Are doctors super-human Messiahs & healers or the ordinary workers & fellow humans, in the same way as human resource recruited to any other profession & department is? This is the most burning yet equally unanswerable question today. The dilemma or the fallacy of excluded middle- whatever that is- keeps turning up every time doctors would take to the streets to raise their ‘valid’ concerns to the local administration & the Health Department, apparently consigning their ‘call for duty’ to oblivion & leaving behind patients languishing outside the closed doors of the abandoned hospital wards & blocks.
In our part of the world, a doctor is not considered a scientist or a healthcare practitioner but would be exalted to the status of a ‘Messiah’ sent to this world to salvage humanity. A doctor is often fragmented off the skilled labor & his/her service made equivalent to liberating mankind from eternal pain & suffering by way of ‘saying chants’ & ‘doing miracles’!
Yet, general masses & the schmuck electronic media mannequins of the ruling class, in addition to smacking the Doctors Union (Young Doctors’ Association) with the ‘blackmailing Mafia’ slang, absolutely denigrating them & refusing to believe in their narrative, always manage to save themselves the bother of asking the tough questions: What made them take to streets? Who took it so far? Were they actually wronged? Did someone bother to go talk to them & get apprised of their narrative?
Poor Healthcare infrastructure: Who is responsible- Doctors or government?
The distorted social theorem devised in our part of the world that doctors are somehow ‘the prime movers’ in the realm of health & disease, having full control over life & death of patients, leads to a problematic mindset: should the patient die through the course of treatment, there MUST have been criminal negligence of the healthcare providers especially doctors somewhere, that needs to be avenged on through vigilante!
Our working class patients interact only with the paramedic staff & healthcare practitioners on the different tiers viz. primary, secondary & tertiary level of state-run healthcare structure, not the beaurocracy & the local administration in the upper strata- the real stakeholders. This is the reason that frustration & exceedingly agitating behavior of patients’ attendants, borne out of frustration at either lack of proper facilities or loss of life due to that, is displaced primarily upon the medic & paramedic staff. It is ultimately the healthcare worker who has to bear the brunt of agitated & distressed attendants’ wrath, not the inefficient ruling elite sitting in the corridors of power, the ones actually responsible for everything that is wrong with this healthcare system.
Who is to be called to account for lack of proper healthcare facilities including hospital beds, essential drugs & diagnostic gadgetry at public-sector or ‘state-run’ hospitals? Who is to be held responsible for low doctor to patient ratio & lack of adequate number of tertiary care hospitals throughout the country? Who should the blame be put on for the delays in access to & provision of healthcare that occurs mainly because of the lack of operationalisation & healthcare development in addition to substandard & deplorable condition of primary & secondary healthcare services? Indubitably, the party having more control & authority over the resource management and political capital- the local administration, the Health Department & government.
Workload, job satisfaction & professionalism:
A young doctor on an average has to work (including both direct patient-care & ancillary work) at least 60 hours per week in Pakistan, having 2 calls (32 hours continuous night & day duties). Additionally, the condition of doctor to patient ratio is absolutely malapropos in full sense of the word. According to the 2010 & 2012 demographic statistics, there are 0.6 hospital beds & 0.83 doctors available per 1,000 population in Pakistan. Moreover, the total healthcare expenditure of Pakistan remains as low as 2.6% of GDP whilst the state is setting a new precedent of benefitting from the free labour of young doctors inducted on residency slots. Only two months back, Dawn reported that about 900 postgraduate residents (PGRs), including 500 of those inducted through Central Induction Policy (CIP) in August this year, are working unpaid in various state-run teaching hospitals across the province of Punjab; 400 amongst them being the old PGRs who have been working without any stipend for a year now.
Long & gruelling working hours have been considered, since the time immemorial, not only fundamental to medical training but also integral for developing enough clinical acumen enabling young doctors to work independently without supervision after completion of training. Yet, there is robust research-based evidence available to indicate that unsafe & laborious working hours not only negatively affect the mental health of medics but might also be prelude, variably, to putting patients’ health & life to risk. It is quite understandable that long ( MOSTLY UNPAID ) & irregular working hours on top of the typical ‘generation-bashing’ on part of seniors & excess work disproportionately assigned to young doctors would not only lead to work overload, low competence levels, emotional exhaustion & frequent burnouts but also low job satisfaction & employee morale, leading to rise in indeliberate unprofessional & disruptive behavior at workplace. This could also be extrapolated to the young healthcare providers feeling ‘victimized’ & being forced to self-sacrifice whilst selling their back-breaking labour at extremely low costs & in certain cases at the cost of nothing or being slapped, threatened & harassed by attendants of the patients they are rendering their services to.
