The alarming surge of COVID cases in India has restricted medical treatment for Afghan citizens, who rely on the country’s health facilities. For one Afghan patient, the stakes are getting higher with each passing day.
Sadruddin, a 70-year-old Afghan citizen, was leading a good life in Kabul until his health took a turn for the worse in 2016.
“My father started coughing incessantly at the beginning of 2016. The doctor in Kabul could not diagnose his disease,” Maryam Beheshta, Sadruddin’s 25-year-old daughter, told DW.
Sadruddin’s health deteriorated in the following months, with Afghan doctors unable to treat him properly.
Public health facilities in the war-ravaged country are not adequate to treat people with chronic diseases, and for that reason, many Afghans travel to India. Beheshta, too, decided to take her father to India.
“I took my father to India in 2018 for the first time. The doctors there told me he had cancer,” Beheshta said. “But there was hope; the medication and therapy that Indian doctors prescribed for my father was helping him,” she added.
Start of the pandemic
After his diagnosis in India, Sadruddin and Beheshta traveled to India every three months for treatment, until the COVID pandemic hit the region in 2020. Lockdowns and international travel restrictions, imposed both by Indian and Afghan authorities, made it impossible for Sadruddin to receive the much-needed treatment for his ailment.
“The situation is now even more complicated because of the spike in virus cases in India,” Beheshta said, referring to the deadly second COVID-19 wave in the South Asian country.
“Now, I cannot contact the Indian hospital where my father was previously getting treatment via video calls — something that we were able to do before the new wave.”
“The hospitals in India are overwhelmed by local patients. I called the hospital many times but have not been able to talk to a doctor there to get the help we need.”
Limited options
Although Afghanistan’s public health system has improved in the past few years, the quality of services remains poor due to insufficient training of the medical staff, a lack of funds and medical equipment.
Many Afghans who suffer from cancer or other life-threatening diseases prefer to get treatment in either India, Iran or Pakistan.
India has become a preferred destination for many Afghans due to its relatively better public health infrastructure, lower costs and easy visa requirements. But Indian hospitals are currently overcrowded with hundreds of thousands of COVID-19 patients. In this situation, treating patients from neighbouring countries is not a priority for them.
A catastrophe for Afghans
The Indian embassy in Kabul continues to issue visas to Afghan students, those in need of medical care and those traveling for business purposes, but the visa requirements have become stricter during the pandemic.
Afghan citizens are also afraid of going to India at a time when the virus spread is at its peak. For patients with chronic diseases, contracting the virus could be fatal.
Sadruddin and Beheshta must wait for things to improve in India, but unfortunately, they don’t have much time.
“My father is coughing again all the time. We have run out of medicines that are available in India, and not in Afghanistan,” Beheshta said.
Beheshta is consulting doctors in Kabul, but they don’t have the facilities to treat her father’s cancer.
“If travel restrictions are not lifted soon, and if India doesn’t bring the virus under control, I am afraid my father’s life will be at a greater risk,” she said.
“My father has gone through a lot. We have spent a lot of money on India visits and his treatment,” she said, adding that the pandemic in India has also proven to be a catastrophe for Afghans.
Most medical tourists need translators, who are hired by hospitals and charge high commissions. Patients are also often forced to do expensive tests, even if they may not understand what’s going on.
Most medical tourists need translators, who are hired by hospitals and charge high commissions. Patients are also often forced to do expensive tests, even if they may not understand what’s going on.
Zubaida. Credit: Ishtiaq Wani
New Delhi: “I had got only $2,000 from Afghanistan,” she says, sitting on a bed with her leg plastered and small bandage on her left hand. Her forehead is covered with sweat as the fan wobbles in the humid room. Medical prescriptions and tests are spread over the two beds, with blankets neatly kept aside.
Zubaida suffers from severe back pain. Along with her son, she came to India for medical treatment thinking it would be affordable. She had never thought she would be duped by her compatriot, who had called her “sister”. Her translator, an Afghani, took Rs 50,000 more than the hospital charged her and fled to Afghanistan when confronted.
