By Smitha Mundasad

“I want to save lives and help people” is the one phrase that thousands of hopefuls have been told not to say at an interview for a place at medical school. This answer is deemed to be too idealistic, and too superficial. Medicine has a lot of challenges; it is not about the chummy hilarity of Scrubs, or the steamy store-cupboard romance of Casualty. But it is about doing more good than harm… right?

Over the last few weeks, more than one million NHS employees have had to face a difficult fact. Sometimes, in the very act of saving a life, they are endangering someone else’s.

Young children around the world are working in sweatshops to make the surgical instruments that are used in our operating theatres, according to Mahmood Bhutta, a surgeon in Oxford.

“There is evidence that children as young as seven are risking their lives to supply us with equipment to save British lives” he said.

During his honeymoon, on a stopover in Pakistan, Mr Bhutta was invited to explore Sialkot’s maze of manufacturing workshops. Many of these workshops are the backrooms of small houses.

Making surgical instruments

Making surgical instruments involves forging, filing, grinding and using chemicals such as sulphuric and nitric acid. In England, workers are issued with adequate protective gear. Mr Bhutta, however, saw children and adults working in dangerous environments, without appropriate protection.

“Some of the workers in the developing world who make medical supplies bound for the NHS are exposed to hazardous working conditions where they risk serious injury and even death,” Mr Bhutta said.

He told me that after witnessing these conditions, he spent the next six months grappling with the ethics of doing or not doing something about this situation. For many of the employees this work puts food on the table. And for some children, this is a job that could give them skills for life. Furthermore, in a market that is highly competitive, firms in Pakistan need to keep prices low.

From Pakistan to the NHS

Manufacturers in Pakistan often lack the infrastructure to market or sell their goods directly to the NHS. Middlemen in European countries often buy these goods from Pakistani firms. A substantial mark-up in price is then added, before these instruments are sold to the NHS.

According to an article by Mr Bhutta, which appeared in the British Medical Journal (BMJ) in 2006, “a pair of fine surgical scissors will cost $1.00 to produce, will be exported from Pakistan to Germany at the price of $1.25 and will probably be sold to a hospital for nearer $80.00”. Mr Bhutta was told these figures via personal communication, but as he points out in the article, there has not been a systematic examination of NHS procurement.

A complex system

Procurement in the NHS is complex – it happens on many levels, from the NHS who negotiates national contracts on products, to independent procurement done by individual hospital trusts.

What is the solution?

According to Mr Bhutta, this is not an issue of blame. He told me that when he approached the NHS, they were unaware of these practices.

Finding a solution is difficult. As Mr Bhutta mentions in the BMJ article boycotting these goods would reduce trade in the region and heighten poverty, the very problem that underlies this issue.

Mr Bhutta continues in the article: “the solution lies in purchasers insisting on fair and ethical trade when sourcing instruments. Pressure must be applied to suppliers in the developed world to be transparent about where their instruments have been manufactured and for them to ensure that the labourers have been paid a fair wage for their work and that basic international labour and health and safety standards have been followed”.

The Fair and Ethical Medical Trading Initiative

In 2007, two years after the honeymoon visit, the British Medical Association and Mr Bhutta set up the Fair and Ethical Medical Trading Initiative. Working with the Department of Health, the NHS Supply Chain, a number of nongovernmental organisations and academics, this group recently produced a set of guidelines for doctors who wish to tackle the issue.

The group is calling on doctors to:

Ask their chief executive to adopt ethical procurement into their institution’s policy

Ask health care suppliers where, and under what conditions, they produce their goods

Form an ethical trade interest group within their institution

Tell others

What has been done so far?

The NHS Purchasing and Supply Agency, in a partnership with the Ethical Trading Initiative has produced a guide to ethical sourcing in the NHS.

The NHS Supply Chain has also produced guidelines.

With NHS funding cuts threatened in the near future, it is difficult to predict the impact of these guidelines. Bringing change to such an ethically complex situation is likely to take time, care and commitment.

The Medical Fair and Ethical Trade Group is now working to ensure that “this is not just a paper exercise”.

The question is, how will our world-renowned health care system react to this situation? Will the NHS choose to be morally cheap? Or will we stand up and fight for global health?