In the World Report on Violence and Health, the World Health Organization defines violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either result in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation”. Healthcare setting broadly refers to the array of services, interactions and places where healthcare occurs.
Over the past four years, we at the Association for Socially Applicable Research have been working on research and advocacy related to violence against healthcare workers. We have collected and collated data, highlighted the problem of violence, and engaged with grassroots workers and policymakers. Last year, noting the systemic nature of the problem and how it impacts all healthcare workers, ASAR released an online petition demanding that the Central government pass the Healthcare Service Personnel and Clinical Establishments (Prohibition of violence and Damage to Property) Bill, 2019, along with better implementation of State laws. The petition has received over 1,70,000 endorsements.
How we see violence
At this pivotal moment, we believe that it is time to fundamentally rethink how we look at violence. Healthcare spaces and interactions are about healing and are not just physical spaces such as hospital wards. For example, when an ASHA worker goes to a village to conduct an awareness campaign about COVID-19 vaccination, she carries a healthcare space with her. Violence includes physical, sexual, mental and emotional violence of differing severity.
Our healthcare settings are spaces of varying vulnerability for those providing as well as seeking care. People belonging to different socio-demographic groups have different risk profiles. Being young, female, and from a marginalised social group, for instance, can increase the risk of facing violence. Patients from poor economic backgrounds who do not have too many options for care are treated not just unfairly but at times violently in healthcare settings. Psychiatric patients are stripped off their dignity and rights. Violence against the elderly is not uncommon in crowded hospitals. Rich, upper caste men, who dominate the doctor cadre among providers, seek care in urban private multi-speciality hospitals where they are best protected from the violence.
The perpetrator-victim relationship can be complex to navigate. Data from decades along with narratives of the last few weeks have demonstrated that there are instances of violence against healthcare workers initiated by patients, visitors, and other healthcare workers. There are also instances of violence against patients from workers and other people in healthcare spaces. For instance, women healthcare workers and patients almost exclusively face sexual violence from men, regardless of the role of men in healthcare spaces. Healthcare workers lower in the power hierarchy, such as ASHA workers, midwives, and ambulance workers, might face a greater risk of violence due to lack of security. Young trainees and resident doctors are at greater risk of physical and mental violence from patient attendants and their seniors owing to more workload, long hours of duty, limited power, and a toxic work culture.
Violence is systemic and structural thereby mirroring the violence prevalent in society. Aspects of healthcare systems and broader societal structures including cultural elements, legal frameworks, and political influences facilitate such violence. This view makes it apparent that certain groups such as lower caste women are more vulnerable to violence than others in healthcare since they are at greater risk of injustices and violence in society.
Articles on the Editorial/Opinion pages that look at the issues of safety and spaces for women, and the adequacy of societal responses and the justice system.
Shift in perspective
We strongly believe that the problem at hand is not just violence against doctors or even healthcare workers; it is violence in healthcare. This shift in thinking is not exactly new, but it is much needed for India. Our view is supported by the international humanitarian law (IHL) that provides a universal legal framework for the rights and obligations of a country in cases of international and national armed conflicts. The IHL mandates the protection of health establishments, healthcare personnel, and the wounded and sick, in case of any violence. It is imperative that this protection is extended generally beyond conflicts where violence is systemic. It is essential that healthcare remains safe and protected, in all circumstances.
Many countries recognise that violence can impact everyone in healthcare. In 2017, Taiwan enacted legislation to protect all healthcare workers and the rights of patients. This also involves stringent prosecution of anyone in the healthcare setting hindering the provision of healthcare services. For accreditation, hospital administrations are required to identify high-risk areas for conflict, such as the emergency department, and ensure strict security. Patient safety takes utmost importance and is a core responsibility of the medical institutions. Anyone found causing harm to a patient is liable to a fine that amounts to ₹70,000- 1,30,000. Violence against healthcare workers is punishable by a fine of up to ₹7,00,000 and imprisonment of up to three years, or may be subject to life imprisonment if the act leads to death of the worker. Learning from such precedents could highly benefit Indian healthcare.
Although violence is a nuanced problem, it is unequivocal that healthcare spaces are a place for healing and there should be no tolerance to any kind of violence that is counterproductive. While the end goal should be to solve social problems, strong formulation and implementation of policies and laws that protect everyone within the healthcare spaces is the starting point.
While the end goal should be to solve social problems, strong formulation and implementation of policies and laws that protect everyone within healthcare spaces is the starting point.
Aatmika Nair, Uma Gupta, Anoushka Arora, Shirish Rao and Siddhesh Zadey are with the Association for Socially Applicable Research (ASAR).
Published - August 27, 2024 01:26 am IST