Medical tourists coming to India are frequently duped into paying extra by hospital middlemen and touts. Most often, self-appointed translators – who are the first contact of these tourists in India – take them to the hospitals and trick them into paying extra.
According to the Ministry of Home Affairs, in the first six months of 2016, 96,586 medical tourists had come to India. Due to the comparatively lower prices of the procedures and treatment, India attracts people from all over the world. In 2012, 41% of the medical tourists came from Middle East and North African countries, and 48% from Asia Pacific region.
Zubaida and her son rented a place in Lajpat Nagar in South Delhi thinking that since other Afghans live there too, it would be easier for them to spend their time and get the information they need. Neither of them speak Hindi.
“Translators charge 30-40% commission. An operation costing Rs 1 lakh would then cost Rs 1.5 lakh,” says Dev Singh Bisht, a pharmacist in Bhogal, who has been working with patients from different countries for over seven years. He learnt Pashto from his Afghan customers and often listens to the problems they face. He has seen laboratories extracting extra money from the customers and translators taking them to the hospitals that pay them the highest commission.
“I saw an Arab patient with a translator in a medical store, the patient was trying to ask the chemist when he has to take his medicines and how. The translator said to the pharmacist in Hindi, ‘Gadha hai (He’s an idiot)’,” says Rezwan. He is in Delhi with his sister Zarmati, whose ailment doctors could not detect in Afghanistan. A journalist by profession, this is his second visit to India. He too thought treatment would be affordable here, but had the opposite experience.
On Rezwan and Zarmati’s second day in India, they went to meet a doctor in a South Delhi hospital. Right away, the doctor recommended tests costing Rs 11,500 and charged Rs 7,500 for the examination. This was a much higher amount than he had expected.
On the day the results of the tests came, they visited the hospital again. The doctor was not available. They waited for a long time, even went back again in the evening, but he didn’t show up. They called the hospital the next day, the doctor was still not back. Zarmati was in a lot of pain.
They visited another doctor with her medical reports, but the doctor rejected the results of the tests the first doctor had asked for. This doctor asked for all new tests, saying that her joints were constricted and that’s why she was in pain.
After spending Rs 85,000 on tests, the doctor suggested an operation that would cost them Rs 5 lakh, plus his fees.
“But how could her joints move, if she had constricted joints?” wondered Rezwan. On asking the doctor, he retorted, “You are not the doctor, I am a doctor.”
Rezwan was faced with a dilemma – either he had to go ahead with the operation or find a different doctor. He was confused, and the behaviour of the doctors he had met so far was only making things worse. He decided to search for another doctor. This was their fourth day.
On the fifth day, they visited another doctor, with the hope that he might be able to help. The new doctor asked for more tests that cost Rs 18,000 and prescribed injections that would ease her pain.
“Her muscles have elongated,” the doctor said. Her pain was gone. They didn’t bother to ask what the disease was called. They are home now.
According to a Grant Thorton and CII report, the medical tourism industry in India is expected to grow to $8 billion by 2020. It is estimated that the current 9% of medical tourists coming from European countries will increase to 16% by 2018, with an additional 45% coming from the MENA region.
Maryam Ahmad Abdullah, 65, a Yemeni, is being treated for cancer at AIIMS, where she is accompanied by her 27-year-old son Abdul Jabbar Makrash.
She was diagnosed with rectal and lung cancer a year ago in Yemen, just a few weeks after her son got engaged. Planning for the wedding ceremony was on, but the news of her illness damped their happy spirits.
Immediately, Makrash applied for two visas to India. “We had to travel to submit the doctor’s prescription at Djibouti and then apply for a medical visa there,” he says. The application procedure included strings of processes; application for visa, approval letters from hospitals, arrangements for lodging, booking interpreters – the list is endless. From getting approval letters and signing piles of permission papers to making a sea journey to Djibouti in East Africa, it took a month’s struggle to complete the travel formalities.
Medical tourists from Arab countries usually find rentals around Malviya Nagar, Lajpat Nagar, Bhogal, Okhla, Tughlakabad and Gurgaon, because these areas are close to private hospitals.
