As I write, an all India cessation of non-emergency services by doctors (residents to be specific) tomorrow is in the works and protests of some sort or the other have been ongoing from the past few days. The trigger for this outpouring of anger and frustration by the medical fraternity, was a depressed skull fracture suffered by Dr. Paribaha Mukhopadhyay, an intern at NRS Medical College, Kolkata as a result of an attack by a 200 strong mob; consisting of the relatives and acquaintances of an elderly gentleman who died while receiving treatment at the NRS Hospital. Attacks on health-care practitioners and allied staff in India are a fairly common occurrence, but the sheer brutality of this particular incident and subsequent mishandling of the matter by the Chief Minister of West Bengal, Mamata Banerjee (who incidentally also holds portfolios of both Health and Home), has made the entire medical fraternity raise its voice in an unprecedented manner and say enough is enough. This article seeks to explore the issue of violence against health-care practitioners in some detail and try to come up with some possible preventive measures.
- VIOLENCE AGAINST MEDICOS- INDIA SPECIFIC, OR WORLD-WIDE PHENOMENON?
Being a health-care practitioner in a 1.25 billion strong nation with meagre budgetary spending on health, is quite a challenge; so one would probably assume that violence against medicos is something unique to India or similar developing countries.
A WHO Publication puts the percentage of Health Care Personnel who experienced at least one incidence of violence (physical or psychological) in the past year at 67% for Australia, 61% in South Africa, 54% in Thailand and 47% in Brazil, with a caveat that these numbers could actually be much lower than actual incidence, as in many cases the incidents go unreported. Corresponding figures for Israel and United Kingdom stand at 74% and 65% respectively; in the United States, 3 out of every 4 cases related to workplace violence are reported from the health care set up (source-http://pimr.org.in/amitav-vol-6-issue-3-2018.PDF).
An Indian Medical Association study came to a conclusion that 75% of doctors in India have faced violence at some point or the other in their careers; most cases being reported form ICUs (Intensive Care Units) and the perpetrators commonly being patient attendants. So, it is safe to conclude, that violence against medical practitioners is fairly prevalent across the globe and is not confined to India or the developing nations.
- POSSIBLE REASONS FOR SUCH HIGH RATES OF VIOLENCE:
Now that it is established that violence against health care professionals is not so uncommon, it is incumbent upon us, to explore the reasons behind such a grim situation. In the hugely overburdened government health sector, challenges are faced by both patients and doctors- patients have unbearably long waiting times before being attended by the staff on duty, while the staff in turn has prolonged and sometimes inhuman working hours. In such a situation, fuses run short on both ends; attendants accompanying the patients end up being frustrated and when the doctor on duty comes to attend the ‘n’th case in a long (and lengthening) list of patients, he or she is not in the best of moods either. Thus, it is a ticking time bomb of sorts.
The above is compounded by the chasm of communication. Most medical studies, patient records and even the labels on drug packaging are in English, a language which most of the patients hardly understand. Thus, what builds is a gap in communication and trust. The author himself has experienced that many a time the patient comes back arguing, ‘Doctor, you wrote a page full of stuff on my patient card, but I got only 1 or 2 medicines from the pharmacy. Where are the other medicines?’ Since the patient can not read English, he or she can not be expected to understand that most of what is written on the case sheet is simply a summary of the patient’s complaints and diagnosis, the medications prescribed come in only at the end. An article in the Indian Journal of Medical Ethics, also zeroes into this communication conundrum as one of the causes, and adds, that situations like sudden deaths during night hours, have only junior doctors present at such times to communicate such delicate news to the attendants. The junior doctors, themselves unexperienced, are not always the best of the communicators.
The immediate enabling factor is the poor security apparatus at most government hospitals. Unlike other public places with high-footfall, there is hardly any screening or checking of entrants from a security point of view in hospitals. The very fact that a mob of 200 odd could reach right where the doctors were working, without encountering any resistance, speaks volumes about the inadequacy of security provisions. During the course of the current protest, one got to hear repeatedly, that doctors are considered soft targets, who can be attacked without fear of any consequences. It is a debatable point of view, because most attacks on doctors, are carried out in the heat of the moment and not premeditated. Since the crime is one of passion, it is doubtful if the doctor or other medical staff being thought of as a soft target has much to do with such incidents. On a subconscious level, at best maybe.
