The Kaparfora sterilisations expose the State administration's tenuous hold over NGOs contracted for conducting family planning camps.
About a fortnight ago, as the sun was setting late one cold Saturday afternoon, a crowd steadily trooped into the premises of a State-run middle school in the backwaters of north-eastern Bihar.
The group, comprising mostly of indigent, illiterate women, hailed from the extremely backward classes (EBC)-dominated hamlet of Kaparfora in Araria district and had assembled in anticipation of a sterilisation camp to be conducted by an NGO. After a long wait, eyewitnesses said, the tubectomy (or tubal ligation surgeries) commenced after dusk, lasting barely a couple of hours. The women were called in, operated upon on rough, unvarnished school benches and their fallopian tubes sealed at breakneck speed.
This appalling barrack-room surgical procedure, bereft of prescribed operating theatre (OT) facilities, started unravelling in the wee hours, when three women started haemorrhaging profusely. Further trouble broke out when the “camp organisers” refused to pay the mandatory amount (Rs.600 fixed by the Bihar government) to the women for undergoing sterilisation. Agitated by the turn of events, an irate mob comprising relatives and attendants of the women caught hold of three youths present on the spot and threatened them to make a clean breast of the affair.
When the police, led by the District Superintendent, reached the spot next morning, they found the ‘Operating Theatre' in utter mess, with the room a diffuse tapestry of spent needles, syringes and some medicines past their expiry date.
The FIR filed that day notes the absence of the surgeon, the anaesthetist and the block Primary Health Care centre doctor, supposed to be supervising such a camp. The youths, who claimed to be working on behalf of an accredited NGO, Jai Ambe Welfare Society, had barely cleared their intermediate exams, the police said.
The NGO's tab-sheet detailed the successful completion of no less than 61 tubal ligation surgeries. There was no evidence of any clinical assessment, pre- or post-operative care or decent waste disposal procedures during the entire run of this “successful camp.”
“There was nobody to look after us once the surgery was completed ... we were lain on the veranda as if we were dead people,” said Rambha Devi, a mother of three who started bleeding after her operation. The women were lying listlessly on the cold, hard floor “scattered like livestock,” notes the investigating officer in the FIR.
While initial police reports suggested that the youths themselves had performed surgeries (The Hindu, January 10), a confession statement given later to the police by Ramanand Jha, one of the nabbed, states: “the birth control operations commenced after 5 p.m. on 7/01/12 and were performed by one Dr. A.K. Choudhary and his staff in barely two hours, after which the doctor and his team left the place.”
‘53, not 61'
When contacted by The Hindu, Dr. Choudhary admitted the surgeries began at 5 p.m. on Saturday. He said he had performed “53, and not 61, surgeries in an operation that lasted five hours,” following which he and four of his assistants left the place.
Asked whether proper regulations were followed during the duration of the surgeries, Dr. Choudhary said: “I am not aware of all that [Health Ministry rules and regulations] ... all I know, sir, that I was requested by the NGO [Jai Ambe] to come for a birth control camp at Kaparfora.” He stressed that he could not be held responsible for any of the rules or arrangements that an NGO had not followed as it was guided by the District Magistrate of that particular district.
In a raid that Sunday, the police tracked down the domicile of the NGO's promoters to an imposing bungalow in the neighbouring district of Purnea. The raid yielded a rich haul of CDs and forged stamp heads.
Forged stamp heads
Among the 60-odd forged stamp heads seized by the police, one included the seal of Dr. A.K. Choudhary. Other forged seals include those of Block Development Officers and PHC doctors from each of the nine blocks in Araria, and some in Purnea and Kishanganj districts. Police sources said the seized CDs contained morphed images of the same women, displayed against different backgrounds, with dates interspersed to coincide with the genuine dates of a fuzzy camp held by Jai Ambe Welfare.
The women, including minors decked up in saris to pass off as adults, were photographed holding slates detailing their names, their spouse's names and domicile address in white chalk. The chalk lettering was deliberately obfuscated and the same women used under different names several times over in order to prove that a “successful birth control programme” had been conducted by the NGO on paper, sources said. The CDs further detail harrowing night surgeries conducted by the NGO under torchlight in other blocks of the district.
The NGO's promoters, Vidyanand Vishwas and Kumar Nath Chaudhary, charged with cheating and forgery, have since been absconding.
Attempts by The Hindu to contact the Jai Ambe trust for its version of the events proved futile as all three of its cell phone numbers returned a “switched off” answer.
At the root of the problem is the State's all-round lack of capacity in the health sector, including family planning. Bihar's Total Fertility Rate (TFR) of 3.9 — the average number of children a woman will bear in her lifetime — is the highest in the country and vastly outstrips the national average of 2.6. According to the National Family Health Survey (NHFS– 3, 2005-06), more than 60 per cent of women in the 20-24 year age group get married by the age of 18 in Bihar.
