At a government hospital in Larkana, I watched a nurse leave a needle open after preparing medication in the children’s ward. Then she tossed it in a regular trash can with the tip still exposed. I did not see any containers for sharp objects. Outside, I asked a cleaner how the hospital handles rubbish. He led me past the hospital gates and showed me the trash that was lined up around its perimeter. There were exposed needles, infusion cannulas, and dirty nebulizer masks everywhere. An incinerator was nearby but was not used. (WHO has since donated new incinerators, but the pandemic has delayed their installation.)
As an ambulance, I have provided medical care overseas in all sorts of dire environments. Still, I was shocked here. Even in impoverished, war-drained countries in sub-Saharan Africa, I was held to the strictest infection control standards as a medical student. The nurses in the operating, work, and delivery rooms had eyes in the back of their heads to warn anyone who violated the protocol. In an HIV ward in South Africa, I was shocked by the tearing words of a fellow student, a local woman, when I was clumsy with a needle. She warned me that no matter how rushed I was, this task cannot be compromised. It is the first lesson we learn here as students, she explained.
Syringes with built-in safety locks that slide forward easily to cover the needle are common in American healthcare facilities, but even the Aga Khan does not have them. In the best case scenario, the plunger will be locked so that the syringe cannot be reused. When I went to several pharmacies that dispose of these needles and asked about the correct way to dispose of them, I received terrible advice. A pharmacist bent the needle to 120 degrees. “We’ll do that,” he told me. The sharp point was obviously still exposed. “In the sewer, on the street,” said another pharmacist when I asked him where to throw the needle before I tossed it out the window without looking. I watched the needle float in a puddle of open sewage. Children were hopping around the corner down the street.
At the time, Rajesh Panjwani was the Sindh HealthCare Commission’s deputy director of inspections for the Larkana area, which also 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. “All hospitals use the safety boxes,” Panjwani assured me, referring to sharp rubbish bins. I told him I didn’t see this, but he denied my characterization. We walked back and forth until he had to take a call. I didn’t even know that Hussain was listening as he was typing briskly on a large desktop computer, but now he was speaking. “They’re 100 percent telling the truth about government hospitals,” he told me.
Panjwani later told me that he had inspected many clinics in the area and that they had security boxes available. I said I hadn’t seen a safe in any of the dozen or so clinics I went to. At that point, Hussain said something to Panjwani and they started arguing in Sindhi. My translator said to me softly: “Hussain says: ‘She is telling the truth. Please admit the truth. There are no safety boxes in the clinics. ‘”
Everything, it seems, is always someone else’s job. Aftab Ahmad, a doctor in charge of monitoring and evaluating the Sindh AIDS Control Program, blamed the district health bureau for the outbreak. “There is a refusal, you are right,” said Ahmad. “People don’t quite do what they’re supposed to do.” The Sindh HealthCare Commission can order a clinic to be sealed, but is asking the police to enforce the order. The commission considers its job to be done when it has issued its recommendation to close clinics with violations. The Commission does not see itself responsible for actually closing the facilities or for ensuring that they remain closed.
The cruel dilemma, however, is that without these private health rooms, many people in Ratodero and other remote areas of Pakistan would not have access to medical care. For the poor and the uneducated, there is usually a choice between terrible care or no care at all.
