Four months into the pandemic, government and hospitals continue to ignore nurses’ concerns

Gufrana Khatoon, a nurse at Delhi’s Hakeem Abdul Hameed Centenary Hospital, tested positive for the novel coronavirus on 3 July. Khatoon had been working at HAHC on a contract basis for three years. She told me that even though she was deployed at its ward for coronavirus patients, the hospital refused to pay for her test. When she was still recovering under home quarantine, on 11 July, the hospital’s administration terminated the services of 84 contractually-hired nurses, including her. The dismissal shocked the nurses, especially as it came nine days after the hospital administration had released an office order directing health workers to not resign. 

Nurses are feeling insecure and unsafe at their workplaces in several states, including Delhi, representatives from two nurses’ associations—United Nurses Association and Indian Professional Nurses Association—told me in July. The representatives said that hospitals are disregarding precautions that are necessary to protect nurses from the virus, arbitrarily terminating their contracts and imposing pay cuts. According to their accounts, hospitals are brazenly sidestepping guidelines issued by the World Health Organization and the central government by enforcing some of these actions. While the associations have raised these issues with chief ministers, central government authorities and even filed a petition in the Supreme Court, the situation on the ground remains bleak for India’s nursing staff. 

During the pandemic, the Narendra Modi-led government famously showed gratitude towards healthcare workers by encouraging the public to bang utensils, in one instance, and making helicopters shower petals on hospitals, in another. Many individuals criticised the moves as publicity stunts, had pointed out that improving facilities for healthcare workers would have been a better expression of gratitude. Now, almost six months after the virus entered India, issues that news reports had highlighted in March and April—such as hospitals neglecting the safety of health workers—appear to persist in many hospitals.

According to news reports, more than two thousand healthcare workers had tested positive for the novel coronavirus till June. The situation appears stark in Delhi, where 226 workers from 21 hospitals and clinics had reportedly tested positive till April end itself. In a case about health workers’ rights, on July 24, the Delhi High Court noted “the aggravated situation as narrated by the petitioner regarding approximately 20 deaths of the nurses and approximately 3,000 nurses having been infected.”

Nurses who worked in Delhi hospitals and representatives of nurses’ associations explained how hospitals, especially private ones, were ignoring guidelines issued by the WHO and the ministry of health. The WHO has emphasised the use of appropriate personal protective equipment and how using parts of the PPE kit more than once can be unsafe. On 8 April, the Supreme Court of India, too, directed state governments to ensure availability of appropriate PPE for all health workers, including nurses, who treat coronavirus patients. But in multiple instances, when the health workers urged hospitals to provide them with appropriate PPE, the administrations tried to strong-armed them into silence, nurses told me.

“Initially, they were not giving us PPE,” one of the 84 dismissed nurses at HAHC told me on the condition of anonymity. “I got seven normal masks till mid-July since the pandemic began.” In an earlier report published by The Caravan, a nurse at HAHC mentioned that the nursing staff even struggled to get access to clean drinking water on duty. 

HAHC’s nurses had raised these issues with the administration several times in June. They planned go on a strike from 15 July if their demands were not met. But on 11 July, the administration terminated the contracts of 84 nurses. The termination order said that the nurses’ contracts were due for extension between February and 10 July and that these cases could not be processed due to the pandemic. It also mentioned that the management would be conducting walk-in interviews to fill vacancies and the nurses could seek fresh appointments then. “If they didn’t want to renew contracts after February,” Khatoon asked, “why did they make us work for months after the contract period?”

While the order stated that cases for the extension could not be processed due to the pandemic, it added a vague insinuation against the nurses, too, according to Khatoon. The order said, “The cases with regard to regular attendance, absence from office due to sanctioned leave, and those who have been absent without intimation/approval were put up.” But Khatoon told me that the suggestion that the nurses had to be dismissed as they abdicated their responsibilities was unfounded. “I was never absent,” she said. “I had even walked ten kilometres to report for duty. A few nurses couldn’t go to work on some days because their buildings, streets were sealed and because of the lockdown they couldn’t go travel.” 

