Anatomy of a medical butchery

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It was the kind of horror that could have happened only in a place where life is cheap and easily disposable. We find out what went wrong in Bilaspur, Chhattisgarh, where fifteen women died after attending mass sterilisation camps and more than a hundred were taken ill
It is five in the evening, and she is waiting for the evening tea to arrive. It has been three days since her daughter Leelabai was admitted to the Intensive Care Unit (ICU) at the Chhattisgarh Institute of Medical Sciences (CIMS), in Bilaspur, and 50-year-old Harkubai is tired. She is tired of waiting in a makeshift camp in the common passageway of the hospital, now weary of the nagging fear that looms over the camp. “What if they call out Leela’s name next?” she snaps. “Three girls have already died,” she says anxiously, almost crushing an empty plastic bottle that she has been holding for the past half hour. She found it near the hospital canteen in the dustbin, lying on top of a garbage pile, and rinsed it with tap water, she says.

As the tea arrives, hot and steaming in two steel decanters, Harkubai dashes off to the counter to be the first in line for it. As she emerges triumphant from the crowd gathered around, she still has the 1-litre soft drink bottle. It now contains some warm milk, seemingly diluted with water. She makes her way through the crowd and finds a three-month old baby wailing away in a pink cradle. She takes the baby in her lap, fills the bottle cap with a few drops of milk and feeds Muskaan, her daughter’s third child.“This the only way to keep the baby quiet,” she adds.

This makeshift camp at CIMS is home to about 20 toddlers and their relatives, as their mothers struggle to survive the tubectomies carried out. Most toddlers are under six months old, being looked after by aunts, grandmothers or hapless fathers learning to tend to their children in the mother’s absence.

As the crowd settles, one realises that most of the attendants sitting in the passageway were actually waiting for milk to arrive. Each person is allowed about a ladle of warm milk, “only for the babies”, as a staff member announces. The tea in the other decanter is meant for the adults. The passageway is dotted with pink and blue plastic cradles, provided by the hospital authorities just the day before for toddlers whose mothers are among the 138 women recuperating in three hospitals—a private one included—from a round of botched sterilisation camps organised in the district on 8 November.

Harkubai too had accompanied her daughter to one of the four birth-control camps held that day. She had taken an hour’s auto ride from village Sakri with the daughter who decided to have a laparoscopic tubectomy done after having Muskaan. The surgery was done at a camp near a foodgrain godown in Takhatpur. She was given a cash incentive of Rs 600 by the government for her participation, and a few strips of tablets for pain relief and to limit infection as part of post-operative care. Of the incentive, Rs 100 was spent on the auto fare, Harkubai clarifies. Leela started vomiting after the third dose of an oblong white tablet, which has now been identified as ciprofloxacin 500, a broad-spectrum antibiotic often given to patients recovering from surgery. Next, before Harkubai knew, an ambulance came rushing during the wee hours of 10 November. “The mitanin (health worker) said there were other girls who were falling sick and needed to be taken to hospital,” she says. Leela is listed as the first patient in the ICU list that hangs by a thin nylon string outside the chamber, and is said to be ‘critical’.

As the night begins to settle, the temperature begins to dip in the dark and dingy corridor. Sita, a nurse looking after the toddlers, chides a father for not bringing sheets to keep the baby warm. “It’s getting colder and they don’t have sheets to cover their babies. We don’t want babies falling sick with pneumonia, anything can happen,” she says, rummaging through a pile of sheets brought in by the hospital staff. But the thin cotton ones they have got are not warm enough. Ramchand, a labourer, pulls out a thick and dusty sheet he has been sitting on for hours, and puts it on his six-month-old baby. His village is about 25 km away from Bilaspur city. He is not sure of how to handle Kisna, the baby, when he cries or gets hungry. “His mother would have looked after him, but the baby has to be with me,” he says. His mother Malti, is still in a critical state on an ICU ventilator.

In a major medical tragedy, 15 women have died so far, and about 138 others have taken seriously ill after attending mass sterilisation camps—four separate ones—organised on 8 November by the Chhattisgarh government in Bilaspur district. Within 24 hours of the tubectomies, conducted by doctors from government hospitals, women began reporting nausea and vomiting, and suffered sudden dips in their pulse and heart rate. The first few deaths, two on the way to the district hospital, also happened within that span of time. As the news came in, the Department went into a tizzy, sending ambulances to all primary healthcare centres in villages and tehsils. The situation, they found, was grave. By 12 November, 13 women were reported to have died and 30 were critically ill. Over a hundred were showing other symptoms of illness—non-stop vomiting, fluctuating pulse rates and extreme dizziness.