Maryam Ahmad Abdullah and Abdul Jabbar Makrash. Credit: Ishtiaq Wani
According to a study by Medical Tourism hub, a not-for-profit organisation based in the US, “Direct air connectivity, proximity, and cultural connectivity have helped people from Gulf to feel comfortable during their medical tour in India.”
Within three days of arriving in India, Makrash and Abdullah visited a private hospital in South Delhi. The first test cost them Rs 40,000 and the medical report stated – unlike the previous diagnosis in Yemen – that Abdullah was only suffering from rectal cancer. The report emphasised that she needed urgent laser therapy and chemotherapy, costing a total of Rs 3 lakh. That was in August 2016.
Makrash hadn’t brought a lot of money, but he could not think of going back home unsuccessful. “I want to see my mother healthy, this is the most important thing to me,” he says, placing a kiss on his mother’s forehead.
Within a span of three months, they spent Rs 6 lakh. His pockets were close to empty and he was slowly running out of hope.
Their expenses – rent, food, conveyance and treatment-related charges like blood tests, x-rays, scans and medicines – kept increasing.
Makrash’s family land in Yemen had been sold off by now to pay the hospital bills. The mother and son duo soldiered on, listening to doctors and paying them in cash for each successive test.
During the last months of 2016, Makrash could no longer afford the medical charges.
“I sold our property, gold and our ancestral weapons, one by one,” he says.
After the chemotherapy was completed, doctors suggested another surgery in a private hospital – but Makrash couldn’t afford it. At the end of December, a few of his friends in the embassy and elsewhere advised him to try his luck at AIIMS. Abdullah was admitted to AIIMS on humanitarian grounds. A few months into the procedures, she felt better.
However, by now, all their savings were over. Makrash’s Arab friends studying in the city started collecting funds for further procedures. With that, they managed to cover the expenses at AIIMS.
Zalmi*, who was admitted to a Gurugram hospital, was not as lucky. He had to return to Iraq without completing the treatment. Before coming to India, he had been to Lebanon, Jordan and Egypt, but his condition had not improved there.
“In India, it is good but expensive,” says his father, who accompanied him. They knew no one here and had to rely solely on translators.
“Anyone can be a translator, contact marketing people in the hospital and you become one. Without being certified and without regulations, they do their work,” says Zayeen*, an Arabic translator working in a Gurugram private hospital.
Zubaida’s son, meanwhile, tried to get his money back from the hospital she was treated at. They refused, saying that they were dealing only with the translator. They tried to lodge an FIR, but police refused to file it. Contacting the Afghanistan embassy didn’t help. Calls to the translator would either be cut or he would answer and threaten them.
“He returned Rs 25,000 and warned us not to approach police. He said this is happening everywhere,” says her son, speaking in Pashto.
The courts have repeatedly stripped the surrogate of the little power she might have in such arrangements, a position the new bill is likely to take forward.
The courts have repeatedly stripped the surrogate of the little power she might have in such arrangements, a position the new bill is likely to take forward.
Thus far, there has been no elaboration on the rights of the surrogate mother in the new Surrogacy Bill.
A few days ago, the cabinet approved the Surrogacy (Regulation) Bill, 2016, which called for a complete ban of commercial surrogacy and made it punishable with a minimum sentence of 10 years. The Bill proposes several modifications to the existing framework, from eligibility requirements to regulatory mechanisms. Foreign minister Sushma Swaraj repeatedly stressed on commercial surrogacy being against the ethos of the country, exploitative and a trade, but apart from criminalising it there seems to be nothing more to keep surrogacy in check. Further, there has been no elaboration on the position of the surrogate mother in the process – for instance, the safeguards for a surrogate and where she stands vis-à-vis the commissioning couple who were now a close family relation. Since, the legitimisation of commercial surrogacy in 2008, the rights enjoyed by the surrogate mother have been systematically overlooked. In most instances, she is reduced to nothing more than another process in the chain of (re)production.
