It is a tragedy of unimaginable proportions. The death of 13 women, after being operated upon at a sterilisation camp in Chhattisgarh, points to the fact that something happened to them medically. The needle of suspicion is constantly shifting, and nothing is what it seems.
Dark shadows have crept over Amsena village in Bilaspur district, 15 km from Bilaspur town. Two young mothers of the village have died and another has been hospitalised after attending a government-run sterilisation camp at Pandari in Bilaspur on November 8.
Women huddle together in silence. Members of the extended family, they are here from distant villages to perform the funeral rites.
It will be a long night in the house of mourning.
37-year-old Roop Chand Sriwas is a barber. The death of his 30-year-old wife Phoolbai has left his three children motherless.
The youngest, Nitesh, is not even a year old yet. Nikita is 4-years-old and Narain 8-years-old.
"On Friday, midwife Bedan Bai visited us and told us about the sterilisation camp in Sakri the next day and asked if we wanted to go. My wife said she wanted to undergo the operation. On Saturday she and my mother went with Bedan Bai," said Roop Chand.
Like Phoolbai, 22 year old Rekha Nirmalkar was accompanied to the camp by Bedan Bai. Bedan Bai is Rekha's grandmother and had helped her elder sister go through sterilisation earlier. Another sister was to undergo the surgery a week later. Rekha died, leaving behind two children, a two-and-a-half-year-old daughter and a four-month-old-son.
The day after the operation, Phoolbai and Rekha suffered an intense spell of vomiting, along with chest pain and drop in blood pressure; symptoms that were experienced by all 83 women who had the surgery at Pandari.
In Ghuru village, we meet Ram Avatar Suryavanshi. A botched surgery when he was 10 left him disabled. He can only do light work as a daily wager and is barely able to make ends meet. His 35-year-old wife Nem Bai had to work to support the family. She also tended to her five children born over the last 18 years. Her eldest child Archana is 18-years-old and her youngest, Suryakant, is three months old.
Archana said,"Our family didn't have enough money for our food and expenses, so I quit school. My mother wanted me to be educated. Even when she was not well, she would go out to work and earn money so that I could study."
Nem Bai knew she had to stop bearing children even if it meant defying the family. She went to the camp without telling anyone at home.
Ram Avatar recalls the events of that fateful Saturday. "She had been operated upon by the time I returned home. She was sleeping. It seemed odd to me because she was fine in the morning. We did plan on her getting the surgery done. I had wanted it done at a private hospital but did not have the money. We thought of it after we had our third child. But the doctor dissuaded us. Then we had two more children after that."
Nem Bai did not survive the surgery. Archana is inconsolable. She says, "My brothers and sisters are refusing to eat. I cajole them (to eat). My baby brother is crying. He is searching for my mother."
Nem Bai's act of defiance emphasises a common thread apparent in the accounts. Contrary to popular perception, there is an overwhelming demand for sterilisation or terminal contraception among women in these villages.
Those at the camp were lactating mothers with newborns and they did not want to get pregnant again. This need was unmet even by private hospitals. While Caesarian operations offer commercial gain to private hospitals, tubectomies do not.
Nem Bai's neighbour Sumenbai was more fortunate and is recovering in the hospital.
Sulekha, Sumenbai's sister-in-law, tell us how the mitanin or health worker had informed them about the camp. Sumenbai went with her husband. There was no compulsion, says Sulekha.
When Sumenbai returned after the surgery, Sulekha asked her to take some rest.
"Three years ago, I had gone to the same camp at Sakri. Every year the camps are held during the four winter months. I did not face any problems. But Sumenbai complained of pain later at night. We told her to take the pills that had been prescribed. The pain remained through the night. In the morning, I suggested she take a pill again. I had no idea that the pill could cause harm."
Nembai and Sumenbai were accompanied by the Mitanin. The government does not pay salaries to mitanins.
She is given Rs 150 for every patient she accompanies to the camp.
Shiv Kumari Tandon, who is the Mitanin of Ghuru village, tells us she gets requests from people to take them to hospital. "If someone's child was sick, I would help them. This has never happened before. Nembai came to my house to say that she would come with me to the camp. I asked her who would accompany her to the camp. She said her brother-in-law Vicky would come. But no one came."
The women of Guru village are unhappy that the Mitanin is being criticised for her role. They say that at least 25 women of the village have got sterilised successfully. She was the one who helped them during the process.
We spoke to families, to the women recovering in hospital, to find out if the Rs 600 paid by the government to women who opt for sterilisation had influenced their decisions. They disagree, saying that the money barely covered their transport costs. Most said they did not have the resources to raise so many children and felt the need to limit their family.
