The Human Cost of Healthcare
Stephanie Ashmore Senior Research Officer British Medical Association, London, UK Mahmood F. Bhutta, FRCS, DPhil ENT Surgery Registrar, John Radcliffe Hospital, Oxford, UK Founder, Medical Fair and Ethical Trade Group, British Medical Association Editor’s Note: During the 2012 Cochrane Colloquium in New Zealand, several Academy members and staff had the good fortune to be introduced to Mahmood Bhutta, FRCS, DPhil, research fellow, Oxford University, and founder of the British Medical Association’s Medical Fair and Ethical Trade Group. Upon hearing of this compelling global health-related concern, they invited Dr. Bhutta and his senior research officer, Stephanie Ashmore, to submit an article for the Bulletin. While the Academy has not conducted research itself on the issue of unethical working conditions in the manufacture of some medical products, we are pleased to share this information with you for your consideration. Introduction Every year, trillions of dollars are spent on medical supplies. In many cases, little consideration is given to the conditions in which they are made and their impact on the people who make them. Research carried out by the British Medical Association (BMA) Medical Fair and Ethical Trade Group has revealed unethical working conditions in the manufacture of a number of medical products, especially those bound for the operating room. 1,2,3,4 The operating room is the largest user of medical supplies within the hospital, typically accounting for a third of all hospital supply costs.5 When making purchasing decisions for healthcare, consideration is given to value for money and quality, but consideration is rarely given to the conditions in which these supplies are made. Abuses of labor standards have been uncovered in the manufacture of many of the high-throughput supplies used routinely in the operating room, including latex gloves from Malaysia,1 surgical masks from Mexico,2 cotton scrubs from South Asia,3 and surgical instruments from Pakistan.4 Awareness of campaigns for fair and ethical trade of consumer products such as coffee, chocolate, and clothing is high, but the same scrutiny is not applied to commodities used every day in medicine. Surgical Instruments A well-documented example is the surgical instrument industry, which is a major focus of the BMA’s ethical trade campaign. The vast majority of surgical instruments are made either in Tuttlingen in Germany or Sialkot in Pakistan. Exports of surgical instruments from Pakistan alone are worth $300 million per year and up to 30 percent are exported to the United States,6 usually supplied through local suppliers as Pakistani companies have difficulty accessing healthcare markets directly. Outsourcing the manufacture of surgical instruments to developing countries can help boost income in local economies and support development, but outsourcing often involves seeking the lowest price, risking exploitation of workers and abuse of labor rights. There are an estimated 50,000 manual laborers working in the surgical instrument industry in Sialkot. A typical laborer will work 12 hours a day, seven days a week and earn about $2 per day, less than the living wage set by the Pakistan government.7 Conditions in the major factories tend to be good, but due to competition and consumer demand for low-cost products, much of the work is outsourced to backstreet garages, undermining labor standards. A finished surgical instrument might be bought by a healthcare provider for about $80; the Pakistani manufacturer would receive about $1.50. Manufacture of surgical instruments is an intensive multistage process involving forging, annealing, filing, grinding, drilling, riveting, de-scaling, and polishing. Workers face risks to their health including injury from heavy machinery, repetitive strain injuries, exposure to poor electrical wiring, metal dust, and noise, as well as toxic chemicals, including sulfuric acid, nitric acid, and trichloroethylene.3,4,8,9 An estimated 5,800 children work full time, six days a week, in the surgical instrument industry, some as young as seven. Children are often employed in high-risk, labor-intensive tasks such as grinding and polishing.8,10 Other Manufacturing Regions Mexico is also a major manufacturer of medical products, exporting $9 billion of low-tech medical products such as surgical masks and bandages to the U.S. every year. The global financial crisis has led to cuts in wages and labor standards as companies try to lower costs and remain competitive. Many workers have been moved from factories to home-based working, where they are not paid regular wages or entitled to benefits. Neither working conditions nor the identity of workers is checked, which risks the use of child labor.2 Problems have also been found in Malaysia, the world’s largest manufacturer of medical gloves. A large Malaysian glove factory employed workers for excessive hours and workers were subject to physical and sexual harassment. Healthcare clothing made in India also has been found to have been made under conditions of excessive working hours. U.S. Purchasing and Policy Supply chains for medical products are often complex. Most of the supplies used in the operating room are probably purchased by the hospital though a Group Purchasing Organization (GPO), which negotiates contracts with suppliers. In the U.S., the healthcare industry spends more than $200 billion annually