On May 30, 2020, flower petals rained down from the sky to honour India’s healthcare workers who are at the frontlines of the Covid pandemic.

It was a poetic gesture, but petals cannot cover up the cracks in India’s healthcare system, exacerbated by the pandemic, that cause doctors distress.

Last month, doctors in Safdarjung hospital held protests over the issue of delays in NEET-PG counselling. While this specific issue has been resolved, plenty more have been stacking up.

From issues like 24- and 48-hour shifts to the risk of Covid, low salaries to poor infrastructure, doctors in Delhi told Newslaundry that things need to change – and quickly.

Pandemic exacerbating existing issues

At the forefront of the NEET-PG counselling protest was Delhi’s Safdarjung hospital. Managed by the centre, the hospital saw 7,000 OPD patients and 1,000 emergency patients every day as of 2015, according to its website. Since then, with the addition of super-speciality and emergency blocks, the inflow of patients has sky-rocketed.

So have the problems of its doctors.

Dr Anuj Agarwal, president of the hospital’s resident doctors association, told Newslaundry that doctors live in fear of contracting Covid. Revised guidelines issued by the health ministry on January 9 no longer mandate the regular quarantine of healthcare workers performing their duties in Covid wards.

Additionally, he said Safdarjung no longer provides those working in Covid wards or ICUs with separate accommodation, or even separate areas to collect samples.

As a result, fear runs high about transmission of the virus from healthcare workers to their families. Agarwal emphasised that this decision was not taken by the government but by his hospital’s administration.

“Ram Manohar Lal hospital is the only hospital that has this facility right now,” Agarwal said. “Other hospitals, including ours, had it in the first and second waves of the pandemic. But it has not returned this time.”

Simultaneously, the workload has increased as India is witnessing a spike in Covid cases. And given the already skewed doctor-patient ratio in hospitals, the surge in patients makes the situation “totally catastrophic for healthcare workers”, said Dr Aviral Mathur, president of the RDA at Maulana Azad Medical College, a hospital run by the Delhi government.

“To illustrate, on a normal day, I could treat 100 patients with the manpower I have,” said Mathur. “That manpower is already compromised due to the lack of resident doctors and sub-optimum number of seats [for doctors to apply]. Under normal circumstances, even without the counselling issue, I am working at a 30 percent reduction in the manpower needed.”

When a hospital allots 50 percent of its beds for Covid patients and treatment, Mathur said, the already “compromised” manpower is divided into two, for Covid and non-Covid purposes.

“This leaves us in a scenario where the number of patients has almost quadrupled,” he said, “and the number of doctors has halved.”

Agrawal concurred, explaining how a junior doctor in his hospital who would, under normal circumstances, have two or three 24-hour shifts per month, is now undertaking two or three 24-hour shifts per week. Government guidelines, meanwhile, state that a doctor should work 48 hours per week, he said.

“The basic thing is that most doctors are so grossly overworked,” he said. “24-hour duty is a normal thing, really, sometimes they have to do 36 hours or 48 hours of duty.”

Importantly, Covid hasn’t spared healthcare workers. In early January, over 150 medical professionals tested positive in Delhi in a matter of days. During the second wave last year, over 100 doctors had died of Covid in Delhi, according to the Indian Medical Association.

The unnatural situation has also impacted medical training.

“During the pandemic, it was more than common for doctors, residents and postgraduate students to be working outside their speciality in the Covid ward,” Agarwal explained. “However, for those doing their postgraduation in a field like general surgery, the situation has been far from ideal. These doctors can only acquire the skills required by assisting on a procedure or doing it themselves – not by reading or watching a YouTube video. The number of surgeries has been reduced since the first wave and the surgery residents are employed for Covid duties. This has seriously affected their training, especially those who joined in 2020, as they will pass out soon and have got very little training. So, this will be a problematic scenario in the future.”

A drain on mental health

“Mere bimar hone ke haq bhi cheen liya gaya hai.” My right to fall sick has been taken away from me.

Early this month, Lady Hardinge Medical College and Hospital in Delhi had issued an order stating that healthcare workers exposed to Covid must continue working while following protocols, “irrespective of the degree of exposure”.

Mathur alleged the Maulana Azad administration is “cooking” a similar order, which has left postgraduate students anguished.

