In the course of just one month two junior doctors in Kolkata were attacked by relatives of patients that led to an agitation in the West Bengal and spread over the entire country, with doctors expressing solidarity, and this has thrown up a lot of issues facing the profession and the public as well. This confrontation came in between the alleged suicide of a woman doctor in Mumbai as well as the over100 encephalitis deaths in Muzzarpur district in Bihar soon after.
These happenings have brought the issue of healthcare and primary health again into focus. The healthcare issue had been conspicuously absent during the furious election campaigns that had dragged on for more than five weeks. Nor, surprisingly, had primary health ever been on the radar of even the founding fathers of the Indian Constitution and the visionary planners who built the grand temples and who were staunch advocates of the scientific temper.
The violence Kolkata doctors were subjected is said to be unique to India, and if that is so there is a need to examine why this happens here and here alone. There had been attacks on doctors elsewhere too, and the most infamous one being the Pol Pot regime’s decimation of the entire fraternity in Cambodia. And as far back as 135 years ago a reputed American journal had cautioned; ‘No physician, however conscientious or careful, can tell what day or hour he may not be the object of some undeserved attack, malicious accusation, blackmail or suit for damages.’
Whether the increasing violence is an indication of the prevailing climate of intolerance in the country or just the increase in the awareness in this era of all pervasive electronic media intrusion and improved connectivity also needs to be examined.
In the Western countries like Canada and Europe, for example, in the past 40 years the nature of abuse seemed to have changed somewhat since most of the healthcare costs have been borne by the government, and the first contact of the patient and the medical service is with the designated general practitioner (GPs) who make house calls and there is no financial anxiety for treatment. In the US, on the other hand, it has been found that a large number of citizens cannot afford to pay for their health care or even for their insurance and thus fall out of the healthcare’s protective net.
One of the reasons for the decline in education standards in West Bengal in the seventies, according to economist Kaushik Basu, has been the reluctance of teachers to go to colleges in the rural areas. The same kind of reluctance seems to manifest among medical professionals as well and most of them gravitate to the cities. The concept of the barefoot doctor and barefoot teacher that Vivekananda had suggested as early as the second half of the nineteenth century does not seem to resonate with most young educated professionals.
According to one expert, there are, broadly speaking, two types healthcare facilities - public and private- with the latter delivering 80 per cent of the country’s healthcare. While doctors of both sectors have been at the receiving end of the violence, the public sector is in general blamed for the faults of the entire sector.
‘The healthcare system is bedevilled with paucity of resources. Doctors work in extreme conditions ranging from overcrowded outpatient departments, inadequate staff, medicines and infrastructure,’ lamented one director of a hospital chain. ‘Meagre healthcare budgets, long waiting time and the need for multiple visits for investigations and consultations frustrate patients on a daily basis.’
Even then we are becoming a violent society and violence as a means for effecting justice has become common as is evident in the daily news that is brought to the drawing rooms. Public intellectuals and academics in the portals of educational institutions where ideas are thrashed out in a sober fashion are perhaps unaware, but everywhere there is this intolerance manifested. By and large intellectuals and doctors remain insensitive to this till they are affected.
At one time violence at workplace used to occur only in factories and places where there are deadline pressures and unhealthy working conditions like lead fumes in lino presses or toxic gases in coal mines. It would seem that despite these factors doctors too are not always completely innocent and there is a need for deeper introspection by society in general and the medical fraternity in particular. Since every issue is debated and resolved, if at all, through violence most of the time, there is a need for both segments to do some deep introspection. Since this friction gets heightened because of the differences, of caste, of politics, of religion, of gender, and the hierarchical order, each issue tends to act as a flashpoint.
The young doctor who is thrown into such a cauldron without his being aware of the tensions simmering beneath the surface is thus somewhat awakened rudely when he becomes the victim. The God-like stature that doctors are held in Indian society is rudely shaken when the public realises that doctors can also be greedy and manifest human emotions and have flaws. When they fall from this divine pedestal the illiterate and the deprived faithful unleash their pent up anger upon them.
The corporatisation of the medical practice and erosion of ethics is also another reason for such a response. Behaviour patterns of healthcare professionals have changed, with over treatment and under treatment, and overpricing and misbehaviour, and ‘compressed communication’ having become the fashion. The old style culture of bedside manners, the attention and time devoted to patients and treating them as humans, the empathy, the aptitude for caring and healing, and the stress on the Hippocratic oath they take when entering the professions, all seem to have become unfashionable. The general practitioner (GP) and house calls have also become obsolete. And increasing violence against doctors is also emerging as one of the reasons for the less than efficient delivery of healthcare systems in the country, especially now that it is undergoing a transition.
According to an Indian Medical Association (IMA) survey in 2015, 75 per cent of the doctors in the country have faced some form of violence or threat at some point in their careers and it has demanded a comprehensive law to deal with such violence. It has demanded ‘exemplary punishment for perpetrators of such violence and this should be incorporated in the Central making suitable amendments to the IPC and CrPC.’ And the Union Health Minister, Dr Harsh Vardhan, has asked states to enact specific legislation for protecting doctors.
It would seem that solutions like beefing up security in the hospital premises can provide only temporary relief, and that is not the answer. Sensitising the young doctor towards the problems of the poor and the underprivileged could reap dividends in the long run. Compassion and empathy with the distressed could go a long way. But these are not on the curriculum in the graduate or post-graduate courses. Teaching of behavioural sciences at the initial stages could be of help as also acquainting the young doctors to the social prejudices. In short to make the young physicians be aware that the prejudices they face and find manifested in the patients are incubated in the society we live in. And insensitivity to such prejudices makes one vulnerable to it also.
It is thus that in primary care centres, especially in Bengal and Maharashtra, violence by patients’ relatives or local musclemen or petty political leaders has come to be reported more frequently. There might be callous doctors, or inadequate facilities or unhygienic conditions and overcrowding in emergency wards, and all this makes for a heady mix, and to add to the plot are the electronic and print media that are insensitive and are on the hunt for sensational stories.
It is not all that bleak and instances of dedication and selfless work by care professionals come from many unlikely quarters. In the predominantly tribal district of Gadchiroli, in Maharashtra, a young doctor couple, brought up in the Gandhian tradition, started a society for education, action and research (SEARCH). They thus built an Arogya Samaj, a society where people’s health is placed in their own hands. One of the objectives was to save the thousands of new born and they thus set up a lab in the thick of forest called Shodhgram, ‘searching village’. Here deliveries take place at home, with trained nurses in attendance. The dai (midwife) is a familiar figure and everywhere she goes she is greeted with respect. Looking at the bright faces of the children one could realise what a quiet transformation had been taking place here. Gadchiroli, incidentally, is also the place where the Naxals are active and occasionally have encounters with the security forces.