In a slum near Mumbai’s largest dumping ground, a doctor practising Unani medicine sees more than 50 patients a day. For just Rs 20, he diagnoses the disease, gives medicines and even administers an injection. In his clinic at Shivaji Nagar in Govandi is a drawer cluttered with disposable injections and a box filled with used syringes. After administering an injection, the doctor meticulously scraps off the needle and discards it, but he puts the used syringe next to the packed ones.

“I am aware that needles cannot be reused but syringes can be," he said, requesting anonymity. "There is no harm.”

The doctor is wrong. Not just needles, even syringes can transmit blood-borne infections like HIV and hepatitis. According to India’s National Aids Control Organisation, an estimated 86,000 new HIV infections were recorded in the country last year. Viral hepatitis kills approximately 3,50,000 people every year in the South East Asia Region which includes India, according to the World Health Organisation. There are no local studies to measure the burden of viral hepatitis in India.

Dr Parveen Malhotra, head of the department of medical gastroenterology at the Post-Graduate Institute of Medical Sciences in Rohtak in Haryana, explained, “When an injection is administered to a person infected with any blood borne virus such as hepatitis C, the blood remnants on the needle and the syringe can spread the infection to any person who comes in contact with the used equipment.”

Hence, conventional medical advice is to dispose all such material immediately after the injection is administered.

A 2012 study by University of Nevada at Las Vegas researchers published in the Indian Journal of Community Medicine found that 12% of HIV infections in India are associated with unsafe injections. According to the same study, an estimated 46% of hepatitis B cases and 38% of hepatitis C cases in India spread through the reuse of needles and syringes. Such cases can be easily avoided. The cheapest disposable injection costs as little as Rs 6.

So why do doctors and nurses continue to reuse syringes?

Syringe shortage

Nagma Quereshi is a 22-year-old woman who lives in Govandi. Pregnant with her first child, she goes to Rajawadi Hospital, a municipal facility regularly for her pregnancy check-ups. She is often administered an injection, but she has rarely observed the nurse throw the used syringes in the dustbin. “They [the nurses] just come and inject,” she said. “We don’t get to see if they have removed the injection from a new packet.”

Healthcare experts said that in situations where the nurses are battling shortage of injections, they are left with two options – either to reuse injections or ask the patient to go and buy fresh ones. If they ask the patient to buy, there is a risk of getting into an argument as hospitals are expected to provide these consumables free of cost. In such a situation, it proves easier to just reuse the syringe.

Dr Pravin Shingare, head of the directorate of medical education in Maharashtra, however, insisted that injections were never reused in government hospitals since the department provided them with adequate supplies. “If need be, we locally purchase the equipment,” he said.

But studies have documented the widespread use of unsafe injections in India.

A study by IPEN, a global network that works for toxics-free environments, on injection practices in India which was published in the World Health Organisation's South-East Asia Journal of Public Health in 2012 found that six out of ten injections administered in Indian healthcare establishments were unsafe.

An injection is considered to be unsafe if the healthcare provider fails to follow the injection safety guidelines prescribed by the World Health Organisation. Scrapping the needle after administering the injection and throwing the used syringe in a bag are some of the safe injection practices that healthcare providers are expected to follow.

A study by a team of doctors from the department of community medicine at Pandit JNM Medical College in Raipur, Chhattisgarh, found that healthcare providers at the hospital failed to adhere to the injection safety guidelines prescribed by the World Health Organisation. In nine out of every ten instances observed by a team of doctors to gauge safe injection practices at government hospital in Chhattisgarh, the nurse did not shred the needle after administering injections.

Another study published in the National Journal of Community Medicine found in 23% of the 2,119 observations made by them at Pandit JNM Medical College, the healthcare provider left the needle on the top of the vial for an additional dose. “At times a vial contains multiple doses in such situation, the nurse is expected to draw the medicine from the vial, administer the injection and dispose it of,” said Dr Divya Sahu, director and professor at the department of community medicine. “However, we saw that the nurses were reusing the same injection to draw additional doses.”

