A Kerala Model of Tragedies

Both tragedies were no accidents but “human-made.” The first was the result of wanton neglect of even basic laws and rules by the boat’s owners and also the criminal failure of the authorities to enforce them. The second was the latest and the most tragic incident in a shocking series of 200 violent incidents against health workers in just the last three years in the state. But murder is happening for the first time in Kerala and just the second in the entire country! And that, too, right in front of many persons while the miscreant was under police custody. As the attacker armed with a surgical scissor went on a rampage stabbing whoever was in sight, everyone including the policemen, fled to safety except the hapless Das, who stood frozen, all alone in a room with him.

The response to both horrific incidents has been, as usual, triggering a sense of Deja Vu. Society is enraged, the aghast medical community has launched an agitation, the media is outraged and political parties are using it to suit their immediate political ends. The government, the prime culprit in both cases, is again going through the motions threatening severe punitive action against the guilty, announcing the judicial inquiry, and promising immediate ordinances to plug legal and administrative loopholes as if they have come to know of them only now. The media, as always, is indignant, but only until another calamity strikes. Look how the boat mishap that killed 22 vanished from pages and screens barely three days after it happened with the doctor's murder.

Meanwhile, my friend Dr. Muralee Thummarukudy, the global disaster expert and popular writer, appears to be soon ordained as Kerala's Nostradamus, with his dark predictions coming true with an eerie regularity. From the 2018 floods to the boat mishap and now even the doctor’s murder, Thummarukudy predicted them like Nostradamus, the 16th-century French apothecary, and astrologer. Despite many of his prophecies contained in 942 poetic quatrains, coming true (though many are now debated), including events that occurred centuries later like the French Revolution, the rise of Hitler, the World Wars, or even the death of Princess Diana or attack on World Trade Centre, the humble Nostradamus insisted that he was no prophet and accounted everything to “judicial astrology” and observation. He wrote to his son Cesar, “Although my son, I have used the word prophet, I would not attribute to myself a title of such lofty sublimity.” Thummarukudy, who also is a rational scientist, has reiterated that his “predictions” too were based on common sense, observation, and also rich experience as a disaster expert.

Thummarukudy has hit the nail on the head. One need not even be a seasoned disaster expert like him to foresee that all his three “prophecies” were just waiting to happen in Kerala. All one required was to keep one’s eyes and ears open to foresee them. Hence Thummarukudy's prediction that Kerala’s next mishap would be a fire in a high-rise apartment need not surprise anyone if it occurs.

The government or the police or health departments, the ministers or bureaucrats who are in charge surely cannot evade responsibility for the mishaps. It is not a lack of sufficient laws or judicial or expert inquiries which leads to the recurrence of disasters. Every time a tragedy occurs, the media cries hoarse on the various inquiries done after similar incidents of the past and their recommendations, which have been observed only in the breach. Kerala’s medical fraternity and hospitals association have been consistently pleading with the government to initiate stern action on perpetrators of violence, especially after a senior doctor was kicked in her abdomen by a person after his wife died in the hospital. The number of 200 incidents in three years is a record that the government doesn't appear to be worried about. It is the height of callousness that the government entrusted the probe into the doctor’s murder -first in the state and second in India recently- with some middle-level functionaries in the police and health department.

Yet, are the authorities only to be blamed? Can the society, which consists of each of us, who has never attached importance to public safety, security, or even laws and rules, stay away from blame? Can politicians and bureaucrats afford to evade their duties without civil society and its institutions like the judiciary or the media letting them look away? Is it alright for us, including the media, to feel outraged and find culprits only in hindsight? While Opposition politicians are out to make political capital blaming the government, the ruling tribe lambasts everyone, including the judges who accuse them of ineptitude or callousness. Look at the abusive trolls on Justice Devan Ramachandran, who called for an immediate report on the doctor’s murder. The abusers appear unconcerned that Justice Ramachandran has been continuously addressing the issue with ordering in December last year (with Justice Kausar Edappagath) the police to register cases within an hour after the information is received about an attack on health personnel. The KPMGA had submitted to Veena George a list of 11 measures to improve safety.

The media also mires on the sensational and symptoms instead of going deep into the roots of the malady. Though Health Minister Veena George displayed insensitivity when she indulged in a mild form of “victim blaming” when she cited Vandana’s “inexperience” for the tragedy, is it something for the politicians and the media to be morally indignant about unendingly? Even senior politicians had no qualms calling her a “shameless woman” or lampooning her for being emotional while paying respects to the young doctor’s body as “glycerin-induced.” The lack of sensitivity of our entire political class has been on full display.

It is high time a top-level team of experts from different fields is entrusted with the growing violence against health professionals in Kerala, India’s best state in public health. Though the growing incidence of assaults in Kerala looks unprecedented, this is not just a national but a universal trend, including in developed countries, which is a sign of the rising violence in society. Hence it is to be looked at beyond the level of a Deputy Police Superintendent or a Deputy District Medical Officer. According to a study published in the British Journal of the Royal Society of Medicine, there has been an increase in violence against health workers in the United Kingdom. While 87% of the health staff are worried about violence in workplaces, 73% suffer verbal abuse. One in every 20 National Health Service staff was threatened with a weapon, and 55% of 250 doctors were victims of threatened violence. In Birmingham, 70% of women general practitioners feared for their personal security during night shifts. Most of the violence occurs in Accident and Emergency (A&E) departments, followed by psychiatry in the UK, while in the US, the psychiatry department is the prime venue, followed by A&E and ICUs. Patients or relatives under the influence of drugs or liquor were the perpetrators in most cases.

The study made many recommendations to improve the situation, including the following.

1. A comprehensive database of all incidents to formulate standard operating procedures.
2. Training to health staff on the avoidance and management of potentially aggressive situations, which should include; awareness of warning signals like the body language that can precede an aggressive outburst, Improved communication skills on how to defuse violent situations and control their own emotions so that not to meet anger with anger, counseling for staff, etc.
3. Reduced lengthy waiting time for patients and improved grievance cells.
4. Auditing patient appointment system by increasing consulting intervals for doctors
5. Inform patients of likely waits and provide explanations
6. Unconcealed CCTV with 24-hour video recording
7. Better standards and facilities and adequate staff in hospitals

Before the Vandana case, the only recent case of murdering a doctor occurred in Jorhat, Assam, in August 2019 when Dr. Deben Dutta, a 73-year-old senior medical officer in the Teok Tea Estate Hospital, was lynched. The accused were all estate workers, and the attack followed the death of their colleague, Somra Majhi. The assaulters believed Majhi died of delayed treatment. In 2020, Jorhat’s District Sessions court sentenced the first among the 25 accused to death, and the rest were awarded life imprisonment. Following the attack on a junior doctor in West Bengal that led to country-wide protests, the central government formed a 10-member interministerial committee to formulate measures to prevent violence against health professionals. Soon the Union Ministry of Health and Family Welfare, when Dr. Harshvardhan was the minister, released a draft bill with provisions of up to 10 years of imprisonment and a penalty of Rs 10 lakhs for attacking health staff. However, even after three years, the bill hangs fire. No central law exists on the topic while the Medical Service Persons and Medicare Service Institutions (Prevention of Violence) is in force in 25 states and UTs, which makes violence against health professionals a non-bailable offence and punishable by up to three years in jail and Rs 50,000 fine. Yet, none in Kerala has been convicted under this law, and most of the accused have received bail at the earliest.

Violence against health professionals affects society seriously. Every study has proved that the fear caused by violence among them seriously undermines their morale and affects the quality of their service. Surely, one more big challenge to the celebrated Kerala Model.