Mumbai: The recent series of attacks on doctors in Maharashtra evoked immense anger within the medical community. Outside the community, some blamed the poor communication skills of — or lack of communication from — resident doctors for the wrath of relatives, and say the escalation to violence is a result of grief or stress.
What gets ignored is the overload on the public healthcare infrastructure that these doctors work in.
A resident doctor in charge of a ward that should accommodate 40 patients usually winds up serving double the number. She or he has little time for gentle conversation with the relatives of patients.
As to the relatives, in addition to their anxiety for their loved one, they are usually already facing additional stress from dealing with unfamiliar tasks like filling out forms, moving their sick family members on stretchers or wheelchairs from one department to another, then fetching test reports and other errands. In this situation, when they see their loved ones’ condition deteriorating, frustration mounts to anger which is, unfortunately, targeted at the person who is the effective face of the hospital, the resident doctor.
“When a group of relatives assault a doctor, he is a mere scapegoat,” says Lalit Kapoor, a senior member of the Association of Medical Consultants (AMC). “The assault is actually on the government, and its infrastructure that is overloaded.” Dr. Kapoor, who is now 71, has been a resident doctor at the Grant Medical College attached to the state-run JJ Hospital early in his career. “Earlier there was no crowd, so there were no attacks. Now the situation is such that the government has a glass with one-litre capacity but it is pouring three litres of milk in it. No one can avoid the spill.”
The gap in the middle
The Municipal Corporation of Greater Mumbai (MCGM) has a three-tier healthcare system. At the primary care level, it runs over 160 dispensaries that administer to minor ailments. For secondary care, there are 16 peripheral hospitals. And for tertiary care, the serious cases, it has Sion hospital, King Edward Memorial, and the BYL Nair Hospital.
The civic body’s grand plans to revamp its dispensaries so that sick people in every part of the city can get treated at the local level for minor ailments have remained on paper. Add to this the lack of facilities in the peripheral hospitals like Cooper in Vile Parle, Shatabdi in Kandivali, and V.N. Desai in Santacruz (and Bhagwati in Borivali, currently shut for renovation), and you have a situation where there is an extra load on the tertiary-care hospitals. State-run hospitals, like Gokuldas Tejpal, Cama & Albless, and St. George, are in much the same situation: in many cases, unable to handle critical cases, they ask patients to go to the Sir JJ Hospital.
“The secondary level public hospitals are a completely failure,” says health activist Abhay Shukla of Jan Swasthya Abhiyan. “This is where the private hospitals like smaller nursing homes have stepped in, but they are eventually bleeding patients. Eventually the patients are landing up in the tertiary-care hospitals and overcrowding them. The decentralisation that is required doesn’t exist.” Dr. Shukla says that, ideally, patients who can be treated in dispensaries and peripheral set-ups should be turned away from the tertiary-care hospital and asked to get treatment in other facilities near to them.
Poor conditions for patients
The MCGM has over 5000 Class IV workers, the orderlies referred to as ‘ward boys’ and ‘ward ayahs’ in everyday speech in the city. These orderlies are supposed to help move stretchers and ferry pathology samples for tests and bringing back reports; in reality, a ward boy or an ayah helping patients is almost an anomaly.
The Class IV workers have a reputation for alcoholism and absenteeism. Their low pay grades see them openly soliciting tips — bribes for all practical purposes — to do their jobs, which just adds to the misery of patients and their relatives. A Sewree resident, whose wife was admitted in Sion hospital for a little over a week, said, “If you hand them a note of ₹50, they will run the errands for your admitted patient. Most ward boys and ayahs will not move an inch for you without money, even if you are on the verge of collapse.”
City civic hospitals also have the unfortunate reputation for being extremely filthy, as hospital authorities seem to ignore hygiene and cleanliness, and the support staff are indifferent. The Sion and Nair hospitals are particularly notorious for dirty corridors.
In a small positive development for patients, cardiologist Prafulla Kerkar, who has been practicing in the civic run KEM Hospital for 30 years, says that the BMC is in the process of putting a computerised system in place so that reports can be accessed anywhere. “This will definitely cut down the stress of relatives to a certain extent,” Dr. Kerkar says.
Resident targets
Doctors were once taught to address patients with the ‘3 Esses’: a Smiling face, Sweet talk and then the Stethoscope. The first two are a rare sight today, especially in public hospitals.
Senior doctors, usually with their own private practices as well, spend a limited amount of time in public hospitals. Most of them avoid appointments in the primary or secondary care tiers. This leaves the resident doctors running the show.
“Resident doctors are cheap labour for the government,” says Dr. Kapoor of the AMC. “They are merely post-graduate students who are gaining practical experience on the field. Why should the hospital services collapse if they are not at work? The answer is simple: [the government] doesn’t want to employ full-time doctors who will come at a heavy cost.”
A resident doctor at the Sion hospital, who asked that his name not be used, says, “After seeing more than 2000 patients in the out-patient department, or working on emergency duty for 30 hours at a stretch, we come back to extremely shabby resident quarters. We don’t even get the time to study or relax.” He says that complaints to the hospital’s dean, Dr. Suleman Merchant, about the shabby resident quarters, have fallen on deaf ears. Given their stressful lives and substandard living conditions, would one expect them to smile? “I am not in support doctors who are impolite,” he says, while admitting that, sometimes, resident doctors fail to explain thing properly to relatives, “but this doesn’t mean that the patient is not being taken care of.”
Contempt for law
A few months ago, a relative of a patient hurled a chappal at a senior doctor in Sion Hospital. This incident, like many other attacks and incidents of abusive behaviour with doctors, went unreported.
Doctors agree that it is very rare that emotional relatives resort to violence. According to Dr. Kapoor, “It is almost always a man from the locality who believes he is a social worker, or some bully who will initiate the attack and instigate the relatives.” He says such people are confident that they will face no retribution, because they know of others who have indulged in such violence and got away with it.
“Many a time, even security guards get beaten up by these bullies,” a senior security officer in Nair Hospital says. “We have had three such attacks on security guards in the past two years. People need to fear the law, only then these attacks will stop,”
The State is in the process of deploying armed personnel in the hospitals. Dr. Shukla says that is hardly a solution: “Till now, relatives were beating up doctors. Now guards will start beating up people. The government has to look for a deeper solution. And that is, strengthen the infrastructure at the ground level.”
