Battered and bruised | Tensions at Kerala hospitals

In Kerala, where it is typical for a patient to be accompanied by friends and family, tension at hospitals often spills over to violence. Long delay for patients in receiving treatment and underinvestment in fixing workforce shortages are being cited as the key reasons for the spike in attacks on frontline staff

Updated - December 23, 2022 04:48 pm IST

Published - December 22, 2022 07:51 pm IST - KOTTAYAM 

Illustration: Satheesh Vellinezhi

Illustration: Satheesh Vellinezhi

It began as a routine orthopaedic consultation — a middle-aged man was looking to treat his back pain. He got progressively more aggressive in the course of the conversation with his doctor, who insisted on conducting an X-ray test on the patient. 

Shaijumon K.M., a 36-year-old general practitioner who runs the clinic at Alanalloor, Palakkad, was in his cabin when he heard a confrontational conversation outside. “The orthopaedic was getting shouted at for something that was not within his control. So, I tried to intervene and it culminated in the patient’s son grabbing my collar,’’ he says.

While the incident, which took place on October 4, did have an impact on the morale of the clinic’s staff, what unfolded afterwards came as a real shocker for them. “The police refused to register a first information report for three days despite a complaint while we continued to receive a flurry of abusive and threatening phone calls. It took them another couple of weeks and a series of protests by the Indian Medical Association to record the assailant’s arrest,’’ says Dr. Shaijumon. 

Ashifa Noushad Ali, 47, casualty medical officer at the Nilambur Taluk Hospital, Malappuram, had just joined duty and was attending to the survivors of a POCSO case when two persons barged into the room. “One of them, who identified himself as an ambulance driver, straight away launched a verbal attack, stating that they had been waiting outside for more than three hours,’’ she says.

Although disheartened, she sought to ignore the incident for once but was soon forced to change her mind amidst a flurry of abuses for the second consecutive day at work. “This time, it was another man who hurled abuses, apparently instigated by the ambulance driver. The police initially appeared unwilling to proceed with the case but soon acted under immense political pressure,’’ she says.

In a State such as Kerala, where it is typical for a patient to be accompanied by friends and family, tension at hospitals often spills over to violence. The most recent episodes in this growing tide of violence were reported from Thiruvananthapuram on November 22, when a man kicked a lady doctor who reported the death of his wife, and from Adoor on December 11, when a patient applied pepper spray on a doctor. 

As per the latest figures provided by the State chapter of the Indian Medical Association, as many as 140 cases of harassment of medics were reported in the State during 2020-21 and 37 cases till November this year. 

These numbers, according to the healthcare workforce, is just the tip of the iceberg and part of a much-more widespread phenomenon where most cases of verbal aggressions are often condoned as emotional outbreaks. Stress levels have reached an almost unsustainable point in the workforce and they are in urgent need of recognition, reassurance, and realism from the government, they say. 

The medics blame patients’ increasingly long delays in receiving treatment and underinvestment by successive governments in fixing severe workforce shortages as the key reasons for a spike in attacks on the frontline staff.

“People are anxious and there can be problems with the healthcare infrastructure as well, which together contribute to the escalation of violence. Medics employed in the government sector, especially women, appear highly vulnerable to such unruly behaviour and its impact can lead to burnouts and, in some cases, depression,” says Samuel Koshy, previous State president of IMA Kerala, who carried out a State-wide campaign on the issue earlier this year. 

Quite frustratingly for the medical community, the police have been reluctant to invoke provisions of the Kerala Health Service Persons and Healthcare Services Institutions (Prevention of Violence and Damage to property) Act 2012, which stipulate imprisonment of up to three years for any attack on a duty-bound doctor, hospital or its staff. The political class, on their part, too have been accused of attempting to score brownie points at the cost of the public health-care staff. 

It is against this backdrop that Dr. Koshy calls for increased monitoring and action to fix accountability. “No one is saying that you are not allowed to have a different opinion,” he says, explaining that personal attacks and intimidation quite often go overboard. “It is really a mater of concern, especially when there appears to be a deliberate strategy by the political class to blame the individual staff for the systemic problems in the health sector. So, we need advocacy at all levels,” he says.

According to Bibin P. Mathew, a medical expert from Kottayam, the obvious risk is that doctors tend to practise defensive medicine. Qualified doctors are increasingly leaving the country out of fear whether work will live up to expectations and also that, over time, stress will begin to outweigh the rewards, he says. 

Binoy S., official spokesperson, Kerala Government Medical College Teachers’ Association, also points to a perfect storm of mismatch between patient demand and capacity in health services, often leading to violence. The staff pattern in the medical colleges, for instance, remains almost the same since 1966 but the patient load factor has more than doubled over the past couple of decades. Access to unverified information on the Internet has further added to the pressure of convincing the public. 

“While the pressure on primary care has been building over the years, there used to be a different dynamic in the government medical colleges. Not anymore. The public have not really caught up with how struggling the whole healthcare system is in tackling the backlog,” he says.

Hena Devadas, State secretariat member of the Kerala Government Nurses Association, too attests to the inadequate staffing levels in the medical college and its impact on delivering quality care. While the stipulated nurse-patient ratio is one to six, the ratio of patients in this equation now stands over 100. 

“Everyone in the workforce is completely shattered and the last thing they need is dealing with the frustration of people and to have a public that do not understand the pressures we are under,” she says. In her opinion, this mismatch between demand and capacity can be addressed to a good extend if the medical colleges turn themselves into referral centres offering specialty treatments only. 

But understaffing, according to B. Ekbal, public health activist and neurosurgeon, is only one part of an increasingly complex health policy picture of the State. The reality is that the healthcare system of Kerala is now carrying the burden of its own success. 

The mortality rate of the State, according to him, now remains on a par with that of the developed countries and the stories on remarkable achievements of Kerala in the public health sector have changed the people’s perception about the sector. “People tend to presume that since the hospitals are equipped with all the modern equipment, slipups must have come from the humans,” he says. 

He also calls for establishment of counselling rooms in all hospitals to ensure protocol-based communication to patients and their relatives. “This system of trainee doctors reporting the bereavement message should end,‘’ he says. 

Acknowledging the significance of effective communication in medical profession, Mohan Kunnummal, Vice Chancellor, Kerala University of Health Sciences, says the varsity has already launched a programme to improve communication skills of its students in Malayalam language.

“In line with a recommendation of the National Medical Commission, we are also launching a special programme to improve the communication skills of students across all streams of medical courses from the next academic year onwards,’’ he says.

The medics, however, recognise that attacks will continue until there is a willingness not just to condemn attacks but to really act towards prevention and accountability. It is in this context that they regard a latest order by a Division Bench of the Kerala High Court, which seeks Station House Officers of police to register a case on such attacks within one hour of receiving information and action against the offenders, to become a game changer. 

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