Blinding Reality, fact-finding into Madhya Pradesh Cateract blindings

Published on: December 17, 2015



Investigation blames un-controlled quality conditions drug procurement as the chief cause for the loss of sight of patients who are poor


Poorly sanitized operation conditions including questionable hygiene and untested quality of drugs, fluids and injections were the primary cause for the tragic loss of vision of 66 persons during the eye cataract surgery camp jointly organized and conducted by the Barwani District Hospital and Lion’s Club between November 16 to 24, 2015, under the District Blindness Control Programme, part of National Blindness Control Programme in Madhya Pradesh. Initially reports suggested that 24 persons had lost vision in one eye but the probe suggests that the figure is higher.
 
These are the major findings of a fact-finding team and investigation conducted by representatives of the Jan Swasthya Abhiyan and Narmada Bachao Andolan that were released on December 17, 2015.
 
The report sums up some of the worst cases and recommends that patients who have fallen victims to this institutional callousness should be immediately referred to higher referral hospitals outside the state (Madhya Pradesh) and every efforts be made by the government to ensure eye replacement surgeries. The issue of fair compensation (reparation) to all the survivors has also been flagged in the report.   At least one member of each affected household should be provided means of regular livelihood and free Medical facilities should be provided to all affected families.
 
Critically, the state government needs to order a high level and ‘independent’ inquiry into the whole issue of the facts and circumstances behind this eye-camp and the conduct of unregulated health camps in general that have subjected many, especially the poor, to unspeakable tragedies. This enquiry should include the process of quality and procurement of all the drugs, fluids, equipment, and the medical process followed at such camps.

The really sticklish and politically and administratively sensitive issue includes pinning of responsibility. The report of people’s organization has also demanded that strict action should be taken against the offending doctors/medical officers/collector/and others involved in the camp. The suspensions of the collector (district magistrate), CMHO (chief medical health officer) and nodal officers of National Blindness Control Programme have also been demanded with immediate effect. Instead of pinning all blame on the single doctor who conducted the surgery/surgeries on the days when the incidents took place, institutional responsibility needs to be investigated and pinned down. If needed then, due criminal action needs to be taken.

Twenty-four persons (initially) lost their eye-sight as a result of  result of an eye cataract surgery camp which was jointly organised by Barwani District Hospital and Lion’s Club between November, 16-24, 2015, under the District Blindness Control Programme, part of National Blindness Control Programme. (The report today states that 66 of the 86 persons on whom surgeries were conducted had lost vision in one eye)  A committee is formed under the District Blindness Control Programme which is chaired by the District Collector. This committee allocates budget to non-governmental organizations (NGOs) for conducting the camp and procures drugs, injections, and other necessary items through state level tender, or local tender or direct purchase under the guidelines set by the government.
 
According to newspaper reports, the state government had suspended eye specialist R.S. Palod and initiated action against the authorities of the Lions Club. The government has also set up a three-member committee to probe the matter. A total of 86 patients from Sendhwa, Silawad, Dhanora, Warla, Chachria, Balwadi, Pansemal, Niwali, Piplaj, Ekkalwara, Kashta, and Dharamrai of Barwani and Dhar district of Madhya Pradesh were operated upon in the camp.
 
Findings of the Independent Fact-finding report:-
  • Ringer’s Lactate solution was used during the eye surgeries which is usually packaged in plastic bottles. This packaging leaves the substance vulnerable to catch fungus. The particulars and quantity of which pre-operative medicines, intra-operative medicines, and post operative medicines that were used in the eye-camp is not known and has not been disclosed by the authorities.  It is a matter of serious concern whether these medicines were procured through a process of procuring state-level tenders, local tenders or through a direct purchasing process.
  • After the operations had been conducted, at the time of discharge, the