In fact, populous states like Bihar and Uttar Pradesh have less than 350 sterilisations per 10,000 unsterilised couples with three or more than three children, with a high unmet need for family planning.
Though NGOs can and do play an important role in augmenting the efforts of the State government, the Kaparfora sterilisations expose the tenuous hold of the Nitish Kumar-run administration over NGOs contracted for conducting family planning camps.
According to Central Health Ministry operational guidelines, an NGO receives Rs.1500 for every successful tubectomy and vasectomy operation performed. Bogus or botched up, on-the-hoof operations can be passed off as successful tubectomies, and the money to be made is considerable.
Signs of cover-up
Speaking to The Hindu, Araria Civil Surgeon Husna Ara Begum said the Jai Ambe trust had been operating in the Purnea-Araria belt for more than four years and had carried out more than 4000 sterilisations in Araria alone.
The district has a TFR as high as 4.6. “Araria has a target of 28,000 sterilisations which has yet to be completed. So, we often contract NGOs to organise family planning camps in the district,” she said.
Despite evidence to the contrary, she denied the camp was conducted after dusk. Dr. Begum insisted they had taken place “during the day and were performed by a registered government doctor.” The surgeries had to be performed in a State-run middle school as Kaparfora was located in the remote hinterland, she said.
Incidentally, the Kursakanta block PHC is less than 2 km from the school premises where the tubectomies took place that day.
In an indication of cover-up, the State Health Department hurriedly circulated a prima facie report on the incident to the media, contradicting police investigations and seeking to assure the public that events had transpired quite differently.
The report, drawn up by the Araria District Civil Surgeon, issued by the District Magistrate (Araria) and presented by the Principal Secretary (Health) Amarjeet Sinha, gave a resounding clean chit to the NGO stating: “53 tubectomy surgeries were conducted successfully by Dr. A.K. Choudhary (M.B.B.S.) and his team in 6 hours in the presence of the head doctor at the PHC, Kursakanta block.” It further says “there were no complaints from any of the women who were sterilised.”
This is at odd with the facts as the women who were bleeding profusely had to be later referred to the block PHC at Kursakanta. One of them, Saraswati Devi (aged 25), was discharged only last week.
Tubectomy surgeries are performed using two methods. In a laparoscopic surgery, a laparoscope (a thin veiled tube containing a small camera) is inserted into the abdomen and the operation performed by making small incisions (usually 0.5-1.5 cm). The equipment is more sophisticated and, therefore, the surgery costlier as compared with a Minilap surgery which requires only basic and easily maintainable surgical instruments.
While laparoscopic surgeries can be performed quickly, a conventional tubectomy (or a Minilap surgery, as it is known) as in the Kaparfora cases, takes relatively longer. A Minilap operation can be performed by a trained M.B.B.S., whereas laparoscopic surgery requires highly-trained gynaecologists (MD or DGO) or surgeons (MS). This, and a number of other factors, including cost, have led to a policy preference for Minilap surgeries in densely populated States with a high TFR figure.
‘Not humanly possible'
The Hindu spoke to many doctors from the Federation of Obstetrics and Gynaecologists Societies of India (FOGSI), who said that it was “not humanly possible” to perform so many Minilap surgeries without a specialised team or standard medical infrastructure.
“It is next to impossible for 50 or 60 Minilap operations to be performed by one doctor in six, let alone two, hours under such conditions. Only a highly trained doctor can perform an operation in 10-14 minutes at the very least,” said Dr. Sanjay Gupte, ex-president, FOGSI, and Director, Gupte Hospital, speaking from Pune. “I have performed a maximum of three Minilap operations in an hour in a superior medical ambience. So, such figures [53 in six hours] are simply unbelievable” says Dr. P.K. Shah, Secretary-General, FOGSI.
Litany of violations
The camp operations themselves read like a litany of violations of the Standard Operating Procedures set out in the Union Health Ministry's Standards for Female and Male Sterilization Services and the Quality Assurance Manual on Sterilization (both 2006). According to them, a camp can be held only on the premises of government referral hospital or a primary or community health care centre, with an ambulance service at hand.
No permission was sought from the school authorities at Kaparfora for such a camp. Neither was any attempt made to disseminate information in the form of posters or pamphlets. Importantly, rules stipulate that camp timings must be during the day (9 a.m. to 4 p.m.), whereas the Kaparfora tubectomies began late in the evening, concluding abruptly at night after a frenzied surgical session.
However, Mr. Sinha said State-contracted NGOs had generally done a commendable job of conducting birth control camps in the past. NGOs like Janani had conducted several successful family planning camps in different parts of Bihar, including Araria, he pointed out.
“We are committed to providing quality healthcare services in the State. In one-off cases like these, there is nothing more we would like but to see the culprits put behind bars. We are not trying to cover up anything,” he told this correspondent.