IJME 5th National Bioethics Conference, Bangalore

5th_nbc_2014

NBC

Indian Journal of Medical Ethics (IJME) organized 5th National Bioethics Conference in Bangalore. The event was co-hosted and organized by SOCHARA, St. John’s National Academy of Health Sciences, Society for Community Health Awareness, Research and Action, and The Forum for Medical Ethics Society (FMES), Mumbai.

Theme of 5th National Bioethics Conference:

After much deliberation with individuals and organizations in India and abroad, it was identified that the subject of corruption in health care and research practices was an important issue and should be the theme of fifth national bioethics conference. In accordance with the theme of the event, Sama presented 5 papers in the parallel sessions of the event and 2 plenaries.

Presentations:

The event commenced on Wedneday, 10th December 2014 with pre-conference colloquium. During this event Sama spoke on the theme of “Ethical Perspective on Gender in Health”. On Thursday, 11th December 2014, 2 papers were presented on the theme “Ethics and Reproductive Health”. The first paper was presented by Ms. Sarojini NB titled “Dying to give birth: The case of Yuma Sherpa and the Unethical Medical Terrain of Assisted Reproductive Technologies”. On the issues of corruption in health care and research Ms. Sarojini NB and Mr. Vaibhao presented a paper on “Corruption in the Practices of Central Drugs Standard Control Organization (CDSCO)”: Findings from 59th Parliamentary Standing Committee Report on Functioning of CODSCO (May 2012).

On Friday, 12th December 2014, plenary was addressed by Ms. N.B. Sarojini on “Integrity in access to public health services with a specific focus on gender and reproductive health”. Sama also presented two papers on ‘Ethics and Gender’. The first paper was presented by Ms. Deepa V. and Ms. Nazia Hassan on “Interrogating Health Care Response to Gender Based violence: Implication for Health Care Integrity”. Second paper was presented by Ms. Sunita Chowdhury and Ms. Simran Sawhney on “Enhancing Adolescent Sexual and Reproductive Health and Rights (SRHR) through Health Systems Engagement”.

On the last day of the event, Saturday 13th December 2014, Ms. Sarojini NB presented a testimony on the unethical practices in clinical trials particularly in the context of HPV vaccines.

For details on the programmes, please visit the following website:

http://5thnbc2014.in/node/30

“Camp of Wrongs: The Mourning Afterwards” – A fact finding report on Sterilisation deaths in Bilaspur by Sama Resource Group for Women and Health, Jan Swasthya Abhiyan and National Alliance for Maternal Health and Human Rights

Camp of Wrongs

The recent  tragic deaths of the 13 women, all in their 20s or 30s and the critical condition of the 70 other women, following procedures of laparoscopic sterilisation in Bilaspur district, Chhattisgarh,  have flagged clear violations of ethical and quality norms in the health care system.

Following these appalling incidents, a team of women’s and health rights activists from Sama, Jan Swasthya Abhiyan and National Alliance for Maternal Health and Human Rights from Delhi and Chhattisgarh initiated a fact finding towards exploring and unravelling the gross violations that had taken place.
​The fact finding teammet and interacted with families of women who had lost their lives, as well as with families of those who were in hospitals following complications. During the fact finding, government officials, doctors, Mitanins and Mitanin Trainers were also met with.
The findings based on these interactions and observations, the emerging issues as well as recommendations have been documented in a report titled: Camp of Wrongs.

Following is the link to the report

Camp of Wrongs – The Mourning Afterwards

Sama Zubaan’s latest release “Reconfiguring Reproduction: Feminist Health Perspectives on Assisted Reproductive Technologies”

Reconfiguring Reproduction

Book Title: “Reconfiguring Reproduction: Feminist Health Perspectives on Assisted Reproductive Technologies”
ISBN: 9789383074525
Edited By: Sarojini N and Vrinda Marwah
Authors: Betsy Hartmann, Sarah Sexton, Renate Klein, Sarojini N, Hedva Eyal, Marcy Darnovsky, Judy Norsigian, Shree Mulay, Madeline Boscoe, Jyotsna Agnihotri Gupta, Young-Gyung Paik, Vrinda Marwah, Deepa Venkatachalam, Preeti Nayak, Tarang Mahajan and Anjali Shenoi.
Published by: Sama and Zubaan
Price: Rs. 595/ US $ 35.00

