A study commissioned by the National Health Authority (NHA) of India has recently (Economic Times Report dated July 22, 2019) red-flagged claims made for hysterectomies conducted in private hospitals in at least six states, under the Pradhan Mantri Jan Arogya Yojana (PMJAY) scheme. It has sought more caution and tighter scrutiny of such claims under the Modi government’s flagship programme that promises universal healthcare to nearly 10 crore beneficiaries.
Hysterectomy is a surgical procedure for the removal of a woman’s uterus ( womb) that houses the infant baby before delivery. Sometimes removal is done along with both ovaries (bilateral oophorectomy). In popular terms, it is called the ‘big operation’, as opposed to tubectomy, the ‘small operation for family planning’ or female sterilization.
FIG 1: Hysterectomy . Courtesy : Wikipedia
In a small proportion of cases, where there are no alternative ways of tackling women’s gynecological illnesses, hysterectomies are medically advised, i.e., indicated, in the interest of the women’s health. Fear of cancer, or pre-cancerous condition, is a major indication for Hysterectomy. Hysterectomy is never the first option, and is suggested only after all drugs and minor procedures fail to work, and that too after due diagnostic procedures establish the inevitable necessity of the surgery. Hysterectomies for women below 50 are advisable only in rare conditions.
The above study is a gross understatement of the malaise, both in terms of its extent and its criminality. It is an unethical medical practice, rather a crime in the healthcare field. However, it is significant because an official body hereby acknowledges how public funds are being misused by the medical profession in particular, by the corporate and private hospitals, (often in collusion with state machinery),to perform un-indicated surgeries that are not only unwarranted but are harmful to women’s health, impair quality of life, pull down the life expectancy and productivity, thereby impairing her livelihood too.
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, says a Report, Pushed into hysterectomies by Roli Srivastava, THE HINDU, June 11, 2016. It says:
“ 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), 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.”
Calling the practice a “human rights violation”, Chittorgarh-based Narendra Gupta, founder of non-profit Prayas based in Rajasthan, moved a PIL in the Supreme Court in 2012-13. He sought compensation for the women who underwent the surgery. Advocate Durga Prasad Saini’s findings formed part of a petition filed in the Supreme Court by physician-campaigner Dr.Gupta against the practice.
Several individuals including Dr. Sapna Desai of Ahmedabad who conducted the study while based at SEWA and the London School of Hygiene and Tropical Medicine, M. Bharath Bhushan of Hyderabad-based NGO, CARPED, health rights activist Devika Biswas of Bihar, Sulakshana Nandi of Jan Swasthya Abhiyan in Raipur, Chhattisgarh, Anuradha Vasan of Karnataka Janaarogya Chaluvali (KJC) exposed the problem. Roli Srivastava (who reported in THE HINDU) is one of the journalists who helped the efforts on the subject.
20 lakh hysterectomies performed in erstwhile AP : DLHS-2007
But it is Dr. SV Kameswari, a gynecologist of Hyderabad, who along with her life partner Dr. Surya Prakash, who carried on a sustained and multi-faceted field work on the problem. The physician couple began their study on the subject almost 20 years ago, had found more than 20 lakh hysterectomies performed in erstwhile Andhra Pradesh, as per District Level Household Survey (DLHS)-2007, conducted by the Ministry of Health and Family Welfare. Disturbed by their own observations in Medak Dt., the couple engaged themselves in a 3-year Study in the District, during 2008-2011.
The state of AP was notorious in this respect. The rate of hysterectomies at one time per 10000 women was 55 in USA, 20 in UK, whereas it was 920 in AP, she wrote citing authentic data. The rate in USA came down from 55 around the year 2000 to 35 in 2013, more so for women aged below 55.
“The study by Dr couple goes into great detail, and the main takeaways present a worrisome picture of exploitation, poor medical ethics and the health of women. Of the sample, 60 percent had hysterectomies below the age of 30 and for them the average age was 24.6 years. The ovaries of 33 percent of the women, for whom detailed information on the surgeries was available, had been removed. More than 90 percent of the women went to private hospitals.”
