Editor’s Note: In the last issue James Miller revealed how women were sterilized in industrial fashion in one sterilization factory in India. Now he will recount what happens at similar camps throughout the country. As we noted previously, population control is literally and figuratively dehumanizing. In India, thousands of women are being herded into mass production sterilization camps, where surgeons mutilate their reproductive organs in assembly line-fashion under unsanitary conditions, sometimes using bicycle pumps as medical instruments, and where mortality rates reach as high as 500 per 100,000 sterilizations. This article, the second of two parts, focuses on abuses in many such camps in India.
While no mortality occurred that day at the Kerala camp, and the researchers never checked for post-operative morbidity, there are numerous reports of wholesale complications in other Indian sterilization camps.
One report of “about 2,800” laparoscopic at rural population over a three-month period in early 1983 disclosed that two deaths had occurred, yielding an appalling mortality rate of 71 per 100,000 cases.”6 Despite the two deaths, and a host of other complications ranging from abdominal pain in 50% of those sterilized, “surgical emphysema,” drug reactions, “needling of the bowel” accompanied by the “passage of foul-smelling gas,” and various “misapplications of [the sterilizing] rings,” the report concluded that the procedure was “simple, safe [and] effective.”
Another report of 4,000 laparoscopic sterilizations performed in different rural camps, recorded 28 eases of “gastrointestinal symptoms,” including 10 cases in which “somehow or other” the bowel had been punctured and “air of the peritoneal cavity started coming out of the rectum.”7 Although there were no reported mortalities, this same report also disclosed 16 cases of “perforation of [the] small gut,” 25 cases of “surgical emphysema,” six cases of “chest infection,” eight of “acute pelvic inflammation,” and 40 of post-operative “wound infection.” Worst of all, from the perspective of those running the program, 20 patients who had been sterilized subsequently became pregnant!
One medical article, reviewing just “398 cases of laparoscopic sterilization done in camps at various family planning centers in Bihar [India],” reported two deaths in the series, which translates into an incredible mortality rate of 500 per 100,000 procedures!8
Nonetheless, the author referred to the number of deaths as being “only two,” and pronounced the sterilization procedure as one that could be ‘safely and widely used as [a] family limitation method in developing countries like India.”
Another article reviewing 11,692 laparoscopic sterilizations performed in various camps reported 274 cases of uterine perforations and 183 instances in which the sterilization ring was dropped into the peritoneal cavity, along with lesser numbers of’ bowel injuries, anesthesia reactions, pelvic inflammatory disease, and pelvic peritonitis, one of which caused a death.9 Altogether, there were two deaths in the series, which yielded a mortality rate of “only 26 per 100,000 cases” as some 4,000 cases couldn’t be followed up.
‘Where did I put that rubber band?’
In regards to the dropped rings, a relatively common occurrence during female sterilizations via tube banding, there was no indication in this (or any other report) that the rings were ever retrieved and fished out. This is not merely an academic problem as one tell-tale article in the prestigious British medical journal Lancet disclosed: In a review of conditions at some of India’s laparoscopic sterilization camps, 92 cases were reported in which “silicon rubber bands were dropped accidentally into the peritoneal cavity; retrieval was possible in 48, while in the remaining 44 [47 %] the bands were left in the peritoneal cavity and forgotten.”10
Data collected from 2,009 women who underwent sterilization over a three-year period at small rural camps in Gujarat, India, revealed two deaths had occurred, for a mortality rate of 100 deaths per 100,000 sterilizations.11 Even omitting one death from tetanus, which may have resulted from an abortion 15 days before the sterilization, the death rate was still high at 50 per 100,000 cases. In this series of cases, the mean length of clinic stay was seven nights, a unique situation which afforded more and better post-operative care than that available in the overwhelming majority of camps where those sterilized were discharged within hours, usually with little or no post-operative follow up. Despite the more favorable conditions, there were the common sterilization complications: bladder injuries, spinal shock, abdominal pain, anesthesia reactions, incision infections, burning urination, etc.
Another report from Gujarat, India detailed 22 deaths among 106,500 women who underwent camp laparoscopic sterilizations over a two-year period.12 (There were three additional post-operative deaths that also may have been caused by the sterilizations.) Five of the deaths occurred “on [the] operating table”: one from an air embolism, two from anesthesia sensitivity, and two from cardiac arrest.
There were nine deaths from peritonitis within two to eight days post-operation, including the only four cases reported of bowel injury. (It would seem doubtful that the only bowel injury eases all resulted in death; other undetected cases of such injury probably occurred with unknown outcome.) The large number of deaths was attributed to the “excessive numbers” of procedures performed daily, especially in the laparoscopic sterilization camps.
Air pumps and errors
The all-too-common primitive conditions at the camps were reported: air pumps for pneumo-peritoneum, bricks to elevate the operating tables, gowns changed only at rest breaks, the lack of an anesthetist as part of the surgical team, the inadequate “sterilization” of instruments, the non-monitoring of patients’ pulse and blood pressure during surgery, and the ignoring of regulations concerning the number of sterilizations to be perfumed per surgical team per day.
The report noted that the “government sponsored campaign to meet [quota] targets set for each state by end of the fiscal year…[led to] a uniformly high risk of deaths in camps [during the] campaign season and a markedly reduced risk in the balance of the year” Another factor contributing to “unsatisfactory outcomes” was the “speedy completion of the sterilizations by the surgical teams who are anxious to return to their home base.”
