#India – Womb and Wolves #Vaw #Womenrights #medicalethics


By Swagata Yadavar, THE WEEK
Story Dated: Monday, April 15, 2013 15:8 hrs IST
Guddi devi, 27: She had sought treatment for a simple stomach ache. The doctor prescribed hysterectomy. Today, with all her vitality sapped, she feels it was the biggest. Photo by Amey Mansabdar

“I feel sick.”
“I feel sick.”
“I feel sick.”
These words still echo in my ears. They did not come from a dying man or a depressed woman. They were whimpered by scores of ‘normal’ women in India‘s rural hinterlands.
The cause lay in two words uttered by their unscrupulous doctors: bacchedani kharaab. These gullible women were told their uteri were faulty, and that they had to be removed.
THE WEEK’s journey through some villages in Bihar and Rajasthan revealed the plight of women—many of them allegedly unmarried—whose wombs were removed as “treatment” for everything, from a simple stomach ache to menstrual issues.
Why? The reason, again, lay in two words: filthy lucre.


Sunita Devi, a 35-year-old labourer of Latbasepur village in Bihar’s Samastipur district, would tell us more. It all started with a debilitating stomach pain, which she had ignored for long. Thanks to the Rashtriya Swasthya Bima Yojana, she hoped to finally get proper treatment at a private hospital.
At Krishna Hospital, one of the hospitals empanelled in the rural health scheme, Sunita was told she needed an appendicitis surgery. And a hysterectomy, too.
She underwent both eight months ago. Today, she is feeble. “I often get palpitations,” she said. “I get frequent headaches and gas trouble.”
The mother of five can no longer work in the fields. She now assists at a small shop in the village. The plight of her two sisters-in-law who also underwent hysterectomies is no different.
Three years ago, the RSBY, which entitles families below poverty line to free treatment up to Rs.30,000 a year, was implemented in Samastipur district of Bihar. It was a godsend for the rural masses. But, in the hands of greedy doctors, it became a cruel instrument to siphon off public money.
The Samastipur scam came to fore when District Magistrate Kundan Kumar found an alarming number of hysterectomies conducted by private nursing homes during an RSBY meeting. Of 14,851 procedures conducted under RSBY between 2010 and 2012 in 16 empanelled hospitals in Samastipur, 5,503 were hysterectomies. That is about 37 per cent of all procedures. In some hospitals, more than 50 per cent were hysterectomies, which costs the highest of all procedures under the RSBY scheme.
Kundan Kumar organised a five-day medical camp to ascertain if the procedures conducted were needed. About 2,600 women who had undergone hysterectomy attended the camp. The expert team found 717 cases of unwanted surgery, 124 cases of underage surgery, 320 cases of fleecing and 23 cases of non-surgery.
The magistrate’s report clearly pointed to gross unethical practices. For instance, Anita Devi, 23, who complained of abdominal pain and white discharge, had been operated upon. The expert team commented: “Conservative treatment should have done, hysterectomy not justified.” Similar was the case of Ratna Devi, 40, who underwent hysterectomy for appendicitis.
The report noted that many beneficiaries mentioned by the private hospitals could not be traced. In many cases, the hospitals simply swiped their RSBY cards but never conducted the procedures. There were also instances of procedures being marked against the name of dead people. Worse, some hysterectomy ‘cases’ reportedly turned out to be men!
It was found that many of the private hospitals and nursing homes did not have the requisite infrastructure for the procedures. Only some of them had well-trained surgeons, and in a few cases, operations were conducted by non-medical practitioners.
Subsequently, 12 of 16 nursing homes in Samastipur were de-panelled from the list. FIRs, too, were lodged against five of these guilty hospitals under various sections.

Sangita devi, 26: She underwent hysterectomy two years ago. Her husband says the doctor who operated upon her often hassles her for signatures on “some paper”. Photo by Amey Mansabdar

The involved doctors, meanwhile, were doing their best to cover their tracks. “Dr Thakur from Krishna Hospital often comes to our house asking for our signature on some paper,” said the family of Sangita Devi, 26. Sangita underwent hysterectomy two years ago. Since then, she has been battling frequent spells of weakness, dizziness and  headaches. She now weighs just 30kg and can hardly manage any work. She has already spent Rs.5,000 on medicine and the frequent trips to the doctors are eating away most of what her husband earns. When THE WEEK contacted, Dr Thakur refused to meet us.