Assisted reproduction is a complex phenomenon, located at the intersection of patriarchy, medicalization and commerce. These technologies create both challenges and opportunities, and responses to them have sought to balance questions of ethics, rights and politics. The essays in this volume map the journey of ARTs in different countries, examining the global industry and the challenges it poses in the context of markets, and look at regulatory framework in diverse setting. Together they bring a feminist lens to the examination of the now-established ART industry. Sama’s long standing work provides a special focus on India: the spread and feature of the industry, the gendered nature of the burden and treatment of infertility, the destabilization of the family as we know it, and feminist debates around surrogacy that reassess ideas of agency and commodification.

Consultation organized by Sama on ‘strengthening response to sexual violence by the health sector’ – 22nd November 2014, Delhi

On 22nd November 2014, Sama organized a consultation on ‘strengthening response to sexual violence by the health sector’ in Delhi. There were 37 participants, which included Doctors from Government hospitals, representatives from 181 helpline, DCW helpline and other organizations. The resource persons for the event were; Dr. Renu Arora, Associate professor and consultant at Department of Obstetrics & Gynaecology, VMMC & Safdarjung Hospital, New Delhi. Adv. Seema Mishra, Lawyer working on human rights issues, including issues of gender based violence. Dr Jagadeesh Reddy, Forensic Medicine expert, Bengaluru, and member of the drafting committee of the MoHFW protocols and guidelines. Ms Shubra Mendiratta, co-ordinator of Rape Crisis Cell, Delhi Commission for Women. The last session was addressed by Ms. Muneera and Ms. Zarina on the 181 helpline services.

Background:

Sama has a long standing commitment in the area of gender based violence and has always maintained its position in considering gender based violence as a public health issue. In its attempt to strengthen the linkages between gender based violence and healthcare system, Sama carried out an assessment of public hospitals in Delhi to understand their readiness to respond to the survivors of sexual violence and domestic violence. The study aimed towards consolidating knowledge about the existing practices, challenges and looking at ways of strengthening inter-linkages and responses in the future. Based on the needs and outcomes of the assessment and Sama’s past engagement on the issue this consultation was organised.

Findings of this study are based on Interviews with health care providers from 22 hospitals in and around Delhi. Some of the key findings that emerged from this study were discussed in detail with the health care providers during the consultation. The consultation also deliberated on building linkages with other service providers; on legal provisions with regard to sexual violence and domestic violence.

Consultation:

The first session commenced with welcome address and round of introductions. The second session focused on the relevance and overview of legal framework, Ministry of Health and Family Welfare (MoHFW) protocols and guidelines, the changes in laws pertaining to sexual violence and its implication on healthcare response. The session commenced with the presentation by Sama’s representatives who briefly shared the key findings and emerging concerns from the assessment done by Sama with 22 public hospitals in Delhi. The next presentation was given by Dr. Renu Arora who shared experiences of Safdarjung Hospital’s response to survivors of sexual violence. Advocate Seema Mishra reflected on the laws pertaining to sexual violence and child sexual abuse and the implications of the changes in laws on healthcare’s response to the survivors. Dr. Jagadish N. Reddy presented an in-depth understanding on the current practices within the health care system in responding to the survivors of sexual violence and domestic violence. He also highlighted the framework of MoHFW protocols and guidelines to address the gaps and concerns in practices and strengthen the response to the survivors of sexual violence. This session was followed by discussion wherein issues and concerns were raised and queries were answered. Majorly these discussions revolved around issues regarding the role of the healthcare provider in providing comprehensive care to the survivor, provision of treatment and process of medical examination. There were queries around the implications of new changes in laws such as mandatory reporting to the Police v/s survivor’s right to treatment and care, biased and unethical practices like commenting on past sexual history and conducting ‘two finger test’. The healthcare providers also pointed out the dilemmas confronted by them while responding to the survivors of sexual violence for which they sought clarifications during the discussion.

The next session focused on strengthening the linkages between the health care providers/facilities and service providing agencies. The first presenter for this session was Advocate Shubra Mendiratta, who focused on the initiatives and services provided by Delhi Commission for Women (DCW) and how DCW provides psycho-social and legal support for women in distress. After this Ms. Muneera and Ms. Zareena discussed on the initiatives taken by 181 helpline service for women in distress.

