[satya71]

This is common practice in much of developed world. Long ago, they used to have re-usable glass syringes that could be sterilized. Unfortunately, people switched to disposable syringes. The unit costs are...high in the US, unreasonable in developing countries.

It's not just this hospital, it's widespread ([1] report 38%)

[1] https://www.emro.who.int/emhj-volume-26-2020/volume-26-issue...

[SanjayMehta]

A quick search found a pack of 100 disposable syringes in Pakistan for PKR 1100/- which is less than USD 4.

That's 4 cents per syringe. Seems quite reasonable to me. Seems they don't have economics as an excuse.

https://ailaaj.pk/products/apple-disposable-syringe-5ml-100s

[leonidasrup]

There is strong correlation between life expectancy and GDP per capita.

https://ourworldindata.org/grapher/life-expectancy-vs-gdp-pe...

Been poor is your biggest health risk.

https://www.un.org/sustainabledevelopment/

[CGMthrowaway]

A month's wage in Pakistan is about $125. So each syringe would feel like a cup of Dunkin does to many in the USA

[bastawhiz]

I have orders of magnitude more cups of Dunkin each year than I get injections at a doctor

[garbawarb]

But Pakistanis don't.

[bastawhiz]

The point is that if the analogy of a $0.04 syringe is supposed to be as expensive as a cup of coffee, it's still not expensive even if you do it often. Maybe they have too many injections. Either way we have a bunch of kids with a disease that can kill because someone thought something as expensive as a cup of coffee was too expensive.

[crazygringo]

Which would be entirely reasonable cost as part of a healthcare visit.

When people complain about healthcare costs, they're not complaining about things that cost the same as a cup of coffee locally.

[kelnos]

I feel like spending the cost of a crappy cup of coffee to get a clean needle so you don't get HIV is money well spent.

[wildzzz]

Median household income in US is $83k so 0.04/125 * 83k is about $26, much more than cup of coffee. If you're sticking like 15 kids a day with the same needle, that's like $400 a day saved.

[MagnumOpus]

You are comparing monthly individual wages in Pakistan to annual household income in the US. That results in your numbers being nonsense.

[Marsymars]

That article also makes it seem like patients in Pakistan are receiving what seems to me like a wildly high number of injections:

> An injection was provided during 53% of patient visits in Rawalpindi and 92% in Tando Allah Yar

> Patients from Tando Allah Yar reported a mean 3.8 visits to a healthcare provider by a member of their household during the previous month, compared to 2.5 by those from Rawalpindi (Table 2). During all such visits, an injection was given. Overall, 56% patients felt that an injection was necessary. Such perceptions were higher in Tando Allah Yar than in Rawalpindi (79% vs. 39%) (Table 2). Providers reciprocated such perceptions in that 44–56% of providers felt that an injection was required for common ailments such as fever, influenza, body aches or diarrhoea.

> Patients expect to receive injections for minor ailments such as fever or influenza-like symptoms and willingly pay for these, on the mistaken belief in the efficacy of injections to overcome common symptoms that eventually abate with time (10). Healthcare providers comply with such wishes and are convinced of the necessity of injections.

> We have previously demonstrated that the total national supply of syringes in Pakistan is sufficient to meet the demand for the ~1.1 billion syringes used annually for immunization, diabetes, laboratory testing and drug administration in clinics or hospitals

On the last point, I did a bit of a search to look for the total number of syringes used worldwide. I'm actually questioning whether that number is using similar methodology to arrive at the ~1.1 billion number, since I'm seeing numbers around 15 billion for the annual number of injections - meaning that Pakistan would be using over double the average per-capita number of syringes (and re-using many of them) while simultaneously having a population that's much younger (23 vs 31 median age) and poorer ($7k vs $26k median PPP/capita) than average.

If those numbers check out, the simple solution would just be to stop giving unnecessary injections, money would be saved, and there'd be no need to reuse syringes.

[Aurornis]

> > Patients from Tando Allah Yar reported a mean 3.8 visits to a healthcare provider by a member of their household during the previous month,

This seems like an excessive number of doctor visits, too. I can’t imagine a household where someone is going to the doctor almost every week. 45 doctor visits a year and they’re getting injections (of what?) most of the time?

[londons_explore]

I, as someone broadly healthy and who has barely used healthcare services, asked to see my health records recently.