“How can they fire us after we caught COVID on duty?” Khatoon said. “Haven’t they heard of mental-health issues faced by health care workers during the pandemic?” With the termination order, HAHC disregarded an advisory issued by the ministry of labour and employment on 20 March, asking public and private establishments to not terminate contractually hired employees or deduct their wages on account of their absence. The advisory noted that such termination or reduction of wages “will not only weaken the financial condition of the employee but also hamper their morale to combat their fight with this epidemic.”

The former HAHC nurse who requested anonymity described the administration’s move as “a plan to get rid of people who raised their voice.” Even so, many of the terminated staff had applied for new contract positions at the hospital out of desperation for a livelihood, the nurse who requested anonymity said. I received a list of 30 nurses who were subsequently hired, which included Khatoon’s name. Her lawyer, Subhash Chandran, spoke to me about this. “Yes, the list shows that. But she didn’t appear for the interview,” he said. Khatoon had moved the Delhi High Court to challenge the dismissal on 23 July. According to him, HAHC included her name in the list after she approached the court. He added that the terms and conditions for the fresh appointment are unacceptable for Khatoon. 

In a video uploaded on the HAHC’s website, Sunil Kohli, its officiating medical superintendent, said that the allegations levelled against the hospital are “completely false.” Kohli told me in an email that it would be “inappropriate to comment on the matter” as it now sub judice. He claimed that the hospital was “transparent and humane organisation and our stance had been open and consistent.” He also attached a letter from the hospital to the chief minister denying any wrongdoing from the administration’s end. 

According to WHO guidelines, health workers should only wear PPE for longer periods than normal as a “last resort,” if they were facing serious shortages or non-availability of protective gear. Kannan Raman—the sub-regional secretary for South Asia of a global trade-union federation, Public Services International’s—told me that at times, wearing PPE for two–three hours could also be suffocating. He said that countries such as South Korea have policies that limit wearing PPE for a maximum of four hours.

But a nurse at another private hospital in Delhi, Primus Super Speciality Hospital—also a COVID hospital—complained that she had to wear PPE for 12 hours in the COVID-19 ward. A nurse who used to work at the hospital, and later resigned, told me the nurses were on 12-hour-long shifts daily for 15 consecutive days at a time. “We were given only one PPE” per day “and we have to wear it again after having food or using the washroom,” she said. “One mask was given for four–five days.” 

“We can’t imagine them working for 12 hours,” Raman, from PSI, said. On top of that, he added, “substandard PPEs used in many private hospitals makes it even worse.” According to a report in the Indian Express, dated 21 July, while India has emerged as the second-largest manufacturer of PPE kits, “in the rush to boost production, quality norms were left behind, with these kits being dubbed as ‘sweat chambers’ by medical professionals and ‘unfit’ for domestic use or export by several stakeholders.”

The nurse from Primus further said that the hospital was disbursing salaries to several nurses late and their pay had been arbitrarily cut. On 18 July, the New Indian Express quoted an anonymous nurse from the hospital who said that the range of the pay cut lay between 10–30 percent. 

Nurses at Primus began protesting in June citing untenable working conditions. After the protests, the management agreed to increase their salary by 25 percent, but the nurse said they did not clarify whether this hike was on their basic or total salary. After witnessing the hospital’s attitude through their ordeal, according to the nurse, several protesters wanted to quit their jobs. “The management was not ready to solve the issues,” she said. “It was a lot of mental pressure. When we thought it was all going beyond the limit, we resigned.” Eleven nurses, including her, quit their jobs. She told me many of them were nurses in-charge of various departments. 

PPE is only one of the transmission-based precautions required to protect healthcare workers and prevent transmission of the virus in the healthcare facilities, according to the WHO. In the absence of effective administrative and engineering controls, PPE has limited benefits. These controls include “ensuring resources for infection prevention and control (IPC) measures such as appropriate infrastructure, the development of clear IPC policies, facilitated access to laboratory testing, appropriate triage and placement of patients.” The All India Institute Of Medical Sciences, Delhi, has also uploaded a video speaking of a designated area to don and doff PPE. 

