There have been numerous media reports of instances of violence against doctors and health-care institutions across India. In most cases, the proximate cause is the death of a patient. All reports suggest that most of these patients could not have been saved with the infrastructure available in the institution, yet their deaths have been seen as a case of neglect by medical personnel. Doctors have responded to these attacks with anger and anguish, by striking work, demanding more security and even taking to social media with messages about how the profession is seen as an easy target.
Growing violence
Violence against doctors is not new. The World Health Organisation published guidelines on handling workplace violence in 2002. However, the incidence and intensity of violence against medical professionals in India is on the rise.
It is important to reflect on how the medical profession — always held in respect in our society — has come to such a sorry pass where health-care workers need protection from the very people they are meant to take care of. It appears that these attacks are symptomatic of a larger malaise, manifested in a general increase in violence as a method of demonstrating power, loss of faith in institutions, anger against perceived marginalisation, and lack of understanding of science and society. The violence against doctors is not the despairing violence of the victim who feels there is nothing to lose and wishes to make at least one statement in a life which has been perceived as full of oppression. It is rather the violence of those who feel empowered to beat another person to their will. It is an act of telling the assaulted that the aggressor can get what he wants from society and the victim better fall in line.In the last few years in India, we have seen several identity groups assaulting, or threatening to assault, people whose views they do not agree with. We have seen people being killed for their views. We have seen writers, film-makers, scientists and others being forced into submission. The state has failed to stand firm on the rule of law. It has become accepted and legitimised to use violence as a method of expressing disagreement. Civil society has been complicit. Each group in our fractured society becomes vocal only when its interests are affected. Thus doctors, pillars of the establishment, have failed to ensure the security of the established society by standing up against violence as a method of settling differences.
Seventy years after independence, we have come to a situation where there is widespread dissatisfaction with all institutions of society. All of them are seen as corrupt and self serving. It is only a matter of degree. No more is the doctor automatically held in high esteem. The default option is now to see him or her as lazy and greedy and ready to serve only the rich and powerful. The idea that most doctors are themselves victims in the current organisation of society, where on the one hand they are expected to be caring, compassionate, competent and considerate, and on the other are not assured of a definite career plan, have severe financial insecurity, especially in the earlier years and are often working long hours with very poor infrastructure does not seem to be understood by the doctors themselves. In their short-lived and usually futile strikes, no major changes are demanded of the government which would make practising medicine in India more meaningful for the profession and more useful for society. The present health-care system in India has inequity built in. Patients can see it. The demand by medical professionals for better pay is seen as selfish. It has to be coupled with demands for patient care such as better access, better facilities, and more personnel so that individual attention can be given. At present, most doctors are not advocates for patients. They play along with governments unwilling to spend on health care and accept the prevalent view that providing public sector health care is a favour and not a right. Doctors are seen as a part of the power structure. When they are attacked, public support and empathy is lacking.
A divide
Also, it is common knowledge that inequality is widespread in Indian society. A citizen’s ability to access common services is largely influenced by the social class to which they belong. Many people show off their social position by their ability to preferentially access public services. Thus the “VIP pass” has become a symbol of power. Discontent against this situation is growing. The discontent is coupled with a desire to prove one’s social position by forcing access to services through violence. The idea that “if I am somebody the doctor would have tried more”, is a proximate cause for assault. The tremendous technological advances in medicine are not available to the majority in India. Increasing privatisation, corporatisation and commercialisation of medical care have ensured that many procedures cannot be accessed by the general public. Examples of the privileged having access to extremely expensive care in the private sector, though many of these interventions are usually futile, propagates the idea that modern medicine can salvage even the most critically ill provided enough money is spent.
There is also a failure to establish and propagate a good understanding of modern science in India. Such understanding would encompass the knowledge that although medicine in the modern world has greatly improved the chances of survival in many serious conditions, there are also many situations in which no intervention will succeed. The continuous barrage in the popular media of this or that “miracle treatment”, and the deification of certain medical professionals as endowed with extraordinary abilities, encourages a false understanding in the public mind that if they had resources, they would have been able to access these extraordinary treatments and doctors. The truth is that such hype is generally completely untrue and driven by the desire for money and fame. Many doctors themselves believe in all kinds of superstitions and unverified and unverifiable treatments. They contribute to the ensuing confusion about what modern medicine can and cannot do. This poor understanding of science and of the limitations of modern medicine Otherwise, there remains a suspicion that all was not done to save the patient and that much more would have been done had the patient paid more for an expensive hospital and doctor. The frustration against their own position in society is vented by attacking the doctor and the facility.
A way out
What can be done? An immediate step is to ensure exemplary action against violence as a means of settling issues. This means that the state must impose the rule of law quickly and fairly, whenever the law is broken. Governments who speak of “action-reaction” and failed to act when the law was broken have sown the seeds of the present unhappy situation. More long-term measures require vastly improved health infrastructure, fewer patients per doctor in line with international norms so that care can not only be given but seen to be given.
Greater accountability is needed, not only from doctors but from all sections of society. Each professional group and government institution, whether they are doctors, civil servants, lawyers or judges cannot continue to act as though it is doing the public a favour by carrying out their duties. The general public must truly believe that the institutions of the state which have been nominally created to serve them are actually doing so. There should not be an adversarial relationship between the public and institutions.
Doctors should participate in spreading understanding of science and society. At present, the public often does not understand the deeper structural problems underlying the apparent failures of the doctors. Medical practitioners should help highlight these. Public anger is often justified, but it is directed against those who are not really responsible, but are forced to take the blame for problems which they have no resources to solve. We must propagate science better. There has to be a better understanding of how the world and society works. We should be able to debate and counter mumbo-jumbo.
The artificial divide between the medical community and the civil society should not be allowed to escalate.The general public must be convinced that except for a small number of really corrupt, most of the doctors are just trying to do what is possible in the circumstances in which they are. In their own interest to protect the doctor community. Differences with medical professionals — as with any other section of society — can never be settled by violence. Peoples’ committees in hospitals will be a welcome step. There must be a constant audit of the working hours of medical personnel and the fatigued doctor should not be left in the front line to deal with an emotionally charged public. Social workers in crucial departments such as accident and emergency wards to handle anxious crowds will certainly reduce the stress of already overburdened postgraduates and house surgeons.
Civil society and the medical community must together to demand better health care for our population. A more peaceful and civilised world has not come about by accident. It is the result of the cooperation of individuals and societies. We cannot falter now.
George Thomas is an orthopaedic surgeon at St. Isabel’s Hospital, Chennai and J. Amalorpavanathan is former Director, Department of Vascular Surgery, Madras Medical College, Chennai
