|Year : 2020 | Volume
| Issue : 5 | Page : 181-186
The “Good, Bad, and Ugly:” Challenges for the health-care professionals in wake of the COVID-19 pandemic
Swati Kedia Gupta, Sudhir Khandelwal
Department of Psychiatry, Holy Family Hospital, New Delhi, India
|Date of Submission||27-Jul-2020|
|Date of Acceptance||14-Aug-2020|
|Date of Web Publication||02-Oct-2020|
Dr. Sudhir Khandelwal
Holy Family Hospital, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Health care has been considered as among the most coveted and noble of all professions. However, the last decade has seen increasing incidents of violence against health-care professionals. The world, currently, faces an unprecedented emergency in the form of COVID-19 and health-care workers are at the frontline, saving lives and exposing themselves to the deadly virus and yet face the stigma of spreading the virus. The public perception has ranged from lauding the efforts of medical staff to unprovoked or unnecessary violence towards them. The current overview aims to understand the challenges faced by the health-care professionals specifically during the pandemic and how it has impacted perception of public and government.
Keywords: COVID-19, doctors, health care, pandemic, stigma, workplace violence
|How to cite this article:|
Gupta SK, Khandelwal S. The “Good, Bad, and Ugly:” Challenges for the health-care professionals in wake of the COVID-19 pandemic. Indian J Soc Psychiatry 2020;36, Suppl S1:181-6
|How to cite this URL:|
Gupta SK, Khandelwal S. The “Good, Bad, and Ugly:” Challenges for the health-care professionals in wake of the COVID-19 pandemic. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Oct 28];36, Suppl S1:181-6. Available from: https://www.indjsp.org/text.asp?2020/36/5/181/297160
| Introduction|| |
“No physician, however conscientious or careful, can tell what day or hour he may not be the object of some undeserved attack, malicious accusation, blackmail or suit for damages…”
As evidenced by the 128-year-old quote, violence against doctors is not a new phenomenon; however, the incidents have seen steep growth in the 21st century. Till a few decades back, health-care professionals were highly revered, respected and almost given a “God-like status,” especially in the Indian subcontinent. Due to various reasons, the pendulum has swayed in the other direction and medical fraternity is now looked down on and all their actions are viewed with suspicion.
As the world struggles with COVID-19 pandemic, health-care professionals are designated as the “frontline warriors” fighting the war. Various places across the globe applauded the indispensable role of health-care professionals in dealing with this calamity. While in other places, stories of assault against them started pouring in. In Mexico, nurses and doctors were pelted with eggs and in Philippines, a nurse was attacked by a man who threw bleach on his face, damaging his vision. In India, many were beaten up, thrown out of the house and harassed, and the last straw was the disruption of funeral proceedings of a COVID-positive doctor. The Indian Medical Association (IMA) decided to observe April 23, 2020 as a “black day”, forcing government to take notice and pass an ordinance amending the Epidemic Disease Act.,
| Epidemiology of Workplace Violence|| |
Violence against health-care professionals, also known as workplace violence (WPV) is a global phenomenon. According to Occupational Safety and Health Administrative (OSHA), health-care professions are at the highest risk for WPV and a fourfold higher likelihood of sustaining an injury. Worldwide, 56%–80% doctors report facing WPV at some point in their career. Reported incidents of WPV in Chinese healthcare system increased from 10,000 in 2005–17,000 in 2010 leading to an editorial in Lancet stating: “Doctors in China are not unique in facing violence. However, for a third of doctors to have experienced conflict and thousands to have been injured, the scale, frequency and viciousness of attacks have shocked the world.”
Also known as “Yi Nao phenomenon” (Chinese for Healthcare disturbances), violence against healthcare professionals is seeing an alarming rise in India. As per the Google search, there were a handful of reported incidents between 1980 and 2000 and a spike has been seen since then. A survey, in 2017, by IMA reported that 75% of doctors faced violence at work with 12% being physical in nature. About 50% were reported from intensive care units or postsurgery and more than 70% of them were committed by relatives of patients. However, for reasons unknown, the study is not available for public dissemination.