Imagine, under all those circumstances, patients’ attendants ganging up to threaten the healthcare workers with violence to avenge poor patient outcome. Patient outcome is the medic & paramedic staff’s responsibility, rightly so; yet it is a preposterous strawman argument to assert that it is only the healthcare providers who are to be held blameworthy for poor patient outcome, not the substandard & collapsing healthcare system — all thanks to the state for its inadequate & ineffective policy making & incapacity to do better for healthcare development.
( The fine line between fundamental rights & ethical dilemmas; hypocrite government & Hippocratic oath)
We are living in an era when a big proportion of our socio-cognitive framework is influenced & shaped by the popular opinion privy to the electronic, print & social media, howbeit misleading & biased that might be. It is quite infallible to contend that the recent YDAP Mayo Hospital Lahore’s protestations & sit-in have made many impressionable media-persons & many of the all-mighty politicians learn the Hippocratic Oath by heart as well as become a circadian clock reminding the protesting doctors of their binding contract with the community, for the past few days. Notably, we are the kind of people who, more often than not make light of our own pledge to the community we would somewhere be bound to, yet never fail to connote others of their contractual obligations.
Hippocratic oath is one of the most revered ancient documents in the field of medical sciences even in 21st century, however, it is indisputable that its certain parts are outdated & have ceased to be relevant today, better put a few sections of it, if fleshed out, would require the moral police crying hoarse over the protesting doctors’ violation of the professional oath to improve their own sense of ‘medical ethics’. Galvanized by our visceral reactions to hold anything in high esteem without will to understand it alike, we often go too far in moral realism. So, do our Media persons in a multitude of cases.
According to United Nations’ Declaration on Human Rights, every human being has the right to assembly & association that is manifested in the right to protest, however the International Covenant on Civil and Political Rights contains certain prohibitions including restriction of the freedom to assembly if it is necessary “in a democratic society in the interests of national security or public safety, public order, the protection of public health or morals or the protection of the rights and freedoms of others.” (Articles 20 and 21.)
Notwithstanding the verbal social contract between the physician & the community that the Hippocratic oath binds them to, there always remains a thin, exhaustive distinction between one’s fundamental rights & ethical dilemmas, from a moral realist viewpoint. ‘Patient protection’ or responsible ‘decision-making’ in the best interest of patients is something that ought not be only in the context of temporal & limited nature of the Hippocratic philosophy.
Where is it that the fine line between one’s own basic rights & ethical dilemmas get obscured? Where is it that the difference between one’s will to survive & one’s duty towards someone’s right to live gets obliterated? Who is responsible for the loss of life that comes off as a collateral damage (as many would state) to fighting for one’s just rights as the last resort?
A doctor’s answer to any of those ongoing questions is no longer unpredictable if there is a factor that helps obscure that fine line and thin distinction: being slapped, harassed, subjected to physical torture, stabbed, threatened on gunpoint at workplace & then terminated– served justice by being victimized! That is not enough, they would be demonized & projected as blackmailers & hooligans in front of the whole Nation– as the selfish beings who can’t move past their pecuniary goals.
One of such responses of a doctor sums up everything:
“Whose rights are more important? Whose responsibility is to ensure that such issues are solved even before they arise? Will to survive never ends anywhere.”
Likewise, the cutting-edge questions on the relevance & validity of the Hippocratic oath with the emergence of new tenets & philosophies in bioethics & modern medicine, with the passage of time, have been well addressed & answered in an AKUH article here.
How dare Messiahs demand security? Narrating stories
There is a very common misconception among common citizens: if doctors are on strike, this has something to do with salaries or money every time. The current issue the doctors have had been trying to address through sit-in was lack of security for doctors within hospitals where anyone could bring 15, 16 hooligans to beat the hell out of them & the security personnel already appointed wouldn’t be able to stop them. Please imagine yourself in their shoes & ask yourself if you are threatened by or subjected to violence by relatives of the ones you are trying to save lives of, would you give a second thought to making your right to security a priority over theirs? Evidently not!
