Safety First

SAVITHRI DEVI HAD never heard of the term ‘de-escalation’ when she encoun­tered her first hospital mob, working as an intern at a government hospital in a Tier 2 city in western India. “My job was to collect blood samples. The duty doctor had stepped out for a short break and in the meanwhile a long line of patients started getting restless. One of them started film­ing and threatening me just because I was the only medical professional present. A few others joined in. I felt shaken, but realised that the other patients were just onlookers. I called security to deal with the man who was shoot­ing the video and the situation was brought under control. But anything could have happened,” says the 27-year-old doctor from Kottayam, who has since defused several situations threatening the safety of doctors and patients. Increasingly, interns, trainee residents and junior doctors—the foot soldiers of our creaking healthcare system—are left to fend off violent attacks with little security to protect them. “Whether it is a premeditated mob or an emotional attack by relatives at the Emergency and Critical Care wards, dealing with violence and abuse has become a professional hazard for doctors,” says Devi, likening the risk of being assaulted to that of being pricked by a needle.

In the wake of the nationwide outrage and protests following the gruesome rape and murder of a resident doctor at Kolkata’s RG Kar Medical College and Hospital on August 9, Devi’s words seem especially dire. “We are discouraged from resting during night duty, even if we are working 36-hour shifts. So, there are no rooms for resting. Our accommodations are 3-4km away and we must take a deserted road without company, often at odd hours, at the end of our shifts. It is a miracle nothing untoward has hap­pened so far. But if it does, no one will be held responsible,” she says.

At a time when elected representatives are trading barbs about whether the Centre or the state should be held responsible for the RG Kar Hospital incident, Devi says it is up to the doctors to look out for their own safety and security. Her first choice for postgraduation was a government hospital in Howrah, but when she saw the quarters—dingy and rundown, with barely any residents occupying it—she opted out, choosing instead to undergo a second round of counselling. For women, the medical profession is a minefield, she says, as they have to negotiate unsafe public spaces and fend off sexual advances, not only from patients but also from seniors under whom they are training. “Unless there is an indepen­dent body to which one can anonymously report abuse by seniors, not many women residents—and certainly not nurses, who are conditioned to be subservient to male figures of authority—will come forward to expose predators within the system,” she says.

Tragic as the RG Kar case is, it has laid bare the plight of doctors working at state-run hospitals in India and triggered a concatenation of events leading to the Supreme Court appointing a National Task Force to formulate an action plan to prevent gen­der-based violence and to ensure dignified working conditions for doctors and interns. “There is a virtual absence of safety for doctors, especially young women doctors. They have 36-hour shifts. There are no separate duty rooms for male and women doctors and personnel. We need a national protocol for safe conditions of work for doctors and medical personnel… It is not that every time there is a rape and murder, the conscience of the nation is awakened. We need a protocol not just on paper, but to be actu­ally implemented,” Chief Justice of India DY Chandrachud noted. Before the in­cident in Kolkata, however, the steady stream of news reports about assaults on doctors, Resident Doctors’ Association-led strikes demanding better infrastructure and security for medicos, and postgradu­ate students dying by suicide did not make big headlines. Not even when a doctor in Maharashtra was attacked with an iron rod and partially lost his eyesight, or when another was waylaid in a small town in Karnataka and beaten within an inch of his life. Last year, over 12,000 doctors went on a strike across Jharkhand after Kamalesh Oraon, a resident working at the paediatric intensive care unit of Mahatma Gandhi Memorial Medical Col­lege Hospital in Jamshedpur, was brutally beaten up upon the death of a young pa­tient. The state, however, is yet to enact a law to protect medical professionals.

“The incident at our hospital would have gone almost unnoticed were it not for the fact that the entire coun­try is seized of this matter today,” says Dr T Kanagaraj, a professor working at the Department of Anaesthesi­ology at Coimbatore Medical Col­lege and Hospital (CMCH). On August 14, the eve of the India’s 77th Independence Day celebrations, a house surgeon pursuing her Compulsory Rotatory Residential Internship (CRRI) at CMCH was grabbed by a man who undressed in front of her. The surgeon was in the two-wheeler parking lot of the hospital and managed to push the attacker to the ground before fleeing. Security at the hospital is outsourced to a private com­pany, and by the time it arrived, the attacker, later identified as Mayank Galar, had run away. City police arrested Galar when he came back to the hospital later in the night, and charged him under Section 74 of the Bharatiya Nyaya Sanhita (assault or use of criminal force against a woman with an intent to outrage her modesty) and Section 4 (penalty for harassment of women) of the Tamil Nadu Prohibition of Harassment of Woman Act. “Our hospital gets a around 6,000-7,000 patients every day. With so many people around, one would think we are safe, but the conditions are actually pretty bad. There are no hostels for PGs and CRRIs. The female students are put up on the top floor of a ward, while the men rent rooms outside. There is no café inside the hospital—if you want to drink a cup of tea, you must walk almost a kilometre,” says Kanagaraj, who is a member of the Tamil Nadu Government Doctors Association. The Coimbatore district administration has reportedly conducted a safety audit of 13 state-run hospitals in the wake of the incident and subsequent protests by CMCH doctors.

