Pakistan Counts the Waste: Who Counts the Workers?

rki.news
By Dr Amaal Khalid Chauhan
Every morning, before Karachi is fully awake, an estimated 40,000 waste pickers are already at work. Between them, they recover roughly 500 to 1,000 tonnes of waste a day from streets and informal dumping points, including places municipal crews do not reach. Much of this happens outside formal contracts, with little protection and almost no occupational-health footprint.
We can count the waste, but we have barely counted the harm.
We do not even know how many waste pickers Pakistan has. Estimates range from roughly 200,000 to more than 333,000, pieced together from the recyclable waste they recover rather than from any national count. Meanwhile, Pakistan produces close to 50 million tonnes of solid waste a year, and that figure is growing by more than 2.4 per cent annually. More waste means more people sorting through it.
That is the contradiction at the heart of waste picking in Pakistan. The country depends on an informal workforce to perform an essential public service, yet medically, that workforce is almost invisible.
There are warning signs. In one Karachi study of 141 garbage scavengers, 77 per cent said they collected discarded needles and syringes. More than half had been pricked more than once. Only 16 per cent wore gloves. Hepatitis B was detected in 18.8 per cent and hepatitis C in 8.5 per cent.
The study is more than a decade old. What is unsettling is not just what it found, but how little long-term Pakistani evidence has followed it.
Pakistan’s evidence thins out just as the questions get bigger. We have snapshots of injury and infection, but a scarcity of research that follows waste pickers over years. To understand what sustained exposure might mean, we have to look abroad. Kampala (Uganda), southern Italy and New York are not stand-ins for Karachi, but they show what has been found when similar hazards are actually measured.
For the immediate hazards, the international evidence is fairly clear. At a Kampala landfill, 65 per cent of casual waste workers reported an occupational injury in the previous year, and PPE use was associated with about 91 per cent lower odds of injury. The study was cross-sectional, so it does not prove PPE alone made the difference. But it supports an ordinary occupational-health principle that seems remarkable only because we fail to apply it: gloves, boots, training and safer handling matter.
Then there is the harder question of cancer, where the Pakistani evidence is thinner still. The international studies cannot tell us what Pakistan’s cancer burden is. They can tell us whether the exposures waste pickers meet are serious enough to justify concern and long-term follow-up.
Waste pickers do not encounter one neat exposure. They sort through batteries, electronics, burning plastic, medical waste, metals and contaminated dust, often in combinations that formal occupational-health systems exist to control and that informal work leaves uncontrolled.
Start with the exposures themselves. At informal e-waste sites in Nigeria, researchers measured PBDE flame retardants and metals in soil and dust and used health-risk models to estimate potential harm. Cumulative cancer risks exceeded accepted thresholds at the sites studied, and burning sites carried the highest risks. These were modelled risks, not observed cancer cases, but they show exposures serious enough to warrant attention rather than assumption.
Next, what happens to people who live with such hazards for years. Across 38 municipalities in southern Italy, an area heavily affected by illegal dumping and open waste burning, researchers found increased mortality and hospitalisation for malignant tumours overall, and for several specific cancers including those of the stomach, liver, lung and kidney, compared with the surrounding region. These were residents, not waste pickers, and an ecological study cannot show that a particular exposure caused a particular cancer. Even so, prolonged exposure to badly controlled hazardous waste is hard to dismiss as medically irrelevant.
New York shows why exposed workers themselves are worth following. After 9/11, workers sifted contaminated World Trade Center debris at the Fresh Kills landfill. A New York City review reports statistically significant increases in several specific cancers among these recovery workers, including multiple myeloma and brain, kidney and thyroid cancers. Their exposure was extraordinary and cannot simply be mapped onto a waste picker in Karachi. But it shows why sustained exposure to complex contaminated debris is something medicine follows rather than forgets.
Germany is useful for a different reason: it shows what becomes possible when workers are visible to the health system. Earlier follow-up of workers at the Ihlenberg toxic-waste landfill found more cancers than expected, with overall incidence about 80 per cent above the reference rate during 1983 to 2006. A later analysis covering 2009 to 2021 identified 31 cancers among 590 workers, fewer than the roughly 45 expected from regional rates.
That sounds reassuring at first, but the two groups were not identical. Workers who had already developed cancer or died before 2009 were no longer in the later cohort, and the researchers themselves cautioned against treating the change as proof that workplace protections had reduced cancer.
What interests me most, though, is not whether 31 cancers is “high” or “low.” It is that someone knew enough about these workers to ask. They had names in a system. Their cancers could be linked through registries, their health revisited years later, and researchers could keep asking what happened next.
Pakistan’s waste pickers largely do not have that.
So this is not an argument that Pakistan has an undiscovered cancer epidemic among waste pickers. We have no evidence to say that. It is an argument against mistaking missing data for reassuring data. We already know the work is hazardous, and we have credible reasons to take its long-term exposures seriously. Yet we have barely begun to measure what ten or twenty years of those exposures mean for Pakistani workers.
Silence is not reassurance. It is a reason to measure.
Pakistan is not without cancer registries. Some regions and institutions, such as the Karachi Cancer Registry, do collect data, but the picture is fragmented and there is no unified national system. More importantly, waste pickers are not systematically identified and followed in a way that would let their occupational histories be linked to later health outcomes.
In my own writing on Pakistan’s brick-kiln workers, I have seen this script before: an occupational hazard nobody properly measures until it becomes too large to ignore. By then, years of exposure have already passed.
The first steps with waste pickers are neither mysterious nor technologically ambitious. Durable gloves and boots. Appropriate masks. Training on sharps and burn hazards. Vaccination, starting with hepatitis B, which was found in nearly one in five of the Karachi scavengers and is preventable. A record of injuries and major exposures, and somewhere to refer a worker when a warning sign appears. A simple health card could travel with the worker instead of depending on a fragmented paper trail.
Some unit costs are modest. Pakistan’s drug regulator currently lists a ten-dose vial of tetanus toxoid from the National Institute of Health at Rs286.22, about Rs29 per nominal dose. A real vaccination programme would cost more once syringes, staff, storage and delivery are included, but these are implementation problems, not technological barriers.
This is where the story becomes a little less bleak. Earlier in 2026, the International Labour Organization, working with the Labour Research and Development Institute under the Pakistan United Workers Federation and the Akhter Hameed Khan Foundation, began supporting efforts to formalise informal waste pickers in Sahiwal. In April and May, a national training-of-trainers workshop in Lahore brought together government representatives, worker and employer organisations, and technical experts to explore cooperative models.
Separately, a UNOPS-ILO project in Islamabad is working on PET recycling, extended producer responsibility and occupational safety and health for informal waste workers. Pakistan is already discussing how these workers fit into a more formal waste system. Health should enter that conversation now, not after the paperwork is finished.
A cooperative can give workers recognition, bargaining power and access to markets. It can also become the practical doorway for PPE, vaccination, injury reporting, health checks and referral. That is the clinical layer currently missing from formalisation.
Pakistan does not need to know the exact future cancer burden before protecting people from known hazards, and it does not need to build a nationwide surveillance system overnight. It needs to start seeing the workers.
We already count what they collect. It is time to count what the work is costing them.
Note: Author is a young medical graduate passionate about tackling social reasons for health inequalities and can be reached at amaal.chauhan1@gmail.com