on medical and non-medical products, with more than 70 percent spent via a GPO.11 At present, the U.S. has no universal policy for ensuring basic labor standards in the manufacture of medical products. The problem with surgical instrument manufacturing has nonetheless been recognized in the U.S. for nearly three decades. Surgical instrument manufacture is listed in the U.S. Department of Labor’s List of Goods Produced by Child Labor or Forced Labor12 and U.S. government policy states that “companies and industry groups should implement social compliance systems to ensure they are not directly or indirectly causing or contributing to labor abuses in their supply chains.” More recently, the U.S. Department of Labor Bureau of International Labor Affairs has created “a standard set of practices” and an online “toolkit” to support the establishment of strong social compliance systems for businesses at http://www.dol.gov/ilab/child-forced-labor/index.htm.13 The policy suggests auditing and monitoring of suppliers, and preventing suppliers using child labor from entering U.S. markets. Although these ideas appear laudable, experience has shown that policies involving audit and boycotting are ineffective and may even be harmful. A culture of audit leads to an antagonistic relationship between manufacturer and purchaser. The majority of factories subject to audit will keep double books and will coach workers ahead of audits.14 Elimination of child labor cannot be achieved without understanding why it exists, identifying alternative education or employment opportunities for children, and realizing the potential economic impact of removing a working member of a family. A simple boycott can make working conditions for children worse. In surgical instrument manufacture in Pakistan, many U.S. and international suppliers have stipulated conditions including a ban on child labor, and the International Labor Organization (ILO) ran a program that aimed to eliminate child labor in the industry.15,16 However, despite decades of work, such policies and programs have failed to significantly affect child labor in surgical instrument manufacture. Ethical Trade and Fair Trade Modern approaches to addressing labor rights abuses focus on models of “ethical trade” or “fair trade.” Both models aim to make international trade work better for poor and otherwise disadvantaged people, through different but complementary approaches. Fair trade is a bottom-up approach that aims to certify products (especially agricultural products) that are made with assured labor standards and includes a premium paid to workers for social causes. The approach relies on labeling of products and so is consumer led, with huge growth in the U.S. in recent years.17 The approach could be used in some parts of the medical sector by certifying the raw cotton used to make healthcare bandages, gauze, or uniforms, or for latex for manufacturing gloves or catheters. Ethical trade is a top-down approach, and refers to the steps that purchasing organizations, such as hospitals or GPOs, take to improve the pay and conditions of people involved in the supply of goods and services. It asks purchasers to systematically assess the risk of labor rights abuses in the goods and services they procure, and to push for improvement where necessary. This includes working with companies throughout the supply chain to help workers realize fundamental rights, such as the right to safe and decent working conditions, to be paid at least the legal minimum wage, to join and form unions so they can bargain collectively for their rights, and to eliminate child labor. Ethical trade relies on transparency, open dialogue, and continual improvement. As such, there is no “ethical trade” label. Evidence suggests that this approach also makes business and financial sense: improving labor standards leads to improved productivity, better quality, and better worker retention through improved morale.18,19 Consequently, ethically manufactured products do not need to cost more and, in many cases, actually cost less to manufacture. Campaign for Ethical Trade in the Healthcare Sector The BMA has been campaigning for ethical purchasing in healthcare since 2007. This has led to UK government support for ethical procurement in the public sector20 and the publication of guidance and training resources for procurement staff.21,22 Procurement professionals in the UK now have the tools to develop an ethical purchasing strategy, map and risk assess their supply chains, seek commitment to continuous improvement from suppliers, and to specify ethical criteria when making purchasing decisions. Similar policies are in place in other European countries, including Sweden, Norway, and Denmark. These resources are relevant to all healthcare procurement systems and accessible anywhere in the world. Doctors in the UK have shown strong support for the campaign, with research showing that 88 percent support the BMA campaign for National Health Service organizations to adopt ethical procurement policies.23 What can clinicians do to influence procurement in the health sector in the U.S.? As end-users of medical commodities, healthcare professionals can be powerful advocates by campaigning for change in the way healthcare providers purchase supplies. A number of advocacy tools have been developed, including a short film “The Human Cost of Healthcare.”24 Healthcare professionals can support the