Content analysis from top ten English newspapers in the country reported that between January and December 2017, there were 93 reported incidents of violence toward health-care professionals (81% doctors; 6.5% staff nurses, and 13% other health-care staff). Similar to findings from other countries-male gender, working in emergency department and night-time were positively correlated with increased chances of violence and in majority of cases, preparators were relatives of patients. Of the reported incidents, 9% were grievous injuries, resulting in deaths of two doctors. An interesting finding was that government hospital doctors were the target in Delhi and Uttar Pradesh, whereas in Rajasthan and Maharashtra, the hammer fell on the private practitioners. The study also looked at the probable causes of violence and reported the following-intolerance to news of patient's death, delay in treatment, poor communication by health-care staff, intoxication in perpetrator and inadequate specialists or facilities.
What is alarming is that most of the incidents of violence go unreported or a first information report (FIR) is not lodged, and therefore, it is very hard to gauge the true extent of this phenomenon.
Sadly, some of the more recent events not only showed the dismal state of health-care professionals, but also highlighted the government's apathy. In June 2019, 800,000 doctors across the country went on strike, after a junior doctor in Kolkata was brutally attacked in the hospital. The government gave it a political and communal flavor with the Bengal Chief Minister openly threatened the striking doctors in the state to go back to work or face consequences.
In India, 19 states follow the medical protection act, which covers all medical professionals. According to the act, offenders would get a jail-term of up to 3 years and a fine of Rs. 50,000/-. However, it is neither covered in the Indian Penal Code (IPC) nor in the Code of Criminal Procedure, making it difficult to file a complaint. Whereas, a doctor who is negligent in their conduct can be booked under section 304A of IPC (causing death due to rash act).
To safeguard health-professionals, the Indian Health Ministry proposed the Health Services Personnel and Clinical Establishments (Prohibition of Violence and Damage to Property) Draft Bill, 2019 that demanded imprisonment between 3 and 10 years and fines between 2 and 10 lakhs for hurting health-care professionals and imprisonment for 6 months-3 years and fine between 50,000 and 5 lakh for damaging healthcare facility. The bill was passed by the Ministry of labor, but dismissed by the Home Ministry who felt that there was no need for a separate law as well as the Supreme Court, which ruled that doctors cannot be provided security at the cost of other citizens.
| Causes of Violence|| |
To bring about substantial changes in this phenomenon, it is imperative to understand the underlying causes of WPV in health care especially in India.
Meagre health-care budget leading to the lack of availability of life-saving drugs, poorly managed, and unhygienic public hospital facilities, and increased waiting time is a source of frustration for public; as per article 21 and 47 of the Indian constitution, health is a fundamental right and emergency care should be provided free by the state. However, most states are not able to provide the same and the load is transferred to the corporate, private sector forcing individuals to pay exorbitant amounts for healthcare facilities. This, along with low insurance coverage has pushed many people in poverty;, Also the lack of personnel and their uneven distribution falls abysmally lower (ranging from 2.5 to 41.6/10,000 population) than the World Health Organization (WHO) requirement reduces time for doctor-patient interactions, and increase burnout.
Globalization, technological boom and population growth has led to wide economic disparity, decreased levels of empathy and civic sense. In general, there is more aggression in society, also known as “mobocracy” that is reflected in road-rages, and increased incidences of violence in educational institutes.
Disbelief in judicial system by both patients and healthcare staff
Leads to low reporting of cases of violence and encourages public to “take law in their hands.”
“Bashing-boys” for media and politicians
Media regularly publish and sensationalize stories of medical negligence and malpractice. In 2012, major controversy happened when Aamir Khan, one of the top actors of the country accused the medical fraternity for being corrupt on his popular show – “Satyamev Jayate.” Politicians often chastise doctors for “not taking care of the needy” or “expecting money for treatment”. Often, they issue statements that paint the entire community as corrupt and thereby justifying the violence. In 2018, prime-minister Modi, in London, hinted at a nexus between pharmaceutical company, indirectly accusing doctors of over-charging their patients. The IMA Secretary-General Dr R N Tandon remarked,–“Engaging in small talk and maligning the entire medical fraternity in India with a broad brush on foreign soil was certainly not expected out of the prime minister of the country.IMA expresses its displeasure on your unfortunate remarks…”.