Next, THE WEEK travelled to Rajasthan’s Dausa district, where a high number of hysterectomies was reported recently. Guddi Devi, 27, felt sick, though she technically was not. Her bones and joints ached all day. Fatigue bound her to bed. Food did not interest her. And her eyesight was fading. It was nothing but a clear case of premature menopause, courtesy the hysterectomy and oophorectomy she underwent three years ago.
“I had gone to the doctor, complaining of stomach ache. He told me that my uterus should be removed or I would get cancer,” she said. Her family, which owns just a small piece of land, was convinced to go for the “life-saving” surgery costing Rs.16,000.
“I feel weak all the time. I constantly fall ill, and the stomach pain for which I sought treatment initially persists,” said the mother of three. She has already paid another 110,000 on treatment of these symptoms, often travelling two and a half hours by tractors and buses to the nearest hospital. Now, her 12-year-old daughter, Rinki, takes care of all the household responsibilities. “I am upset about spoiling her education,” added a sullen Guddi.

Angoori devi, 34: She underwent hysterectomy as treatment for excessive menstrual bleeding. She recalls that about 40 women were admitted along with her in the same hospital for hysterectomy. Photo by Amey Mansabda

Every village THE WEEK visited had similar stories to tell. “I went to the doctor for excessive menstrual bleeding and he advised hysterectomy,” said Angoori Devi, 34, of Sikandara. “She cannot do anything now; she gets easily tired,” complained her daughter, Guddi. The family had to sell their buffalo to pay for the surgery, which gave her joint aches, indigestion, dizziness and fatigue as companions.
“When I was admitted in the hospital, there were about 40 women who were undergoing the same operation,” Angoori recalled about her stay at Madaan Hospital. Activists in the area said as many as 2,300 women in the region have undergone unwanted hysterectomies at private hospitals in the past two years.
An RTI application filed by advocate Durga Prasad Saini of Dausa revealed that of 385 procedures conducted over six months in three private hospitals of Bandikui town in 2010, at least 226 were hysterectomies. And of them, 185 were below the age of 30.
“Is there an epidemic in Dausa that forces women to undergo hysterectomy?” asked Saini, who is also National General Secretary of Akhil Bharatiya Grahak Panchayat (ABGP). “If there was a suspicion of cancer, why was not a single biopsy done?”
What compounds the issue in such villages is the people have no one else to go to. For instance, the post of a gynaecologist had been lying vacant for many years in the community centre in Bandikui despite repeated requests.
Though the centre got a gynaecologist, it wore a dark and deserted look when we visited. “Tell us how we will manage when such a big centre only has five doctors,” said an employee. On the other hand, there are five big private hospitals in the town, doing well.
“The doctors have an understanding with the rural practitioners, who are promised a commission on referrals,” alleged Dr O.P. Bansal, who runs a hospital in Dausa. Even employees at government hospitals act as agents who take patients to private clinics.
Hysterectomy was so ubiquitous in the town that some households had three generations of women who had gone under the knife. Take the case of Sushila Devi of Maanpur village who had gone to Katta Hospital to meet a relative, Guddi Devi, admitted for hysterectomy. Sushila, too, got caught in the trap and was operated upon three days later.
Guddi Devi, a mother of four, was advised hysterectomy to cure body ache. Now, she can no longer work as a labourer. “I feel dizzy when I am in the sun, I cannot lift heavy loads and get frequent palpitations,” she said.
Surprisingly, despite protests and frequent media reports, no action was taken against erring private hospitals. “They have consent papers from the women, so we cannot do anything unless the Clinical Establishment Act is passed,” said O.P. Baherwa, chief medical and health officer, Dausa.

Vimla Devi, 20: Her caesarian section that went wrong was followed by a hysterectomy. The childless couple has filed a police case. But her husband, Mahendra Kumar, says the cops have been threatening him to not pursue the case. Photo by Amey Mansabdar