Courts and the surrogate mother
The Supreme Court has since April suspended deliberations on surrogacy arrangements until the enactment of a law on it. Prior to this there have been few instances where courts have had to deliberate on issues that arose from surrogacy arrangements. With every successive case, the courts have expanded the meaning of motherhood not only to include the commissioning mother but also to actively exclude the surrogate from it.
Perhaps the first step in evolving the meaning of parenthood vis-à-vis surrogacy was taken by the Madras high court in K. Kalaiselvi v. Chennai Port Trust. The question that arose was whether the petitioner, who had a child via commercial surrogacy, was entitled to maternity leave. While granting the petitioner maternity leave, the court noted:
This court does not find anything immoral and unethical about the petitioner having obtained a child through surrogate arrangement. For all practical purpose, the petitioner is the mother of the girl child G.K.Sharanya and her husband is the father of the said child. When once it is admitted that the said minor child is the daughter of the petitioner and at the time of the application, she was only one day old, she is entitled for leave akin to persons who are granted leave in terms of Rule 3-A of the Leave Regulations. The purpose of the said rule is for proper bonding between the child and parents.
The court in this case recognised the rights of the petitioner with respect to the child on the basis of the admission of all parties that the child is the daughter of the petitioner. Thus, the court first ruled out a challenge to the maternity and then conferred it to the petitioner post delivery.
This interpretation was slightly modified by the Kerala high court. While deciding a similar petition, the court noted that there should not be any discrimination on the basis of the means of maternity or the fact that the commissioning mother herself did not undergo the pregnancy. On the question of maternity the court observed that from the moment the child is born, the commissioning mother is to be treated as the mother of the child. As opposed to in the Kalaiselvi case, the Kerala high court unilaterally located the maternal rights with the commissioning mother post-delivery. In this manner, the court very clearly negated any right of the surrogate mother with respect to the child post-delivery. With regard to motherhood the court noted:
It (motherhood) is no longer one indivisible instinct of mother to bear and bring up a child. With advancement of reproductive science, now, on occasions, the bearer of the seed is a mere vessel, a nursery to sprout, and the sapling is soon transported to some other soil to grow on.
The above interpretation reduces the surrogate to a passive, inanimate receptacle that holds the child till it is ready to be delivered. However, despite the issues associated with the court recognising the maternity of the commissioning mother only post-delivery, the court seems to at least recognise the rights of the surrogate with regards to the child during the pregnancy.
But even this limited right was curtailed by the Delhi high court in Rama Pandey v. Union of India. The case also dealt with the question of maternity leave in cases of children obtained via surrogacy. While interpreting motherhood, the court noted:
In my opinion, where a surrogacy arrangement is in place, the commissioning mother continues to remain the legal mother of the child, both during and after the pregnancy. To cite an example: suppose on account of a disagreement between the surrogate mother and the commissioning parents, the surrogate mother takes a unilateral decision to terminate the pregnancy, albeit within the period permissible in law for termination of pregnancy – quite clearly, to my mind, the commissioning parents would have a legal right to restrain the surrogate mother from taking any such action which may be detrimental to the interest of the child. The legal basis for the court to entertain such a plea would, in my view, be, amongst others, the fact that the commissioning mother is the legal mother of the child. The basis for reaching such a conclusion is that, surrogacy, is recognized as a lawful agreement in the eyes of law in this country. [See Baby Manji Yamada v. Union of India, (2008) 13 SCC 518]
As opposed to the previous interpretations in the Rama Pandey case, the court located the maternal rights of the commissioning mother right from conception. Not only does this interpretation negate any maternity rights of the surrogate mother, it also vests control over the surrogate’s body to the commissioning couple. The rational given for such an interpretation is the legality accorded to surrogacy arrangements by the Supreme Court in Baby Manjhi. This is a flawed reasoning as in Baby Manji the Court never went into the deeper aspects of surrogacy with regard to the rights of the parties concerned. Thus, citing the legality of agreement to rob the surrogate of rights otherwise recognised is not only an erroneous interpretation but also arbitrary and unjust. The Delhi high court in effect creates an arbitrary distinction between a woman who is pregnant and the surrogate. The result is the complete de-humanisation of the surrogate who is reduced to an entity, subject to the control of the commissioning couple for the course of the surrogacy. In this process, she is stripped of control over her body and any assertion of the same becomes a breach of her contract. Even the physiological changes undergone by the surrogate are given a secondary status compared to the onus on the commissioning mother to raise the child. It is also ironic that the court recognises the commissioning mother’s right to maternity leave but goes to lengths to negate the reproductive labour of the surrogate.