(See for more on their work: Womb crusaders : Dr. Vinjamuri and his wife, Dr S.V. Kameswari, A Report dated November 5, 2018 by Umesh Anand and Lakshman Anand. https://countercurrents.org/2018/11/womb-crusaders-dr-vinjamuri-and-his-wife-dr-s-vkameswari).
The uterus and ovaries are essential to conceive and have babies. And they are also linked to the overall health of a woman. The ovaries, for instance, produce estrogen, a female hormone, the lack of which leads to heart problems, weakened bones and lack of libido. The odd infection in the reproductive tract or white discharge or perhaps a little bleeding could have been easily treated without surgery. Instead, in the hands of manipulative doctors, women have been subjected to the violence of surgeries and left minus an organ so essential to womanhood.
Photo : Dr SV Kameswari and Dr Vinjamuri Surya Prakash, doctor-couple of Hyderabad , worked as a team fighting against unwarranted Hysterectomies , and could put a check on them in AP and Telangana. Before that , lakhs of unwarranted Hysterectomies were going on in AP. Here they are seen explaining complex reproductive health issues to village women, see a model of uterus in his hands, which is a regular activity for them. They published, in August 2017, a popular educative book, in Telugu, which was reprinted too. They campaigned in villages, attended several meetings on the issue and published work . Dr. BM Hegde presided one such meet of ISSA and appreciated the work to be emulated.
The doctor couple ( See photo ) ever since carried on a campaign on the issue and published an educative, popular book, of more than 100 pages, full with diagrams and information, in Telugu (August 2017). Its title rendered into English is : Let us protect the uterus, and strengthen the society. At great risk they carried on a battle against the illegal hysterectomy and got it de-listed from Arogya Sri (Subsidized health-care) scheme, after convincing the AP Government, then led by Chief Minister Dr. Rajasekhara Reddy, himself a doctor.
“We are giving them basic knowledge. Eighty percent of the surgeries are being done because of white discharge. The women don’t know that white discharge can be good for them. They don’t know the difference between healthy white discharge and unhealthy white discharge,” explains Dr Kameswari.
Currently they also focused on unnecessary caesarian operations in the place of normal deliveries. The Telangana Government now is making efforts in that direction. They presented papers at various fora and addressed thousands of women on the issue, among other health problems of women. We from FMRRC Karnataka have been friends as healthcare activists for the last few years.
(For details about their work, visit / write to Life-HRG Blog, http://lifehrg.tripod.com/about.html or to : firstname.lastname@example.org.)
NHA Study : A Belated Admission
The NHA is the implementing body for PM-JAY and had commissioned a working paper titled Patterns of utilisation for hysterectomy: An analysis of early trends from PMJAY in May this year. economictimes.indiatimes.com (ET) published a report dated Jul 22, 2019 and titled Hysterectomy tops Ayushman claims; red flags raised. It said:
The working paper was part of a regular analysis of the trends and data within the health scheme to ensure checks and balances in its implementation. “Hysterectomies have traditionally been a source of misuse by the private sector for insurance claims. Wrongfully done procedures have a bearing on the overall health of women as we saw in recent news reports. This is a public health issue,” a government official at Ayushman Bharat told ET when contacted. Chhattisgarh (21.2%); Uttar Pradesh (18.9%); Jharkhand (12.2%); Gujarat (10.8%); Maharashtra (9.0%); and Karnataka (6.6 %) topped the list with highest number of claims under PM-JAY, adding upto nearly 75% of all hysterectomy claims, submitted across 24 states and union territories so far.
States like Chhattisgarh and Uttar Pradesh have a large number of claims made from the private sector. While claims from Uttar Pradesh were nearly 5% of all medical claims under the Ayushman Bharat scheme, it generated 18.9% of all hysterectomy claims. In Chhattisgarh, 94.5% of all hysterectomy claims in the state were made from private hospitals which raises concerns.