The same study also observed the practice of reusing of the syringe by inserting a new needle. “During our study, we observed at five different instances where the nurse instead of disposing of the needle and syringe, only disposed of the needle and reused the syringe with a new needle,” said Sahu.

The study also found that in 26% of the instances, the used syringe were kept in an area accessible to public including children who could play with the biomedical waste.

Biomedical waste disposal

It is not just the deliberate reuse of injections that is a cause for worry. Doctors suspect the presence of an illegal recycling industry that recycles used medical equipment and sells them again in the market. “We know of healthcare providers reusing the needles but also there is an industry that recycles them,” said Dr Malhotra of the Post-Graduate Institute of Medical Sciences in Rohtak.

Fears expressed by doctors in Haryana over the recycling of biomedical waste are echoed by those in Mumbai too. This correspondent visited several clinics in the slums of Mumbai to find that many continue to throw their biomedical waste as household garbage.

A dental clinic located in Bharat Nagar slums of Bandra Kurla Complex, the swanky financial neighbourhood of Mumbai, maintains a single dustbin which is used to dump both used injections and tea cups. The clinic which is operating in the locality for over two decades does not dispose of its biomedical waste as required under the law. The attendant at the clinic who has been working there for three years said that the sweeper who collects the household garbage from the locality also collects the garbage from the clinic which includes used gloves, injections and soiled cotton.

A Unani clinic in the same locality that boasts of treating nearly 100 patients every day disposes of its biomedical waste in a similar fashion. “The lady who comes to clean the clinic puts all the waste in a black bag and throws it off,” said the attendant at the clinic.

In Mumbai, which is home to over 10,000 healthcare establishments including corporate hospitals, nursing homes and clinics, there is a system in place for disposal of biomedical waste. The local corporation has appointed an agency that collects the biomedical waste from the healthcare facilities and performs the incineration process. In 2014, about 12 metric tonnes of biomedical waste was generated in the city officially.

Infectious disease expert Dr Om Shrivastav said it is wrong to expect the patient to be vigilant here. “In our country, patients rarely question the doctor,” he said. “The person disposing of these hazardous waste should be made responsible for the waste he is discarding.” Shrivastav said the rise in viral hepatitis infections is evidence that “somebody at the level of disposal is not doing what they are expected to”.

Catching violators

An operator of biomedical waste disposers in Mumbai said, “We suspect that some waste is being siphoned off from hospitals to the grey market where they are perhaps recycled.” In 2010, the Mumbai police had nabbed a tempo filled with biomedical waste near Deonar. The tempo was filled with used medical equipment, including bloodstained gloves.

The Maharashtra Pollution Control Board’s officials did not deny the possibility of biomedical waste being recycled. “We act promptly on any complaints we receive," said Amar Supate, principal scientific officer, MPCB. "Last year, an FIR was filed after we found some people were recycling biomedical waste. The problem is with very small clinics. It is physically impossible to check their biomedical disposal mechanism. The local corporations should keep a vigil and cancel their license if they are found disposing off their waste as any other garbage.”

However, senior officials from Mumbai's municipal corporation said it is the responsibility of the pollution control boards to take action against those found flouting biomedical rules.

This blame game only helps the healthcare establishments get away with dangerous disposal practices.

Smart injects = smart solution?

Worried about used needles and syringes finding their way back into the market, Malhotra’s department in Haryana has started distributing free needle cutters among doctors practicing in localities where the burden of Hepatitis cases is high.

“We are distributing burners so they can discard of these disposable waste and they don’t fall into hands of recyclers,” he said.

However, this still leaves room for discretion on the part of doctors and nurses.

To completely eliminate the possibility of reuse of injections, several states in India are responding to WHO's call to use safety engineered syringes called smart injects which automatically get locked after the injection is administered. Maharashtra is one of them. “We will be adopting the reuse prevention injections or smart injections in all our government hospitals,” said Sujata Saunik, principal health secretary, government of Maharashtra.

But the smart injects cost 20% more than the conventional disposable injections, according to industry experts.

While governments will be able to afford the injections, would private clinics, particular those in poor neighbourhoods, shoulder the extra cost?