Violence Against Healthcare Professionals in India: We Need To Stop This Barbarism!

The increased incidents of violence against healthcare professionals pose extreme consequences upon the overall healthcare system. Though violence against doctors and medical staff is not exclusive to the COVID-19 pandemic, it has only garnered media now. The government, for the longest time, didn’t promulgate specific laws to deal with such violence. But the Epidemic Diseases Act amended last year provides for some respite, although it is draconian in its own way. Gunjan Bahety analyses existing judicial pronouncements and legislation, suggesting adequate changes for them. She also presses for a balanced law that protects healthcare professionals without impinging on the common persons’ right to legal recourse.

*Trigger warning: The post contains expression and images of violence*

Violence against healthcare workers

By Gunjan Bahety, Intern at Academike and fourth-year law student at Maharashtra National Law University, Nagpur.

Introduction

At the beginning of this month, a video surfaced on the internet where a bunch of men were brutally beating up a junior doctor. The video had explicit imagery of the doctor getting kicked and punched mercilessly with metal trash cans and bricks by the relatives of a covid patient who had died allegedly due to oxygen shortage. Such images have been circulating from across Assam. Many such photos and videos have surfaced since the beginning of the pandemic, enough to be finally noticed.

The article discusses the plight of the frontline healthcare workers amid the COVID 19 pandemic through recent incidents of violence against the healthcare professionals in Assam, Karnataka and other states. The violence is inflicted not only upon the doctor but also the hospital, ambulances and clinics. The article details the judicial pronouncements that discussed the recent acts of violence against healthcare professionals.

The article also provides an insight into the provisions of The Epidemic Diseases (Amendment) Act, 2020, to understand how the legislature and legislation have addressed this issue. Furthermore, it tries to understand the provisions of the Act and if they are rendering justice.

Lastly, it analyses the study, providing some workable suggestions under the existing tools at India’s behest.

Even though the violence against healthcare professionals is not a covid phenomenon exclusively and is relatively standard, there has been a lack of specific provisions under the law dealing explicitly with the commission of such offences.

In such cases and absence of a specific law, the Indian Penal Code, 1860 (IPC) provisions, especially Section 323, 325, 352, 506, function as a resort. So far as property damage is concerned, Section 425 is imposed.

Though some states have enacted their own laws to address such violence, there is a desperate need for a law that is both uniform and predictable.

The issue is all the more relevant, as a doctor’s death directly affect the healthcare system. The doctor to population ratio in India is 1 to 1456, far more than the WHO’s recommendation for 1 to1000.[1]

Therefore, even if a single doctor is injured, it could be fatal for more than 1,456 patients, further burdening the healthcare system.

A 2019 study by Indian Critical Care Medicine reveals the extent of the violence and its effects. The 2019 statistics show:

“Out of 295 HCWs, 11 (3.7%) HCWs faced physical violence, whereas verbal abuse was faced by 147 (50%) HCWs. A higher number of incidents of physical violence (91%) and verbal abuse (64%) were faced by HCWs in the age group of 20-30 years. Verbal abuse was faced by 49.3% of nurses, 53% of junior residents, 61% of senior residents and 36% of consultants. Out of 158 incidents of workplace violence (WPV), maximum occurred in ICUs (62.0%) and emergency (21%).”[2]

These numbers only affirm that violence against doctors is not new and had existed well before the pandemic as well.

However, the recent sharp rise in such incidents is worrisome. Given that our healthcare system is already in a precarious state, violence at this pace will only lead to a collapse. And we are not ready for that. Besides, even on humane grounds, such instances disrespect the lives and profession of doctors who worked selflessly in this pandemic.

The Recent Incidents of Violence Against Health Care Professionals

Among the numerous cases that have surfaced recently, this section will engage only with a few. Although all the cases of violence are equally condemnable, stressing on a few will help address the urgency better.

Violence Against Healthcare Professionals in India: We Need To Stop This Barbarism!
On violence against healthcare workers Source: Nath, Hemanta Kumar. “24 Arrested for Attack on Junior Doctor in Assam’s Hojai.” India Today, 2 June 2021, www.indiatoday.in/india/story/arrested-attack-junior-doctor-assam-hojai-ima-1809795-2021-06-029795-2021-06-02

Karnataka recently reported fresh instances of violence against healthcare workers. In this case, after a six-year-old dengue patient died, four people attacked a fifty-year-year old doctor and brutally assaulted him.