I was shocked to see 500+ 'interactions' between me and the healthcare provider! However it turns out the majority of those interactions are very minor things - ie. "Patient received text message reminder about appointment". "Patient was sent letter with test results" etc.

When you count interactions like that, you can get a big number fast.

[sokka_h2otribe]

Member of household = significantly bigger. I believe your numbers suggest a household size of 1 person. I also would suggest that most likely old people live with their families, and skew towards "which member" of the household went to the doctor.

Well, with such a low mean age it could also be very young people skewing the number, im fully speculating.

[ceejayoz]

A similar thing happens in the US; people demand antibiotics for a cold. It’s easier to say yes than to explain the reason it won’t work.

[Aurornis]

Antibiotic overprescribing was a problem in the past, but in my experience providers around me are very resistant to giving antibiotics at all.

My doctor’s office even has a big sign in the waiting room saying they don’t prescribe antibiotics for common infections.

The last time I got strep throat the urgent care clinic was resistant to testing me but finally gave in. When it came back positive the doctor acted oddly like he was reluctantly willing to prescribe antibiotics for it.

[hgoel]

My dad in India gets prescribed antibiotics whenever he's sick. Despite my constant explanations, he insists that this is how it should be, because when you're sick your immunity is lowered.

On the other hand, the last time I got prescribed antibiotics was probably almost 10 years ago when I ended up in the hospital from an abscess.

Granted, my dad is old, but that part of the world still seems to expect doctors to do more for a common cold than just tell you to rest for a week and take an acetaminophen or phenylephrine if/when needed (even when that's really all you need).

[Marsymars]

> Granted, my dad is old, but that part of the world still seems to expect doctors to do more for a common cold than just tell you to rest for a week and take an acetaminophen or phenylephrine if/when needed (even when that's really all you need).

FYI phenylephrine is effectively a placebo and the FDA has proposed ending its use in OTC drugs. (There've been HN threads on the subject, with many comments.)

Pseudoephedrine works great though.

[devilbunny]

Phenylephrine is a placebo for nasal congestion, but it’s a solid drug for raising blood pressure. Used all the time in anesthesia (obviously not an OTC use).

[Marsymars]

> The last time I got strep throat the urgent care clinic was resistant to testing me but finally gave in. When it came back positive the doctor acted oddly like he was reluctantly willing to prescribe antibiotics for it.

For strep in particular, wiki indicates that not treating with antibiotics isn't unreasonable (presumably opinions will vary by doctor): https://en.wikipedia.org/wiki/Streptococcal_pharyngitis#Anti...

[ButlerianJihad]

I don’t know how widespread it is, but some people will beg for antibiotics when they definitely have a viral infection.

My friend who always used a naturopath would go on endlessly trying to diagnose herself with viral or bacterial to decide whether she should ask for antibiotics, but I definitely got the point.

I suppose many patients simply don’t know the difference.

[imtringued]

I know antibiotics are really popular because killing bacteria seems really effective, but have you considered asking your doctor for a probiotic treatment?

Oral probiotics tend to work really well (similar effect to getting rid of bad bacteria) because they don't have to survive the stomach acid.

[fastasucan]

Why do you say oddly? Prescribing antibiotics just because is how you get resistance.

[array_key_first]

Prescribing antibiotics for contagious bacterial infections is their exact usage.

Some doctors argue against using antibiotics for strep, but it's definitely debatable.

[shigawire]

Is that true or just a rumor? All the family medicine people I know would not do that. Only in a case where it is 50/50 bacterial or viral like an ear infection in a young kid.

[kube-system]

There is more effort today to avoid overprescribing antibiotics, but in cases where diagnosis is not certain, most providers will oblige

[gib444]

In the UK, nothing is ever bacterial lol

I had a horrible tooth infection that anyone with a nose could tell was a bacterial infection yet I was massively gaslit and denied antibiotics until I went to the hospital at 11pm after a week of horrendous pain

Doctors very rarely do any kind of test in my experience (I would have thought oozing stinking green stuff would have been easy to test...)

Later

I am somewhat against antibiotics as I have a fragile/already destroyed gut. But there are times when I don't know what other solution there is after exhausting home remedies, other medication and waiting it out

[dzhiurgis]

A friend passed away few months ago in London from kidney infection.

