The NHS may be buying medical equipment unethically and exploiting developing countries, it has been claimed in an article published on bmj.com today.

Unlike the campaigns for fair trade of goods like bananas and coffee, there have been no such campaigns for medical commodities, says Dr Mahmood Bhutta, a specialist registrar in otolaryngology (head and neck surgery) at Guy's and St Thomas' Hospital in London.

Dr Bhutta says that while NHS suppliers are encouraged to act in an ethical business manner, they do not and there are currently no checks or assessments made into the origins of surgical instruments used by the NHS.

"The trade in surgical instruments is open to unethical sourcing because many such instruments are manufactured in the developing world," writes Dr Bhutta.

The global trade in hand held stainless steel surgical instruments is worth around 352million ($650m, 507m) a year and many of these instruments are made by firms in towns in Europe and Asia. The two largest producers are Tuttlingen in Germany and Sialkot in Pakistan.

Companies in Sialkot use more traditional production methods with most instruments manufactured and finished by hand, so production is more labour intensive, employing 50,000 people (7,700 of whom are children aged from 7 and older) to supply a fifth of the world's surgical instruments.

Many firms in Sialkot sub-contact the initial production of these instruments to workers in small workshops or their own homes in an attempt to reduce overheads and minimise costs. These workers earn around 1 a day ($2, 1.50).

The firms sell to suppliers and retailers in the developed world who then sell on to companies in Germany which sell to the NHS and elsewhere in the world at a marked up price, says Dr Bhutta.

"The solution lies in purchasers insisting on fair and ethical trade when sourcing instruments," he adds.