Indian doctors take to streets to demand better securityBMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1518 (Published 24 March 2017) Cite this as: BMJ 2017;356:j1518
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In mid-2016, a doctor, the medical superintendent of a district hospital in one of the remote districts of Nepal, was badly assaulted and had black soot smeared in his face by a group of people(1). This is a story from Nepal, where doctors are compared with god and the medical profession is considered to be one of the respected and noble professions. Blaming doctors for the patient’s death, negligence by doctors in treatment are frequently heard in recent years. Demanding financial compensation seems to be the motive in many cases. There are circumstances where settlement of cases of death in hospital ended up with financial transactions. This has led to the formation of groups, to gather a mob in the hospitals claiming for financial compensation and keeping a certain percentage of money as a share.
Not much research can be found regarding this issue. The root cause for this issue should be analyzed both from the demand and supply side. Long duration of working hours among doctors resulting in poor communication with patient, patient or patients’ relatives stress due to waiting time, increasing privatization, and ineffective hospital management are some issues to be considered(2). This has already been an alarming issue in this part of the world. Effective measures and policies should be implemented by the government taking into consideration all the stakeholders.
1. Lamichhane S. Doctors under threat. The Kathmandu Post [Internet]. 2016; Available from: http://kathmandupost.ekantipur.com/news/2016-07-01/doctors-under-threat....
2. Magar A. Violence against doctors in Nepal. J Nepal Med Assoc. 2013;52(192):8–9.
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Almost all these attacks are in government hospitals. Doctors are overworked. Why do we have this system of 36 hour duties? Can we not have better manpower planning? Do we allow air pilots to fly for 36 hours at a stretch? Do we allow bus drivers to drive 36 hours at a stretch? Then why this insanity in the medical profession? The government must restrict work hours and hire more doctors.
The problem with government healthcare in India is, there is no ownership. National health programs are funded by the Centre but health is a state subject. It is almost as if there has been a neat division of labour where the central government funds preventive and promotive care and the states are supposed to fund the tertiary care. Plus the fact that health is not an election issue in India. Unless people demand better care, politicians in India are not going to spend on it. It is shameful that Indian public hospitals do not have enough ward boys. Paradoxically, attacks like these might actually help India’s healthcare system in the long run, since they bring into the limelight the lacunae in the system, which administrators and politicians are then forced to address, hopefully.
Senior doctors have to show the way in shouldering the workload as well as dealing sensitively with patients. But this is easier said than done if the workload is irrational. An overworked doctor is an insensitive doctor. Workload rationalisation is the crying need of the hour.
Several cases land up at government hospitals after inappropriate care in the early stages where the patients might have approached either quacks or doctors who didn’t exactly follow prescribed treatment approaches. In most cases, patient education is abysmal, and even simple things like lifestyle changes for hypertension and diabetes aren’t stressed upon, with the entire focus being medication oriented. Even here, there is tremendous mismanagement. For example, the patient may not be trained in the right way to administer a daily insulin injection. These are the result of a weak public primary healthcare system.
It beats us why the Indian government has to bring in a bill to spend 2.5% of GDP on healthcare. They certainly didn’t feel the need to bring in a bill when they wrote off Rupees 6.11 lakh crore rupees ($91 billion) in corporate subsidy, i.e. subsidy to the rich, in the last financial year. And this is an annual phenomenon. The size of the Indian budget was just under 20 lakh crore rupees ($300 billion). Which means an amount almost a third of the size of the Indian budget is being forgone each year. Misplaced priorities are costing India dear.
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Doctors leaders and organisations need to do more about violence
Recent incidents of extreme mob violence targeting hospital doctors in India are horrifying [Ref 1]. Doctors have felt compelled to go on strike demanding better protection from irate relatives.
The incidents of violence and the response of doctors' organisations must both be seen in the social and political context of contemporary developments in India. Doctors - and indeed patients too - have been let down both by poor leadership of the profession and by populist governments that have invested pitifully small sums on publicly funded health care systems.
Doctors in general are seen as rich and well-paid. They are also sadly seen, not entirely without evidence, as exploitative. There is a widespread mistrust of doctors and a belief that they act as a cartel ordering unnecessary tests, inflating bills, and carrying out unnecessary procedures. The leaders of the profession have done little to call a halt to such practices nor to call out and act against those of its members who are corrupt. There is no generally agreed mechanism for patients and families to complain of poor- quality care. When complaints are made the response is far from open and welcoming. Legal cases take years if not decades to settle and the profession closes ranks. Doctors' training in ethics, behavioural sciences and compassion is woefully inadequate. A doctor-knows-best attitude coupled with a do-as-I-say approach to decision making is widely prevalent. The resultant paternalistic attitude to clinical medicine means that doctors are generally content to occupy the pedestal that patients put them on.
The background social and political context is one of increasing recourse by groups to mob violence as a means of protest against developments they disapprove of. For instance there have been violent attacks on film crews because the agitators decided that the subject matter of the film offends their religious sensibilities. A member of India's Parliament assaulted an airline employee as a means of protest against perceived poor service. Vigilante groups set up with the tacit connivance of state governments to protect cows have brutally attacked and killed innocent people presumed to have eaten beef or accused of 'illegally transporting' cows. The prevalent social heirarchy leads to disrespectful and uncivil treatment of the poor, the marginalised, and minority groups.
Faced with these constraints it is not difficult to understand - however unjustified it may be - why dis-satisfaction sometimes boils over into rage and leads to outrageous violence against the lone doctor.
Doctors' leaders have done little to recognise violence in society as a health priority. They have seldom spoken out against police brutality, deaths in custody, politically motivated mob violence, or criminal intimidation by politicians.
It is good that doctors organisations and leaders have spoken out against violence targeted at doctors. But they need also to realise the huge influence they still enjoy over societal attitudes. They could do more to present the profession in a positive light; to champion the cause of their patients needs for freedom from violence in all settings; to protest against violence especially mob violence wherever and whenever it occurs; to call for and demand swift police investigation and prosecution of perpetrators of violent attacks.
Doctors are safest from violence and abuse when society is non-violent. Doctors' organisations need to do their bit for a non-violent society.
1. BMJ 2017;356:j1518
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