Responding trenchantly to escalating incidents of violence against health workers across India during the COVID-19 pandemic, the Indian Medical Association (IMA) has reportedly appealed to the Prime Minister and written to the Union home ministry demanding a central law containing sections of the Indian Penal Code (IPC) “against healthcare violence”. Despite the urgency of the demand, in empirical terms data regarding healthcare violence in India is surprisingly sketchy and anecdotal.
The IMA reportedly said, “Healthcare violence has become an alarming phenomenon across the country. The real size of [the] problem is largely unknown and recent information shows that the current knowledge is [the] tip of [the] iceberg (sic).”
What can be gleaned from existing data, which comprises independently published testimonies and analyses by doctors of violence against health workers (defined in most data as “doctors”) are broad, macro-trends. Many reports quote an IMA survey, which claims 80% of doctors in India are stressed in their profession, while 75% of doctors have dealt with some form of violence during their practice. This includes verbal, emotional, sexual, psychological, physical and cyber intimidation, threats, abuse, and occasionally even extreme bodily harm and injury caused by patients, patient-attendants, or even mobs of ‘miscreants’. As many as 62.8% of doctors are unable to see their patients without any fear of violence; 13.7% fear criminal prosecution most days of the week; and 57.7% of doctors have thought of hiring security in their premises.
Notwithstanding these disquieting trends, violence against health workers is a global phenomenon likened to a pandemic in its own right, which poses pernicious challenges and risks especially for developing and less-developed countries with fractured histories of health services.
In India, the COVID-19 pandemic has exposed distinct socio-cultural and ethico-moral dimensions of the problem through the macabre confrontation of emergency medicine and mass deaths.
Healthcare violence, which reinforces and reinscribes deeper and wider forms of discontentment and distrust between patients, patient-families, medical caregivers and health systems thus requires a critical analysis tailored to the present context. The following five themes can help us decipher the complex dimensions of this egregious public health challenge.
Shifting burdens of care amid a heightened sense of abandonment
In India, violence against health workers is part of a larger malaise in which the burden of caregiving is disproportionately shifted out of the hands of the state. Violence against doctors, nurses and paramedical caregivers needs to thus be examined against the backdrop of incidents in which patients are abandoned into performing critical tasks of medical care themselves. This is viscerally evident during the current pandemic as hospitals make the saving of lives contingent on the civic preparedness of patients.
Especially in the ‘second wave’ of COVID-19, the media has been inundated with reports in which ordinary people are having to provide life-saving medical supplies including oxygen cylinders, drugs like Remdesivir, ventilators, ambulances and even basic hospital infrastructure. Tragically, there are also reports of the kin of COVID-infected patients ‘living’ inside ICUs as caregivers (often without protective gear) and having to perform advanced medical duties even outside hospitals, in streets, cremation grounds and homes.
While civic participation in public health is crucial to the goal of health justice, what we are witnessing in the pandemic is a cruel inversion of the same; public health is being surrendered to the hands of the ‘public’ without the critical mediation of health providers – largely because they are overwhelmed and outnumbered – and systems. This entrenches health injustice especially for India’s most marginalised patients and their families. When patient health becomes the sole moral and material burden of patients themselves and their attendants having to negotiate structural differences in healthcare access, potent conditions for resentment and discontentment are created.
These problems are exacerbated by the chronic shortage of medical staff, doctors and nurses leaving patient-attendants (and even patients themselves) to perform psychologically, emotionally and physically traumatising duties in the face of viral infections and death.
Structural violence and systemic inequalities
Structural violence operates differently for doctors and for patients. For patients, structural violence arises from the social, cultural, economic and political contexts and constraints within which an affliction like COVID-19 becomes lethally embedded and on which its treatment, care and palliation become conditional under constraints of a public health emergency.
The cruel nature of India’s health crisis (particularly in the ‘second wave’) and the unpreparedness of the state (and by extension, hospitals) have exacerbated ‘traditional’ reasons for patients’ discontentment including delays in medical treatment, lack of attention by doctors, lack of health insurance, catastrophic out-of-pocket expenditures, economic debts and financial insecurities.
What may seem like ‘impulsive outbursts’ of violence by patients or their attendants against doctors in the present usually have deep underlying roots, which mutate from episodic to everyday forms of aggression, indignation and hostility under conditions of chronic neglect by Indian public health.
