India: the plight of health workers amidst pandemic and falling infrastructure

The following was written by a comrade in India about the appalling situation facing healthcare workers in India: before and during the COVID-19 pandemic.

“The bourgeoisie has stripped of its halo every occupation hitherto honoured and looked up to with reverent awe. It has converted the physician, the lawyer, the priest, the poet, the man of science, into its paid wage labourers.”

Karl Marx and Fredrick Engels (The Communist Manifesto)

Marx rightly predicted the social and moral degradation of the people who genuinely contributed to fulfilling social needs – by reducing them to mere wage-labourers. When Marx was writing these lines, he recognised the beginning of a process, whereby once-honoured professionals are forced to sense the profit motives of capitalists for whom they work, and take on their views so that doctors see patients as nothing but objects from which to extract profit.

To this day, we can hear the line being used quite rampantly by teachers in medical colleges; how the medical profession is a noble one, and how doctors have huge respect in society. Little do they acknowledge that this sense of nobility does not exist in the real world. Not anymore. Doctors have lost their social respect, and the misery afflicting doctors has risen manifold. This stems from both material and psychological factors. The medical profession is different from others in the sense that it calls for a service of humankind. You have to abide by medical ethics. You can’t commercialise, you can’t advertise, you can’t chase after profits.

But in present times, with 70 percent of private sectors delivering healthcare, the medical system has been turned into business without any concern about professional/medical ethics. Doctors can advertise, use marketing tactics and are incentivised to bring more profits to capitalists. For these reasons, the medical profession is also included under the Consumer Protection Act, whereby patients are seen as customers.

The struggle to become a doctor under capitalism

Doctors struggle for years to become qualified, and face poverty and terrible working conditions in the public sector, meaning many turn to private practice / Image: Trinity Care Foundation, Flickr

With the privatisation of all major sectors, unemployment has risen like never before. From the day a child is born, he/she is persuaded to become a doctor or an engineer because most parents see no future in private companies due to the uncertain future in any private profession with no job security. This puts a lot of academic pressures on students. Under capitalism, the education system has lost its utility of helping students realise their full potential and to show the massive range of societal roles that a student can play in the future. The ‘rote learning’ culture in the education system encourages the student to just pass their exams without any concern for meaningful learning. Hence, critical thinking abilities are rarely found among these students. Within this devastated education system, the government is unable develop new medical colleges. As a result, only a few students manage to secure a place in a medical college after facing fierce competition. Students usually spent thousands of rupees on private coaching centres, who leech from their parents. Life becomes hard for a poor student who cannot afford greedy private coaching centres, and instead get a mediocre education from government high schools and colleges. After going through all these tribulations, involving a huge expenditure of money and time, one doesn’t become a doctor to treat the patient but to earn money from ‘customers’. After securing a medical seat, the nightmare doesn’t stop: the student has to pay a considerable amount of money to get qualified as a doctor.

The medical course is among the toughest to clear. Medical students sacrifice their family and personal lives just to pass their exams to receive an MBBS degree after five and a half years. It takes three more years to complete a postgraduate course. Super specialisation takes two more years. So, you need at least 10 years to become a full-fledged doctor. After studying for these many years, if one is lucky enough to get into the public sector, a young doctor often gets an initial job posting in a remote, rural area without any utilities and amenities. The healthcare centre in rural areas even lacks basic equipment, including laboratories, X-Rays, MRI machines, CT-Scan machines, etc. Doctors work for nearly 10-12 hours daily without proper sleep and with no time for physical rehabilitation. Also, the salaries are low in proportion to the working hours.

Therefore, after sacrificing a decade to medical education, and spending millions on getting a medical degree, private practice seems lucrative to young doctors as they can rip-off customers for profits and fulfil their dream of a luxurious life.

Healthcare sector and the Indian state

If we look at the government’s spending on the healthcare sector, it’s evident that it is not a priority in India. With just 1.2 percent of GDP being spent on the healthcare system, you can’t expect much from government hospitals. The working conditions for doctors are abhorrent too; both in government and private hospitals. Doctors are overworked, without proper sleep, food or water. Even after working in these circumstances, they become the victims of violence at the hands of the aggressive relatives of some patients. The worst part is that doctors can’t even protest or strike against their lot, as the lives of millions depend on them. One day strike will wreak havoc in this nation. The High Court directs the medical fraternity to get back to work immediately for just staging a protest, to send a message to the government; but the same court sits silently over the issue of violence against doctors at the workplace, sometimes even leading to the death of healthcare workers.

According to official data released by the Health Ministry in June last year, there is only one doctor per 11,082 in the population; one government hospital bed per 1,844, and one state-run hospital for every 55,591. The WHO recommends an average of 1 doctor per 1,000.

The situation is so dire in this country that a 2017 study published in the medical journal ‘BMJ OPEN’ revealed that the average time that primary healthcare physicians spend with patients in India is at an abysmal rate of merely two minutes. “It is concerning that a large proportion of the global population has only a few minutes with their primary care physicians,” the report concluded. “Such a short consultation length is likely to adversely affect patient healthcare and physician workload and stress.”