Reportedly in Assam, the horrific incident of assault against a doctor has been caught on camera wherein it can be seen how a mob attacked a junior doctor. The Maharashtra State Government recently told the Bombay HC that 674 cases got registered from 2016 to April this year.

A letter written to Amit Shah from 2020 brings to attention the heinous attacks on doctors.

The letter mentions the ordeal of Dr Dinesh Varma, head of Alfa Speciality Hospital, who succumbed to his injuries after he was stabbed in several places by a relative of the COVID 19 patient.

The letter speaks of how the police charged the accused under a relatively lenient Section 307 IPC, refusing to invoke the amended Epidemic Diseases Act. Again, starting this month, owing to the recent incidents, the Indian Medical Association (IMA) wrote to Union Home Minister Shah, demanding an effective law against violence on healthcare workers. The IMA also pleaded that the hospitals should be classified as protected zones.

On June 4, doctors across various states conducted widespread protests. For instance, in Madhya Pradesh, three thousand doctors resigned after the Madhya Pradesh High Court declared their strike illegal. The protest in MP was organised to demand a stipend hike and treatment for the doctors’ families. When writing this article, the protest has extended more than a week without any backing despite the High Court’s order, manifesting a severe outrage among the medical staff.

Violence Against Healthcare Professionals: What Do Judicial Pronouncements Say?

Healthcare professionals include doctors and nurses, paramedical, mess boys, laboratory technicians, ambulance drivers, security professional and others.

In Azra Usmail and Others v. Union Territory of Jammu and Kashmir,  the High Court of Jammu and Kashmir pointed out that such violence highlights dangerous consequences like the spread of infection, imperilling the lives of healthcare professionals and damage to public property.

The Court observed:

“the professional engaged in the treatment of COVID 19 patients and prevention of the infection would be working beyond the call of their routine duties and also overtime… In order to ensure full attention of the professional addressing the COVID 19 issues, it is necessary that they are kept free of any personal tensions and needs”.

The Apex Court, in Jerryl Banait v. Union of India, dealt with a matter wherein the doctors who had gone to screen certain patients were attacked and faced stone-pelting. The Supreme Court observed and directed:

“The pandemic which is engulfing the entire country is a national calamity. In wake of calamity of such nature all citizens of the country have to act in a responsible manner to extend helping hand to the government and medical staff to perform their duties to contain and combat the COVID-19. The incidents as noted above are bound to instill a sense of insecurity in Doctors and medical staff from whom it is expected by the society that they looking to the call of their duties will protect citizenry from disease of COVID-19. It is the duty of the State and the Police Administration to provide necessary security at all places where patients who have been diagnosed coronavirus positive or who have been quarantined are housed. The Police security is also provided to Doctors and medical staff when they visit places for screening the people to find out the symptoms of disease.”

In another case, Sanpreet Singh v. Union of India, the High Court of Karnataka directed the Karnataka Government to ensure proper nourishment and necessary care to the healthcare professionals. Additionally, the Apex Court also directed District Magistrates to look into the grievances of these workers.

In Abdul Naser v. State of Kerala, the Kerala High Court observed that apart from subjecting doctors to agony and anguish, attacks and violence on them adversely affect the treatment of all patients. It practically leads to a halt in functions, jeopardising the health of many persons, which is a matter of grave concern.

Legislation To Deal With Violence Against Doctors

For the first time, the Healthcare Service Professional and Clinical Establishments (Prohibition of Violence and Damage to Property) Draft Bill addressed violence against healthcare professionals at the national level.

It criminalised both the commission and incitement to commission of violence against healthcare professionals and damage to the property of clinical establishments.[3]

However, it never saw the light of the day. The bill was stalled, citing reasons that the existing provisions under IPC already covered the elements of ‘violence’ as defined in the Draft Bill.

The Epidemic Diseases (Amendment) Act 2020 is an amendment to the Epidemic Diseases Act 1897. The principal Act comes under the State List under Schedule VII and is pre-independence legislation.

The 2020 Amended Act defines ‘acts of violence’ committed by any person against the healthcare service professional serving during an epidemic as one, which may cause, harassment, hurt, injury, a hindrance to services, damage to property or documents in custody.