Moreover, Indian health metrics, crucial for advanced policy planning, have never taken the socio-cultural determinants of health seriously, thereby depriving us of knowing the true extent of structural injustice perpetrated against patients by health systems along lines of caste, religion, gender, ethnicity and class. Not only has the neglect of these indices prevented targeted health interventions for the most vulnerable, it also prevents doctors and hospitals from deploying staff, systems and services ethically and equitably.
For doctors, structural violence operates foremostly through systemic problems like discharging medical duties in acutely resource-poor settings, with long hours of working (often without protective gear, poor remunerations and insurance incentives), lack of personal or social life, harassment by police, politicians and even ‘discursive violence’ by media narratives against doctors and medical systems.
In public hospitals, infrastructural and service-delivery lacunae combine with high patient turnovers, whereas in private hospitals, high costs of care and perceived medical profiteering tend to create chronic conditions for maltreatment and healthcare violence.
Further, the socio-cultural and occupational norms of medical practice in India have never prioritised the reporting of workplace violence for doctors, instead encouraged the suppression of psychological and emotional stress over the long duration of medical studies. Even in medical training, intimate incidences of bullying, abuse, intimidation, caste and gender-based humiliation of junior doctors by seniors set the tone for what becomes full-blown healthcare violence in emergency medicine.
The emergence of new solidarities and status hierarchies
As much as social media has charted a ‘pandemic of misinformation and fake news around COVID-19, mediatised social networks have also enacted novel forms of transregional and transgenerational solidarities. Connections between those in need of emergency care, like elderly patients, the disabled, the critically ill, and those in positions to provide humanitarian aid to complete strangers are crystallising independent forms of civic health justice through social media.
In a recent case at a Gurugram hospital where at least six ICU patients lost their lives after doctors allegedly ‘abandoned’ patients and deserted the hospital in the absence of oxygen, moral demands for justice are being kept alive by patient families on WhatsApp groups.
Likewise, virtual solidarities among those strung together by intimate experiences of medical neglect amplify social demands for health justice rapidly raising public expectations, which fractured health systems and the media seldom fulfil (in terms of failing to keep public attention focused on the injustices of particular cases).
In all this, the state calculatingly (or due to its own ineptitude) vacates itself from public and private systems of healthcare. Left in direct confrontation, patients, their families and health workers become the protagonists of a distortedly ‘dyadic conflict’. For aggrieved attendants (and patients), the space of the hospital and the figure of the doctor become embodied incarnates of the state’s invisible treachery, while the dead bodies of patients become evidence of the moral failure of doctors, medical systems and public health itself.
Novel forms of solidarity have also emerged for doctors who are not only hyper-visible to the middle and upper-middle classes as a unified group (on television talk shows, newspaper editorials and telemedicine platforms) but are also enacting widespread protests against poor working conditions, wages, lack of security and insurance on social media.
From virtual Twitter storms to public demonstrations – as are being seen in Madhya Pradesh after 3,000 junior doctors resigned owing to the state’s failure to raise their paltry stipends – these nationally amplifying solidarities of health workers in the pandemic hold the moral power to demand rights for caregivers (and by extension seek justice even for patients) whilst simultaneously posing a mortal challenge to chronically ailing patients and health systems plagued by delays and shortages of skilled personnel and staff.
Moreover, doctors have traditionally and professionally enjoyed a high moral status in Indian society; the erosion of this status due to individual acts of medical malfeasance and invisible acts of subterfuge by the state is foremostly eroding the status of doctors and health workers as a fraternity. In this context, it is equally unfortunate that there has been no corresponding enhancement in the social or economic status of nurses, paramedical care workers, mortuary workers and other ‘invisible’ health workers whose presence invisibly upholds public health systems.
Moral contradictions of medicine and mortality
Dramatic and drastic levels of mortality in the pandemic have exacerbated intimate tensions and tussles between health workers and patients at an everyday level. On a discursive scale too widespread experiences and everyday knowledge of death among people furnishes distrust in the capacities of medical systems and health workers to save lives. What undergirds this, however, are entrenched cultural ideas around living and dying.
Biomedically and socio-culturally, the object of ‘Life’ becomes opposed in binary ways to ‘Death’. Neither has biomedicine been able to explain and enact to patients what a ‘good death’ is (in biosocial terms) nor has society adequately accepted or acknowledged the importance of end-of-life care in conditions when death is ‘inevitable’. Despite the present moment, mortality remains a stigmatising sphere for patients and caregivers alike (albeit for different reasons).
