Indu Paswan was just 22 when the doctor told her that her uterus needed to be removed. After giving birth to her third child, the resident of Rewari village in Samastipur district of Bihar was suffering from piles, a known condition after normal child birth.

In November 2011, Paswan went to Samastipur city escorted by her mother-in-law, Champa Devi. At her first meeting with the doctor at Bhawani Nursing home, she was told that she needed to undergo surgery.

“The doctor said that the surgery for piles may cause an injury to the bachdani (uterus),” said Paswan, “so, it is important to remove it.”

The nursing home was empanelled with the Rashtriya Swasthya Bima Yojana, the central government health insurance scheme, which, at that time, gave coverage of up to Rs 30,000 to people below the poverty line. Under the scheme, 10-bed hospitals with qualified doctors and basic facilities were empanelled to treat patients holding the Rashtriya Swasthya Bima Yojana card.

In the budget earlier this year, the Centre changed the scheme’s name to the National Health Protection Scheme, and increased the coverage to Rs 1 lakh per family.

Paswan is one of the 702 women that the Bihar government will compensate for undergoing an unnecessary hysterectomy under the Central insurance scheme. These women are poor, survive on a daily wage, and mostly belong to landless families.

Doctors in Bihar have been accused of milking the scheme by conducting unnecessary hysterectomies on women, some even as young as 22. Each surgery would bring them at least Rs 10,000 from the government.

A total of 33 First Information Reports have been filed in connection with the scam of which 13 are against doctors. However, four years after the scam was uncovered, most of the doctors involved have still not been punished. Though a handful of doctors were booked by the police, their cases have still not been heard. The doctors’ regulatory body, the Medical Council of India, has not taken any steps to cancel their registration either.

Never the first option

Hysterectomies are associated with higher risk of cardiovascular disease, stroke, urinary incontinence, and problems with sexual function, and are usually not the first option.

“There are many indications for hysterectomy,” said Dr Yogesh Jain from the non-profit, Jan Swasthya Sahyog. “It can be done due to fibroids, or cancer, or dysfunctional bleeding. But it should not be the first line of treatment.”

The scam emerged in 2011 when Kundan Kumar, who was then the district magistrate in Samastipur, organised special medical camps to re-examine women who had undergone hysterectomies under the scheme after the local administration received complaints about unnecessary surgeries.

In 2012, Bihar Chief Minister Nitish Kumar ordered all district magistrates and civil surgeons to check the running of the Central insurance scheme.

A thorough investigation by district authorities into each case revealed that the majority of women who underwent unnecessary surgeries were from Samastipur (316 women) and Gopalganj (318 women) districts. Some cases were also found in Siwan, Sheikpura, Madhubani and Nawada.

In Samastipur, 267 women whose uteruses were removed unnecessarily were under the age of 40.

When the scam first emerged in the media, the Bihar State Human Rights Commission asked the state to file a detailed report seeking the total number of unwarranted hysterectomies performed, and the details of the affected women.

Calling the act of performing such surgeries “barbaric”, the commission spoke of the physical and psychological shock a woman suffered with the loss of her womb.

On April 28, the Bihar State Human Rights Commission ordered that the 702 women identified as having had unnecessary hysterectomies under the central scheme be compensated. Women under 40 years would be awarded Rs 2.5 lakh and those over 40 years Rs 1.5 lakh.

The state government has promised that the compensation will be disbursed by November 3, the next date of hearing.

However, activists point out that mere compensation will not prevent another scam.

Health issues

Why did Indu Paswan agree to undergo a hysterectomy at such a young age?

The young woman did not think it was her call to make. “My guardian [referring to her mother-in-law who escorted her] agreed,” she said. “My husband also said get the uterus removed.” Paswan spent eight days in hospital to recover from the surgery.

Paswan, who spoke to in the presence of her mother-in-law, was not keen on talking about any problems that she suffered following the surgery. Only after much prodding, did she admit that the operation had left her “weak”. She was almost always in pain and not able to take up any work outside home.

Her inability to contribute to the work in the household seemed to be a cause of tension.

“She is always lying down, and says she is not able to get up,” said Champa Devi, her mother-in-law. “She faints often.”

In the nearby village of Chaita, 30-year-old Soniya Devi Das also seemed to suffer from similar health problems. When went to her home, she was away, visiting her parents.

“She is always sick,” said Anila Devi, Das’s sister-in-law. “She says her stomach hurts. Her blood pressure falls and she keeps fainting. Who will take care of her?”

