As told to Devjyot Ghoshal for Quartz – www.qz.com.

In 2004, we performed a census of Chhattisgarh’s public hospitals that were equipped to perform caesarian sections routinely, and found that there were only three such government hospitals in the entire state. There were, of course, many more in the private sector, where people could go if they paid, but they were not accessible to the majority of the population.

I travelled all across Chhattisgarh with a particular focus on public health facilities. There was inadequate clean water to drink. There was a lack of food and nourishment. There was a total lack of even very ordinary healthcare facilities for conducting a safe delivery on a routine basis. So all together, it was an absolutely abysmal situation.

That is the context for this incident.

The surgeon who has performed these operations is someone who has been awarded by the state government for performing a huge number of sterilization operations. He is not some fly-by-night operator. This whole business of setting targets for female laparoscopic sterilizations is a well-established government practice in many state “family welfare” programmes.

These operations were conducted in hospitals where the physical infrastructure was absolutely abysmal. This is also routine. People are made to lie down on the ground. There is no place for them to lie down with dignity and care in a clean facility.

And this is not the first time such an incident has happened in Chhattisgarh.

We grade such incidents on the number of people who die. When one or two people die, those incidents don’t get highlighted. But such incidents keep happening all the time in the state. In a similar camp for eye operations at Balod some months back, many people developed infections and lost their eyesight. It is an absolutely horrific scenario in Chhattisgarh as far as healthcare is concerned.

We can get caught in establishing individual culpability for such cases—but that is not enough.

Over the years, there have been some changes. A lot of money has been spent on infrastructure but the services remain minimal because the staffing, the training and other aspects are all part of the same ineffective scenario. Of the number of gynecologists that were supposed to be available in the government sector in Chhattisgarh, roughly a quarter are deployed.

While a lot of infrastructure has been put in place and many intellectuals have testified that the public distribution system is supposed to be very effective, the point is that we do not have a system of measuring the outcome—whether or not people are adequately fed and have enough nourishment, clean water, and accessible, adequate healthcare. We are only now coming to a stage when the proper numbers for malaria deaths are available in the state.

We have accessibility problems in areas where internal conflicts are occurring. Large parts of Bastar, for instance, do not have access to medical services. The medical services that were available in those areas were because of the efforts of non-governmental institutions. Many of these initiatives, like the clinics run by the International Committee of the Red Cross, have also been terminated.

Poor not a priority of this government

There is an unmet demand for family planning services, which are safe, free, and technically adequate. Right now, there is a lot of effort to coerce prospective patients, especially with the deployment of what are pitiful cash incentives, which do make difference in a marginalized population. It’s important to recognize that almost all the people who underwent surgeries in this particular camp, had below poverty line cards and were entitled to the princely incentive amount of Rs1,400.

Male sterilization is a much easier and safer method than female sterilization but not adequately promoted or available in the official “family welfare” programme. And the other forms of contraception are not available on an adequate basis because of the lack of healthcare facilities.

Coercive mass sterilization programmes are a hold over from the period of the Emergency. The situation is that the entire public health spending in government is absolutely inadequate. Family planning services, for which there may well be a felt need, are also reduced to a ridiculous kind of target-based hunting-down-the-poor game. And that’s what these deaths are. They are really a form of medical homicide and the direct outcome of policies deliberately articulated by the state.

The problems of the poor are simply not a priority of this government. The whole philosophy of development is expressly targeted at sequestering common pool resources and taking them out of the hands of the poor and handing them over to corporate interests. This is the sum total of development as practiced under the current regime, certainly in Chhattisgarh, but also in many other parts of the country.

A large number of doctors are doing the best they can under extremely difficult circumstances. But there are also those who have internalized the governmental mindset to the extent of being driven to chase unrealistic and unethical targets. There is a limit beyond which non-state resources cannot be stretched to fulfill the tasks that are mandated. And the political culpability of the rulers of the state must be acknowledged, not glossed over with remarks like “it is the doctors and not the ministers who operate,” as the chief minister of the state is reported to have remarked.

These absolutely tragic and horrific incidents do not make sense until they are put into the context of the overall development policy of the state. And I am not talking only about Chhattisgarh here. There are many other Indian states in the same situation.