The Government Medical College and Hospital (GMCH) in Nagpur, like its counterpart in Coimbatore, is a large hospital which gets thousands of patients daily. It also has, its resident doctors say, fairly good facilities for them compared to public hospitals elsewhere in the country, and its entire campus is well guarded, with several guards on duty at any given point of time. But that does not stop incidents of aggression from patients and their relatives that sometimes spiral out of control.

Dr Mahima Advaitha, a 25-year-old resident doctor, experienced this last year when a large group of around 25 relatives accompanying a patient turned aggressive. Advaitha has been in several such situations, and usually manages to defuse and de-escalate them. But this particular case – where the patient, a boy of about 10 years of age who had been involved in a major road accident, could not make it through – turned rapidly beyond her control. “GMCH is a tertiary hospital. So many of our cases in the casualty section are those who are in a severe condition and who have been referred to us from smaller hospitals. And when it comes to cases like road accidents, they often tend to be so bad that many don’t make it through,” says Advaitha, who was in charge of the trauma centre that day. “In the boy’s case, despite our best efforts, we couldn’t save him. The whole situation was already very tense when they brought him, and when he did not survive, although we tried to counsel them, they became abusive and aggressive,” she says.

The situation quickly went out of control, with the mob abusing the doctors and nursing staff and stopping them from attending to other patients. At one point, a relative even picked up an IV stand, and made a move to strike the doctors and nursing staff. Advaitha and another doctor who was present, along with the nurses, rushed to the nursing cubicle adjacent to the trauma centre to seek refuge. The security present at the hospital arrived soon after and managed to make the mob leave. “Unfortunately, situations like these are becoming more common,” she says. “Twenty five years ago, doctors might have been viewed with great respect. But that is not how it is today.”

While assaults on doctors and poor working conditions in public hospitals are a big issue, the current case at Kolkata’s RG Kar Hospital incident reveals the dangers posed in particular to female doctors. “Assaults on doctors, as terrible as they are, have become quite common,” says Dr Jyothi Ramegowda, who serves as the National Convenor of the Junior Doctors Network in the Indian Medical Association (IMA).“This case is very different. Here a female doctor was raped and murdered inside a hospital, in what we [doctors] would think is our safe space.”

Ramegowda points out that while all resident and junior doctors face difficulties, it is the female doctor who is particularly vulnerable. “Most government hospitals have no places for doctors to rest or washrooms for them, let alone separate rooms or washrooms for female doctors. In many public hospitals, especially those in small towns, you will find people coming in and going out at all times, with large numbers accompanying a single patient. Female doctors spend long hours in these spaces, often late at night, without a room to themselves. They move from ward to ward to check on patients. How secure are these spaces for our young female doctors? After this case, all these questions are coming up and making us feel very unsafe,” Ramegowda says.

Ramegowda is aware of the challenges young junior and resident doctors face, both from her experience as the national convenor of IMA’s Junior Doctors Network and her days as a young medical student in Bengaluru. Some years ago, when she was posted as a resident doctor in a Bengaluru public hospital, she remembers how late one night, her female colleague on the same shift, was almost assaulted by the relative of a patient. “A young boy had been admitted to the hospital, and for some reason the relative thought we weren’t paying attention. So when she went to check on the boy, the relative placed a rod against the door and locked her in,” Ramegowda says. The relative was probably going to assault the young doctor, Ramegowda says, but another male doctor happened to be passing by and intervened. Things often went out of hand and at some point the junior and resident doctors instituted a rule that if a doctor was assaulted, all doctors would stop what they were doing until the police apprehended the accused. “I don’t know if the hospital still follows it. But in our time, we instituted this ‘Code White’ where all doctors would cease doing whatever they were doing till the police caught the accused,” she says.

The deep moral voice of the doctors’ agitation in Kolkata has resonated across the country and the Union health ministry has approved a 25 per cent increase in security deployment at all government hospitals. The Union government has also issued an advisory to state-run health institutions asking that women medicos be provided safe transport to and from their quarters at night and that they not be deployed for night duty with­out an escort. However, doctors continued to strike work on August 21, suspending elective medical services and calling for a swift and transparent investigation in the RG Kar incident. “It is not enough to generalise the incident or to make a lone arrest. A judicial inquiry must be conduct­ed and the role of the hospital, which has been a centre for corruption and unethical practices for a long time, must be ex­posed,” says Dr Sourav Datta, an oncolo­gist, who is the chairman of an action committee formed in the aftermath of the RG Kar Hospital incident, and a represen­tative of the Indian Medical Association (IMA), which has spearheaded protests across the country. Datta says that IMA has not given up on its demand that the Cen­tre introduce the 2019 Healthcare Services Personnel and Clinical Establishments (Prohibition of Violence and Damage to Property) Draft Bill, which never saw the light of day. The Centre, meanwhile, has maintained that most states have passed legislation to safeguard healthcare pro­fessionals and that what was really lacking was implementation.

