Print edition : December 12, 2014

At the Chhattisgarh Institute of Medical Sciences hospital in Bilaspur on November 13, one of the women who took ill after a government sterilisation camp at a disused charitable hospital being shifted to a private hospital. Photo: ANINDITO MUKHERJEE/REUTERS

Dhania Lal Yadav of Digora village who lost his wife, Deepthi. His youngest child is three and a half months old. The guidelines expressly prohibit tubectomies on women within six months after childbirth. Photo: T.K. Rajalakshmi

The abandoned charitable hospital where the camp took place. Photo: T.K. Rajalakshmi

Family members of one of the 13 women who died following the sterilisation drive. Photo: T.K. Rajalakshmi

A protest against the sterilisation deaths, in Bilaspur. Photo: T.K. Rajalakshmi

The sterilisation drive that resulted in the death of 13 women in Chhattisgarh points to the flawed targeted-sterilisation programme with focus on women and the blatant violation of family planning guidelines.

A DISUSED charitable hospital, a failing public health system, a government oblivious to the real concerns of the people but yet keen to meet demographic targets, and a population desperately hopeful of anything that could lead them to a better life—all these and more were the ingredients of a tragedy in the making. The death of 13 women, all in their 20s or 30s, after being sterilised by a government doctor who has won an award for having conducted a record number of sterilisations, in Bilaspur district of Chhattisgarh, is a wake-up call to the State government and sheds light on the national family planning policies that are highly skewed against women.

Even as public health services such as primary health centres (PHCs) and community health centres (CHCs) have bare minimum facilities, as has been the case in areas from where the victims hailed, the government’s focus has been on women meeting population-control targets. Mass sterilisation camps, where not only individual attention gets disregarded but general medical precautions and preparedness are taken casually, are the norm, a public health practitioner stated, presenting an anatomy of the public health tragedy. While the immediate cause of death is septicaemia, which is the most common factor in such botched sterilisation cases, a parallel theory of the antibiotic administered getting contaminated with rat poison has also been circulated in order to perhaps shift the focus from the “operative and surgical” part of the negligence. The post-mortem reports have been kept under wraps though officials, both in the administration and in the medical fraternity, conceded that it could well be a combination of both—septicaemia and toxicity arising out of the contaminated antibiotic.

On November 8 and 10, four sterilisation camps for women were held in Sankri, Gorela, Pendra and Marwahi, all in Takhatpur block of Bilaspur district. Close to 140 women were herded into these camps from adjoining villages; the largest camp for 83 women was on the premises of an abandoned charitable hospital and research centre in Pindari. A few hours after the procedure—a tubal ligation using the laparoscopic method—the women were discharged. Most women seemed normal for some time in spite of the discomfort following it, but that very night they started vomiting, which continued well into the next day. The auxiliary nurse midwives and the health workers, called mitanins in Chhattisgarh, who were the “motivators” of the programme, managed to take most of the women to hospital. But it was too late for 13 of them. As many as three dozen others are said to be in a critical state and are undergoing treatment at a well-known private facility in the State which boasts of a government medical college, a district hospital and an All India Medical Institute in the capital, Raipur.

Almost all the women who died had up to three children. Some of them, with infants as small as three and a half months old, had been operated on. This was in total violation of the guidelines, which expressly prohibit tubectomies on women within six months after childbirth. Almost all the families are landless and their main source of income is daily-wage work.

Several norms were violated, most of them knowingly, by the higher-ups in their zeal to show that health funds were being put to good use and the “national objective” of population control was being met. The camps were organised by the State Health Department under the National Family Planning Programme. The surgical procedures were conducted by a government doctor in violation of the guidelines. Two sets of Supreme Court orders ( Ramakant Rai vs Government of India, 2005, and Devika Biswas vs Government of India, 2012) explicitly state that not more than 30 operations should be conducted in government facilities in a day. They further state that a doctor can conduct only up to 10 surgical procedures a day, and that too with two separate laparoscopes.