The event was concluded with the thank you note to the resource persons and the participants for their contribution and making the consultation successful. It was emphasized that this consultation is a beginning step towards more consistent engagement with the health system, especially at the state level, towards a more gender sensitive, ethical and standard care response to survivors of gender based violence. It was emphasized that there was a need for engagement of the healthcare fraternity to advance advocacy around ethical and standard practices towards the survivors.

Joint press Release on Chhattisgarh Sterilizations and related issues

Health Activists held a Press Conference on 19th November to draw attention to the range of issues raised by the recent tragic and completely avoidable deaths of more than a dozen women and the critical condition of many more following their laparoscopic sterilis​ation in Bilaspur, Chhattisgarh.The manner in which the surgeries were performed, in complete violation of all standard operating procedures,and subsequent events amount to grave violation of some very basic health rights of the affected women.  In addition, they point to the callous and biased attitudes towards poor women that persist among health functionaries and policy makers, and the tenacious hold of the “targets” approach in the family planning programme despite statements to the contrary.

83 women -predominantly Dalit, tribal, and OBCs- were subject to sterilization within a short span of 5 hours. It needs to be pointed out that the sterilization procedures flouted two sets of Supreme Court Orders (Ramakant Rai Vs Govt. of India, 2005 and Devika Biswas Vs Govt. of India, 2012). These orders instruct that a maximum of 30 operations only can be conducted in a day,and only in government facilities with 2 separate laparoscopes; one doctor cannot perform more than 10 sterilizations in a day.  Notwithstanding such orders, we see that in Bilaspur a single surgeon performed about three times the permissible number of surgeries (83) in less than 5 hours in a private hospital which has reportedly remained closed for 15 years.

The state government has announced several measures – monetary compensation and support to the affected families for care of the children of the dead women; suspension of several officials, and appointment of an enquiry commission.  The High Court has also taken suo moto cognizance of the tragedy.  There are also statements that the doctor is not to be blamed and that the problem lay with contaminated medicines that were given to the women.  As health activists who have been repeatedly calling attention to the deep-rooted problems afflicting the health system in the country and advocating several remedial steps, we believe that these measures are not adequate and do not touch the systemic and policy factors that lead to such incidents.  We feel that these are attempts to obfuscate the actual causes of death and the reasons leading to the incident.   A series of issues need to be addressed in the immediate to medium to long term.

In the short term, a thorough, impartial and unimpeded investigation and medical audit must be done immediately, by a competent team of medical and public health professionals, into the causes of the deaths and the illness of the women who underwent the sterilization.  Accountability and culpability need to be clearly fixed for the deaths of otherwise healthy women following a medical procedure.  That would be one of the first steps towards ensuring that mistakes and lapses are not repeated and such tragedies do not recur.Even 10 days later, such an investigation has not been announced by the state.

It is pertinent to remember that the failures in implementing guidelines and standards, and other kinds of violations in the sterilization component of the family planning programme have been repeatedly raised by civil society groups over the last decade or so, and are the subject matter of several petitions in the Supreme Court, such as the two referred to above.  Given that a lot of documentation already exists from several parts of the country, it is the need of the hour to compile all these evidences to learn the lessons and also ascertain why its implementation is so shoddy and poor.

In the medium to long term, several policy matters and systemic issues need to be addressed; among these are: (i) to do away with the continued emphasis of the Family Welfare Programmes on female sterilization in the name of reproductive rights and reproductive health.  It is seen that despite all the talk and concerns expressed by the state and international agencies for women’s health and maternal health,at the ground level the action is centred on such sterilizations and institutional deliveries only for reducing maternal mortality. The state still focuses on such permanent methods of contraception  rather than provide safe temporary methods for spacing and increasing access to safe contraceptives. In addition to this,​the two-child norm significantly contributes to the pressures for sterilisation.  Such ‘Camps’ (euphemistically called ‘fixed day static’ camps) are routinely organised in many States in the country in an irresponsible manner. Health providers in many parts of India confess that they are under pressure to fulfil unwritten targets coming from the top.

(ii) to improve the dismal condition of the government health institutions, make them functional by improving availability of  doctors and other health personnel and medicines.  Why is it that despite years of planning and allocating money for health system improvements, under reproductive and child health, under the NRHM, and despite years of so-called technical assistance for improving health system management, there are no improvements at the ground level?    There is no substitute for increasing material, human and financial resources to strengthen the primary health institutions across the country.