Low health literacy
The presence of myths and misconceptions often lead to false accusations that the “doctor did not do enough”. Furthermore, with increased technological system, there is a widespread belief that doctors would be able to guarantee a good outcome, if they really want.
Inadequate communication skills by healthcare staff
Due to lack of counselors or social workers who are specifically trained in communication skills, the task falls on doctors and other staff who are inept in handling the same (e.g., communicating to patients and families regarding the diagnosis, prognosis, course of treatment, or breaking bad news). Often health-care professionals, knowingly or unknowingly, display a condescending attitude toward patients. This leads to increase in mistrust and results in conflictual situations.
| Covid-19, Violence Against Health-Care Professionals and Other Challenges|| |
No published studies, except for a couple of news excerpts, have focused specifically on violence during periods of epidemics and pandemic like the Spanish flu, HIV/AIDS or H1N1 flu., In his book – “Twelve Diseases that Changed Our World,” Irwin Sherman  pointed out the rampant stigmatization of races, communities, country or individuals as source or carrier of infectious disease and how that led to increased violence. For example, during the Black Death, Jews were killed as it was believed that they poisoned the well  or how quarantine during cholera changed people's worldview – “when quarantine becomes a social policy, its effects can be pernicious: it can isolate more than those labelled as 'diseased' and can stigmatize an entire group.”
“On March 24, 2020, two female residents from a reputed government hospital in Delhi had stepped out of their house to buy fruits, where they were assaulted by a 42-year-old man, accusing them of spreading coronavirus.” “By end of March 2020, reports started pouring in that house-owners were evicting healthcare professionals stating the increased risk of COVID infection. A 38-year-old nurse was threatened by her landlady and asked to leave the house within 24 h”. “On April 2, 2020, health professionals were injured as residents of the area where they had gone for screening and contact tracing, pelted stones on them.” Moreover, then there have been stories of ASHA workers attacked while collecting COVID data; Tablighi Jamaat attendees spitting at health-care staff at quarantine centers. The last straw was the mob attack in Chennai to stop the burial of a doctor who, a frontline worker, died due to COVID infection.
It can be stipulated that the current violence is a combination of covert hostility that has been increasing over the last few decades and certain factors unique to the current pandemic–
- Widespread nature of the disease, quarantine and lockdown that no-one in their lifetime has ever witnessed creates panic and uncertainty leading to increased stigmatization of the medical community as they are the closest to the disease and therefore potential carriers and a threat to the community 
- Increase in fake news due to various technological and social media platform increasing fear and stigma related to the disease as well as its carriers 
- Lack of awareness or misconceptions, in general public, regarding the spread of the diseases and protections offered by personal protective equipment (PPEs) that prevent the doctors and nurses from getting the infection and spreading it further
- A general decrease in empathy and humanitarian attitude that leads an individual to act selfishly without concern for welfare of others.
Apart from the violence, health-care professionals all around the world, especially India face additional challenges such as increased risk of infection, shortage of PPEs, lack of clean and hygiene quarantine facilities, long working hours, exhaustion due to prolonged use of heavy protection gear, isolation from loved ones because of the fear of spreading the infection, and increased risk of burnout and mental stress.
| Some Respite during the Crisis|| |
All over the world, the pandemic forced the government and public to accept the indispensable role of health professionals. On the “World Day for Safety and Health at Work”, observed on April 28, 2020, the WHO called upon all employers to take urgent measures to protect health and ensure safety of health professionals and emergency responders. The WHO also urged the governments to develop national programmes for providing occupational health services to the health professionals.
