A sore point: The vulnerability of hospital campuses

Unsuitable duty rooms, broken monitoring systems and inadequate safety measures have meant that medical professionals in India are forced to work in unsafe conditions

New Delhi: On August 9, a 31-year-old postgraduate medical student of RG Kar Medical College and Hospital in Kolkata hoped to catch some sleep on the floor of a seminar room as a part of a 36-hour work shift. What happened subsequently has shocked the nation.

Even as investigators piece together various facets of the brutal crime to get a complete picture of the horrors that unfolded that night, a crucial question that warrants addressing is why the medical student chose the seminar room instead of the on-call duty room for rest.

According to the victim’s parents’ petition filed in the Calcutta High Court, the seminar room, equipped with air conditioning, was her preferred spot to rest and study, given the “uncomfortable and inadequate conditions of the designated on-call room”.

The on-call room for resident doctors is a small, non-air-conditioned space that is often hot and suffocating, making it nearly impossible for anyone on a 36-hour duty cycle to rest properly. The petitioners submitted to the High Court that such inadequate facilities had contributed to their daughter’s vulnerability, as she was forced to seek comfort elsewhere within the hospital premises. 

Since August 9, several women in the healthcare sector have once again highlighted the dangers of working in premises that do not have basic safety provisions, which are crucial, particularly in high-contact professions such as this. 

“This is simply not acceptable. The repeated requests from the medical community for protective measures have gone largely unanswered, leaving our colleagues vulnerable in environments that should prioritise their safety. It is time for the hospitals to invest in the safety and security of doctors,” says Alexander Thomas, founder and patron, Association of Healthcare Providers India.

Poor-quality duty rooms for residents are among several shortcomings that junior doctors have flagged as a part of their overall demand to improve the service conditions in government hospitals.

The demand is not a new one. Five years ago, an angry mob of 200 people stormed NRS Medical College and Hospital, another government facility in Kolkata, following the death of a 75-year-old. The mob broke the skull of a doctor and injured several others.

As protests erupted over the administration’s failure to secure the hospital, the doctors sat on strike and were soon joined by peers from other hospitals. The agitation spread across the country, leading to a draft legislation titled “The Healthcare Service Personnel and Clinical Establishments (Prohibition of Violence and Damage to Property) Bill, 2019”.

The bill, with a punishment up to 10 years in certain cases, was debated within the government but did not find enough support to make it to Parliament. In 2022, the draft was withdrawn.

While rejecting the draft bill, the Ministry of Home Affairs argued that it would set an improper precedent for other fraternities to demand exclusive protections based on their profession.

Following the RG Kar episode, the Union Health Ministry has now promised to form a panel to review security measures available in hospitals for better protection of doctors. But no clear commitment was given on reconsidering a central legislation – doctors and the Indian Medical Association demanded that hospitals be declared “safe zones” like airports. 

For years, resident doctors have been facing violence in hospitals. “There have been many incidents where attendees have come with weapons, barged through our doors and threatened us to complete the scans quickly. A man grabbed my colleague’s hand during a scan and refused to let go when she pleaded. We are forced to work amidst such circumstances,” notes one resident doctor on the condition of anonymity.

Globally, violence against healthcare workers is high in India and China. “In 82% of cases in India, the perpetrators are either family members or friends of the patients. Over 60% of doctors fear violence in emergency medicine, critical care and psychiatry,” says M I Sahadulla, chairman and managing director of KIMS Health in Thiruvananthapuram.

Several government resident doctors in Bengaluru, many of whom are women, recount horrifying instances of harassment, disregard for their work from both patient attenders and seniors and a prevailing lack of safety.

“Many CCTVs on our campus do not work. Our scan rooms are in one poorly-lit corridor in the OPD block of the hospital, which is not guarded by any security personnel after 4 pm,” says one resident doctor of a prominent government medical college and hospital in Bengaluru.

The lack of security enables unidentified persons to lurk in secluded spots or long corridors with unsecured doors, no cameras, or lighting, note several doctors. One doctor says that if they were to scream for help at night, “there will be nobody to listen to our voices.”

A brutal incident was reported last year when 22-year-old MBBS internee Vandana Das was murdered by a 42-year-old at Kottarakkara Taluk Hospital in Kollam district of Kerala. The accused was under the influence of alcohol and had been brought to hospital by police for medical investigation.

The incident triggered strong protests, forcing the Kerala government to amend a state law by enhancing the punishment for attacking health workers to seven years of imprisonment and a fine of up to Rs 5 lakh.

The amended law says that chargesheets in such cases should be filed in 60 days and trial completed in a time-bound manner.

Sulphi N, former president of the India Medical Association (IMA) Kerala chapter claims that after the enhancement of punishment there has been a decline in the number of attacks on health workers. Nearly 200 such incidents were reported in Kerala between 2020 and 2023.

