Medical negligence, improper facilities, incentives, easy targets, unwillingness among men are deciding factors
New Delhi: In January 2012, 22-year-old Jitna Devi and 50 others got sterilized in a government-organized mass sterilization camp in Bihar that happened in a setting that can only be described as dystopian.
The operations were carried out in a school with desks joined together to double up as operating tables.
There was neither electricity nor tap water and the operations were reportedly carried out under flashlights.
The women claim they were given just a single dose of painkiller after the operation and abandoned. In an affidavit filed with the Supreme Court by Human Rights Law Network (HRLN), a collective of lawyers and social activists, Devi claims she was three months pregnant at that time and miscarried.
Devi should consider herself lucky.
On 8 November 2014, 83 women got sterilized at a similar camp in Bilaspur, Chhattisgarh. Till Wednesday, 13 of those had died. The others are in hospital. Among them is 23-year-old Soni Jangde, who thought she was doing the right thing for her young family (she has three children) by getting sterilized. She also received ₹ 600 (some media reports say the camp organizers took back ₹ 200 for transport).
Hours after the sterilization, she got a headache, followed by abdominal pains and vomiting. She assumed it was a normal side effect till state health officials came and rushed her to a hospital.
“We are completely afraid," Jangde said on Tuesday from her hospital room, where her husband, with their six-month-old baby, stood by her bed. “The government is playing with the lives of women and poor people like us."
The tragedy at Bilaspur highlights the perils of such sterilization camps or one-day drives that India regularly holds to keep its 1.2 billion population in check. Married women are the most at risk. While more than a third of them have been sterilized, only 1% of men have undergone a vasectomy, according to a 2006 National Family Health Survey.
Sterilization camps may evoke memories of the late Sanjay Gandhi’s notorious family planning drive during the Emergency (1975-77), but they remain the cornerstone of the government’s population stabilization policies.
“Sterilization is still the most popular Family Planning method adopted by our people to limit their family. As the demand for sterilization services remains very high, with a large unmet need the country has continued with the camp mode..," states the foreword of the booklet on Standard Operating Procedures for sterilization services in camps issued by the family planning division of the ministry of health and family welfare in 2008.
“The idea behind the camps is to provide access to sterilization in remote areas to people who do not have it. As an idea it is required, but the fault lies in not taking care of quality," said Sona Sharma, joint director of the Population Foundation of India, a non-governmental organization (NGO) leading policy advocacy efforts and working as a think tank on population issues.
In 2007, India increased incentives for women to undergo sterilization, and focused efforts on Chhattisgarh and other underdeveloped states. India now has the world’s third-highest female sterilization rate—after the Dominican Republic and Puerto Rico— among over 180 countries tracked by the United Nations.
Sterilization is the most popular form of contraception among women worldwide, but in India informed consent remains an issue, said Kerry McBroom, head of the reproductive rights initiative at HRLN in New Delhi.
Sterilization remains the best option for many women, she added, but “it needs to be an option in a context where there is education, counselling, quality control, access to primary care... In the current context, you don’t have any of these things".
Then, there is the implementation itself.
In February last year, private news channel NDTV aired footage of unconscious women in Malda district of West Bengal dumped outside the Manikchak rural health centre. More than 100 women were reportedly sterilized by two doctors in a single day.
“I have been to so many of these camps where the women are lying on the floor post the procedures; there are no arrangements for housing or even for an emergency situation. In some instances, they have been brought from neighbouring districts," said Vandana Prasad of the Public Health Resource Network (PHRN), an independent body that monitors health policies of the government.
Raman Singh, chief minister of Chhattisgarh, has pinned the blame for the Bilaspur tragedy on surgeon R.K. Gupta, who has been suspended and faces a criminal investigation.
Gupta used dirty instruments to sterilize 83 women in about six hours, according to a local medical official who asked not to be named because details of the investigation are private. He also breached guidelines that limit surgeons from performing more than 30 sterilizations a day, the official said.
Those guidelines were laid down by the Supreme Court in 2006. They also add that only 50 sterilizations a day can be carried out in a camp and mandate that a laparoscope be used for only 10 procedures (in Bilaspur, the same one was used for 83).
And while the venue in Bilaspur might not have been a school like the one Devi was sterilized in, it was no better—a private hospital that had been closed for almost a year. Each state is required to have an approved panel of doctors, said McBroom, but a public interest litigation by HRLN found that states had done the bare minimum. “So, there is an approved panel of doctors, but it dates back to 2007. Similarly, a quality assurance committee might have been formed (by the states to oversee the camps), but there are no minutes of any meeting," she said.