This terrible incident should be taken as a wake-up call.This incident must be declared an emergency, and we demand that:

  1. An independent and comprehensive epidemiologically-sound investigation into this incident should be carried out. On the basis of the findings, responsibility must be fixed in terms of criminal negligence not only on the medical team which performed the operations, but also in identifying other officials who sanctioned and were involved in managing this particular camp.
  2. Negligence and contributory negligence may be fixed on all parties involved, including those providing contaminated surgical equipment, medicines, etc. State is vicariously liable and ought to pay higher compensations for the lives lost and also to those who are sick.
  3. Further deaths and damage arising of poor quality of health care system, lack of compliance with SOPs, inefficient oversight system for quality control of health care delivery at the grassroots, and medical negligence should be entirely eliminated.The govt should must be held Sterilization operations only in well fully equipped  government hospitals and sterilized places, not abandoned hospitals that are shut, or in make shift places, where sanitization and cleanliness is compromised and there is a high likely hood of women undergoing a procedure in acquiring infections.
  1. ​The ‘camp method’ with incentives and targets of sterilization should be stopped with immediate effect. Instead, sterilization should be offered as one of the options among other safe, non hazardous, non invasive, long acting methods of contraception. It should be provided as one of the services through an improved basic primary health care system.
  2. ​The family planning programme needs a thorough re-analysis and over-hauling, that centre-stages the reproductive and health rights of women. Emphasis should be placed on male sterilization such as vasectomy, and other forms of family planning methods including use of condoms which involves far lesser health risks.

Jan Swasthya Abhiyan

Sama Resource Group for Women and Health

All India Democratic Women’s Association (AIDWA)

National Alliance for Maternal Health and Human Rights (NAMHHR)

Medico Friend Circle (MFC)

Muslim Women’s Forum

National Federation of Indian Women (NFIW)

Nirantar

Coalition against 2 Child Norm

Healthwatch Forum UP

Initiative for Health & Equity in Society

Diverse Women for Diversity

Human Rights Law Network

Joint Memorandum on Deaths and serious health consequences for women following sterilisation procedures in Chhattisgarh

To
Shri Dr Raman Singh,
Chief Minister,
Chhattisgarh
Chief Minister’s Office
Civil Line, Raipur
Chhattisgarh – 492 001

17 November 2014

Subject: Deaths and serious health consequences for women following sterilisation procedures in Chhattisgarh

Shri Dr Raman Singh,

We, Health networks, Coalitions, Women’s Groups and concerned citizens, are deeply shocked at the negligence of the Health Department, Government of Chhattisgarh that has led to the deaths of 16 women and the critical condition of 47 other women following procedures of laparoscopic sterilisation in Bilaspur, Chhattisgarh.

As you are aware that these deaths and morbidities are evidently a result of a botched-up sterilization operation camp organized by the Department of Health and conducted in the premises of a non functioning and abandoned private hospital under the National Family Planning Programme in Takhatpur Block of Bilaspur District on 8 November 2014. Horrifically, during this camp, 83 women were subject to surgeries in a short span of 5 hours. Those who have died—predominantly Dalit, tribal, and OBC women—are victims of the worst violation of their reproductive and health rights, and have left behind shattered families and young children.

This tragedy raises grave questions about the unsafe, unhygienic conditions and the slipshod attitude with which these operations were conducted. Moreover, the women who are presently critical continue to get treatment in inadequate conditions, exposing them to further risks and danger.

The surgeries were conducted in complete violation of the Supreme Court Orders (Ramakant Rai Vs Govt. of India, 2005 and Devika Biswas Vs Govt. of India, 2012). These orders instruct that a maximum of 30 operations can be conducted in a day with 2 separate laparoscopes only in government facilities. Also, one doctor cannot do more than 10 sterilizations in one day. Despite this, a single surgeon in Chhattisgarh performed about three times the permissible number of surgeries (83) in less than 5 hours in a private hospital which has reportedly remained closed for 15 years. a blatant and complete violation of standard protocols.