The COVID situation and ensuing violence against healthcare professionals led the Indian government pass of the amended Epidemic Disease Ordinance 2020. The ordinance defines a health professional as “a person who is at risk of contracting the epidemic disease while carrying out their duties related to the epidemic.” It classified “acts of violence” as (a) harassment that impact living/working condition; (b) harm, danger to life; (c) causing obstruction in their line of duty and (d) loss or damage to the property. According to the ordinance, it's a nonbailable offense to assault a health-care professional and offenders would be faced with imprisonment of up to 5 years and a fine of up to Rs. 2 lakh. Finally, the ordinance state that investigations about the registered cases should be completed within 30 days of filing the FIR and the trial should be completed within a year.
On April 20, 2020, the Department of Health and Family Welfare issued a circular with respect to the “Measures to be undertaken to Ensure the Safety of Health Workers” and updated on June 20, 2020, had the following highlights:
- Health-care professionals would include all doctors and staff working in the government and private hospitals and ASHA workers
- Use of hydroxychloroquine for positive health-care workers
- Provision of PPEs and timely payments to government staff and ASHA workers
- Provision of psychological support for ASHA workers
- Provision of Accidental Insurance cover of 50 lakhs.
| Way Forward|| |
It has now become highly important that the country ensures the occupational health for health-care professionals by testing them as a priority, ensuring PPE and safety kits for all, creating safe and hygenic quarantine facilities and imparting knowledge and training in effectively dealing with the pandemic.
Highlighting the relentless efforts of health-care professionals, educating public about the disease and disseminating information to clarify myths and misconceptions can reduce the current threat that the general public feels. However, these are temporary solution to a problem that has become a pandemic in its own right. All stakeholders would need to come forward and multifaceted steps would be required to combat this situation.
In 2015, an enquiry into effectiveness of medical protection act revealed disheartening results, as neither police nor public was aware of the act and therefore no guilty person was booked. Thus, government can do its part by increasing health-care budget, strict implementation of health policies and laws against WPV; strengthening of primary health-care centers, Mohalla clinics, etc.; and taking actions against politicians who promote “VIP culture” or insult doctors publicly.
Responsible media behavior
Balance between positive achievements of health-care professionals and cases of medical negligence/lack of empathy can alter public perception. Furthermore, the media should desist from “Media trials” of doctors outside the court. The media should also be used to disseminate information, clear myths and misconceptions and help people in making informed choices.
Role of hospitals
Both Government and Private hospital should ensure provision of hygienic environment; employ counselors or social workers who can spend more time with patients, especially in breaking bad news; strengthening their security systems and put up signs displaying laws against violence.
Role of health-care professionals
Right from medical school, all health-care professionals must be trained in adequate communication skills, stress management, and how to identify early indicators of violence (e.g., staring by patient's relatives, verbal threats etc.) and how to mitigate them (e.g., talking calmly, explaining the situation, and calling for backup).
| Conclusion|| |
The world struggles with an unprecedent situation. The novel coronavirus has ushered in a pandemic and a lockdown that the world has not witnessed in the last century. India reported its first case on March 2, 2020. On March 22, a Janta curfew was imposed and all healthcare professionals were applauded for their efforts as “frontline warriors in the war against COVID-19. However, a couple of days later, reports of assault on health-care professionals started pouring in from all over the country and doctors were accused of “spreading coronavirus.”
Violence against health-care professionals is not a new phenomenon, nor is it restricted to India. Various factors at individual, societal, systemic, and political factors such as poor healthcare budget, lack of infrastructure and personnel, rising class differences, rising cost of healthcare, poor empathy, lack of trust in justice system, negative portrayal by media and politicians, patient's over-expectations and lack of patience, and poor communication skills by health-care professionals specifically in communicating diagnosis, prognosis or delivering bad news like death.
In the current situation, the hostility that has set in over the last two decades combined with stigma related to COVID, uncertainty of the situation, lack of awareness about the illness, and fake news spread on social media platform has fuelled further violence against the same people who are saving people's life. Apart from the violence, health-care professionals face multiple other challenges as they deal with this deadly disease.
Every dark cloud has a silver lining and this situation has highlighted the indispensable role of health-care professionals and need for strengthening the health-care systems. All over the world, various steps have been taken by organizations, communities, and government to lessen the challenges faced by health-care professionals. However, we have a long way to go to bring about permanent, long-term, systemic changes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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