In a serious breach of medical ethics, doctors and private hospitals in Karnataka, particularly in Kalaburagi district, have been exploiting poor and illiterate women by conducting unwarranted hysterectomies. BY VIKHAR AHMED SAYEED

PINKUBAI GORAKNATH RATHOD, 24, lives in the picturesque Lambani hamlet (tanda in local parlance) of Belamogi in Aland taluk of northern Karnataka’s Kalaburagi (Gulbarga district). Pinky, as everyone calls her, has distinct features—she is fair, has sharp features and light eyes—that mark her out as a Lambani or a Banjara, as the community is also known. She is originally from a tanda near Malkhed, on the other side of Kalaburagi district, and came to Belamogi 11 years ago after her marriage.

By the end of 2014, Pinky was the mother of three children. Her husband was struggling to find a steady job, as eking out a living from one acre (0.4 hectare) of land that he owned was not feasible. At this time Pinky developed severe abdominal pain accompanied by whitish vaginal discharge.

When the primary health centre (PHC) in Belamogi could not help her, she ended up at a private hospital called Girish Noola Surgical & Maternity Hospital in Kalaburagi, the closest town, some 50 km away. “The doctor at the hospital told me that my uterus is swollen [soojan] and pus had formed. He said that anything could happen and I could even get cancer,” Pinky recalled. “I panicked. I felt that I did not have a choice when the doctor said that I needed to do the bada [big] operation immediately. I borrowed Rs.20,000 from my sister-in-law and underwent the operation.” She was only 22.

The “big” operation was a total abdominal hysterectomy (TAH). A survey conducted in July 2015 by members of the Karnataka Janaarogya Chaluvali (KJC, Karnataka People’s Health Movement), a public health rights movement based in Karnataka, found 20 cases of hysterectomies performed on women under 40 in Belamogi tanda, a remarkably high number considering that there are only 87 families in the hamlet. A pattern emerged in the KJC’s survey undertaken in 38 tandas coming under the jurisdiction of 19 panchayats spread across four taluks—Kalaburagi, Chincholi, Aland and Afzalpur—in the district. An ab normally high number of hysterectomies among young women were recorded in all these Lambani hamlets—707 in all. Of these women, 355 were under 35 when they had the operation.

The KJC had done a similar survey in a village near Birur in Chikkamagaluru district in 2013. But its findings in Kalaburagi showed that the problem was on a large scale in this district and affected thousands of women. Teena Xavier, an activist of the KJC who lives in Kadaganchi village, around 25 km away from Kalaburagi, was the first to suspect that something was amiss. “In the villages where I work in Aland taluk, I heard about the enormous number of hysterectomies,” she said.

Dr Shaibya Saldanha, a gynaecologist based in Bengaluru with 25 years’ experience, explained to Frontline how a hysterectomy affects women’s health: “A hysterectomy is a major surgical procedure that means the removal of the uterus and is done for certain medical conditions. After a hysterectomy, a woman loses her child-bearing capabilities. It is to be done only in cases of poor quality of life, prolapsed uterus or a threat to life like cancer. In younger women, the circumstances under which this surgery is done would be rare. The removal of the uterus also induces surgical menopause. Sometimes, the ovaries are also removed, which has drastic effects on a young woman’s health. Every hysterectomy is a major surgical procedure and will have side effects and complications.”

Long-term implications include the hastening of osteoporosis and cardiac disease. Sexual intercourse becomes non-pleasurable and there is a loss of libido as well. A hysterectomy, therefore, is not recommended unless absolutely essential, especially for younger women. Pinky no longer complains of abdominal pain, but she suffers from a dull nagging pain in her shoulders and hips accompanied by general fatigue and an inability to lift heavy objects, all common complaints after a hysterectomy. Pinky also complains of a gradual decline in her vision, something that stumps Dr Shaibya Saldanha. “I have been hearing a lot of women complain of this, but this is something that we don’t have a medical explanation for yet,” she said.

