COVID-19 and Violence against doctors – Why a law is needed?

Abstract

Today, when India is reeling under the COVID-19 epidemic, a new epidemic disease (Amendment) Ordinance has been brought out with regard to protection of the health care staff, which is a big welcome step to the medical fraternity. A much-needed step. The assaults on doctors have been happening in hospitals in India for a long time. This review article traces the journey of the Prevention of the Doctors Violence Act and suggests a way forward with regard to violence on the doctors and why there must be a permanent solution for the same. Methodology is based on a detailed study across a range of published literature in journals, articles, and other online sources. An extensive review has been undertaken of these articles based on an explanatory approach. The review provided insight into the current status of violence against doctors. Most of the initiatives on prevention of violence against doctors mentioned in the studies are mainly directed towards patient-doctor relationship, lack of infrastructure, strenuous working environment, and societal obligations. Study findings revealed that there was less emphasis on the current legal measures available and its implementation. This article highlights the critical aspect of protection of the health care workforce and also shares recommendations to enhance the protection of doctors at their workplace by sharing the current state-level legal measures available and advocates the impelling need for central legislation. These recommendations have been suggested as a combined effort of the medical fraternity, media, and the academic community.

Introduction

In India, assaults on medical workforce such as doctors have been happening for a long time. The COVID-19 epidemic brought the violence against doctors out in the open. Because this was the time, when the entire country was reaching out to them – from the public, government, associations, corporates, and students. India had finally woken up to the critical need of the health care staff. But this need was marred again by violence against doctors. There were incidents of violence across COVID designated hospitals, quarantine centers, and even at the residence of these health care workforce. The Central and State governments rose to the occasion and came out in strong support of the doctors and other health care personnel. The new Epidemic (Amended) Ordinance, 2020 was passed in India. The amendment was done to include protection for health care personnel combatting epidemic diseases. The United Nations – World Health Organization (WHO) has also tabled a framework to address workplace violence in the health care sector.[1] This review article based on extensive literature review highlights the current measures on prevention of violence against doctors and identifies the gap with regard to the legal measures currently available with the doctors. The purpose of this review article is to first – highlight the current measures and steps taken for prevention of violence against doctors in India, second – apprise the doctors on the legal measures available at the state level, and lastly advocates the need for a central legislation.

Methodology

Detailed literature review with regard to violence against doctors was done across articles in journals, newspaper articles, and online posts. A systematic search was conducted across databases such as Scopus, PubMed, Science Direct, and Google Scholar. Websites such as WHO, World Health Statistics, and various websites of ministries such as Ministry of Health and Family Welfare, India were also searched. The literature study was undertaken by means of an explanatory method based on the “realist Review“[2] approach and was limited to studies in the last five years (2015-2020). The study presented a better understanding of doctor's violence at hospitals. The findings of these articles highlighted the gap with regard to the current steps taken for the prevention of violence against doctors and the legal measures available to the doctors.

Findings and Discussion

The journey with regard to the protection of doctors has a long history. Assaults on the medical workforce such as doctors have been happening for a long time across various states in India. It was not just during the current epidemic of COVID-19. Except that this time, it was happening and getting noticed at a national level. The other case was in June last year when there was a nation-wide protest by doctors when two resident doctors were attacked in a hospital in West Bengal. The Indian Medical Association (IMA) also supported this protest. It was around this time that the demand for security against doctors and other people in the hospitals gained increased attention. The Health Minister at that time had written to all chief ministers to consider enacting specific legislation for protecting doctors and medical professionals, and also attached a copy of the draft provided by the IMA that is the Protection of Medical Service Persons and Medical Service Institutions (Prevention of Violence and Damage or Loss of Property) Act, 2017.[3]

Why is the security of doctors a grave concern?

