BioEd Online

The trade in high-quality surgical instruments may be exploiting workers in the developing world, says a new report. Children as young as seven are working to make scalpels, scissors and other items, in sometimes unhealthy and dangerous conditions.

The problem is probably compounded by the low wages paid to workers in Pakistan, which produces around 20% of the world's surgical instruments, says Mahmood Bhutta, a London-based surgeon who investigated working conditions while on a trip to Sialkot, the Pakistani centre for the industry.

Shoppers are used to demanding that products such as coffee and bananas are fairly traded, says Bhutta. But healthcare institutions in the developed world should also be striving to ensure that the products they buy do not exploit poor workers.

Some 50,000 people are involved in making stainless-steel surgical tools in Sialkot; around 7,700 of them are children, Bhutta reports in the British Medical Journal¹. Most start at the age of nine, although some as young as seven work in Sialkot's many small workshops.

Metalworkers

Although complex, expensive instruments such as endoscopes are chiefly made in Germany, many simple metal implements are made by skilled Pakistani workers, who have inherited a tradition of metalworking that extends back to seventeenth-century swordsmiths. "A pair of scissors that is finely crafted and machined can be made by manual labour by someone who is appropriately trained," Bhutta says.

But although the world trade in handheld surgical tools is worth at least $US650 million every year, poor workers do not see much of the money. A pair of scissors might retail for $80, but the German companies that market them typically pay the manufacturer around $1.25.

A Pakistani study in 2003 found that half of children making surgical instruments reported injuries at work, with 95% suffering sleep problems and 80% enduring back, neck or shoulder pain, as well as eye and lung problems. This probably stems from the use of grinding, milling and corrosive chemicals, and the high levels of dust and noise in workshops.

Better pay

Boycotts, however, are not the answer, says Bhutta: refusing to buy tools from these places at all could exacerbate the poverty problem. Instead, ensuring that adults are paid a fair wage should help to remove the need for their children to work alongside them, he says.

The situation is similar to one encountered in Sialkot in the manufacture of sporting goods such as hand-stitched footballs, says Stefan Durwael, executive director of the International Fair Trade Association near Utrecht, Netherlands. Sialkot and the surrounding area produces some 75% of the world's footballs, and in 1997 sports manufacturers signed the Atlanta Agreement, which declared that under-14s should not work stitching footballs.

"The big downside was that children had to find other work," says Durwael. With poor families still struggling, many of their children may have ended up making surgical tools instead.

Clear chain

Fair trade consists of making the "whole supply chain transparent", Durwael says. Bhutta says that he intends to consult with the British Medical Association and its international counterparts to investigate the scale of the problem and what might be done about it.

When contacted by news@nature.com, the British National Health Service's Purchasing and Supply Agency said that, although they provide a list of recommended suppliers for surgical instruments, and strive to ensure that these goods are not produced unethically, individual healthcare trusts in Britain are free to source their goods from wherever they like.

Some of the healthcare regulations in the United States and Europe also seem to be inadvertently fuelling the problem. In 1994, US legislation demanded that all surgical goods conform to international quality standards. This meant that rival companies were left producing essentially identical products and competing only on price - leading them to increase the use of cheap labour.

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