Imagine you are a female doctor on duty at 4:00 am at a public-sector hospital. An old, high-risk patient of a chronic illness at the terminal stage dies even after getting all the possible medical intervention, having been provided with every facility at disposal. The tens of attendants of the deceased believe that you have full autonomy over life & death & should you have tried more, the patient could be saved. So, their immediate response to acute stress & grief is blaming the doctors & labelling them as killers. They gang up & try to attack you, wardboys & other staff protect you somehow & you have to run for life & get yourself locked inside the duty room for an hour. They keep banging the door & if you are unfortunate enough to have locked yourself in a room with glass doors & windows, odds are that they would pelt stones & smash the windows. Security staff appointed outside is not enough to intercede & rein in. You are somehow rescued & what happens next is that your parents refuse to send you back to the same hospital to continue training. Such a big, well-deserved reward for years of tough education & cheap labour? Yes.
Now imagine you are an OBGYN resident on duty in the Emergency Labor Induction Room of a public hospital. If someone has ever been to one, would be apprised of the usual condition there. You have, presumably, been working for the past 11 hours now, emotionally & physically drained. You have explained something to a patient & the attendants five times & lose your cool when they ask it again for the sixth time & throw a temper tantrum (uncalled for, by all means) but that means the attendants are sanctioned to combat harsh words with physical violence or by slapping the doctor?
Imagine again a patient’s attendants assaulting & torturing you, a doctor on duty, for lack of availability of adequate number of beds & for the fact that there are two to three patients on one bed.
Imagine that you are a doctor on duty in the Emergency Surgical Floor. A patient comes with 3rd degree burns ( involving head, neck, arm & perineum). The patient is immediately resuscitated with antibiotics, analgesics & intravenous fluids following the standard protocol. For some reason, there is exchange of harsh remarks between tens of the attendants & an old man sitting on the counter making ER admission slips. They physically attack the old man, you go outside, try to stop them & get manhandled. Somehow security personnel try to control the situation. The patient dies later despite all efforts to save life. A week later, you receive a call from a nearby Police station that you are going to be booked under Section 302 (Punishment for wilful muder/ Qatl-i-Shibh-i-Amd), something not even applicable on the doctors’ community.
The legal PPC definition: “When a person intends to cause harm to body or mind of any person, and causes death of that person or death of any other person by means of a weapon or an act which in ordinary course of nature is not likely to cause death, he/she commits qatl-shibh-i-amd.”
Fair enough? These stories are not made-up but real life scenarios, not even equivalent to the tip of an iceberg, narrated only to explain what is happening outside your comfort zones where you spew venom against every single doctor from, in real life & on social media. Such incidents occur on daily basis in public hospitals. Female doctors get slapped every other day! Why? Because a patient, in his terminal stage of chronic illness that lasted more than 30-40 years, expired even after he was provided every possible healthcare facility available & every single thing at disposal? Or maybe it’s because the doctor chose to stay in this country even if had the privilege to leave? Because he/she is a demigod, a Messiah not a human who deserves respect, dignity & security at workplace?!
The Real Story: Different Versions
The YDAP Mayo’s Version:
The story behind the recent sit-in begins when a Surgery resident gets manhandled & physically assaulted by ‘influential’ attendants of a patient with Road traffic accident injuries at the East Surgical Ward, Mayo Hospital on October 15th, 2016.
The political henchmen of a beaurocrat/ DCO tried to take away the medicolegal case file of the patient & tamper it. When the nursing staff rebuked them, they started harassing them & a female HO on duty, later physically attacked the male resident on ward week duty (168 hours straight duty of a surgical trainee) who intervened & stopped them from harassing the female staff. After that the matter was resolved at a local police station following the attendants’ written & verbal apology! Since the YDAP Mayo’s chairman had been spearheading the campaign against the Central induction policy (CIP) & had not been in good books of the Health secretary; on account of personal vendetta, the KEMU administration was bypassed & termination letters of two doctors & the nursing staff were issued; that was projected in media as terminations following fair inquiry. CIP is something that by no means affects any of the terminated doctors; instead, they had taken stand against it for the healthcare community & system.
