Nearly two years into a global pandemic that has turned the world upside down, strange happenings and unforeseen breaking news have become our staple diet. In this overwhelming barrage of negativity and abject nihilism, it may seem cumbersome to read yet another article that makes you worry about the world. But we assure you, this isn’t the regular read. What we’ve tried to do is put forth some numbers and experiences for your perusal. Empathise, or sympathise, we would leave that to your judgment.
Like every other ‘normal’ that’s been flipped, there’s a shift in hospitals these days. Doctors, nurses, and other healthcare workers not only have to put on personal protective equipment (PPE) but also have to steel themselves against their fears of being abused, threatened, and even violently attacked.
India presents a difficult dichotomy where a culture of deifying medical professionals runs parallelly with anger and violence towards them.
Generalised name-calling, including ‘demons’ and ‘money-making parasites’, by patients, their families, and even the media, has somehow become a norm.
Staggering Figures
Some of the patients’ frustrations are understandable and healthcare workers (HCWs) have their share of responsibility towards enhancing the quality of medical care and improving the communication with the patients and families. However, violence against people caring for your health hardly seems like a valid response. Violence against healthcare workers has risen globally in the past few years, and the COVID-19 pandemic has only exacerbated the problem.
Globally, 62% of HCWs have experienced some kind of violence at the workplace, with close to 25% having experienced physical assault, while 57% have faced some form of non-physical assault such as verbal abuse. While these numbers are staggering, India has a disproportionately high share of violence-related incidents and has garnered global attention for the particularly discriminatory and vehement opposition to doctors during the COVID-19 pandemic. A recent study found that 75% of Indian doctors have experienced violence of some kind in the workplace, with 63% unable to visit patients without fear of violent action. Most of these issues materialise in high-stress situations, like during psychiatric treatment or in an intensive care unit (ICU).
Insecurity Insight (II), a not-for-profit organisation dedicated to collecting global data on people in high-risk situations and generating actionable insights based on them, has reported a total of 200 incidents of violence against healthcare workers (VAHCW) in India during the past five years, of which 133 (66.5%) incidents took place during the pandemic in the past one year
Data from the Safeguarding Health in Conflict Coalition (SHCC) show that there has been a sharp rise in the number of healthcare workers assaulted in India, from 49 in 2017 to 155 in 2020. (Figure 1)
Category-wise VAHCW incidents in India. Data based on 'Safeguarding Health in Conflict Coalition (SHCC)' for 2017 (the most recent year for routine Indian data) and COVID-19 pandemic (January-December 2020). Incidents are aggregated over multiple perpetrators (state forces, civilians, non-state actors).
(Figure credits: Siddhesh Zadey, ASAR)
While violence against healthcare workers and disruption of health systems is considered primarily a problem in conflict settings, where it might be beneficial to cripple your adversaries’ health infrastructure, data clearly highlight the extent to which violence is also perpetrated by civilians – a group composed mostly of relatives of the patients. Although the II monitoring systems have started picking up more of the Indian data only since the last year, the problem has been chronic. When the Association for Socially Applicable Research (ASAR) reviewed data from two previously published studies covering the period from 2007-2019, they found a high incidence of violent events.
But Who Ultimately Gets Hurt?
However, looking at the number of such incidents is a very narrow way of understanding the problem. Beyond the numbers, we need to look into the downstream impacts of such attacks on healthcare workers, i.e., how they affect the broader society. Can unsafe healthcare workers do their jobs well? If healthcare workers can't function at their best, wouldn't it ultimately hurt the patients? Employing the rhetoric of the impact that violence against healthcare workers might have on the population's health can enable better advocacy for the protection of healthcare workers.
The problem of violence also needs to be understood within the context of the health system. For instance, improper management due to limited resources and staff in public hospitals, high care costs, and extended stays in private hospitals are key factors leading to situations that can turn violent. During the pandemic, widespread fear, mistrust, and myths about COVID-19 further aggravated violence against healthcare workers.
The government of India has temporarily amended the Epidemic Diseases Act to mitigate the problem, but it lacks effective implementation. More importantly, this Act in no way can solve the larger systemic problem that Indian healthcare workers face.
Violence against healthcare workers is dealt with quite differently across Indian states and Union Territories (UTs). The offence is cognisable (i.e., a criminal offence where the police can arrest without a warrant to conduct an investigation with or without a court's consent) and non-bailable in 26 states and UTs. Of these, 25 states and UTs have implemented the Medicare Service Persons and Medicare Service Institutions (Prevention of Violence and Damage to Property) Act, 2008, and despite assault being a punishable offence under the Indian Penal Code, the process to seek remedy is not streamlined.
Can Stringent Laws Help?
