Labour and occupational health violations in the manufacture of surgical goods

Produced in cooperatives, unregulated factories or sweatshops in Pakistan, Mexico, Thailand or the USA, the jobs generated under this open global competition are often unregulated, insecure and highly unhealthy,1 3 6 and often imperil, rather than safeguard, the health and well-being of workers and their dependants both in the short-term and long-term. This tends to be the case whether or not states have ratified the International Labour Organization’s conventions18 and regardless of the existence of adequate legislation and enforcement mechanisms.1 21 Since 2007, NGOs such as the British Medical Association, Swedwatch and Finnwatch have produced reports on labour rights violations and precarious employment in the healthcare manufacturing sector which supplies the NHS. The most notable examples are the Pakistani surgical instruments and Malaysian gloves manufacturing industries. In Pakistan, the manufacture of surgical instruments is associated with non-compliance with local labour laws with regard to minimum wage and excessive overtime, unfair contractual obligations, widespread child labour and an absence of health and safety protections.4 5 18 In Malaysia, the gloves industry is associated with ad hoc employment, poor remuneration, compulsory overtime, insufficient health and safety provisions, anti-union activities and bonded labour of migrant workers involving illegal retention of passports.17

There is little information regarding the specific disease burden associated with working on these production lines and, as happens with other industries, attempts at measuring this burden are often obstructed by suppliers, buyers, producers and/or governments themselves.20 21 The limited available evidence indicates that in the manufacture of surgical instruments in Pakistan, musculoskeletal problems and injuries are common, sometimes leading to significant impairment, including loss of limbs.5 There are serious dangers at various stages of the manufacturing process, including exposure to heavy machinery, hazardous electrical wiring, toxic and corrosive chemicals, metal dust and deafening noise-levels in grinding rooms.5 18 When unmanaged, these occupational hazards can cause cuts and burns to hands and feet, repetitive strain syndrome, trauma to the eye, noise-induced hearing loss, visual loss, electric shocks, chronic obstructive pulmonary disease or lung cancer.22 However, as employers are able to freely curb collective-bargaining rights with anti-union policies,18 disempowered workers in need of an income often operate machinery that is not regularly checked without any personal or collective protective equipment.18 Further, workers’ wages are insufficient even by Pakistan’s own household income standards5 and therefore do not permit regular contributions to social insurance mechanisms that could enable workers access to healthcare or disability benefits.

The manufacture of other healthcare goods presents similar risks. For instance, the manufacture of healthcare textiles has been associated with silicosis and lung cancer, while unprotected glove-manufacturing is associated with exposure to chemical products, temperatures above 45°C (and sometimes as high as 70°C), noise levels that can cause hearing loss, skin and eye burns, fume inhalation and other physical impairments associated with repetitive motion and frequent lifting.17

In spite of these harms, as happens with other industries, many governments bend existing legislation in their efforts to increase much-needed local and national employment and economic opportunities, manufacturing companies accept these deals to maintain or expand their operations, and poor and disempowered jobseekers often pursue these jobs in the absence of alternatives.20 21 In order to remain competitive and maintain profits, many suppliers continue to cut costs by outsourcing production to locations where lower wages will be accepted and labour and occupational health regulations can be disregarded.23 To maintain contracts with buyers, some industries (eg, Mexican surgical masks manufacturers) have further reduced production costs through eliminating factory operations and instead relying on hundreds of homeworkers who receive no employee benefits and only an insecure income.15

Existing efforts towards ethical procurement in the NHS

Since 2009, ethical sourcing within the NHS Supply Chain has been guided by the Supplier Code of Conduct (SCC), which outlines basic standards in relation to labour rights and worker well-being. According to the NHS Supply Chain, this code is a contractual requirement and any violation of the obligations it stipulates are considered a breach of contract by the supplier.24 In response to evidence of continued labour right violations since the implementation of the SCC, the NHS Supply Chain worked closely with various industry bodies and ethical trade organisations to develop the Labour Standards Assurance System (LSAS) in 2011. The LSAS is intended to support the SCC for products where there are documented labour rights violations, such as surgical instruments, gloves and textiles.17 18 Piloted in 2012 in relation to surgical instruments, LSAS requires suppliers in the NHS supply chain to demonstrate they have systems in place to guarantee the labour and human rights of workers, and helps them to develop rectification plans when necessary. Strengthened by the Modern Slavery Act 2015, which makes companies accountable for labour abuses occurring along their whole chain of operations, the SCC and LSAS quickly became the cornerstone of the NHS Ethical Procurement Strategy.

