This article is written by Jaya Vats from Vivekananda Institute of Professional Studies, Delhi. In this article, the author discusses the increasing cases of violence against doctors and healthcare professionals.

Introduction

Throughout the COVID-19 pandemic in many countries, doctors, nurses, and other health workers in the frontlines were praised as heroes for their efforts. Nevertheless, not all of them support their efforts. The news has also reported reports of healthcare workers suffering attacks since the beginning of this pandemic while commuting from and to medical facilities. Reports in India define the beatings, stoning, spatting, intimidation, and expulsions of health workers from homes. Unfortunately, it is no new practice of violent acts against medical workers. Such attacks were more and more documented in clinics and hospitals around the world before the COVID-19 pandemic. Violence must be condemned in all circumstances. It is the fact that health care staff respond to a crisis that affects all societies that are particularly frightful in the current attacks.

Background and current scenario

Violence against doctors is not a new phenomenon in their workplace. However, recent studies have shown that doctors are thrashed by patients and family members in India as well as around the world, and the same is also shared on social media. Far too few doctors are educated to avoid or deal with such situations and almost every doctor is worried about violence in their workplace. Violence against doctors in India includes: 

(i) telephone threats; 

(ii) bullying; 

(iii) oral/verbal abuse; 

(iv) physical but not harmful attack; 

(v) physical assaults that cause injury; 

(vi) vandalism and arson. 

Doctors facing violence have been known to develop depression, insomnia, post-traumatic stress, and even fear and anxiety causing absenteeism in India. More than 75% of doctors are exposed to abuse at work, according to a report by the Indian Medical Association. The husband of a pregnant woman who was admitted to the hospital in a serious condition killed a lady doctor in Tuticorin. She was taken to another hospital but passed away before she was able to be moved. With three accomplices, the husband entered the doctor’s consultation room and assailed her by a sword.

In 2014, after the death of a boy who was named a tertiary hospital, a medical clinic was burnt in Mansa district in Punjab, but died. Countless incidents of violence against doctors are reported almost every day in India, leading to serious injuries. Even the country’s leading medical institution i.e the All Indian Institute for Medical Science (AIIMS), New Delhi was not spared. Nineteen states of India have passed and notified acts of some kind in the past ten years by the Medicare Service and Medicare Service institutions. In compliance with the Right to Information Act (RTI), the Medicos Legal Action Group Trust (MLAG) demanded the following information from all senior police superintendents in Punjab and Haryana, two states where the Law on Drug Prevention has been developed over 8 years.

• How many patient or attendant complaints have been reported under this Act by doctors or hospitals?
• How many were punished by the law from 2010 to 2015 for those accused of assault?

The replies show that most complaints were not registered in the FIR, which is a binding process to be followed by all policemen, according to the judgment delivered in the case of Lalita Kumari vs Uttar Pradesh by the Supreme Court of India. The FIR was cancelled in some cases based on a complaint after the parties had reached a compromise and the local magistrate was given a cancellation report. Very few cases have entered courts since they filled Challan, but the Medicare services and the Medicare service institutions (Violence or Damage or Property Prevention) have not been penalized under the Act of Punjab and Haryana from 2010 to 2015 for the assault on the medicare establishment.

Causes of violence 

The inability by governments in certain countries to provide and properly maintain the resources in the sense of the pandemic leads to a constant danger for the life of health workers by taking care of COVID-19 patients without sufficient protective equipment and other safety measures at work. This situation in some places has generated violence against them, mainly for carrying out their work. The increase in violence against medical workers is attributed to multiple reasons but not limited to an increase in racism in society as a whole:

