Student Intern- Sociology, Jadavpur University, Kolkata
The struggle does not ends here if one wishes to opt for post graduation, during which some young medicos needs to work for around 15 hours (including both day and night shift). Only then the doctor (general practitioner) gets into professional career as a physician.
In India, many aspiring youths dream of becoming a doctor, some with a passion for helping and healing humanity, whereas some with a passion to earn respect and money. Becoming a doctor is not an easy task and the strain on resources makes the process more difficult. The first stage demands one to get a seat in government or private medical institute by clearing the NEET (National Eligibility cum Entrance Test) and acquiring a rank out of millions of students. After entering college, a medical student gets deeply immersed in books, patients and exams for the next five years of their life. Only after surviving all these hurdles, one receives their degree of graduation (e.g. MBBS, BDS).
But the current scenario indicates that along with women and children, even the doctors are no longer protected from attacks and assault. The recent issue indicating the same problem dates back to the night of June 10,when a mob of reportedly 200 people gathered outside Nil Ratan Sircar (NRS) Medical College and Hospital in Kolkata, West Bengal. According to Sneha Bhowmick, a 26-year-old first-year post-graduate trainee at NRS’s ophthalmology department, who was working at the hospital just hours before the attack, said that the mob came in two trucks, armed with laathis (sticks). And the reason being that a 75-year-old patient named Mohammed Syed had died in the same hospital a few hours before, and his kin alleged medical negligence of the NRS doctors. The mob attacked any doctor or medicinal faculty they saw and during this a junior doctor named Paribaha Mukherjee was severely injured and left with a fractured skull. This was followed by protest by the staff members of NRS hospital, where around 300 members refused to work and they shut all the medical services except OPD. Later on the protest was joined in by doctors from other hospitals in the state. And on 17th June, Indian Medical Association stretched solidarity to the doctors protesting in Kolkata by calling for an All India shut down of non-essential medical services, in which around 8 lakh doctors across the country participated.
According to a 2015 study by the Indian Medical Association, 75 percent of Indian doctors have faced verbal abuse, while 12 percent of them have been subjected to physical attacks. The survey also records 50 percent of violent incidents taking place in the Intensive Care Unit (ICU), while in 70 percent of the cases; relatives of patients were actively involved. And on 18th June when Supreme Court announced its decision on the issue by saying that “We understand it is a serious issue but we can’t provide security to doctors at the cost of other citizens. We have to look at the larger picture. We are not against protection to doctors”. This legal judgement is completely contrary to what we see in Australia where in Queensland state as part of the Safe Night Out Strategy to stamp out violence, if you commit an aggravated serious assault on a nurse, doctor, paramedic – or any health professional – you could be hit with up to 14 years’ imprisonment.
(source: Article by Vice. Link to the article- https://www.vice.com/en_in/article/ywykdb/indian-doctors-tell-us-about-the-times-they-were-threatened-and-abused)
What happened two years back was also a similar case of accusing and victimising the doctors. The UP government had arrested paediatrician Dr Kafeel Khan, principal Rajiv Misra, and anaesthetist Satish Kumar at the Baba Raghav Das Hospital in Gorakhpur in August 2017 after the hospital ran out of oxygen and 63 children in critical care died. The plight of doctors in Gorakhpur, who were suspended by the Uttar Pradesh government, was no better. The doctors who were affected by the suspensions and have asserted that they have faced state-supported victimisation said the IMA had done nothing substantial to help them and waited nearly eight months to express its support for them. Dr Kafeel Khan had to face severe allegations and was main target of the angry public and as a result of all these, his brother was shot and had to undergo surgery for the removal of the bullets. After eight months Dr Kafeel was released on bail, having found him not guilty by Allahabad High Court. Despite of the orders by Allahabad High Court on this year 7th March sanctioned the Utta Pradesh government on clearing Dr Kafeel’s suspension paper work, he has not being reinstated. But above all this, is Dr Kafeel’s commitment to medical profession which has backed him and hence he has being on tour to the Muzaffarpur’s worst affected area by Encephilitis in order to detect the symptoms and recommend instant testing. He has drawn a connection between what has happened in Gorakhpur two years back and what is happening right now in Muzaffarpur, and in both the cases it is the state governments and state run hospitals unpreparedness towards such outbreaks which has actually worsened the situation.
Attacks on doctors and their family is now a mainstream issue in India. When on one side a doctor saves a patient from a deadly disease or injury, he is considered as a personified god and when on the other hand a doctor fails to save one’s life, he considered a murderer and in fact a demon. Such events are unending, like on this 21st may The drunk bystanders of a patient attacked a doctor at Nizam Institute of Medical Sciences, Telangana; similarly on 1st January 2019 a senior paediatrician was injured at the rib and the lung by the relatives of a patient at Hyderabad, Telangana; on 15th October 2018 a scheduled caste doctor was assaulted by the relatives of an upper cast patient, demanding the service of an upper caste doctor at Jabalpur, Madhya Pradesh; and many more such incidents.