Apart from these, Madhya Pradesh has implemented a special law, ‘The Madhya Pradesh Chikitsak Tatha Chikitsa Seva Se Sambaddha Vyaktiyon Ki Suraksha Adhiniyam', which makes violence against healthcare workers a cognisable and non-bailable offence. Jammu & Kashmir, Meghalaya, Mizoram, Nagaland, Sikkim, Andaman & Nicobar Islands, Chandigarh, Dadra & Nagar Haveli, Daman & Diu, Ladakh, Lakshadweep have no laws at all. For 19 states, the penalty fine is Rs 50,000, and for 18 of them, there is a prison sentence of up to three years (excluding the state of Punjab, where imprisonment is up to one year).
Arunachal Pradesh has a very high fine of Rs 5,00,000, whereas Himachal Pradesh imposes a fine as low as Rs 5,000. Laws in Haryana, Tamil Nadu, and the Union Territory of Puducherry do not specify a precise punitive sum while stating, "Liable to pay compensation for the damage or loss caused to the property". The law is ambiguous in the Union Territory of Chandigarh, which is a shared capital of Punjab and Haryana. Among several other reasons, it is possible that the existence of legislation that holds perpetrators of violence accountable has contributed to null or minimal recorded incidents in regions such as Goa, Manipur, Haryana, Arunachal Pradesh, Jharkhand, Chhattisgarh, Himachal Pradesh, and Puducherry.
State-wise VAHCW incidents and variation in penalisation (nature of offense, imprisonment, monetary fine) against VAHCW under the Protection of Medicare Service Persons and Medicare Service Institutions Act. Ranjan et al. 2018 and Mehta et al. 2020 use different methods for defining and searching incidents of VAHCW. The data for Jammu & Kashmir and Ladakh is shared, as it was collected before the splitting of the state formerly known as Jammu & Kashmir.
(Figure Credits: Dr. Vincy Koshy, ASAR)
In a recent article published in the British Medical Journal, we suggested that enactment of a central law and improved enforcement of existing state laws are the steps that governments must take to grant justice to healthcare workers who have experienced violence and abuse in the line of duty.
The Healthcare Sector Needs Deep Reforms
The pandemic has put a spotlight on the vulnerabilities of the health system and problems faced by healthcare workers. However, India faces systemic issues within a labour-intensive healthcare sector, marred by years of public under-funding with a social narrative calling out healthcare workers when economic and social determinants have been ignored by the government for decades.
We need to advocate for better policies on the matter. Back in 2019, the Ministry of Health and Family Welfare proposed the Health Services Personnel and Clinical Establishments (Prohibition of Violence and Damage to Property) Bill, which could impose jail sentences of up to 10 years and an indemnity penalty of up to Rs 10,00,000 on those assaulting healthcare workers. It also accorded healthcare workers a broad definition, including doctors, dentists, nurses, paramedics as well as medical students, diagnostic technicians and ambulance drivers.
However, this publicly popular Bill was repudiated by the Ministry of Home Affairs, citing that a special law for the protection of doctors is neither necessary nor appropriate. As pointed out here and at other places, there is enough and growing evidence that special protections are needed. Otherwise, we might soon see a day with no healthcare workers willing to work in our country.
It's critical to invest in developing stronger surveillance systems around violence against healthcare so we can measure and understand its scope and see where workers are most vulnerable. With increased surveillance and analysis of past incidents, we can have a better understanding of how to deal with this issue. We also need to think about prevention – along with prosecution – as a potential solution. By deconstructing data and understanding the different contexts of such attacks, there is potential to learn communication and counselling techniques, and also de-escalation strategies, at instances of conflict.
Almost every other day, there is a new report on assault against a healthcare worker in some part of the country. There is a critical role here for the citizens, with a clear incentive. If healthcare workers feel safe, they can provide better care to the patients.
Cracks in the 'Big Picture'
Beyond the HCW community, we need public action seeking reform from governmental agencies. Dr Rajeev Joshi, a practising paediatrician and former President of the Indian Association for Medical Informatics (IAMI), says:
"There is no citizen-led activism for protection of doctors from violence. I am not saying that there is no negligence or misbehaviour from doctors, but the remedy for the wrong is not violence.”
However, he also notes that actions that he and others like him have been taking: “The phenomenon of medical accidents is neither appreciated by patients, government, nor judiciary, which is the commonest cause of mishaps during medical treatment leading to an unexpected, undesired outcome. Jurisprudence teaches that duty comes with corresponding rights, so I decided to file a Public Interest Litigation requesting the Hon'ble Court to issue guidelines to protect doctors.”
As we emerge from the pandemic, let's zoom out and see the picture the way it is – broken.
(Siddhesh Zadey BSMS MScGH, is a co-founder of the non-profit think tank ASAR. Madhav Bansal is an MBBS student and a volunteer researcher at ASAR. Yash Kamath is also an MBBS Student and a research intern at ASAR. Rohini Haar, MD, is an emergency physician and a research fellow at the Human Rights Center at UC Berkeley’s School of Law. Christina Wille, PhD, is the director of Insecurity Insight, a Geneva-based not-for-profit organisation. This is an opinion piece and the views expressed above are the author’s own. The Quint neither endorses nor is responsible for them.)
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