Rince Joseph, the president of the United Nurses Association, said that there are infrastructural issues in several hospitals across the country. The UNA is a pan-India umbrella network of nurses’ unions with a membership of 3.8 lakh. It has been raising issues that nurses are facing during the pandemic, evening by filing an intervention petition to the Supreme Court in a case regarding the proper treatment of COVID-19 patients. “The doffing and donning facilities are ridiculous and there are no separate washrooms for nurses,” Joseph said. The nurses’ union at AIIMS, Delhi, also raised this issue in June, when it went on a nine-day-long strike. Among other things, the union reportedly demanded the hospital to establish proper donning and doffing area, along with a uniform four-hour-long duty with PPE in COVID areas. They resumed work after the management agreed to most of their demands.

The WHO has made several recommendations to ensure that nurses are not robbed of their rights while on pandemic duty. Its guidelines clearly state that the novel coronavirus should be classified as an occupational disease when health workers contract it in the course of their work. Nurses are therefore entitled to compensation, rehabilitation and curative services. But these guidelines are not being followed, according to the nurses I spoke to. 

Khatoon told me that HAHC did not pay for her COVID-19 test. “I got tested on my own and did not get any help from anybody,” she said. “Today, I am surviving only because my family took care of me.” Along with her, another nurse who had contracted the virus was among the 84 who were dismissed from their jobs. The capital is also not regularly monitoring and testing healthcare workers for the virus, Joldin Francis, the secretary of the UNA’s Delhi unit, alleged.

The current testing protocol allows testing only for symptomatic healthcare workers—not different from the guidelines issued in April. Three health and civil-rights groups published a position paper on 21 April, titled “Health workers’ rights in the time of COVID-19,” emphasising the pitfalls of such restrictive testing. “As current testing protocols are restrictive, health workers might find that they are compelled to go for testing in private labs, and incur costs,” the organisations—Jan Swasthya Abhiyan, All India People’s Science Network and Public Services International India National Coordination Committee—wrote. Moreover, the paper noted that many private hospitals across the country pay nurses below the legal benchmark for skilled workers. It also recommended that access to testing and treatment needs to be ensured; workers should be allowed to opt out of performing their work in conditions that put them at risk, without risk of losing their jobs; health workers should be covered for COVID-19-related sick leave, quarantine and provided compensation. 

But Joseph told me that several hospitals still do not provide health workers with quarantine facilities. “Any staff working in the hospital could be carriers,” he said. “Nurses spend almost 24x7 with the patient. When they are going home, they put their families at risk.” According to Joseph, bigger hospitals that have quarantine facilities are encouraging nurses to self-quarantine at home so that they can save money on renting accommodation. Siju Thomas—the joint secretary of Indian Professional Nurses Association, an association for registered nurses which operates in several states—also gave a similar comment. “None of the hospitals in Delhi are properly giving quarantine facility to those working in non-COVID facilities even if they have been exposed to the virus,” he said.

Nurses deployed in non-COVID wards in Delhi may be susceptible to contracting the virus, but get access to quarantine facilities even more rarely, Thomas told me. “Those who work in COVID-units are given seven-day duty and seven-day quarantine. But, the staff in gynaecology and emergency wards cannot wait for COVID reports to start treatment.” Representatives from both IPNA and UNA added that staff in these wards do not get the appropriate PPE. Even if they are exposed to the virus, Thomas said, they are not given these facilities unless they have symptoms.

On 17 June, the Supreme Court had passed an order in the case of Aarushi Jain vs Union of India, directing the health ministry to issue necessary orders to provide quarantine facilities to health workers. The order mentioned that Tushar Mehta—the solicitor general, representing the central government—had informed the court that people directly in contact with COVID patients are not denied quarantine facilities. He submitted that since doctors and health workers are required on the frontlines, “quarantine period should be initially for one week only and thereafter taking the profile of the health worker a decision to be taken for further period of one week.” Within two days, the central government revised the quarantine period for health workers with high-risk exposure to the virus from 14 days to one week, which may be extended if needed. 

