Letter from Nepal

Violence Against Doctors: A Threat to the Nepalese Community

Nepal is facing a period of sociopolitical instability after a decade of political insurgency. Its consequences are visible even in the healthcare sector. In particular, workplace violence in healthcare institutions or involving healthcare professionals has risen sharply in the past decade.^[1] The United States Department of Labour has defined workplace violence as an act or threat ofphysical violence, intimidation, harassment or any disruptive behaviour that occurs at the workplace.^[2] This type of violence includes verbal abuse, physical assault, homicide or any aggressive act at the workplace which may have a negative impact on employees’ personal and professional life.

Workplace violence against doctors has ranged from bullying, verbal abuse to physical assaults.^[1] Many instances of severe physical assaults on doctors have been reported from Nepal.^{[3],[4],[5],[6]} News of doctors being beaten, threatened, physically challenged, kidnapped and humiliated frequently comes to notice.^[4] These criminal acts are conveyed to the Nepal Medical Association (NMA) and appear on the front pages of national newspapers.^[5]·^[6] At the time of writing this article, we hear of violence against doctors from the eastern part of Nepal. A junior resident was beaten and verbally abused by the patient’s kin while he was trying to explain the poor prognosis of a patient admitted to the intensive care unit (ICU).^[7] The son of the patient complained that his father had died due to medical negligence. While the claim of medical negligence was not proven, the case was settled after the hospital agreed to waive off the expenses and provide funds for transport of the body to the deceased’s house. It is likely that some of these instances of violence may have occurred to get a waiver for the medical expenses or to obtain some form of compensation.

Some time ago, another incident concerning the Medical Superintendent (MS) of a district hospital hit the headlines on social media. A group of women smeared black soot on the face of the MS while he was on duty. The women justified their actions by stating that the MS denied an ambulance for a pregnant woman.^[5] Such assaults and harassments are not limited to doctors working in peripheral areas in Nepal. Senior specialists at tertiary care centres in maj or cities too have faced similar problems. A 40- year-old woman got admitted to a tertiary centre for surgery of the deviated nasal septum (DNS). According to the patient’s husband, she had a DNS from birth and when she came for a routine nasal check-up, doctors suggested a minor nasal surgery. However, after surgery, she had persistent vomiting and continuous nasal bleeding. Although the attending surgeons were not at fault, the patient’s relatives insisted that the death was a result of medical negligence.^[8] The hospital administration urged the deceased’s relatives to initiate a legal process. While deaths after septoplasty are extremely rare, there are reports of mortality during nasal surgery without any negligence on the part of the doctor concerned.^[9]

Although violence against doctors has been reported throughout Southeast Asia, the situation in Nepal has become alarming.^[210] In a report titled ‘Impunity in Nepal’, the Asia Foundation records that ‘When patients at hospitals died owing to the alleged negligence of doctors or hospitals, family members and onlookers stormed hospitals and attacked medics rather than let the law take its course’.^[10] According to a survey in 2013 among 747 health workers, 23% felt insecure due to the threat of violence at the workplace.^[11] In 2014, the Health Science Journal reported that violence against healthcare workers was the leading cause of Nepalese doctors and nurses moving abroad.^[12] In Nepal, the doctor-to-people ratio is 2 per 1000, which is lower than that in high-income countries (27 in the USA, 21 in the UK, 37 in France and 21 in Japan). Nepal is far behind even other low- and middle- income countries (17 in Brazil, 29 in Mexico, 6 in India, 4 in Nigeria and 5 in Iraq).^[13] Due to their very small number, Nepalese doctors see a large number of patients every day in the outpatient clinics, in addition to attending to emergency calls and regular inpatient rounds in public hospitals. Doctors in Nepal are paid meagre amounts and hence most of them practise at multiple centres.

Medical associations around the globe play an important role in protecting rights of doctors. The members of the NMA are participating actively these days to create a better working environment for doctors in Nepal. In September 2017, doctors and paramedics across Nepal protested against a cabinet decision to introduce a law that requires the attending doctor to pay compensation if the patient had any injury or death due to medical negligence. The NMA is appealing to the government to repeal the law on ‘jail without bail’ so that doctors can serve their patients without fear.^[14]

South Asian countries share a similar educational system, economic challenges and political instability. We hope our article will increase awareness in the international health community about the physical assaults on healthcare providers in Nepal. The collective data on violence against healthcare providers may help doctors to engage government and policy-makers in low- and middle-income countries such as Nepal to facilitate and implement proper laws to stop these barbaric acts.