Many FIRs, too, were lodged in the local police stations against the doctors. Mahendra Kumar filed a case against Madhur Hospital and its owner Dr Rajesh Dhakar, after his 20-year-old wife, Vimla Devi, was subjected to hysterectomy following a failed caesarian section.
The crestfallen childless couple alleged that the police did not investigate the matter properly and threatened ‘action’ if Kumar pursued the case.
The attitude of officials at Dausa was, indeed, sympathetic towards the doctors. “People here attack the doctors and threaten to destroy the hospital, hoping to get compensation,” said District Collector Pramila Surana. Police Inspector Rohitash Devanda said he had not come across any cases against doctors since he took charge 10 months ago. “These people blackmail doctors to gain money. If some patients die during treatment, it does not mean the doctors are at fault,” he said. A clock bearing Madhur Hospital’s name hung on his office wall.
The RSBY triggered a uterus loot in Chhattisgarh, too. Health Minister Amar Agrawal stated that 1,800 hysterectomies were done in just eight months last year. It was estimated that at least 7,000 hysterectomies were conducted in the state over the past three years under the RSBY scheme. The issue, which was noted by the National Human Rights Commission, led to a furore and licences of 22 private hospitals were cancelled.
Down south in Andhra Pradesh, it was the state government’s insurance scheme, Arogyashri, that led to rampant exploitation. Ever since the scheme was implemented in 2007, there was an exponential rise in hysterectomy cases.
Hyderabad-based NGO Centre for Action, Research and People’s Development found that 171 women under age 40 in just one administrative block of Medak district had undergone hysterectomy. About 95 per cent of them had gone to private clinics for treatment and 33 per cent had their ovaries also removed.
A survey by the Andhra Pradesh Mahila Samatha Society found that as much as 32 per cent of about 1,000 women who underwent hysterectomy were below age 30.

These case studies and statistics point to deep rot in the health care system. In fact, it is disheartening to see a project like the RSBY—termed by the World Bank as “path-breaking”—being exploited. The RSBY was seen as a prelude to the Centre’s ambitious Universal Health Coverage, which is expected to be implemented under the 12th Five-Year Plan (2012-17).
While private health providers bring better infrastructure and quality, they also bring in the risk of greed and exploitation. Without proper monitoring, this kind of public-private partnership is a cause for concern, said Padma Deosthali, coordinator of Centre for Enquiry into Health and Allied Themes, Mumbai. “For instance, there is no mention of quality of care in the empanelment under the RSBY scheme. Not even basic standards like presence of a qualified medical practitioner and nurse,” she pointed out.
“More than treating health problems, the focus is on procedures and surgeries, which was exploited by private nursing homes,” said Dr A.V. Sahay, medical officer and district head of Bihar Swasthya Seva Sangh. He also stressed on the need for enhancing the public health care system and improving the “reproductive hygiene” of women in rural regions.
Dr Yogesh Jain of Jan Swasthya Sahyog said a major flaw in the scheme was that it did not cover out-patient treatment and, hence, encouraged unwanted hospitalisation. Without strict guidelines, doctors cannot be expected to regulate themselves, he added.
Currently, however, the Central government has directed all state nodal agencies of RSBY that approval from the insurance company concerned is mandatory for hysterectomies performed on women under age 40.
But does the issue end there? The brouhaha shall pass. The scam will turn stale. But what about the innocent women who went under the knives for no reason? Sadly, no one, except a few NGOs, has reached out to them.
“The cost of maintaining the health of a woman who had undergone hysterectomy with medicines and supplements is Rs.18,250 a year,” said Dr Prakash Vinjamuri of Hyderabad-based Life HRG, which studied the surgery’s impact on women in Medak district of Andhra Pradesh in 2011.
The toll is not just monetary. Loss of vitality and libido affects the psychological and social health of the woman. The study in Medak, for instance, found women whose uteri were removed faced domestic violence over sexual issues, and many husbands had extra-marital affairs. The worst part was the impact on the next generation, as children of these women are forced to quit school to handle household chores.
When and who will compensate for all these losses?

Vital loss

Hysterectomy  is the surgical removal of the uterus but may also involve removal of the cervix. A patient may require 3-12 months for full recovery.

TYPES
Radical hysterectomy
Removal of cervix, upper vagina, lymph nodes, ovaries and fallopian tube. Recommended in case of cancer.

Total hysterectomy
Removal of uterus and cervix.

Subtotal hysterectomy
Removal of the uterus.

RISKS
* Excessive blood loss, injury to ureter and bladder
* Cardiovascular disease
* Osteoporosis
* Decline in psychological well-being
* Decline in libido
* Premature death
* Affects the functioning of ovaries in 40 per cent of women

Early menopause
The average age of menopause in India is 51 years, and removal of ovaries advances it by 3.7 years. Menopause leads to a drop in oestrogen (female hormone) level, causing calcium loss and bone breakdown.

When is hysterectomy needed?

Hysterectomy should be a last resort in conditions such as cancers of the reproductive system, severe infections, persistent vaginal bleeding, uterine prolapse, endometriosis and to prevent further conception.

Before undergoing hysterectomy, one should undergo either a hormone test, sonography or a pap smear to test for cancer.

 

#India- Forced hysterectomies, unscrupulous doctors #Vaw #Reproductiverights


Swapna Majumdar/Women’s Feature Service

Consider this chilling statistic: In the last two years, in various states of India, more than 30,000 women were reported to have undergone hysterectomies.