UK seems very to be very cautious of over diagnosis, while my experience in Eastern Europe was opposite - my infant received 3 different kinds of steroids (potentially what stunned his growth).

[gib444]

I'm very sorry to read that

IMO there is a huge amount of denial of treatment to save costs. The gaslighting over symptoms, the refusal to refer you to specialist, the refusal to order tests etc is all part of it. And they never ever say it's about costs - just a tight lipped, "I know what's best" attitude

[throw0101a]

> A similar thing happens in the US; people demand antibiotics for a cold. It’s easier to say yes than to explain the reason it won’t work.

Are there placebos that could be given instead?

[thayne]

More than that, it's often easier to just prescribe something than to figure out if it is bacterial or viral.

[MassiveQuasar]

Could just prescribe sugar pills then instead of antibiotics for a cold.

[thayne]

IME, most people (in the US) don't bother going to a doctor for a cold unless it lasts a long time or is especially bad, because you'll probably get better on your own and going to the doctor is expensive.

[ButlerianJihad]

I was working in a church office when I came down with a runny nose and other cold symptoms.

My supervisor told me I could stay home for a day, but if longer than that, I would require a doctor’s excuse.

Now, that seemed fair from a labor perspective, but it is extremely unfair to someone like me. Because I do not own a vehicle, and seeing a doctor would involve boarding one or more buses and snorking the entire way there and back. Risking infection for everyone around me was exactly what I sought to avoid by staying home.

So what else could I do, but come into work and carry on? It is this sort of unreasonable requirement that fuels “presenteeism”.

[loeg]

We don't give these hypochondriacs saline injections with dirty needles, though.

[LorenPechtel]

Probably patient demand for *something*. The problem of antibiotics for viral infection is well known but the problem with needing to do something is far more widespread. I wouldn't be surprised if a lot of saline is getting injected.

[loeg]

> This is common practice in much of developed world.

Do you mean "developing?" This is not common practice in rich Western countries.

Additionally, as sibling has already pointed out, sterile disposable syringes are extremely cheap.

[Ferret7446]

The reason we switched is because it's cheaper (including the logistics overhead costs). Sterilization and transport isn't free

[SoftTalker]

It's also not perfect. Sure you can throw instruments into an autoclave or even boiling water but they have to be kept sterile after they come out, which is probably harder to do especially in underdeveloped, resource-poor areas.

[M95D]

> they have to be kept sterile after they come out, which is probably harder to do especially in underdeveloped, resource-poor areas

It's actually very easy. Sterilization takes place in a stainless steel container that has "windows" on it's sides. When the sterilization cycle ends, these "windows" are closed just as the container is taken out of the autoclave. The container will remain sterile inside until opened.

Also, simply opening the container to take one syringe from it doesn't make it dangerously contaminated. As demonstrated by the article, the biggest danger comes from other people's blood (HIV, HCV, HBV), not ordinary bacteria we have on our skin.

[themafia]

> The unit costs are...high in the US

So many products are bundled into purchase agreements at hospitals that you can't, in general, sensibly talk about per-unit costs.

[imtringued]

The unit costs per syringe are incredibly low even by Pakistani cost of living standards and the cost of reusing a syringe is extremely high.

You're coming up with an extremely complicated solution that would be a complete non-issue if the yearly salary of Pakistani citizens rose by even a single dollar.

[i7l]

Do you know why they couldn't switch back to glass syringes?

[ButlerianJihad]

Equipment that can be sterilized has been forced out of the market by these disposable things. It is far easier to push disposable product on medical providers and encourage rent-seeking and subscriptions to such things.

It’s exactly the same way with contact lenses. When I was in college in the ’90s, I could get a pair of permanent contact lenses. They would cost a few hundred bucks, but they would last me several years if the prescription didn’t change. They were the same as glasses. You would clean them everyday and disinfect them, and they would serve quite well permanently.

But the contact lens industry decided that wasn’t good enough, and decided that they could sell subscription services for contact lenses that you would need to discard every night.

And those daily wear contact lenses, the disposable kind, basically forced out of the market the permanent ones and now the optometrist regards me as a Martian when I request permanent lenses instead.

[cromka]

You completely ignored human error aspect. Before the blood donation centers used one time use equipment, donors were getting infected with something nasty every now and then. You can sure as hell expect people to commonly forget to properly sanitize those syringes.

