Yogesh Jain and Raman Kataria: The pathology of a public health tragedy

yj_pic Lessons from the Bilaspur sterilization camp 

The recent deaths of 13 women in India operated on at a sterilization camp in Bilaspur, Chhattisgarh, has thrown up urgent questions on the delivery of these services. As doctors observing health systems for the poor from close quarters in Bilaspur for the last fifteen years, we are convinced this was a tragedy waiting to happen. It is a collective failure of our society as a whole to see the stark inequity that erodes the health system, which these poor women have had to pay for with their lives.

A factfinding investigation has revealed that a single laparoscope was used for all 83 surgeries performed at the camp that Dr. Raman Kataria (1)day. Between procedures it was cleaned by dipping into a bowl of iodine-tinged water, wiped dry, and used in the next woman. Through meticulously arranged duties of the staff, the surgeon could maintain a speed of performing each procedure within one minute. Eighty-three surgeries took a little over 90 minutes. None of the staff changed gloves between each one. The needles and syringes were reused. After being handed an incentive of Rs. 600 (US$10) and 10 tablets each of an antibiotic and an analgesic, the women went back to their villages. Preliminary investigations also suggest the antibiotics were laced with toxins, and are likely to have caused these deaths. Apparently, all regulations that should guide procurement of these drugs by the state were flouted.

This was not an unusual day. It was just another sterilization camp in rural India, meant for poor women. These surgeries are done at a mass level ostensibly to fulfil the large unmet need of people as well as the planned targets of India’s family planning program.

The inequity in the way the poor are treated finds resonance first in the technical basis of health policy and thereafter, in the way policy is put into practice. A policy that accepts camps as satisfactory for performing surgical procedures like tubal ligation trivializes and violates any sanctity that surgeries deserve.

Can anyone justify doing elective surgical procedures outside functioning hospitals, except at a war front? If these women had been kept under the observation of trained staff in a hospital after the surgery, early symptoms of sickness may have been detected and possibly some deaths averted.

Further, given the numbers and speed these camps demand, it is impossible to provide basic surgical antiseptic measures, or dignity to people. The response of the state in the aftermath of the incident is also questionable. The beleaguered state health department instructed that sick patients are transferred to a corporate hospital rather than offering to provide care through the public hospital. This leaves the rank and file of public providers demoralised.

At the community level, the kneejerk reaction to confiscate all publicly provided drugs from community health workers has created a sense of insecurity. The hard-earned trust of the community in health workers, attendance at public hospitals, and use of government supplied generic drugs has taken a beating. Healthcare for the poor, who largely rely on the public system, is further jeopardized.

This is a time to pause, think, and improve public health services. Only effective public systems can provide care to the poor in this unequal world. Privatizing health services further is not the way. This tragedy must lead us to rebuild the public health system rather than disband it, and have equity underpin it – not merely in accessibility or cost, but also in quality.

Yogesh Jain (pictured top) and Raman Kataria are rural doctors working at Jan Swasthya Sahyog, Chhattisgarh.

No competing interests.

  • Atul Singhal

    I am surprised that only 13 women died, given the circumstances. The survivors just got lucky. This is an example of utter callousness on the part of all involved parties – not a lack of skill or resources. A complete disregard for human life that has invaded health care systems in many societies.
    It is easy to make news headlines out of such disasters, while the real story goes untold. Sudden unexpected death of 13 young women is an eye opener. But the death and disability, by slow poisoning of large numbers of people, by the hands of corrupt/greedy/incompetent/careless physicians or pharmaceutical companies is an epidemic of epic proportions in at least the two countries I am very familiar with – the US and India. The healthcare systems and the resources in these two countries couldn’t be more different, but iatrogenic morbidity and mortality in the two is probably comparable.

  • Jyotishankar Raychaudhuri

    If Bhopal could not move this country, doubt this episode will……from Budhha to Sankara to Rammohun to Modi…..we have seen many try…..what Yogesh and Raman are doing is more Gandhian than even what Gandhi did…their dedication and perseverance I am aware at close quarters since the days when it first started in Hostel 2 rooftop when they were medical students. Yes, public health must be strengthened in India as NHS in England is. However, given the nature of corruption and complicated conspiracies hatched in this country by very intelligent crooks, a completely public or a completely private system will be subject to same corrupt practices. It is accountability and quick legal oversight that is needed. Then again Jolly LLB is the state of affairs of the Judiciary in India. Only time will heal the wounds as it has in western countries and create new diseases of the future.

  • Tim

    Another example of the depths of depravity to which health-care systems have sunk. Whether it is a rising power such as India, The NHS colossus in the UK, medical practice in Canada or the USA, doctors, regulators, administrators the world over have denied patients their right, to safe, effective and altruistic care.
    Congratulations to these two Indian doctors who have helped to expose the brutality of modern medicine.
    I work in Canada and oft-times, I have wondered whether I am in a Nazi death-camp or a health-care system.