Although various aspects of this version of the story become questionable when compared to the Media version, for once let’s presume this is the real one. How’s justice served to the doctor who is beaten up by attendants for calling them out not harasss paramedics; later threatened & stabbed? By terminating him!
When indoor & Out-patient department services were partially withdrawn as a part of the peaceful movement for demanding reinstatement of the terminated doctors, the same Dr. was attacked again, who this time also survived a defense stab wound on his surgical hand.
They were later threatened and harassed by DMS Mayo on gunpoint to not hold the peaceful protest camp within Mayo & the protest-rally in front of the CM secretariat. That is when they lost cool, decided to withdraw all services including locking down the emergency block & hold the sit-in on Mall Road to demand foolproof security in hospitals & declaration of hospitals as zero tolerance zones plus reinstatement of the terminated staff & an apology from the Health secretariat for victimization of doctors & vindictive actions against them drawn on personal vendetta. Four other big hospitals of Lahore also observe complete withdrawal of services.
Doctors refused to call off withdrawal from services at OPDs & Indoors, unless their demands were met. Government refused to give an ear to their demands of reinstatement of the terminated doctors. The triple threat match between Electronic Media, Punjab Government & the protesting doctors from YDAP went on for more than 2 weeks, also taking the toll on lives of two patients, as reported. by Dunya TV.
Raiding on doctors’ & Nursing hostels, beating them, registering FIRs & terminating more young doctors was the Punjab Government’s stereotypical yet childish response & approach to resolution of the conflict.
Quoted, as published:
“The incident surfaced on October 15 in the East Surgical Ward of Mayo Hospital. Dr Shaharyar Niazi-the chairman of Young Doctors Association (YDA) of the hospital, was accused of beating the patient up. According to eye witnesses of the tragic episode, a patient named Waqar Amin complained of being ignored repeatedly. This annoyed the doctor on duty, Shaharyar Niazi, who proceeded to beat the patient. As a result, Waqas Amin, the brother of the patient, filed a complaint in the office of Deputy Medical Superintendent (DMS) Dr Niazi entered the scene, forced entry into the DMS office with members of YDA and again beat the patient up along with his brother. Both were taken to the police check post of the hospital where the patient was locked up before the arrival of police.
A three-member fact finding committee was formed the very next day to probe the incident and Vice Chancellor University of Health Sciences (UHS) was made the convener of the committee. Other members of the committee were Special Secretary of SHC & MED and Professor (retired) Eice Muhammad. Action against the doctors was taken on the recommendation of the fact finding committee.”
It gets more confounding if you compare both these versions, but the former version is something eyewitnesses from medical community would testify to.
YDAP: A workers’ Union or ‘a patronage operation with privileged interests’?
Since its inception in 2008, YDAP has taken to the streets to put forward its demands for about 129 times; its hundreds of members got baton-charged, raided on, tortured & jailed. They fought for their just rights and got repressed with brute force yet kept on the resistance. Sometimes their voices were heard but mostly stiffled. Largely, the Union worked for the just causes & demands such as a proper service structure, fixed working hours & salaries and fighting against administration’s vindictive actions towards the medical community. On the other times, the organization itself fell victim to the self-inflicted factional divisions, hooligan culture & identity/ family politics in various chapters, even leading the rival groups to opening fire at one another to settle the scores & the subgroups to accusing one another of corruption, bribery & malpractice. Even the recent incident is telling of the current situation of the Union when certain factions resorted to backdoor deals with the Health Minister on CIP issue along with disowning its own members after they were terminated.
That said, apparently the Young Doctors Association Punjab has probably been failing to keep its unity & integrity whole. The conflicts & divisions at the level of state-run hospitals throughout Punjab, have now suffused at the central leadership of the Union, apparently splitting it into two rival groups. It would be devious & inexcusable to not mention all these flaws & divisions within the Union & not to assert the need for the young doctors’ community to do some introspection. Or else, if stayed divided & disarrayed, more hapless patients as well as the healthcare community & system would suffer. The citations to this could be read in detail here.