1. Budget for better health and low healthcare quality: The wretched conditions in which patients are treated in government hospitals are among other sources of violence against physicians in India. The population is overcrowded, there are no proper facilities, there are several visits and appointments taken by patients so that they can meet doctors, two or even three patients sometimes have to share beds, and lack of hygiene and sanitation also causes problems. Frustration is caused by structural issues in government hospitals, including the shortage of inadequate equipment and staff. Such issues are unlikely to improve in light of the low budget allocation to health in India. Of those 9,38,861 doctors who are registered for health care for a population of more than 120 crores, only 1,06,415 are employed by the Indian government. Just 27,355 of those centres (PHC), servant to rural residents, are working at primary health centres. Given the country’s increasing growth, the public health system is on the verge of failure with inadequate infrastructure and a little rise in the number of government doctors reported. Violence against the provider of medical care is just the symptom of this instability.
2. Ability to trust in the judiciary: The lack of faith in law and order machinery and the judiciary is another cause of violence against doctors in India. A plaintiff has little trust in the legal remedy processes. Sometimes there is a perception that doctors who are well connected will get away, and therefore there is a tendency to take the law into their own hands by resorting to violence. This is often assumed that the attendants of the patient who attack doctors will remain unpunished.
3. Security deficiency: Violence in Indian healthcare facilities is easily organized, partially due to the absence of funds among small and medium healthcare establishments (SMHCE), security personnel in the government and the private sector. With inadequate budgets, it would be impractical to expect adequate protection in Indian hospitals, even in a few corporate hospitals, to employ enough doctors and nurses.
4. Health expenses: The rising healthcare costs are the key reason why doctors and patients are separated. Also, the USA accounts for half of all financial bankruptcies in devastating medical expenses. Doctors earn 20% of all money for personal health in the US, but the bulk of the remaining expenditures are determined by their decisions. While the prices of all medical services are much lower in India than in the west, they are high enough to make many families indebted and fall below the poverty line. In a household where a daily meal is largely nutritious, it is understandable to lose frustration and sadness after investing more than what it should do, but it sometimes culminates in abuse. Whatever the provocation, justifying any violence, especially against a doctor who is trying to help in times of need, must be strongly condemned.
5. Poor physicians’ image and the media’s role: Physicians in India have historically been highly respected by society. The prevailing view of those of the profession’s private sector culture has resulted in a negative portrayal of physicians. One of the contributors to this bad physician image is the sensationalization of each news story that sometimes overlooks facts that gloss over daily specifics and exempts a doctor from suspected medical negligence. An illustration of this is that a TV reporter shouts at the medical superintendence of a hospital in Delhi under the influence of dengue patients that the patient who died of dengue was not given antimalarial drugs.

Prevention of violence

The following steps can be taken to prevent violence in the event of such crises:

1. Doctors should ideally aim to increase patient interaction and minimize lengthy waiting times for patients in the waiting rooms as much as possible. To achieve this, it may be useful to use digital technologies, mobiles. For example, long in-hospital queues, a lack of doctor communication, and opaque billing systems have been seen time and time again as important predictors of violence in India. Digital and mobile technology can make a significant contribution to this field.
2. There can be a lot of help in hospitals to reduce violence. In government hospitals, this can be done as part of a general reform of hospital services in the form of, (i) improving services on a global scale; (ii) employing a sufficient number of physicians and other steps to ease patient rushes and long waiting hours; (iii) using computer and internet technology; (iv) strengthening hospital safety and the need to be properly informed, etc.
3. Patients, their families, and society as a whole have an enormous duty to discourage such abuse. Disputes between patients and hospitals or physicians should not be resolved by violent means, but disputes should be resolved through civilized means. It should be understood that vandalism and violence in a hospital or clinic is a criminal offence, and any civilized society should have a low tolerance for such heinous acts.
4. Both print and electronic media have a duty not to sensationalize the news. Medicine is not a black and white subject, and so is its management. Patient diagnosis is essentially hypothetical and detractive and the diagnosis of several cases continues to be refined with new evidence through investigation and knowledge.
5. In India, there is a multi-layered cause of violence against doctors. Government spending about 1 percent of GDP in a population that has grown five times since independence is not enough. Modern medicine is progressing by leaps and bounds, but most of the country’s medical colleges and hospitals have struggled to keep up with the growth. The government needs to put the effort into seeing how to avoid overcrowding in the hospitals. No nation can build hospitals for 1300 million patients, but it is possible to create hospitals for a relatively healthy 1300 million people. In a country like India keeping 1300 million people healthy is a humongous task.
6. The fundamental requirements are nutrition, immunization, health education, pollution control, personal hygiene, clean water access, unadulterated milk, unadulterated food, exercise facilities, playground, etc. Preventive medicine should be the focus of its activities. The government will punish someone who hurts the doctor and vandalizes the hospital with illegal behaviour. 

