DOCTORS' DIRTY NEEDLES SPREADING DISEASE IN CHINA

LUOPING, CHINA A worried Dou Zhe rushed into Dr. Wang Yujia's storefront
clinic carrying a precious bundle. "He's sick," announced Mr. Dou,
unwrapping layers of colorful blankets from his 2-year-old son, a chubby,
listless boy in a blue jumpsuit. "He's normally mischievous, but since
tonight he's hot. He just wants to sleep -- he won't eat or play."

Dr. Wang, a kindly weathered man in a long white coat, determined that the
boy had a red throat and a fever of 102. He had a cold, one that would
almost certainly pass on its own in a few days.

Nonetheless, Dr. Wang drew up what has become an all-too-common rural
Chinese cure -- a syringe filled with four different medicines -- and
plunged the needle filled with yellow goo into the screaming boy's behind.

"We always come to see him, because he's a good doctor," Mr. Dou, a
construction worker, said with a note of satisfaction. "My boy's had lots
of shots."

China's love affair with injections and infusions is becoming a medical
nightmare, spreading illness rather than curing it, experts say.

In large part because syringes and needles are often inadequately
sterilized in rural China, experts say the overuse of medical injections
helps explain the alarming spread of blood-borne infections in China,
particularly hepatitis and, to a lesser extent, AIDS.

Today, 60 percent of Chinese have had hepatitis B, compared with just 1
percent in the United States and Japan. Some 150 million Chinese have the
chronic variety of the infection, which over time causes liver failure and
liver cancer.

"To a large extent the very high rate of hepatitis B has to do with unsafe
injections and excessive injection for common illness during childhood,"
the United Nations Common Country Assessment for China said in 1999.

The problem of needless shots is particularly severe in rural areas, where
doctors often have little formal medical training and receive extra income
for each injection they give, and where patients and doctors alike see
shots as a sign of progress.

Dr. Wang, for example, is not really a physician, but a former farmer who
learned his basics when he was appointed a "barefoot doctor" under China's
Communist system in the 1960's. In all, he has received just two years of
medical training, and that in the mid-1980's, when Western medicines were
not available in the countryside.

And so when a little boy arrives with a cold, he draws up an injection
composed of two antibiotics that are unnecessary and will promote
resistance, an antiviral drug that has no use against the common cold and a
powerful steroid that will only make his immune system less able to fight
infection.

A 2000 survey of medical care in 40 rural counties conducted by Unicef and
the Chinese Health Ministry found that 47 to 65 percent of children had
received injections as treatment for their last cold.

While it is extremely rare for children in the United States to get shots
aside from immunizations, many Chinese children get more than half a dozen
a year.

But far more important than the immediate side effects of these
freewheeling injections is the risk of acquiring devastating disease,
since, as in much of the developing world, rural Chinese doctors try to cut
costs by reusing potentially contaminated equipment.

While there is no evidence that this 2-year-old suffered lasting harm from
his shot, in one 1999 study, Chinese researchers found that 88 percent of
injections in a large rural county were unsafe, most often because doctors
reused needles and syringes after inadequate or no cleaning.

The Health Ministry has encouraged clinics to switch to disposable needles
and syringes, but even those are sometimes reused, or cleaned and
repackaged in a large underground market, according to medical experts here
and reports in the Chinese press.

Such practices have probably also contributed to China's emerging AIDS
problem, though scientists believe that H.I.V., the virus that causes AIDS,
spreads less efficiently than hepatitis by this route. Statistics on the
spread of H.I.V. in rural areas have been shrouded by official secrecy and
many victims do not even know that they are infected.

"We already know many people have been getting hepatitis from shots," said
one health expert who has worked extensively in China. "And that worries me
a lot about the spread of AIDS."

Although there is now a hepatitis B vaccine that is widely used in the
United States, it is expensive and not included in the Chinese government's
free vaccination programs, so a majority of poor rural children do not get it.

Government officials have acknowledged the problem of unsafe injections and
have repeatedly tried to ensure proper use of sterile medical equipment and
better regulation of its manufacturing and disposal. But the problem has
been difficult to stop.

"Unfortunately, rural doctors often rely on medicines and shots for income,
and the farmers think they need an IV to be cured," said Zhu Ling, an
economist at the Chinese Academy of Social Sciences who studies health
care. Even rudimentary clinics in rural China now have rows of IV bottles
hanging ready along the wall.

Government regulations allow rural medics to charge only pennies per visit,
but they may add fees for the medicines and shots. With only minimal
training, many do not understand how to use many of the medicines that line
their shelves, or even the risks of injection or failure to use proper
sterilization techniques.