campaign by raising awareness among colleagues or setting up a multi-stakeholder team with representatives from across healthcare organizations. Involving individuals from across the organization is important—for example, the corporate social responsibility lead, chief executive, public relations manager, and procurement manager, as well as clinicians. Most healthcare providers in the U.S. make purchasing decisions in a committee. Find out who is on this committee and tell them about ethical procurement. Once senior-level support is secured, the committee could raise these issues with their GPO. The healthcare sector, with its huge purchasing power, can improve conditions for workers around the world. The more individuals and organizations raise these issues with suppliers, the more companies will change procurement practices and drive ethical improvements in supply chains. By supporting this campaign, healthcare professionals can improve not just patients’ lives but those of workers risking their health to make products for the health sector—whether children making surgical instruments in Pakistan, women sewing nurses’ uniforms in India, or home workers producing surgical masks in Mexico. Find out how you can get involved; visit www.fairmedtrade.org.uk. References Bjurling K. Papyrus Sweden AB’s purchase of Nitrile gloves from Malaysia. Stockholm: Swedwatch, 2010 www.vgregion.se/upload/Regionservice/Ink%C3%B6p/Milj%C3%B6h%C3%A4nsyn/Rapport%20om%20handskar.pdf Roberts O, Garcia A, Bhutta MF. Medical Fair and Ethical Trade Group: Visit to Medical Manufacturing Companies Mexico. London: BMA, 2010. Swedwatch. The Dark Side of Healthcare. Stockholm: Swedwatch, 2007 www.swedwatch.org/en/reports/dark-side-healthcare-0 Bhutta MF. Fair trade for surgical instruments. BMJ. 2006;333(7562):297-9 www.bmj.com/content/333/7562/297 The Business Case for Greening the Operating Room – Practice Greenhealth www.c4spgh.org/HCW1_Presentations/GOR_FullSet_Guidance%20Docs_Web_042711.pdf Surgical Instrument Manufacturers Association of Pakistan www.simap.org.pk/facts.php (accessed December 2012) Pakistan Institute of Labour Education and Research. Denial and Discrimination: Labour rights in Pakistan. Karachi: PILER, 2007 www.piler.org.pk/labourestatusreport.pdf Ethical Trade in Surgical Instruments: Bringing Change to the Supply Chain: BMA, 2008. Adverse Health Effects of Child Labor: High Exposure to Chromium and Oxidative DNA Damage in Children Manufacturing Surgical Instruments, Muhammad Sughis et al (June 2012) Environ Health Perspect. 120:1469–1474 (2012). http://ehp.niehs.nih.gov/1104678/ Akida Management Consultants. Baseline survey report on child labour in surgical instruments manufacturing industry in Sialkot. Lahore, 2004. HealthTrust Purchasing Group www.healthtrustcorp.com/Content/BecomeAMember/WhyChooseHT.htm U.S. Department of Labor’s List of Goods Produced by Child Labor or Forced Labor www.dol.gov/ilab/programs/ocft/2012TVPRA.pdf 22 U.S.C. § 7112: US Code – Section 7112: Additional activities to monitor and combat forced labor and child labor 22 U.S.C. 7112(b)(2)(D) http://codes.lp.findlaw.com/uscode/22/78/7112 Progress not Perfection – Impact’s 10th Anniversary Report (2007) www.impacttlimited.com/resources/resources-part-8-2 ILO-IPEC, Nasir Dogar, Workplace Monitoring Project in the Surgical Instrument Industry, Working Papers on Child Labour in Asia – Vol -2, Bangkok, ILO, 2001 www.ilo.org/wcmsp5/groups/public/—ed_mas/—eval/documents/publication/wcms_126892.pdf Combating hazardous and exploitative child labour in surgical instruments manufacturing through prevention, withdrawal and rehabilitation – Phase II (2009) www.ilo.org/wcmsp5/groups/public/—ed_mas/—eval/documents/publication/wcms_126892.pdf Fair Trade USA 2011 Fair Trade Almanac http://fairtradeusa.org/sites/default/files/Almanac%202011.pdf Oxfam International. Better jobs in better supply chains. Oxford, 2010 http://www.oxfam.org/en/policy/better-jobs-better-supply-chains Ethical Trading Initiative, June 2009. www.ethicaltrade.org/in-action/member-performance/productivity-and-wage-rises-go-hand-in-hand Department of Health. Health is global: a UK Government strategy 2008-13. London, 2008 www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_088702 Ethical Procurement for Health: Workbook www.ethicaltrade.org/resources/key-eti-resources/ethical-procurement-for-health-workbook www.fairmedtrade.org.uk BMA Omnibus Survey – August 2012 The Human Cost of Healthcare: www.youtube.com/watch?v=iJ_vvac2tyE
Stephanie Ashmore
Senior Research Officer
British Medical Association, London, UK
Mahmood F. Bhutta, FRCS, DPhil
ENT Surgery Registrar, John Radcliffe Hospital, Oxford, UK
Founder, Medical Fair and Ethical Trade Group, British Medical Association
Editor’s Note: During the 2012 Cochrane Colloquium in New Zealand, several Academy members and staff had the good fortune to be introduced to Mahmood Bhutta, FRCS, DPhil, research fellow, Oxford University, and founder of the British Medical Association’s Medical Fair and Ethical Trade Group. Upon hearing of this compelling global health-related concern, they invited Dr. Bhutta and his senior research officer, Stephanie Ashmore, to submit an article for the Bulletin. While the Academy has not conducted research itself on the issue of unethical working conditions in the manufacture of some medical products, we are pleased to share this information with you for your consideration.
