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6

Contrary to the belief that the ever increasing attacks on doctors in India are isolated, much has to do with the deteriorating situation of law & order, crumbling public health infrastructure and evangelization of vigilantes.

According to the Indian Medical Association, 75% of doctors in India have faced violence. Although we don’t have any data for Maharashtra, from my experience, I could say almost every resident doctor in a Government hospital has either been abused or manhandled. The attacks are so frequent and intense, that BMC hospitals in Mumbai had hired a private security firm, Eagle Security a year ago. This security is apart from the police units stationed 24×7. And still doctors are facing some of the worst attacks. Previous UPA Gov’t passed Maharashtra Medicare Services Persons and Medicare Service Institution (Prevention of Violence and Damage or Loss to Property) in 2010. This law has been poorly implemented as the data speaks for itself. Even after constant assaults, not a single person was convicted in the last 2 years. Even though the imprisonment extends upto 3 years and the offence is non-bailable, the alleged attackers are bailed out within a day as it happened in Sion hospital after a Polio inflicted doctor was attacked 5 days ago.

The Cause

India spends only 1.4% of GDP on healthcare compared to 8.3% in US and 7.6% in UK. Even many African countries spend more on healthcare than India. As per World Health Statistics 2015, India’s per capita government expenditure on health in 2012 was a meagre $60, while the US spent $4,153. Central, State Governments and Municipal Corporations have evaded investing in healthcare for decades which has compounded the worsening of the situation. To make matters worse, Fadnavis led Government has actually reduced the health budget allocation for 2017-18 by ₹569 crores. The health budget of 2016-17 was in turn ₹1,308 crore less than in 2015-16. Maharashtra will also spend ₹900 crores less on nutrition schemes. Many ministers and spokesperson have repeatedly assured about increment in health budget, bu the reality is quite different. Public hospitals are constantly hit by shortage of medicines and staff. Patients being told to buy even IV and inhalational drugs in the casualty is a common sight, which obviously angers them. Resident doctors are at the front end of an inefficient, unjust and poorly funded public healthcare system.

IMA survey says 70% of attacks are due to relatives accompanying patients. Dozens of relatives, of which half are drunk accompany a patient in the casualty late at night. Even after constant complaints to the administration, this issue is never sorted out. Be it Dhule or Sion incident, every major assault was carried out by scores of relatives. On paper, only 1 relative is issued a visitor pass to be with the patient. As every other rule, this one lies in the dustbin too. One can’t expect a doctor to work properly who is under the constant threat of an assault. One can’t expect a surgeon to have a steady hand when he is perspiring due to fear.

Dilapidated infrastructure and horrible planning is the cornerstone of every Government project which is 10 times amplified in a public hospital. The X-ray room is situated almost 500 metres away from the casualty. There is always a shortage of wheelchairs and trolleys due to which, again, the junior doctors have to face the brunt, as they are the only ones present there. MRI, USG, CT scan appointments have a waiting period of months. Apart from the well-equipped trauma ward, every other ward has an issue. The resident doctors and interns do the job of class 4 employees due to lack of staff for tracing medical reports, carrying blood from blood bank, shifting patients to other ward. Many a times, I have personally trolleyed the patient to USG and X-ray. There is no clear distribution of duties among staff. Public frustration of this chaos is unleashed on doctors as we are the only ones they could identify.

Normally, only 2 or 3 resident doctors are present in the casualty at night. They are bound to provide only emergency care and diagnostics. Full treatment can only be issued after consulting with senior doctors. This process takes time which agitates patients. There is no counsellor to talk to patient. As the resident doctor has to take history, write notes, examine and provide emergency care; the not so important talking part takes the back seat. A faulty system like this, promotes more attacks on doctors. Not to mention, a resident doctor in a public hospital is overburdened. He/she normally works 14-18 hours a day with at least one 36 hours continuous shift once a week. In towns, such 36 hours shift is almost on every alternate day. Even a basic function like sleep becomes a privilege.