While it is still not possible to get a reliable figure for the number of hysterectomies taking place in the country, an estimate can be made from data from the third round of the District Level Household Survey, which shows that around 2 per cent of women in the 15-49 age group had undergone hysterectomies (12,888 in a sample of 6,43,934 women). The  figure was higher among women from rural, lower-caste and deprived backgrounds.

A cross-sectional study in 2010 of 2,214 women showed that up to 9.8 per cent rural women in Gujarat had undergone hysterectomies. A few years ago, large numbers of unwarranted hysterectomies were reported from Dausa (Rajasthan), Samastipur and Kishanganj (Bihar) and rural areas of Chhattisgarh. In 2010, there were reports of women of the Lambani community becoming victims of unwarranted hysterectomies in Kannaram village of Medak district in Andhra Pradesh (now in Telangana). The reason seems to be clear: it is an easy way for doctors to make money, taking advantage of the lack of awareness among the women concerned.

The large number of unwarranted hysterectomies performed in Kalaburagi seem to make a pattern: the women are rural, belong to marginalised communities (the Lambanis come under the Schedule Caste category in Karnataka, forming around 12 per cent of the S.C. population in the State) and are largely uneducated. Pinky, one of the more literate women from the Lambani community, has studied up to the seventh standard.

While the National Family Health Survey (2015-16) has questions on hysterectomy in its questionnaire, the results have not been included in the published State and district fact sheets. Once these results become available, a precise picture will emerge on the scale of hysterectomies in the country. But what is certain so far is that unwarranted hysterectomies are happening all over the country in a serious breach of medical ethics.

A perusal of news reports all over the country regarding cases of unwarranted hysterectomies shows that the women went to doctors with similar symptoms—abdominal pain, white discharge, smelly discharge, lower back pain, and itching—and ended up on the operation table. In Kalaburagi, the doctors who advised patients to undergo a hysterectomy did so only on the basis of a scan and without any clinical examination. They also did not take a pap smear or conduct an examination under anaesthesia (EUA) and dilation and curettage (D&C). In Pinky’s hamlet, and in the neighbouring hamlets, the stories were almost uniform. In a few cases, the symptoms were different, but hysterectomies were performed nonetheless.

Lalitha Bhimsingh Chavan, 38, is a resident of Ambalaga tanda, again in Aland taluk. Three years ago, she had abdominal pain and difficulty passing urine. She consulted a doctor in Umarga, a town just across the border in Maharashtra’s Osmanabad district. (From interviews with the Lambani women, it sounded like Umarga was another major hysterectomy hub, along with Kalaburagi.) “The doctor in Umarga conducted a few tests and then sent me to ‘Loola’ [a common misnomer for the Girish Noola Surgical & Maternity Hospital in Kalaburagi], where they told me that I needed to undergo a hysterectomy immediately as my womb had gone bad and I could die soon,” Lalitha said. “I was in hospital for seven days. The operation cost me Rs.20,000.” The bill that the hospital provided to Lalitha is scribbled on a prescription slip.

After the operation, Lalitha’s inability to pass urine and burning micturition continued. Tests revealed that she had renal calculus, or kidney stone. Not surprisingly, the removal of the uterus had not helped. Lalitha narrated her tale while drinking cold bottled water, as her current doctor had prescribed. “I have spent Rs.30,000 on other costs since then,” she added.

Lalitha was surrounded by several other women of her tanda aged between 27 and 48 who had also undergone hysterectomies. In this hamlet of 55 households, 17 women lost their wombs under the surgeon’s scalpel.

Sunita Yemnath Chinni Rathod, 35, of V.K. Salagar tanda in Aland taluk had to sell two goats to finance her hysterectomy four years ago. She first had an operation to remove her uterus and a second one to remove her ovaries. “I went to Loola when I had severe abdominal pain. The doctor first did an operation for Rs.25,000 and then a second operation after three months at a discounted price, for Rs.15,000,” Sunita said. The KJC survey of 2015 recorded 24 hysterectomies in this tanda of 84 households.