This issue is not centric to any particular geographical location and in fact is a global problem faced by doctors across the national boundaries, who are divided by locations but united by faith and profession. For e.g. medical workers fighting Ebola in the Democratic Republic of Congo are demanding that authorities provide better protection for them after an attack on a treatment centre left one doctor dead on this year April 19, and his name was Dr Richard Valera Mouzoko Kiboung, a Cameroonian epidemiologist with the World Health Organization. Even China faces this problem and survey by the Chinese Hospital Association reported an average of 27.3 assaults per hospital per year in 2012, up from 20.6 assaults per hospital per year in 2006. On October 2018 in China, a man attacked Dr He Yingdong and his collegues after they refused to give his wife a caesarean and Dr He was left with fractured jaw and eye socket. But to prevent and eradicate the problem of violence against medical professional, a scheme of blacklisting is being introduced by the China’s National Health Commission and other government departments. Those in the blacklist will be the one who severely disrupted medical procedure and were involved in assaulting doctors and hence they will be flagged in a nationwide social credit system.
According to a journal named Violence against doctors- a wake-up call by Kanjaksha Ghosh; the most important difference in violence as is seen in western countries is how quickly the verbal abuse becomes physical assault and vandalism and how rare it is that other patients and their relatives or third party make no efforts to stop it and there is a need for a detailed longitudinal study across the country to understand the prevalence, nature and regional differences in violence perpetrated against doctors in this country. According to another journal named Medical violence (Yi Nao Phenomenon): It’s past, present and future; advanced medical care technology has revolutionized medical care outcomes on the one hand; however, it has led to high expectations for 100% cure among patients and relatives. The difference between these high expectations and actual ground realities is the main root cause of this curse.
After all the allegations, struggle and assault; the doctor are still found serving the public in need. And hence the boon of medical profession needs to be protected from the local assaulting goon.
SOME HIDDEN REALITIES:
India currently spends 1.02% of its GDP on public health which is lower than even Singapore’s health spending which is 2.2 of its GDP, according to National Health Profile data. That is to say that India’s per capita public expenditure on heath was Rs 1,112 in 2015-16.
According to the World Health Organization (WHO), most of the healthcare expenditure in India – which averages $75 per capita – comes from the private spending of households. For local Indians, the cost of private healthcare is about four times greater than the country’s public healthcare. About 72 percent of residents of rural areas and 79 percent of residents of urban areas use private healthcare services.
This inclination of people towards private hospital might indicate towards the degrading quality of services in public hospitals, but considering this trend the government neglects the fact of improving the conditions in the public healthcare institution and rather plans on privatising the public hospitals. This solution was sorted by NITI Aayog, the government think-tank, which suggested running district hospitals on the public-private partnership (PPP) model because “the system continues to remain constrained with a set of systemic issues”. The reason behind this was stated that the involvement of private players on state-run hospital space will reduce the burden of fund allocation for non communicable diseases. But the reality is the neglect by government which fails to execute the proposed plan of resource allocation. (Source link- https://www.downtoearth.org.in/news/health/government-hospitals-on-sale–58399)
It is known that studying in medical college is costly. Starting from the academic fee to the hostel and mess cost, everything is expensive. In India, many dreams of becoming a doctor or medical professional shatter each year due to parent’s incapacity to pay such hefty amount. While medical education is pricey, there are government medical colleges in India that charges relatively less.
It is known that seats are limited in medical colleges (both central run and state government colleges) and hence the competition is high. The policy of reservation is also applied here to ensure participation in medical profession by those who are socially backward and hence can afford a seat in these institutions through reserved seats. Also, the rules relating to age limit and qualifying marks required to enter the exams are relaxed for the reserved candidates. Apart from the 50 percent reserved seats, the fees charged for application and during the duration of course is less for the reserved candidates than that paid by unreserved candidates. Are these policies implemented on ground when the administration and the whole process itself is controlled by upper caste?
What about those who belong to economically backward upper caste, middle class people, who need economic support but do not get the state’s benefit and hence they accuse the candidates and professions in education institutions for taking away their seats by reservation. But it is important to understand the context that has mandated the affirmative action in India, i.e. it is to compensate for the discrimination faced by the lower caste people for centuries in India in terms of caste and higher caste norms and looking at the current incidents it is of no surprise to say that in spite of the legal acts like The Scheduled caste and tribes (Prevention of Atrocities) act 1989, people face discrimination on caste identity. There are personal judgments held by upper caste people that those who has actually taken the benefit once of reservation, continues to take reserved seats based on their caste, in spite of improved economical status.
