Crime, health worker safety and self-assessment

A gathering in Vijayawada, Andhra Pradesh | Photo credit: KVS GIRI/THE HINDU

In 2017, doctors in Maharashtra staged violent protests after a series of violent attacks on medical staff in relatively short succession — as is invariably the case with sensational crimes. Despite the scale of the problem, the solution was simple and mundane. It involved beefing up security in public hospitals and strengthening legal instruments to bring the perpetrators to justice swiftly. Similar incidents came and went, and much has happened during the COVID-19 pandemic. The knee-jerk reactions have continued, too. It is difficult to recall any notable precedents of swift justice.

There is a deeper problem

It is the case of the gruesome death of a promising doctor in Kolkata that has left the country in turmoil and prompted the Supreme Court of India to give a ruling his engine knowledge of the event. However, emerging responses to the issue remain reflexive and simplistic, and may reflect an incomplete understanding of the underlying malady. In its proceedings on August 20, the Court ordered the constitution of a national task force to devise measures to strengthen security in hospitals. Improved infrastructure and closed-circuit television surveillance, increased security presence in hospitals and safe night transport are said to be some of the areas that will receive attention. In the same vein, the West Bengal government has set up the ‘Pied Piper Saathi (night companion’) programme aimed at improving the safety of women working night shifts, particularly in medical colleges and hospitals. While such initiatives are crucial, they implicitly confuse this problem with archetypal health worker violence, which is initiated by disgruntled patients due to perceived poor health care services, or women’s safety in general. What lies beneath is the far more insidious problem of corruption of criminal proportions.

Conventional responses to health worker violence, such as improving hospital safety and newer legislation, have failed miserably to address the problem in recent years. These include reasons such as underfunding, which are no different than the reason why our health systems remain weak overall. But the extent to which corruption contributes to the overall loss of life has been vastly underestimated. If the new reports are anything to go by, there is a strong possibility that deep-rooted, organised corruption contributed to the heinous crime in question, not to mention other incidents and the steady erosion of public health services that may have gone unnoticed until now. The fact that this is a top health facility in an already underfunded state public health system is deeply troubling.

WHO estimates

The World Health Organization estimates that corruption costs the world nearly $455 billion annually, more than the cost of expanding universal health coverage for all. In much of the developing world, corruption, rather than lack of funding, is the single largest cause of health care crises and poor health outcomes. Although the discourse on medical corruption in India is often sensational, it has largely focused on private losses and misconduct, while its criminal dimensions have been largely underestimated. Healthcare systems that require large numbers of staff are a rapid breeding ground for expansionary corruption, including the worst forms of sextortion, particularly in political systems where underfunding and poor oversight are widespread. In such circumstances, it is difficult to imagine how much help would realistically be gained by simply improving the state of health worker safety and hospital infrastructure, even if these were somehow adequately implemented. The fact that medical corruption can cost the lives of health workers in addition to patients suggests that the public health system and its drivers may be in need of some rigorous self-examination.

Speedy delivery of justice in the Kolkata case is undeniably of paramount importance, for nothing else said or done can ever be a consistent deterrent. It goes without saying that we have traditionally fallen short in this regard, and the consequences are there for all to see.

More steps are needed

But the national task force has a task that is arguably more monumental than simply recommending safeguards: devising a robust roadmap to prevent and stop medical corruption, particularly in the public sector. This certainly cannot be tackled by a team of physicians alone. It requires expert input from public health, medico-legal and other related disciplines, in addition to earning the participation and approval of the larger government and administrative community. And the strategies thus devised must go far beyond the creation of yet another legislative instrument. Apart from reforms that focus on administrative transparency, accountability and oversight, effective whistleblower reporting and protection mechanisms and thorough digitalization of public management systems are crucial. The need for ombudsmanship and other tools to minimize political interference and maneuvering cannot be overstated. Inspiration can be drawn from the way other countries such as Brazil continue to combat political corruption in medicine. Much also remains to be done in the way of modernizing the typical ‘control and command’ Indian public hospital, which is still steeped in anachronistic ways. While there are many efficiency reasons for such modernization, their urgent moral and regulatory underpinnings are clearly visible today and can no longer be overlooked.

Dr. Soham D. Bhaduri is a public health specialist and an independent researcher