‘Lack of evidence’ comes in the way of justice

Even though unwarranted hysterectomies continue to be rampant in the state, there is absolutely no action from the government, said Akhila Vasan, co-convenor of Karnataka Janaarogya Chaluvali (KJC), a public health movement in the state. “There is no law to pin down people who engage in medical malpractice,” she told DH.

The fate of four unwarranted mass hysterectomy cases in recent years in the state where the doctors were found guilty prima facie reinforces her words.

One of the cases involved four hospitals in Kalaburagi and thousands of Dalit and Lambani women from surrounding areas. The Karnataka Medical Council (KMC), in its order, though acknowledged that “the doctors have done excess number of hysterectomies compared to other surgeries without proper indication in their nursing home,” did not give a definitive opinion “in [the] absence of complete evidence in the form of records.” Ironically, not maintaining proper records, which activists believe was intentional, went in favour of the hospitals though Karnataka Private Medical Establishments (KPME) Act makes it mandatory for hospitals to maintain medical records.

Two committees were constituted to probe unwarranted hysterectomies in Kalaburagi — one by the State Department of Health and Family Welfare and another by the Women’s Commission. The reports submitted by both the committees were critical of many aspects such as conducting hysterectomies without proper indications, unprofessional diagnostic criteria and large-scale manipulation of records. The committees also concurred that most of the cases did not warrant a hysterectomy. “In spite of such strong evidence, the government and the KMC failed to take any action. The KMC didn’t even consider the Women’s Commission report while hearing the case,” said Akhila.

Turning a blind eye

“It’s been three years since we submitted the report to the government and we haven’t heard from them yet. How does one justify this? Such a passive attitude of the government towards the rights and health of the vulnerable makes offenders fearless,” grassroots activist K Neela, who headed the Women’s Commission’s committee, told DH. She said that the Women’s Commission had failed to follow it up with the government.

Dr N Rajkumar, deputy director, Family Welfare, ASHA & Maternal Health, Department of Health and Family Welfare, in an email response to DH mentioned that guidelines have been issued by the department to prevent undue hysterectomies.

Some of the crucial pointers in the guidelines include: For benign conditions of the uterus, alternatives to hysterectomy should be mandatorily offered, especially when the woman is less than 40 years. Two consultants should agree and document their consent for a hysterectomy if the woman is less than 40 years of age. The woman should be counselled thoroughly prior to planning the surgery. The practitioner should discuss the short-term and long-term implications of hysterectomy and document when counselling a woman for hysterectomy. The risk of premature ovarian failure (20%) in spite of conserving the ovaries should be clearly understood by the practitioner before subjecting the lady to hysterectomy.

“These guidelines are quite comprehensive. But we have not received any such circular,” Dr Sanjeev Kulkarni, a gynaecologist, said. “Doctors are well aware of these aspects. Ultimately it boils down to the gross misuse of knowledge, unethical practice, gender injustice and crass commercialisation.” he said.

The department also mentioned that the four hospitals in Kalaburagi have been closed after the incident came to light. But Dr M K Patil, district health officer, Kalaburagi, said that the licence of one of the hospitals was renewed recently. “The hospital has to send monthly reports for six months. It is not allowed to carry out hysterectomy during the period,” he told DH.

“Tales of misery and betrayal unfolded as we interviewed hundreds of women who had survived unwarranted hysterectomies. From meeting expenses to post-surgery complications, the women had endured it all,” Neela said. “The doctors who made these surgeries had not sent any of the specimens for histopathology. Isn’t it a clear indicator of their motive?” asked Neela. “We have on record doctors saying the patients forced them into conducting hysterectomies. Have hospitals become supermarkets?”

Transfer as punishment

In other cases, government medical officers who conducted the surgery without having a special qualification in that branch were suspended for a short period by the government, ‘warned’ by the KMC, and then transferred to some other place.

An enquiry committee member in one of these cases also mentioned how the members had to withstand intimidation tactics when they were probing the case. “The government is least bothered about the nature of the crime. It is a clear failure of the public healthcare system. The department has not developed a preventive mechanism which is the first step towards creating a safe world for vulnerable women,” Rupa Hassan, a grassroots activist from Hassan, told DH.

Rupa had moved public interest litigation on unwarranted hysterectomies at the Karnataka High Court three years back. It was recently dismissed by the court after a single hearing. “The court said that the issue doesn’t come under its ambit and professional bodies such as the KMC should work towards developing strict guidelines to stop the practice,” said Vivek, an advocate who presented the case in the court.

Karnataka’s situation mirrors that of many states in the country. “The case is moving at a snail’s pace,” said Dr Narendra Gupta, when asked about the public interest litigation moved by him in the Supreme Court. He conducted a fact-finding on hysterectomies in Rajasthan and collected documentation of similar practices in Bihar and Chhattisgarh before filing the petition. Several states, including Karnataka, are respondents in this case. “Karnataka hasn’t responded yet. Some states set up an enquiry committee and cancelled the licences of some practitioners in this regard. However, they soon set up a second committee and reinstated the licences. This is how governments are responding to a practice which is a gross violation of human rights,” he said.

The recent reports from Beed district in Maharashtra point to a horrifying trend where women had to undergo a hysterectomy as employers were not willing to hire women who menstruate. “This might be prevalent in other sectors that involve heavy manual labour. It calls for a detailed investigation,” Dr Narendra told DH.

“There are verbal reports of unwarranted hysterectomy from across the state. There are no continuous efforts to deal with this lurking evil,” said Vijayakumar S of KJC.Dr Annadani M Meti, president, Indian Medical Association-Karnataka (IMA), said that the association discourages unethical conduct and promotes best practices. “The entire medical fraternity is seen in a negative light because of the wrongdoings of some doctors. Some such reports may be wrong too. It is affecting the patient-doctor relationship. In the Kalaburagi incident, the local IMA unit might not have had sufficient evidence to believe that the doctors involved had committed the offence. Hence they might have supported them,” he told DH.