The report has also asked for a closer scrutiny of claims in Haryana, Jharkhand and Arunachal Pradesh due to discrepancy found in the data submitted.
“There is a tradition of hysterectomies being conducted for family planning procedures in several states. Women would often have their uteruses removed to be able to work in the fields and earn their wages, unhindered by menstruation. Hysterectomies conducted before the age of 40 can cause early menopause in younger women that affect their health early,” an expert, (quoted by the Report,) said.
This is a distortion and an understatement of heinous practices pushed by the commercial and vested interests in medical field. The surgeries in fact impair the health and capabilities of toiling women. Women are being misled, even forced to go in for hysterectomies. Hysterectomies are indeed very recent, and cannot be called a tradition. They are a sequence of over- commercialization of medicare, more so in the era of LPG, of Liberalization, Privatization and Globalization. (There is evidence to show that the unethical practices for profit have some link with USA, where it was pushed sometime ago.) Earlier only tubectomies were being done as part of family planning drive.
However, altogether on a different footing is unindicated hysterectomy that has become notorious in India, based on ignorance, misinformation, utter poverty, and going up to gross cheating. This has been a notorious malpractice, belatedly mentioned by the NHA. PTI had reported four years ago, on July 16, 2015, how allegations of heinous practices were taken note of even by the government.
Maharashtra Health Minister Deepak Sawant today said he will inquire into the reports of hysterectomies allegedly done without valid reasons in various districts in the state. “I will check the veracity of these claims. If anything of this nature is happening, action will be taken,” the minister told reporters here after a report was aired by a Marathi channel on doctors performing mass hysterectomies on gullible women for money.
Nandkumar Panse, who conducts cancer awareness camp for the Barshi-based Nargis Dutt Cancer Hospital, said such cases rose in last four years in districts including Latur, Beed and Osmanabad, says the Report of 2015.
“The hysterectomy surgeries were conducted on women engaged in sugarcane cutting and belonging to low income group and mostly from illiterate background,” he said.
Shashikant Ahankari of Hello Foundation (an NGO working in Marathwada) said corruption in medical profession is responsible for the rising cases of hysterectomy operations sans any valid reasons.
“Sometimes the surgery is performed on women in their mid-20s,” Ahankari said. The doctors terrify women stating non-removal of uterus leads to cancer, he said.
Rural poor cheated and thrown into debt-bondage.
Maharashtra government, led by Devendra Phadnavis of BJP, did little to curb the malpractice in the last few years despite the assurance by the Health Minister.
This can be seen by the following report titled: In drought-hit areas of Maharashtra, a uterus is a financial burden. It was a report by The Hindu datelined Sangola (Solapur), May 22, 2016. It shows how poor women farm laborers are misled and cheated by commercialized medicare. The sugar cane-farming and related business actively promoted hysterectomies, unscrupulously and unwarrantedly. It has become a pathway for indebtedness of rural poor and to reduce poor women into a sort of debt-bondage. The report (See photo of women from Solapur, Maharashtra) said:
Doctors mapping hysterectomies in India estimate that approximately 50 to 60 per cent of women in many rural parts of the country have undergone the procedure. In the developing story of the rising numbers of hysterectomies — reported from various states over the years including Karnataka, Andhra Pradesh, Telangana, Rajasthan, Madhya Pradesh — its widespread occurrence in a small taluka such as Sangola could well be anecdotal evidence of what is clearly a national concern.
What makes it different here, however, is that doctors have been prescribing hysterectomies frequently, making it almost a rite of passage, where a woman undergoes the procedure once she is through with her reproductive ‘duty’ of giving birth to children. But in this part of Western Maharashtra, hysterectomies are not rooted in medical malpractice alone. Heavy labour can also led to prolapse of the uterus — where the uterus drops into the vaginal canal — which is another reason for doctors to suggest hysterectomies, says Gautami Dadagade of Astitva, a Sangola-based NGO that has just completed a study on hysterectomies in the area along with Tata Institute of Social Sciences.