For doctors, confronting deaths on the job or reporting them to patients primarily makes mortality a medicalised issue. Globally renowned surgeon and author Atul Gawande evocatively writes, in Being Mortal, “Our [doctors’] reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and denied them the basic comforts they most need.” Gawande’s intervention stands in for broader medical structures of education and wider cultures of biomedical practice in which the moral import of mortality is not only dismissed but seen to counteract the ethical impulse of doctors.
On the other hand for patients, mortality is almost always a moral issue. This is not to say all doctors inherently lack a moral compass or are morally wanting but that structures of biomedical training and hospital environments (much like wider society) are unlikely to emphasise the morality of a ‘good death’ over the mortal success of a life saved. This unresolved contradiction which is at the heart of doctor-patient relationships in India is being rehearsed in egregious ways during the current health emergency through escalating healthcare violence.
‘Pandemic profiteering’ and the everyday limits of emergency laws
It’s hard for medical systems to counter blame from socially-held beliefs about their profit-oriented and profligate nature at the moral expense of people’s lives in the pandemic. Social beliefs (influenced by a range of factors including social media, poor communication by the state and material conditions in hospitals) are grounded equally in people’s intimate experiences of injury and wounding amidst underlying economic precarities.
The triage of the socially privileged in private hospitals is conditional on their capacities to spend exorbitantly on protracted hospitalisations for COVID-19. For the less privileged and marginalised, catastrophic out-of-pocket expenditures (which account for nearly 60% of current health expenditure in India) decidedly drain and debilitate patients’ lives much before hospitalisation even comes into the picture. Shortages and bottlenecks in supplies of oxygen and crucial drugs, like Remdesivir and Tocilizumab, have, moreover, left desperate families of Covid patients, especially the poor, exposed to the vagaries of ‘black markets.’ The indebtedness and dehumanisation arising from this has scarcely been accounted for yet.
On the other hand, as is the wont of neoliberal ‘care’, the responsibility of ailing health systems is shifted onto the afflicted; the failure of the poor to procure health aide is becoming framed as their problem in which the state escapes moral or material culpability. Coupled with the fact that India’s public health spending, at close to 1% of GDP is abysmal to begin with, it is no surprise that doctors – as social intermediaries of people’s moral and medical afflictions – are becoming targets of violence. Ironically, accusations of medical profiteering during the pandemic (including in the rollout of vaccinations) are as pervasive as the ideal spread of public health infrastructure in India ought to be.
It should also be mentioned that laws against healthcare violence exist in India. At least 19 Indian states have passed the Medical Protection Act (MPA) covering doctors in affiliated institutions, independent practitioners, and outlawing attacks against physicians, including damages to their property. Yet, critics argue that such a legislation is futile, for it features neither the Indian Penal Code (IPC) nor the Code of Criminal Procedure (CrPC) making it difficult to file criminal complaints, approach the police and seek justice. Similar criticisms are made of the recent Ordinance (2020) to the Epidemic Diseases Act (1897) to protect health personnel combatting COVID-19 on India’s frontlines. Doctors have raised “serious doubts” about the ability of such legal provisions to sustain beyond emergencies and ensure the everyday dignity and protection of doctors after the pandemic has abated. Moreover, there are apprehensions about the implementation of a central law given the fact that health – including the protection of doctors – is a “state subject”. As I have tried to show, socio-cultural and ethico-moral factors reveal the limits and complexities of such a framing.
In conclusion, combatting violence against health workers requires that it first be recognised as a public health challenge of profound importance. The primary moral responsibility and accountability to ensure the dignity of doctors and patients rest with the Indian state. Fundamentally overhauling and improving public health services and thus the quality of care (and life) is the most sustainable way to ensure that pressure on both doctors and patients eases.
While the IMA’s appeal to the Prime Minister and repeated demands for a central law to protect doctors is urgent, broader calls for health justice must also include not only resident doctors, nurses and junior medical staff but even the countless ‘invisible health workers’ like mortuary staff, sanitation workers and cremation workers (many of whom belong to ‘lower’ caste and class backgrounds and face undocumented levels of everyday violence). Dignity to doctors is morally incomplete without ensuring dignity to the most marginalised health workers (and patients).
Nikhil Pandhi is a doctoral candidate in medical and cultural anthropology at Princeton University. A Rhodes Scholar, he ethnographically researches global health and the socio-cultural determinants of health in India.