The gruesome murder of a young lady doctor at the R G Kar Medical College in Kolkata, as a cruel sequel to a barbaric sexual assault, created a surge of anger in a sea of societal shame. The case is now being investigated by the Central Bureau of Investigation under supervision of the Supreme Court which took suo motu notice of the case amid bickering between the central and state governments and conflicting claims from the CBI and West Bengal police.
Outrage at the dastardly crime also triggered a countrywide strike by doctors. This interrupted medical services, except for some emergency care. The medical profession was unified in its protest against the lack of assured and adequate protection for healthcare providers. The Indian Medical Association (IMA) led the protests in every state. Nurses and allied health professionals joined, not only out of solidarity but also because they too are often victims of abuse and assaults by irate attendants, or the family and friends of seriously ill patients.
Apart from the terrible tragedy in Kolkata, there have been numerous instances of violence against healthcare providers—only a fraction of which is reported in the media. An even smaller fraction of culprits face criminal charges. This often results in flash strikes by doctors, resulting in many patients being denied timely attention, investigation and treatment despite their being innocent of the crimes against medical personnel.
The distress caused to patients when medical services are suspended was poignantly voiced by the chief justice of India. The government’s many assurances that there would be strong measures—both to protect healthcare providers as well to punish offenders who indulged in physical or verbal aggression—did not carry conviction to the protestors. However, the CJI emotively appealed to the conscience of the striking doctors by affirming that doctors and judges cannot go on strike because their work “involved matters of life and liberty”. The court pointed out that if services are unavailable in public hospitals, those who need them the most would be affected.
On August 17, the Union health ministry announced the setting up of a committee to recommend measures to prevent and punish violence against doctors. However, the committee’s composition was not revealed, nor was a notification issued following the announcement. Judicial intervention by the CJI followed soon after. A national task force (NTF) comprising 10 eminent doctors and four high-ranking ex officio members was announced when the Supreme Court took up the Kolkata case.
The NTF has reputed specialist doctors drawn mostly from high-profile institutions in metros, but does not provide voice to doctors in district hospitals and remote medical colleges where violence is often inflicted on healthcare providers by irate mobs. Despite the short time available to it, the NTF should take a pan-India perspective to identify challenges at different levels and settings. They should also consider the safety and dignity of all categories of personnel working in clinical care institutions and public health programmes.
Given the short interval between the health ministry’s announcement and the Supreme Court’s constitution of the committee, it is not clear whether the government’s recommendations were reflected in or routed to the NTF. In any case, the top court’s intervention was impactful because its authority and intentions created greater confidence among doctors than the amorphous assurances by the government. The CJI emerged as a knight in shining judicial armour.
While the recent surge of angst among healthcare providers was allayed by the sensitive approach and astute problem-solving skills of the Supreme Court, the reasons for public misconduct and haunting insecurity often experienced by healthcare providers need to be identified and remedied if we have to find appropriate and enduring solutions. The causes vary from systemic deficiencies and structural faults to personal shortcomings like lack of communication skills.
There has been chronically low public financing of health services—failing to reach even 1.5 percent of the GDP for many decades, despite repeated affirmations of the intent to reach 2.5 percent. Health systems vary widely across states in budgetary investments, infrastructure, numbers and skills of different categories of personnel, assured availability of drugs and equipment, emergency transport, governance, constancy and cordiality of community engagement, and efficiency of inter-sectoral coordination. Even the private healthcare sector is heterogeneous in composition and imbalanced in geographic distribution. An overloaded healthcare provider is neither efficient nor empathetic.
Healthcare providers, especially doctors, had previously not been trained in soft skills like clear, courteous and compassionate communication. This is a much needed part of professional health education. The National Medical Commission is now trying to address this gap. Having medico-social workers to guide patients and physician assistants to communicate with attendants and families will reduce the travails of persons seeking care and lower the burden on doctors.
Safety and security protocols are needed for all healthcare institutions with regard to screening at entry and limits on visitors. The response to any untoward incident must be immediate and efficient, since waffling from a baffled administration will only enrage the offended. A national law for protection of doctors and other healthcare personnel was mooted by the national government in an agreement with the IMA in 2017, but it did not move ahead as health as well as law and order are state subjects. The Kerala government has enacted a Code Grey protocol, while the government of Delhi has adopted a Code Violet protocol.
Neither the Supreme Court nor the NTF can remedy all the causes of violence against healthcare providers, but they can certainly identify the problems that are fixable in the short term while proposing policy measures to restore the caring nature of the health system and prevent it from becoming an embattled arena of conflict and chaos. As both public health votaries and politicians will agree, prevention of disease, disorder and disaster is better than belated attempts at resuscitation, or rushed attempts at rescue and relief.
K Srinath Reddy
Distinguished Professor of public health, PHFI, and author of Pulse to Planet
(Views are personal)
(ksrinath.reddy@phfi.org)