Introduction
Every year, trillions of dollars are spent on medical supplies. In many cases, little consideration is given to the conditions in which they are made and their impact on the people who make them. Research carried out by the British Medical Association (BMA) Medical Fair and Ethical Trade Group has revealed unethical working conditions in the manufacture of a number of medical products, especially those bound for the operating room. 1,2,3,4 The operating room is the largest user of medical supplies within the hospital, typically accounting for a third of all hospital supply costs.5
When making purchasing decisions for healthcare, consideration is given to value for money and quality, but consideration is rarely given to the conditions in which these supplies are made. Abuses of labor standards have been uncovered in the manufacture of many of the high-throughput supplies used routinely in the operating room, including latex gloves from Malaysia,1 surgical masks from Mexico,2 cotton scrubs from South Asia,3 and surgical instruments from Pakistan.4 Awareness of campaigns for fair and ethical trade of consumer products such as coffee, chocolate, and clothing is high, but the same scrutiny is not applied to commodities used every day in medicine.
Surgical Instruments
A well-documented example is the surgical instrument industry, which is a major focus of the BMA’s ethical trade campaign. The vast majority of surgical instruments are made either in Tuttlingen in Germany or Sialkot in Pakistan. Exports of surgical instruments from Pakistan alone are worth $300 million per year and up to 30 percent are exported to the United States,6 usually supplied through local suppliers as Pakistani companies have difficulty accessing healthcare markets directly.
Outsourcing the manufacture of surgical instruments to developing countries can help boost income in local economies and support development, but outsourcing often involves seeking the lowest price, risking exploitation of workers and abuse of labor rights.
There are an estimated 50,000 manual laborers working in the surgical instrument industry in Sialkot. A typical laborer will work 12 hours a day, seven days a week and earn about $2 per day, less than the living wage set by the Pakistan government.7 Conditions in the major factories tend to be good, but due to competition and consumer demand for low-cost products, much of the work is outsourced to backstreet garages, undermining labor standards. A finished surgical instrument might be bought by a healthcare provider for about $80; the Pakistani manufacturer would receive about $1.50.
Manufacture of surgical instruments is an intensive multistage process involving forging, annealing, filing, grinding, drilling, riveting, de-scaling, and polishing. Workers face risks to their health including injury from heavy machinery, repetitive strain injuries, exposure to poor electrical wiring, metal dust, and noise, as well as toxic chemicals, including sulfuric acid, nitric acid, and trichloroethylene.3,4,8,9 An estimated 5,800 children work full time, six days a week, in the surgical instrument industry, some as young as seven. Children are often employed in high-risk, labor-intensive tasks such as grinding and polishing.8,10
Other Manufacturing Regions
Mexico is also a major manufacturer of medical products, exporting $9 billion of low-tech medical products such as surgical masks and bandages to the U.S. every year. The global financial crisis has led to cuts in wages and labor standards as companies try to lower costs and remain competitive. Many workers have been moved from factories to home-based working, where they are not paid regular wages or entitled to benefits. Neither working conditions nor the identity of workers is checked, which risks the use of child labor.2
Problems have also been found in Malaysia, the world’s largest manufacturer of medical gloves. A large Malaysian glove factory employed workers for excessive hours and workers were subject to physical and sexual harassment. Healthcare clothing made in India also has been found to have been made under conditions of excessive working hours.
U.S. Purchasing and Policy
Supply chains for medical products are often complex. Most of the supplies used in the operating room are probably purchased by the hospital though a Group Purchasing Organization (GPO), which negotiates contracts with suppliers. In the U.S., the healthcare industry spends more than $200 billion annually on medical and non-medical products, with more than 70 percent spent via a GPO.11 At present, the U.S. has no universal policy for ensuring basic labor standards in the manufacture of medical products.
