Children as young as 12 years old are making surgical instruments in hazardous conditions in Pakistan.
Illegal child labour was witnessed in at least a dozen small workshops in in Sialkot, the north-eastern city of Punjab province, where 99% of the country’s surgical instrument production is centred, prompting fears that the tools could be used in the NHS.
Boys are paid less than $1 (70p) a day to cut, drill, bend and polish steel pieces into gleaming surgical tools for export, the Guardian has discovered.
Inside the cramped workshops, metal dust is everywhere and the noise of the grinders, polishers and generators is deafening. But there is no sign of protective goggles, earphones, masks or other safety equipment.
Three companies that export to the UK said they buy instruments from these workshops.
The evidence has ignited fears in Britain that tools used routinely in NHS operating theatres and consulting rooms are made with child labour.
NHS Supply Chain, among the largest suppliers to the NHS, bans child labour from its “first tier” suppliers, most of whom are based in the UK. However, it admitted it does not know which manufacturers are used in Pakistan.
Doctors, politicians and a labour rights group, the Ethical Trading Initiative, say more must be done to ensure child labour is not found in the NHS supply chain.
Dr Mahmood Bhutta, an NHS surgeon and founder of the British Medical Association’s (BMA) Medical Fair and Ethical Trade Group, said: “For many of the instruments I use, I have no reliable way of ensuring they have not been made by children.”
Britain is the third largest buyer of surgical instruments from Pakistan, accounting for 10% of the country’s total exports. In all, 80%-90% of surgical instruments are manufactured in the country, according to NHS Supply Chain.
Bhutta said that while pay and conditions have improved in some larger factories since the BMA first investigated the issue in 2008, serious worries remain.
“We still don’t know where most surgical instruments coming into the NHS are made. But we do know a lot of them will have come from Pakistan. I would be amazed if at least some of the instruments used in the NHS weren’t made in these small workshops.”
The protection of workers’ rights, as well as more transparency, should be written into the NHS constitution, Bhutta said.
Cindy Berman, head of modern slavery strategy at the Ethical Trading Initiative, said: “NHS budgets are tight, but savings mustn’t come at the expense of human rights.
“We know child labour exists in the surgical instrument sector in Pakistan, often in the initial stages of production, and it’s likely that some of these instruments will end up here in the UK. While NHS Supply Chain has taken important first steps in tackling these abuses, more can and should be done.”
She said child labour flourishes when adult workers cannot afford to feed, house and clothe their families, which is why public bodies like the NHS need to make sure they are paying fair prices and sourcing ethical suppliers.
The Pakistan export market in surgical tools is worth $358m (£255m), a tiny slice of a lucrative global market worth $17bn. Most of it is based in Sialkot, but local manufacturers receive only a small portion of the revenue, while outsourcing importers make the largest profits.
Iram Zafar, secretary general of the Surgical Instruments Manufacturers Association of Pakistan (Simap), said the sector had produced and exported more than 15,000 pieces to the UK between July and December last year, worth $11.4m.
According to Simap, 3,600 factories produce 150 million instruments a year. Labour forces vary from 15 to 450 people.
Pakistan has signed up to the UN’s sustainable development goals, which call for an end to child labour by 2025. Punjab laws ban under 18s from working in “hazardous industries”, and children under 14 from working at all. But child labour is common in a country where poverty is endemic, compliance with labour laws weak, unions scarce and profit margins low.
While no official survey has been carried out in Pakistan since 1996, the underage workforce is estimated at between 5.7 and 12.5 million. The ETI suggests the incidence of child labour is high, against a declining trend globally.
Zain, 12, who began work in one of Sialkot’s surgical instrument shops eight months ago after his father died, works eight hours a day, six days a week to bring home $25 a month.
“I know it’s dangerous, but I have to pay some debts and support my family,” he said.
At busy times, he can work as many as 12 hours a day. At night, the children often suffer from dry coughs, asthma and other respiratory problems.
His colleague Azwar got a job in a small workshop more than a year ago, when he was 12. “I have to support my parents and siblings to make ends meet,” he said.
The workshop’s owner, who declined to be named, said his business had never been inspected by the Punjab Labour Department in 25 years. He acts as a sub-contractor for the city’s larger factories, but refused to provide names.
The sub-contracting, combined with the complexity and lack of transparency of the supply chain, makes it difficult to trace the surgical instruments from forge to operating theatre.
NHS Supply Chain is not subject to the same transparency requirements of private companies under the Modern Slavery Act, something that campaigners, including the ETI, are keen to change.
Lola Young, Baroness of Hornsey, has proposed a private member’s bill to promote transparency across supply chains of British companies and public bodies, by requiring them to provide a statement on slavery and trafficking in their annual reports and accounts.
“If including child labour is in your business model, you have to change your business model,” said Young, who has been involved in supply chain analysis in the fashion industry.
NHS Supply Chain said it does not know which manufacturers its suppliers use in Pakistan. Neither does it require its suppliers to audit their Pakistani suppliers, although it said that some do.
The Guardian wrote to 22 of NHS Supply Chain’s “first tier” suppliers asking if they source instruments from Sialkot. Only six replied, one of which said it did not supply to the NHS. Two confirmed they did source instruments from Sialkot and three said they did not. NHS Supply Chain confirmed 11 of its suppliers source from Pakistan, but declined to give company names.
A spokeswoman said NHS Supply Chain was committed to working with suppliers serious about managing labour standard issues in their supply chains, but accepted more needed to be done.
She said: “We are aware of the potential for labour standards abuses to occur within supply chains [for] surgical instruments, which is why we have taken steps to increase requirements for supplier due diligence in our contracts and worked … to develop guidance and systems to address these issues.
“We believe that the supplier code of conduct, the LSAS [Labour Standards Assurance System] approach and the guidance and advice that we have provided to our suppliers has been effective in shining a light on the issue across the industry, however, we are not complacent and we recognise that it will require continued effort and vigilance across the sector to raise and maintain standards uniformly.”
The LSAS was introduced in 2012, requiring first tier suppliers to map their supply chain and assess labour abuse risks.