Critical analysis

The Government of India, by passing a required ordinance to protect HCW from violence during the COVID-19 pandemic, ultimately met the aspirations of Healthcare Workers (HCW) in India. Although violence against HCW in India is nothing new and has been taking place regularly, in front of all the public, the legislatures, the administrators, and the politicians, nobody has been serious enough to take serious notice of this violence and, as a result, the perpetrators of it have continued to rampage. The Government of India only came forth and took this prompt action because of the absolute and dire necessity of the HCW during this COVID-19 health crisis. While this regulation has included null tolerance for violence against the HCW, the effectiveness of its implementation is clear. The Government of India’s legal and moral responsibility to safeguard the HCW is imperative and strictly honour and protect those citizens who save the lives of others by jeopardizing their lives.

The Government of India amended the Antiquated Epidemic Diseases Act of 1897 and laid down the non-leasing offence of HCW attacks, the imposition of a jail sentence of up to seven years, as well as fines from Rs 2.00,000 to 5.00,000. The regulation covers all HCWs including doctors, nurses, paramedics, and social-health staff accredited. The decree is a positive step. However, strong law enforcement measures need to be added to this. It may not be so difficult to make an order, but its strict implementation will pose a major challenge for the Government of India, as a major gap in law enforcement has so often been seen. The Government of India and the Prime Minister of India praised HCW ‘s role and stressed that it was essential to combat the COVID-19. To be effective in India, the Government of India has to take some steps. They can do this in many ways like: 

1. Educate the public annually, through print and online media ads and often notify voters of certain new initiatives by the political parties. 
2. When carrying out screening operations, the Government of India must increase the presence of safety both with and without medical facilities. This will improve the morale and trust of the doctors and bring order to the hospital proceedings. 
3. HCW has called for security at home and while switching back and forth, a few overzealous resident welfare associations (RWA) office-bearers have shown hostility to HCW treating COVID-19 patients, while some have been attacked outside hospitals. Arrangements must be made for HCWs that need temporary accommodation and transport. Besides, a team of police, municipal and revenue officials will alert and prevent these RWA officials from any attempts to evict doctors from the premises of the company and, if necessary, take stern action. Such doctors should be provided with a helpline number to call in case of need.
4. For that HCW who is at the head of this ‘war’ against the virus, a high-risk allowance in these unprecedented times should be provided. The Delhi Government, which announced Rs 1.00,000 for the family of a fallen corona warrior, not only doctors but also police and other people fighting against the pandemic, are welcome to do that. It’s awesome. Other countries should also emulate such a move. 
5. Anti-violence perpetrators against the HCW should be pushed through and strictly. It not only raises their conscience but dissuades others as well.

While the Epidemic Disease Act of 1897 has been amended by the new ordinance of the Government of India for this pandemic and similar outbreaks in the future, it should be further expanded and integrated into existing legislation to protect the HCW in non-epidemic situations to carry out its duties without fear for the benefit of patients who are ill or wounded.

Conclusion 

Violence against doctors is detrimental to society. All physicians must be aware that this can happen and take measures to prevent it. Doctors must persuade the government to compare a doctor’s attack with an officer’s attack. To provide effective deterrence and to avoid more cases of violence against doctors, the IPC and the Criminal Procedure Code (CrPC) must make required amendments urgently. But a coordinated effort is necessary for this to happen. We hope that healthcare staff will not lose their lives before their associations and the government starts an action. 

References

• http://www.nmji.in/article.asp?issn=0970-258X;year=2017;volume=30;issue=2;spage=97;epage=100;aulast=Nagpal#ref17
• https://www.researchgate.net/publication/340915995_Ordinance_to_protect_the_Healthcare_Workers_against_the_violence_in_India_is_a_welcome_move

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