Dr. Wang owns one of many private clinics in this small city in China's far
southwest, and he is clearly more careful and conscientious than most of
his competition.

He is proud, for example, that he has switched to disposable plastic
syringes and needles, which he unwraps to give 2-year-old Dou Youjun his
shot and then quickly deposits into a large cardboard box on the floor
overflowing with others like it.

In many rural clinics, used syringes and needles sit on the counter,
waiting for reuse.

In a December 1999 study in The Chinese Journal of Epidemiology, 56 percent
of rural doctors said they changed equipment only if they could see blood
in the syringes.

But it is not at all clear that Dr. Wang's disposable syringes will be
disposed of properly. In theory, and according to official government
policy, used disposable needles and syringes should be destroyed, since
they are made of materials that can not be fully cleaned.

But here, Dr. Wang said, his box is picked up once a week by someone who
"takes care of them."

"These can't be used more than once," he said. "They need to be taken off
and sterilized first."

Most rural doctors know little about what happens to their discarded
equipment, but there is ample evidence that it sometimes makes its way back
to the bedside.

At a huge "recycling center" just outside the Fourth Ring Road in Beijing,
a migrant worker in a padded gray jacket who gives his name as Mr. He
reaches into a metal bin and pulls out a massive tangle of plastic IV
tubes, with needles still attached.

In this vast open yard where hundreds of small traders in paper, metal,
cardboard and plastics sort through the detritus of life in Beijing,
unmarked trucks from hospitals and clinics routinely deliver syringes,
blood bags and IV tubes, often with fresh blood still clinging to the side.

"It's a good business, since medical plastics sell for much more than
ordinary plastic," said Ren Xinyang, a skinny 30-year-old, standing in a
stall littered with old needles.

Most of the plastic from this center goes by truck to Wenan in Hebei
Province, about 60 miles outside Beijing, a place renowned for its
wholesale plastic market.

Every yard in Wenan is littered with plastic castoffs. In one tidy
compound, owned by a family named Jiang, bags of dirty medical waste are
the raw material of a business that nets $5,000 a year.

Behind a white tile wall, blood-tinged syringes and needles are fed into a
large manual grinder that spits out bent needles and deposits plastic
fragments on the other side, which are given a cursory wash in a shallow
cement pool before being packed away for sale.

The plastic is then used to make heavy-duty plastic sacks, a family member
said.

But there are also bags of whole syringes. And although family members
insist that they do not sell those anymore, they acknowledged that they had
in the past. "Two years ago, people from Henan and Zhejiang would come to
buy whole syringes, and we got a much higher price than selling scrap," Ms.
Jiang said.

In the last year, Chinese newspapers have covered several police raids on
small backyard factories that were illegally cleaning and repackaging
disposable syringes. One such workshop in Zhejiang Province held more than
14 tons of used single-use medical equipment, including more than four tons
of needles, The Legal Daily reported.

Since most Chinese get so many shots, it is nearly impossible to prove that
any one injection was responsible for disease. But doctors say the
cumulative effect is obvious from China's alarming problem with hepatitis B.

Hepatitis B causes pain, nausea and fatigue and can become a chronic
infection, leading to liver failure or cancer of the organ. Liver cancer,
rare in the West, is the leading cause of cancer deaths in China.

Hepatitis B can be transmitted three ways: during childbirth, through
intercourse or through infected medical equipment or transfusions. Research
suggests that a huge number of children are getting the disease after birth
but before they are old enough to have intercourse, making injections the
by far most likely explanation in their cases.

In one study, 9 percent of pregnant women had active hepatitis, meaning
that at most 9 percent of children could get it at birth. But by age 6, the
researchers found, 34 percent of children were infected.

Other research has found that the likelihood that a 2-year-old had
contracted hepatitis was directly proportional to the number of injections
he or she had.

Among toddlers who had one to five shots, only 12 percent were infected.
Among those who had 6 to 10 shots, 25 percent were infected. And among
children who had 11 to 20 shots, the figure was a whopping 62 percent.

At a recent medical conference, Dr. Liu Shijing estimated that 30 to 40
percent of hepatitis B in China resulted from medical exposures, and some
foreign experts put the number even higher.

"Shots should be preventing this disease," said the medical expert who has
worked in China, "but you can see from the numbers that now most are
getting it from shots."

Accompanying article:

GRAPHIC: Photo: At a huge "recycling center" in Beijing, a migrant worker
who gave his name as Mr. He reached into a bin and pulled out IV tubes with
needles. (Elisabeth Rosenthal/The New York Times)(pg. A10)

Map of China highlighting Luoping: Luoping is a small city in a rural part
of southwestern China. (pg. A10)