According to Maslow's hierarchy of needs[4] – safety/security is a basic need for every individual. As per a study of the IMA, more than 75% of doctors across the country have faced some violence.[5] Another study shared that the annual incidence of workplace violence in health care and social assistance is four times more as compared to other professions. Furthermore, health care–related workplace violence remains grossly neglected and underreported.[6] The World Medical Association advises the right to work in a safe environment without the threat of violence.[7]

But the reality in both public and private hospitals across India is different. Primary care physicians are also part of this health care delivery eco-system, and who are sometimes the first point-of-contact for some people. There are frequent cases where doctors have had challenges on the security front. This is particularly heightened in sensitive areas such as the emergency ward and Intensive Care Unit. Studies have shown that these are areas where most cases of violence against doctors occur.[8,9] The junior/resident doctors work in the emergency section predominantly and hence are the most affected. They are the frontline – people who address patients first and are relatively young. Violence-related cases are more so in the public health care sector.[10] But what does violence lead to? Fear, inability, hesitancy to give their best in the job, and then as a last resort when nothing helps, they look at protests to garner attention to their needs. This protest can be a silent protest like wearing a black band to work or a strike from work.

Below Table 1 shares details on doctor's protests on workplace violence and demand for security in the year 2018-19 [Table 1].

Table 1.

State-wise details of doctors strike in the period 2018-2019s

State	Month of Strike (2018)	Month of Strike (2019)
Bihar	September	September, November
Gujarat	May	July
Delhi	April	July, August
Jharkhand	June	August
Maharashtra	May	June
Punjab	December
Karnataka	November
Rajasthan	November	October
Uttar Pradesh	July, November
West Bengal	August	June

Source: Times of India[11]

The table above highlights the frequent battles of the doctors and the medical fraternity in the public forum with regard to raising their voice on protection. It is happening across states and across the year. In the last 2 years, there have been multiple attacks on doctors and yet little has been done to resolve the problem. Society and media highlight all the problems faced by the public when doctors go on strike. Yet, the doctors' protests, as a fallout of violence, continues unabated. Even in the legal dictionary, the right to protect oneself is recognized.[12] In India, health falls under the “State List,” and hence the obligation to implement measures to ensure the safety of doctors rests with the states and not the central government.

About the Doctors Protection Act

Protection of Medicare Service Persons and Medicare Service Institutions (Prevention of Violence and Damage to Property) Act, also known as the Medical Protection Act (MPA), has currently been implemented in about 23 states in India. Andhra Pradesh was the first state to implement the MPA in 2007.[13]

Some of the key points of MPA are as follows:

• Any act of violence against a “Medicare Service Person” or damage or loss to the property of a “Medicare Service Institution” is prohibited

• Any offender who commits or attempts to commit or abets or incites the commission of any act of violence shall be punished with imprisonment, which may extend to 3 years and with a fine, which may extend to ₹ 50,000

• Any offense committed under this act shall be cognizable and nonbailable and triable by the Court of Judicial Magistrate of the First Class.

Source:[14]

But the concern is whether this is being implemented at the right levels to provide support to the doctors. Some details in this regard are set out below:

• A study undertaken in two states of Punjab and Haryana revealed that no person was penalized under the Medicare Service Person and Institution Act between 2010 to 2015. In most cases, the First Information Report (FIR) was not registered or canceled post a compromise[15]

• In Maharashtra, the police were not even aware of the act. Sensitization measures were initiated in 2017, while the MPA was passed in 2010 in the state[16]

• Even though 17 states have brought out laws against the violence on doctors and hospitals, there is disparity across these laws[17]

Now, there is an Act, but the concern is on its implementation, which starts from communication and awareness. Many studies have been undertaken on security concerns and workplace-related violence in the health care workforce. These studies highlighted key challenges, such as low doctor-patient ratio, long working hours, and hierarchy in hospitals across states in India. Studies also included manpower, infrastructure, and health care set up.[18] Suggested measures include need to address workforce shortage, strengthening primary care, and effective patient-doctor communication.[19] But very few studies have highlighted or references the MPA passed by a state to inform readers about the legal measures to prevent violence against doctors and others.

Below mentioned Table 2 gives a snapshot of some articles in the last 2 years (2018-2019) in the context of doctor's violence.

Table 2.

