The tragedy in Chhattisgarh, to use a business lingo, rests on three verticals: the economy of intentional mis-governance, the economy of malevolent business practices and the economy of stark gender-based cultural apathy (the verticals are arranged in order of importance). And since the verticals are near-universal in India, such incidents are ticking time-bombs planted across the country; if some of them have been defused, one can only attribute it to the benedictions of belonging to a polytheistic country. So let us not stand on a pedestal and look down on Chhattisgarh – the tragedy happened only because the gods decided to take a break.

Ironically all affected parties have taken out protest marches against the ‘injustice’ meted out to them – save the victims’ families: the Indian medical association (IMA) for protecting the doctors, the suppliers union for protecting the tainted manufacturing company and the Congress for bringing down the BJP government of the state. 

Also read: The decaying underbelly of a resurgent India

What really happened
The official narratives, however, are imbued with contradictions. Consider three cases:
On November 8, Phulbai Shriwas, 30, left her village, Amsena, for a sterilisation camp to undergo tubectomy in nearby Pendari at around 12 pm. After two hours, her husband went to look her up in the camp. She was lying in the corridor at Nimabhai cancer hospital (a deserted building used for the operations) with other patients and with two strips of tablets, brand-named Ciprocin 500 and Brufen, on her chest. The nurse explained how the tablets are to be taken. Phulbai kept vomiting all night and had excruciating body ache and swelling after coming back home. On November 10, the nurse from the Pendari camp came to Amsena village to announce that all those who had undergone sterilisation had to be compulsorily hospitalised.

At 2 pm the same day, Phulbai left her home with her husband and the youngest of her three children, who is a couple of months old, suckling at her breasts. She was first taken to the Amsena health clinic and at 3 pm to the zilla (district) health clinic where the district collector, Siddharth Komal Singh Pardeshi, and the block medical officer (BMO) met her. The first question the collector asked was whether Phulbai had the ciprocin tablets with her. The collector immediately confiscated the strips. From there she was shifted to the Chhattisgarh institute of medical sciences (CIMS) and at 10 pm to the Apollo hospital.

Her child was still suckling when Phulbai reached Apollo. She gave the child to her husband and walked inside. By 2 am, the doctor at the ICU told her husband that his wife, Phulbai, was critically ill and peculiarly asked, “What will you do now?” An hour later, the doctor announced that Phulbai was dead. Looking at her body, the husband recollects, “Her saree was thrown on the side and her face up. I touched her. She was cold.”

Kamla Koushik, a 58-year-old woman of Ganiyari village, got a cut on her foot. She went to a doctor named GC Jain on November 13. Though Jain is a retired Ayurveda physician, he seems to double up as a regular, allopathic doctor for the area. He has freely doled out ciprocins to many people who have been hospitalised since. After consuming ciprocin prescribed by Jain, Kamla felt dizzy, had chest pain and swelling in the body. She was first admitted to Sai Baba hospital, where a doctor advised that she should be shifted to Raipur. When her son Santosh Koushik took her to Narayana hospital in Raipur, the doctors declared she was brought dead. It was November 14 and less than 24 hours after Kamla consumed ciprocin. Santosh wailed, “My mother was so healthy. How could this happen?”

Kamla’s neighbour is Anil Koushik, a 35-year-old man who had mouth sores. He went to the same doctor, who prescribed the same medicine, ciprocin. After swallowing two tablets, Anil’s body started swelling and he was trembling. It was November 12. TV announcements regarding fake ciprocins had already started. Anil was lucky that he was literate and a man. He tallied the batch number from the TV news and immediately drove to CIMS to get admitted. Another neighbour said, “Anil survived because he got medical attention on time while Kamla was dependent on the men of the family to take her to the hospital.”

