Indian resident doctors and medical students seem to have found a new political voice. Usually their protests are limited to issues concerning remuneration, safety at the workplace and better working conditions (1). Even today, residents in many states of India get paltry salaries despite putting in long hours of work each week. Almost all residents in clinical disciplines work much more than the 48 hours a week specified in residency rules.

Recently, however, residents have been striking work and organising protests on issues concerning policy matters. Of course residents have struck work in the past over policy matters (the MARD strike over setting up of private medical colleges in 1984) but the rate at which it is happening now is alarming (2).

The reservations issue

In March 2006 the Indian government proposed introduction of a 27% quota for "other backward classes" (OBCs) in higher education institutions of the central government (3).

Caste-based quotas in educational institutions and jobs are not new to India. The ancient and well entrenched caste system ensured discrimination against the lower castes whose members were treated as untouchables and remained educationally, economically and socially backward. To combat these inequalities, the Constitution of India gave the Scheduled Castes and Tribes reservations in education and jobs when India became an independent nation.

Many believe that the quotas or reservations have created a "creamy layer" among OBCs, which is pocketing all the benefits. The new provisions by the central government are seen as being meant for the not-so-backward but politically strong lobby of the OBCs. These castes constitute a large population and reserving seats for them would reap immense electoral benefits for the ruling coalition. Interestingly, OBCs refer to backward classes and not backward castes but the definition of an OBC was based on the person’s caste. Also, these reservations have created an ever-increasing demand by various caste groups to be labelled backward.

The central government proposals were not acceptable to a vast majority of Indian medical students. They believed that the proposal was aimed at deriving electoral benefit. How can one claim to fight the caste system by reserving seats on the basis of caste, they queried. If caste has to cease to be a reality in modern India, we have to go beyond caste and creed. Were not the proposals aimed at creating divisions amongst Indian youth?

Indian medical students came together under the banner of "Youth for Equality" and started organising nationwide peaceful protests against the new reservation proposals. They demanded that caste-based reservations be revoked. On May 13, 2006, the Mumbai police ruthlessly lathi-charged the peacefully protesting medical students thereby provoking the five medical colleges of Delhi to go on an indefinite hunger strike and the resident doctors to strike work (4). The eminent All India Institute of Medical Sciences (AIIMS) became the epicentre of the struggle and tents were pitched on its lawns by the striking students.

The strike continued for almost three weeks even as negotiations between the striking students and government officials, including the prime minister, failed (5). The health services in Delhi were affected from the very first day. Other cities joined in and soon the agitation had taken a pan-India shape.

Many labelled the protesting medicos as upper caste elites who were fighting for their personal benefit. Threats of sacking as well as the offer of leaving all general seats untouched failed to move the protestors. Then the Supreme Court intervened and asked the doctors to get back to work. Eventually everyone came around and the 19 day agitation came to an end (6).

Prof Venugopal and autonomy of AIIMS

The dust over the reservations issue had not completely settled when the government kicked up another row by unceremoniously sacking Prof Venugopal, the director of AIIMS, who, it believed, had supported the strike.

The resident doctors again struck work, this time to demand Prof Venugopal’s reinstatement. The faculty association of AIIMS also backed the director, and saw the health minister’s action as undermining the autonomy of the institute. The matter reached the courts and the judiciary reprimanded the minister and stayed the director’s removal (7).

Compulsory rural postings

India has a dearth of doctors especially in rural areas. To overcome the problem the government toyed with the idea of a compulsory one-year stint in rural areas for students prior to their graduation, thus increasing the duration of the MBBS course by a year.

The scheme was first implemented in Tamil Nadu where it was greeted with protests by medical students (8). The students argued that this would only serve to increase the duration of the course to six and a half years and that the government was shying away from appointing regular staff for rural areas.

The right to strike

In all the three instances-the OBC reservation, the AIIMS director, and rural postings-the resident doctors were protesting against policy issues which do not directly concern their working conditions or pay scales. The issue of whether resident doctors should strike work has been discussed on numerous occasions and therefore anything said would be a mere repetition (1). Suffice it to say that the resident doctor’s work concerns human lives and hence stopping work should be done on rare occasions and under rare circumstances.

Threats to the lives of working doctors would be the most justifiable reason to protest. Nobody has the right to attack a doctor on duty; complaints of negligence can be handled in the appropriate forum. Hence the reactions and protests resulting from such incidents are probably justifiable. Also, one can empathise with protests that aim to obtain more pay and better working/living conditions for residents who work impossible hours and get little in return. The trend to protest policy decisions, however, is not entirely tenable.

Policy decisions and the residents

To make policies and programmes is the job of the legislature and the executive. Policies have to be made to accommodate the felt needs of a lot of groups including the doctors, nurses, support staff, and above all the patients. The doctors alone cannot be entrusted this responsibility and therefore the new position the government is considering regarding rural postings or any other policy matter (like the appointment of the director of AIIMS) cannot be held to ransom by protesting against it.

This is not to absolve the government of irresponsible behaviour in not taking all the stakeholders into confidence before going ahead with such proposals. It is but natural that medical students feel aggrieved at the sudden increase of a year in the MBBS course. It would have been better if implementation of the new rule had begun with a new batch of students who would be aware of what they were getting into. But does this give residents the right to strike work and put human lives in danger? After all, there are so many things one does not agree with and yet one has to accept them. The job of residents is to provide healthcare to patients, and while they have every right to ask for their due (good pay, security at the workplace and good working conditions), they must not interfere in policy matters which are the government’s responsibility.

Concerns of residents and medical students

It is also pertinent to point out that the government healthcare system, especially the tertiary system, is basically resident based. It is the sweat and toil of these young professionals that makes the system work. With the worst of facilities, grossly understaffed and crowded Out Patient Department and casualties, it is their hard work that saves the day, every day. To neglect the aspirations of such individuals is something that no responsible government should do. Any decision likely to affect the lives and careers of residents and students should at least be first discussed with them and their views taken into account.

The concerns of students in all the situations where they struck work were genuine. One can argue about whether the strike was a logical step, but everybody must agree that the concerns of residents should be dealt with fairly. Since civil society and the government expect residents never to strike work, it is their collective responsibility to ensure that residents’ concerns are quickly redressed. Here lies the solution to this vexed issue. A responsible, caring government can ensure that residents never strike. For every strike that resident doctors resort to, at least a part of the blame lies with the health ministry.

Statement of competing interests:

Both authors actively participated in the students/residents strike against caste-based reservations. They have no other competing interests or any financial conflicts to declare.