Rather than only limiting responses to punishment and harsher penalties, policymakers must address the underlying structural factors that lead to violence against healthcare professionals.
As Indian healthcare professionals battle the raging COVID-19 pandemic, several media agencies have reported disturbing incidents of violence against healthcare professionals. In Indore, stones were pelted at healthcare workers trying to screen for the coronavirus, while in Hyderabad, a junior doctor was assaulted by relatives of a deceased patient. Similar incidents have been reported in other parts of the country as well.
While the COVID-19 pandemic is admittedly unprecedented, these incidents of violence are themselves not new and are part of a larger pattern that has received widespread media coverage in recent years. The Vidhi Centre for Legal Policy’s research on violence against healthcare professionals analysed 56 such reported incidents of violence between January 2018 to September 2019. In a number of such instances, the death of the patient was an immediate trigger for violence, while aggressive relatives prompted violence in other situations.
A review of Indian studies and academic writing on the issue revealed the crippling lack of infrastructure and personnel to deal with growing numbers of patients, poor quality or complete lack of primary care, leading to overburdening of secondary and tertiary care facilities, and overall poor communication skills as distinct causal factors of violence.
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Turning a crisis into an opportunity for bigger reforms
An immediate response to violence against healthcare professionals is usually prosecution under harsh laws and calls for new laws to deter similar conduct in the future. This response is based on the theory of deterrence which assumes that offenders make rational choices and avoid indulging in certain conduct due to the high costs associated with the consequences.
Deterrence-based reasoning, however, works better when laws are accompanied by efficient enforcement and criminal conduct is premeditated rather than the result of sudden and violent emotions. In India, violence against healthcare professionals occurs in specific contexts and situations and is hardly ever premeditated. Further, the well-acknowledged slow pace of the criminal justice system questions the efficacy of only using criminal laws to address violence in healthcare settings.
In light of COVID-19, the policy-makers are focusing their attention on meeting the immediate needs of healthcare professionals such as supplying adequate personal protective equipment (PPEs) and ramping up infrastructure by increasing isolation facilities and ventilators. However, the crisis presents an additional opportunity to take a long, hard look at Indian healthcare and address many of the systemic issues which have led to violence.
Therefore, rather than only limiting responses to punishment and harsher penalties, policymakers must address the underlying structural factors that lead to violence against healthcare professionals.
Members of Resident Doctors Association of AIIMS wearing bandages on their heads protest to show solidarity with their counterparts in West Bengal. Photo: PTI)
Need for structural changes
While global best practices suggest that several steps can be taken by the healthcare establishments themselves to prevent violence and to provide redress to their employees, hardly any steps are taken in India at the organisational level to prevent and address such violence in healthcare establishments. The World Health Organisation (WHO) recommends that specific obligations should be imposed on healthcare establishments to prevent violence like the elimination of risks of violence, routine assessment of the incidence of violence and its causes, developing policies, plans and monitoring mechanisms to combat violence, setting up adequate mechanisms for reporting.
Post-incident interventions should also be undertaken by healthcare establishments like providing medical treatment, counselling, management support, representation and legal aid, rehabilitation etc. Additionally, having proper grievance redressal mechanisms in healthcare establishments for patients can prevent them from getting triggered.
Further, as healthcare professionals in India are not protected by labour laws, having an occupational health and safety framework in the health sector in India, similar to the US, can go a long way in addressing the issue of violence. In the US, employers including healthcare establishments are liable to provide their employees with a workplace free from recognised hazards likely to cause death or serious physical harm. In addition to violence, this kind of framework will also impose greater accountability on healthcare establishments towards ensuring the safety of healthcare workers in a pandemic when they are exposed to higher risks.
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As poor communication skills in healthcare professionals have been identified as one of the factors linked to the rise in violence against them, the Indian medical curriculum needs to be reformed to make medical graduates equipped with effective and empathetic communication skills. The medical training curricula should focus on techniques to deal with the grief of the patient’s attendants, socio-political reasons underlying the flareups involving patients and their relatives, and the ability to deal with vulnerable groups such as the victims of sexual abuse and the LGBTQ+ community. Addressing these issues will contribute to preventing the triggering of violence due to the lack of communication skills in doctors. In the context of the current crisis, where doctors may be overburdened even accessible public communication about the pandemic could go a long way in addressing misconceptions.
Another factor that has contributed to violence in recent incidents and has come in the limelight in the current COVID-19 crisis is the breakdown of trust between the healthcare system and the patient population. For instance, COVID-19 has highlighted concerns regarding access to ventilators and prohibitive costs in private hospitals. These correspond to identified reasons which include high cost of procedures, medication, and hospital stay; inconsistent quality of treatment based on patient’s ability to pay; perceived corruption of the doctor-pharmaceutical company nexus, among others. This highlights the urgency of rehauling the regulation and governance of healthcare in India to ensure accessibility and greater accountability on the part of healthcare establishments, both public and private.
Turning our attention towards these structural issues in the long term will not only address the problem of violence in healthcare settings but will also help build trust in doctor-patient relationships. The COVID-19 pandemic is an opportunity to think deeply about these issues.
Akshat Agarwal and Shreya Shrivastava are research fellows at the Vidhi Centre for Legal Policy. Views expressed are personal.
