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The uterus snatchers of Andhra
A group of Lambada tribal women sit huddled in Kannaram village of Medak district clutching prescriptions and plastic bags with multi-coloured pills. They pop these, they say, for relief from the various aches and pains they have been battling ever since they underwent the "operation".
Most women in this village of 125 households have had a hysterectomy - even those as young as 20, some even younger and in their teens - for complaints as routine and as easily curable as abdominal pain or white discharge.
Doctors in the rural pockets of the state, however, do not prescribe antibiotics to these hapless women. They prescribe complete removal of the uterus and ovaries, cutting short their reproductive lives and snapping their estrogen supply.
And it is not just the women of Kannaram who have hit an early menopause in Andhra Pradesh. A disturbing number of women in rural pockets from across the state have gone under the knife, surrendered their savings and losing their uteruses and ovaries to quacks who market hysterectomies as aggressively as salesmen sell water purifiers in cities.
These victims of rampant medical malpractice and government apathy now make for a startling statistic of the National Family Health Survey - the number of young menopausal women is the highest in Andhra Pradesh, standing at a staggering 31. 4 per cent.
But what do doctors gain from the cruelty heaped on the women? Money. A hysterectomy can fetch anywhere between Rs 10, 000 and Rs 50, 000, depending on the facilities they showcase. On the other hand, treating a routine gynaecological problem with pills wouldn't earn them a fraction of that.
The modus operandi used in the hysterectomy racket is simple. A woman, often illiterate and unaware, lands up at a private rural clinic complaining of, say, excessive bleeding or leucorrhoea (vaginal discharge) and she is prescribed a hysterectomy as the only way out. A senior doctor who conducts medical camps in rural parts of Andhra Pradesh says, "My routine question to women in villages now is, 'Do you have a uterus?'" The women are told that they would die if they don't stem the discharge or bleeding with a surgical process.
Manjula, one of the unfortunate lot, is not quite sure why she had to have her womb scalped. And it's affected her in more ways than one. At 28, she can pass off for a 40-year-old;she tires easily and often feels older than even her 45-year-old mother. Having undergone hysterectomy five years ago, the daily wage worker says she is unable to toil on the farms anymore. She spends on medicines the little that she earns. "I have been spending Rs 500 a month on medicines and I visit the doctor every week. He tells me to eat healthy food and rest, but can I do that?" she asks, knowing the answer only too well.
An ultrasound scan of the abdominal and pelvic area in the presence of this reporter confirmed the women's claim that they had undergone complete hysterectomy. Gynaecologists, at least the ones with ethics, maintain that total hysterectomy is rarely warranted these days. Whenever hysterectomy seems inevitable, an effort is made to salvage the healthy part of the ovary so that the woman's body continues to get some supply of estrogen, they add.
Clearly, such caution finds no place in the hysterectomy market of Andhra Pradesh, where scores of women undergo the procedure in makeshift operation theatres in roadside clinics. Some of these are two-room tenements, with one part serving as a clinic and the other as OT. Interactions with these women and studies on the subject have established that the procedures are more often than not performed by registered medical practitioners (RMPs) or city-based general surgeons who zip over to small town clinics over weekends. Village quacks provide the necessary reference work.
While this medical malpractice was highlighted five years ago by the Centre for Action Research and People's Development (CARPED), an NGO that works mainly in Medak district, a recent state-wide study undertaken by Andhra Pradesh Mahila Samatha Society (APMSS) shows most women who have undergone the procedure are suffering from health problems ranging from fatigue to osteoporosis.
The study, which was conducted across 225 villages in five districts, concluded that the issue was not restricted to a particular area but spread across the state. "In none of the cases did the women undergo a thorough medical check-up before the operation and there was no counselling on the hormonal imbalances leading to early menopause and other related health conditions, " the study stated. The reason why women opted for the procedure ranged from excessive bleeding to irregular menstrual cycle.
What has shocked health experts is this rampant practice remaining unnoticed. State health officials confirm that hysterectomies in AP are the highest in the country given the number of women involved, and they also admit that the government is insensitive to the plight of these women. Sources in the ministry of health note how hysterectomy is a growing racket involving quacks, private hospitals and RMPs.