The courts have thus worked towards not only championing the rights of the commissioning mother but effectively stripping the surrogate of the little power she might have in the arrangement. By severing the rights of the surrogate and the child she bears, the courts re-affirm parenthood within the strict confines of genes and heredity. While such a reductionist interpretation is extremely problematic even if one agrees with it and accepts that the surrogate mother should not have any rights over the child she has carried for nine months, it still raises questions about role and rights of the surrogate in the arrangement. Recognising the commissioning couple’s rights over the child in the womb translates into control over the body of the surrogate for the duration of the pregnancy.
Unresolved issues
Frankly, we don’t know, as the entire text of the Bill is yet to be made public. Swaraj went to lengths to list the duty of the commissioning couple, including accepting the child completely and treating it as a biological child, but remained silent on the rights of the surrogate mother. Some of the questions that remained unanswered include: would the surrogate be allowed to abort the child in the first trimester on her own or would it be decided by the commissioning couple? Would the surrogate have to conform to the wishes of the commissioning couple during the pregnancy under the guise of the welfare of the child? How does the Bill aim to tackle the very patriarchal nature of Indian families where the ‘close family relation’ might not be allowed the space to exercise her agency or be ostracised for exercising it?
Swaraj is correct when she states that several women are exploited through forced commercial surrogacy arrangements. But surrogacy arrangements may be coerced even in familial relations; the mere absence of money does not remove the exploitative aspect from the arrangement.
A study I conducted in 2013 on commercial surrogacy in India (published by Tata Institute of Social Sciences) brought to fore the fact that it is financial necessity and economic security that compelled women to enter into surrogacy arrangements. Many women I spoke to in the course of the study said that if they could get other jobs they would not have become surrogates. It is this very reality that should also caution the state against a complete ban. The extreme poverty, and lack of social and economic security will continue even after a ban. Thus, similar to organ trade, the ban will only push the powerful and prosperous surrogacy industry underground. This, in effect, will make the surrogate even more vulnerable than at present through the added threat of prosecution.
The debates surrounding surrogacy should go beyond ethics and morality, and should take into consideration the larger political economy that not only compels women to become surrogates but also sustains the industry. The need of the hour is a well-thought out and cogent policy/law to safeguard the interests of the most vulnerable in the process – the surrogates. A simplistic ban is not the answer.
Championing the Surrogacy Regulation Bill, Sushma Swaraj said it will protect women from being exploited, especially by the rampant medical tourism industry.
Championing the Surrogacy Regulation Bill, Sushma Swaraj said it will protect women from being exploited, especially by the rampant medical tourism industry.
Sushma Swaraj headed the proposal for surrogacy regulation.Credit: PTI
New Delhi: India is all set to ban commercial surrogacy with the Surrogacy (Regulation) Bill 2016, being cleared by the cabinet for introduction in the winter session of parliament. The proposed law seeks to protect women from exploitation and ensure rights of the child born through surrogacy.
Once approved, there will be a complete ban on commercial surrogacy, but altruistic surrogacy will be permitted for needy infertile couples under strict regulations. The draft law allows only Indian citizens to avail of surrogacy, not foreigners, NRIs or PIOs. And in a provision that reflects the moral conservatism of policymakers – both in the present BJP-led government and the previous Congress-led one – the law discriminates against Indian citizens who are homosexuals, would-be single parents, and live-in couples. Individuals who fall in these categories will be ineligible to avail of surrogacy even if they are infertile. Finally, couples who already have children – biological or adopted – will not be allowed to go in for surrogacy, though they can adopt a child.
