The strike by resident doctors of Maharashtra in February and March this year (1, 2) focussed attention once again on the poor state of affairs in public hospitals in India. In the recent past there have been a number of such strikes in various parts of the country.

Such protests should be seen as indicators of the conditions in which resident doctors work. Junior doctors labour unreasonably long hours and within a system that is completely inadequate to meet people’s needs. Since they cannot change the situation they soon learn to cope, but at the expense of patients’ needs. Occasionally the pent-up frustration manifests as a strike. The government’s response invariably ignores the underlying structural problems which affect both working conditions and patient care in public hospitals.

The stressful conditions under which junior doctors work have been the subject of study in many parts of the world. In Europe, for example, the European Working Time Directive has imposed strict regulations to reduce residents’ working hours. They have been cut back to 58 hours a week and will be further reduced to 48 hours by 2009 (3). These regulations have been born of the recognition that junior doctors, who form the backbone of the system, are overworked and underpaid.

The immediate provocation

Resident doctors in Mumbai went on strike after one of their colleagues was attacked by a patient’s relative. This has become a commonly reported phenomenon in recent years, and in fact has been the reason for most such strikes in the recent past. The critical question is: why do patients or their relatives attack doctors? In the answer to this lies the understanding of the real solution.

Any casual visitor to a public hospital in India will be struck by the huge crowds of patients everywhere. There are a pitifully few number of doctors to attend to these patients. Further, the infrastructure simply cannot meet the requirements. Early in their professional lives, young doctors are overwhelmed with the problems of patients, problems which they have no means to solve. The only advice most seniors give is to do what is possible and forget about it. Thus it is not uncommon to see patients lying in a ward for months without the real problem being addressed, and without being told that nothing useful is going to be done.

Patients are unlikely to be interested in whether doctors are overwhelmed. They’re more concerned that doctors, especially in public hospitals, can be brusque, dismissive, and outright rude.

Overwork, frustration, and a general ethos that the patient is a supplicant are some of the factors that make most doctors rude. Logically, patients are the reason for doctors to exist. Without patients, obviously, we do not need any doctors. And, on the other hand, it is to consult doctors that patients visit hospitals. But in the current scheme of things, quite often patients and doctors see each other as adversaries. A survey of public hospitals in Mumbai around the time of the strike is published in this issue of the journal (4). To investigate the triggers to violence against hospital staff, the authors interviewed providers, staff and patients in hospitals in Mumbai. They found that bad working conditions, overcrowding and inadequate facilities are responsible for the increased friction between patients and providers. But will the authorities take note of such information?

It is no accident that the public medical care system is understaffed and under-equipped. Although successive governments, both Central and State, have expressed their commitment to a universal medical care system, they have not provided the money to make this a reality. There is a silent conspiracy to provide only the bare minimum in the public medical system. This suits the powerful medical elite as well as the political elite. Both are making big money through the heavily privatised medical care system in India.

Junior doctors can take comfort in the fact that this is only a short period in their professional lives during which they have to work under such miserable conditions. But for the poor who have nowhere else to access medical care, the occasional venting of anger is merely an event in a continuous scenario of neglect.

One can debate endlessly the rights and wrongs of doctors going on strike, and indeed the pages of this journal have discussed this issue in the past (5, 6, 7, 8). But we must recognise that when all else fails, it becomes

a moral imperative to protest against an unjust system in the strongest possible way. And in this case the junior doctors seem to have been driven to the wall.

Too few doctors for too many patients

Huge ethical problems exist when there are too few doctors to attend to too many patients. The most obvious and common are errors in diagnosis. A study published in the Journal of the American Medical Association, of junior doctors who had worked 90-hour shifts, showed that they had significant neuropsychiatric alteration in behaviour (9). Frequently a junior member of the staff will perform a procedure without adequate training and without supervision. All this is accepted under that wonderful phrase “the learning curve”. We don’t know how such practices affect the young doctor’s psyche but it should be no surprise that many doctors in India continue to behave similarly in later life. The basis for the rot is settled early. Also, in India, the number of patients that junior doctors have to see in the out-patient department is not controlled. Thus they may see up to 20 patients an hour. They soon learn to deal with the “problem”. It is common to ask the junior doctor to “dispose” of the crowd. The emphasis is on crowd management not on treating patients.

These are just some of the ethical stresses under which junior doctors work. On top of it, the remuneration that they get is not indexed to inflation. Thus every few years they are forced to struggle for a rise. This struggle often takes the form of a strike.

Thus one can see that discontent among junior doctors is endemic and is inherent to the way in which the government treats them. These highly trained young people, who should be considered a precious human resource, are treated very shabbily.

The real solution to the problem of discontent among junior doctors is to improve their working conditions and link their remuneration to inflation. The real solution to the problems of the patients in public hospitals is to improve their access to care, and the quality of this care. The question is not: can we afford to do this? It really is: can we afford not to do this?