[M95D]

Sterilization is* the most strictly controlled process in any hospital. Nobody can just "forget" to sterilize or pick up a used syringe thinking it's sterile.

* Or at least it should be. It seems that Pakistan is different.

[cromka]

> Sterilization is* the most strictly controlled process in any hospital.

As aviation has shown—where human error has been studied for decades—reducing mistakes is difficult and expensive because it requires multiple layers of quality assurance. In countries where labor is costly, especially in healthcare, it has got to actually be cheaper to use single-use equipment, with the added benefit of reducing the risk of infection through that route to zero.

[LorenPechtel]

There is also the reality that a sealed package is more of a guarantee of sterility than something that should be autoclaved. Even in the US there have been cases of nasties being passed by inadequate cleaning.

And we had a big scandal locally. Were they doing a shoddy job of colonoscopies? Probably. But genetics left no doubt that they were using one needle per jab, but one syringe per patient. And drawing up from multi-use vials. Stick the hep C patient, in pulling back a bit ends up in the syringe. Discard needle, syringe is still infected. New needle, old syringe, draw from the vial again, vial is now infected.

[ButlerianJihad]

There is a secured room here where I've been assigned a PIN, but the room's door is unlocked between 6am-6pm. Nevertheless, I always enter my PIN on the pad, or at least try to recall it clearly. Because if you're in the habit of pulling that door open during the day, 8 months later will come a time it is locked, and you won't remember your PIN because you've never ever used it.

The same goes for sterilizing such things in a medical setting. I think HCPs are very accustomed to the disposable and pre-sterilized supplies that they don't even consider an item's sterile status or the need to sterilize it after use. So this is the pitfall that comes with all the disposable stuff: that routine sterilization is forgotten as a skill or as a necessity.

[SoftTalker]

You can still get rigid gas-permeable lenses that last basically forever, I wear them every day. You have to take them out at night and clean them, but you only buy them once (unless you damage or lose them, or your prescription changes).

[stratts]

Daily isn't the only option - you can still get monthly lenses.

[ButlerianJihad]

Like I said, with proper care and disinfection, permanent lenses could last for years, not days or months!

[kube-system]

Weren’t those the hard plastic ones with low oxygen permeability? They’re not as good for your eyes.

[ButlerianJihad]

No, they were soft, “hydrophilic” or for astigmatism, toric. The hard ones were old, old technology, and largely superseded.

[jonahx]

I share your hate of rent-seeking and subscription culture, but tbf disposable contact lenses are legitimately a nicer product to use. I've done it both ways.

[nulld3v]

It's not like glass syringes are out of production though? They are still pretty cheap, I get them for $0.50 each from China.

[technion]

Surely there is a cost to sterilising too.

[kqgnkqgn]

If you can't trust them to follow the very easy directions of "throw away the single use syringe", how likely is it that they are going to follow the much more complicated process of properly sanitizing the glass syringe?

[faangguyindia]

If you forget to autoclave them or not done properly you end up with infected patients, risk is just too much

[seb1204]

Sounds like the same risk as this situation of reusing them.

[kube-system]

Well if you’re going to infect people, might as well save money while doing so :)

[jjk166]

We sterilize plenty of other common tools like scalpels so that doesn't seem like a valid reason. Obviously the disposable design is not even an adequate solution to the risk of cross contamination. I would imagine if it were a real concern you could easily add something like a color changing strip that would indicate whether the needle has been autoclaved since its last use without rendering it useless.

[NDlurker]

Prions aren't destroyed by autoclave

[Marsymars]

They can "survive" autoclave cycles that render other pathogens dead/inactive, but there do exist autoclave cycles that seem to pretty reliably inactivate prions.

[Loughla]

No but viruses and bacteria are. What's your point and how common is transmitting prions?

[NDlurker]

My point is disposable is superior

[nameconflicts]

1. They're talking about the current situation, but you're bringing up history. 2. Given the lessons from the past, why would you still want to do something this dangerous?

[SanjayMehta]

From the WHO article linked to by GP, the issue is that patients also insist on injections over oral meds.

That's driving the insistence on injections, and rural doctors/clinics cutting corners.

[seb1204]

Cost, or availability due to cost. Still a driver in developing countries.