At a government hospital in Larkana, I saw a nurse release a needle after preparing the medicine in the pediatric unit. Then he tossed it, the tip still exposed, in a regular trash can. I did not see any sharp container. Outside, I asked a cleaner how the hospital deals with garbage. He saw me from near the front gate of the hospital and showed me the garbage around his perimeter. There were exposed needles, ivy cannulas and dirty nebulizer masks everywhere. A devour was nearby, but it was not in use. (The WHO has since donated new incinerators, but the epidemic has delayed their installation.)
As an emergency-room doctor, I have provided medical care abroad in all kinds of horrific environments. Still, I was surprised here. Even in the debilitated, war-torn countries in sub-Saharan Africa, I was held to the strictest of infection-control standards as a medical student. Nurses in the operating and labor and delivery rooms had eyes behind their heads, ready to break any protocol. In an HIV ward in South Africa, I was shocked to hear the words of a fellow student, a local woman, as I clumsily handled a needle. He warned me that no matter how far I run, this work cannot be compromised. This is the first lesson we learn here as students, he explained.
Syringes with built-in safety closures that move easily to cover the needle are common in US health facilities, but are also not available at the Aga mine. Best of all, the rider stops, so the syringe cannot be reused. When I went to several pharmacies where these needles were dispensed, and asked about proper disposal, I received terrible advice. A pharmacist tilted the needle to 120 degrees. “This is what we do,” he told me. The apparently sharp tip was still exposed. “In the sewer, in the street,” another pharmacist said when I asked him where to leave the needle, look at it before looking out of the window. I saw a needle floating in a puddle of open sewage. Around the corner, children fell on the road.
At the time, Rajesh Panjwani was the deputy director of oversight of the Larkana region of the Sindh Healthcare Commission, which includes Ratodero. I managed to see him. He shared an office with Faraz Hussain, an administrator; Their desks were at right angles to each other. Panjwani told me that all hospitals are using safety boxes. I told her it was not what I saw, but she disputed my characterization. We walked back and forth until he had to pick up the phone. I didn’t even know Hussein was listening, as he was typing fast on a large desktop computer, but now he spoke. “You are telling 100 percent truth about government hospitals,” he told me.
Later, Panjwani told me that he had inspected several clinics in the area and had safety boxes available. I said that I have not seen a safety box in any of the dozens of clinics. At this point, Hussain said something to Panjwani, and they started arguing in Sindhi. My translator quietly said to me, “Hussain is saying: ‘She is telling the truth. Please accept the truth. There is no safety box in the clinic.”
Everything, it seems, is always someone else’s job. Dr. Aftab Ahmed, in charge of monitoring and evaluation in the Sindh AIDS Control Program, held the district health office responsible for the outbreak. “There is some denial, you are right,” Ahmed said. “People are totally not doing what they should have done.” For the Sindh Healthcare Commission, while it may order a clinic to be sealed, it looks to the police to enforce the order. The Commission does its work when it has recommended closure of clinics with violations; The Commission is not responsible for actually closing the facilities or ensuring that they remain closed.
However, the cruel dilemma is that without these private health places, many people in Ratodero and other remote areas of Pakistan would not have access to any health care. For the poor and uneducated, the choice is usually between ghastly care or nonexistent care.