The unravelling of what caused the tragedy is a reminder of the abysmal healthcare services in India. Suspecting negligence at the surgery level, initial police action involved the arrest on 12 November of Dr RK Gupta, a celebrity government doctor who had won accolades for conducting 50,000 tubectomies in his career—a record of sorts in 2014. But he had done 83 laparoscopic tubectomies— more than double the permissible limit as per government guidelines—in less than two hours on 8 November at one of the camps, a makeshift one in a rundown and abandoned charitable clinic, and was thought to be the culprit.

Performed under general anaesthesia, a laparoscopic surgery involves the use of a telescope-like instrument called a laparoscope that is inserted into the body through a small incision which is made near the navel. Another surgical instrument is inserted lower down the abdomen to block the fallopian tubes. The cuts are then closed with one stitch each and the patient is fit to leave within a few hours. The stipulated time for such a surgery is about half an hour.

The initial post-mortem reports suggested septicemia as a cause of death, which could have been due to a bacterial infection developed after surgery— or perhaps due to the use of rusted or unsterilised instruments. However, on 13 November, the state government announced that chemical analysis of samples from the victims suggested spurious medication. Mitanins were sent to villages and homes of victims to take away the medicines given to them after the surgery. It was later found that the white oblong tablets, thought to be a commonly used antibiotic, may have been the culprit.

The manufacturer of the medicines was Mahavar Pharmaceuticals, a Raipur- based drug maker. Its executives were arrested, their offices raided. All tablets of that particular batch were confiscated by the government. However, the following day, the health secretary of the state made another shocking revelation. Samples of the collected medicines contained traces of zinc phosphide, commonly used as rat poison. The symptoms displayed by patients were consistent with those of being poisoned by this chemical.

The drug analysis departments of the state and Centre are yet to submit their final investigation reports. While the Chhattisgarh government is in the process of probing the tragedy, the death of a 70-year-old man on 14 November added yet another dimension. Mahavir Suryavanshi of Ganiyari village—which witnessed the death of a local woman who attended a camp on 8 November— had died with similar symptoms. He was believed to have visited Dr DC Jain, a retired government ayurvedic doctor in the village. With district hospitals too far away from this cluster of villages, Dr Jain had many villagers in the district as his clients. Suryavanshi, it turned out, had taken the same white oblong tablet made by Mahavar. As panicky villagers rushed to CIMS with samples of the same tablets prescribed by doctors, the government raided Dr Jain’s clinic on 14 November and recovered samples of medicines manufactured by the company. Dr Jain, 77, is still on the run, and according to Sonmoni Borah, Divisional Commissioner of Bilaspur, “Nothing can be confirmed till the drug analysis reports come in.”

As the nurse comes with a syringe to draw some blood, 23-year-old Shagun screams in panic. The wife of a driver in Bilaspur city, and a mother of two, Shagun is from Pindari. Lying on a bed in the general ward at CIMS, she refuses to let the nurse draw a blood sample for a routine test. Her five-month-old daughter, in her grandmother’s arms, begins to howl too. “What if it is a used syringe? They are saying that we fell sick because of the instruments used in the operation,” she says, bursting into tears.

Like most of the victims, Shagun too had a bout of vomiting within 24 hours of her tubectomy. She, however, recovered quickly. As she pulls down her salwar to show the incision, covered by a taped rectangular swab of cotton and a bandage, she recalls regaining consciousness before the surgeon had finished the sutures. “I was slapped by the doctor as I was moving too much,” she says, and then surrenders, letting the nurse prick her with the needle on the reassurance that it’s a fresh needle. Shagun remembers lying on the floor, on a gadda, with two other women on either side. “We arrived at the camp at 1 pm, the doctor arrived at 4 pm, and by 6.30 pm, I was on my way back home,” she says. Her mother, Parwati, who accompanied her to the camp, adds that most women were lying on the floor during the surgeries. And like Shagun, many regained consciousness while the doctor was still doing the procedure.