These recent regulatory changes have led to small demonstrable improvements in some workers’ lives. For example, some surgical instrument suppliers subject to the LSAS requirements in Pakistan have demonstrated efforts towards improving labour standards, including minimum wages and paid overtime.18 Glove manufacturing audits have also indicated some improvement to working conditions, including formalised contracts, some leave entitlement and minimum wage as per national regulations.17 However, these advances are neither widespread nor lasting, and several counts of non-compliance were observed during visits to factories in both Pakistan and Malaysia, primarily regarding working time, production targets and safety measures.17 18 Recent media reports have also revealed continued abuse of migrant workers in the Malaysian gloves manufacturing sector, including in factories that are subject to the LSAS standards required by the NHS Supply Chain.17 When asked about the challenges they face, Pakistani factory owners and managers highlighted the negative impacts that low payments and volatile contracts have on their ability to comply with labour regulations and invest in safety measures: ‘…buyers need to understand the costs. They do not want to pay much but have lots of demands. Without sustainable contracts and prices how is it possible for us to improve?’.18 Clearly, a key challenge to ethical procurement for the NHS is the NHS Supply Chain’s single-minded emphasis on maximising savings.

Global health inequality

A public good is a physical or non-physical resource or service that meets human needs or desires and is non-excludable and non-rivalrous.35 A good being non-excludable means that it is not possible to prevent those who do not pay from benefitting from the good; a good being non-rivalrous means that one person or group’s use of the good does not reduce the utility of the good to others. Herd immunity to an infectious disease is a public good, and is easily established to be both non-rivalrous and non-excludable, likewise for clean air, street lighting, pavements and certain forms of knowledge. Well-funded, free, universal healthcare—that is, the NHS in principle, if not in practice—may be argued to be a public good. It is non-excludable, since everyone who is ordinarily resident in the UK qualifies for it regardless of their level of contribution, and it is non-rivalrous, since (provided it is well-funded), no one person’s use of the service precludes anyone else’s.

Even if one can argue that healthcare is a public good in the UK (and we will not attempt to take up this challenge here), one certainly cannot argue that health itself is a public good. Healthcare is only one determinant of a person’s health, and is often not the most important. Together with rights and entitlements, diet, exercise, living conditions, occupation, socio-economic status, ethnicity and gender (among other factors) are strongly determinative of a person’s health possibilities.2 36 Since these contributors are manifestly not public goods, health itself cannot be a public good, rather, it is a good that is rivalrous and excludable to the extent that these determinants are affected by factors that are rivalrous and excludable, notably, economic considerations which are definitionally so. Understanding health inequalities therefore requires attention to its political economy, especially since healthcare and other health determinants are increasingly marketised and privatised within an ever more globalised economy.37 Political economy approaches to health are perhaps best expressed by Nancy Krieger, who writes that “analysis of causes of disease distribution requires attention to the political and economic structures, processes and power relationships that produce societal patterns of health, disease and wellbeing via shaping the conditions in which people live and work”38 (p. 168).

At the global scale, health outcomes in different world regions vary dramatically. One can see this for instance in the 34 year gap between the life expectancy of Japan, at the top of the life-expectancy table, and Sierra Leone, at the bottom.39 The wealth of Global North states enables the health of their citizens; the poverty of Global South states tends to limit the health of their citizens, and a similar dipole is observed within nation-states where socio-economic inequalities determine in-country health inequities. Importantly, the wealth of certain world regions and populations is related to the poverty of others, notably through histories of colonialism, and the present-day neo-colonial global economic system, which tends to concentrate capital in Global North states, elites and corporations.40 As Benatar et al 41 note, “the present dominance of perverse market forces on global health” has led to a situation in which “disparities in wealth and health have persisted and, in many places, widened” (p. 646). Globally, health is excludable, rivalrous and uneven because wealth and power are excludable and rivalrous, and are vastly unequal at the global scale.

In this article we are concerned with one particular case within a variety of ways in which health is rivalrous: a reduction in the health of one group is related to an improvement in the health of another group. Such cases seem particularly pernicious, since it is morally troubling that the health of one group should ever be facilitated at the expense of another’s.

