Dr Amit Malviya & Jurysha Nongdhar
In India the cost of health care has risen tremendously (and Meghalaya is no exception) but peculiarly due to low literacy rates people expect better outcomes, thinking that paying more money would save one’s life.
“Violence against doctors is nothing but a superficial sign of deeper systemic failure”
At the time when the whole world is gripped by a deadly pandemic and the entire medical fraternity in India is struggling with the second wave, we hear of heinous acts of violence against doctors. Violence against doctors is not unique to India and it is reported from both developing and developed countries. But, the unique and disturbing part is the frequency and severity of attacks which sometimes have fatal outcomes. Unique is the brutality and inhuman behaviour which is not seen elsewhere in the world. In a recent survey by IMA more than half of the doctors in this country reported stress due to fear of violence and around two thirds admitted to having faced some sort of violence in their practice.
I choose to write this article at a time when IMA is planning nationwide protests against these attacks. Does the treatment of a symptom cure the disease! Is it ok to bring down the fever caused by malaria with paracetamol without prescribing anti-malarial medicines? Would wearing black bands around the arms bring down the incidences of violence against doctors? Is it enough to demand higher security in hospitals? The point is, violence against doctors is a social evil and we need to learn the root causes for it before we plan to cure it. So let us explore the causes which are responsible for violence against health professionals in our country. Why we have reached such a stage where national protests are needed to protect doctors? Why is the human form of god on earth in so much danger in ourcountry?
The proximate cause: Readers would agree, that whenever a complication or death happens, the first thing which comes to mind of people (not all!) is that the doctor must be negligent or must have done given some wrong treatment. Why so? It’s because of lack of trust. The reasons may be many but we as citizens lack trust in our own medical system and healthcare delivery. Whenever the patient party decides to take the law in their own hands it’s because they feel cheated, dissatisfied and have a belief that something was left out. I am not justifying the act by any stretch of imagination but trying to reason with facts. If we look at the profile of these incidences, there are few things which are common to all. Small or peripherally located hospitals, poorly staffed, young doctors on duty, very sick patients or a small child and a mob with instigators. In India, perpetrators of violence are mainly patient’s relatives, unknown sympathizers and criminal offenders.There is a pre-set milieu in the society and sometimes with just the wrong situations it precipitates the ugly incidents. In the following paragraphs I discuss how these common factors are related to violence against doctors.
The root causes:
Policy matters
First and foremost causes of dissatisfaction among the community delivering healthcare in our country are the factors related to health policies, which over a period of time have resulted in overtly stressed health system, poor quality of healthcare and less equipped healthcare infrastructure. India spends around 3% of GDP on health which is very less, even when compared to other developing countries. More over healthcare delivery in India is uneven and only one-third of healthcare delivery is done by the government, the rest 70% is by private healthcare setups and dominant among those are small private hospitals with limited capabilities of treating sick patients. In India, there are 0.7 govt beds per 1000 population so majority of the patients have to seek care in private set-ups. The negative image of doctors and the role played by media, poor socio-economic status of the patient and the ever-rising cost of treatment make the small medical establishments particularly susceptible to violence and aggression at the time of billing or death of patient.
Social factor: Secondly, the conditions faced by patients attending hospitals for seeking treatment are quiet challenging . Overcrowding, long waiting time to meet doctors, absence of a congenial environment, multiple visits, sharing beds and poor hygiene and sanitation lead to anxiety and discontent amongst patients. In India the cost of health care has risen tremendously (and Meghalaya is no exception) but peculiarly due to low literacy rates people expect better outcomes, thinking that paying more money would save one’s life. Poor knowledge towards healthcare can also affect the perception of the community. There is a hidden and unspoken impression of profiteering by the doctors which has crippled the profession as well as doctors and this along with sensational media coverage of such incidences has led to a common belief that all doctors overcharge and all of them are inherently negligent. A person with a grievance does not trust the mechanisms of redressal provided by law. There is a perception in society that doctors being well connected will get away and hence there is a tendency to take the law into their own hands by resorting to violence. Another important social factor is the primal financial mindset and planning attitudes of majority of population in India. People still do not have health budgets or health insurance cover and any excessive expenditure incurred for health reasons leads to deep resentment. In private hospitals, the whole expenditure is often wrongly attributed to doctors’ fees. This unfairly leads to widespread antipathy in the minds of patients and their relatives, and in case of untoward outcomes of treatment, it finally culminates in violence against health-care providers.
Communication Gap: The third factor is lack of communication between the doctor and patient or attendants. Due to reasons such as being overworked, lack of time to explain matters, patient load etc., whatever little prognostication happens ends up in being ineffective. Because of this lack of rapport between doctors and patients/attendants and the communication gap in understanding all aspects of the illness and treatment including chances of complications, if anything untoward happens there is a sense that the doctor failed in his/her duty thereby leading to violence. Being a doctor and from the perspective of the medical fraternity I can assure one thing; no doctor ever wants to hurt his patient or to lose a patient. This is not only on moral and ethical grounds but professionally as well. after all it’s their livelihood.
The instigators
Fourthly, the political milieu of a particular place is a determinant in inflaming violence in the hospitals. Local strong men or politicians incite the crowd, either as a display of their power or to score brownie points amongst communities, on issues as sensitive as death of a loved one. Lack of health care infrastructure at the small PHCs raises serious issues. Patients needing critical care cannot be treated at such health centres which lack the basic facilities. Hence PHCs usually refer the patient to a CHC or Civil Hospital and this exposes the doctor to threats and intimidation by the relatives of the patient. Mob instigators take advantage of such situations. I am not denying that medical negligence does not exist but it’s very rare and for all practical purposes it does not gain enough priority to be in the list of root causes for inciting violence.
Lack of deterrence
Finally, In addition to above there are no strict laws to punish the perpetrators of such crimes and people take matters in their own hands as and when they feel that they are cheated. There is need of stricter laws than the current ones to deter people from indulging in such acts.
Good medical care cannot be achieved under conditions of fear, uncertainty, and suspicion.We need to have mandatory organizational and policy changes and stricter laws need to be enforced in our country along with widespread social elimination of this method of “instant justice “to ensure safe work place for doctors as well as for all health care professionals. A spirited effort from the government, media, social organizations and public at large is needed to uproot this social evil from our country.
A person with a grievance does not trust the mechanisms of redressal provided by law. There is a perception in society that doctors being well connected will get away and hence there is a tendency to take the law into their own hands by resorting to violence.
(Dr Amit Malviya, DM Cardiology, NEIGRIHMS, Shillong & Jurisha Nongdhar, MPH)