One general surgeon described how he was “taken aghast” when he was twice called out to rescue an inexperienced doctor who on one occasion had opened “the urinary bladder in which he was searching for the fallopian tubes,” while the second time he had opened a loop of bowel in his search for the tubes!”13
Although one could go on and on in like vein, perhaps the best overall summation of what is really going on in India‘s sterilization camps was the devastating reply of two Indian physicians14 to a glowing Lancet editorial15 endorsing the camps.
The doctors noted that in some cases “a bicycle pump [was] being used to create a pneumoperitoneum” for laparoscopic sterilization — a grim symbol of how medical standards have been lowered in the zeal to meet national sterilization targets.”
They wrote of laparoscopes being “re-used after a quick wash,” of ordinary, non-sterile ‘“air (not carbon dioxide)” being used to create a pneumoperitoneum, of the “high incidence of uterine perforations,” of complications which “are rife.” and a “ease fatality rate as high as 70 per 100,000.” [See above] They condemned the system in which “local authorities are under pressure to achieve set targets and the doctors are paid on a case basis,” while “inducements (cash or otherwise) are routinely sanctioned to candidates for sterilization and the motivator is similarly rewarded.”
Under such conditions, the doctors declared, “informed consent is certainly not obtained.” The coercive role of the “motivators” was clearly evident in one report that lamented the tact that “40–45% of [the] couples [in a particular study] considered eligible for family limitation, refused to accept sterilization despite (the] intensive efforts by the staff to motivate them into such acceptance.”16
Finally, the “follow-up of laparoscopic tubal ligation in India is poor so the true incidence of failures and late complications is unknown.” The physicians noted that “available data suggest a failure rate of 1% and ectopic pregnancies account for 15–60% of these.” With sterilizations running at four to five million per year, some 4000 to 5000 ectopic pregnancies can be expected. Since most of these would arise in “rural areas where blood transfusion and emergency services are inadequate, the resulting deaths would have to be set against the deaths from unwanted pregnancies that were avoided.”
Despite the many horrors of the sterilization camps, population control advocates (many from the United States, including USAID, which provided most of the laparoscopes and heavily funded the enterprise),”17 waxed lyrically over the alleged success of India’s program, literally praising it to the skies. Two Bombay surgeons, for instance, endorsed laparoscopic sterilization as a method on which “the women of today can fly away on the wings of this new technology.”18
Except as otherwise noted, all information and quotations in this report were taken from: M. Ramanathan, et al, “Quality of care in Laparoscopic Sterilisation Camps: Observations from Kerala, India,” Reproductive Health Matters, No. 6, November 1995, 84–93, at 85. The camp was conducted at a rural hospital in the Palakkad district in October 1994. Endnote numbering is continued from Part I, published last month.
6 Sinha, “Laparoscopic sterilization vis-à-vis rural population,” Journal of Obstetrics and Gynecology of India, June 1985, V. 35, No.3, 559.
7 Prasad and Jha, “An experience of laparoscopy sterilization,” Journal of Obstetrics and Gynaecology of India, April 1985, V. 35, No. 2, 346–49, at 348.
8 Rani, “Laparoscopic tubal sterilisation and its effect, ”Journal of the Indian Medical Association, June 1986, V. 84, No.6, 180–2.
9 Sud and Malan, “Analysis of 11,692 laparoscopic sterilizations in Himachal Pradesh,” Journal of Obstetrics and Gynaecology of India, August 1985, V. 35, No. 4, 721–5.
10 Sheth et al, “Laparoscopic female sterilization camps,” Lancet, 17 December 1988, 1415–6, at 1415.
11 Bhatt et al, “Female sterilization in small camp settings in rural India,” Studies in Family Planning, Feb.-March 1978, V. 9, No. 2–3, 39–43.
12 Bhatt, “Camp laparoscopic sterilization deaths in Gujarat State, India, 1978–1980,” Asia-Oceania Journal of Obstetrics and Gynaecology, V.17, No. 4, 1991, 297–301.
13 Tongaonkar, “Complications of surgery in rural India — a personal review,” Indian Journal of Surgery, December 1987, V. 45 (supp.): 25–6.
14 Kabra and Narayanan, “Sterilisation camps in India,” Lancet, 18 November 1989, V. 335, 224–5.
15 Editorial, “Meeting the need for female sterilisation,” Lancet, 18 November 1989, V. 334, 1189–90.
16 Maru et al, “Non-acceptors of female sterilisation the hard core?,” Journal of Obstetrics and Gynaecology of India, April 1985, V. 35, No. 2 t343.
17 Ravenholt et al, “The use of surgical laparoscopy for fertility management overseas,” in Phillip, ed. Endoscopy in gynecology, (Downey, CA: 1978), 213–225. The US Agency for International Development (USAID) has been involved in laparoscopic sterilization from the very beginning, including research to develop better laparoscopes and the development of the Hulka clip and the Yoon ring methods of tube banding, USAID sponsored the training of several thousand foreign surgeons (mostly at John Hopkins University) in the laparoscopic technique, and distributed (by the end of 1977 — the figure is certainly far higher today), more than 10,000 minilaparotomy kits and laparoscopes in scores of developing countries. Through the years, USAID has given several hundred million dollars to the Association for the Voluntary Surgical Sterilization (AVSC) to provide sterilizations around the world. Collectively, similar sums of money were given to the International Fertility Research Program, International Planned Parenthood Federation, Pathfinder Fund, and Family Health International, among others, for their sterilization programs.
18 Virkud and Purandare, “Laparoscopic sterilisation with silastic bands: difficulties and complications,” Journal of Obstetrics and Gynaecology of India, October 1987, V. 37, No. 5, 713.