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Against everything she has been taught

March 22, 2009 -- Today the Sunday Times (U.K.) ran a long feature by Amy Turner about the harm that used needles cause in India, where they kill an estimated 300,000 people each year. Most of the piece is devoted to general discussion of the problem, with comment from corporate and non-governmental officials involved with global safe injection efforts. But there is also the story of a nurse at a Delhi hospital who is deeply distressed because she regularly gives injections with used needles she knows are unsafe. Apparently she does so because she feels it would be pointless--and endanger her employment and social situation--to question the revered physicians and hospital managers who insist on the practice. The report does not explore potential measures to address that power imbalance, focusing instead on technological efforts to reduce the epidemic, mainly "auto-disable" syringes. It would have been useful for the reporter to interview not just a guilt-ridden nurse, but also a physician who might defend the use of such needles or otherwise comment. But the piece does highlight one striking example of the harm to global health that occurs when nurses feel they lack the power to advocate effectively for their patients. We thank Ms. Turner and the Sunday Times.

The article is "Used needles are causing a health crisis in India." All over that nation, "children scavenge in the filth for discarded syringes to sell back to hospitals and quacks." Turner describes such a "quack" giving an injection in a New Delhi slum, then adding the needle to a "grimy pile" of needles, some of which have been used so many times that "crusts of flesh are stuck to them." The piece reveals an unfortunate factor driving the problem:   In some nations, many people believe that injections are "a miracle cure" for whatever ails them, a piece of advanced health technology to which they are fortunate to have access. In settings like these, deadly infection is rife, with common problems including HIV and hepatitis B and C. The report says that worldwide, about 50 billion syringes are manufactured each year--syringes that should be disposed of after one use. The piece says that of the 12 billion "medical injections" given annually, an estimated 40% are unsafe. And the World Health Organization estimates that 1.3 million people die worldwide each year from unsafe health care injections.

The article also spends significant time discussing responses to the problem, which it says have been hampered by lack of awareness and the sense that the issue is not as "sexy" as other health issues, like immunization. It describes the work of a U.K. charity called SafePoint, which has sponsored a massive campaign to increase awareness of the problem in India. The report says the campaign has spurred the Indian government to begin taking some actions to address the problem. The article's main source is SafePoint chairman Marc Koska, who also has a company called Star Syringe. The piece reports that in 1997 Koska patented a design for an "auto-disable" (AD) syringe called the K1, which features a plunger that locks on the first use and cannot be re-used. Star Point sells about 700 million of these each year, and as the report notes, the company benefits from the increased interest in AD syringes that SafePoint promotes. AD syringes no longer cost much more than the traditional kind. But of course reusing a syringe makes if far cheaper, and because of the complex factors in the health equipment market, there have so far been inadequate incentives to adopt the AD technology. AD makers are reportedly fighting for the market for immunization campaigns, which do use AD syringes, but that is only 5% of the total needle market. The item reports that a draft WHO recommendation urges governments to mandate the use of AD syringes for all injections, including therapeutic ones, but the recommendation has not yet been implemented.

The piece emphasizes that the problem is not just "quacks" in "slums":

Private and government hospitals are also reusing syringes. Thousands of people are entering hospitals with minor ailments and leaving with life-threatening infections because practitioners won't spend money on new equipment, or simply don't know any better.

And this is where the nurses come in. In noting that the Indian government's response to the problem is still inadequate, the report says that "SafePoint has recently filmed three nurses at a government hospital, administering injections to multiple patients with the same syringe." And the only person the feature describes in any detail who actually confronts the issue at ground level--the only clinical health worker--is 24-year-old Delhi hospital nurse "Neela" (a pseudonym). We hear about her after the reporter wonders why "trained medical staff flagrantly disregard basic rules of infection control." Neela feels "terrible" injecting patients with dirty needles that could harm them, a practice that "goes against everything she has been taught." Why does she still do it?

We're told to. They tell us to use the syringes sometimes two times, three times, 10 times. I have seen them reused 30 or 40 times. ... It's for many reasons... They are accustomed like this -- they have practised this way always, and they will continue. It may be they think if they reuse [syringes] they will save money. But it's also a way of mind. It's not just syringes: they will cut the cord of the baby, and reuse the instrument next time. ... I didn't argue with [my employers] because I knew there couldn't be [a different] outcome. There is no point. ... I knew it would be happening [at a different hospital too]. Many private hospitals reuse. I talk to a lot of my friends who work [in them].

The piece says Neela believes the "way of mind" is the biggest problem. Commendably, the article also provides helpful context about the difficulty of Neela's own situation:

In India it is considered dishonourable to criticise the medical profession. Doctors are among society's most respected and important people. Furthermore, Neela is of marriageable age, and a nurse is quite a catch. Speaking out against her employer could cost her her job, disgrace her family and sabotage her chances of a good match.

The piece stresses that Neela "sounds horribly distressed. She is a clever girl and a dedicated nurse, facing the reality that the turning of a blind eye might be fatally ingrained in the system of her chosen profession, and possibly her culture." The needle maker Koska, who has reportedly spent decades on this issue, does not sound as interested as the reporter is in exploring the underlying reasons for actions like Neela's. He is quoted as saying that he "can't understand"--"how can she go on giving injections, knowing she might be infecting patients? Killing them, basically. Is a life so cheap?"

The piece gives a fairly good sense of why a nurse like Neela might go on giving unsafe injections, relating it even to her marriage prospects, though we are not sure nurses are always considered "great catches" in South Asia, where some reportedly consider them to be like prostitutes. The nurses' situation would seem to have a lot to do with the fact that the vast majority are women, with far less social power--which the report does not discuss directly. In fact, to the extent nurses are seen as less than respectable, it would make their social and economic situation even more tenuous, and actually increase the risks involved in questioning powerful persons. The piece notes that Neela is a "clever girl" with health care training, as it mentions "everything she has been taught." And although the report makes clear that Neela is not advocating for her patients, that she is "turning a blind eye," it is possible to see her willingness to speak with the reporter as a kind of patient advocacy. She is at least helping to make the world more aware of the problem. The fact that she feels compelled to use a pseudonym underlines the risks she feels. And in a sense, the very fact that the journalist would assume that it might be Neela's job to stand up for her patients and stop this practice implies that the journalist has some expectations for nurses.

Of course, including Neela's story and that of the three nurses SafePoint filmed--with no comparable anecdotes about the physicians and hospital managers who reportedly drive the unsafe needle practice--would seem to overemphasize the role of professional nurses in the epidemic. If nurses like these feel unable to reduce the practice, then what about focusing on the more powerful hospital physicians and managers who are reportedly the root cause of the problem? Where is the interview with them? The piece concludes by asking readers to

imagine a world where transmission of HIV and hepatitis through needle-sharing is virtually eradicated, and even the ill-educated cannot unknowingly contract deadly diseases from the doctors in whom they place so much trust.

The piece should have asked an Indian physician who enjoys this "trust" to explain what he or she is doing to earn it with regard to injection practice. And the report's suggestion that "turning a blind eye" to these health problems is "fatally ingrained" in nursing is clearly wrong, though it may be sadly common in some places due to prevailing social and economic factors. Many nurses do speak up for their patients, and thereby save lives.

On the whole, the article offers a compelling look at the relations among nursing, medicine, and dangerous health practices, particularly the risks when nurses feel unable to advocate for patient safety. We thank Amy Turner and the Sunday Times.

See the article "Used needles are causing a health crisis in India" in the March 22, 2009 Sunday Times (UK) by Amy Turner.


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