Her mother-in-law also complained that Das did not do work much at home.

Das suffered from stomach ache after her second child was born. This compelled her to go for treatment in Samastipur in October 2012. At that time, she was 25- or 26-years-old.

At Krishna Hospital in the city, she said that Dr Sardar Thakur told her that she needed to surgically remove her uterus because there was a swelling in it. Das underwent the surgery immediately, and was kept in hospital for eight days.

“Mar mar ke jeetein hai (I can barely survive),” said Das, on the phone. “Last week, the doctor gave me two bottles of saline.”

Hospital lane

Nearly four years after the scam was exposed, all the accused doctors are flourishing.

A stone’s throw away from the District Civil Hospital in Samastipur city is hospital lane. Nursing homes stand tall next to chemist shops and one-room clinics run by quacks. The lane spills over with patients from across the district.

Many of the hospitals that were empanelled under the Rashtriya Swasthya Bima Yojana had set up hospitals in this lane, and in the adjoining, Kashipur lane. They are no longer associated with the scheme, but still operate.

One of the hospitals is the two-storey high Mishra Nursing Home. It had no doctor on call when this reporter visited it. There were not even nurses in the ward where some patients were recuperating.

The doctor who runs this hospital, Dr Rajesh Kumar Mishra, was booked in connection with the scam in 2014 but is out on bail.

A person who claimed he was Dr Mishra’s aide but refused to identify himself, said the doctor was conducting surgeries.

“You understand that the doctor conducts surgeries all evening,” said the aide, who was casually filling bullets into a gun as we spoke. “He cannot possibly come to meet anyone when the patient has been opened up, can he?”

Outside Mishra Nursing Home, the doctor's aide wields a gun. (Photo credit: Menaka Rao).

Lalmaniji Prasad from Life Line Hospital, was more forthcoming. His brother, Vishnu Prasad, the proprietor of the hospital, was booked in connection with the scam. He had to seek anticipatory bail from the Bihar High Court.

“The doctors in our hospitals gave the opinion to conduct the surgeries, not us,” said Prasad. “We just run the place.”

He then asked if this reporter had any medical knowledge.

“Let me explain,” said Prasad. “These people get married when they are just 16 years old. They are not literate. They are so poor. They have so many children. When they get periods, they use dirty cloth. Can you imagine what their health will be like? Obviously their uteruses will be infected.”

He said that all the patients Life Line Hospital operated upon needed the surgery and were in a “serious” (critical) state. “If [we go] according to government rules, these patients will die,” he said, throwing his hands in the air.

Life Line Hospital runs despite being under the scanner for conducting illegal hysterectomies. (Photo credit: Menaka Rao).

Another doctor, who was implicated in this scandal, is Dr Mahesh Thakur, who runs Krishna Hospital. He questioned the credentials of those who led the enquiry into the fake hysterectomies.

“The enquiry was not done by qualified people,” said Dr Thakur. “My opinion can only be challenged by a gynaecologist.”

He reiterated what Prasad said about poor hygiene among women in the state. “Uterus infection rate is very high among these women,” said Dr Thakur. “My treatment was conservative…You tell me, why would I operate upon a 23-year-old patient? You think I do not have enough patients?”

He claimed that he was so busy, he was conducting surgeries till 11 pm. Relatives of his patients watched television in the waiting area.

Krishna Hospital has a fancy waiting area with a television for its patients and their relatives. (Photo credit: Menaka Rao).

Dr DS Singh, the doctor who operated upon Indu Paswan, was exonerated in the state enquiry. He runs Bhawani Nursing Home. Dr Singh claimed that he is the “whole and sole” of the nursing home. He is a medical graduate, and does not have a further qualification for surgery or gynaecology.

Defending himself, Dr Singh said: “Under MBBS [the undergraduate medical degree awarded to medical students], we can conduct surgeries. Anyway, RSBY [Rashtriya Swasthya Bima Yojana] did not have any restrictions for MBBS doctors conducting surgeries.”

Devika Biswas, a health rights’ activist from Bihar and Jharkhand, who headed a fact-finding committee to look into these cases in 2012, said that a similar scam could take place again. “Many quacks were also empanelled in RSBY [Rashtriya Swasthya Bima Yojana] then,” said Biswas. “We need more safeguards under the scheme. Or else there is nothing to prevent a similar scam from happening again.”

