Dr Sahil Sanghavi Orthopedic Surgeon, Sancheti Hospital Pune and Aashay Abhyankar, Managing Partner, Abhyankar IAS Academy bring forward the pressing issues faced by healthcare professionals in times of COVID 19 and plea for justice and compassion
Societies, homogenous or heterogeneous, are held together through customs, traditions and commonality of values that bind societal stakeholders in an unwritten social contract to maintain moral and social balance. Laws are important too, albeit external regulatory mechanisms. Recent attacks on doctors and healthcare professionals during the COVID-19 crisis raises a fundamental question as to whether professionals in their line of duty can be subjected to horrors of patient/citizen wrath, mistrust, insinuations that endanger their personal well-being and safety. All this when the latter don’t always face ethical or legal accountability?
Incidents of violence in India
Violence against healthcare workers seems to be a global phenomenon. According to American College of Emergency Physicians, in a 2008 poll of more than 3500 emergency physicians, 47 per cent reported to have been physically assaulted at work and 71per cent said they had witnessed another assault. Notably, 52 per cent of healthcare workers in the United Kingdom have faced violence. The Indian Medical Association reports that 75 per cent of doctors in India have faced some form of violence in their line of work.
The COVID_19 crisis has brought some alarming facts to light which would earlier have gone unnoticed or unreported. The angels with stethoscopes are at the receiving end of not only physical assaults but mental torture and ostracism at hands of society at large which once lauded their role as lifesavers. A suspected COVID patient’s son attacked a junior doctor on duty at the Osmania General Hospital in Hyderabad demanding an immediate discharge when test results were awaited. Residents of Chandpura village in Haryana pelted stones at doctors after refusing to allow the cremation of a COVID-19 suspect. Some physicians and their families have also been boycotted by their neighbours because of their exposure to patients infected with COVID-19. In most of these cases, the perpetrators are relatives, sympathizers, local political representatives, acquaintances etc. who resort to physical abuse, vandalism and mental torture in the name of protest.
What according to patients/citizens justifies this violence?
Inordinate delays in admission often fuel fear and anxiety, particularly in situations like the COVID-19 outbreak. When a 66-year-old lady of Delisle Road, in Mumbai, tested positive for COVID-19 she had to spend 30 hours in the KEM Hospital parking lot before she was finally admitted elsewhere. The fear of staying in quarantine and stigma associated with contracting and spreading the contagious disease also fuels public anger and outbursts. Videos of doctors getting pelted with stones and sticks when they were identifying positive patients during the COVID outbreak in Indore’s Tat Patti Bakhal area had created a public furore demanding action against the miscreants.
The Charak Samhita one of India’s ancient treatises and a repository of knowledge on medicine equated the medical profession as a noble one identifying compassion as the core value of a medical professional. Contemporary times have fueled the perception that commercialization of the medical profession has robbed it of its fundamental value of altruism. The inclusion of doctors within the ambit of the Consumer Protection Act has reworked patient-doctor dynamics making them more business-like and diluting the goodness associated with saving lives. However, the right of a patient or society at large to be treated by a doctor doesn’t give him ownership or proprietary rights over the doctor and healthcare professionals become the ideal punching bags in situations like these. Doctors cannot breathe life into a patient who has passed and have limitations.
However, citizens and patients need to bear in mind the yeoman service rendered by healthcare professionals in pandemic situations like these. 10 per cent of deaths in Italy were of healthcare workers. Breathing in PPE suits for duty hours stretching over 16 hours aren’t the ideal work conditions that anybody would sign up for. A doctor at the JP Hospital in Bhopal has turned his car into a temporary home as he is treating COVID patients and staying away from family. In such cases, the sacrifices go beyond the professional realm taking over the personal lives of healthcare professionals. Also, the fear of losing life and concerns of the future of family can plague any individual; doctors and frontline health workers are no different.Imagine doctors and health workers going on a strike in times like these? It will paralyze and cripple the whole society!
Does it take two hands to clap?