Life never the same: (Left) Right Sarika Raju Kalgurde (23) of Hatkarmangewadi village in Solapur district underwent a hysterectomy last year, while her mother Jhimbai (38) underwent the procedure over a decade ago. (Right) Susheela Samadhan Hipurkar is 26 and a mother of three. She got married at 14 and underwent a hysterectomy at the age of 24. —Photos: Roli Srivastava
And superstitious beliefs around the menstrual cycle have also made hysterectomies rather acceptable. Dig a little deeper, however, and the key reason emerges: in this water-scarce region where women migrate to work in sugarcane factories or in road construction work, periods are a financial strain as they mean loss of wages for five days a month.
Sarika Raju Kalgurde, 23, ( See photo) has just come back to her village after putting in six months of work at a sugarcane factory. She says it is a labour intensive job and the work hours are unpredictable. Last year, Sarika underwent a hysterectomy, a procedure a private doctor prescribed to cure her of irregular menstrual cycles and white discharge. She readily agreed as she had had two children. Besides, her mother, Jhimbhai (38), too had undergone a hysterectomy more than a decade ago. (Note their ages.)
Most importantly, the decision took care of the five days of being ostracised. “During periods, we are made to sit outside the hut,” she says, “and also served food outside in separate vessels. When my periods started becoming irregular, and longer, my time outside also increased.”
Doing physical labour during periods was difficult. “So my parents sold their animals and pawned their jewellery for this operation that cost us Rs 43,000.” Other women took loans from their employers and now put in more hours at work to be able to repay them.
Yesabai Kishan Karande, 60, took a loan from her employer for her hysterectomy about a decade ago and she is still working to repay it. She says the work is difficult: she cuts sugarcane, and carries piles of it to load them on to a tractor. And work timings depend on when the tractor gets there. “If the tractor comes at midnight, we have to work.”
Sugar cane-cutting women labor in Maharashtra are misled into un-indicated surgeries. Landlords and Labor contractors ‘convince’ , or rather con the women , and more their husbands, that it helps them to do work unhindered, and thus enhances their income. They even advance loans for surgeries.
Low rainfall notwithstanding, this belt is fertile land for private medical practices. Is there a nexus? Over a dozen private hospitals dot the Sangli-Sangola belt and offer hysterectomies.
Doctors there admit that over the last 20 to 25 years, the number of women undergoing hysterectomies has shot up. “It is the women who want it,” says Dr. S.A. Kulloli, who runs Kulloli Hospital in Sangli.
“They want to get rid of the pain. It comes in the way of their work.” He maintains that a hysterectomy is never the first option, but is suggested only after drugs fail to work.
However, at the Rural Hospital, Sangola, medical superintendent Dr. Piyush Patil says a hysterectomy is often the first line of treatment doctors in the area prescribe. And women believe doctors, as they widely believe (or rather made to believe, misleadingly) that white discharge could be the first symptom of cancer.
That view is strangely corroborated by the Taluka Medical Officer, Dr. A.M. Qazi: “It is the right course of treatment,” he says, adding that there is a high possibility of cervical cancer. He, of course, says that proper diagnostics need to be followed.
Dr. Amita Maheshwari, gynaecological oncologist at Tata Memorial Hospital, says that even if cancer is suspected, a hysterectomy isn’t the right course of treatment; a diagnosis can’t be made without a clinical examination and tests, including a pap smear. That awareness is conspicuously missing in the villages of Sangola.
Child marriages are a footnote in the bigger concern of hysterectomies, which explains why women undergo the procedure as early as their twenties. Like Susheela Samadhan Hipurkar, 26, who was married off at 14, had three children, and underwent a hysterectomy two years ago. She has just returned from a six-month stint at the sugarcane factory and is now working as a farm labourer. Her joints ache all the time, and she looks older than her age. She has no alternative. “I have no time to rest,” she says.
Missing wombs: the health scandal
Though years rolled by and voices against the malpractice were raised, the practice not only continued but got aggravated as can be seen in the latest .thehindu.com report of May 08, 2019, Missing wombs: the health scandal enslaving families in rural India.
