India’s under-supported force of healthcare professionals is crumbling under the pressure of COVID-19

A doctor examining a suspected coronavirus patient in the isolation ward at Patna Medical College and Hospital, on 14 March, without protective gear. As they prepare to confront a wave of COVID-19 cases within an already under-funded public health infrastructure, healthcare workers in various parts of India have raised concerns about the shortage of supplies such as masks, coveralls, gloves, among others, that will protect them from contracting the novel coronavirus. Santosh Kumar/Hindustan Times/Getty Images
29 March, 2020

On 27 March, the Mahatma Gandhi Institute of Medical Sciences in Sewagram, in rural Maharashtra, was notified that it would be the nodal centre for the treatment of COVID-19 in the region. As the announcement circulated among the staff, it brought with it a wave of shock. The hospital was unprepared. It had only two ICU beds and was running out of personal protective equipment, or PPE, with only a small stock that they had bought at an inflated price. 

A female resident doctor, speaking on condition of anonymity for fear of losing her job, said that she was terrified—she and her husband worked at the hospital, and had a newborn baby at home. Only one of them should risk infection, they decided. Her husband would work on the frontlines, while she stayed home and supported the hospital’s administrative work remotely. She fears that she will not see her husband again. “We are all very scared. I don’t speak just for myself,” she said. “All the resident doctors had similar conversations the minute the notification came in.”

Meanwhile, at the Jhansi Medical College in Uttar Pradesh, the nursing staff has not received their salary for seven months. On 25 March, faced with the looming threat of the COVID-19 pandemic, they boycotted work for the day. In an interview to the media, one nurse said that she met a member of the administration who asked them to “cooperate.” She said she told the administration, “We have been cooperating for seven months now. Corona has just appeared on the scene, a month, or a month and a half ago. It hasn’t been around for seven months, right? Then why are you not paying the salaries? Give it to us after two months, but at least give it.”

“They tell me the budget hasn’t been allocated,” the nurse continued. “Then I said you should let us move forward. But they had already made us sign stamp papers saying that we cannot go on strike, or work anywhere else. If we violate the agreement, we will be expelled from our jobs.” Doctors at the isolation ward at the Jhansi Medical College had not yet been given PPE kits, the nurse said, and hand sanitiser was not being provided either. The staff had been purchasing sanitiser privately, and now it was no longer available in the market.

These grim vignettes are a harbinger of what is to come, as India’s chronically under-resourced healthcare system prepares to confront a wave of COVID-19 cases. India has less than one allopathic doctor per thousand people—the minimum recommended by the World Health Organisation—and only 1.7 nurses per thousand people, again well short of the WHO-recommended three-per-thousand. As of 2016, the Indian Medical Association registered a shortage of tens of thousands of critical-care specialists. The dominant share of India’s doctors and beds are in the private healthcare sector, which has enormous leeway to self-regulate, at the cost of patients and the public. 

In countries that have been severely affected by COVID-19, such as Italy, Spain and the United States, strained healthcare systems have reached their breaking points. Shortages of masks and other forms of PPE have become widespread, putting medical professionals at severe risk. At Mount Sinai Hospital, in New York City, the epicentre of the outbreak in the United States, some nurses resorted to using black plastic trash-bags as PPE, according to a photo posted on social media. On 24 March, Kious Kelly, a 48-year-old nurse manager at Mount Sinai, died after contracting COVID-19. 

A scarcity of medical workers has also plagued countries that are struggling with the COVID-19 pandemic. The government of the United Kingdom asked 65,000 retired nurses and doctors to return to work, along with final-year medical students. “We can’t do it alone, so I am urging all recent former nurses to lend us your expertise and experience during this pandemic, because I have no doubt that you can help to save lives,” Ruth May, chief nursing officer for England, said in a statement to the media. 

The shortage of medical professionals in India is even more dire, and the few that are available are being called on to ration crucial supplies. “A humble request to all health care professionals of the country. It is extremely important that we protect ourselves with appropriate PPE and at the same time be aware of supply constraints which plague even developed countries like the USA, UK, Italy, etc. While the government ramps up to meet the supply demands, workforce optimisation by dividing the number of health care workers on duty, rationing supplies and doing teleconsultation, when possible, is the way forward,” Dr Srinivas Rajkumar T, the general secretary at the All India Institute of Medical Sciences, India’s leading government hospital, in Delhi, told The Caravan. “We understand that the times are rough and there are severe shortages, and the reinforcements are coming. But up until they come, the doctors have to stay put and work,” he said.