State-wise details of articles and studies related to doctor’s violence

Year article published	States covered as part of the study	Number of articles/study	The date the act was implemented in the state	References to the Act
2018	Madhya Pradesh	1	2008	No
2018	Maharashtra, Uttar Pradesh	1	2010, 2013	No
2018	Maharashtra	2	2010	No
2018	Tamil Nadu	1	2008	No
2018	Manipur	1	2015	No
2018	West Bengal and Maharashtra	2	2009, 2010	No
2019	Andhra Pradesh, Delhi, Haryana, Rajasthan, Tamil Nadu, Odisha, Punjab	1	2007, 2008, 2009 2008,2008 2009,2008	Yes
2019	Maharashtra	1	2010	No
2019	Maharashtra, West Bengal Assam	1	2010, 2009 2011	No
2019	Gujarat	1	2012	No
2019	West Bengal, Assam	1	2009, 2011	Yes
2019	West Bengal, Delhi Maharashtra	1	2009, 2008, 2010	Yes
2019	Rajasthan	1	2008	Yes
2019	Gujarat and Maharashtra	1	2010	No
2019	Delhi	1	2008	No
2019	Karnataka	1	2009	No
2019	Punjab, Uttar Pradesh	1	2008, 2013	Yes
2019	Maharashtra, Punjab	1	2010, 2008	No
2019	Delhi	1	2008	No
2019	Gujarat, Tamil Nadu, Karnataka, Telangana	1	2012, 2008, 2010, 2007	No
2019	Haryana	1	2009	No
2019	West Bengal and Maharashtra	1	2009, 2010	No
2020	West Bengal	1	2020	No
2020	Tamilnadu, Telagana	1	2020	Yes

Source: Data compiled from journals in Index Copernicus, Pubmed Central, Elsevier, ANED, BMJ Open, and Google Scholar (2018-20), IJSREG, IAMJ, and criminallawstudiesnluj.wordpress.com

All the above details mandate the implementation of the Act at the strictest level. This was realized during the epidemic and the new Epidemic Diseases (Amendment) Ordinance Act, 2020 Act was promulgated.

About the new Act

The Epidemic Diseases (Amendment) Ordinance, 2020 was promulgated on April 22, 2020. The Ordinance amends the earlier Epidemic Diseases Act of 1897. The Ordinance provides for the prevention of the spread of dangerous epidemic diseases. The key point is that this Ordinance amends the Act to include protections for the health care personnel combatting epidemic diseases such as COVID-19 and expands the powers of the central government to prevent the spread of such diseases. The text of key provisions of the Ordinance is set out below:

• “Healthcare service personnel” as a person who is at risk of contracting the epidemic disease while carrying out duties related to the epidemic. They include: (i) public and clinical health care providers such as doctors and nurses, (ii) any person empowered under the Act to take measures to prevent the outbreak of the disease, and (iii) other persons designated as such by the state government

• An “act of violence” includes any of the following acts committed against a health care service personnel: (i) harassment impacting living or working conditions, (ii) harm, injury, hurt, or danger to life, (iii) obstruction in the discharge of his duties, and (iv) loss or damage to the property or documents of the health care service personnel. Property is defined to include a: (i) clinical establishment, (ii) quarantine facility, (iii) mobile medical unit, and (iv) other property in which a health care service personnel has a direct interest, in relation to the epidemic

• The Ordinance specifies that no person can: (i) commit or abet the commission of an act of violence against a health care service personnel, or (ii) abet or cause damage or loss to any property during an epidemic. Contravention of this provision is punishable with imprisonment between 3 months and 5 years, and a fine between ₹ 50,000 and 2 lakh. This offense may be compounded by the victim with the permission of the Court. If an act of violence against a health care service personnel causes grievous harm, the person committing offense will be punishable with imprisonment between 6 months and 7 years, and a fine between ₹ 1 lakh and 5 lakh. These offenses are cognizable and nonbailable.“

Source: https://www.prsindia.org/billtrack/epidemic-diseases-amendment-ordinance-2020

What does this mean for doctors?