To avoid long queues in OPD, many patients come directly to casualty for instant treatment. Doctors can easily differentiate patients requiring an emergency or an elective care. Indian patients don’t accept oral drugs as they always expect IV drugs in a casualty. This delays the treatment of those who require urgent care. Most of them sit at home and visit the doctor only when the disease takes a severe turn. Diabetes Mellitus and Hypertension can be easily managed by drugs, but due to non-compliance, patients come with severe complications requiring surgeries. OPDs managed by 6-8 doctors have 300-400 patients on a daily basis. Sion hospital itself caters to 20 lakh OPD patients annually. Despite all this, the Government isn’t interested in increasing the number of hospitals. Only 1 out of every 20 MBBS graduate gets a PG seat.

There is no fear of law among mobs assaulting healthcare professionals. Relatives of the arrested Dhule assaulters tried attacking a nursing staff outside the campus. A doctor in Sion hospital threatened of the same consequence of Dhule doctor if the patient doesn’t get well. A rural hospital ransacked in Sangli for an alleged delay in post-mortem. A casualty officer in Bhabha hospital, Bandra slapped. All within the past 24 hours, during the ongoing strike!

The Demand

Residents doctors are fed up with constant fake assurances and lack of proper implementation of current laws. Gov't keeps on repeating the same promises with a different date. The main demand revolves around providing improved security and limiting entry of relatives.

  • Appointment of more security and police personnel immediately
  • 2 pass system per patient
  • To start the installation work of effective alarm system in every casualty
  • To revoke all charges and action taken against resident doctors
  • Strengthening of 2010 law, no bail for accused for at least 3 months
  • Filing of FIR by the institution itself
  • To release funds to implement the law and appoint a brand ambassador to spread awareness for the safety and security of doctors
  • To enact a strict law to prevent trespassing in hospital
  • Formation of a vigilance team within 15 days
  • Formation of a legal cell withing 15 days

An Ortho resident doctor in Dhule was attacked on 12th March while the statewide strike started on 20th March. The violence was so brutal, that he had an orbital fracture and is feared to lose vision in his left eye permanently. The state Government remained dead silent for a week. In fact, doctors and interns in GMC, Dhule were threatened of dire consequences if they go on a leave. Fearing political pressure, the leave was called off in Dhule. On 18th March, after a helpless junior doctor was attacked in Sion hospital, 4,000 resident doctors decided enough is enough. Even after multiple meetings with Medical Education Minister, Girish Mahajan and Chief Minister, Devendra Fadnavis, there is no visible improvement in the security as of now.

To make matters worse, CJ Manjula Chellur of Bombay High court said, “If doctors are so afraid that you will be assaulted then resign and sit at home. It is a shame on the profession if doctors go on strike like factory men. They are unfit to be doctors then.” This statement seeks of victim blaming, elitism and promotes violence against doctors. It’s a moral equivalent of saying, if women are afraid of rape then they should sit at home. Judiciary, Media and the Government are busy blaming doctors for everything that is wrong with our healthcare system.

The Present Status

As of now, the resident doctors of KEM, Sion, JJ, Solapur and Latur Government hospitals have got eviction notices and suspension of their degrees. According to resident doctors, water supply in PG hostel of KEM and Sion hospital was cut-off. MARD (Maharashtra Association of Resident Doctors) has colluded with Girish Mahajan in breaking the unity of doctors by giving out fake statement of mass leave being called off. An utterly despicable tactic which is the hallmark of the current political discourse in the country. Media has played a disgusting role by siding with the Establishment and parroting their lies. No one is questioning the Gov't for their repeated fake assurances and rehashing their old promises with a different date. No primetime discussions on the dwindling health budget. Even when doctors join their duty again, this faulty health system will still persist.

Individual doctors of public hospitals and not MARD are involved in this protest. Although there is no official confirmation yet, MARD chapter in Mumbai has been dissolved. On 23rd March, more than 40,000 doctors of IMA & IDA joined in an indefinite strike by shutting down all OPD and elective services pan-Maharashtra. Dentists, interns, teaching staff, senior doctors, paramedical staff, nursing unions, class 4 employees in public hospitals are supporting this resistance. Medical Teachers Association has threatened mass resignations if security isn't improved within 48 hours. Over 10,000 doctors in 40 major hospitals except AIIMS, have gone on a mass casual leave in Delhi. Barring pseudo-scientific doctors union, everyone else is echoing #IssBaarAarYaPaar. As I write this article, a new union consisting of resident doctors, private practitioners, IMA members, lecturers, professors, SMOs, DNB doctors, ex-MARD members is being formed.