In this context of claims and debates, a new bill was passed this year i.e. Constitutional (124th Amendment) Bill, 2019 creating a 10% quota for the economically weaker sections (EWS). According to this reservation policy, the focus is on the poor section of the society and assuring them a 10% quota in reservation scheme (increasing the 50% limit to 60%) and those who are termed as poor and are eligible for EWS quota are the ones whose household annual income is 8 lakhs per annum. But surprisingly as per the Indian Human Development Surveys, around 98% households has income less than 8 lakh per annum and within this category of poor there is a deep rooted caste dimension, that is to say that the average income of the poor scheduled caste (SC) household was around half (56%) of the average income of the poor upper caste households in 2005-2012. But it has been clearly stated that the EWS quota benefits will not be entertained by those already in the receiving ends of SC-15%, ST-7% and OBC-27% quotas (socially backward criteria). This 10% quota seems to be tilted in the favour of upper caste people who are already socially privileged and share the bare minimum level of existence (in terms of income) with 95-98% of the population. How can an affirmative policy exclude people (who needs it i.e. lower caste category in spite of the fact that the mentioned criteria make them eligible for it)? It is important here to understand that this quota is itself unconstitutional because i)It is based on economic criteria and it overturns the entire purpose of affirmative action which is to empower socially and culturally backward people because it was them who were and still are most affected by the caste system. ii) It is not inclusive in nature and excludes much of the economically weaker population on grounds of belonging to the socially backward criteria. iii) The estimation of 10% EWS reservation is not based on proper study and survey (like the 27% reservation for OBC who has 54% of the population share, was backed by the Backward Class Commission Report). So, the question still remains – Is this really a solution? Or is it ripping off the intention behind introducing affirmative actions?
There is a need to sensitize people about how even the reservation policy i.e. 49.5 %, fails to protect the integrity of SCs and STs Category people’s dignity. And neither can this claim of reserved seats put a veil on the discrimination faced by lower caste medical students who although might get through with the admission in medical colleges via reservation scheme, but the reality is the struggle that they face to survive the torment of discrimination faced in those 5 years. It is of no surprise that much of the students in India commit suicides for various reasons which show the rising insensitivity towards students by both other fellow students and faculty members. However the disproportionate number of dalit and adivasi students who have committed suicide, especially at premier institutions, also highlights the caste discrimination prevalent at these institutions. For instance, Jaspreet Singh, a final-year medical student in Chandigarh, hanged himself in his college library in January 2008, unable to bear the insults and taunts. The suicide note recovered from his coat pocket charged one of his professors with discrimination on caste grounds. He was accused by his community medicine professor for being a lower caste candidate, and was hence failed twice based on his caste identity.
Another such case was of Balmukund Bharti, final-year MBBS student at AIIMS, New Delhi, who killed himself on March 3, 2010. His parents accused AIIMS of caste discrimination that drove their son to suicide because of constant humiliation faced by him on the virtue of being born as a dalit and demanded a probe.
On 22 May 2019, Payal Tadvi, a second-year MD student at Mumbai’s TN Topivala National Medical College (TNMC) had to go through an ordeal of harassment, humiliation and punishment in her college which resulted in committing suicide in her college hostel room. She belonged to the Tadvi Bhil Muslim community, a Scheduled Tribe. Three of her senior colleagues were arrested for allegedly tormenting her about her caste, and abetting her suicide. She was mentally harassed by her room mates, and was burdened with intense paper work and many such incidents of humiliation and distortion. They were remanded to judicial custody till 10 June. Students from Scheduled Caste (SC), Scheduled Tribe (ST) and Other Backward Class (OBC) backgrounds at medical colleges face caste prejudices in hidden and obvious ways. There is intense work pressure on medical students (specially the junior doctor) and this burden is doubled with caste discrimination in case of scheduled caste/ tribe students.
What happens behind the walls of premiere institutions of medical science is a hidden reality and what might be called as ‘Casteism hides behind white coats’. Indian Medical Association voluntarily fails to recognise the prevalence of caste based discrimination and hence no legal action is taken to put an end to it. So the only option left for those pursuing medical degree with their surnames indicating one’s lower caste identity is twofold i.e. the weak hearted who cannot take such humiliation commits suicide or are victims of anxiety and depression, and the remaining others usually sought to social media blogging and exposure. But where is justice here? Remarks from senior professors and senior fellow mates are derogatory is nature in spite of the fact that some of the students belonging to SC/ST/OBC are equally competent as the general category students. This lane of remarks and discrimination seems to be never sending for the lower caste people, be it the degree days or the years followed by job duties. Much of the caste discrimination and especially against the Dalits, is perpetuated through the educational system in India which often results in dropouts.