Chandrashekar Dubey had a bad bout of cough and cold. On November 10, he was taken to Jain who prescribed – yes, you guessed it – ciprocin. After taking the medicine, the 66-year-old felt restless and dizzy. The family took him back to Jain who insisted that Dubey continue with ciprocin. His condition worsened. Dubey was reluctant to be admitted in a hospital but was forced by his family to do so. By 8 pm next day Dubey was dead. His brother Ghanshyam Dubey saw the brand name of the antibiotic being flashed on TV and realised that it was the same medicine given to his brother. He beat his head and said, “Yeh wohi jaanleva dawaai thi (it was the same killer drug).”

Coming back to the sterilisation camps, a quick run of the facts would be useful. Bilaspur is the third largest district of Chhattisgarh. Two sterilisation camps were held on November 8 and 10 in the villages of Pendari and Gourella, respectively. As many as 83 women in Pendari and 38 women in Gourella camps underwent tubectomy, and 13 of them have been declared dead by the state government. Almost all the surviving women have been hospitalised, and 66 of them are on life support in the Apollo hospital. The sterilisation tragedy has blown the lid off a massive fake drugs racket in the state.  

Also read: Sterilisation: A health clamp
 
Anomalies within anomalies
A letter dated October 27, accessed by this correspondent, to all the chief medical health officers (CMHO) listed the medical camps to be held in November 2014 along with the doctors for each camp. Though union health minister JP Nadda proclaimed on November 21 that sterilisation was not target-driven but a demand-driven programme, the letter specifically instructs achieving tubectomy targets for all districts. In the past, the salaries of doctors and other stakeholders who have not been able to achieve targets have regularly been withheld.

Curiously, the Pendari camp has not been mentioned anywhere in that letter from the state government. The standard procedure requires the district collector to personally visit the camps. Not only was the collector nowhere to be seen both the days but he also denied knowing that the Pendari camp was held on November 8. Considering that the camp was a big event and the fact that the Nemi Chand cancer research hospital is only nine kilometres from the collectorate, this admission can only mean two things: that the collector has achieved a level of inefficiency where he has no business being in administration anymore, or he is feigning ignorance either for saving his skin or for pressure from the higher-ups or both.

Chaitibai, a 29-year-old Baiga woman operated upon at the Gourella camp, died. She was smart, articulate, and the leader of a self-help group in her village. This scheduled tribe is a ‘particularly vulnerable tribal group’ (PVTG) and sterilisation among them is discouraged to protect their population.

After the incident it was found that nearly 18 Baiga women had already undergone tubectomy in the government-held camps. Also, Chaitibai’s husband told a TV channel that they have two children while the BMO claimed on the same channel that Chaiti has three children and therefore had decided to undergo sterilisation. Moreover, for people from STs to undergo sterilisation, the law requires a written consent from the sub-divisional magistrate (SDM) or the district collector. Chaitibai was used to signing her name instead of using her thumb print for signature. However, her consent form bears a thumb impression giving rise to speculations that the impression was taken after she was dead or when she was highly sedated.

RK Gupta, the surgeon of the Pendari camp, awarded by the government on January 26 this year for conducting a record number of female sterilisations, has already been suspended. He has been slapped with charges under section 304 of the Indian penal code (culpable homicide not amounting to murder). However, the doctor of the other sterilisation camp at Gourella, KK Sav, is still a free man despite the fact that a Baiga woman died in his camp. Sav is said to have “good connections” in the BJP.

It served the government well to divert attention from the fake drugs – at the root of the unfolding tragedy – to the proclaimed incompetence of a doctor; this obfuscates the fact that four people had died during the same time, three of whom were men who did not undergo sterilisation. However, the BJP government was left red-faced when the principal secretary of health, Alok Shukla, declared that an analysis of ciprocin batch number 14101 – the contaminated batch – revealed that it contained zinc phosphide, a chemical compound commonly found in rat poison. Batch 14101 with 1,52,000 tablets had been sold to four drug stock-lists in districts across Chhattisgarh.