The emergency services in both private and public hospitals are still working due to senior doctors, nursing staff and interns. The healthcare system is affected, but we have tried our best to reduce the impact. IMA and resident doctors will evaluate about the leave after they get a written court order. Judiciary, netas, celebrities all get private security. All we ask for is improving safety in public hospitals.

The resistance continues.

Primary health care with skilled nursing facilities and medical technology for prenatal care and delivery. Possibly medical technology for a cesarean section and a neo natal intensive care unit. How complex can it be for the abilities of an upcoming superpower like India? Health care reform is an urgent need, yes, but what does it take to provide a clean and safe birthing environment? Even speaking of skilled nursing facilities, what terribly difficult skills are involved?

Mistry is a carpenter. He has worked with my husband for many years. Today, he arrived in a hurry to collect some money my husband had left for him. Thin, wiry man in his fifties with a cadence from rural Maharashtra, he claimed to be in a hurry and refused tea. Accepting a glass of water, he chatted with me for a short while as he took out a miniature cheap note pad and a "one rupee pen" (the plastic kind you get in trains) from his shirt pocket. Tucked in the spiral bound notebook was a carefully folded A8 size paper with numbers. Presumably accounts or information related with the job. Frowning in concentration, he noted something on the paper, carefully folded it and tucked it into that notepad and returned both note pad and pen to his shirt pocket, hooking the clip of the pen on the cloth so it won't fall off. Testing to make certain the pen was secure.

This is a working class man from an older generation. No flash and dazzle for him. Careful work. Attention to detail. Careful recording of hard earned money.

When I enquired after his family, he informed me that he needed the money for his daughter's hospitalization. Alarmed, I asked him what was wrong with her. There was nothing wrong. Her pregnancy due date was near. Mistry was to be a grandfather soon, and his wife had returned to her parent's home for her first delivery.

He said he had gone to the government primary health care center first, for prenatal care and to register for delivery. He was told to take her to a private maternity home for delivery because the government hospital didn't have skilled nursing facilities or medical technology - these were the two exact reasons given. Remarking wryly that in his time women had babies at home, he said he was collecting all his dues and taking advances where possible to have money ready. He did not want his daughter to suffer unnecessarily or face risks to her health or life as her pregnancy due date approached.


Community health in India

The people in the government hospital had recommended him to a private hospital telling him that she would be safer there. I was aware that this is likely a routine practice of getting paying customers by advertising to people approaching public health facilities. My mother had been recommended to another private nursing home a few years ago in the very first meeting when we had first started to get her help for schizophrenia. This is in spite of government hospitals boasting of "expert doctors" (who usually own private clinics).

I remarked that private hospitals are not necessarily better with medical care considering my experience with Nisarga's nightmare birth, where I was in the private maternity hospital that specialized in deliveries and was reputed to be the best in the area. Besides, delivery hardly takes any specialized medical technology in routine cases, and government hospitals with their surgical facilities and doctors on duty and neonatal wards would be far better in a crisis than a private maternity home, where doctors are usually absent till the baby starts crowning.

He agreed. Then paused and said that if it was this bad in a private hospital, the government one would be worse. His daughter may not be helped with pain management or the medical care may be lacking or his grandchild may suffer infections. Can't dispute that. Particularly the last. Hospitals are hot beds of neonatal infections in India. I have two friends with children who died within a day of birth from infections - ironically, both in highly competent medical facilities with the latest in everything, but this was clearly not the time to bring it up. And in any case, the government hospitals have no better records to go by news.

Besides, the government hospital near their home was not so big and it hadn't looked very hygienic when he went there. I cringed, knowing that this man is paying for private care he cannot afford, because the government facilities are there, yet not. For a moment I almost recommended a home birth which, in my opinion is probably the most healthy choice, particularly with a home healthcare provider, ideally a midwife or "dai" - check out infant mortality in hospitals), then stopped. It was a long reasoning and against the recommendations of what is best by the "medical profession" in which he had put his faith. If anything went wrong... This was not the time to throw him into indecision on the basis of my ideas, with the pregnancy due date within a week.

