Sumati Devi knew before she arrived at the grimy government clinic in northern India that she would be paid to be sterilized. She didn’t know that she would lie on an operating table with bloody sheets, that the scalpel used on her would be stained with rust, or that she was supposed to get counseling on other birth control methods before consenting to have her fallopian tubes cut and tied. The main reason Devi agreed was that the $10 she received—about a week’s wages for a poor family—would help feed her three children. “I did it out of desperation,” says Devi, 25, as she lies on the concrete floor recuperating at the clinic in Bihar state. “We need the money. Health officials came to our home. They told us it would be best.”
India carries out about 37 percent of the world’s female sterilizations. Quotas set by state governments and financial incentives for doctors contributed to 4.6 million women being sterilized last year, many for cash and in the unsanitary conditions Devi encountered. Vasectomies accounted for just 4 percent of all sterilizations. “Women are the easiest prey, whether it’s government officials or their husbands asking them to undergo the operation,” says Kerry McBroom of New Delhi-based Human Rights Law Network, which provided the lawyer for an ongoing court case against the government that was filed last year. The lawsuit documents the brutal practices at sterilization camps, where large numbers of women are gathered to have the procedure, and calls on the Supreme Court to issue guidelines to prevent abuse.
Only about half of Indian couples of child-bearing age practice modern birth control methods, United Nations data show. The government doesn’t pursue the costly option of teaching often-illiterate women how to use contraceptives. One in five babies born worldwide is Indian, straining supplies of land, food, and water. “A fast-growing population affects everything: the economy, the environment, quality of life,” says Vishwanath Koliwad, secretary general of the Family Planning Association of India, an advocacy group.
Outside the clinic in the town of Sonhoula, 33 women who signed up for surgery line up in the heat as guards carrying bamboo sticks watch over them. They are led into a dimly lit room, with bare concrete floors, and placed on makeshift operating tables propped up with bricks. A.K. Das, the surgeon at the clinic, moves from one operating table to the next as he makes an incision below the navel in each woman, then cuts and ties their fallopian tubes. The patients are laid shoulder-to-shoulder on the floor in a separate room to recuperate. Das, who spends three minutes on each operation, runs out of anesthetic with more than 10 patients to go, forcing him to use a weaker sedative. He says he’s paid an extra $2 per patient by the government for using the weaker drug. It’s more dangerous because the women are not completely unconscious during the procedure. After each operation an assistant washes the scalpel in a tray of warm water.
“Look at this,” says Das, pausing during an operation to hold up the rust-stained scalpel he’s using. “This is dirty and that will significantly increase the chance of infection.”
A majority of those attending sterilization camps in India are lured by incentives such as money or improved welfare benefits offered by local officials under pressure to meet targets each year, says Abhijit Das (no relation to Dr. Das), director of the Centre for Health and Social Justice in New Delhi. While the federal government formally abandoned targets for sterilizations in 1996, that hasn’t filtered down to all states.
Most of the operations are performed in the first months of the year—a period doctors dub “sterilization season”—to fill quotas before the fiscal year ends on March 31. Health workers in Gujarat say they were threatened by their supervisors with salary cuts or dismissal if they failed to meet targets, according to Human Rights Watch. Women are pressured to undergo sterilization surgery without being told they will never again bear children, the group said after interviewing 50 health workers. Repeated calls and e-mails to Gujarat Health Minister Nitinbhai Patel weren’t answered.
S.K. Sikdar, who runs national population control programs at the Ministry of Health and Family Welfare, rejects the idea that women go to the camps under duress. “There’s no pressure. People are free to do whatever they like,” Sikdar says. “There may be some isolated districts where there are overeager officials, but they are rogue operators.” Sikdar says sterilization is “one way” that India is trying to reduce the population, “but we are promoting different birth control methods.”
The sterilization program has coincided with a slowdown in the birthrate. India’s population grew 17.6 percent in the decade to 2011, according to census data, four percentage points less than in the previous 10 years. States that have successfully curbed population growth have improved female education, increased work opportunities for women, and made a range of contraceptives available. In Kerala, where female literacy is over 90 percent, the population grew only 4.9 percent.
At the clinic, a medical assistant pricks each woman’s finger, using the same needle, to test their blood for anemia. Flies swarm through the windows. Das, the surgeon, removes his surgical mask after several operations because of the heat. The electricity shuts down, and a generator is cranked up. Dogs walk down the corridors. Nurses step around women on the floor, offering painkillers to those in agony. “The program should be voluntary,” says Das, his face dripping with sweat. “There shouldn’t be any targets. The entire system needs to be changed.”
The pressure to cut the birthrate never lets up. “At the end of the year we are judged on how many sterilizations we have done,” says Dr. M.A. Rashid, who runs the Sonhoula clinic in Bihar. “The government doesn’t want excuses.”