The doctor-patient relationship, which should mutually benefit one another, has become contradictory under capitalism, where capital rules over labour. Doctors are viewed as blood-sucking monsters who are waiting to leech huge sums of money with no guaranteed outcome for the quality of the patient’s health. This is a direct consequence of the poor infrastructure of government medical hospitals and the boom of the private hospitals, which only look for the potential profits they can gain from destitute patients. The image of a doctor that has formed in the public opinion is expected, of course, but not justified.

There was a time when state-run hospitals outnumbered private ones. Today, nearly 70 percent of healthcare delivered to the public is done through the private sector. This corporatisation started aggressively after the economic liberalisation back in 1991. In India, where a significant proportion of the population is still agrarian-based and constitutes the lower socio-economic strata, the lack of proper healthcare checkups in government sectors forces the common masses to avail of sub-standard medical services. Even though private hospitals have all the required equipment and modern technologies, it’s not accessible to most Indians because of such high costs.

Universal health coverage in India is a hoax: grassroots level healthcare centres are in adverse conditions with poor infrastructure and maintenance, with an acute shortage of medical equipment. Any minor ailment that can be treated at the Primary Health Centres is referred to the higher centres or hospitals. A qualified doctor with the required knowledge is unable to treat the patients due to poor infrastructure at PHC. This leads to overcrowding at the district hospitals because, as the law dictates, they cannot refuse any patients.

Accredited Social Health Activist (ASHA) workers and nurses are not in a good condition either. Nurses, who play a major role in any hospital and stay in contact with the patients more than doctors themselves, are heavily exploited. They get paid far less and spend more unpaid working hours. ASHA workers play an extremely crucial role in providing healthcare in rural areas. They are the grassroots level workers who help in making foundations of the healthcare system strong. But their agony and grievances are never considered. During a day, an ASHA worker counsels an elderly couple, delivers medicines to a pregnant woman, takes newborns and mothers to the district hospital, keeps a watch on city-returnees who are home-quarantined, enforces social distancing and educates people. During this COVID-19 pandemic, they have come into the limelight, and people started realising their importance. But the question is: can mere recognition fill their stomachs when they get a monthly payment of just ₹4000 ($54) per month? Even the living wage in India is ₹10300 ($138) per month.

Such a poor state of government-run hospitals form a conducive environment for the booming of private sectors. People have lost their trust in state-run hospitals. The majority of the population does not look at the systematic cause of the problem and hold the doctors liable for everything. Doctors are made an easy scapegoat for the monumental systemic failure of the government in providing accessible, quality healthcare for all. It’s a matter of shame that corporations who only look for profits and money, having no concern for ethics and morality, are topping the lists for providing better healthcare facilities; whereas the government, which is elected democratically, has no concern for human lives.

The COVID-19 pandemic and its impact on healthcare workers

India's dire healthcare system has contributed to it having the third-highest death rate from COVID-19 / Image: ILO Asia Pacific, Flickr

Conditions for healthcare workers during the COVID-19 pandemic are even worse. After the Tablighi Jamaat incident, whereby it came to be called a coronavirus hotspot and super-spreader, the ruling political party BJP used this incident to spread their Islamophobic agenda with the help of the media barons to divide the working class even more. With the Hindutva agenda attaining mainstream status after Modi came to power post-2014, even doctors weren’t spared from its ideology. Hidden and cornered racism, casteism, sexism, Islamophobia got placed into the limelight. In these times, it’s easy to espouse all of these ideas without having any sense of guilt. The consequence of this manifests daily. Lynchings of Muslims have become rampant. Dalits are beaten to death in daylight by upper-caste-Hindus. Rapes, murders, and other crimes have increased manifold.

After the Tablighi Jamaat attendees returned to their native places, doctors were sent to their villages and localities to do sample testing of the returnees. There were many reported cases of doctors being attacked by the Muslim residents, spit at, and beaten.

Nothing justifies bad behaviour with healthcare workers just like there is no justification for Islamophobia.

Due to the unavailability of testing kits, screening for COVID-19 wasn’t being done aggressively until quite recently. Everyone is aware of the poor state of the medical system in India, so the people didn’t expect much of it since the beginning of the pandemic. The people were more interested in preventing the event rather than curing it. But, due to poor planning of the lockdown and many other issues, India has today become the nation with the third-highest number of COVID-19 cases throughout the world; the USA being the first, followed by Brazil at number two.

In all this, it is the health workers who are suffering the most. Doctors and nurses are being overworked without proper Personal Protection Equipment (PPE), putting their lives in danger. They are staying away from their homes for days and months. Even during this pandemic, where healthcare workers are playing a significant role in combating the pandemic, violence against doctors is truly appalling. There are many reported cases of brutality inflicted on doctors and other healthcare providers during this period. The government pays symbolic ‘tributes’ by clapping, banging thaalis, etc., while healthcare workers die after getting infected during the course of treatment due to a lack of PPE. A lower number of doctors and lack of ICU beds are making the situation worse. Many doctors and healthcare workers have even died while treating patients. With the way cases are rising every day, we can only expect the complete collapse of the medical system.

Only under a socialist, planned economy, we can achieve standardised accessible and affordable medicare for all by nationalising the whole healthcare sector.

Down with privatisation!

Down with anti-people policies!

Down with capitalism!

Long live socialism!

For the triumph of labour over capital!