There are some important analogues to consider. First, the international ‘brain drain’ of health workers, in which those who are trained in lower-income countries, often at the expense of taxpayers, migrate in search of higher pay, health entitlements and better living and working conditions, and therefore end up benefitting the health of those in destination states, while leaving their own communities with stark shortages of health-workers.42 This seems even more problematic when one considers the inconsistency of the migration of medical workers into the NHS and the increasingly draconian restrictions on migrants’ access to free NHS care. Clearly, achieving good health for some groups is deemed to justify the poaching of health-workers from communities with a dire need for them, but the people of those communities may not access high-quality healthcare if they migrate.43 Consider also environmental racism and classism, where polluting activities take place close to, or within, the neighbourhoods of those with low socio-economic status, thereby decreasing their health possibilities in order to protect the health possibilities of those of higher social status.44 Finally, consider the global waste trade, in which high-income states pay lower-income states to dispose of, or recycle, their waste, including healthcare waste45 and items that are toxic.46 It has been reasoned that the cost to the health of those in the Global North renders in situ disposal not worthwhile, given the priorities of Global North people, while the sums that are paid to low-income states renders the cost to health acceptable.47

To see more clearly why these cases are particularly morally concerning, consider the following thought experiment: a new machine is invented that filters dangerous pollutants from the air of a particular wealthy neighbourhood, improving the air quality and therefore the health of those who live in this area. However, the machine requires a team of workers to continually clean the filters, releasing high concentrations of pollutants which they cannot avoid inhaling, causing serious health problems. It seems morally intuitive that we should reject such a ‘health-improving measure’ given that it is in fact health-endangering for some. Indeed, calling such a machine a ‘health-improving measure’ would be a misrepresentation of its total effects, and would amount to an admission that the health of some people was more important than the health of others, which points to an obvious injustice (A utilitarian might argue that the machine would be justifiable if the beneficiaries of the clean air sufficiently outnumbered the workers harmed by it, or if the harms to the workers were relatively minor, but these arguments would be more forceful if the workers were equipped with high standard protective gear to mitigate the risks they face, which dovetails with the argument we are making.).

In principle, health need not be rivalrous, since resources could be distributed in such a way as to ensure that everyone had equitable and adequate access to the determinants of good health (see for example48). In the current global economic system, the determinants of health are closely tied to the distribution of wealth and other predictors of quality of life (including labour protections), with the result that good health for some is often secured in ways that negatively affect health for others, as in the examples just described. This analysis can also be applied to health-enhancing healthcare goods, which are produced in health-endangering work environments, where the mandate that profits be optimised is prioritised over all other considerations. The obvious moral lens through which to understand this injustice is cosmopolitanism—the idea that moral consideration transcends national borders.49 50 This is appropriate when considering health-enhancing products that rely on workers from other states and regions within a globalised economy.

Cosmopolitanism requires that we do not favour one group’s claims to health above another’s merely on the basis of geography or any other contingent factor, so that the health-enhancing effects of healthcare goods must be considered alongside the health-endangering aspects of their production, regardless of the physical distance between the sites of benefit and harm or the citizenships of those affected. Cosmopolitanism also demands that we start from the assumption that the health needs of every person, regardless of their nationality, is equally important. It then follows that a health system that manages to provide a high standard of healthcare to its citizens because it economises by relying on products which harm citizens elsewhere is acting unjustly. If health is to be understood as rivalrous, then health justice requires all actors to be sensitive to the ways in which the improvement of health in some contexts might harm health in other contexts. This is in contrast to a ‘statist’ perspective, in which one sees the UK or the NHS as having special or limited obligations to its own citizens or users, and companies or government of states in which healthcare products are manufactured as having sole responsibility for their workers or citizens (see for example51 52). Given that health is a rivalrous good which is sought against the backdrop of a globalised economy, we contend that statism is an inadequate lens through which to seek health justice, particularly in the case under study.

Finally, it is worth noting that while other forms of work may also involve serious risks and burdens for the benefit of others (eg, a nurse working on an infectious disease ward), consider that the protections offered to those producing healthcare goods are woefully inadequate, while those working in other professions and contexts tend to have protections and (sometimes) remuneration which reflect the risks and burdens they face. We can therefore say that while many workers face burdens and risks, some burdens and risks are unjust.

In short, we should be concerned about whether the production of healthcare goods is worth the cost to those who make them, and whether they are improving health as a whole, rather than just for some people. Of course, the answer lies not in rejecting masks, gloves and instruments, but rather in ensuring that the conditions of their production are such that avoidable risks to the health and well-being of workers are minimised. We turn to this in the next section.