The above is the title of Report by Thomson Reuters Foundation, published by The Hindu with the dateline Karauli, May 08, 2019. It is based on “ visits to about a dozen villages in Maharashtra, Rajasthan and Telangana states over five months. ”
The Foundation found hysterectomies were routinely done leaving families destitute and trapping people in modern-day slavery. Below are some points from the same.
Telangana has the highest number of hysterectomies in India. The surgery halved the family income of Maloth Bhuti whose mother and daughter-in-law are among 50 women in their village to have undergone the procedure. “I can no longer work. My children take care of me. My husband had to leave the village to work on the money lender’s farm. He had no choice,” said Bhuti, 45, a mother-of-four.
Telangana Health Director G. Srinivas Rao said the state was informing women in villages of the health risks of the surgery. “We have also asked hospitals to fill out details of each hysterectomy case, which is then audited by health officials. There is some change,” said Rao, a doctor. https://www.thehindu.com/news/national/missing-wombs-the-health-scandalenslaving-families-in-rural-india/article27072438.ece
“Unnecessary and unethical”
The PIL by Dr Gupta, mentioned above, pending in India’s top court, and subsequent requests to officials, prompted the government to carry out the first-ever national hysterectomy survey, it is said.
“There are enough studies and reports that show clearly that there is a rising number of hysterectomies,” Dr. Gupta said. “A lot … are being conducted without other non-invasive methods being explored.”
While hysterectomies in the West are common post-menopause, activists say many rural Indians are having the surgery young , after being told it offers a quick fix to their period problems.
Performing hysterectomies is a money-making racket even without insurance, as was found, for instance, 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.
Inquiry committees were appointed by Rajasthan government, in Chhattisgarh and Karnataka too. More often, they were formal and let the doctors go scot-free.
( See for more : Pushed into hysterectomies by Roli Srivastava in THE HINDU,June 11, 2016 . http://www.thehindu.com/opinion/columns/column-article-by-roli-srivastava-pushedinto-hysterectomies/article8710537.ece)
Action and inaction
On 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. But the malpractice is yet to be stopped.
“This is a crisis,” says Dr. Veena Shatrugna, former Deputy Director of the National Institute of Nutrition. : “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.
Can there be end an end to the atrocity? Various sections of the civic society including Senior medical practitioners, health workers, social activists, women’s groups, mediapersons should join hands, and carry on concerted activities to check the menace. They should press the legislators and law-enforcing agencies who have their own role to play.
( About Dr. M. Bapuji : An activist who was a Retd. Senior Scientist, CSIR 1973-2002 (30 yrs), in Odisha, with vast experience across disciplines. M.Bapuji, born 1948, had a Ph.D in organic chemistry, he guided six to Ph.D in varied cross disciplinary subjects, and was associated with various universities and an IIT. Has published 70 papers, holds 6 Patents, transferred 9 technologies to industry, helped stop imports of a group of chemicals, discovered a 80km-long ridge reef off Odisha coast, reported about 140 sponges, corals etc for the first time from this reef. Established lab for microbes associated with sedentary fauna. Studied over 1200 microbes from this resource. Was General Secretary (3 yrs) and President (3 yrs) for All India CSIR Scientific Workers’ Association (SWA) affiliated to the World Federation of Scientific Workers. Director of a rural PG centre at G.Mamidada for five years; senior academic consultant for Nannaya University and for T.D.University, Bangalore. In recent past was a Visiting Professor and Research Adviser, Acharya BM Reddy College of Pharmacy, Bangalore,. Working on fluorosis voluntarily with FMRRC (as Scientific Adviser, FMRRC, Hubli, Karnataka) for the last seven years. Working on improvement of tribal schools, education, labs, faculty in W.Godavari dt(AP). Currently based at Hyderabad. Has contributed to countercurrents.org.
Email : email@example.com, ph no.7901083682
See also by the same author:
Socio-Political and Economic Aspects Of Fluorosis (April 17, 2017 )
Co-authors : M. Bapuji and KS Sharma