Why uterus removal is common among India's manual scavengers

In stomach-churning details, Archana recalls the days leading up to the surgery to remove her uterus. “I would have blood on my clothes, and occasionally it would even seep down to my feet.” 

Now 45, she had undergone hysterectomy in her late-30s, hoping it would solve her problems. “I had undergone surgery thinking it would boost my productivity at work. However, post the surgery, I have more problems to deal with,” she adds. 

But this is not Archana’s story alone. Thousands of women across India, all from the country’s lowest social strata called the Dalits, have been forced to surgically remove their uterus after picking up infections at work – manual cleaning of dry toilets that involves picking up faecal matter with bare hands, loading the waste into cane baskets or metal troughs, and carrying them on their hips and head for disposal. 

Not even the respectful title of ‘sanitation worker’ – they were called ‘manual scavengers’ earlier – could hide these women's sheer irony and agony, forced into a job no other people would do. And because of their status in India’s highly caste-ridden society, they have no other source of income.

As India celebrates Swachh Bharat 2022 (Clean India), much can be said about the progress of the world’s largest cleanliness drive Swachh Bharat Mission, often cited by Prime Minister Narendra Modi in his speeches and radio talks. The initiative claims construction of 95 million new toilets in place of dry toilets. 

However, the ground reality speaks of the situation differently. A large number of toilets constructed under the mission use technology that would require periodic emptying and offsite treatment of the faecal matter. This has merely converted “manual scavengers” into “sanitation workers” while the nature of the work remains menial.

Jalaun district of India’s most populous state Uttar Pradesh provides a classic case study of the unfolding horrors.

“I veil my face while working. My clothes would get covered in faeces when it rains and would not dry. The house would stink of faeces. I started suffering from rashes and bear frequent infections,” says Anita (42), another sanitary worker like Archana. Anita too had her uterus removed not too long ago and for the same reasons.

And Archana’s declaration is chilling as it is brutally honest. “No woman here has a womb.” 

The provision of protective gear is scarce – all these women have is their ratty dupattas (stole) that they wrap on their faces as they pick and dispose of human waste with their bare hands. Other gears like gloves and t-shirts are rendered useless, since they are built to fit men. In such situations, the huge, flimsy equipment hanging from their bony frames does not provide any substantial protection.

Despite a 2013 law prohibiting the profession of manual scavenging, the women involved in this work still routinely clean human faeces from public and private dry toilets. 

“This is the last job on earth anyone would want to do. We do this because we do not have an option. We inherit this job because of our caste. Society can never see our identity beyond our caste,” adds Anita.

Institutionalising caste oppression 
Manual scavenging, a labour-intensive, caste-sanctioned profession, persists in several parts of South Asia. In India, an estimated 1.3 million Dalits (so-called “lower-caste”) are forced into sanitation work, around 75 percent of which are women employed as manual scavengers.

Despite their labour, they hardly receive remuneration from their employer. “Instead of giving me my daily wage, my employer gives me rotis (bread). They skip it for the day when I do not turn up for work,” Archana adds. 

According to a report by Jan Sahas, a social development society, on the “socio-economic status of women manual scavengers”, the handling of human excreta on a daily basis exposes them to severe health consequences like tuberculosis, nausea, typhoid, and even need for removal of the uterus. 

A hysterectomy is a surgical procedure to remove a woman's uterus but can sometimes lead to the removal of the ovaries, cervix, or fallopian tubes. Other than a C-section, it is the most common procedure performed on women in India and worldwide.

A 2018 Indian government survey found that “more than 22,000 Indian women aged 15 to 49 out of 700,000 surveyed—31.8 percent—had undergone a hysterectomy.”

According to a 2018 Rashtriya Garima Abhiyan report, women manual scavengers are prone to infection since their work exposes them to chemicals in unhygienic working conditions. “There is an increasing incidence of hysterectomies among the women manual scavengers of Jalaun which leaves their families destitute and trapped in debt bondage,” claims local activist Kuldeep Kumar Baudh. Baudh’s organisation, the Bundelkhand Dalit Adhikar Manch, has been working for the rights of Dalits for the past 10 years.

The surgery is heavy on the pocket and most women end up using the amount they received via the provision of rehabilitation of manual scavengers under the Prohibition of Employment as Manual Scavengers and their Rehabilitation Act, 2013. The families reported the surgery costing between 30,000 and 50,000 rupees (approximately US$ 370-600), but many ended up paying more for post-procedure problems.

Prevalence of hysterectomy 

According to  Deeksha Pandey, a gynaecologist who led a yearly audit of hysterectomy at the Kasturba Medical College, “sanitation workers are prone to infections, especially genital tract infection. This is due to their constant exposure to harmful chemicals in their work environment and unhygienic living conditions.”

“The absence of safety gear for them makes them vulnerable to infections in their physiologically toxic work environment. Hence, the women manual scavengers of Jalaun district have been undergoing hysterectomies,” adds Pandey.

According to research published by the US-based National Library of Medicine,  hysterectomies are being performed at an unprecedented pace in rural India. However, data on hysterectomy in developing countries like India is limited due to poor population surveillance, hospital records data and surveys.

Pandey highlights that this trend is driven by both the mindset and commercialisation of such procedures. Women from rural India share a common attitude towards their uterus. 

“They feel it is redundant after they have completed their family and having it removed is better than suffering from multiple health issues like menstrual pain, heavy bleeding and continuous backache. This notion is inadvertently being reinforced by doctors (who are generally male, with a margin of 5:1 in India) as they get to line their pockets in return for performing a one-time big surgery.”

“Rural women are especially at risk since their decision-making is badly impacted by a lack of literacy. Doctors frequently use the possibility of ovarian cancer and fibroids to persuade women that having surgery is a wise decision,” adds Pandey.

The hysterectomy debate is a case study of everything wrong with women's gynaecological health awareness and care in a patriarchal society. Owing to their limited knowledge, the nature of their job, and systemic apathy, the women manual scavengers become the victims of this “unethical medical practice”.

“I cannot afford to have serious ailments as I have a family to look after. I will undergo any surgery if it makes me fit to work and earn. Even if it comes with a cost of grave consequences,” says Anita.