This incident also rendered the progressive community coming down on the young doctors, infused with laughable hasty generalizations. Regardless of figuring if the protesting faction of YDAP is really the ‘pressure group’ with privileged interests or the one that had been fighting against the same menace.
Oblivious to the real issue at hand, many progressives kept on passing the condescending remarks, mainly because a few of them were ‘taken hostage’ by the traffic issues that occurred owing to young doctors’ sit-in.
It is unscrupulously unfair, as well, for a few rights champions with ‘liberal or progressive values’ to label the Doctors’ Union as a patronage operation- a group of politicized individuals whereas themselves never missing a chance at assimilating the oppressed & utilizing causes & individuals to futher political goals. It is also insincere of the leftist community to believe that workers should only raise voice after someone gets burnt or killed as an occupational hazard or maybe only if he has been living on scraps, otherwise any sort of his demands are selfish & privileged interests.
Just because a patient is poor or belongs to the working class, doesn’t mean they cannot be wrong. Fighting along class lines doesn’t mean that one stops taking possibilities into account. Admittedly, we have a poorly evolved culture of violence, when intertwined with our collective passive aggression, compels us to resort to violence instead of resolving the conflict through discourse. Class dynamics hold no bound for that, power dynamics likely do.
The Media Mannequins:
Each of the few talkshows on the young doctors’ issue that I flipped through were dominated by anchor-persons trying to overwhelm the spokespersons from the doctors’ side, by resorting to incendiary & condescending remarks about the whole doctors’ community. A reminder: there exists, as well, a remarkable distinction between ‘struggle for’ Target Point Rating & the media-persons’ sense of professional responsibility whilst discussing & reporting on issues having the potential to formulate & perpetuate stereotypes amid the public, if portrayed recklessly.
Calling a labour Union a blackmailing Mafia run by hooligans & selfish murderers; focussing camera lenses on their blankets and disposable boxes & plates to show there is biryani up for the lunch, zooming in to show female doctors gulping up icecream & taking selfies, in order to sensationalize the subject-matter and inciting those in power to use brute force against them, speaks pretty low of the Media Ethics, to say the least.
When was the last time we saw someone on Media applauding the same young doctors’ valiant endeavours to save lives they do every single day? When was the last time you saw any of those media parrots & mannequins talking of doctors’ community but in criticism, negativity & hostility?
A sincere piece of advice to those TRP hungry Media buffoons to do some soul-searching too or STFU!
Examples from across the world
It is often put forth that nowhere in the whole world dutiful doctors would ever withdraw from patient care to demand their just rights. That they always hold patient care superlative to themselves. Contrary to this ‘popular opinion’, the will to one’s own survival & safety is also as much strong elsewhere as among young doctors here.
Here are a few examples from across the world:
1. 3,000 doctors to strike in New Zealand
2. Government Hospital Doctors In Delhi To Go On Strike Over Salaries, Allowances
3. Resident Doctors Strike Across Rajasthan Affects Health Services.
4. Punishing strike by resident doctors grinds on in Haiti |
5. Doctors in England stage historic strike
6. The UK Junior Doctors’ strike: Takeaways for the Rest of the World
Defining identity- All doctors are the same!
The term ‘Doctor’ is the universal identity of a healthcare practitioner that, however, is not an identity stronger enough to hybridise the individual & personal identities. All doctors are not the same- they could be ‘good’ or ‘bad’ & they could be equally ‘good and ‘bad’. Likewise, before this good or bad argumentation begins, we need to define both from the hedonist & utilitarian moralist standpoints, if either of the labels is monolithic or exists outside the indefinitely complex human nature.
Instead of dangerous oversimplification in the context of ‘good & evil’ why are we not, as a society, willing to accept the spectrum of human behaviour, just as it is?
Professionalism is not merely limited to the universal identity but also underpins the subjective personal & relative individual identities working as confounding variables including relative personality traits, cognitive framework, emotional quotient & behavioral patterns of individual healthcare workers.
The ‘passion or profession’ cliché is as much the precarious tautology as is the overdone Messiah rhetoric! Last time I checked neither was humanity standardized nor was empathy the universal emotional element.