Another Supreme Court order, in the case titled Jerryl Banait vs Union of India, mentioned that Mehta had submitted before the court that appropriate instructions would be issued by the Directorate General of Health Services to the private hospitals to not to deduct any salary from healthcare workers. Accordingly, on 18 June, Preeti Sudan, the health secretary, issued an order stating that salary deductions of healthcare workers engaged in COVID duties would violate the Disaster Management Act and the Indian Penal Code. “Action will be taken against the defaulting hospitals and institutions and authorities,” she wrote. Shubash Chandran, an advocate who represents UNA, told me that the order would be applicable for all private institutions and contract staff. 

Despite this, many hospitals are deducting salaries and delaying payments, representatives of nurses’ associations and news reports alleged. “Some of the smaller hospitals are paying only 15 days salary and asking the nursing staff to go on 15-days-mandatory leave,” Joseph said. Moreover, many hospitals are considering the quarantine period as absence from duty or forcing the staff to go on casual or earned leave and cutting their salaries, according to Jibin TC, president of UNA’s Maharashtra unit.  

Nurses at RG Stone Urology and Laparoscopy Hospital, a non-COVID private hospital in Delhi’s East of Kailash area, shed some light on the apprehensions that come with facing a pay cut during the pandemic. The nurses told me on the condition of anonymity that in April and May, salaries of around thirty nursing staffers were cut by 50—60 percent. One of them said that when the lockdown to contain the coronavirus began in March, the administration asked the nurses to not report for work for every day. “We were asked to go after one to four days gap and work for 12 hours a day,” the first nurse said. “They gave no indication that there was going to be a pay cut. If they informed us earlier at least we could have been prepared. We all feel betrayed.” He added, on 28 July, that a group of the staff were yet to receive the salaries for the month of June. The nursing staff wrote a letter to the district labour office about this too. 

The second nurse from the RG Stone Urology and Laparoscopy Hospital told me that nurses at private hospitals are scared of speaking up as it would be extremely difficult to find another job at this time. Thomas told me that the nurses received about Rs 10,000–Rs 25,000 per month. “Half of that would be hardly enough for nurses to survive in Delhi,” he said, “considering the fact that most of them are migrant workers from other states.”

Issues of job security and salaries are not just confined to private hospitals; several government-run hospitals in Delhi have also seen protests by nurses raising similar difficulties, according to representatives of nurses’ associations. On 15 July, the Delhi government-run Janakpuri Super Speciality Hospital terminated forty-two nursing staff as Avani Paridhi—a human-resource management agency—that they had been hired through had been blacklisted by the government. Five days later, forty nurses held protests in front of the hospital, demanding their jobs back. The staff at the North Delhi Municipality Corporation-run Kasturba hospital also went on strike for a few days in early July. They reportedly complained of non-payment of salaries for three months. 

Even so, several people told me that private hospitals were more inconsiderate of their staff. According to Joseph, nurses face more obstacles in private hospitals as their focus is on generating revenue. Joseph and Thomas told me that in private hospitals across several states—including Maharashtra, West Bengal and even Kerala, which is usually praised for its healthcare model—nurses are working for the whole month and being paid salary for just about 15 days in some cases. Some are imposing pay cuts citing a drop in the number of patients, according to Joseph. “They are saying that because the footfall is less, revenue has declined,” he said. “They are charging huge amounts from patients, but are not paying for the nurses who take care of those patients.”  

According to the representatives, hospital administrations were pushing nurses to do twice the amount of work, at the cost of their safety, effectively saying they did not have workers’ rights. “This is totally unacceptable,” Francis told me. “They are exploiting the nurses. When some guidelines are issued by the government in favour of management, they are using that to exploit the nurses. If there are any orders in favour of nurses, they are not implementing it.” Francis suggested that hospital administrations often tried to invoke the nurses’ moral duties to deter them from complaining about abysmal working conditions. He told me that the administrations cite lack of staff during the pandemic as a reason and tell the nurses “to be with them during such a crucial time.” 

When this does not work, the representatives said, hospitals often threaten them with legal consequences. In Maharashtra, the Maharashtra State Essential Services Maintenance Act, 2017 is being misused to force the nurses to keep going to work without providing them with appropriate safeguards, according to Jibin. Francis said that private hospitals in the capital are stopping nurses from taking leaves. He added that the administrations threaten nurses with “job loss and FIRs.” According to Amarjeet Kaur, the general secretary of the All India Trade Union Congress—affiliated to the Communist Party of India—hospitals are misusing the Disaster Management Act to force the nurses to work for “up to 20 hours.”