  • Suhas Kadam

    I live in Bilaspur and this tragedy happened, 9-10 kilo-meters away from my stay, I can clearly say that this tragedy has killed the India’s family planning program. After this incident, I could meet few families of victims and survivors and then the survivor of this camp. I also met few Mitanin who is the female community
    health volunteer who provides preventive primary health care services to the community and act as the main link between the community and the public health system. I have heard the words of the Mitanin saying “In the community, now no one would listen to us easily. We try very hard to get these people in the camps or to public health care systems by counselling and motivating them. They are from our villages, our close relatives, our close friends. But after this incident, the families are blaming us.” She said, “I thank god that the woman whom I took to the camp, has survived, else it would have been very difficult for us to live here in the village”.

    After this, what I could suggest is to strengthen public health care institutions – make them functional by improving infrastructure, availability of doctors and other health personnel, counselling,
    medicines, etc. and also strengthen capacities of human resources at all levels of the health system, to ensure provision of comprehensive information, adequate response to the needs of persons wanting to access contraceptive services. Provide routine contraception services through an improved public health care system offering safer contraceptive methods such as condoms, oral pills and encourage male responsibility.

  • Braj SG

    The tragic incident which was happened at Chhattishgarh is a
    collective failure of public health systems in India. Matter of regret is that they died not because of any morbidity; they died because of an unaccountable and highly compromised health system prevailing in our country which is unable to deliver safe health services to its citizen in the twenty first century.

    To this unfortunate incident there are many layers of reasons are associated with it. Till today various explanations have been generated and expressed are just the tip of the iceberg. In my opinion this incident is a mix up of various factors like failure of population control policy, unethical management, breaching of rights, political health, mistrust and societal discrimination along with clinical and infrastructural failure.

    The exercise of family planning should be done with the proper
    understanding and consent of the party. It is expected that whether women will be undergone for family planning or not that decision should be taken by them only. But in India the case is bit different! As a part of an utopian policy the government allures people by giving money as a benefit of family planning; actually they are contravening the inalienable rights of family planning, freedom of expression and decision making. The national population policy 2000 is draconian in nature which does not conserve the right to exercise freedom of family planning. Many a times the vulnerable population of rural community either they have very little knowledge of family planning or they are exploited by the acceptable wrong doings of the existing system. As a result of it, all those downtrodden people are highly likely to be fallen into this trap of getting hard cash without knowing their right. This avoidable incident raises the very valid question whether common people hold any right to take their own decision for family planning or not! It also questions with qualms about the validity and reliability of the government’s incentive policy for encouraging family planning. It would be better to say in a phrase that it is an utter failure of political health and health governance in this country.

    Along with procedural and infrastructural failure, we came
    to know about the shocking truth about the post-operative drugs which had been provided to the patient was of poor quality. With the utter scariness, the common people want to know about the existence of quality control or pharamacovigilance within the health system. This incident added fuel to the existing mistrust between health service provider and consumer. The way gap has been increasing which may transform this chronic ulcer to non-healing sore. In long term this issue could make a negative impact on using of generic medicine and people are likely to be skeptical about its quality.

    Still now very little has been discussed on the societal discrimination which has been going on very drastically with the present family planning system. Few social schools expressed their concern with the present system which is ready to target all those vulnerable groups like minorities, primitive tribes or poorest of the poor just to reduce the total fertility rate (TFR) by any means. From the ethical point of view this kind of medieval practice is highly objectionable and offensive to disdain the rights of ill-protected people.

    With the help of encashment whatever may be progress we
    achieved which has not been going to be sustained in future. This kind of moronic and heart less policy is mediocre and friable in nature and very much vulnerable to breach the law of human
    rights with the advent of time. Still there is a huge unmet need of family planning in different parts of India. It is highly desirable that the government should build such a system where we equitably
    distribute tools of contraception wherever may be necessary. A public display of penitence is not enough to raise the bar of India’s policy on family planning. To sustain the effect of family planning the policy maker need to address various factors like education
    gap, gender gap, understanding of the purpose of family planning, felt need of family planning etc. To make the procedure of family planning we should create an enabling environment which favors the decision making process without of any hesitation, scariness and allurement of hard cash.

  • Braj SG

    Still now very little has been discussed on the societal discrimination which has been going on very drastically with the present family planning system. Few social schools expressed their concern with the present system which is ready to target all those vulnerable groups like minorities, primitive tribes or poorest of the poor just to reduce the total fertility rate (TFR) by any means. From the ethical point of view this kind of medieval practice is highly objectionable and offensive to disdain the rights of ill-protected people.Still now very little has been discussed on the societal discrimination which has been going on very drastically with the present family planning system. Few social schools expressed their concern with the present system which is ready to target all those vulnerable groups like minorities, primitive tribes or poorest of the poor just to reduce the total fertility rate (TFR) by any means. From the ethical point of view this kind of medieval practice is highly objectionable and offensive to disdain the rights of ill-protected people.

  • VR

    I fear what would have happened if none had died?..More medals for the doctor and justification of the callous manner in which these mass camps (or mass exploitations in other arenas too) are planned and implemented and foremost of all, disrespect for human lives?

    Until whenever and wherever we treat the poor, ignorant, or deprived as not equals or like animals, that too from a different planet, I fear seeing such headlines often.