India struggles to quash dirty syringe industry
===============================================

* Natalie Alcoba

In Okhla slum, the medical quacks — unlicensed medical practitioners — know what to say when they’re asked about syringes: use once, and only once; break immediately. They make a snapping motion with their hands to impress how they destroy a device. One proudly shows off a syringe cutter and a dispensing drawer full of snipped-off ends.

But in India, where vast swaths of the urban population live in slums and a third are illiterate, experts say the reuse of syringes is rampant —and deadly.

The World Health Organization estimates that 300 000 people die in India annually as a result of dirty syringes. Across the world, that figure is 1.3 million.

A landmark study, Assessment of Injection Practices in India — An India-CLEN (Clinical Epidemiology Network) Program Evaluation Network Study, presented at a conference in Mumbai, India in 2005, indicated that 62% of all injections in the country were unsafe, having been administered incorrectly or “had the potential” to transmit blood-born viruses such as HIV, Hepatitis B or Hepatitis C either because a glass syringe was improperly sterilized or a plastic disposable one was reused.

The IndiaClEN study, sponsored by the Indian Ministry of Health and the World Bank, also pointed to a shocking failure to properly manage health waste — more than a third of plastic syringes and needles were not properly disposed of in Indian hospitals and clinics, along with more than half of the injection waste.

Those startling figures prompted the United Kingdom-based nongovernmental organization Safe Point Trust, to press the government for legislation mandating the use of auto-disposable syringes.

The government says it has been trying to get hospitals to switch over to auto-disposable syringes since 2007. In 2008, it issued another order directing public hospitals and clinics under the Central Government Health Scheme to switch to auto-disposable syringes by May 2009.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/181/1-2/26/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/181/1-2/26/F1)

A study sponsored by the Indian Ministry of Health and the World Bank estimated that over a third of plastic syringes and needles, and more than half of injection waste, are not properly disposed of in Indian hospitals and clinics. Image courtesy of Reuters/Tanushree Punwani

But in a country that has significant gaps between legislation and enforcement, practices often change slowly.

“A few states already have, some states are saying ‘no we’re not going to do it,’ and a few are just in the process,” says Marc Koska, founder of Safe Point Trust.

Koska has designed an auto-disable syringe that prevents reuse by locking the plunger in place after one injection. But while his company, Star Syringe, has grown globally and rapidly in the last 5 years, the Indian manufacturer of his product has seen no increase in sales in India and in fact has been exporting to African countries.

“I kept observing that it wasn’t as simple as the product. It also involved public awareness and waste management,” says Koska, who last fall crisscrossed the country as part of a campaign that was estimated to have reached 509 million through print and broadcast advertising.

The magnitude of the challenge appears enormous. For example, in April, following a hepatitis outbreak that killed more than 80 people, the western state of Gujarat announced it would switch over to auto-disposable syringes.

Yet, this is the same state that garnered headlines for uncovering warehouses bursting with used syringes, highlighting the gargantuan task that officials face in quashing an informal industry that thrives on the mismanagement of health waste.

Ragpickers — the name given to poor people who recycle trash for a profit —sell used syringes for US12-cents a kilo to companies that repackage them and make them look like they’ve never been used, Koska says.

Syringe manufacturers and health practitioners say the increased cost of auto-disposable syringes is a barrier to use, but Koska says the 2.5-rupee (6-cent) price tag isn’t prohibitive and doesn’t wholly explain the willingness to use unsafe needles.

“It’s incompetent supply lines. It’s bad stocking. It’s just a continual atmosphere of reuse, where they believe that everything has a second life,” Koska says. “There’s only so much you can do, and you can push and push and push. What I don’t want to do is try and be a nanny to India. I think we provided some good stimulus and this is really the last phase of that campaign.”

As he walks through the Okhla slum, Safe Point official Atul Sharma says the average unlicensed practitioner wouldn’t publicly admit to reusing syringes.

Along the slum’s main drag, a handful of storefront medical centres — each the size of a modest walk-in closet — are crowded among the barber stalls and candy shops. Each kiosk typically features a professionally dressed quack equipped with a stethescope, a vial atop his desk and a wall of over-the-counter medications.

After years in the business, they have often a measure of local trust, says Sharma.

But the combination of used syringes and unlicensed medical practitioners can be lethal, he adds.

Passing a dumpsite littered with opened packages that once contained syringes, Sharma urges caution, although no needles are immediately evident within the trash.