The high risk of HIV and Hepatitis B and C infections due to contaminated blood, blood products, surgical instruments, and needles should force us to rethink why the offending practices are common in India. In fact, this is a problem common to all developing countries and not just prevalent in India. So the need to devise effective strategies for developing countries, without first expecting to reach the per capita income of Western countries, is urgent in light of the pandemics. This note is simply my attempt to probe deeper into the causes and find possible solutions to the problem.
Before looking at causes and solutions it is appropriate to ask how large is the risk? Indian government study (http://www.NACO.nic.in) based on data from HIV sentinel survey centers concludes that about 10% of the HIV infections are due to blood, blood products, surgical instruments, and needles. So, one could argue that in a resource scarce country this is remarkably good -- without mentioning that we don't really know the true magnitude of the problem due to under reporting, the inability to pinpoint the cause, and also because the HIV pandemic is still young in India. To me the more telling statement of the severity of the risk is that, today, no educated and well-to-do person is willing to go to a hospital, especially a government hospital, and accept a blood transfusion unless they personally know a doctor there who will pull the ropes and do the checks. So, in my mind, the risk is very high for all.
I would like to divide, in a very simplistic way, the people promoting the risk due to the above factors into three categories:
To address the first point I start with a question. Is it really possible that doctors and certified owners/operators of blood banks are unaware of the consequences of their actions? I believe that in this community of trained professionals, the perpetuation of the risk is not due to lack of information or awareness since medical education already teaches the ethics and correct practices, and since these activities require a license to practice. It is also clear that there exist very precise government directives and laws prohibiting use of contaminated blood, blood products, or instruments. What is lacking is the timely and just implementation of the laws -- the offenders are not held accountable. In this environment, one can continue to ask the government to create "stricter" rules, but unless we, as a society, have the ability to hold ourselves and others accountable, past experience suggests that just having more rules will not provide adequate deterrent.
In spite of my strong belief that professionals cannot claim "ignorance" as an excuse, we can reduce risk in the following way. First, the public should be made aware, by a vigorous media campaign, that it is their right to ask doctors to show them that medical instruments have been properly sterilized. The public should not feel intimidated by the doctors, and the doctors should be much more sensitive to the trepidation in the minds of the public. The fatal sequela of these diseases more that justifies the publics concern. In fact, if more and more doctors voluntarily make it a habit to show all patients their sterilization procedures, the public will get trained to recognize the danger and avoid going to doctors that do not take adequate precautions. What is well documented worldwide is that the business of doctors that practice such openness grows rapidly. It is, therefore, well worth their while to spend a few minutes providing such education to their patients if for no other reason other than to protect their livelihood, i.e., their clients.
Another suggestion I would like to make is that owners/operators of blood bank should, each year, be required to sit through a training class and to take a test on blood safety and the associated medical code of ethics before their license can be renewed. The goal should be to make sure that these professionals cannot use ignorance, in their own mind or in the court of justice, to justify such criminal malpractice. They must be made to understand why their own family is being put at risk if such malpractices continue.
There is a second component of risk due to ignorance. There are many untrained and unqualified people practicing invasive medicine. This is especially true in rural India where there is an acute shortage of trained medical workers, and there is little hope for a decrease in this shortage in the near future. Even in this case "ignorance" is often being used as an excuse. Nevertheless, assuming that there is genuine ignorance, the strategy for intervention has to be threefold. These people have to be prevented from doing malpractice, which again is the issue of how well can we implement the laws of the land. Second, training classes must be held regularly to teach them simple but correct procedures. Expensive solutions, for which they have no resources for adopting, are counterproductive. Third, and perhaps most important, the public should be made aware of the deadly consequences of visiting such charlatans. Of these three, more attention should be devoted to the last aspect as it removes the market. This requires a sustained media campaign that discusses the problems openly and directly.
In addition, all employers -- government, industrialists, households -- should educate their employees on a regular basis on the dangers of visiting quacks. The realization that it is in the financial interest of the employers to assume such a responsibility is beginning to occur in the larger corporations, but unfortunately not in the small scale industry which is the major employer in India. Such practice has historical precedence -- it was not that long ago when this responsibility was a hallmark of Indian society, when even domestics help was considered as part of the family. This behavior lead to long term commitment and to stable healthy relationships that proved beneficial to both parties. Hopefully, the final step in this development will be that all employers provide adequate health care and education to all their workers and their families. This is the most cost effective way of having a healthy, productive, and cooperative workforce and of ensuring an more enlightened next generation.
