“Watchful expectancy and masterly inactivity.” This was the dictum my obstetrics professor taught us to assist a woman in labour. But it seems it has been adopted by professional bodies of doctors in response to the problem of unethical surgeries.
It is now fashionable to blame politicians or the government for all evils in society. Sorry, but not for unnecessary hysterectomies. Doctors cannot absolve their own responsibility in this. Whatever the government’s policy (“Diagnosis of a prolapse” Yogesh Jain and Raman Kataria, Op-Ed, July 16, 2012) or the socio-cultural reasons (“Insurance does not cover the womb’s woes,” Sapna Desai, Op-Ed, August 9, 2012), ultimately, it is doctors who carry out the surgeries, and who must be held responsible.
At present, there is no system of peer review of reported overuse of medical procedures, either investigative or curative. There is no peer pressure that can work to eliminate or reduce medical malpractice. Disowning an errant colleague and professionally excommunicating negative deviants do not happen at all. Professional bodies (Federation of Obstetric and Gynaecological Societies of India, Association of Surgeons of India, Indian Medical Association, etc) have completely abdicated their role as guides, custodians and watchdogs of medical ethics. The Medical Council of India (MCI), “the watchman at the gate,” is asleep all the time.
Hysterectomies without reasonably sound medical indications have been happening in many parts of the country even before the Rashtriya Swastya Bima Yojana (RSBY) and other health insurances like Arogyasree came into existence. State-funded health insurance only contributed to the ease of harvesting profits by the unregulated private sector. The underlying phenomenon is old.
Five years ago, in June 2007, after the media published several reports of unethical hysterectomies in Medak district in Andhra Pradesh, I was part of a fact-finding mission on behalf of Unicef’s “Safe Motherhood programme.” Three private nursing homes were doing hysterectomies in the district’s Narsapur town. The establishments were owned by a qualified ayurvedic doctor, a homeopathic doctor as well as a lab technician posing as a doctor. The actual surgeries were being done by qualified gynaecologists or surgeons who came from Hyderabad on a weekly basis; they received half of the total fee charged. Most patients were from the Lambada tribal community, poor and illiterate. With an early marriage and completion of family at a young age, they were having recurring problems of backache, vaginal discharge, minor bleeding, etc. There was no gynaecologist at the Narsapur government Community Health Centre (CHC) for a long time. Finally when she arrived, she refused to do any surgeries in spite of there being good facilities and an operation theatre. After finding that government hospitals were not able to provide a satisfactory cure, the suffering women went to private clinics where they were told that all their troubles would end with the removal of an organ which has served its purpose, with a one-time expenditure. The amount for this purpose was easily available from the opportunist-friendly local money lenders.
This was the story not only in Medak but also in many other parts of Andhra Pradesh.
For the patients, it was cheap. Compared to the Rs.10,000-Rs.12,000 being charged those days in Hyderabad, private clinics charged only Rs.4,500. But should the specialists from Hyderabad have got involved in an unholy business nexus with the unqualified doctors running private nursing homes, especially when the conditions of facilities were so compromised for surgery and post-operative care? The selection of some of the cases for surgery were also questionable.
The doctor at CHC Narsapur was complicit in this too. By not being available, she drove patients to these nursing homes. When she was, she never prescribed a cure.
The question then in my mind was: “Why doesn’t the health department throw open the sub-optimally functioning good infrastructure of Narsapur CHC to the same visiting specialists from Hyderabad to deliver services to the poor of Narsapur?” That would have been a good example of public-private partnership.
In addressing unethical hysterectomies, we must go beyond both the role of insurance or gender bias, to the root of the problem: unethical doctors. Keeping doctors on the straight and narrow is the responsibility, first and foremost, of their peers. They cannot sit back and ask the government alone to bring in effective regulations and control the villains among them.
(Dr. K.R. Antony, president, Public Health Resource Network, India, was health and nutrition specialist for Unicef and director, State Health Resource Centre, Chhattisgarh. Email: firstname.lastname@example.org)