The statute also defines ‘health care professional’ and ‘property’, providing a wide ambit for better protection. Section 2B provides that no person shall indulge in any act of violence against a healthcare service professional or cause any damage or loss to any property during the epidemic.

Section 3(2) provides punishment for commission or abetment of commission of an act of violence. Section 3(3) deals with committing an act of violence against a healthcare service professional, causing grievous hurt as defined in section 320 IPC. Section 3A of the statute provides that the inquiry or trial must conclude within a year.

If not concluded within the given time period, the judge must record the reasons for the delay and extend the time period accordingly. However, this period may not be extended for more than six months at a time.

When prosecuting a person for causing grievous harm to a healthcare service professional, the Court will presume that person is guilty of the offence unless the contrary is proved.

In any prosecution for an offence under Section 3(3) requires a culpable mental state on the part of the accused, the Court shall presume the existence of such mental state. Still, it shall be a defence for the accused to prove that he had no such mental state with respect to the Act charged as an offence in that prosecution.

In addition to the punishment provided for an offence, the person so convicted shall also be liable to pay, by way of compensation, as may be determined by the Court for causing hurt or grievous hurt to any healthcare service professional.

Moreover, in case of damage to any property or loss caused, the compensation payable shall be twice the amount of fair market value of the damaged property or the loss caused.

The Need for a Balanced Approach: Analysing the Existing laws for Violence against Health Care professionals

 Ordinances are valid only for a few months. When it is not in session, the parliament has six months to pass any immediate legislative as needed.

The Epidemic Diseases Ordinance 2020 was converted into an Amendment Act in September 2020. Strict laws under the Ordinance, given the medical emergency that the country faced during the pandemic, might be reasonable. However, making it a law, in general, could do injustice to a common person.

The Amendment was enacted to curb multiple incidents of violence despite us having the IPC provisions and the Medicare Service Persons and Medicare Service Institutions (Prevention of Violence and Damage to Property) Acts or the MSPMSI Acts in several states. Even though the provisions therein are similar to the existing statutes. The same was justified to counter the need for proper and stricter implementation of such laws. Even though the provisions therein are similar to the existing laws.

Section 3C and 3D of the Act provides for ‘presumption to be guilty of the offence unless proved otherwise by the accused defendant’.

Section 3D states that the culpable mental state of the prisoners will be presumed to exist unless disproved. As per sub-clause 2 of Section 3D, the same has to be proved ‘beyond reasonable doubt’.

These regressive clauses seem unfair and draconian. Presumption mixed up with such a high degree of proving innocence may lead many innocents behind bars. Similar provisions exist under the Narcotic Drugs and Psychotropic Substances Act 1985 (NDPS Act), wherein the initial set of facts must be proved by the prosecutor initially, instead of completely shifting the entire burden to the accused under the Epidemic Diseases (Amendment) Act.

Though the Act has not come into force in every state yet, the concern is genuine.

Besides, despite the amendments, the Act has serious limitations. One that cannot be overlooked is that the principal Act is more than a hundred and twenty years old. And it does not address the current issues, including- the dangerous epidemic diseases, global connectivity, closed urban spaces, greater migration, new communicable diseases and affected population across different age groups.

It could be why the IMA has urged Amit Shah to ratify a uniform, effective and comprehensive law against such violence on the health care workers. It can’t be said enough, India needs a modern framework to tackle a pandemic of this scale.

Oppressive measures under the Epidemic Amendment Act can worsen the situation by creating a sense of disaffection and resentment among people. Passing legislation like these to protect the health care workers might end up hurting many innocents.

There can always be ways to have a balanced approach to deal with these issues. For instance, in Abdul Naser v. State of Kerala, the High Court of Kerala discussed what is already provided under the state legislation. While considering the application for anticipatory bail, the Court observed that three factors must be considered in such cases.

  1. The nature and gravity of the injury, if any, sustained by the doctor/hospital employee.
  2. The extent of damage, if any, caused to the property.
  3. The circumstances under which the acts of violence were committed.

These factors can help take a holistic view of the offence committed by the accused by providing provisions for anticipatory bail, which is one of the most crucial remedies. The same provides an outline that could be implemented to omit any vagueness and imbibing reasonability.

What Must Be Done?

Although we need a balanced approach, we also need to focus on injustice and inhumane treatment against healthcare workers. The bigger question is what must we do to protect our doctors and other healthcare workers.