The problem with surgical instrument manufacturing has nonetheless been recognized in the U.S. for nearly three decades. Surgical instrument manufacture is listed in the U.S. Department of Labor’s List of Goods Produced by Child Labor or Forced Labor12 and U.S. government policy states that “companies and industry groups should implement social compliance systems to ensure they are not directly or indirectly causing or contributing to labor abuses in their supply chains.” More recently, the U.S. Department of Labor Bureau of International Labor Affairs has created “a standard set of practices” and an online “toolkit” to support the establishment of strong social compliance systems for businesses at http://www.dol.gov/ilab/child-forced-labor/index.htm.13 The policy suggests auditing and monitoring of suppliers, and preventing suppliers using child labor from entering U.S. markets.
Although these ideas appear laudable, experience has shown that policies involving audit and boycotting are ineffective and may even be harmful. A culture of audit leads to an antagonistic relationship between manufacturer and purchaser. The majority of factories subject to audit will keep double books and will coach workers ahead of audits.14
Elimination of child labor cannot be achieved without understanding why it exists, identifying alternative education or employment opportunities for children, and realizing the potential economic impact of removing a working member of a family. A simple boycott can make working conditions for children worse. In surgical instrument manufacture in Pakistan, many U.S. and international suppliers have stipulated conditions including a ban on child labor, and the International Labor Organization (ILO) ran a program that aimed to eliminate child labor in the industry.15,16 However, despite decades of work, such policies and programs have failed to significantly affect child labor in surgical instrument manufacture.
Ethical Trade and Fair Trade
Modern approaches to addressing labor rights abuses focus on models of “ethical trade” or “fair trade.” Both models aim to make international trade work better for poor and otherwise disadvantaged people, through different but complementary approaches.
Fair trade is a bottom-up approach that aims to certify products (especially agricultural products) that are made with assured labor standards and includes a premium paid to workers for social causes. The approach relies on labeling of products and so is consumer led, with huge growth in the U.S. in recent years.17 The approach could be used in some parts of the medical sector by certifying the raw cotton used to make healthcare bandages, gauze, or uniforms, or for latex for manufacturing gloves or catheters.
Ethical trade is a top-down approach, and refers to the steps that purchasing organizations, such as hospitals or GPOs, take to improve the pay and conditions of people involved in the supply of goods and services. It asks purchasers to systematically assess the risk of labor rights abuses in the goods and services they procure, and to push for improvement where necessary. This includes working with companies throughout the supply chain to help workers realize fundamental rights, such as the right to safe and decent working conditions, to be paid at least the legal minimum wage, to join and form unions so they can bargain collectively for their rights, and to eliminate child labor. Ethical trade relies on transparency, open dialogue, and continual improvement. As such, there is no “ethical trade” label. Evidence suggests that this approach also makes business and financial sense: improving labor standards leads to improved productivity, better quality, and better worker retention through improved morale.18,19 Consequently, ethically manufactured products do not need to cost more and, in many cases, actually cost less to manufacture.
Campaign for Ethical Trade in the Healthcare Sector
The BMA has been campaigning for ethical purchasing in healthcare since 2007. This has led to UK government support for ethical procurement in the public sector20 and the publication of guidance and training resources for procurement staff.21,22
Procurement professionals in the UK now have the tools to develop an ethical purchasing strategy, map and risk assess their supply chains, seek commitment to continuous improvement from suppliers, and to specify ethical criteria when making purchasing decisions. Similar policies are in place in other European countries, including Sweden, Norway, and Denmark. These resources are relevant to all healthcare procurement systems and accessible anywhere in the world.
Doctors in the UK have shown strong support for the campaign, with research showing that 88 percent support the BMA campaign for National Health Service organizations to adopt ethical procurement policies.23
What can clinicians do to influence procurement in the health sector in the U.S.?
As end-users of medical commodities, healthcare professionals can be powerful advocates by campaigning for change in the way healthcare providers purchase supplies. A number of advocacy tools have been developed, including a short film “The Human Cost of Healthcare.”24
Healthcare professionals can support the campaign by raising awareness among colleagues or setting up a multi-stakeholder team with representatives from across healthcare organizations. Involving individuals from across the organization is important—for example, the corporate social responsibility lead, chief executive, public relations manager, and procurement manager, as well as clinicians. Most healthcare providers in the U.S. make purchasing decisions in a committee. Find out who is on this committee and tell them about ethical procurement. Once senior-level support is secured, the committee could raise these issues with their GPO.