Dr M Prakasamma of the Academy for Nursing Studies fishes out her 2002 study, which found that "more and more women of younger age group are observed to be undergoing hysterectomy".
Eight years later, not only has the government remained seemingly oblivious to this health tragedy, it has also inadvertently pushed the trend further. The state health insurance scheme, Arogyasri, is being used to fund these operations. This scheme pays for the private treatment of those below the poverty line.
In fact, in 2008-2009 alone, around 11, 000 women were hysterectomised and each procedure was funded by the state government. Sources say that in many of these cases, the age of the woman was between 25 and 35. Alleging that nursing homes in the districts were even fudging the date of birth, they say in at least 50 per cent of cases the woman was less than 40 years old.
Some health officials are now demanding that hysterectomies be scrapped from the list of procedures covered under Arogyasri, but their voices are not aggressive or persuasive enough. Arogyasri, anyway, is a recent reason for the rise in such cases. Veena Shatrugna, former deputy director of the National Institute of Nutrition, points out another unnerving factor driving the trend: sterilisations.
What happens is that sterilistations are done after the birth of the last child when a woman is in a pre-menopausal stage. Family planning procedures are often carried out in government camps (to meet targets) and women quite commonly develop infections that need treatment. Unscrupulous doctors are quick to suggest a completely unnecessary hysterectomy.
Shatrugna's analysis fits in with the facts and figures. The APMSS study on hysterectomy found that 82 per cent of the women who had undergone a hysterectomy had had a family planning operation prior to it.
Doctors believe that rural women develop infections because of poor menstrual hygiene. "But you do not remove the uterus for that, " says Dr A Vani, who heads the primary healthcare centre in Kannaram village. She admits that women prefer visiting RMPs to her centre because they see hysterectomy as a way out of dealing with periods.
Activists working on the issue squarely blame the government for its apathy. "We have been highlighting the issue since 2005 and have met health officials too. But nothing has been done about it, " says M Subhash Chandra, director, CARPED.
Dr PV Ramesh, principal secretary, health, agrees that the "the issue is serious" and that the government is looking at launching a campaign to raise awareness among the masses. Until that happens, the number of menopausal women will keep piling up in Andhra Pradesh. And till then the stories of helpless rage will keep pouring in.
"I sold my one-acre plot and even my gold jewellery for my medication. But my abdomen still hurts, " says Bhuli, who hit menopause at 30 when she underwent hysterectomy.
While others calculate the thousands they have lost on treatment, 25-year-old Maruni broods over the other incalculable loss. Mother of one, she underwent a hysterectomy at 22. "I couldn't work on the fields anymore. So I was of no use to my husband who left me for another woman. And then I lost my only son, " she says, even as the RMP she consulted continues to flourish in the village.
WHEN IT ALL BEGAN...
Healthcare experts say the hysterectomy racket has its roots in the privatisation boom in the medical sector back in the mid- '80s. Till star politician NT Rama Rao came to power, healthcare was state-driven in Andhra Pradesh.
"It is around this time that the practice of unwanted hysterectomies first started showing up in the state, " notes Veena Shatrugna, former deputy director of National Institute of Nutrition. She says the number of such procedures have steadily risen over the last two decades.
In government hospitals, poor patients are never randomly advised hysterectomies because government doctors stand to gain nothing by doing so. "But private hospitals are not accountable to anyone and people were willing to pay for the procedure, " she says.
Private doctors have also managed to wean away the queues from public hospitals with promises of quicker and better care.
Soon, these doctors, both MBBS and RMPs, became the points of contact for private nursing homes and allegedly started getting a 30 per cent cut (from the cost of treatment) for each case referred. Worse, many of them started performing the procedure themselves.
"People can also be so naïve. They believe that once the uterus is removed all their troubles would end, " says Dr Choranur Ambuja, secretary (Hyderabad chapter), Indian Menopause Society.
Health activists now hope to spread greater awareness about medical malpractices in the villages. "The only way to curb the practice is by improving awareness. And in the absence of government will, only responsible doctors can do it, " says an activist.
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