There is a need to look at this issue from a legal, sociological and academic perspective. There are several steps that healthcare establishments themselves can take to redress these issues.

The primary step that they can take is to create an internal protocol for combating violence. Most hospitals do not have a system of reporting violence or policies at the organisational level to prevent and address violence. In 2020, a report was published by Vidhi legal, which was titled ‘Violence against Healthcare Professionals in India: Recent Legal and Policy Issues’. The Report analysed the gap in legislation to counter violence against healthcare professionals and the increased number of case. Although the Report was published before COVID-19 had hit us, but it provides comprehensive suggestions that are noteworthy:

“The WHO, along with the ILO, ICN and Public Service International, has come up with Framework Guidelines (“WHO Guidelines”) to address workplace violence in the health sector. These guidelines clearly lay down the responsibilities of employers and their organisations with respect to providing and promoting a violence-free workplace. These include ensuring the health and safety of workers, elimination of risks, routine assessment of the incidence of violence and its causes, developing policies, plans and monitoring mechanisms.”

Additionally, the Report also poses post-violence measures like legal aid, counselling, management support, medical treatment, rehabilitation, etc.

Besides, there has to be a focus on mandatory reporting and proper investigation.

Interestingly, the United States has the Occupational Safety and Health Act of 1970 (OSH Act) provide a safer workplace to healthcare employees. It focuses on preventing such hazards and risks through safety and health training, record-keeping, evaluation etc. And mandates that any failure on the part of the employer should also be met with appropriate consequences.

The Report by Vidhi Legal also suggests that medical education shall be equipped with effective skills, especially empathetic skills for effective communication. It is often due to poor communication skills coupled with factors like insufficient time spent with patients contributing to the rise in violence.

Lastly, the public must be made aware of the healthcare worker’s perception. Patients and relatives at large must be sensitised about the medical profession and the challenges associated with it.

There’s also a need to inculcate desired etiquettes in hospitals, focusing on punishments that improve the behaviour of those who tend to breach these norms.

The World Health Organisation’s ‘Framework Guidelines for Addressing Workplace Violence in the Health Sector’ provides comprehensive guidelines to tackle special risks. They include protocols for informing staff that a colleague is away from the base, the approximate or expected time of return, emergency alarm systems, and emergency codes to request help without alerting the assailant.

It provides for uncrowded work practices and minimum waiting time. For better safety, it recommends transportation facilities for staff. The Framework suggests having identifiable whole unit tasks rather than fragmented ones.

It recommends avoiding overworking for professionals. It also suggests maintaining a moderate or balanced approach and time at work, allowing professions to access means of communication.

Among various other recommendations, it also mentions the significance of orientation to the workplace environment, management policies, grievance procedures and instilling interpersonal communication skills. Importantly, it also suggests self-defence training for medical workers.

These suggestions can be helpful because of their specific nature to deal with the ongoing trend of violence against the medical staff. They cover almost all the significant aspects that can be considered while studying the probable reasons for such violence.

The pandemic and current crisis bring to the fore the critical issue of violence against healthcare professional and the damage to the property of healthcare establishments.

Needless to say, infrastructure at every level is in short supply and has to be protected. Beating up doctors and other healthcare professionals could bring down the optimism and zeal of young medical aspirants. The profession can be extremely taxing both mentally and physically, and such instances may deter young doctors from pursuing their oath.

It’s even more essential for the government to realise that health care infrastructure needs a massive boom. And it must ensure that the population to doctor ratio is improved, which can be done by effectuating policies for equitable education in medicine. Every citizen needs to be moved by the incidents of violence that have come up. Therefore,  expressing solidarity to those on the frontline.

Endnotes

[1]Vikram Sarabhai Library, IIM Ahmedabad. “Economic Survey 2019-20.”https://library.iima.ac.in/public/Economic_Survey_2019_20_Vol_2.pdf

[2] Sharma S, Gautam PL, Sharma S, Kaur A, Bhatia N, Singh G, et al. Questionnaire-based Evaluation of Factors Leading to Patient-physician Distrust and Violence against Healthcare Workers. Indian J Crit Care Med 2019;23(7):302-309, available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6686582/

[3] Section 5,  Healthcare Service Professional and Clinical Establishments (Prohibition of Violence and Damage to Property) Bill, 2019.

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