According to Kerry McBroom, director of the reproductive rights arm of Human Rights Law Network based in Delhi, this is typical of such camps. As part of a fact- finding team that visited the victims of Bilaspur, McBroom says that most women she spoke to remembered receiving five injections, with at least five of them made to sit on one bed. “They remember being stitched up on the floor and absolutely none of them know about the consent form that is mandatory to be signed by the patient before the surgery,” she says. None of the victims or families of the deceased was given a sterilisation certificate—also mandatory.

The sterilisation programme depends heavily on cash incentives offered to women who volunteer to get themselves sterilised and on Accredited Social Health Activists, community health workers popularly known as ASHA workers or mitanins (‘friends of the village’) in Chhattisgarh. These workers are volunteers from within the community who act as mediators between citizens and the state’s primary healthcare system. Mitanins too are given cash incentives for drawing volunteers to the camps. Most women who attended these camps were women who visited vaccination camps held by the state. According to Meena Suryavanshi, a mitanin in Ganiyari, a meeting was held after Diwali and mitanins were asked to bring volunteers for the camp. “We started asking young mothers to volunteer and spread the word,” she says. The selection criterion would involve mothers with two or three children—at least one being a boy. “This happens every few months, but women never fell sick. People have now lost their trust in me,” she says helplessly.

Veda Bai, a 70-year-old midwife associated with the district primary healthcare centre in Amsena, a village 25 km away from Bilaspur, is still in shock. She had taken her youngest granddaughter Rekha for the surgery, but ended up losing her on 12 November. As Rekha’s four-month-old son struggles to digest powdered milk bought by his uncle from a market 7 km away, Veda Bai says her elder grand- daughter Nandini now refuses to undergo a tubectomy. “It would be a good thing for her, she has already had three children, but how do I explain to her now? No one will trust me,” she says, wiping tears.

Recalling the night of 10 November, when Rekha started vomiting, Veda Bai speaks of her panic when she realised there weren’t enough glucose bottles in the primary health centre barely 50 metres away from her house. “There were two other girls who needed drips too. Fortunately, the ambulance came at around 3 am and took all three of them,” she says. Two of them died, Rekha and Phool Devi; and 28-year-old Shitla Devi’s condition is still critical.

Apart from the way sterilisation camps are held in India, the Bilaspur tragedy has exposed gross irregularities in the way drugs and medicines are made and distributed in rural areas. According to a statement made in 2012 by Amar Aggarwal, the state health minister who happens to be an MP from Bilaspur, Mahawar Pharmaceuticals was found guilty of manufacturing faulty medicines in 2011 and was issued ‘show cause’ notices for the same. 13 of the 17 samples were found faulty. While the firm kept making medicines at its plants in Bilaspur and Raipur, and even received a ‘Good Manufacturing Practices’ certificate in 2013, the outrage evoked by this case has brought it firmly under the scanner.

Witnesses to the raid on Mahawar’s units claim that these plants were not properly functional and that its record books were riddled with irregularities. A press statement by the company alleges that claims of rat poison in the tablets are being made solely on the basis of a sticky pad, meant to trap rats, that was found in its laboratory during the raid. The role of the local district procurement agency, which procured the medicines especially for the camps, is also likely to be examined closely; there are signs of clandestine attempts to destroy samples, pointing to irregularities in procurement. That medicines from the same manufacturing batch landed in Dr Jain’s clinic, who is believed to have bought these medicines from government sources, only highlights the problems further.

As the dust around the village settles, following a flying visit by Congress vice-president Rahul Gandhi on 15 November, memories of Phool Devi’s death already seem to be fading. As residents of Amsena throng the village chaupal, first to catch a glimpse of the celebrated politician who was in the village to both point fingers at the state government and demand a probe, and later to watch a fellow villager bring a brand new truck into the village, her husband Roop Chand is already thinking of going back to work. A barber in the village, he claims that he has spent about Rs 40,000 on the last rites of his wife. “We will now make a trip to Allahabad,” he says, adding that the expenses will be borne partly by the Rs 2 lakh compensation offered by the government for his wife’s death. “Once the relatives are gone, I will be alone with my three children,” he says dolefully. “The youngest is only a year old. The money should be for them, but I don’t know how long it will last.”