As the news of the deaths of women sterilised at a camp at Takhatpur block of Bilaspur district started to filter in on November 10, officers in Chhattisgarh’s health department pro-actively called all the 83 women present at the camp to hospitals in the district headquarters. Then, news came that women who had attended other camps too were feeling unwell. Within hours, the operation to gather all the 137 women who were sterilised in four camps-one on November 8 at Nemi Chand Jain hospital in Sikri, Takhatpur, and three on November 10 in Gaurella block-was initiated. (See `How the tragedy unfolded’).
Once the women’s health stabilised, they were sent home with a bag of goodies that included a shawl, blanket, saree, salt and a kit of toiletries for their babies. The administration began brainstorming the cause of deaths. It sought the list of medicines given to the women post-surgery in all four camps. Four drugs were common in the list-diazepam, ibuprofen, ciprofloxacin and povidine iodine. Looking at the symptoms of the affected women, they zeroed in on two drugs, namely ibuprofen and ciprofloxacin. Of these, ibuprofen tablets were manufactured in 2013 and were in circulation for some time and, therefore, considered safe.
|How the tragedy unfolded
An account of what happened in Takhatpur from November 8 onwards
- First camp held at Takhatpur. Eighty-three women sterilised
- Three camps at Gaurella, Marwahi and Pendra villages. Fifty-four women sterilised
- The first death occurs. Six women taken ill
- Compensation of Rs 2 lakh for the deceased
- Seven more women die
- R K Gupta, surgeon who operated upon women in Takhatpur, arrested by police
- Compensation increased to Rs 4 lakh for the deceased and Rs 50,000 for survivors
- Two more die, one from Pendra town
- Medicines come under scanner
- One-member judicial commission under retired judge Anita Jha appointed
- Zinc phosphide found in ciprofloxacin
- MahawarPharma promoters arrested
- Private Delhi laboratory confirms presence of zinc phosphide in medicines
- Fixed deposit of Rs 2 lakh announced for each child of the deceased
“We found that ciprofloxacin, on the other hand, was manufactured in October 2014. This made us suspicious and we tested it,” said Ayyaj Fakirbhai Tamboli, mission director, National Rural Health Mission (NRHM), Chhattisgarh. Preliminary tests of ciprofloxacin tablets showed they were contaminated by zinc phosphide, commonly used as a rodent killer. The state government says the labs in Delhi, Nagpur and Kolkata have confirmed the presence of rat poison but it has not made the reports public. The owners of Raipur-based Mahawar Pharmaceutical Private Limited and Bilaspur-based Kavita Pharma were arrested for culpable homicide.
The culprit had been found. The poison that killed the women had been discovered. Or so it seemed.
Dularin Patel, 27, of Lokhandi village in Takhatpur was one of the 13 women who died. “She was fine till Monday afternoon when she visited us. She had taken medicines on Saturday night and twice on Sunday,” says Gorabai, Dularin’s mother. “She started vomiting from 4 o’ clock in the evening. Then, we got a call from her in-laws, who stay 70 km away, that the mitanin (local health worker) has asked her to go to the hospital. By 3 o’clock on Tuesday morning, she was in Chhattisgarh Institute of Medical Sciences (CIMS).”
“I fed my daughter black tea and bread toast before she left home. I did not know that was going to be her last meal,” says Dularin’s mother, not being able to contain tears in her eyes. By early evening on Tuesday, Dularin was declared dead.
Preliminary results of the post-mortems of the victims have been submitted to the investigating agencies. They have not been disclosed to the public but a senior medical officer who closely monitored the post-mortems told Down To Earth (DTE) that Dularin had developed septicaemia. “She had inflammation of the peritoneum, the membrane forming the lining of the abdominal cavity. There was half-a-litre of thick yellowish fluid in her lungs and septic foci was found in all organs,” said the source, requesting not to be named. “This is a clear-cut case of postoperative infection.”
DTE has accessed seven post-mortem reports. Five of these are of women who died on November 11, one of a November 12 victim and one of November 13. All five reports from the first day showed infection of the abdomen. The report from the second day showed high infection in the body. The report from the third day showed septic shock.
“This shows the infection kept increasing among women who were sterilised on November 8. The results show definitively that the women got infection which must have come through unsterilised instruments,” says a forensic expert at Lady Hardinge Medical College in Delhi.
The administration’s beautifully crafted story of contaminated medicines collapses. The women were prescribed one tablet each of two medicines, twice a day for five days. One of the medicines was the antibiotic ciprofloxacin, which the administration claimed was contaminated with rat poison, zinc phosphide.
Zinc phosphide is linked to kidney failure. “We did not get any renal failure in our post-mortems,” informed the source. He said the infected laparoscope must have been the reason for the deaths.
As the forensic expert in Delhi explains, zinc phosphide poisoning shows up as ulceration of the gastrointestinal tract. The source confirmed that signs of this were missing in post-mortems. However, confirmation of poisoning can only be through viscera report, which is awaited.