In neighbouring Tamil Nadu, a female PG student at a government medical college says house surgeons and students should be provided with “proper retiring rooms” that are safe. “Safety is very important. Sometimes, it is quite scary to walk from the hospital to the hostel. The most important thing is we should be given retiring rooms that are spacious with all basic facilities,” she says.

Many hospital and medical college campuses are not even properly lit, forcing students to depend on torches or mobile phone lights to cross the campus at night. 

In the absence of safe accommodation inside the hospital, students are forced to sleep in conference rooms or other places where there is no security or monitoring mechanisms.

Senior doctors question the government decision to rapidly increase the medical seats in colleges. “Why such a hurry? Without creating the necessary infrastructure and facilities and improving the overall ecosystem, seats are increasing year on year. Without a doubt, we require more doctors, but this approach is not the right one,” observes Kiran Madala, the state general secretary of the Telangana Teaching Government Doctors Association.

As the protests over the rape and murder incident at the Kolkata hospital spread, authorities in Silchar Medical College Hospital in south Assam issued advisories in which they asked women students and doctors to avoid isolated, poorly-lit and sparsely populated areas for their safety. They also asked women not to go out of their campuses during late or “odd hours.”

The advisories issued on August 12 angered students, who staged a protest, following which the advisories were withdrawn.

“Last year, we saw the death of Vandana Das while on duty at the hands of a criminal. Such incidents lay bare the thread by which the entire medical and healthcare infrastructure of the country is hanging, which time and again becomes a noose around the neck of the healthcare professionals,” says Rimy Dey, a consultant surgeon of emergency medicine, who hails from Assam and has worked in a public sector hospital and in rural areas.

A medical professional from Guwahati, who does not wish to be named, says lady doctors posted in government hospitals in interior areas of northeast India face harassment and often resign to join private hospitals mainly due to safety concerns.

“Forget about security; most (government) places do not have basic amenities. Women find it extremely difficult to use washrooms. You do not find changing rooms either,” says a woman doctor at Osmania General Hospital in Hyderabad.

Notwithstanding 26 states having their own laws to protect healthcare workers, the doctors, IMA and other medical associations seek a central legislation as an enabling mechanism for better implementation of the state laws.

“A central legislation is needed because it will be a ‘procedural law’, which provides the machinery for the implementation of ‘substantive criminal laws’ like state laws. The state-wide Medicare Acts provide only substantive laws which are inadequate without a procedural law in the form of the Criminal Procedure Code (or Bharatiya Nagarik Suraksha Sanhita),” explains an IMA official.

More than a decade ago, Maharashtra was one of the first states to put in place the Maharashtra Medicare Service Persons and Medicare Service Institutions (Prevention of Violence and Damage or Loss to Property) Act, 2010, to prevent attacks on doctors, healthcare workers and hospitals.

“It has been 14 years since the law came into existence. Around 600 cases have been registered. Sadly, so far, there has only been one conviction, in Palghar district,” says Shivkumar Utture, national vice-president of the IMA.

A physician in Mumbai observes that doctors in medical colleges and hospitals face severe risks due to unauthorised entry of many in hospitals and ICU corridors. “Doctors become the victims in case anything untoward happens to the patients. Interference by local politicians too is a major issue,” he adds.

Another concern for agitating doctors is prolonged duty hours for junior residents — mostly postgraduate medical students. A professor at the All India Institute of Medical Sciences, Delhi, says resident doctors should not be put on duty for more than 12 hours as long duty hours can adversely affect their judgement. 

G R Ravindranath, general secretary, the Doctors’ Association for Social Equality in Chennai, says PG students are overworked as they are forced to do duty for 24-36 hours at a stretch, which takes a toll on their mental and physical health. “While the institutions say it is the students who volunteer for long duty hours, the truth is otherwise. They are forced into this by the medical college,” Ravindranath adds.

For those who are on a 24-hour duty schedule, there is a window to take rest, but the condition of the duty room should be good. 

A task force set up by the National Medical Commission to look into the mental health issues of undergraduate and postgraduate medical students has recommended that residents work no more than 74 hours per week, and that duty hours are limited to 24 hours at a stretch. This includes one day off per week, a 24-hour shift, and 10-hour shifts for the remaining five days. Ensuring medical students get 7-8 hours of daily sleep is crucial for their mental and physical health. 

“It is imperative to recognise that postgraduates and interns primarily serve educational purposes rather than filling gaps in healthcare staffing,” it notes.

(With inputs from Arjun Raghunath in Thiruvananthapuram,
E T B Sivapriyan in Chennai, Mrityunjay Bose in Mumbai, S N V Sudhir in Hyderabad, Sumir Karmakar in Guwahati and Udbhavi Balakrishna in Bengaluru)