To reduce the risk due to the second possibility, the lack of resources, there is no alternative but for the government to devote significantly more resources to health care. It is essential to have more funds for (i) a vigorous campaign to increase voluntary blood donation, (ii) easy and cheap availability of disposable (single use) syringes and needles, (iii) proper handling/disposal of these hypodermic needles, and (iv) to provide facilities for doctors to sterilize their instruments, especially in rural situations. Simultaneously, the public must be made aware of the dire need to check, to their satisfaction, whether proper sterilization has been carried out. The government and other institutions should, using all forms of the media, encourage the public to (i) use disposable hypodermic syringes and prevent reuse by making sure that a disposable needle is, in their presence, cut after use; and (ii) the educated and the aware, by personal example, should showcase the value of active participation in voluntary blood donation, i.e. to eliminate the need for professional donors and the existence of a black market in blood and blood products. The largest commitment and funds required will be to reach the poor, the illiterate, and the marginalized. For this to happen depends, in a very large part, on whether the well to do within the society are willing to accept the responsibility and provide for the less fortunate. This requires an attitude change; today most of the funds are controlled and retained by the well-to-do to serve the well-to-do. Also, this momentous change has to start taking place today as each passing day means thousands of more infections.
Focusing on resources, while essential, unfortunately detracts from understanding that social and cultural norms also need change. For example, India uses about 2 million units of blood per year. This amount can easily be collected voluntarily if we have the social will. All it requires is that all medical professionals gave one unit of blood once a year, OR all the university students, OR all the railway workers, OR all members of the bureaucracy. Certainly, there is the capacity for voluntary donation from just within the educated, but realizing it requires the enlightenment that by donating blood one is acting in his/her own selfish interest. The government and prominent citizens can play a very large role in promoting this change in attitudes by being responsible role models. In fact, I believe, only if they act as enlightened role models and donate blood regularly will we remove the risk of blood borne transmission of diseases.
Finally, I come to the third class of people, which I believe are contributing very significantly to the pandemics. The root cause of their behavior, I believe, is corruption. So one has to challenge the pervasive feeling that corruption is acceptable or that survival without corruption is not possible. Today, increasingly, a significant fraction of the people, at all levels of socio-economic stature, are driven by the desire to make money by whatever means possible. The system has failed to enforce accountability, and law and order has been subverted by corruption. The honest constantly feel besieged, they are the laughing stock, they are the simpletons who face ridicule for being people without imagination. The society has begun to value money more than human life and dignity.
In this environment should we blame just the nurses/doctors for reusing contaminated needles, or a blood bank manager for selling contaminated blood on the black market? After all, they too are doing this to give something extra to their children! We must all think long on the question -- Can corruption by society at large be considered acceptable, while that by the medical profession not? There is no question that the medical professionals, by not practicing safe procedures, are committing a criminal act, but are they alone? We need to find a real solution, and for that we must look for the root cause. In short, I believe that today the whole society is at fault and therefore on trial.
Corrupt practices have resulted not just out of a need for survival in a resource scarce country. So often I have met very learned, well-to-do, and well-meaning people who have a very strong code of ethics, but this code is applied very selectively. They have, at a very deep level, come to believe that they have the right to break certain laws that they consider are unfair or detrimental to their business. In short, they choose to define what laws they will obey and which they will break. The net result is a general widespread disrespect for the law. This has resulted in a lack of accountability and money has become the more important social regulator than following the law. The tragedy is that the tone has been set by the people with the means and with the power. The poor and the rural population often learns to adopt this system after many hard knocks. Faced with emerging health pandemics like HIV and Hepatitis, the well-to-do are, once again, looking for easy solutions that provide them safety from these emerging pandemics but leave their ill-gotten prosperity unchanged. Unfortunately, no such solutions exist, and unless we recognize this, our efforts will be nothing more than say applying band aids to treat a ruptured appendix.
Corruption, unfortunately, is a very addictive habit. It is much harder to shed than alcoholism or drug addiction. It is, after all, driven, internalized, and justified by short term gain and need, and at times even by survival. What we fail to accept is that corruption is a vicious cycle -- if we cheat today, that person cheats another, and that yet another, and finally somebody someday will cheat us. Today this circle is complete and is claiming the lives of many innocent people. The specter of HIV and Hepatitis B and C is only one consequence -- but it is the one that has begun to haunt us in our sleep and threatens the well-being of the country. It is very important to understand that either we can make money by whatever means possible or remove the risk of fatal blood borne diseases. We simply cannot have both.
So the question really is -- is each one of us ready to stand up and display the courage to not become a link in this vicious circle of corruption? Does each one of us have the courage to take the first step to stop corruption without waiting to see if others are also stepping forward? The need for awareness and action is greatest here -- can the people with the power and the means learn to regulate their lives and set the tone for others? All successful intervention strategies require behavior change, and to my mind, stopping corruption in our lives first is the most central and important.
So, unless we, as a society, restore respect for the law and develop the fortitude to hold ourselves and other people accountable, we cannot expect to get rid of the risk and fear of HIV and Hepatitis infections through contaminated blood, blood products, surgical instruments, and needles.
For further information on HIV/AIDS and if you wish to explore ways in which you can help I can be reached by e-mail at rajan@lanl.gov. Links to information on HIV/AIDS and a summary of my work can be obtained from the web page http://t8web.lanl.gov/people/rajan/AIDS-india/