The government arrested the doctor for conducting the marathon surgery and suspended some lower-level health officials, but Health Minister Amar Aggarwal has refused to step down despite demands for his resignation. The government also distributed cheques for Rs.4 lakh to the next of the kin of the deceased though many of them do not have bank accounts. The government declared that it would take full responsibility of the schooling of the dead women’s children until they completed 18 years of age.

Women as specific targets

Various health and women’s organisations have called upon the Central government to abandon the camp method and “targeted” sterilisation, in terms of both setting targets and using women specifically as targets. Groups such as the Jana Swasthya Abhiyan, the All India Democratic Women’s Association (AIDWA), the Sama Resource Group and the National Alliance for Maternal Health and Human Rights, while underscoring the need for sterilisation to be offered as one of the options among other safe, non-hazardous, non-invasive and long-acting methods of contraception, say these should be provided along with other quality care and accessible general health services, which, at present, seem to be absent amid all the “development” hype in certain States. Toilets for women can be a yardstick of ensuring their good health, but safe contraception for women should also be a major priority for policymakers. The other issue is the disproportionate focus on women for achieving family planning targets when there is negligible responsibility on men. This is despite the fact that India adopted a target-free approach to family planning in 1996 and subsequently drafted a National Population Policy in 2000.

Despite the Centre’s “no target” approach to family planning, several States still have the two-child norm that bars people from securing government entitlements or contesting panchayat and municipal elections if they have more than two children. Chhattisgarh and Madhya Pradesh governments have announced targets for family planning and incentives to motivators such as health workers and doctors. Last year, the Madhya Pradesh Chief Minister announced a renewed drive for family planning with a target of 7.5 lakh sterilisations for the year and incentives such as Nano cars, washing machines and DVD players for the surgeons and other motivators.

In May-June 2012, consultations organised by the Family Planning Association of India verified this occurrence, often camouflaged under terms like Expected Levels of Achievement. While the Programme Implementation Plan (PIP) for Chhattisgarh suggests the “fixed-day” static camp approach for women and child development services, it discourages the camp approach for intrauterine contraceptive devices services. However, such fixed-day static camps even for sterilisations are routinely organised in many States, and health providers are forced to meet the targets.

The PIP for Chhattisgarh, prepared under the overarching National Health Mission (NHM), lays down the compensation package for sterilisations for women at Rs.600 (it is higher for men) and the number of targeted beneficiaries for the year 2014-15 at 1.5 lakh. A total of 800 camps for female sterilisation have been budgeted at a cost of Rs.60 lakh and 80 no-scalpel vasectomy (NSV) camps at Rs.8 lakh. Of the Rs.807 crore under the National Rural Health Mission (NRHM) or the NHM provided to the State, Rs.269 crore was budgeted for reproductive and child health services. A good proportion of the funds went to camp-type family-planning services.

The women and the camps

The Nemichand Charitable Hospital, where the sterilisations took place, has an impressive facade. The hospital looks whitewashed and spacious. A lone ambulance parked in its porch is indicative of some activity that happened recently. “An Ayurvedic college was supposed to be opened here. But we don’t know what happened,” said a watchman on duty. He said retired District and Sessions Judge Anita Jha, the one-member judicial inquiry commission which the Chhattisgarh government appointed to probe the botched sterilisations, had visited the spot recently.

A closer look of the hospital reveals evidence of disuse—broken windowpanes and a reception area hurriedly assembled for the sterilisation camp for women. The irony of the situation is that the poor women, after being operated upon in miserable conditions, were under treatment in five-star conditions at the private hospital in the city for which the government was paying a handsome sum each day—a euphemism for subsidising the private sector. “What can we do? We do not have enough ventilators,” said a senior official of the administration while conceding that the government could have created the infrastructure. But camps are held every winter.

The theory that the antibiotic given after the procedures was contaminated by rat poison began doing the rounds after one man, who was given the medicine by an Ayurvedic practitioner in Ganiyari village, died. Samples of the medicine with possible contamination of zinc phosphide and the viscera were sent to as many as four laboratories for chemical and biological testing. A medical practitioner told Frontline that for zinc phosphide to have a fatal effect, it had to be taken in its purest form.