The ultrasound reports of the abdomen and pelvis of Pinky, Lalitha and Sunita are in the possession of Frontline. When these were shown to Dr Shaibya Saldanha, she said the scan reports did not demonstrate any need for a hysterectomy. She explained what the doctors had done with an analogy: “Imagine, if a patient comes to me I take one look and I decide that he’s anaemic because he’s looking pale and I give him two blood transfusions. That’s ridiculous, isn’t it? That’s what’s happened in this case. Pinky’s case is especially scandalous as no 22-year-old woman undergoes a hysterectomy.”

There have also been three recorded deaths over the past few years. Savitabai died in July 2015 just after the completion of her operation at Basava Hospital in Kalaburagi. She had come to the hospital with complaints of abdominal pain. The doctors told her family that she needed a hysterectomy because her uterus was swollen. When she died, a doctor at Basava Hospital hastily paid a sum of Rs.3 lakh to Savita’s family, an act that raises suspicion. Two other Lambani women in Chincholi taluk died in 2015 of post-operative complications following hysterectomies.

Consequent to the KJC’s complaints in 2015, two inquiry committees were set up with gynaecologists on them. The first one was constituted by Karnataka’s Department of Health and Family Welfare and was headed by Dr A. Ramachandra Bairy. It submitted its 12-page report on October 17, 2015, after an inquiry that lasted for two days. While 36 hospitals were named in the complaint made by the KJC, only 25 submitted information on the number of hysterectomies they had conducted in the preceding 30 months. Girish Noola Surgical & Maternity Hospital topped the list with 900 hysterectomies out of a total of 2,258 operations.

The report implicated the hospital for lack of proper records, which cast doubt over whether the hysterectomies had been necessary. It recommended action against the hospital under the Karnataka Private Medical Establishments (KPME) Act (2007) and the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act (1994). Three other hospitals were also marked out for violations.

A second inquiry committee was set up in September that year by the Karnataka State Women’s Commission and was headed by K. Neela. This committee submitted its 105-page report in April 2016 after a thorough inquiry. Its members interviewed 66 women, and in all the 66 cases they concurred that a hysterectomy was not necessary. It has brief summaries of interviews with the victims as well as inferences. After their interview with Pinky, and perusal of her medical records, the committee noted: “Age of patient precludes hysterectomy. Examination shows hypertrophic cervix and erosion. Pap smear showed no evidence of malignancy. Scan diagnosis of Pelvic Inflammation Diseases (PID) insufficient. PID was not treated with antibiotics.” The committee discussed Lalitha’s case, and its inference was: “Diagnosis was renal calculus and recurrent Urinary Tract Infection (UTI) for which no treatment was given.”

The women interviewed by the committee were diagnosed with PID, bulky uterus, thickened endometrium and fibroids. The common complaints included chronic backache, excessive uterine bleeding, chronic abdominal pain and white discharge per vaginum. None of these warranted a hysterectomy, the committee concluded, and could have been treated with a variety of antibiotics, vitamin supplements, safe sexual practices and painkillers. Such problems, moreover, are not unusual among rural women who undertake hard labour and are associated with early marriage, multiple and quickly following pregnancies, malnutrition, lack of sanitation and unsafe sexual practices. Pinky, like many other women in the Lambani community, was 13 when she was married and had three children in quick succession. Lalitha, at 38, is already a grandmother.

The report has held the doctors responsible for the hysterectomies guilty of violation of medical, ethical and legal norms. The committee implicated Girish Noola Surgical & Maternity Hospital, saying it had insufficient evidence to show there was good reason to perform the hysterectomies. The hospital did not have any medical records of the patients who underwent the oper ations. The report held that the doctor couple who managed the hospital, Dr Girish Noola and Dr Smitha Noola, had created a “psycho fear” [sic] in the minds of the largely illiterate and poor victims. It has called for criminal action to be taken against the doctors at Girish Noola Surgical & Maternity Hospital and Basava Hospital, apart from other doctors involved in this malpractice. It has also recommended that the victims should be financially compensated.

