPMC in front of the main block and when he was probed for details, he assured me that his syringes were original. He claimed to buy them from Boulton Market and earned a one to two rupee profit on each syringe. “I do it to earn money for my small kids,” he said, adding he had been doing this for the last eight months (The poor man was picked up and sent packing when the hospital authorities were informed of his presence.)

One way to control reused syringes is to declare them ‘drugs’, a system that will facilitate their monitoring. Dr Zafar said that just like surveillance bodies check the way drugs are manufactured and sold, the same can be done to syringes to ensure strict quality control.

Besides scavengers, drug addicts eye garbage dumps in their search for needles. One of the doctors told The Review that addicts cannot afford to buy a fresh syringe and when they have easy access to the syringes found lying in the dumps, they need not worry about stealing money from somewhere in order to get a syringe. “They use the same injection on each other and keep injecting it in their bodies until the needle is broken or gets damaged,” said the doctor. “It is not just heroin that enters their bloodstream but deadly viruses are transmitted along with it.”

In light of all these hazards of disposable syringes, recently there have been some suggestions to use auto disposable syringes that are automatically rendered useless after one use and are much safer than ordinary ones. Commenting on this Dr Shah remarked that auto disposable syringes were five times more expensive than the common syringe. Moreover, such syringes only prove to be useful when they are needed in bulk like for immunization purposes. He reiterated his belief that the main emphasis should be on educating people about rational use of injections. “Don’t put fear in their hearts; it is not recycling that should be our concern but rational use of syringes,” he said. This is one of the many effective steps that need to be taken to discourage people from believing that their ailments can be cured by an injection.

“More than 95 per cent of the injections given are unnecessary”

Q: Why is a proper disposal system of syringes not followed at hospitals and clinics?

Q: Should a law be enacted to check the re-use of syringes?

A. A law can be of some help but it is the spread of awareness among the people which will help control the situation.
 

Q: What has the National Aids Control Programme done to educate people regarding the misuse of syringes?

A: We run ads in the print and electronic media on issues like safe sex, unsafe blood transfusion and the unsafe use of syringes as well. We also hold awareness programmes, seminars for youth, media, doctors, nurses, sex workers, truck drivers and drug users.
 

Q: Have you observed any change?

A: Yes, indeed. People have started questioning whether they are being given fresh syringes. For example I went to Khipro, a deserted area in interior Sindh to visit an eye camp. At such camps they usually give local anesthesia to all patients using a syringe of about 25cc. One of the workers came to me and pointed out that the same syringe was being used for everyone. When asked where he learnt about this, he replied he had seen it on TV. We have found that the sale of disposable syringes has increased since people use new syringes and the use of glass syringes is on a decline. And besides, patients are asking for alternative treatments to avoid unnecessary use of injections.
 

Q: Are you aware about used syringes being repackaged?

A: This issue has been blown out of proportion. There could be some truth to it but chances of re-use or re-packing are minimum. We have tracked syringes from Civil Hospital to Shershah. Mostly sweepers sell syringes to plastic waste dealers, or kabaris for a few rupees per kilo. These items are then molded to make buckets, lotas and hangers.

There are chances that there might be some people who clean a syringe and wrap it to sell it to the medical stores but what is the margin of profit? It is just a three rupee syringe. These syringes are sold at half prices to medical stores so the profit is minimum. Money has to be spent on it as people have to be paid for cleaning and re-packing and if they are sold at half rates then why do it? I don’t think it is happening but this issue can be investigated.
 

Q: There have been reports about people buying new syringes which had specs of blood or some particle inside. Are you aware of them?

A: Do you think these are authentic reports? Can they be verified? We have heard a lot of stories. There may be some possibility but the setback we get due to these rumours is enormous. People think that every disposable syringe sold at medical stores is contaminated. Newspapers carry reports without verification. Let’s suppose that 100,000 syringes are sold in one day in Karachi; maybe two per cent are contaminated but 100 per cent doubt has been created. I feel chances are very low, but we have planned a study to verify this claim.
 

Q: How safe it is to use products made from the plastic of syringes and drip bags?

A: When the plastic waste is used to make other items, chances of survival of any living organisms or germs is impossible.— S.S.