In 2011, 16,000 women opted for hysterectomies in Bihar; doctors performed about 7,000 uterus removal surgeries over a period of 30 months in Chhattisgarh, while a total of 11,000 such procedures were done over a period of two years in Andhra Pradesh.

Not only is this sudden rise in hysterectomies deeply worrying, even more serious is the fact that 80 per cent of the women who underwent them were between the ages of 20 and 40 years. Health activists contend that rural women living below the poverty line (BPL) are being advised to go under the knife to avail of their health insurance money provided under the Rashtriya Swasthya Bima Yojna (RSBY), the union government’s premier insurance scheme that provides health coverage to underprivileged families.

According to reports, in Bihar’s Samastipur district alone, 14,851 BPL women were admitted to 16 private hospitals in the past one year to avail the benefits under the RSBY scheme. In Chhattisgarh, private nursing homes billed the state government Rs 2 crore under the scheme for conducting hysterectomies of 1,800 women over a period of eight months last year. In Andhra, under the Aarogyasri scheme, the state health insurance plan, a sum of Rs 2.9 crore was paid for 656 surgeries carried out in 2009-10.

According to Sulakshana Nandi of the Jan Swasthya Abhiyan, a collective of over a thousand NGOs working on health rights, “The RSBY and similar health insurance schemes are incentivising unethical practices leading to the large number of irrational and unnecessary surgeries.”

Here’s why health activists are concerned. Under the RSBY, cashless insurance of Rs 30,000 is given yearly to a BPL family – and a doctor can charge a hefty Rs 12,500 for a hysterectomy. In Andhra, for instance, a hysterectomy can cost up to Rs 60,000 – an amount that was reimbursed under the state’s Aarogyasri scheme.

Nandi, who has done four studies assessing the implementation of the RSBY in Chhattisgarh, points out that private hospitals were cherry picking the patients they wanted to treat. “Doctors chose patients who needed high-end surgeries that are more expensive and, therefore, more profitable. For example, a hysterectomy is considered a more profitable surgery compared to a caesarean section. It is ironic and scary that a woman can, in some sense, have easier access to hysterectomy than simple treatment for her problems at an early stage of any uterine infection because of RSBY and other insurance schemes,” she contends.

In Andhra Pradesh, ‘aarogyamitras’, or health helpers, are appointed by private hospitals to scout around for patients who can be enticed to get operated upon in private hospitals, reveals N. Purendra Prasad of the Department of Sociology at Hyderabad University. Prasad, along with research scholar P. Raghavendra, found that “a spurt in unnecessary surgeries had been reported after Aarogyasri was launched. For instance, in district Warangal’s 13 private and five government hospitals, 38,090 cases, of which 3,346 operations related to hysterectomy, were reported from August 1, 2008 to August 21, 2010. As there was scope for quick money to be made in surgeries, private hospitals used registered medical practitioners (RMPs) to refer poor women with gynaecological problems as hysterectomy cases”.

Unfortunately, it is the women who are ultimately paying a very heavy price. When Rajamma of Kannaram village in Andhra’s Medak district went to the doctor complaining of pain in her lower abdomen, she was wheeled in for a hysterectomy. All she was told was that this would help relieve her pain. Rajamma was just 20.

But it was not just Rajamma who went under the knife. Almost all the women in Kannaram village had undergone hysterectomy for routine complaints like abdominal pain or white discharge. This was revealed by the Centre for Action, Research and People’s Development (CARPED), a Hyderabad-based NGO. The 2009 survey found that most of the women in the 125 households in the village had undergone procedures to remove their uterus. This was backed up by a study in the same year by the Andhra Pradesh Mahila Samatha Society, a state government organisation, which found hysterectomy cases in women between the ages 25 and 40 had increased by 20 per cent since Aarogyasri was launched in 2007. Of the 1,097 women surveyed in five districts, 30 per cent reported that doctors had told them that they would die if they did not get operated.

In Chhattisgarh, health activists say that poor illiterate women complaining of back pain were warned that they would contract cancer and die if their uterus was not removed, even as those suffering from excessive bleeding or vaginal discharge too stood no chance of escaping the surgery. While the procedure may have been necessary for some, in most cases it was not required.

According to Dr S.V. Kameswari of Life-HRG, a Hyderabad based NGO providing healthcare to rural women and campaigning against the unnecessary hysterectomies in the state, the reason for the indiscriminate usage of surgical treatment in the state was a combination of the socio- economic and cultural background of the women. “The lack of awareness of the women and the power of the medical practitioners to influence their decision led to the spate of unnecessary hysterectomies,” she contends.