In India, a lot of states have laws that penalize violence against doctors and hospitals, but there is no central legislation.[20] At the national level, there was one bill that was tabled in the parliament in 2018.[21] Then in 2019, the Ministry of Health, Government of India proposed the “Health Services Personnel and Clinical Establishments (Prohibition of Violence and Damage of Property) Bill,” which had contemplated imprisonment of up to 10 years and imposition of fine of around ₹ 10 lakh on those who assaulted health care personnel.[22] But this was again put down with the suggestion that there cannot be a separate law for doctors.

Implementation of a Central Law is difficult because “health” is within the legislative purview of state governments. But there is one central act in the field of Health which, is the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act, 1994. This is a central act because authorities saw a unique problem that needs to be monitored and remedied by a central law.[23] One can now draw a parallel with the doctor's violence here. In the current epidemic, there is a need to monitor violence against doctors, as the consequences, such as COVID-19, are severe. In the coming years, health care needs are only going to increase – from both a need perspective, for instance during natural calamities like the epidemic, and to cater to the growing population and economy of the country. The point to note here is that health care does deliver a lot of revenue to the country. Hence, it has to be considered from both the economic and the social angle. The time is now right for a central law that will help aid in reducing the violence against the doctors. Central legislation together with the existing state legislation is more likely to ensure safety and security for doctors. The passage of a central law will not only instill fear in the public but also instill confidence in the doctors. It is that which will percolate to all levels of the society – the same way the PCPNDT and the current Epidemic Diseases (Amended) Ordinance Act, 2020 has done today.

Way Forward

The way forward does not stop at just asking the government for a central law. The onus also lies on the medical fraternity, the academic community, and the media.

Medical Fraternity

Let us first look at the patient care ecosystem, which is what the doctors and the hospitals are part of. It is not just a doctor-patient relationship. There are other stakeholders involved – such as society, medical institutions (faculty and management), governing agencies, financial agencies such as insurance, education/medical loan providers, and public sector institution policies. In essence, the responsibility to ensure the security of doctors lies with all. The first step is for all stakeholders to be involved in the solution. That would aid in the strict implementation of the Act. A second step would be to build the right security infrastructure. This must be done in various ways such as:

• Communication of the Act and the Ordinance at all strategic locations of the hospital to bring to the attention of the general public and the staff. This can be done by means of banners, signboards, and digital media. It must also address the penal aspects of the Act and the Ordinance, which can deter violence at the hospital

• Building a strong security support system within the premises of the hospital. Some of these include alarm bells at strategic points for doctors to quickly seek help, visible cameras as per permissible limits in public spaces, and the presence of an adequate number of security personnel

• Strict processes with regard to the number of people entering the premises. For e.g., only one person can accompany the patient etc

• Continuous interaction with the local police and legal authorities for quick action on filing complaints and taking quick action against the offenders

• Providing training to members of the health care workforce on measures of self-protection and the process to follow when harmed.

Academic Community

The second step involves contribution from the academic community. Academia must encourage more researchers to study security and workplace violence–related aspects of the health care workforce and also highlight the legal aspects such as the Doctors Prevention Act, which will add currency to the ongoing discussion and need to bring about changes in the medical institutions. Academia must also jointly work with the medical fraternity, such as established doctors and people in international bodies such as the WHO, in designing academic modules with regard to training and communication in the context of prevention of violence, which will help deter violence and aid protection of the health care workforce.

Media

Third, it is imperative for the medical fraternity to work with the media to publicize and inform the general public about the Doctors Prevention Act. As outlined above, the quantum of information shared today is not enough, and more detailed information needs to be percolated to the general public.

Conclusion

The key question to ask is – what comes after the epidemic? Will security for the health care workforce continue to be strong as it is today? Will violence against doctors be quelled or continue to decline even after the Epidemic Ordinance Act is not applicable? These are serious doubts, especially given the history of violence that shocked India in the last few years. This is the time when all the stakeholders – academic fraternity, academia, and the media must come together and push for central legislation. Organizations such as the IMA, while supporting the new Ordinance, must continue to advocate central legislation on the protection of doctors with stringent consequences. This will function as a strong deterrent to violence against health care personnel at hospitals. All stakeholders of the medical ecosystem must work together in building a safe workplace environment. And this goal calls for a combined effort, which cannot be delayed anymore.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.