“There are doctors who are more fragile...and asking them to come back to duty is blunderous,” Mathur pointed out. “This concern is an infestation in the minds of doctors right now. The workload is already an issue under normal circumstances. There is pressure from senior doctors and patients, and there is a lot of paperwork that comes with the patient load.”

This and more has worsened the mental health of healthcare workers across hospitals to become a “growing epidemic”, according to Mathur.

Maulana Azad Medical College has a psychiatry department open to doctors, residents and postgraduate students. But this translates to one psychologist for 600 people, Mathur said, though he added, “We are happy there is someone at least. The seat had remained vacant for a long time.”

During the first and second waves, he added, NGOs collaborated with the hospital to offer mental health services to healthcare workers, with a panel of 60 counsellors contacting doctors in Covid wards to discuss their issues. This allegedly did not continue in the third wave.

The situation is equally dire at Safdarjung, where Agarwal said doctors are constantly worried about putting their families at risk even as they work long shifts. It is this normalising of a work culture revolving around “polluted, bonded labour”, he said, that results in residents and students dying by suicide.

On the way forward, Agarwal said, “First thing is that the optimum number of doctors should be there. Secondly, the division of working hours should be made proper. For example, the number of shifts can be increased. If the number of doctors increases, then the duty hours per doctor would decrease. Those kinds of things can be done”

Infrastructural and structural deficiencies

Simultaneously, infrastructural problems at hospitals have worsened the pressure and stress.

Safdarjung hospital, for instance, has only one functional CT machine and one MRI, according to Agarwal.

“The other two CT machines have not been working for about three years,” he alleged. “This is the situation in a hospital like Safdarjung, that gets a huge patient load. In other hospitals like GTB hospital, there is no MRI at all. All the machines that are not working here are beyond repair.”

Agarwal believes that these structural deficiencies, coupled with too few doctors, has led to increased cases of violence against doctors. While Safdarjung and Maulana Azad do not officially record instances of violence, Agarwal said doctors bear the brunt of patient anger.

Last month, for instance, the father of a patient at Maulana Azad pulled out a gun while arguing with a doctor. The doctors subsequently met with the medical director of the hospital and asked, among other things, for an institutional enquiry into the incident and for CCTVs to be installed inside the hospital premises.

Mathur said, “We immediately created a ruckus and got the police involved. But this isn’t an isolated case. There are several instances where it is not an overt threat of violence, rather scenarios like these.”

Agarwal also called it “shameful” that basic amenities are lacking.

“Something as basic as the doctors’ duty room is so dirty and ill-maintained,” he said. “If the hospital is going to make us work 24 to 48 hours, the least we can expect is a decent room to rest. There is no storage or locker to keep our clothes. The beds in the male DDR, located in the emergency OT, are infested with bedbugs.”

There are also too few DDRs given the number of doctors who need to use it, he said.

Agarwal also said the hospital does not provide doctors with scrubs or slippers to use in the operating theatre; the doctors are expected to arrange these by themselves.

“Regarding the state of bathrooms, it’s so bad that female residents have to use the washroom in the library,” he said. “The washrooms meant for them in the ward are very unhygienic...General cleaning for all washrooms also does not happen every day. We are not asking for much: a commode that is functional, a washbasin that works, and water. Until recently, we did not even have a water dispenser for every ward.”

He added that when repairs to the washroom take place, they are of “such low quality” that they do not last.

The last issue raised to Newslaundry was that of salaries.

“For the quality and quantity of work that we do, we are underpaid,” Mathur said. “When compared to a private hospital, for instance Fortis, a senior resident in the ICU department will get paid Rs 2.5 lakh per month. At a government hospital, that kind of money will only be available at the director level – and that also has started only in the last three or four years. So, this gap needs to be bridged.”

He added that a private hospital resident will have a 50 percent exemption on his professional income, whereas a government employee will be taxed on the full salary.

“So, if I work hard for three months here, at a place where the patients are more and doctors are less, the private hospital resident will earn four times more than me in the same time period,” Mathur said. “Also, I have been working continuously since September as a senior resident and till now, I have received only one month's salary. We are in the process of speaking to the hospital administration to get it, but these delays also happen."

Research assistance by Saeeduzzaman.