The health department’s second assertion too falls flat. It said apart from the women who underwent sterilisation operations, 26 more people fell sick after consuming the same medicine. Six of them died.DTE accessed the post-mortem reports of three of the six. “There was no peculiar finding in their post-mortems. These can only be confirmed after the chemical analysis of viscera,” said the source.
Though the officials claim that medicines are the culprit, they refuse to provide the details, saying the matter is sub judice. The only information they are ready to part with is that two laboratories have confirmed that the medicines were contaminated with zinc phosphide. They would not say what was the concentration of the contaminant.
Experts do not believe this theory. “According to standard books, an adult female needs to consume 4.5 g of zinc phosphide to die,” says B L Chaudhary, from the Department of Forensic Medicine and Toxicology at Lady Hardinge Medical College. The Chhattisgarh administration claims that 500 mg tablets of the antibiotic were contaminated. For the sake of argument, even if one assumes that the entire 500 mg was zinc phosphide, a woman would have to consume nine tablets for the poison to prove fatal. Most women started to complain from Monday. By this time, they had taken three to five doses of the antibiotic. This casts doubt on the poisoning argument.
Citing some of these gaps, this reporter asked the officials about an alternative line of investigation. “This seems quite conclusive to us. We are not looking at any other theory. The rest, the lab reports and other tests will tell,” said Tamboli of NRHM.
The state government has set up a one-member judicial commission to investigate the deaths. It has to collect testimonies of the survivors. But the commission seems to have placed the responsibility of reporting grievances on the survivors. People wishing to give testimony will have to visit the commission’s office in Bilaspur city which remains closed most of the time. "It is impossible to understand how the poor, uneducated and sick women will travel to this place," says Sulakshana Nandi, Raipur-based member of Jan Swasthya Abhiyan, the India chapter of People's Health Movement.
The Bilaspur fiasco has also exposed irregularities in drug procurement. The much-maligned ciprofloxacin was purchased locally by Chief Medical and Health Officer (CMHO) R K Bhange. An official in the health department informed DTE that Chhattisgarh Medical Services Corporation Limited (CGMSCL) has written to at least one inquiry team, stating that the antibiotic stock was available with the authority on November 8.
“The CMHO has the discretion to buy medicines or procure from CGMSCL. Following good practice, he should have chosen the government agency, where the tenders are invited from companies that have been certified by accredited labs,” said the official.
“It was a double whammy for the women. The tragedy happened due to multiple reasons. Firstly, the operations were conducted in pathetic and absolutely unsafe conditions, leaving the women medically vulnerable. Then they were fed contaminated medicines,” says T Sundararaman, founding director, Chhattisgarh State Health Resource Centre and faculty, Jawaharlal Nehru University (JNU), Delhi. "All these factors should be investigated by an independent team. The state should be held responsible for bungling on all the fronts."
Things don't change
The manner in which the operations were conducted paints a disturbing picture. It resembles a scene straight out of the documentary on sterilisation, Something Like a War, by Bengaluru-based filmmaker DeepaDhanraj, where a gynaecologist boasts:
This year, I have done more than 2,000 operations. I could do these in school classes, college rooms and zilaparishad halls. These operations are so easy. [A woman moans in severe pain in the background.] I thought of this particular method and I took 45 minutes for the first operation... Now, I can finish this operation in 45 seconds.
This was 1991. Cut to 2014. Like the gynaecologist in the film, R K Gupta, operating surgeon at Takhatpur, performed surgeries like an assembly line (see ‘Evil of efficiency’). He was awarded by the state government on January 26, 2014, for a record 50,000 surgeries in his career.
Accounts of healthcare providers at the Takhatpur camp show gross violation of the 2006 guidelines, Standards for Female and Male Sterilisation (see `Flouting of norms on November 8’). Even basic medical ethics went for a toss. According to the accounts, women started coming to the camp from 10.30 am. Their blood and urine tests were conducted by junior doctors. It was only at around 3.15 pm that R K Gupta came and he was gone by 5.00 pm after operating 83 women, giving less than one-and-a-half minutes to each woman. The same syringe and suture needle were used for all the women. The staff did not even change their gloves. The hospital floor was just mopped, on which the operated women lay down in the absence of beds. “This is a sure-shot recipe for fatal infection. The women could have acquired infection at any stage,” says Subha Sri, member, Common Health, a non-profit working on maternal and neonatal health.
|Flouting of norms on November 8
What happened at the camps and what should have happened
Event at the camps
Guidelines of 2006
- 83 women sterilised
- One doctor sterilised them all
- Each woman sterilised in one to one-and-a-half minutes
- One laparoscope used
- No woman knew of the side effects
- Nemi Chand Jain hospital was shut since April
- No woman knew of other methods of avoiding pregnancy
- Operation theatre was cleaned with a mop
- Only 30 persons to be sterlised in one camp
- One doctor cansterlise only 10 in a day
- Prescribed standards would take an average of 5-6 minutes per case
- Three laparoscopes to be used for a maximum of 30 patients
- Women should be counselled about side effects
- Camp should be conducted in a working hospital
- Women have to be counselled about contraceptives and IUDs
- The operation theatre should be fumigated thoroughly by burning formaldehyde tablets and liquid ammonia 48 hours before the surgery