Amnesty Magazine


Lethal Injection: When Medical Devices Kill


Every year the reuse of dirty syringes infects millions of people with AIDS and hepatitis and causes 1.3 million early deaths and 26 million years of life lost.

BY WILLIAM CARLSEN

William Carlsen is a former reporter for the San Francisco Chronicle who has written extensively about the origin of AIDS and the dangers of syringe reuse and accidental needle sticks.

It is the worst kind of irony. Hundreds of Romanian children have been infected with AIDS; thousands of Egyptians have been given hepatitis C leading to liver cancer; a million Chinese were infected, almost simultaneously, with HIV, and millions more—in one province, more than half the population—have been put at risk of chronic liver disease and early death from hepatitis B. These blood-borne infections come though a single source: needles and syringes that have been used and reused during vaccination campaigns, blood collection, and medical treatments. The hollow steel hypodermic needle—a simple medical device with the potential for saving millions of lives—is cutting a swath of death and disease across the globe, hitting Asia, Africa and Eastern Europe the hardest.


Boy from a Naibori slum earns his living by scavenging for medical and other waste in a dump. (© Robert Maletta)

The World Health Organization (WHO) calls unsafe injection practices the “plague of many health systems.” It estimates that every year the reuse of contaminated needles and syringes causes at least 1.3 million preventable deaths, a loss of 26 million years of life, and an annual burden of $535 million in direct medical costs.

“Poverty and inequality prevent those on the margins of society from accessing the information and services they need to realize their basic right to the highest attainable standard of health,” says Viena Colucci, AIUSA's director of Membership Networks Program. “The International Covenant on Economic, Social and Cultural Rights obliges all governments to provide effective prevention, treatment, and care to all without discrimination. It also obliges the international community to assist in that effort.”

The statistics for AIDS and hepatitis are staggering. Annually, dirty needles infect up to 160,000 people with HIV and cause millions of new cases of hepatitis B and C, according to WHO. These numbers are certain to rise because the full effects of hepatitis B and C do not appear until years, often decades, after the initial transmission. The worst hit are young adults, who are now being cut down from non-sterile vaccinations and other injections they received as children when they were most vulnerable to these viruses.

Behind these numbing statistics are the human tragedies. New York Times reporter Elisabeth Rosenthal wrote a searing portrait last summer of a Chinese village devastated by an AIDS epidemic spread though non-sterile practices at blood collection centers. Starting in 1992 hospitals, clinics and groups affiliated with the military opened collection centers across Henan. Impoverished farmers in the central China province rushed to sell their blood. Collectors often pooled the blood, extracted the plasma, then re-injected the remaining red cells back into the sellers. As a result, Rosenthal reported, a large proportion of the adult population of some villages is now ill with AIDS and dying en masse. A million farmers may be infected, according to some experts, although Chinese officials put the figure at 30,000. Reused blood collection needles, as well as the reuse of other needles and syringes during medical treatment—a common practice in rural China—have almost certainly accelerated the epidemic.

The human and economic impact in Henan has been devastating. In early 2001, there were no orphans in one village. A year later, there were 20, and many families now have one parent dead and the other sick with AIDS. The number of families living below the official poverty line in a single Henan county soared last year from 40,000 to 270,000, according to statistics quoted by Rosenthal. Houses that were built with the money from blood sales are emptied of furniture used to pay for medical bills. In some families, generations of adults are dying in anguish with no money for painkillers. Farms go untended. Children leave school to support a dying parent, and live in hopeless poverty. “I have no future,'' said one 14-year-old who has cared for her 10-year-old brother since her parents and other relatives died.

The suffering in China is being repeated throughout Africa, Asia, and other developing regions of the world. Not surprisingly, there is a huge discrepancy between rich and poor countries. In the United States and western Europe, which began switching to disposable needles in the 1960s, one-use needles are affordable; they are routinely used once and discarded safely. In the impoverished developing world, however, where syringes and needles have always been in short supply, medical workers have relied on durable reusable syringes that could be sterilized between uses. Although WHO immunization programs have provided specialized steam cookers in the field, the organization's field surveys have shown that the needles are often not heated long enough, or gaskets break, or fuel to run the steamers runs short.

Over the last decade, cheap, disposable needles have started flowing into poor nations, pushed by global syringe manufacturers like Becton Dickinson. But when money is desperately short, even a 5-cent syringe is too precious to throw away after only one injection. So people are routinely taking needles that were not designed to be used more than once and washing them in water, or not even trying to clean them, and using them on one person after another.

In worst-case situations, children roaming municipal dumps in India, Pakistan, and Kenya gather used syringes from discarded hospital waste, then sell them to syndicates that repackage them without adequate sterilization and market them at substantial profit. “Everywhere you go you see young kids, boys and girls, rag pickers, picking up disposable syringes, urinary bags, catheters, all kinds of medical waste and laying them out by size,” says Dr. J. M. Mehta, vice-chair of Serum Institute of India. “The syringes come back onto the market nicely packaged, with a lovely label on them, and millions of people in India don't know they are being injected with used syringes.”

There is plenty of blame to go around. Health experts have known for nearly two decades that non-sterile injections pose a significant global problem, but they were at first reluctant to go public for fear of turning people away from immunization programs. Peter Evans, a WHO official studying the problem, said that he and his colleagues had initially “low-keyed” the crisis to protect the vaccination programs. Another WHO official, Michel Zaffran, said: “We wanted to avoid creating a panic” until there was solid data about how serious the problem was.