The government went into overdrive, sending advisories recalling and banning the sale in the State of the antibiotic used in the surgery. The drug manufacturer and his son were arrested. “All six drugs used in the operation have been prohibited for further use. We have seized 44 lakh tablets from all over the State and a police case has been registered against the drug manufacturer,” Bilaspur Commissioner Sonmoni Borah told Frontline.

The drug manufacturer had been blacklisted earlier. The arrest of the doctor and the drug manufacturer evoked two interesting reactions. Even as the medical community went on the warpath protesting that one of them was targeted, a whispering campaign about the low quality of generic drugs and the inefficacy of the public health system as a whole began gaining currency. A redeeming factor was that the government rounded up all the women from the Pindari camp and took them to the hospital. Had it not done so, the casualties would have been higher.

A hospital is not just four walls

Significantly, none of the women or their families had any kind of documentation, including medical indemnity (insurance) papers. Neither was there any record of informed consent that was taken from the families. “A definition of a hospital is not just four walls. Tubal ligation is not regarded as surgery, but it is one. The procedure of laparoscopic ligation has been [considered] on a par with pill therapy, which it clearly is not,” said Yogesh Jain, a public health physician and one of the founders of the Jana Swasthya Sahayog, a community rural health programme which has hospital facilities at Ganiyari village.

The mitanins, themselves women from poor families, now face the ire of not just the villagers but the administration too. Some of these women to whom Frontline spoke said they were told to “bring” as many as 30 women. “You see, it is competitive. If one of them does it, it puts pressure on others. Then there is the incentive of Rs.150 per case. What do we do? All our work is incentive-based. We are not regular employees, but we implement all the government schemes at such low payments,” a health worker said.

“I feel very bad about the women who died. If more than one had died from one village, our houses would have been burnt by the angry villagers,” said a mitanin, requesting anonymity. In Ganiyari village, one woman died and another one was admitted to hospital. “My mother-in-law will have to look after my three children now. What do I do? Go to work or look after them?” asked Bahuri, 32, a daily wager whose wife, Shivkumari, was among the dead.

In Amsena village, which Congress vice-president Rahul Gandhi and a host of his party leaders in the State, including former Chief Minister Ajit Jogi, visited, the PHC was hardly functional. A PHC is meant to service a population of 30,000, but the doctor came for just two hours a day and there was no woman doctor. A compounder and a ward boy were the only permanent staff.

The PHC, said a retired government servant, was like a first-aid box. “Deliveries take place here, but there is no facility beyond that. For everything we have to go to the town. The ambulance comes on time. Those who are better-off rely on the private sector while the poor just have themselves to fall back on. No one demands anything. It is a village, after all,” he said.

Roopchand from the same village, who lost his wife, said the doctors took away all the medicines from them. He said that his wife seemed to recover after she was admitted for treatment. “No one explained what had happened to her. They told me her heart had stopped beating,” he said. The couple’s oldest son is eight years old and their youngest just one. “ Jo hona tha, woh to ho gaya. Ab dekhte hain woh log kya karte hain (What had to happen has happened. Let us see what happens to the promises given to us),” he said.

“There has to be a preparation for tubal ligations and for emergencies as well. We heard that the same scope was used for many women without proper sterilisation. One does not even know whether the doctor and the staff doing the sutures changed their gloves or not,” said a government gynaecologist.

The camp approach, said Yogesh Jain, could be described as an error of judgement, but if equity in health care was an objective, there had to be minimum guidelines. “What guarantee is there that the standard operating procedures would be followed now, especially after violations of existing guidelines?” he asked. The danger now, many feel, is that public health institutions would be demonised. The solution lies not in silo-based solutions to health care, which include unsafe, camp-based methods of sterilisation, but in investing more in public health. In fact, questions are raised whether even “safe targets” are violative of many aspects of individual choice.

The rights of women definitely go beyond toilets. The Raman Singh government, which was re-elected for a third time in Chhattisgarh giving the Bharatiya Janata Party a fillip in the Lok Sabha elections as well, seems to have slipped rather badly. By protecting the Health Minister, it has failed to fix accountability at the highest level. Unless the Central and State governments abandon their tunnel vision in the matter of health care, especially reproductive health care, such tragedies will continue to occur. And poor lives usually become expendable.

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