The announcement of Rs 4 lakh compensation and suspension of officials (Director–Health Services; State Family Planning Nodal Officer; BMO,Takhatpur; the operating Surgeon; and Bilaspur CMHO) are not adequate to ensure that such incidents will not happen again. The systemic failures which led to this incident need to be addressed.

While understanding the specific lapses in the way the sterilisation camp in Chhattisgarh was organised, one should not forget the role played by the misguided and dangerous policies and practices of the governments in the area of family planning services. Such ‘Camps’ (euphemistically called ‘fixed day static’ camps) are routinely organised in many States in the country in an irresponsible manner. Health providers in many parts of India, confess that they are under pressure to fulfil unwritten targets coming from the top.

The state still focuses on permanent methods of family planning rather than temporary methods. In addition to this, the two-child norm significantly contributes to the pressures for sterilisation. All this despite the Government of India’s promises of ‘Repositioning Family Planning’ – to move away from permanent methods to spacing methods, and to increasing access to safe and effective contraceptives.

This incident must be declared an emergency, and we demand that:

- Immediate responsibility must be fixed in terms of criminal negligence not only on the medical team which performed the operations, but also in identifying higher officials of the state who sanctioned this particular camp.
– A proper epidemiologically-sound investigation into this incident should be carried out. A three-member probe team has been constituted but these members are a part of the state, which signals a serious conflict of interest and thus, there should be an independent inquiry committee.
– Further deaths and damage should be minimized. It must be ensured that the technically most competent medical care is provided to the women to avoid further deaths.
– The ‘camp method’ of sterilization needs to be stopped with immediate effect as quality of care is seriously compromised in mass sterilization programme to meet earmarked targets. Instead, sterilization should be provided as a service through strengthened basic primary health care services.
– Women, adolescents and men need to be provided with safe choices for contraception. Emphasis should also be placed on male sterilization such as vasectomy, which involves comparatively lesser health risks.
– Quality of contraceptive services, including counseling, has to be monitored both from within the system and from outside through community monitoring.
– The family planning programme needs upheaval and a re-analysis, that centre-stages the reproductive and health rights of women.

Endorsed By
1. Jan Swasthya Abhiyan
2. Sama Resource Group for Women and Health
3. CommonHealth
4. National Alliance for Maternal Health and Human Rights
5. Medico Friend Circle
6. Centre for Enquiry into Health and Allied Themes (CEHAT)
7. Saheli
8. North East Network
9. Manasi Swasthya Sansthan
10. Muslim Womens Forum
11. Nirantar
12. Sadhbhavana Trust
13. Vanangana
14. Sahiyar Stree Sanghtan
15. National Alliance for Peoples Movements (NAPM)
16. SOPPECOM
17. Olakh
18. SANGRAM
19. Queer Feminist India Reclaim the Night
20. Jagori
21. LABIA
22. Forum Against Oppression of Women
23. Prayas
24. AIDWA
25. Oxfam India
26. Centre for Health and Social Justice
27. Partners Law In Development
28. AIPWA
29. AKL KA DHABA Collective
30 . National Federation of Indian Women
31. PWESCR
32. Bhopal Gas Peedit Mahila Stationery Karmchari Sangh
33. Bhopal Group for Information and Action
34. Dr Kavita Panjabi
35. Prof Gita Sen
36. Prof Uma Chakravarthy
37. Admiral L Ramdas
38. Lalita Ramdas
39. Prof Ilina Sen
40. Rajashri Das Gupta
41. Dr Veena R Poonacha, SNDT Women’s University
42. Shahida Murtaza
43. Rachana Johri , AUD
44. Neeraja Ved Malik
45. Nandini Rao
46. Anuradha
47. Farah Naqvi, Journalist
48. Sadhana Arya
49. Kalyani Menon Sen
50. Surabhi Sharma
51. Juhi Jain
52. Ayesha Kidwai
53. Radhika Desai
54. Poulomi Pal
55. Ramlath Kavil
Supriya Madangarli
57. Amrita Shodhan
58. Geetanjali Gangoli
59. Shreya Ila Anasuya
60. Lata PM
61. Vasudha Mohanka
62. Prof Vibhuti Patel
63. Runu Chakraborty
64. Swati Sheshadri
65. Sumi Krishna
66. Prof Mohan Rao
67. Dr Amar Jesani
68. Dr Dhruv Mankad
69. Dr Veena Shatrugna
70. Paromita Vohra
71. Dr Joe Varghese
72. Dr Bijoya Roy
73. Sulakshana Nandi
74. Indira Chakravarthi
75. Ravi Duggal
76. R. Srivatsan
77. Kiran Shaheen
78. Lata Singh
79. Dr Sunil Kaul
80. Sandhya Srinivasan
81. Bindhulakshmi TISS
82. Dr Mira Shiva
83. Nandita Gandhi
84. Roshmi Goswami
85. Janaki Abraham
86. Amrita Nundy
87. Dr Hazel D’Lima, Retired Prinicipal, Nirmala Niketan College of Social Work
88. Astrid Lobo
89. Dr Kaveri RI, WSS
90. Dr Padmini Swaminathan
91. S. Srinivasan LOCOST
92. Kamla Bhasin
93. Soma KP
94 Jarjum Ete, APWWS
95. Dr Anita Ghai
96. Rohini Hensman