One problem is that most doctors do not care to file FIRs, says M Ratnadeepthi, a 45-year-old doctor working in the Department of Physiology at the Government General Hospital in Kakinada, a coastal town in Andhra Pradesh. She is familiar with two cases of grievous assault—both against women doctors—at the hospital in recent times. “One happened in the labour room when we lost a mother and child to excessive bleeding. The other happened to an anesthesiologist. In both cases, mobs of 30-40 people descended on the wards and security personnel struggled to deal with them. The doctors were injured but neither filed a complaint. With mob violence, the crime tends to get diluted and it is difficult to pin blame on one or two perpetrators. So the entire mob goes scot free. This has to change,” she says.

Even as the RG Kar case continues to simmer, yet another assault, this time on a resident doctor in Mumbai’s Sion hospital, has come to light. The relatives of a patient, who was reportedly drunk and involved in a scuffle outside the hospital, attacked a young resident doctor when she was treating him. The patient is believed to have felt some pain while the doctor was removing the gauze covering a wound. According to reports, a female relative then shoved the bloodied gauze into the doctor’s face and attacked her. “The doctor had abrasions on her arm and she was shaken,” says Dr Diksha Bajaj, a member of the Maharashtra Association of Resident Doctors, and a resident doctor in a government hospital in Maharashtra. “Most government hospitals have no hostels or accommodation for doctors. Even at their places of work, there are often no dedicated rooms or washrooms for doctors. So when a resident doctor works herself to the point of exhaustion, she will just lie down anywhere for an hour or two, without caring how safe that particular area is,” she says.

While hospitals are now in the process of setting up panic buttons, refurbishing their CCTVs and undertaking basement security audits, the animus that seems to prevail between doctors and patients threatens to further corrode a relationship already endangered by the increasing corporatisation of healthcare and a general sense of distrust in a system that allegedly let down millions of people during the Covid pandemic. “It might help to take the pressure off young doctors and residents simply by be­ing nice to them and not loading them with unnecessary work. Medicine is extremely hierarchical and seniors do not just take advantage of juniors but are often cruel in keeping with the old adage ‘what doesn’t kill you, makes you stronger’,” says Dr Karan Shetty, a Bengaluru-based plastic surgeon with a private practice. When he was an assistant professor at Victoria Hospital, Shetty says he made sure that he treated students well. “What you can’t change as a student, you can at least attempt to change as a teacher,” he says.

Good leadership makes all the dif­ference to a hospital, especially to one in a non-metro that is starved of funds as well as inspiration. At the Government General Hospital in Nizamabad, Telangana, Dr Prathima Raj, the 40-year-old superintendent who took charge five years ago, proactively addresses cases of violence and harassment. The hospital registered three cases of violence against doctors in the past year. “Every day, there are scuffles as a lot of patients come drunk and we cannot turn them away. I have created a WhatsApp group with junior doctors—we have about 200 residents and 100 interns, half of whom are wom­en—and the Special Protection Force, who are first responders in case of any incident. For a hospital with 250 ICU beds and 2,500 outpatients, we have only 53 security personnel—and they get beaten up routinely. Someone recently suffered a fracture and quit. Just a few days ago, a patient was roaming the wards while brandishing a blade and we were so scared,” says Raj, who was instrumental in getting philanthropists and corporates to donate most of the ICU beds and high-tech equipment the hospital currently has. “In big cities, people don’t worry about general hospitals because they have other options. We are the major hospital in Nizamabad and we have to ensure the safety of our doctors if we are to cater to patients from this part of Telangana.” She has approached the government to limit access to the wards so that doctors do not get mobbed. “Not only relatives, YouTubers and local mediaper­sons with cellphone cameras prowl the hospital for ‘scoops’, filming without per­mission and circulating false news. We are under pressure because of such anti-social elements,” says Raj, who is fighting several defamation suits in court.

A recent RTI has revealed that in the past five years, 58 postgraduate medical students died by suicide, many of them presumably due to pressure and bad treatment by their seniors. InarecentonlinesurveybyNational Medical Council, 37,000 medical students self-reported mental ailments with the risk of suicide. With IMA estimating that 60 per cent of all Indian medicos now being women, this means that there are tens of thousands of women doctors-in-training who need sav­ing from a system that has let them down —fromthewaytheyareassessedasstudents to how they are trained and the hostile work environments they will soon inhabit.

(With Lhendup G Bhutia)

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