Editor’s Note: Dr Arshad Altaf is an HIV and injection safety expert and works as a consultant for the World Health Organization (WHO). The opinions expressed in this article are his own.
Patients in Pakistan like to receive injections. They believe that without an injection the treatment, even for minor ailments, is incomplete.
Doctors in Pakistan like to give injections to satisfy patients. Providers can also make extra money by adding an injection to the prescription, even when the ailment can be treated with pills or other medicine.
In poorer areas of the country, some providers reuse syringes in order to cut corners and save money.
That is why the unfolding scandal in Ratodero, a city in Pakistan’s southeast Sindh province, where almost 1,000 people have been diagnosed with HIV thought to be caused by unsafe needles – as horrifying as it is – shouldn’t come as a great shock.
Media coverage has focused on that city and the particular providers involved, but the reusing of needles, often for unneeded injections, has contributed to a growing crisis on a national scale.
Pakistan has seen multiple outbreaks of hepatitis B, and has one of the highest burdens of hepatitis C infection in the world, largely due to the continued use of unsafe injections.
Hepatitis can lead to numerous complications, but it is not usually deadly, unlike HIV which in poorer communities can often develop into AIDS and prove fatal.
Pakistan’s HIV rate has been steadily rising since 2000, in part because many prevention programs focused on syringe and needle exchanges, disease and condom awareness never got off the ground, or even when they did, were unable to attract sufficient support to make much of an impact.
Treatment for HIV is provided for free in Pakistan, but it can only be effective when those infected with the virus are aware of their status.
The steady spread of the virus through reusing needles, combined with a lack of prevention programs and awareness has resulted in the infection level reaching a dangerously high level among at risk populations.
Among intravenous drug users, the prevalence of HIV has been documented at 38%, while the rate among transgender sex workers, another at risk population, is above 10%.
Tackling the crisis
In Pakistan, a large proportion of primary health care is carried out by private providers.
There has been a mushrooming of the private sector in recent years because of myriad problems within the public health system, most prominent of which was the closure of the majority of government health centers around 2 p.m. each day. This meant working people had no choice but to visit private providers in the late afternoon or evenings.
Unfortunately, unsafe injection practices are common at private clinics and dispensaries. In areas where literacy rates are low, many times the patient may not even know if the provider is trained or licensed to practice medicine. There is hardly any concept of infection control, and the reuse of syringes and needles at blood-stained preparation counters is a common sight.
This has led to numerous outbreaks of both hepatitis B and C, and in more recent years, the spread of HIV among previously low-risk communities.
Larkana, another city in Sindh province, has seen three HIV outbreaks in the past 15 years. The first, in 2004, was among intravenous drug users. The second was linked to a dialysis center in 2016, while a third one earlier this year was due to the reuse of syringes and intravenous drips.
Other cities have experienced similar issues. The only thing that is unique about the Ratodero outbreak is the media frenzy surrounding it. Much of this has focused on a single provider, but the issue is a systemic one that will not be solved by banning one doctor.
To prevent future outbreaks, there needs to be a major overhaul of Pakistan’s health care delivery system. Regulatory authorities must crack down on quack practices of all types, and ensure providers are trained and licensed. Government-run primary health centers must remain open for longer to provide services to patients and communities when they need it.
There is also a need to increase awareness among patients and communities about the risk of reusing syringes, as well as for men visiting barbers to ensure that new blades are used for shaving purposes.
AIDS control programs must also work out a strategy to identify as many people living with HIV as possible, and give them access to the proper medicine, as well as improving prevention programs among at risk populations such as sex workers and drug users.
There is no easy fix for this crisis, but something must be done. Without a multi-pronged approach, enacted in the near future, Pakistan will continue to experience disease outbreaks, and many more people will be put at risk.