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PAKISTAN: Injecting Disease With Medicine

Zofeen Ebrahim

KARACHI, Feb 28 2011 (IPS) - Once every two weeks, 45-year-old Perween Riaz enters a place with a sign outside that says “Ghazi Medical Centre” where she gets injections for headache and nausea from someone people know is not a real doctor.

He checks her blood pressure, tells her it is low and goes behind a tall table covered on three sides to prepare her shot. She never asks him any questions, too grateful for the relief he provides.

“Till I don’t take an injection, I don’t get well,” said Riaz, a mother of seven.

The waste bin next to the table is empty. Instead, half-used vials and several used syringes lie around, some with needles, others without, apparently to be used for the next patient’s shots.

Almost 80 percent of healthcare in Pakistan is provided by private doctors, many of them unlicensed and unqualified. These “quacks” are believed responsible for unsafe practices such as administering unnecessary injections, and using non-sterile syringes or needles, says Dr Aftab Moshsin, director of the Prime Minister’s Programme for Prevention and Control of Hepatitis.

The person who gave Riaz her shots, for instance, was actually a dispenser pitching in for the real doctor who was on leave, and knowingly reuses syringes and needles. “We change the needle if the injection is given intra- muscular. There is no need to use a new syringe every time,” said the “doctor” who serves poor and illiterate Pakistanis like Riaz in Karachi’s impoverished Shireen Jinnah Colony.

Nine out of 10 injections administered in this country are unnecessary, says Dr Naveed Zafar Janjua, an epidemiologist based at the British Columbia Centre for Disease Control and the University of British Columbia. Seven out of 10 are given using non-sterile syringes or needles, a practice now the leading cause of Hepatitis B and C. “No part of the syringe should be reused,” says Dr Arshad Altaf of the Safety Injection Global Network (SIGN) Pakistan, a coalition of volunteers aiming to achieve safe and appropriate use of injections throughout the world.

Altaf said even if the needle is changed, the barrel and the plunger come in contact with body fluids and blood, risking transmission of blood-borne pathogens.

Altaf is familiar with the set-up at the centre Riaz frequents. “The dispenser brings the injection after preparing it behind the counter so the ignorant patient does not know whether the syringe is new or old,” he said.

“Sometimes these people are so ruthless that they only change the needle when it becomes blunt and they are unable to poke the patient or the patient complains of extraordinary pain because the blunt needle does not pierce his or her skin,” Altaf added.

“All evidence points to unsafe, improper and unnecessary use of syringe for 80 percent of new infections of HCV (hepatitis C virus) in Pakistan,” said Mohsin. Hepatitis C is the infection of the liver caused by the hepatitis C virus (HCV).

Of Pakistan’s 180 million people, an estimated 12 to 15 million are infected with hepatitis. The country also has the highest number of patients with chronic liver disease in the world, says Mohsin.

Injectable medications became popular after these were used against malaria and yaws in the early 1900s, and penicillin was introduced in the subcontinent around World War II. “These had a dramatic effect and led people to believe that medication administered through injection made them get well faster,” Janjua said.

Altaf cites economics: “Practitioners prescribe an injection for common ailments because with an injection, the prescription cost increases.”

Hepatitis viruses are classified as A, B, C, D and E. Of these, B, C and D are transmitted through blood and body fluids. Hepatitis is also called the silent epidemic, as the symptoms may not show till after 10 or 20 years.

Most individuals don’t develop acute symptoms, but a large majority go on to develop cirrhosis of the liver (fibrosis of liver) or liver cancer. “Cirrhosis of the liver manifests itself with collection of fluid in abdomen, vomiting of blood, blood in stools and later stage altered mental state,” Janjua explained.

Janjua quotes a study his group conducted in 2003 in three districts of Sindh province. He and his colleagues found that between 30 to 50 percent of injections were not administered with new disposable syringes, and that a single needle was used on multiple patients.

The government’s Hepatitis Programme website estimates the prevalence of Hepatitis B to be 2.5 percent of the population, and Hepatitis C, 4.9 percent.

But several studies show the figure to be as high as 6 percent. Janjua’s study of 2007 in a community in this city, showed 24 percent of respondents to be infected with HCV.

Tania Rab, communication advisor to the Prime Minister’s Hepatitis Control Programme, said the biggest hurdle towards disease control has been the unethical practice by quacks.

“There is no legal framework in place to ban re-use and misuse of syringes and no law that prohibits quacks from carrying on their business,” she said.

Early this year, however, the Sindh assembly passed a law against the manufacture, sale and use of disposable syringes other than the ones that autodestruct. Those in violation will be punished with a prison term which may extend to two years and a maximum fine of 500,000 rupees (5,857 dollars) or both.

“While we have been successful in controlling reuse of syringes in hospitals, and regularized the working of blood banks, to some extent, there is no check on quackery,” she adds.

“Till that time, we have to continue engaging with unqualified providers and private practitioners rather than scaring them away,” says Rab. One part of the programme under this year’s theme of “Safety Injections” is to raise awareness regarding reuse, misuse and unnecessary use of injections among unqualified healthcare practitioners.