When Healers Become Targets - The Rising Violence against Medical Professionals in India

As we come to the end of 2024, two incidents which shook the medical professionals in India need to be remembered and condemned in strongest words. The first incident involved a lady postgraduate medical student at RG Kar Medical College in Kolkata, who was sexually assaulted and brutally murdered on the hospital premises while on night duty. The incident sparked off nationwide protests and the resident doctors of West Bengal are on strike over the issue of safety of doctors at the workplace.[1] Honorable Supreme Court of India took Suo moto cognizance of the matter and inter alia considered the broader issue of safety of healthcare professionals at the workplace in general and women professionals in particular. The bench led by the Chief Justice of India constituted a National Task Force to study the issue of safety of doctors at the workplace. While the medical community was still reeling from this horrific act, in another incident at a government hospital in Chennai, a relative of a patient with cancer stabbed the medical oncologist on duty blaming the doctor for the adverse effects of chemotherapy.[2] Such incidents have become increasingly frequent, causing significant distress and fear among medical professionals in India. In 2023, a young lady doctor was brutally killed by an intoxicated patient at a government hospital in Kerala.[3] Incidents of physical assaults, verbal abuse, threats, and intimidation are far too common at the workplace, although only the fatal incidents gain national attention. More than 200 cases of violence are officially registered by doctors across the country in the past 3 years without a single conviction and many cases from rural India go unreported.[4] These cases often involve the young junior doctors who face the major brunt of the situation, creating serious impact on their morale. Violence against healthcare workers is not a new phenomenon in India and elsewhere in the world. A report by the Indian Medical Association states that nearly 75% of doctors in India have faced some form of violence at the workplace by patients, relatives of the patients, or an angry mob. There are reports of such violent incidents and even fatal assaults from other neighboring countries such as Nepal, Bangladesh, Pakistan, China, and even from the developed western countries such as the USA and Europe.[5] In India, the response of medical community to such violence has become predictable. Medical associations issue statements, demand action, seek protection, hold protest marches, submit memorandum to the government, and junior doctors go on strike but after a few days, the discussions fade until the next incident occurs. The reactions of the doctors are mostly within the silos of their social groups or professional associations, lacking a systematic effort to analyze the problem or seek long-term solutions. Violence against doctors and hospitals is not just a problem of the medical profession but has enormous ramifications on the healthcare delivery of the country. Working under constant threats of violence affects the quality of services provided as doctors resort to defensive practices by avoiding procedures or treatments in situations with uncertain outcomes, which does not bode well for society. Although most incidents are due to aggressive outbursts of emotions at emotionally charged circumstances when their near and dear ones have suffered or succumbed, there are deep-rooted systemic factors. Increasing costs of healthcare, low penetration of health insurance, high out-of-pocket expenditures, higher expectations from the doctors, growing commercialization of healthcare, an overburdened public healthcare system with lack of facilities and insufficient workforce, lack of proper communication with patient and their relatives, insufficient budgetary allocation to healthcare, growing public distrust on doctors and hospitals, frustrations at longstanding failures in the system, delay in legal proceedings, the role played by the media in further fueling the mistrust, role of local politicians, and a general increase in violence in society are some of the many reasons often discussed. A “class war” theory has also been described in the genesis of this problem.[4-8] Given the complexity of the problem, obviously, no single solution can be offered to curb the menace. Nevertheless, the situation demands immediate intervention from all stakeholders including doctors, professional organizations such as Indian Medical Association, Association of Physicians of India, and many more, all state and central governments, print and electronic media, judiciary, and civil society groups to find a solution to this crisis and instill confidence among the professionals about a safe working environment and for the public to get good quality affordable healthcare. Indian Medical Association and several medical associations have been demanding a stringent central Act to curb violence against healthcare professionals. Although a draft bill was prepared in 2019, it never saw the light of the day. Over 20 states and union territories have enacted state Acts to prevent violence against medicare personnel. However, there has not been a considerable change in the ground situation. Studies in Punjab and Maharashtra show that the uptake of these legal provisions by healthcare establishments and police is low, and conviction rates remain minimal due to legal loopholes.[5,7] Recently state governments of Kerala and Karnataka have amended their laws to give more teeth to the existing acts with hopes for improved outcomes in the future. Against this backdrop, the benefits of the demanded central Act against violence need to be weighed upon. Laws alone are insufficient deterrents to the crimes and measures are needed from other fronts as well. It has been reported that the National Task Force appointed by the Supreme Court of India has also recommended that a separate central Act to deal with violence against doctors is not necessary.[9] Samant et al. have investigated the role of media in developing public opinion about violence against medical professionals. They have analyzed 60 newspaper reports and articles on this topic published in a single newspaper Sakal and analyzed two distinct patterns in the articles which creates two types of narratives. While the articles and views presented by the doctors and medical associations created an impression of taking to victimhood, the articles by the journalists put emphasis on changing dynamics of doctor–patient relationships and put the responsibility on doctors’ shoulders. The authors have analyzed the doctor–patient relationship and “declining nobility of medical profession” from the social perspective.[10] Doctor–patient relationship has been described as an unwritten social contract wherein society grants medical professionals “status, respect, autonomy in practice, the privilege of self-regulation, and financial rewards on the expectations that physicians would be competent, altruistic, moral and would address the healthcare needs of the individual and the society.” This contract defines the roles and expectations of each party to the contract.[11] Over the years, changes in the attitudes and perceptions about each other have resulted in a disconnect between the parties in understanding the nature and importance of this social contract.[10] Understanding the problem of violence against doctors should also include a discussion on the disconnect of this social contract by both the parties, i.e., medical profession and the society. Although this seems like a western concept, the tenets of this principle of social contract exist in India since ancient times where traditionally doctors have been kept on a higher pedestal in the society. With changing times, there has been an erosion of these values and principles by the society as well as the profession which seems to be the major social cause of increasing incidences of violence against doctors. These social dynamics changed further and assumed a legal dimension when the profession came under the ambit of Consumer Protection Act by considering the doctors as service providers and patients as consumers. The situation cannot be left to take its own course but needs a proactive approach from all involved. The Supreme Court’s initiative to ensure safe working conditions for doctors, especially women on night shifts, is a welcome step forward. The governments at central and state levels should take this on priority to formulate measures to ensure that such tragic incidents do not recur. Medical associations should scientifically analyze the underlying issues and collaborate on legal, administrative, and social remedies. Engaging civil society is crucial, as both the medical profession and the public are affected by this escalating problem and cannot afford to ignore it any longer.