State of public health

In a paper published in Indian Journal of Medical Ethics (Volume II, No. 1, January-March, 2017), KJC members Teena Xavier, Akhila Vasan and Vijayakumar S. discuss the implications of this sordid affair. They write: “A medical procedure such as a hysterectomy has morphed into a ‘business strategy’ in the ‘medical/health care market’ with poor women’s bodies being trafficked for profit. Governments that ought to protect citizens from such predatory motives have not merely failed in their duty, but have turned accomplice in their crimes by ushering in policies that encourage exploitation.”

They continue: “So long as the profit motive drives the provision of health care, the most vulnerable will continue to fall prey to the predatory motives of the system. Radical policy shifts aimed at reining in the medical profession, transforming medical education, disallowing ‘profit’ in health care, rolling back public-private partnerships, and strengthening the public health system meaningfully to regulate and deliver health care are required urgently to reverse the commercialisation of health care. Enacting a broad-based law to protect health/patients’ rights and to bring the medical profession under the ambit of criminal prosecution is of critical importance to ensure the safety of citizens, particularly those most vulnerable.”

The KJC survey data show the dismal state of public health. Only 13 of 707 women identified by the KJC in 2015 reported that they got the procedure done at the District Government Hospital in Kalaburagi. According to the District Health Officer (DHO) of Kalaburagi, Dr Shivaraj Sajjanshetty, there is only one hospital in the entire district with facilities for hysterectomy, the District Government Hospital. “Two years ago, when I was posted there, we had difficulty even doing caesarean surgery, how can we get gynaecologists to do hysterectomies? We simply don’t have the facilities,” he said. The PHCs have also failed at being the first-tier providers of medical relief. “Many of the complaints that the women had could have been resolved with a simple course of antibiotics, but not enough doctors visit the PHCs,” said Teena Xavier.

The submission of the two reports has led to some action by the district administration. The registrations of four hospitals, including Girish Noola Surgical & Maternity Hospital, have been cancelled, but the licences of the gynaecologists and surgeons practising in these hospitals have not been rescinded yet. Criminal action has also not been initiated. The DHO said a letter dated January 23, 2017, had been sent to the president of the Karnataka Medical Council (KMC), Dr H. Veerabhadrappa, requesting suitable action be taken. On his part, Dr Veerabhadrappa said: “KMC will conduct a civil court-like procedure once we receive the letter from the DHO.”

On February 6, several hundreds of Lambani women gathered at the Deputy Commissioner’s office in Kalaburagi to protest against the district administration’s inaction on K. Neela Committee’s recommendations. The National Human Rights Commission (NHRC) has also taken cognisance of the malpractice and issued notices to the governments of Karnataka and Maharashtra.

Seasonal migration

Back in Belamogi, Pinky waits for redress of her grievances. She has filed a writ petition in the Karnataka High Court. Her eldest child was diagnosed with leukaemia in early 2015, and she has been spending the past year getting him treated at the Kidwai Memorial Institute of Oncology in Bengaluru. Her husband left the tanda in 2015 in search of work and is somewhere in Saudi Arabia or in the United Arab Emirates—Pinky is unsure about his exact location —from where he calls her once a week. Many of the women who were interviewed for this article had husbands who had migrated for work, a common practice among Lambanis in the region. They are seasonal migrants. They do own land, but their small landholdings do not amount to much in this arid, drought-prone region. Many of them work as construction labourers in Mumbai. Earlier, the wives accompanied them. But now many of the wives stay back as hysterectomies have rendered them unfit for hard labour.

Pinky does not have a phone number to contact her husband, who seems to have joined the legions of exploited construction labourers in countries around the Persian Gulf. “His passport is with his employer. He can’t return as his contractor owes him Rs.2 lakh [in unpaid wages],” Pinky said.

http://www.frontline.in/the-nation/a-tale-of-exploitation/article9583441.ece