It is not just in the practice of medical studies and profession but also in the benefaction from the healthcare system, where the Dalits are segregated and discriminated. Due to the presence of taboos and social norms which exhausts the minimum advantages of survival, the Dalits are more susceptible to illness than upper caste because of lack of safe drinking water to more than 20% of the Dalits who due to this suffer from fatal diseases like malaria, diarrhoea etc and still, Dalits in 21.3% villages are denied entry into private health centres or clinic and 65% of the Dalit communities do not receive healthcare benefits. The scenario for Dalit women is more horrifying. So it wouldn’t be wrong to say, having this context of discrimination in healthcare system, that healthcare has now turned into a luxury affordable and accessible only for those who do not carry the tag of being a Dalit or any other lower caste per se. (Source Article- India’s inequality in healthcare; the caste divide. & Casteism behind white coats)
Caste based inequalities is not new to India and neither is this a new phenomenon where each castes have pre-determined labour work assigned and not at all surprising is the fact that Dalits and other lower caste people are assigned menial task (filthy and polluting) and even in this changing time are expected to stick to those tasks only. And when people from these categories get into other reputed professions, they are the main targets of abusers. The Dalits who step outside their so called domains of work, are physically abused and are socially cut off from community life. In India, almost most of the violence has a deep rooted link to the caste mindset and to understand the dynamics of these problem and issues, it is important to dig into the caste context. Similarly, the wholesome issue of violence against medical professionals also has a caste dimension to it.
Right from the colonial regime which sought to work with social elites, till the post independence development structure of India, made the high castes occupy a privileged position in terms of opportunities and white collar profession (including medical profession). The hindrance to enter such positions by lower caste was a result of the mainstream practice in India to exclude and restrict the lower section of society. The data from 2001 census confirms that till now the lower caste are yet to make a significant presence in the medical profession, whether it is allopathic or indigenous form of medicine. Tribal community is least represented in this profession. The interesting point to note is combined population of SC and ST during 2011 census was 24.4 percent.
The Indian Medical Association has guidelines for how medical professionals should fraternise with their co-workers, one of which mandates treating colleagues with respect and dignity. Insinuating that a large number of doctors are incompetent solely because they belong to certain castes is definitely a violation of these guidelines. People from upper caste who has always benefitted from their social capital tend to boost the level of discrimination faced by lower caste people by questioning the merit of these people and their deserving status. One such resentment by unreserved category people came when implementation of two new categories of reservation – for economically weaker sections (EWS) and socially and educationally backward classes (SEBC) was introduced in Maharashtra for admission process of post graduation medicine degree.
Along with protection and security of doctors from patients family and local goons, there is a need for protecting young medical practitioners and medical students from caste based discrimination that plagues even the medical profession which is supposedly affirms to the concept of humanity above all.
Such discrimination also exists in countries other than India, although in a different form i.e. based on race and religion. Racism and discrimination are deeply ingrained in the social, political, and economic structures of western society. Considering the case of U.S.A. where Donald Trump won the presidential elections of 2016 and since then religious intolerance and racism has been a common practice. For e.g. a Muslim- American doctor named Altaaf Saadi shared her experience of being discriminated by her white patients on the ground of religion and because she wore headscarf. She even experienced discrimination faced by infants in paediatric centres on racial terms i.e. African-American infants receive less attention than white infants.
Another instance of discrimination faced by doctors on racial grounds was recorded by J. Nwando Olayiwola who is a physician at San Francisco General Hospital. She said that being a doctor is in itself a privilege and power, but this power can shift if you belong to a ethnic minority. For instance, a white patient refused to be treated by her because she was a black woman. Such discrimination is widespread, some gets highlighted and others go unrecorded.
Even in distant lands, the trend of caste based discrimination is sustained by the immigrants (especially Indians and South-East origin). One such incident is shared by Pramod Theetha Kariyanna who is a cardiologist in the U.S.A. He says that because he belonged to the shudra category of the caste hierarchy in south India, he was often being made fun of and this identity of his had nothing to do with his academic brilliance and yet still he had to face remarks by people (mostly Indian origin who tend to know the caste system very well) based on his caste identity. So the propagation of caste discrimination is not limited to Indian Territory (and it’ neighbouring countries like Nepal etc), but in fact is being endorsed in foreign land by the minority community itself.
There is a need to preserve the integrity of medical profession from possible discrimination and unethical practices, and this need is trans-national in nature.
English