The wages of fear

The casualty department of an Indian government hospital after dark is one of the more revealing places in the republic. Under failing tube-lights, a single resident—often a woman, often in her twenties, often awake for the better part of two days—stands between a swelling crowd and the dead or dying. When the worst happens, as in medicine it sometimes must, the grief in that corridor can turn in an instant into something with fists. The doctor who an hour earlier was the family’s only hope becomes its chosen culprit. Furniture is broken; so, with depressing regularity, are bones.

This is not a rare scene. Survey after survey arrives at roughly the same grim figure: about three in four Indian doctors say they have faced violence at work during their careers. A study of resident doctors across six departments of a tertiary hospital in Delhi found that four in five had been verbally abused and more than one in five physically attacked. The aggressors are seldom strangers and seldom, in the technical sense, criminals: in most studies the commonest perpetrators are the patient’s own relatives, followed by the organised mob that materialises with alarming speed outside Indian emergency rooms. The violence clusters, tellingly, where the stakes and the uncertainty are highest—obstetrics, surgery, intensive care, the casualty ward at 3am.

The country has lately been forced to look at this directly. In August 2024 a postgraduate trainee was raped and murdered on duty at the R.G. Kar Medical College in Kolkata, her body found in a seminar room she had used to rest. The horror produced nationwide strikes, a suo-motu intervention by the Supreme Court and a National Task Force on the safety of medical professionals. Months later, in another city, a relative walked into a Chennai hospital and stabbed an oncologist, apparently holding the doctor responsible for the side-effects of his mother’s chemotherapy. The first case was a crime against a woman; the second, a crime against the idea of medicine itself. Both belong to the same epidemic.

The wrong victim

The instinct, understandable enough, is to frame all this as a workplace-safety problem—a matter of the doctors’ welfare, to be settled with more guards, more cameras and the occasional stern editorial. That framing is too small, and it flatters the assailants by accepting their premise: that the quarrel is between an aggrieved family and an individual in a white coat. It is not. The deepest casualty of violence against doctors is not the doctor who is hit. It is the patient, as yet unknown and unborn into the system, who will one day need a desperate intervention and will not receive it—because the doctor capable of providing it has quietly learned that desperate interventions are how careers, and skulls, get broken.

Economists and clinicians have a name for this learned caution: defensive medicine. It comes in two varieties. The first, “assurance” behaviour, is the ordering of needless scans, tests and referrals to paper a file against future blame. It is wasteful and it empties the pockets of the poor, but it rarely kills. The second variety is the dangerous one. “Avoidance” behaviour is the practice of declining the risky patient and the risky procedure altogether—of finding a reason to refer the bleeding mother elsewhere, to delay the operation that might not work, to send the gravely ill towards some other doctor’s door and some other doctor’s corridor of furious relatives.

Here the logic is brutally simple, and it is the heart of the matter. A surgeon who operates on a patient with a 30% chance of survival, and loses, has done nothing wrong and may still be assaulted that night. The same surgeon who declines the case, and lets the patient die in transit, faces no mob at all—the death is diffuse, unattributable, somebody else’s statistic. Violence, in other words, rewards abandonment and punishes courage. It places a private tax on exactly the behaviour a functioning health system most needs: the willingness to take on the cases most likely to end badly. A doctor responding rationally to that incentive will, over a career, treat fewer of the sickest people. Multiply that by a million practitioners and the result is not an inconvenience. It is a body count.

What the numbers whisper

Direct measurement of avoidance is hard, for the obvious reason that no doctor records “patient I chose not to save” in the ledger. But the surrounding evidence is consistent and pointed. When Egyptian researchers studied physicians exposed to malpractice claims and physical violence, they found both were statistically linked to defensive practice—and that the avoidance was specific and severe: the great majority of doctors admitted to steering clear of high-risk procedures, and a similar share to avoiding high-risk patients outright. There is no reason to think Indian physiology of fear is different. Indeed, when medical students in Kerala were asked, nearly nine in ten predicted that rising violence would push the profession towards defensive medicine. They are not guessing about a foreign country; they are forecasting their own working lives.

The Indian studies that do exist gesture in the same direction. After a violent episode, a majority of the Delhi residents surveyed wanted to change their workplace or their pattern of work; most reported damage to their mental well-being; a significant share said they had begun to reconsider the profession altogether. People who are frightened, demoralised and looking for the exit do not run towards the hardest cases. They edge away from them. The edging away is invisible, deniable and lethal.

A system that cannot afford the loss

In a country with doctors to spare, this would be a manageable disease. India has the opposite. The government likes to cite a doctor-to-population ratio of around 1:811, comfortably inside the World Health Organisation’s old benchmark of 1:1,000. The figure is an accounting fiction. It counts every doctor ever registered, including the retired, the emigrated and the dead, and it leans on hundreds of thousands of AYUSH practitioners to flatter the total. Strip the register down to doctors actually practising modern medicine, and the real density is far thinner—and grotesquely lopsided. Urban India is reasonably served; rural India, where most Indians live, makes do with something closer to one doctor per 10,000 people. Roughly seven in ten specialist posts at the community health centres meant to serve villages sit vacant.

