It was about 11 years ago when a Hyderabad-based NGO stumbled upon what it thought then was a strange medical practice. Several Lambada tribal women in the villages of Kowdipally mandal of Medak district had undergone hysterectomies — as early as in their twenties. Sensing something amiss, the Centre for Action, Research and People’s Development (CARPED) undertook a door-to-door survey and recorded 728 such cases.
CARPED, however, did not know what to do next. There was no historical data with which these findings could be compared. So, it divided the women by age group, and qualitatively mapped each case study. “A pattern then emerged,” recalls M. Bharath Bhushan, the founder of the organisation. “Many of the women were in their 20s and 30s, had gone to private doctors, and had sold their jewellery to fund the procedure.” The NGO consulted health experts to resolve its doubt: hysterectomies for women below 50 were rarely advisable. What CARPED had discovered was not just a strange but alarming medical malpractice.
Hysterectomies have been reported from rural pockets of about half a dozen States — Gujarat, Rajasthan, Bihar, Chhattisgarh, Karnataka, Maharashtra, especially in the last six years. The case studies are similar: poor illiterate women are prescribed the procedure for white discharge, irregular menstrual cycles, even abdominal pain. Their willingness to undergo the procedure stems from the fear of cancer (which doctors convince them of) to the belief that their uteruses are of no use once they have had children. Loss of daily wages during menstruation only makes the prospect more appealing.
Health activists say this is a strong case for the government to take action. A number of young women are being pushed to menopause and to a life of battling health conditions such as weakness, aching joints and hormonal imbalance — all of which they can barely afford to treat.
Calling the practice a “human rights violation”, Chittorgarh-based Narendra Gupta of Prayas moved a PIL in the Supreme Court in 2012. Most States have been made respondents in the case, he says. “The total number of hysterectomies in India is lower than in the West. But it is alarming that 30-32 is the average age group of women undergoing the procedure here, while in the West post-menopausal hysterectomy is common,” Dr. Gupta says.
Connecting the dotsIn 2010, the Andhra Pradesh government dropped hysterectomies from Aarogyasri, the State insurance scheme, after finding that it was only fuelling what was already an established medical malpractice in various parts of the State. The same year, the Self Employed Women’s Association (SEWA) in Gujarat also noticed a high number of hysterectomy claims under its community health insurance scheme in Ahmedabad district.
“Most of the women had consulted doctors for heavy bleeding, cramps, and were never offered any non-invasive treatment option,” says epidemiologist Dr. Sapna Desai who conducted the study while based at SEWA and the London School of Hygiene and Tropical Medicine.
And a year later, local mediapersons in Samastipur in Bihar reported hysterectomies among young women. “We found that most women were in the 30-40 age group and were covered under the Rashtriya Swasthya Bima Yojana (RSBY),” says health rights activist Devika Biswas.
That the RSBY was fuelling the trend was also established in Chhattisgarh’s Dhamtari town, hub of many private hospitals. “The private healthcare system is not really known to be ethical, just that now they were being paid for it,” says Sulakshana Nandi of Jan Swasthya Abhiyan in Raipur.
Performing hysterectomies is a moneymaking racket even without insurance. In Gulbarga district of Karnataka, where the racket was busted in 2014, Karnataka Janaarogya Chaluvali (KJC) compiled a list of 707 women who had undergone hysterectomy. Of them, 50 per cent were under 35 years, 22.5 per cent were under 30. “Though both the State insurance scheme and RSBY cover hysterectomy, the women we spoke to were not covered under the scheme,” says Anuradha Vasan, co-convener of KJC. So, hysterectomies among young women are not exactly a recent phenomenon; they were in place even when there was no State insurance cover. In the water-starved Sangola taluka of Solapur in Maharashtra, for instance, women for years have been made to believe that hysterectomy protects them from cancer.
Action and inactionOn the face of it, governments have taken some action. “An inquiry committee was set up and licences of doctors cancelled,” says Dr. Gupta, who had complained to the Rajasthan government about the rampant practice in Dausa. “But a second committee was set up that gave the doctors a clean chit. Private hospitals were hand in glove with diagnostic centres that would do a sonography, give the report in an hour, and conclude that the uterus is about to become cancerous,” he adds.
In Chhattisgarh too, two inquiry committees were formed. The second one again let the doctors go scot-free. In Karnataka, three inquiry committees have been formed; their reports are still awaited.
“This is a crisis,” says Dr. Veena Shatrugna, former deputy director of the National Institute of Nutrition. In a co-authored study, Dr. Shatrugna found that over 18,000 insurance-funded hysterectomies are conducted in Bihar and Chhattisgarh alone. “Hysterectomies cause physical and emotional damage to women. There is a need for regulation like in the case of the PNDT (Pre-Conception and Pre-Natal Diagnostic Techniques Act) that doesn’t allow an ultrasound without proper documentation,” she says.
In the absence of composite national data, regulation is difficult. But for the first time, the National Family Health Survey-4 has included a question on hysterectomies. This fact sheet, yet to be published, will be the first comprehensive data on the worrying trend.
Hopefully, these numbers will push the government to set up guidelines for private hospitals, and tighten norms of insurance schemes, say activists. There is optimism too, albeit a tad misplaced, that the government will realise that outsourcing healthcare to private players isn’t a pragmatic measure, but one that puts human lives at the altar of business interests.