It has been 11 days since the tragedy that claimed the lives of 13 women. Nearly 66 women remain in hospital. There is an air of despondency and suspicion as investigators have yet to pinpoint the cause of this episode. Was this a disaster waiting to happen? The focus first fell on the Government's sterilisation camp approach; with makeshift arrangements and lack of adherence to guidelines.
Dr Yogesh Jain, founder of the Jan Swasthya Sahyog, said, "Tubal ligation is a surgery and surgery has a sanctity. It is not that you need a table and a knife and a person who can give anesthesia and a little bit of drugs and chemicals thrown in. There is a way the linen needs to be looked at, the air around it, the water supply for the people, the management of the utensils. These are all necessities of a surgery for which a decent institutional infrastructure is required. Otherwise it is poor rate medicine for the poor. I think we must take this cue from this huge demand, make our infrastructures and superstructures."
According to Geeta Sethi, Secretary General of the Family Planning Association of India, "There is a high demand for family planning services of various kinds, but are we providing the most relevant quality service to those who need it? Are we doing it in a way that makes it is safest or that is real quality? Do we look at any underlying conditions whether it is anaemia, diabetes, heart problems, address those first and then give them a choice of different contraceptive technologies that they can use or are we just pushing them into no preparation, no follow up. Thus there is neither continuity of the service nor quality of the care that we give them.
The symptoms of the hospitalised women are not pointing to a single specific cause.
Did a bacterium take on a virulent form and infect the patients as is the case with hospital acquired infections?
The 'jugaad' approach at camps does not allow for sterile conditions.
There was clearly a supply-demand dysfunctionalism. At the heart of the problem is a desperate shortage of gynaecologists in rural areas, and vacancies galore in government hospitals.
In Barwani in Madhya Pradesh, for instance, of the seven community health centres in the district, only one has a gynaecologist. (Source:DLHS 3)
That's the reason why more women are sterilised by fewer doctors.
With 83 women reaching the Pendari camp, there was clearly pressure on Dr RK Gupta, the laparascopic surgeon.
However, what are unacceptable are compromises on quality and safety of care and the lack of monitoring by a committee at the grass-root level.
The sterilisation procedures at Pendari flouted Supreme Court orders that allow a maximum of 30 operations a day with two separate laparoscopes. A single surgeon performed three times the permissible number in less than five hours.
Analysts say it is a misconception that the family planning programme's targets are responsible for the situation.
Any well planned programme will have targets. The problem lies in the fact that the targets did not put pressure on the Government to provide for better infrastructure for poor people.
Dr Arvind Shukla, pediatrician at the Bilaspur district hospital, said, "So many patients are being treated at so many camps at so many places. This is known to everybody, from the DHO, CMO, secretaries. Why did the Government not take any action?"
"This is not the doctor's fault. The surgical technique was correct. Nobody died because of the surgeon's mistake. People died by infection of the body by a very lethal content."
The administration has responded to the tragedy by indulging in a blame game. There was no clinching evidence, yet the surgeon was arrested and the chief medical officer dismissed from service.
The chief medical officer, RK Bhange, was appointed two months ago. He says he had no information about the camp at Pendari.
According to the surgeon, he is a cog in the government's health structure. At a protest rally organised by the Indian Medical Association, his colleagues at Bilaspur's district hospital demanded his release from jail.
And then came reports of drug contamination. An oral medication Ciprocin 500 manufactured by a local company was said to have been the cause.
Sonamani Borah, Bilaspur Divisional Commissioner, said, "We found out that there is a strong suspicion of zinc phosphide poisoning. We have already sent the drugs used for the sterilisation operations and the Government has already banned six drugs which were used during these operations, and batch-wise."
A few days after the women died, some people developed similar complications after taking the same drug. Two men died of drug toxicity. The others were hospitalised. They had gone to a private doctor for minor ailments.
Says Borah, "We have seized 43 lakh tablets. Our local level investigations have confirmed that it is zinc phosphide but we will have to wait for the final report from the national lab. As of now the owner of the pharmaceutical company is behind bars and the government has already lodged an FIR under Sections 420 and 34."
The irony is that two years ago, the Government had filed a case against the company and banned seven medicines. Clearly there is violation of rules and procedures for procurement of drugs. The Government has announced a judicial inquiry. The report is scheduled to come out after three months.
The lapses at various levels indicate that despite standards being set, guidelines were not followed. There is lack of training and supervision to ensure people do what they are supposed to do.
This tragedy is an opportunity for the Government to rebuild the fragile public health system, to improve its efficiency, equity and effectiveness.