The Lancet has helped bring global attention to the problem of violence against doctors in China through its Editorials in 2012 (May 12, p 1764)1 and 2014 (March 22, p 1013),2 and has stimulated local discussion on potential solutions. India’s health system faces a similar crisis and the magnitude of the Indian problem is, perhaps, greater. More than 2000 junior doctors from 17 government-run hospitals in India’s largest city, Mumbai, went on strike for 4 days in March, 2017, to protest a recent spate of violence against doctors.3 At least four separate incidents of assault on a junior doctor at a government hospital were reported in the week preceding the strike in the state of Maharashtra of which Mumbai is the capital.4 The chief demand of the striking doctors was better security from the government to protect them at hospitals. Violence against doctors in India is not new, and a 2015 survey by the Indian Medical Association suggests that as many as 75% of doctors in India have faced some form of violence at work.5 Patient dissatisfaction—as might be expected—is the proximate cause, agitated friends and relatives accompanying patients are the usual perpetrators, and accident and emergency, intensive care unit, and post-surgical wards are the most common settings for such violence.5
Each state in India has the right to enact its own laws related to health care. An incident in February, 2017, in Kolkata, West Bengal, India, where a private hospital was vandalised by an irate mob following the death of a patient due to alleged medical negligence led to the state government rapidly introducing a new law.6, 7 The law enforces far more severe financial and regulatory penalties than currently in place, including the possibility of criminal prosecution of doctors for medical negligence in private hospitals, and imposes direct price controls on private health services in the state. However, violence against doctors perpetrated by patient escorts is a superficial sign of a deeper systemic failure. Reactionary measures, such as enhanced security at government hospitals or harsh medical negligence laws, are unlikely to boost the flagging morale of the medical workforce or represent sustainable solutions for the delivery of safe, effective, low-cost, and truly universal health care in the long term.
Since the 1970s, medical education in India has increasingly emphasised specialisation over general practice, and it is now common for patients with relatively minor conditions to be treated in the first instance by specialists at tertiary hospitals. Paradoxically, the paucity of new investment in an ever-eroding primary care infrastructure has meant that patients who could have been diagnosed in the earliest stages of their disease often slip through the primary care net to present at the same tertiary hospitals with advanced and frequently incurable disease. This issue has led to an overburdened tertiary health system for which triage is routine. Consequently, the duration of each patient encounter is invariably brief, particularly in government hospitals, and does not afford the doctor—particularly the trainee doctor—the scope to develop a meaningful doctor–patient relationship. The tenuous relationship that does develop is especially susceptible to breaking down into violence when the financial implications of care are discussed in India where each year an estimated 60 million patients are forced to pay out of their own pocket for drugs and surgical procedures that they are in no position to afford.8
Against this backdrop, as an Indian doctor who trained at a government hospital in Maharashtra, I implore the striking doctors—and India’s entire medical fraternity—to leverage this crisis as an opportunity to come together with their patients to demand greater nationwide political commitment to address the underlying social determinants of violence against doctors.