Rashtriya Swasthya Bima Yojana was run by the state labour department until recently. Last year, it was moved to the Health Ministry. “We could not supervise the empanelment until recently,” said additional civil surgeon, Dr Ghanshyam Jha.

Accused doctors still thriving

Except for Samastipur, the enquiry against erring doctors in other districts was not conducted till recently. Some of the accused like Vishnu Prasad and Dr Mishra were booked in 2014, and were released on anticipatory bail. Despite running a huge practice in the city, Dr Thakur was shown as “absconding” until March.

In Gopalganj, Sheikhpura, and a few other districts, the district authorities moved after the State Human Rights Commission sought an action-taken report from the state on April 28. The First Information Reports in these districts were filed a few days before that hearing. Some districts have only filed legal notices against the hospitals and are still seeking replies.

Officer on Special Duty for the state health department, Shankar Prasad, said: “We have to clear some queries by the home department. They have asked us to file a report on the action taken against the doctors and the hospitals.”

The Medical Council of India, which was also informed, has not taken any action either.

“There is an ongoing enquiry, which is being looked at by the Ethics Committee,” said Dr Shahjanand Prasad Singh, the president of the Bihar Medical Council.

Singh expressed doubts about the police investigation. “The age of these patients is doubtful,” said Singh. “Besides why would these doctors conduct these surgeries on women who are so young? The doctor works so hard to get credibility. Why would he lose all that for such less margins (profits)?”

However, he added, cautiously, that the organisation cannot speak against the State Human Rights Commission.

Informed consent?

The five women whom spoke to, all of whom are slated to receive compensation for the unnecessary hysterectomies, admitted that they had all consented to undergo the surgery.

However, the surgeries are problematic regardless of whether they led to health complications. Several women underwent the surgeries without possibly understanding the full implications and the risks involved.

Some were surprised to hear that their surgeries were suspect. “I feel better after the surgery. Dard theek hai,” said Munni Devi Das from the same village.

Munni Devi Das has no complaints after her hysterectomy. But she is happy that she will receive compensation. (Photo credit: Menaka Rao).

During the course of the conversation with these women, others would gather and speak of their experiences. Many of them said they had undergone hysterectomies, and would talk about how it was not a big deal.

Sita Devi Das was 33 when she underwent a hysterectomy four years ago. She lives in Barbatta village in Sarairanjan block in Samastipur district.

“I did not have any problem after the surgery,” she said. “They told us before removing the uterus.”

Sita Devi Das has six children. She was selling bangles in a nearby village when went to her house. She spoke to this reporter over the phone. The family owns no land, her husband is a daily wage labourer, and her children do not go to school.

In Devika Biswas’s report too, nine out of 10 women said that they had no complaints.

“Maybe they felt that they have been rid of their reproductive functions,” sai Biswas. “Freedom from periods maybe. It is difficult to say.”

However, health rights activists argue that the question of informed choice and consent is suspect in these cases. “Women appear to opt for it, but they do not have the information,” said Jasodhara Dasgupta, from Sahayog, a women’s rights organisation in Lucknow.

She added: “It is the question of informed consent.”

Agreed, Sulakshana Nandi, from Jan Swasthya Abhiyaan, in Chhattisgarh. “We do not question doctors about other options for the surgery,” she said. “The relationship is unequal. If they are sick after the surgery too, they may not understand or link it to the surgery.”

For instance, Tetari Devi Das from Barbatta village in Sarairanjan block of Samastipur, was 35 when her uterus was removed in a hospital whose name she did not remember. She was told that she suffered from hernia and had to undergo surgery for the hernia, as well as one to remove her uterus. She had given birth to five children already.

Ever since her hysterectomy, Tetari Devi takes injections every two weeks for her pain. (Photo credit: Menaka Rao).

“I paid Rs 5,000 for one surgery, despite having the insurance card. The doctor did not give me any papers,” said Tetari Devi.

The surgery has left her at the mercy of quacks in the area. “I feel sick all the time,” she said. “My stomach hurts, and I find it difficult to walk.” Every two or three weeks she gets injections that cost Rs 200 from a local quack to help her with the pain.

Nandi goes back to the question of medical ethics.

“The question is whether the treatment was rational or irrational,” said Nandi. “Irrational treatment is anyway problematic, whether there was consent or not.”

While the women do not really understand why they are being compensated, they welcome it.

Sita Devi Das, who had no complaints against anyone, just wanted to know one thing: “When will the state authorities come home? I need to stay home on that day [to receive the compensation].”