Onto this shortage, two pumps work to drain the pool further. One is emigration: India is among the world’s largest exporters of physicians, with tens of thousands working in Britain, America, Canada and Australia, and thousands more leaving every year for better pay, saner hours and the quaint privilege of not being beaten at work. The other is attrition of the spirit—the talented young resident who, after one bad night in the casualty ward, decides that radiology, or dermatology, or a clinic in the Gulf, looks a great deal more survivable than emergency surgery in a district hospital. Violence is an accelerant on both. A country that assaults its healers is, in effect, subsidising the recruitment drives of the NHS.

The clearest signal of where the profession is heading can be read off the postgraduate entrance exam. Year after year, the highest cut-offs in NEET PG—the scores that only the very top rankers can reach—belong to dermatology and radiology. These are not the specialties that save the most lives or fill the emptiest posts; they are the ones furthest from the emergency corridor. The reasons candidates and counsellors give are stated without embarrassment: lifestyle, predictable hours, handsome private earnings and, implicit in all of it, a working day with no grieving mob at the door. The frontline disciplines where violence actually concentrates—emergency medicine, general surgery, obstetrics, anaesthesia—command markedly lower scores and, increasingly, the leftover candidates. India’s brightest young doctors are not merely fleeing the country. Before they ever pick up a scalpel, they are quietly pricing in the risk of assault and choosing, rationally, to specialise in the parts of medicine where almost no one dies in front of them. The flinch now begins at the moment of career choice. A nation that lets dermatology outrank trauma surgery in the ambitions of its finest minds has already begun to ration courage at source.

And the burden of all this falls, as such burdens always do, on those least able to bear it. The rich retreat to private hospitals with security details and air-conditioned waiting rooms, where the social contract between doctor and patient still more or less holds. It is the poor who depend on the overcrowded, understaffed government hospital—the very place where violence is concentrated, and therefore the very place where defensive avoidance will bite hardest. The patient most likely to be turned away from the difficult operation is precisely the patient with nowhere else to go. Violence against doctors is, among its other distinctions, a regressive tax on the dying.

The grievance is real; the remedy is wrong

None of this is to canonise the profession. The fury in those corridors does not come from nowhere. India’s public hospitals are often squalid, opaque and exhausting; bills in private ones can bankrupt a family in an afternoon; communication is frequently terrible, and a frightened relative who is told nothing for six hours is a relative primed to believe the worst. Negligence and profiteering exist, and the doctors who practise them coarsen the trust on which everyone else depends; they should be pursued, hard, through the courts and the medical councils. A grieving family’s rage is human and, in its origins, often justified.

But the justification of the anger is not a justification of the violence, and confusing the two is how a society talks itself into tolerating the intolerable. The remedy for a bad outcome is investigation, compensation and reform. It is never the assault of the person who stayed up all night trying to prevent the outcome. A nation that lets that distinction blur will find, soon enough, that it has fewer and fewer people willing to stay up all night.

Beyond the toothless statute

India’s official response has so far been long on gesture and short on deterrence. Some two dozen states have passed laws specifically protecting healthcare workers. The National Task Force convened after the Kolkata murder concluded that no separate central law was needed, since serious offences are already covered by the Bharatiya Nyaya Sanhita, the country’s new criminal code. On paper, the doctor is protected. In the corridor, at 3am, the law might as well not exist. The state statutes are barely invoked; convictions are vanishingly rare; the mob has correctly calculated that the cost of breaking a doctor is, in practice, close to zero. A right that is never enforced is not a right. It is a press release.

Fixing this does not, for once, require a grand new architecture. It requires that the existing one be made to bite. Assault on on-duty medical staff should be registered swiftly and prosecuted visibly, with a handful of real convictions to puncture the assumption of impunity. Hospitals must be built and staffed so that they are less combustible to begin with—triage that works, a designated officer whose job is to talk to families, security that protects rather than decorates. And the deeper grievance must be addressed at its root: the under-funding that keeps Indian public health spending near a miserly 1% of GDP, and that guarantees the overcrowding, the waiting and the despair out of which violence grows.

The argument for all this is usually made in the language of justice for doctors, and that argument is sound. But it is also the weaker case, and the one the mob can most easily dismiss. The stronger case is colder and harder to wave away. Every doctor who is beaten teaches a hundred others to flinch; every flinch removes a fraction of courage from the system; and that courage, aggregated across a vast and under-doctored country, is the thin margin that separates a difficult case that lives from one that dies. India does not protect its doctors as a favour to the medical profession. It protects them as the cheapest available life-insurance policy for everyone else. To break a doctor is, in the end, to vandalise the hospital one’s own family will be carried into next.