With virtually no law governing surrogacy, India, in recent years has emerged as a surrogacy hub for couples from different countries. There have been incidents concerning unethical practices, exploitation of surrogate mothers, abandonment of children born out of surrogacy and rackets of intermediaries importing human embryos and gametes as there is no real legal framework in place. There are about 2000 surrogacy clinics spread across the country. Several celebrities including Shah Rukh Khan and Tushar Kapoor have gone for surrogacy recently.
“Surrogacy is not a fashion or a hobby, but we have surrogacy as a celebrity culture,” said external affairs minister, Sushma Swaraj, who headed the group of ministers that looked into Bill and was fielded to explain its salient features to the media on Wednesday.
She brushed aside questions reporters asked about the exclusion of homosexuals from the law’s purview by saying “this is against our ethos”.
The draft law will allow surrogacy only for “legally married couples (man and woman)”after five years of marriage and with a certificate from a doctor saying that they are medically unfit to produce a child. Women within the age group of 23 years to 50 years and men aged between 26 to 55 years will be eligible to go in for surrogacy.
In an attempt to stamp out commercial exploitation and middlemen, the surrogate mother can only be a close relative, like a sister or sister-in-law who is married and has at least one healthy biological child. Even mothers can become surrogates for their children. A woman can be a surrogate only once in her lifetime. She will have to be medically insured. The commissioning parents will have to accept the child or children born to a surrogate mother irrespective of their number (twins or more), or their physical and mental condition. The child will have all the rights, including those of inheritance, as a biological child. “There will be no exchange of money between the prospective parents and the surrogate mother. The only expenses would be that of medical bills which will be paid to the clinic,’’ the minister said.
There have been instances of parents abandoning girls and mentally or physically disabled children or even taking one child if there were twins. Vulnerable women from poor families are lured to become surrogates for money, though it is the middleman or the surrogacy clinics which makes the most out of the process.
“I wonder why surrogacy has been linked to marriage,’’ N. Sarojini of Sama wanted to know. “My concern is on the implementation of the law. It should not lead to black-marketing or share the same fate as the Pre-Conception and Post-Natal Diagnostic Technique Act where the authorities hardly ever meet ,’’ she told The Wire.
Proposing a hefty penalty of imprisonment of not less than 10 years and a Rs 10 lakh fine for violating the provisions of the law, the Bill also requires all surrogacy clinics to be registered. The records of the child born through surrogacy will have to be maintained for 25 years just in case he/she wants to go through the records as an adult.
The Bill will regulate surrogacy in India by establishing a National Surrogacy Board at the central level and state surrogacy boards and appropriate authorities in the state and union territories. The Bill shall apply to whole of India, except the state of Jammu and Kashmir. The central surrogacy board will be headed by the union health and family welfare minister, while the secretary department of health research will be its vice chairperson. Three members of parliament will be selected as members of appropriate authorities in addition to a representative from a women’s group among others.
Surrogacy was earlier covered under the Assisted Reproductive Technology Bill, which the government has been trying to finalise for many years now. However, assisted reproductive technology would now be covered under a separate law.
Commercial surrogacy is banned in New Zealand, Australia, Japan, China, Mexico, the UK, Philippines, South Africa, Canada, Netherlands, Spain, Switzerland, Sweden, France, Germany and most European countries. Thailand and Nepal have recently banned commercial surrogacy in the wake of exploitation of women. Commercial surrogacy is allowed in Russia, the Ukraine and California in the US.
The 228th report of the Law Commission of India had recommended prohibiting commercial surrogacy and allowing ethical altruistic surrogacy to needy Indian citizens by enacting a suitable legislation.
In-vitro fertilization (IVF) expert, Anurag Bishnoi, recently in the news for helping an elderly couple in Amritsar have a child, has cautiously welcomed the draft of the Bill. “The present draft would impact medical tourism in the country. While quite a number of countries in the world including the United Kingdom do not allow surrogacy, particularly commercial surrogacy, those which do allow are governed by stringent guidelines,’’ Bishnoi said in a statement. How exactly the law will be implemented and monitored is unclear, he added.