The guidelines also stress post-operative care, but doctors and anaesthetists leave soon after the camps are concluded, leaving the people with no one to turn to.
Sterilizations are voluntary and couples choose between a tubectomy or vasectomy, Harsh Vardhan, who was the health minister at the time, told Parliament on 18 July. From April 2010 to March 2013, the government paid out ₹ 51 crore for 15,264 deaths or failed surgeries, he said.
Tamil Nadu alone reported 32 insurance claims for deaths due to sterilization in 2012, according to data released by the health and family welfare department of the state.
“Complications occur all the time. You need required personnel, but there is a complete lack of concern for poor people," said Prasad of PHRN.
Dr Gupta, 63, said in a phone interview on Wednesday that he made no errors. He blamed the death on oral medicines given after the sterilization. “I’ve committed no mistake—my conscience is clear," he said, adding that he had performed more than 50,000 surgeries since 1987 without incident. “There was a problem with the medicines. Those who gave the oral medicines should be asked and blamed."
Some media reports have claimed that the medicines did not have expiry dates marked on them.
On the afternoon of 8 November, Jangde arrived at the clinic in Bilaspur. Five medical staff were present: Dr Gupta, two nurses and two other staff members.
They took her blood pressure, and then she gave urine and blood samples. The operating room was neat and tidy, she said, with two beds. The procedure went smoothly and was over in 10 minutes.
“I don’t know what went wrong," Jangde said, recalling the incident and looking frail and weak.
Shivkumari Tandon, 30, a village health worker who has participated in sterilization drives for the past 10 years, is also facing criticism. She brought four women to the hospital on 8 November. One of them is dead.
“People are blaming me," Tandon said while visiting the victims on Tuesday. “People are afraid. Family planning will be stopped in my area. No one will come forward to do this now."
The government has declared that there are no targets for population stabilization, but there is immense pressure at the district and block level with 1% of the population of the state considered as the base figure.
“The government talks about expected levels of achievement vis-à-vis sterilization, which is essentially setting of targets indirectly. Yes, there is a need for population stabilization, but that does not mean we do it in a haphazard way," said A.R. Nanda, a former health secretary. He is particularly critical of the policy providing incentives to health workers for getting patients for sterilization.
Tandon is one such.
These workers are paid ₹ 200 for every individual they bring to a mass sterilization camp. This, coupled with pressure from district authorities to meet the expected level of achievement, ensures that sterilization is promoted heavily. Even state departments have been known to offer incentives. There have been media reports of districts in Rajasthan coming up with incentives like a lottery in 2011 with a Nano car and a colour TV for people who took part in a sterilization camp. Then there is the added incentive of cash for those who participate. Women are usually given ₹ 1,500 and men ₹ 1,000.
“The attitude is ‘get them in, get them sterilized’…there is a huge push for sterilization in a system that just can’t handle it," said McBroom of HRLN.
Women are the primary targets of the government’s population stabilization programmes because it is they who seek them out the most. According to government data, Uttar Pradesh reported 320,168 female sterilizations compared with just 11,803 male sterilizations in 2012-2013, while in Tamil Nadu, 337,944 female sterilizations were carried out that year as opposed to only 1,901 vasectomies according to the annual report of the ministry of health.
The reasons for more women opting for sterilization as opposed to men range from a genuine desire on the part of the women to control child birth to more exposure to health programmes to simple unwillingness among men.
“It’s easier to target women and the whole health system is designed for that. They interact with healthcare workers during pregnancies, when they take their children to the aanganwadi, etc. On the other hand, it is quite possible that an adult male in a rural area can go by for years without meeting a healthcare professional," said McBroom.
Still, while the way sterilization camps are conducted remains an area of concern, what happened in Chattisgarh is not the norm. There are sterilization camps where the Supreme Court’s guidelines are followed and where care is taken to ensure that all health parameters are met. Without any accountability or strict penalties for not following the norms, though, there well could be a repeat of what happened in Bilaspur.
“There is a genuine need for good quality medical services, especially for poor people who are unable to struggle for their rights. Solid investment in the health sector is the need of the hour," said Prasad of PHRN, who cites examples such as Jan Swasthya Sahyog in Chhattisgarh, a people’s health support group that works for the socio-economically disadvantaged. “NGOs are providing services at low cost for poor people with no support from the government."
On paper, the government’s guidelines for population stabilization are water-tight and take into account every concern possible, but until the system views the economically and socially marginalized as individuals rather than just numbers whose fertility has to be controlled, more Bilaspurs will occur.
Jangde, wrapped in a red blanket, said she is sorry she ever listened to government messages promoting sterilization. “I’ll never encourage my relatives to do family planning," she said. “If they do, I’ll stand in the way."