Prabhas Srivastav, the head of IMA’s Chhattisgarh chapter, said, “How could the patients have died of toxicemia resulting from infected instruments as the government claims? The blood reports of the patients were clear before they entered the ICU. And they died within 24 hours. This is only because of highly toxic drugs.”

Asked why Sav was not arrested along with Gupta, Srivastav only said, “Maybe the government has realised its mistake of arresting one doctor and doesn’t want to commit another mistake.”

The India head of IMA is scheduled to meet chief minister of Chhattisgarh Raman Singh soon to secure the release of Gupta, failing which they have threatened to go on a nationwide strike.

Poison as medicine
Ciprocin is an antibiotic manufactured by Mahawar Pharmaceuticals. Its managing director Ramesh Mahawar and his son have been arrested. However, they have been charged under section 420 of the IPC — covering offences related to cheating and dishonesty — which draws much lighter punishment as compared to section 304. 

Mahawar Pharma has a history of producing sub-standard medicines. It was barred from manufacturing medicines for 90 days in 2012. However, its licence was not revoked. Not only is it surprising that Mahawar pharma and other such drug suppliers got through state-level regulators for drug supply but also that the state government bought medicines from a disreputable company when there was enough stock of the medicine with the state’s central procurement agency. It is important to note that Ramesh Mahawar is perceived to be close to Amar Agarwal, the state health minister, and is a strong BJP campaigner.
 
A tainted history
Chhattisgarh has a botchy record of health camps. The government-sponsored camps at Kawardha and Balod in September 2011 for cataract operations left two dead and 20 blinded, and four dead and 49 blinded, respectively. In the Durg eye camp of April 2012 three patients lost their sight. And the Bagbahra camp saw 145 eye operations, of which 15 patients had severe infection and nine patients had their eyes taken out.

The worst, perhaps, was the ‘uterus scandal’ in 2012, when 1,800 hysterectomies were performed on village women without a valid medical reason in order to claim money from a national insurance scheme. Only 10 doctors had their licences revoked, only to be reinstated quickly by the state government after the IMA’s intervention.

In the Devika Biswas vs. Union of India and Others case, the supreme court issued notices to the centre and every state on a public interest litigation  (PIL) filed by the Human Rights Law Network (HRLN). Devika Biswas, a health rights campaigner in Bihar, revealed the gruesome details of a January 2012 sterilisation camp at Araria district. The PIL specifically mentioned coerced and unsafe sterilisations in Kerala, Madhya Pradesh, Maharashtra, and Rajasthan.

The apex court granted time to the centre to implement the directions sought by Biswas and others in the form of guidelines on sterilisation. While the decision is awaited, standard operating procedures continue to be flouted across the country.

When this correspondent visited the Nemi Chand hospital, three friendly stray dogs greeted her on the entrance steps of the hospital. Bilaspur SDM Fariha Alam Siddiqui, along with a group of policemen, was examining the operation theatre (OT). Even after a massive cleaning operation of the OT after the deaths, the instruments had a thick layer of dust. In this theatre, Gupta had sterilised 83 women in five hours.

In a blatant contravention of the world health organisation (WHO) rules, the women were not examined prior to the operation, were not counselled about other contraception methods or informed of the possible side-effects of sterilisation.

The district administration has been busy collecting the fake ciprocin batch 14101 from every nook and cranny in the district, sometimes voluntarily and sometimes by threatening the victims’ families. The local newspapers reported that district collector Pardeshi had overnight destroyed thousands of ciprocin tablets in the Nemi Chand hospital premises.

When Ghanshyam Dubey went to the police station to file a first information report (FIR), the police refused to take his complaint for almost three hours. Most of the families have not filed an FIR owing to lack of knowledge about legal procedure, as also because they do not want to enter into an altercation with the all-powerful state government. Dubey said SDM Fariha had threatened him saying, “Give us the medicines; otherwise don’t blame us if you are in trouble.”

