Web of Incentives in Fatal Indian Sterilizations

AMSENA, India — Rekha Nirmalkar already had children, and her family was poor. So when a local health worker offered her twice her husband’s daily wages to get sterilization surgery, she jumped at the chance.

“She was saying, ‘We have two kids, we don’t have any land, we are a happy family,’ ” said her grandmother, Bedan Bai.

But when Ms. Nirmalkar arrived at the “sterilization camp” on Saturday, she found a clinic streaked with cobwebs, its hallways covered by a film of dust, so long abandoned that trees were poking tendrils through the windows. Health workers were trying to fit as many patients as possible inside.

There were village “motivators,” who typically receive around 150 rupees, or $2.44, for each patient who shows up. There were government nurse-midwives expected to meet sterilization targets, lest their salaries be docked. And there was a surgeon who claimed in an interview to have once performed 300 tubal ligations in a single day, and who was entitled to a per-patient fee of 75 rupees in cash.

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From The Archives

Echoes of India's Painful Past

Associated Press

• During a two-year state of emergency that began in 1975, Prime Minister Indira Gandhi led an aggressive campaign of sterilization that was later deemed to be a violation of human rights.

  • In 1976, she announced that ''strong steps which may not be liked by all'' were under consideration. More than six million sterilizations, many forced, were performed. Violent protests ensued.
  • After Mrs. Gandhi's resounding election defeat in 1977, the new government shunned old measures and sterilizations declined to 188,000 in 1977 and 1978.

In the state of Chhattisgarh last weekend, all of these incentives converged to produce a disaster. Ms. Nirmalkar, the 22-year-old wife of a bricklayer and a mother of two young children, was one of 13 women who died after undergoing tubal ligations.

Various possible explanations have arisen for the cluster of deaths, including inadequate sterilization of instruments, bacteria in the operating room, and tainted medications that may have been given to the women, said Amar Agrawal, minister of health and family welfare in Chhattisgarh. People who took part in the sterilization drive described an assembly-line atmosphere with little regard to hygiene or patient comfort.

The surgeon who did Saturday’s operations, Dr. R. K. Gupta, was arrested late Wednesday on charges of culpable homicide. But the investigation had expanded beyond Dr. Gupta to include two camps overseen by another government surgeon on Monday, which have already resulted in the death of one woman and dozens of hospitalizations.

Lata Sinh, who has been an auxiliary nurse-midwife in Amsena for 21 years, numbly watched a group of mourners on Wednesday. Among those who had died, she said, were women she had treated since their wedding days; they called her Didi, or “big sister.” A tear slipped out of her eye as she spoke.

“We have lost face before these people,” she said. “What are we supposed to tell them?”

Ms. Sinh knows how the system works. For years, she has managed to meet her target of 60 sterilizations a year, knowing that if people in her position do not, “they will stop our salary.” Sterilization is the main form of birth control available to women in India, so finding patients has never been a problem.

Still, she was disturbed by the events on Saturday, when she assisted patients in the recovery room. Though Dr. Gupta has said he performed the 83 operations in six hours, Ms. Sinh said she believed he had done them in a shorter period, perhaps two hours, dipping his laparoscope in disinfectant for the length of time it took to slide one patient onto a mattress on the floor and replace her with another.

“It was too fast,” she said. “The sanitary conditions were not as good as they should be. But we are small people. What can we do?”

Dr. Gupta acknowledged that he had performed the operations quickly but said that state officials had determined the scale of the event. If “the administration had wanted, we could have done it better over two days,” he said in a telephone interview before his arrest on Wednesday. But he added that he was capable of performing many more procedures without putting women at risk.

“These were only 83 operations,” he said. “I have done 300 on a single day many years ago.”

Though India has safety standards for sterilization drives, recommending that a surgeon perform no more than 30 procedures a day, Dr. Gupta said it was nearly impossible to limit the number because recruiters generated such a crowd.

“I have no business telling the authorities that I will operate on a smaller number on a given day,” he said. “If I say I will limit operations to a number, there will be agitation against me. The villages will raise an agitation as to why aren’t we being operated on. They will say that we have come so far, so why not on the day that we have been called here?”

He said the women who underwent the procedures on Saturday had received injections of three drugs, including the sedative diazepam, and had been sent home with ciprofloxacin, an antibiotic, and ibuprofen, all provided and distributed by state health officials — the same ones who arranged virtually every other aspect of the drive. He said the ciprofloxacin and ibuprofen were “clearly spurious medicines.”

After finishing the operations, Dr. Gupta said, he received 6,225 rupees, or about $100, in cash from a local medical officer.

He spoke from a friend’s house, where he said he was hiding out of fear that “the mob will lynch and kill me.” He said he had little hope that the government inquiry would uncover the true cause of the illnesses.

“They are trying to save the system’s skin,” he said.

The view of Dr. Gupta was harsh in Amsena, where Ms. Nirmalkar’s family was gathered in a dark room of a mud-walled house. One of her sisters carried her 4-month-old son. Asked to find a picture of Ms. Nirmalkar, she disappeared for some time and returned with a tiny passport photo, her face wet with tears.

When asked about the surgery, Ms. Nirmalkar’s grandmother, Ms. Bai, spat out her answer and beat the ground in front of her with her hand with every phrase.

“They took her, they made a cut, they did the stitches, they put her outside, they set down the medicines, and then they say, ‘O.K., take her away,’ ” said Ms. Bai, a thin woman, blind in one eye, with silver rings on her toes.

The doctors, she said, had laid the women on mattresses and left medications on pieces of paper beside them. Ms. Nirmalkar took two pills at 8 p.m. on Saturday and began vomiting an hour later. She vomited for most of the next day, complained of chest pain and died in an ambulance around 6:30 p.m. on Monday.

Down the street, two government officials arrived with compensation checks for Roopchand Siras, whose wife, Phool Bai, also died on Monday. Mr. Siras, a barber with a gentle manner, posed obediently when the officials asked to photograph him with the checks: 200,000 rupees, or about $3,250, a huge sum in a region where many earn less than $5 for a day’s work. But when they were gone, he held the checks between two fingers, as if he did not know what to do with them.

“This money is useless to me,” he said. “Who is going to take care of my children?”

Mr. Siras seemed dazed. He said his wife had begun vomiting on Sunday but still seemed all right when he took her to the hospital Monday. He was perplexed when a doctor emerged to say “her heart was not pumping.”

“I told them, ‘It was such a small surgery; how can her heart be a problem?’ ” he said. The oldest of their three children, an 8-year-old boy, stood at his elbow, eyes downcast. Half an hour later, Mr. Siras said, the doctors told him she was dead.

“I saw her lying on the bed,” he said. “Her mouth was open and her eyes were closed. They tied up her toes, as per procedure. Then they sealed the body and put it in the freezer.”