There are some other factors as well, which add fuel to the fire of frustration– ballooning of pocket health expenditure, lack of the basic most of supplies and health infrastructure (meaning more need for the patient to procure them from private medical stores), late arrival to the hospital (many a time due to loss of crucial hours at hands of quacks), due to which the patient is already in a non-salvageable state by the time he or she receives attention from the doctor and the popular culture which places the doctors on a pedestal as equivalent to Gods, leading to high expectations.
- WHAT DOES THE LAW SAY IN INDIA, AND HOW DOES IT COMPARE TO OTHER COUNTIRES?
One of the demands of the protesting doctors (which in principle was accepted by Dr. Harshavardhan, the Hon. Union Minister of Health and Family Welfare), is a strong law to deal with perpetrators of violence against health care professionals. It is interesting to note, that there already exists, in as many as 19 states of India (including West Bengal), a Protection Of Medicare Service Persons And Medicare Service Institutions (Prevention Of Violence And Damage To Property) Act, also known as the Medical Protection Act (MPA). As per provisions of the Act, attacking a health-care professional or causing damage to property in a health-care facility can attract a fine of Rs. 50,000 and a jail term of 3 years. Additionally, there are the general provisions of the Indian Penal Code (IPC) dealing with assault, injury and grievous injury (the fracture suffered by Dr. Paribaho would have been one). Protection of patient rights, falls under the Consumer Protection Act (COPRA).
There are problems with the implementation of the MPA, as it is as yet not included in the IPC or CrPC (Code of Criminal Procedure) and the law enforcement system in India is ill-famed for its tedious, slow moving pace. Moreover, in many cases (possibly including the latest one in Kolkata), the perpetrators of violence against the health-practitioners are linked to the party in power at the local level or enjoy its patronage. In such cases, the law enforcement machinery can hardly be expected to be unbiased and efficient in bringing to book the perpetrators.
Queensland, Australia has one of the harshest laws to deal with violence against healthcare professionals, with provisions of imprisonment of up to 14 years. A new law promised by Dr. Harshavardhan (Hon. Minister of Health and Family Welfare, Government of India), comes close- with 12 years of imprisonment in such cases, envisaged to be made part of the law. The National Health Service in United Kingdom has a ‘Zero Tolerance’ policy towards violence against health professionals. The Assaults on Emergency Workers (Offences) Act provides for imprisonment up to 12 months. Even in the much more federal United States of America, with provisions differing from state to state, of late, there have been calls to move towards more uniform policies to deal with and prevent violence against health-care professionals, an example being the Health Care Workplace Violence Prevention Act tabled in 2018.
- POSSIBLE PREVENTIVE AND DETERRENT MEASURES?
For a country of the scale of India, any problem is a complex one and does not have any easy one stop solution. While the strengthening of laws (more importantly ensuring correct implementation) and providing more security at workplaces of health-care professionals will definitely go a long way towards ameliorating this pressing problem, there is also much more which needs to be done.
Firstly, training in communication, identifying, pre-empting and dealing with tricky situations (which have potential of spiralling out of hand) needs to be included in the syllabus of medical schools right from early years. Simulations and mock-drills could be carried out from time to time to check the systems at hand and plug loopholes, if any. One possible step could be gradually incorporating indigenous languages more and more in the med-school syllabus, to enable better doctor-patient communication and mutual understanding.
Better screening and security checks at the entrance to the hospital, to flush out any articles that could possibly be used to attack others could help. Moreover, there needs to be a strict cap on the number of attendants that are allowed to step into the emergency or ward areas along with one patient. Another step that could help, is divesting security of hospitals (at least the large ones) from local police forces (most liable to be influenced by local ruling politicians) and handing it over to a force on the lines of CISF (Central Industrial Police Force), which provides security to airports and metro stations.
There are many from within and outside the fraternity that push for self-defence training for doctors. While not a bad idea entirely, it’s utility in the real world is debatable. In many cases of violence, the doctor is simply outnumbered by patient attendants. Also, how such a practice bodes for the doctor-patient relationship, based on trust and compassion, is something to be thought about.
Long term solutions for this problem, of course, lie in enhancing the per-capita budgetary spending on health, ensuring proper supply of essential drugs and consumables in the government set-up, subsidised health insurances (Ayushman Bharat for example) to reduce the out-of-pocket expenditure and most importantly, inculcating a rational and humane perspective right from the schooling years in the masses at large, so that fewer and fewer end up perpetrating such violence in the heat of the moment.