Finally in the late 1990s, WHO started documenting the extent of the crisis and pushing for solutions. For more than a decade, the organization had been working with technicians to develop “auto-disable” or AD syringes, that automatically jam after a single use. AD models have been available since the late 1980s, yet donor states and organizations, manufacturers, and agencies including UNICEF, which supplies syringes for global immunization campaigns, have been slow in making them available.

“It's inexcusable that these diseases are still being spread,” says Joel Schoenfeld, a small New Jersey manufacturer who developed one of the first AD syringes. “Donors can make a difference,” he said, noting that the slightly higher cost of the ADs isn't the impediment. “It's ignorance and stupidity and corruption. The money is there and the donors need to insist that only AD syringes be used for immunizations.”

Becton Dickinson, the dominant player in the global syringe market, was also slow to take up the challenge. In 1986 WHO put out requests for new syringe designs. Instead of spending money to develop its own AD syringe, Becton Dickinson waited until 1989 when it agreed to take over several AD designs developed—with U.S. taxpayers' money—by a Seattle non-profit group. When the giant U.S. corporation finally jumped into the AD market in the mid-1990s, it squeezed out most of the smaller manufacturers, but failed at first to produce enough AD syringes to meet the demand from UNICEF for global immunization programs. Today, however, the company is the largest producer of AD syringes in the world.

Critics also say that many global health experts are still in denial—or worse—about the risk of non-sterile needles. “We've been warning UNAIDS people about the higher risks for two years now,” says David Gisselquist, a co-author of a recent study that found that needle reuse may be much more important in spreading HIV than previously thought. Gisselquist is a World Bank consultant who has traveled extensively throughout Africa, calling for HIV prevention programs to promote safe injections as well as safe sex. He says that in Romania, Russia, and China, where HIV outbreaks have been traced to non-sterile medical practices, authorities have taken direct action to stop it. “But in much of Africa, UNAIDS officials advise their employees to carry sterile injection equipment for their own use while telling patients to go to clinics for medical injections or blood testing,” he says. “That's the level of hypocrisy.”

Despite impediments, groups of dedicated individuals have made progress and moved the needle reuse issue to the top of the agenda at many global health meetings. Bill and Melinda Gates have used the clout of their Children's Vaccine Program to insist that clean injections and AD syringes be a priority worldwide. WHO and UNICEF are moving to ensure that all immunization campaigns include enough needles and syringes to eliminate the need for reuse.

Immediate prospects, however, remain grim. Most of the efforts have been made in the area of vaccinations, which represents only 3 percent of the 16 billion injections given each year. The vast majority of shots, containing vitamins, antibiotics, and other medications, are administered by village healers, community pharmacies, and poorly trained and equipped doctors and nurses.

And the lack of needles and syringes is only part of the problem. Injections per capita are dramatically higher in developing countries than in industrialized nations. In many cultures, shots represent modern medical technology, and people don't believe they have been adequately treated unless they've received one. Healers, pharmacists, and doctors also profit substantially from administering injections. In many countries in Africa and Asia, according to WHO studies, more than half of all outpatient visits result in a shot, and more than 70 percent of these were unnecessary or could have been replaced with equally effective, and usually cheaper, equivalent oral medications.

While vastly increasing the supply of needles will ameliorate some problems, it will exacerbate others. Even when needles are reused dozens or even hundreds of times, disposal is a serious concern. But providing a new disposable syringe for every injection now being given will multiply the problem. Communities without the mechanisms to prevent black market recycling or the technology to protect the environment will have to find ways to safely dispose of billions of additional plastic syringes. Improper burning of plastic, for example, releases toxic chemicals, including dioxins.

Slowly but steadily, international efforts to confront the complex crisis are increasing. Leaders of WHO, UNICEF, and the International Red Cross and Red Crescent Societies issued new guidelines in 1999 urging countries to shift to AD syringes in all immunization programs by the end of 2003, and requesting that all donors cease funding for standard disposable syringes. These officials have also proposed “bundling” the same number of vaccine doses and AD syringes together in a puncture-proof “safety” box that can be filled with used syringes and then buried or incinerated. While these measures are mandatory for UNICEF and WHO programs, others are free to ignore the guidelines.

The NGOs argue, however, that health ministries that absorb the higher initial costs will ultimately save money. The extraordinary medical burden from hepatitis and HIV alone, means “that each unsafe injection costs governments between three and five times the extra cost of auto-disable syringes, not to mention the toll in human suffering,” says British health official Dr. Sobhan Sarkar.

Safety Injection Global Network (SIGN) a worldwide network of medical and technology groups, donors and financial institutions, has also sprung up to focus on eliminating needle reuse. The group mounts national information campaigns and works through medical societies to educate doctors, nurses, and health officials in developing nations about the crisis.

“Awareness of the problem is now very high, and everything is moving much faster than we ever thought it would,'' said Scott Wittet, an official with the Gates-financed Seattle foundation. He added that the battle will not be won until needle reuse is also eliminated in the huge number of therapeutic injections. Wittet and other SIGN members say that goal will require mass behavioral change.

The stakes are enormous and growing every day. UNAIDS predicts that by 2010 China will have 10 million HIV cases. India is facing an explosive epidemic of HIV. Hepatitis C, for which there is no vaccine or practical cure, is coursing at an accelerating rate throughout Asia and Africa. People infected with these deadly viruses will become ever-expanding pools of new infections if needle reuse is not stopped.