He left.

I am left with thoughts of how 65 years after independence, the government's healthcare system cannot assuredly handle something that has been happening naturally since the birth of mankind and usually happens spontaneously with very little "facilities". Nor can it monitor private facilities for something this basic. We have discarded ages and ages of wisdom in favor of a new system we cannot offer consistently. So the common man is literally left neither here nor there.

One has to wonder what exactly it is that the government means by healthcare. Or is it healthscare? A citizen has a right to free health care. A government hospital refering patients to private clinics because it doesn't offer basic medical facilities must ask the patient to submit the bill for reimbursement!

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Republishing this post today to add this quote of horror:

Usha Devi, a slum dweller, went into labour at night on the 12th Jan 2012 . She was taken by her husband to Chittaranjan Hospital, which refused to admit her, and sent her to Shambhunath Pandit Hospital. On the way there, she delivered a baby outside Chittaranjan Hospital. Uma Devi, the newborn and her husband went to Shambhunath Pandit Hospital, who refused to admit her and asked them to go back to Chittaranjan hospital. She delivered her second baby outside Shambhunath Hospital and died. The twins, losing their mother within a day of their birth are themselves in serious condition. The macabre treadmill goes on.

A little over two months ago, 30 infant deaths in West Bengal Government hospitals was big news. Around the same time, another story went viral. That of a pregnant woman who was in labor being denied admission in a hospital. She delivered on the street outside the hospital. Everybody and his cousin were angry with West Bengal authorities for shoddy healthcare and callous disregard.

One would imagine that this was an outrageous incident, and I think many imagined that, but it is really an outrageous pattern. I mean, pregnant women dismissed have delivered outside hospitals, in cars, outside emergency wards, outside elevators... because the  refused to hospitals refused to help them. Even twins! I mean, a woman ready to deliver twins is like really obviously badly pregnant. Can't be missed. Pregnancy and delivery is still a natural phenomenon, and one way or the other, deliveries happen, unless there are complications. And it isn't like being admitted is any kind of guarantee that anyone cares. Read the story of Nisarga's birth.

Victims of torture refused admission have spent the night on the street. Howzzat!

Another documentary had gone viral about conditions of government hospitals in Delhi. Frankly, all this information is the best advertisement for home birthing if no health concerns are present.

Today, a fire broke out in the basement at AMRI in Calcutta. This is a high end, centrally air-conditioned hospital, and that central air-conditioning took the smoke from a basement fire and circulated it all through the building. People died desperate deaths as staff escaped and left them to die. Unbelievable accounts of security guards refusing entry to locals come to help, reluctance to call fire brigade and windows that couldn't be opened have tempers blazing in empathetic fury.

Other information emerging about basement used like a godown, warnings from Fire Brigade ignored, lack of emergency plans even inability to provide very basic information to fire fighters likel locations of emergency stairs is adding to public fury. The Uphaar tragedy was relived in a hospital.

Many praised Mamata Banerjee for swift action against the culprits. I don't see it as anything extraordinary. For that matter, there was no need to play extra curricular superman. Police ought to have arrested them anyway. What does it mean that it takes Mamata for them to be arrested after such an incident? Will our police not arrest rich people if they commit crimes unless someone tells them?

And there are hordes of other scams (will add links later - bad network) related with government funding but no free treatment for poor, vaccines, referrals, transplants.... you name it.

It isn't about government hospitals being substandard. It is a lack of standards all through.

It all comes down to one root cause - lack of standards being enforced. Without appropriate oversight, people are free to twist the system to taste, and this is turning our healthcare into a health scare.

Employees in government hospitals grudge patients care. Maternity hospitals promote more expensive cesareans, induce women before time to fill "empty beds". More expensive hospitals create increasingly service industry type "products" and focus more on delivering an experience. Researchers conduct shady trials that they couldn't in other places. Others promote additional vaccines, while government vaccine productions capabilities are decreased, leading to extremely lucrative deals.

This whole scenario reminds me of something P L Deshpande said about Pune's shopkeepers (satire) "In the entire shop, if there is anything to be ignored, it is the customer."