Our system of education & examination alongside ‘Human Resource Management’ is hinged on primitive, discriminatory & deplorable tenets of social Darwinism – a system that has fragmented the human labour into perpetually mechanized non-sentient phenomenon, whose only end is: To be selfishly, apathetically competent & become the installed, out-of-order parts of a dysfunctional system.
Cheap labour & Service to humanity:
Consonant to what has been discussed earlier, we always confuse a doctor’s skilled labour with the service to humanity- something fundamental to the medical profession. The case for doctors is simple: If we want someone to perform their duty of saving lives & ensuring and maintaining health, diligently & conscientiously, we have to first off satisfy their own need to work with contentment, dignity & sense of security. The spirit of being a healer won’t last long if the ones they are healing & their loved ones would threaten them for life.
A doctor is in fact a unification of the terms Messiah, worker, healer & human. Behaviorism/ humanism is the cornerstone of this profession like Che Guevara called it ‘the very human profession’, yet doctor-patient relationships in public sector hospitals of Pakistan are, in all likelihood, paralleled with dysfunctional class-relations & social hierarchy whilst everyone goes around offering their own share in perpetuating the subtle expressions of systematic oppression at hospital- a place considered a citadel of humanity & healing.
A public sector hospital in Pakistan is not a monolith. It is as much a citadel of apathy & privilege as of healing & compassion. Maybe another place meant for dehumanization of the economically, socially & educationally disadvantaged people of the working class.
Behavioral sciences & medical ethics is taught as a separate subject at medical schools across the country but majority seems not to care about it later, let alone realizing what else is wrong in addition to medical workers recurrently treating patients (of working class) as lesser beings-maybe something interdependent to job dissatisfaction, work overload, stress, burnout or low employee morale.
Like Che Guevara in his Essay ‘On Revolutionary Medicine’ said what needs to be done in the field of Social Medicine is to aware the dormant energy or the sense of solidarity long asleep within the masses in general & healthcare workers in particular, by way of individual endeavors to become new & better humans. Doctors remain ordinary workers & their labour cannot be fragmented off their identity, yet their status as healers and Messiah could be assimilated to contribute to the greater good.
Che writes in ‘On Revolutionary Medicine’- an essay I believe every single medical student, doctor & healthcare worker/ practitioner should read:
Almost everyone knows that years ago I began my career as a doctor. And when I began as a doctor, when I began to study medicine, the majority of the concepts I have today, as a revolutionary, were absent from my store of ideals.
Like everyone, I wanted to succeed. I dreamed of becoming a famous medical research scientist; I dreamed of working indefatigably to discover something which would be used to help humanity, but which signified a personal triumph for me. I was, as we all are, a child of my environment.
Because of the circumstances in which I traveled, first as a student and later as a doctor, I came into close contact with poverty, hunger and disease; with the inability to treat a child because of lack of money; with the stupefaction provoked by the continual hunger and punishment, to the point that a father can accept the loss of a son as an unimportant accident, as occurs often in the downtrodden classes of our American homeland. And I began to realize at that time that there were things that were almost as important to me as becoming a famous scientist or making a significant contribution to medical science: I wanted to help those people.
But I continued to be, as we all continue to be always, a child of my environment, and I wanted to help those people with my own personal efforts. I began to investigate what was needed to be a revolutionary doctor.
Then I realized a fundamental thing: For one to be a revolutionary doctor or to be a revolutionary at all, there must first be a revolution. Isolated individual endeavour, for all its purity of ideals, is of no use, and the desire to sacrifice an entire lifetime to the noblest of ideals serves no purpose if one works alone, solitarily.
How long does the will to serve one’s community last?
What have you contributed to this community & country even when your education was subsidized?
If you have so many problems, why don’t you leave then?
Well, they are leaving already, taking into account the statistics of thousands of medical graduates being imported from Pakistan mainly to Western countries each year. Why? I am leaving the answer to this question for the readers in addition to mentioning that they leave because they are self-centered enough to want to pursue better careers & get paid & respected for their labour in return somewhere else, instead of being fool enough to stay & get slapped, harassed, threatened, stabbed, terminated and declared a criminal & murderer as a reward for the low costs they are selling their cheap labor at.
The will to serve one’s community lasts only as long as it doesn’t sabotage one’s will to live with dignity & security. The question that still remains unanswerable is: what if one’s will to survive could sabotage someone’s right to live?