Some medical professionals are objecting to such demands, speaking out against the lack of support and equipment. As The Caravan previously reported, at the King George’s Medical University in Lucknow, Uttar Pradesh, the resident doctor’s association wrote a letter to the university’s administration on 23 March, imploring them to provide adequate PPE. The doctors at the hospital said that they were treating approximately 200 to 300 patients a day, without protective kits. “We residents are scared in such working conditions, causing emotional and psychological stress,” the association wrote. The fears were not unfounded: a doctor at KGMU recently tested positive for the novel coronavirus, and is now under treatment.

But the staff’s objections have not been well received. On 28 March, Rudrarpan Chatterjee, a fellow in clinical immunology and rheumatology at the Sanjay Gandhi Postgraduate Institute of Medical Sciences in Lucknow, shared a letter from the vice chancellor of KGMU on Twitter. The letter asked the staff to give up a day’s salary to fund the supply of PPE. “There is an urgent need for three layered surgical face masks for the protection of the workers who are treating patients afflicted with the corona virus,” the letter said. “In these circumstances, it appears appropriate that we propose that one day’s salary be cut for the entire regulated-division staff, resident doctors, paramedical and nursing staff, third and fourth division worker towards the treatment of the coronavirus epidemic.” Chatterjee subsequently shared another letter showing that this order had been rescinded. But it remains indicative of the desperate situation that many medical workers may soon find themselves in, and the exploitative demands that they will face.

The Caravan has also reported that in Punjab, healthcare workers were using diluted sanitisers and cloth masks, even as the state’s health minister insisted that it was well-prepared for the pandemic. Doctors also noted that the state was testing far fewer people than needed, and that they were forced to treat patients without knowing whether they had COVID-19. A similar situation persists in Bihar, where 83 junior doctors have developed symptoms of COVID-19, but are forced to continue treating patients.

Medical professionals in India are also facing another insidious threat, in addition to viral infection: stigma. Across the country, medical professionals have reported ostracisation by the public, who fear that they could serve as vectors for the novel coronavirus. “They recognise us with our lab coats and stethoscopes,” a junior doctor at Hyderabad’s MGM Hospital told The New Indian Express, on condition of anonymity. “Many doctors have been asked to vacate their rented homes by their landlords as they believe that doctors staying at their houses may make them more susceptible to Covid-19.” 

On 24 March, the leadership of the resident doctor’s association at AIIMS Delhi released a letter to the union home minister, Amit Shah, requesting that the government take action against the eviction of healthcare professionals from their homes during the COVID-19 crisis, and to provide transport for them during the nationwide lockdown. “Many doctors are now stranded on the roads with all their luggage, nowhere to go, across the country. We condemn such attitude and hereby, request you to release an order, as soon as possible, prohibiting the landlords/owners to evict the tirelessly working Doctors and other Healthcare Professionals from their rented houses. This would ensure our selfless services to our country in crucial time of COVID-19 pandemic,” the letter stated.

The letter also requested the home minister to arrange proper transport for healthcare workers across the country and to “direct the Police and involved Security Administration to allow them to travel hassle free to their workplace.” The home minister reportedly fulfilled this request, and directed the Delhi Police to ensure security for doctors. Some doctors have faced threats and harassment as they attempted to travel to work under the nationwide lockdown: in an incident that was caught on video, an anonymous female doctor in Telangana was abused, assaulted, and hauled to a police station while attempting to answer a last-minute call from the hospital for a shift. 

Now, with healthcare workers staring down a rapidly approaching crisis, the longstanding failures of India’s under-supported healthcare system have been thrust into the spotlight. Without a surge of government funding and attention, medical professionals have little reason to believe that they will be protected or supported as they serve on the frontlines of India’s response to the pandemic. The already-strained workforce is at risk of collapsing under pressure. The consequences of this would be disastrous.