Dr Kameswari, who studied the medical ethics of hysterectomies in rural Andhra Pradesh, found several aberrations. “Instead of following the normal protocols while examining women with complaints of abdominal pain, bleeding or vaginal discharge doctors performed or advised hysterectomies,” she reveals.

Standard protocol demands that women have to be informed about the after-effects of such a surgery. Medical studies have established that those who have undergone hysterectomy face long term health implications, including a higher risk of heart disease and osteoporosis. They are also more likely to become depressed.

At least Dr Kameswari’s study had a positive outcome. “We were called by officials of the Aarogyasri scheme to discuss the data emerging from our study. Other experts were also consulted. Thereafter, revised guidelines were issued banning private hospitals empanelled under the scheme from conducting several surgical procedures including hysterectomies, appendectomy and the removal of the gall bladder,” she states.

While governments of Chhattisgarh, Bihar and Andhra Pradesh have initiated action against erring hospitals, nursing homes and doctors, health activists argue that great damage has already been done. They say that the number of unnecessary hysterectomies conducted may have come down in Andhra after the guidelines were revised in April 2010, but it could not undo the harm done to the thousands of women who were encouraged into removing their uterus.

It cannot assuage the grief of women like Rani whose chances of having a second child have ended because of a callous system. Much to the shock and horror of the 19-year-old who was admitted to a private hospital for a severe stomachache, her uterus was removed instead of being operated for appendicitis, as her family had imagined.

Health activists believe that unless there is an effective, efficient and accountable public health system, unethical practices will continue. The absence of quality healthcare in rural areas forces women to approach “good doctors” in towns. The doctor’s advice to remove their uterus makes them believe that it will end their medical problems once and for all. What makes the procedure more attractive is that being covered by the RSBY or other government sponsored insurance schemes, it is free. They are neither informed about its long-term consequences, nor the alternative medical treatments available.

Not only is a more robust monitoring of the insurance schemes needed, focused attention on improving basic health services could save women like Rani from losing a second chance at motherhood.

16,000 ‘illegal’ hysterectomies done in Bihar for insurance benefit #VAW


Aug 27,2012- Indian Express

Over 16,000 hysterectomies (surgical removal of the uterus), most of them “unnecessary”, have been reported at private hospitals across Bihar during the last one year allegedly to “avail insurance benefit” under the Rashtriya Swasthya Bima Yojna.

The RSBY was launched by the Centre in April 2008.

Preliminary investigation by Samastipur, Madhubani and Chhapra district authorities, which reported the maximum number of complaints, showed 10,000 hysterectomies took place in these three districts alone. While Samastipur administration found 1,300 of such operations suspicious, Chhapra has put 1,700 such cases under the scanner. Madhubani conducted over 1,200 such surgeries in a year.

Under the RSBY, a BPL family can avail maximum Rs 30,000 in case of hospitalisation. A BPL family has to pay Rs 30 for getting registered under the health scheme. The government pays the annual premium amount for BPL families.

Bihar has 76 BPL families availing the scheme, under which a biometric smart card is given.

The labour resources department, which is the nodal agency for implementation of RSBY, has sought report from district magistrates of 38 districts. Samastipur DM Kundan Kumar has finalised his report. Saran (Chhapra) DM Vinay Kumar has set up an inquiry team under sub-divisional officer V K Pandey. His report says that most women having undergone the surgery were below 30 years.

Chief Minister Nitish Kumar ordered inquiries into the alleged illegal uterus removals last month.

Bihar Labour Resources Minister Janardhan Singh Sigriwal told The Indian Express: “It will be too early to call it a scam. Only five per cent of women in the state have gone for hysterectomy as against the national average of over seven per cent.”

He said that if DMs’ reports suggest any nexus between private hospitals, NGOs and intermediaries to siphon off insurance amount, the government would take action.

“We are waiting for reports from DMs. We have heard about some initial findings from Chhapra and Samastipur. We will get the cases examined by medical teams and then arrive at any conclusion on police action,” Sigriwal said.

IN SAMASTIPUR

8,000 hysterectomies in year — maximum in the state

5,000 in clinics in and around Samastipur town

Private hospitals claimed reimbursement of Rs 12 crore over last one year

One hospital claimed Rs 1.28 crore while another got Rs 97.18 lakh

A clinic in Shahpur Patiori block claimed reimbursement of Rs 55.42 lakh

Another at Dalsingsarai claimed Rs 32.24 lakh

DM’s report said 489 operations were summarily conducted without any need

Some surgeries conducted only on paper

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