Years spent in medical schools often impart cutting edge medical knowledge and skill but exclude modules on empathy and etiquette that form the bedrock of any community-based service provider. To quote William Osler “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has”Tackling delays and reducing paperwork in admitting patients, providing them basic counselling and information to dispel doubts and fears are the sine quo non- for this noble profession. The responsibility often lies on senior doctors to lead by example and ensure timely correction in signs of errant behaviour of the juniors. Roy Ziegelstein, MD, at Johns Hopkins, calls getting to know patients as people “personomics”—understanding their concerns, their personal relationships, their hobbies, their work, and what you can add to their care, to almost counterbalance the technical aspects of the patient-physician interaction. Medical care needs to be built on the bedrock of humanism to foster compassionate and empathic relationships with patients and colleagues. It must demonstrate attitudes and behaviours that are sensitive to the values, autonomy, and cultural and ethnic backgrounds of patients. Professionalism includes subordinating our own interests to the interests of those we serve, and just like with humanism, we must adhere to high standards and respond to societal needs.
What makes the Indian scenario so complex?
India with its burgeoning population of over 1.3 billion cannot possibly provide for a health infrastructure that allows for 1.3 billion hospital beds. Health care spending is abysmally low in India at around 2 per cent of its GDP in comparison to 6.5 per cent of Australia, 7.4 per cent of Canada and around 8.5 [er cent of the US. According to the Central Bureau of Health Intelligence (CBHI), the National Health Profile, 2019, stated that the number of registered allopathic doctors possessing recognized medical qualifications (under the MCI Act) and registered with state medical councils for 2017 and 2018 was 43,581 and 41,371. This roughly translates into 1 doctor for about 10,000 citizens.
Deterrence and punitive action, not the only road forward:
Andhra Pradesh was the first state to enact a law to protect doctors and healthcare professionals. Many other Indian states followed suit but there have been no convictions against offenders up to 2015. The Karnataka Prohibition of Violence against Medicare Service Personnel and Damage to Property in Medicare Service Institutions Act 2009 has remained alive only on paper on account of poor implementation. Violence against doctors and healthcare workers affects their motivation to work, damages image and reputation which cannot be compensated through deterrence or punitive action and can have a long-term impact on their physical and psychological wellbeing.
The central government recently brought an ordinance to amend provisions of the Epidemic Diseases Act, 1897 to end violence against health workers. It carries imprisonment from 6 months to 7 years if anyone is found guilty. This seems to be the best interim step to reign in the chaos. However, Amendment 2b states “No person shall indulge in any act of violence against a health care personnel or cause damage or loss to any property during an epidemic”. The amendment is silent on forms of attack that move beyond the physical realm and limit it only to times of epidemics. No doubt this is an ordinance to quickly reign in the situation; however, comprehensive legislation guaranteeing the safety of healthcare workers is critical, epidemic or otherwise, to ensure a safe environment for the discharge of duty.
Carrots and not sticks, alone, can, therefore, be a long-term solution. More so, because situations like these warrant behavioural and mindset change.
Multi-pronged stakeholder participation holds the key to success
The media, print electronic and mass, need to play a constructive role that helps in boosting morale, instilling confidence and generally building a positive outlook among citizens. Highlighting stories of COVID survivors, dispelling myths through tele and online medicine platforms are needed. Blame games that hinge on garnering TRP’s isolate groups and create prejudices and fissures that weaken efforts for collective combat.
The government’s initiatives are multi-dimensional and irrespective of ideology needed to be lauded. Screenings of mythological serials on Doordarshan, community involvement in the lighting of lamps and ringing of bells as a gesture of appreciation for all frontline workers may seem symbolic to a few but strengthen unity and integrity of the idea of India, firming the roots and values of this 5000-year-old civilisation. The decision of the Mumbai Mayor, Kishori Pednekar to don her nursing uniform to volunteer as a nurse for a night shift and manage mayoral responsibilities by the day is an example where empathy inaction speaks louder than mere words.
In a country so understaffed and overworked at critical times like these, ensuring that frontline health workers can carry out their duties fully and fearlessly needs to be guaranteed by mechanisms beyond the law. Delhi government’s announcement of a 1 crore grant to the kin of government staff who died in the line of COVID19 duty is a short in the arm for all frontline workers who place their own lives on the line.
In this war against COVID-19, the unwritten rules and ethics of war need to be adhered to, to safeguard our COVID warriors; both sides need to keep their head high, irrespective of loss or win.