HT

Sterilisation deaths: Rusty, infected tools killed women in Chhattisgarh?

 Ejaz Kaiser, Hindustan Times  Bilaspur, Chhattisgarh, November 12, 2014                                                

First Published: 20:41 IST(12/11/2014) | Last Updated: 09:47 IST(13/11/2014)


Furious protesters took to the streets in Chhattisgarh on Wednesday as activists complained standard procedures and guidelines were not followed in the state’s mass government-run sterilisation programme that left 13 women dead.

A team of doctors rushed to Bilaspur to investigate the deaths following the operations performed by a doctor accused of using rusty equipment in an operation theatre that had not been used for four months.

The cause of the deaths was not immediately clear, but officials said the victims showed signs of toxic shock, possibly because of dirty surgical equipment or contaminated medicines. The victims had suffered vomiting and a dramatic fall in blood pressure after undergoing laparoscopic sterilisation, a simple process in which the fallopian tubes are blocked.

“Preliminary examinations suggest septic shock may have caused the deaths,” said local government official Amar Thakur. “It looks like the equipment that was used was probably infected. We are waiting for the report.”

A total of 83 women, all villagers under the age of 32, had the operations on Saturday and were sent home that evening, but more than 50 became seriously ill later and had to be hospitalised.

The expert team from Delhi’s All India Institute of Medical Sciences (AIIMS) reviewed the clinical details of the women who fell ill, but did not say what led to the deaths.

“All of us unanimously think that the cause of the illness can only be ascertained after all laboratory results and post-mortem findings are available,” said Dr Anjan Tirkha, who headed the seven-member team.

Sources said the death may have been caused by drugs prescribed to the patients or internal malfunctioning resulting in renal failure, respiratory failure and liver infections.

The doctor has been accused of operating on more than 80 women in just a few hours with the help of two assistants in an abandoned private hospital, officials said.

Police have filed a case of causing death by negligence against the doctor, RK Gupta, Bilaspur IGP Pawan Dev told HT.  The state government rewarded Gupta on January 26 for accomplishing his target of laproscopic tubectomies.

N Sarojini, founder and director, Sama Resource Group for Women and Health, said the Bilaspur surgeries violated Supreme Court orders saying that a medical team can conduct a maximum of 30 operations in a day with two separate laparoscopes.

“One doctor cannot do more than 10 sterilisations in one day, yet the surgeon in Chattisgarh did an astounding 83 surgeries in a short span of five to six hours… The scale of these deaths and critical morbidity clearly show that these operations were not done under standard protocols,” she said.

“The only step that has been taken by the government till now is to announce Rs. 4 lakh compensation for the families of the dead and suspension of some doctors. These steps are not adequate to ensure that such incidents do not happen again. The systemic failures that led to this incident need to be addressed.”

Although the surgery is voluntary, rights groups say the target-driven nature of the programme has led to women being coerced into being sterilised. Women are given Rs. 1,000 rupees and men Rs. 2,000 as incentive to undergo the procedure.

Shiv Kumari Yadav, 26, and Parvati Bai, 25, said they would not have opted for the procedure had they known about the surgeries were carried out in an unhygienic operation theatre. “Two women were simultaneously handled on the two parallel beds by the doctors,” said one of the patients.

The Chhattisgarh high court has issued notices to the union and state governments as well as the Medical Council of India seeking a detailed report within 10 days.