Arianne Shahvisi and Mei Trueba.
One of the greatest controversies of the UK coronavirus crisis is the shortage of PPE for NHS workers. Yet most PPE is made in sweatshops, and its production endangers the health of those who make it. Ironically, workers who produce personal protective equipment for others invariably have inadequate protection themselves.
Over the last few decades, many in the UK have sneered at what’s seen as a “health and safety” culture, a “nanny state” where people are over-protected by mountains of “red tape.” That particular gripe is falling out of fashion as we write, with the UK facing a health and safety failing of a previously unimaginable scale, with our most critical workers exposed to deadly risk as they work against the odds to save others’ lives.
More than a hundred NHS workers have now died on the frontlines of the coronavirus pandemic. It is likely that many, if not most, of these deaths could have been avoided had workers been supplied with appropriate personal protective equipment (PPE). Some workers would have avoided contracting the virus, while others would have been exposed to lower viral loads, leading to less serious illness.
Instead, as the UK government stalls, staff are buying their own masks, wearing bin liners as gowns, and relying on members of the public to donate homemade scrubs and visors. The alternative is sharing equipment with others, or, in far too many cases, making do without. Despite widespread alarm, and continual promises from the government, the situation seems to be getting worse. Key PPE items such as gowns, visors, swabs and body bags were not included in the government’s pandemic stockpile, bringing into question the UK’s pandemic preparedness and explaining some of the PPE shortages faced today.
Attempts to blow the whistle on this terrifying shortage of essential equipment have led to NHS employers silencing their staff. It has been suggested that the UK government may be acting unlawfully in failing to provide adequate PPE. Article two of the European Convention on Human Rights requires that citizens are protected from avoidable risk, and both the 1974 Health and Safety at Work Act and the Personal Protective Equipment at Work Regulations 1992 place a duty on employers to ensure that suitable PPE is provided to those who are exposed to health or safety risks while at work. There will be grave moral and legal questions to answer once the height of this crisis has passed.
Yet even if workers did have all the PPE they need, there are other serious ethical issues to contend with. Most masks, gowns, and gloves are manufactured under sweatshop conditions in low-income countries such as India, Turkey, Myanmar, Malaysia, China, Mexico and Thailand. Within these settings, workers are rarely paid minimum wage, and are often required to work excessive hours. Many factories are known to employ children, forbid unionisation, and illegally retain the passports of employees. In Malaysia, workers manufacturing gloves face serious labour violations, including forced labour and in debt bondage of impoverished migrants from Bangladesh and Nepal. Nor are these violations limited to low-income states. Garment factories in Los Angeles have resourcefully rebranded as mask producers, but workers are earning half the minimum wage, under conditions which do not adequately protect them from contracting COVID-19 at work.
There are also serious occupational health risks associated with the production of PPE, and workers are afforded few protections. Ironically, workers who produce personal protective equipment for others invariably have inadequate protection themselves. The production of healthcare textiles such as masks and gowns has been linked to lung cancer and silicosis, a long-term scarring and inflammation of the lungs due to exposure to silica dust. Those manufacturing gloves are exposed to toxic chemicals and fumes, skin and eye burns due to temperatures as high as 70°C, and the risk of hearing loss due to excessive noise levels.
As PPE demand has risen exponentially, factories in PPE-manufacturing countries have been prompted to continue and often upscale production in precarious conditions despite nationwide lockdowns. Increased demand has also spawned the predatory development of new and improvised sweatshops in Turkey, Afghanistan, Bangladesh, China, and South Africa that, often operating with no certification, risk the health of both workers and of the potential users of the products manufactured.
Recognising the importance of good corporate citizenship, NHS procurement has since 2019 been guided by a Supplier Code of Conduct that later incorporated a Labour Standards Assurance System to help protect workers’ rights in healthcare supply chains. However, evidence of continued labour violations within NHS supply chains illustrate that much more needs to be done. Further, the government has now announced emergency procurement measures which shift the focus onto rapidly accessing PPE, leading to the side-lining of ethical concerns.
This pandemic looks set to stretch far into the future, and PPE, being both essential and disposable, will remain in high demand. Ensuring a reliable supply of products is critical to keeping health workers alive and well and able to protect others. However, in securing PPE for NHS staff we must not ignore the abuse of the very many impoverished factory workers who, in responding to the surge in demand, have become more vulnerable than ever. To do so is to privilege one kind of protection over another, and to treat one group of workers as more deserving of safe working conditions.
Pandemic or not, the NHS Supply Chain must factor ethics into its procurement decisions, or we who benefit from NHS care do so at great cost to the health of others elsewhere in the world. Occupational health is essential for everybody, and the NHS should not be securing it for some in ways that preclude it for others.
Authors: Arianne Shahvisi and Mei Trueba
Affiliations: Senior Lecturer in Ethics, Brighton and Sussex Medical School [AS]; Lecturer in Global Health, Brighton and Sussex Medical School [MT].
Competing interests: None declared.