The Apollo hospital has been converted into a fortress where no media or even the families of the victims are allowed. Sixty-six women are struggling for their lives there. Raju Yadav’s daughter, 26-year-old Sitala, has been on a ventilator in the hospital since November 10. Raju has no news of her since then. The authorities won’t let him see his daughter. “Whenever I ask the doctor he tells me, ‘What will happen if you see your daughter?’” complains Yadav. Indeed, a strange question to ask a parent.

Tapasi Praharaj, secretariat member of all India democratic women’s association (AIDWA), calls it a “genocide” by the state government.

As Governance Now goes to press, the correspondent was informed by a senior district official that the women who were on ventilator and dialysis had recovered. He termed this a “miracle and god’s blessings”. However, four of the released women have been re-admitted with serious complications.

The government in its haste is clearing patients by the bulk. Given the dire socio-economic conditions of the victims, where even one episode of illness is enough to send a family spiralling down the poverty ladder, it remains to be seen how the families will financially cope with the post-trauma care required after such a severe bout of health failure.

The state government has constituted a one-person commission of justice Anita Jha to investigate the deaths. The Daily Chhattisgarh editor, Sunil Kumar, questioned the choice of a retired judge of the state civil court rather than appointing someone from outside the state. Moreover, Jha has a record of delaying judgments in probe panels; one such report is pending for three years. Kumar said, “Since you can’t deliver we are giving you some more cases. A retired judge getting two inquiries is a clear favour to her.”

Everybody loves a botched sterilisation
The Apollo hospital has reportedly whipped up a bill of '80 lakh for the state government. Chief minister Raman Singh remains unabashed through the tragedy, having perhaps adroitly “managed” such botched-up camps before. He refused to suspend his health minister Amar Agarwal. Giving a whole new dimension to moral responsibility in governance, Singh stated, “Why should he resign? Did he do the surgeries?”

Amar Agarwal made headlines when he was caught laughing during his visit to meet the victims at CIMS. He said, “Tragedies happen in the health sector.” Amar Agarwal, son of a veteran BJP leader, owns a factory of gudakhu, a tobacco product, when his party, BJP, has been in favour of stronger measures against tobacco consumption. The fortification around his house has increased manifold after the incident.

The victims’ families have been promised '4 lakh for the deceased. The state government has also promised to play parent to the children of the dead women by adopting them. As 38 women were released from CIMS, the district authorities posed for photographs in front of neatly-arranged Milton flasks and blankets that were being given to patients on their discharge from the hospital.
 
A paradoxical culture
According to the UN data, contraceptive prevalence between the ages of 15 and 49 for 2006 through 2012 in India was 54.8%. The report on world contraceptive patterns 2013, released by UN population, states that in India 35.8% females and 1.1% males have undergone sterilisation.

This is so despite the fact that vasectomy (male sterilisation) is far easier and safer than tubectomy (female sterilisation). The cultural structures in India strongly encourage tubectomy where a woman’s life is more dispensable than that of a man who is seen as the breadwinner of the family.

The trend is further buttressed by incorrect notions such as vasectomy leads to a loss of virility for a man and an incapacitation for hard work. Encouraging such regressive ideas the government has surprisingly never upped the ante for male sterilisation or undertaken any social programme for rectifying wrong views on vasectomy. This attitudinal jumble of the government remains a mystery. 

A group of men from Ambasena village say that the last government-sponsored male sterilisation camp was held 20 years ago. Asked if they would undergo sterilisation instead of the women, they said, “We have heard that men lose their capacity to work after such a procedure. Who will feed our families if we can’t work?”

A mitanin, the government village-level health worker who gets paid '250 for every woman she induces to get sterilised, is not even aware that male sterilisation is possible.

An old woman, mother of one of the young women who has died, whispers, “Amar Agarwal and Raman Singh will not be able to live happily with their families having done this to our daughter. This is the curse of a mother.”

While some wait for karmic atonements to kick in, one can only hope that another bomb planted in some other part of the country does not snuff out young lives as mercilessly.

The story appeared in December 1-15, 2014, issue