In December 2014, Yem Chrin, an unlicensed Cambodian doctor, was charged with murder. By reusing the same syringe, he had infected over 270 people in a remote community in the Battambang province, from the ages of two to 82, with HIV.
While many instances may not be so high-profile, reusing syringes is a major way HIV and other diseases can be transmitted. A 2014 WHO report estimated that in 2010, as many as 33,800 people were infected with HIV, up to 1.7 million with hepatitis B virus, and 315,000 with hepatitis C virus, through the reuse of syringes in healthcare settings.
"In some countries where resources are very limited, it became clear that people were reusing syringes," Lisa Hedman, project manager at the World Health Organization, told me. "There was an ingrained belief that you could use the same syringe for members of the same family and that it didn't matter [...] When you're bringing healthy people into a facility and injecting them with something to help them not get sick, if you send them away with a disease that's actually pretty terrible."
In February 2015, the WHO issued a policy that urged all nations to switch to the use of "smart" single-use syringes by 2020. These are syringes that are specifically engineered with a metal clip to prevent the plunger from being pulled back after use, or which have a weak spot in the plunger that makes it break if someone attempts to reuse it. The transition could potentially help save millions of lives.
Marc Koska, founder of the company Star Syringe and inventor of the K1 Auto-Disable syringe—which breaks after a single use, and which he has been working on for the past 31 years—thinks the policy will put more pressure on syringe manufacturers to start producing smart syringes.
"The WHO's global policy has been a massive step forward because now we're able to say to manufacturers: 'Number one, you've got to do it; number two, you've got to do it otherwise you look like you're negative; and number three, you've got to do it because that's the only product being paid for by the international donors," Koska told me over the phone.
"Most healthcare workers who do reuse syringes are really decent people, but the system forces them to."
While a regular syringe's plunger can be moved up and down without a hitch, Koska's smart syringe has two specifically engineered parts. A small valve mechanism is moulded into the front end of the plunger, and a ring-like device is placed inside the wall of the barrel. Once an injection is administered, the two lock together, any excess force causing the plunger to snap in half.
This prevents reuse of the syringe. Currently, reuse is caused both by lack of awareness, but also when external factors such as governance, infrastructure, and corruption affect the supply of syringes to locations in the developing world.
"Most healthcare workers who do reuse [syringes] are really decent people, but the system forces them to," said Koska. "If the shipment gets lost or destroyed on the way and you're 500 miles away from the warehouse and you're in Sudan, or in Congo, what do you do when you've only got 12 syringes and 200 customers? Their choice is really very limited."
Hedman also pointed out the discrepancy between supply and demand as a key determining factor for syringe reuse.
"There's a lot of wild west advocacy where people say, 'Surely people should be willing to pay for a syringe if they're willing to pay for airtime on their mobile phone,'" said Hedman. "But that's not really the question. The transport and storage costs for syringes are actually enormous [...] it's not necessarily whether it's affordable to the patient or the consumer; for the patient to actually pay for that service and say 'yes, I'm actually going to buy a syringe'—it actually has to be there for them to purchase."
According to Hedman, so far Egypt, Uganda, and India have expressed high levels of interest in making the switch to smart syringes as soon as possible. "The way Hepatitis C gained prevalence in Egypt was through the reuse of syringes. This was many years ago, but once you've created a spread like that it's really difficult to bring that back down," she said.
In order to curb the spread of the hepatitis C virus, of which Egypt has the highest percentage in the world, Hedman explained that the country was mobilising both its local manufacturing industry to start making the smart syringes, and launching public information campaigns later this month.
Koska primarily gears his syringe technology toward the developing world. In 2006, he founded a charity, the SafePoint Trust, which raises awareness on safer immunisation practices in India and Pakistan. While he has seen demand for his auto-disable syringe increase since the WHO's policy was implemented in February 2015, he explained that at present the supply couldn't meet it.
"We currently don't have enough [smart syringes] being made. This will be a revolution in manufacturing—we'll see normal syringes being replaced by auto-disable ones," he said.
Koska is one of many people and companies who have been working on single-use syringe technology. He has been fine-tuning various iterations of the K1 Auto-Disable over the last decades. He explained, however, that the aim was never to start up the manufacturing process from scratch, but rather to work with what's already out there.
"It was very much a simple transition of the product—the aim was to make [the K1 syringes] on existing machinery, for the same use, and for the same price [as a regular syringe]," said Koska.
"I realised that we've got a really ingrained industry which is fully tooled up with huge amounts of capital expenditure on all these bits of kit we use, and that if I was going to come along and say, 'This is all rubbish throw it all away,' it would have been a non-starter; so I had to make it as cooperative as possible with the existing tech."
But that meant coming head-to-head with opposing business models, and bigger companies that have resisted change.
"One of the biggest learning curves for me was to understand that syringes in particular were very much a loss leader. They are made as a commodity, shipped around the world very much as a brand carrier for the manufacturer," said Koska. "The manufacturers always want to have reasonable syringe sales with good branding on the syringes because that allows them to have a market share where they can sell other products, which have a much higher margin."
For Koska, who went earlier this year to Roka—the remote community in Battambang province where more than 270 people were infected with HIV—the mission is simple.
"What we're doing by making these syringes auto-disable, is we're raising awareness of the reuse and bad practices issues," he said. "But we're also raising awareness to health care workers and the public, so that they keep asking for the same products either to use, or to be used on them, because they know that they're better."
Modern Medicine is a series on Motherboard about how health care and medical technology can move forward so rapidly while still being stuck in the past. Follow along here.