The healthcare sector, with its huge purchasing power, can improve conditions for workers around the world. The more individuals and organizations raise these issues with suppliers, the more companies will change procurement practices and drive ethical improvements in supply chains. By supporting this campaign, healthcare professionals can improve not just patients’ lives but those of workers risking their health to make products for the health sector—whether children making surgical instruments in Pakistan, women sewing nurses’ uniforms in India, or home workers producing surgical masks in Mexico.
Find out how you can get involved; visit www.fairmedtrade.org.uk.
References
- Bjurling K. Papyrus Sweden AB’s purchase of Nitrile gloves from Malaysia. Stockholm: Swedwatch, 2010 www.vgregion.se/upload/Regionservice/Ink%C3%B6p/Milj%C3%B6h%C3%A4nsyn/Rapport%20om%20handskar.pdf
- Roberts O, Garcia A, Bhutta MF. Medical Fair and Ethical Trade Group: Visit to Medical Manufacturing Companies Mexico. London: BMA, 2010.
- Swedwatch. The Dark Side of Healthcare. Stockholm: Swedwatch, 2007 www.swedwatch.org/en/reports/dark-side-healthcare-0
- Bhutta MF. Fair trade for surgical instruments. BMJ. 2006;333(7562):297-9 www.bmj.com/content/333/7562/297
- The Business Case for Greening the Operating Room – Practice Greenhealth www.c4spgh.org/HCW1_Presentations/GOR_FullSet_Guidance%20Docs_Web_042711.pdf
- Surgical Instrument Manufacturers Association of Pakistan www.simap.org.pk/facts.php (accessed December 2012)
- Pakistan Institute of Labour Education and Research. Denial and Discrimination: Labour rights in Pakistan. Karachi: PILER, 2007 www.piler.org.pk/labourestatusreport.pdf
- Ethical Trade in Surgical Instruments: Bringing Change to the Supply Chain: BMA, 2008.
- Adverse Health Effects of Child Labor: High Exposure to Chromium and Oxidative DNA Damage in Children Manufacturing Surgical Instruments, Muhammad Sughis et al (June 2012) Environ Health Perspect. 120:1469–1474 (2012). http://ehp.niehs.nih.gov/1104678/
- Akida Management Consultants. Baseline survey report on child labour in surgical instruments manufacturing industry in Sialkot. Lahore, 2004.
- HealthTrust Purchasing Group www.healthtrustcorp.com/Content/BecomeAMember/WhyChooseHT.htm
- U.S. Department of Labor’s List of Goods Produced by Child Labor or Forced Labor www.dol.gov/ilab/programs/ocft/2012TVPRA.pdf
- 22 U.S.C. § 7112: US Code – Section 7112: Additional activities to monitor and combat forced labor and child labor 22 U.S.C. 7112(b)(2)(D) http://codes.lp.findlaw.com/uscode/22/78/7112
- Progress not Perfection – Impact’s 10th Anniversary Report (2007) www.impacttlimited.com/resources/resources-part-8-2
- ILO-IPEC, Nasir Dogar, Workplace Monitoring Project in the Surgical Instrument Industry, Working Papers on Child Labour in Asia – Vol -2, Bangkok, ILO, 2001 www.ilo.org/wcmsp5/groups/public/—ed_mas/—eval/documents/publication/wcms_126892.pdf
- Combating hazardous and exploitative child labour in surgical instruments manufacturing through prevention, withdrawal and rehabilitation – Phase II (2009) www.ilo.org/wcmsp5/groups/public/—ed_mas/—eval/documents/publication/wcms_126892.pdf
- Fair Trade USA 2011 Fair Trade Almanac http://fairtradeusa.org/sites/default/files/Almanac%202011.pdf
- Oxfam International. Better jobs in better supply chains. Oxford, 2010 http://www.oxfam.org/en/policy/better-jobs-better-supply-chains Ethical Trading Initiative, June 2009.
- www.ethicaltrade.org/in-action/member-performance/productivity-and-wage-rises-go-hand-in-hand
- Department of Health. Health is global: a UK Government strategy 2008-13. London, 2008 www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_088702
- Ethical Procurement for Health: Workbook www.ethicaltrade.org/resources/key-eti-resources/ethical-procurement-for-health-workbook
- www.fairmedtrade.org.uk
- BMA Omnibus Survey – August 2012
- The Human Cost of Healthcare: www.youtube.com/watch?v=iJ_vvac2tyE