These concerns did not seem unfounded. In HAHC’s 2 July order—released nine days before firing 84 nurses—it directed nurses to “refrain from sending applications for resignation/resignation notices or requesting leave without pay, citing personal reasons.” It cited the pandemic and HAHC being declared a COVID hospital under the Disaster Management Act as the reason. In mid-June, Primus had lodged a complaint with the district authorities and the police against its nurses, accusing them of “abandoning patients.” 

According to Jibin, administrations of private hospitals falsely portray that the nurses are not committed to their jobs and are abdicating their responsibility in fear of contracting the novel coronavirus. But that is not true, he said. “The attrition rate among nurses were always high and this has come down now,” he told me. “The salary offered is low and when people are risking lives, they need the basic assurance that ‘when, if we get in trouble, somebody would take care of us’—that security is lacking.” 

Jibin said court orders have made little impact, at least in Maharashtra. “I don’t see any changes in the situation in Maharashtra,” he said. “The burden is increasing day by day, stretching working hours beyond 12-13 hours with PPE, while facilities for stay, transportation and food remain so pathetic.” Perhaps the only silver lining that emerged in recent months was a central government decision to extend its insurance scheme, worth Rs 50 lakh, to healthcare workers treating COVID-19 patients in private hospitals too.  

On 15 April, the Supreme Court directed the central government to set up helplines which would address concerns of nurses. In its order, it mentioned that Mehta had said in court that these helplines were already set up and calling on them would resolve all issues in two hours. 

But representatives of nurses’ association told me these helplines were of no use. Francis, the secretary of UNA’s Delhi chapter, said that if nurses dial the number they do not get any proper directions. “They had said that the issues would be resolved. But the issues are increasing day by day,” she said. Thomas told me that the numbers are not functioning properly in several states. Even when they are operational, he said, they do not give useful directions to the health workers. “All they say is to contact the nodal officer in the area from where we are calling and in rare cases they pass on that number,” he said. “It is not useful, and we are not calling that number anymore.” 

In June, the Distress Management Collective filed a petition before the Delhi High Court highlighting that private hospitals were disregarding safety protocols for healthcare workers. The petitioner drew attention to the case of a young nurse who attempted to kill herself in a leading private hospital in Delhi-NCR, Gurgaon, after she tested positive for the virus. The incident emphasised the need for a counselling helpline for all the nurses, including those working in private hospitals. On 24 July, the Delhi High Court asked the central government to consider a special dedicated helpline for nurses and other healthcare workers as it  

The WHO guidelines state that health workers should “not be required to return to a work situation where there is a continuing or serious danger to life or health, until the employer has taken any necessary remedial actions.” On 23 June, the UNA and Public Services International shot letters, with the same content, to the National Human Rights Commission of India and the National Commission for Women, explaining the dangers to nurses’ health during the pandemic. “It is regrettable that a number of nurses feel that the situation is so grave, and their health and safety so perilous, that they have no option but to resign from their position,” the letters said. 

I emailed the union ministry of health, the departments of health of Delhi and Maharashtra for comments, as well as the administrations of Janakpuri Super Speciality Hospital, RG Stone and Primus hospitals. They had not responded at the time of publication. This story will be updated as and when they reply.

Raman told me that increasing the public-expenditure budget is crucial in addressing the issues faced by health care workers. India spent only 1.28 percent of GDP on healthcare in the year 2017–18. The position paper dated 21 April—released by health and civil-rights organisation—mentioned that underfunding of the public-healthcare system has exacerbated the crises brought by the pandemic. 

“I feel that the nurses are not safe anywhere in India,” the nurse who resigned from Primus told me. “How many times will we go to the chief ministers and other authorities to raise our issues? Still, they remain unresolved.” She said that the nursing staff are willing to offer all help during such a health crisis. “But the government and private managements should provide at least the minimum support we need to do our duty.”