Dr Sajan Thomas
“Hospital attacks” refer to situations in which an angry crowd attacks hospitals/clinics, destroying the infrastructure and injuring doctors and other medical personnel. Both government-run and privately managed hospitals are vulnerable to these attacks. In most instances, neighbours, friends, and/or relatives of a patient storm into the hospital alleging serious negligence. Attacks occur in response to a wide array of situations ranging from a patient’s death to dissatisfaction with the treatment.
It is noteworthy that hospitals starting from the village-level primary healthcare clinics to the super speciality hospitals in the cities have come under such attacks, sometimes several times. Under pressure from doctors’ unions and hospital management associations, the state government framed The Kerala Health Service Persons and Healthcare Services Institutions (Prevention of Violence and Damage to Property) Act 2012, which made an offence committed under it “cognizable and non-bailable.” The act also contains clauses for initiating criminal proceedings against any doctor on account of medical negligence.
The difficulty in interpreting the act of the attackers is what makes hospital attacks analytically interesting. What underpins most literature on healthcare in Kerala is a sort of rational reductionism premised on linearity and predictability. It often assumes the presence of a group of health-seeking individuals exercising their freedom of choice within a framework of better access and better knowledge of medical facilities. For instance, themes like health awareness, access to medical care and health care utilization are integral to much of the healthcare literature on Kerala. It is argued that an educated populace has a higher degree of health awareness and this has made possible a near-universal utilization of healthcare facilities.
It is often portrayed in the ‘Kerala Model’ literature that Kerala has an ‘exceptional’ population who are educated enough to act rationally and so strive to create and sustain an enlightened social order. What makes the afore-discussed approach to Kerala’s healthcare domain problematical is the presupposition that a sick person in Kerala is an ‘instrumentally rational actor’, behaving in a maximizing, goal-driven manner. I would like to use here Max Weber’s notion of modernity as involving a process of rationalization where all areas of social life become increasingly subjected to a means-ends calculus of instrumental efficiency. Weber argues that “social action can be determined in an instrumental (or goal) rational (zweckrational) way: through expectations of the behaviours of objects in the external world, and of other human beings, and in the use of these expectations as ‘conditions’ or as ‘means’ for the attainment of actor’s own rationally pursued and calculated ends”. In such a situation, rationality is a matter of choosing an attainable goal and devising the most efficient means for achieving the same. The predominant approach to Kerala’s healthcare domain–underpinned by the Weberian schema of rationally acting individuals–is insufficient to explain a multifaceted violent act like the hospital attacks. For Weber, history is a progression from irrationality to rationality. Such a rationalist vision is of little use when it comes to explaining a collective action like the hospital attacks. Those who attack hospitals may be unconscious of the rationality underlying their actions or may not have rationalized the act to themselves beforehand.
At a simple level, hospital attacks encode tensions against an educated class of medical professionals whose competence and commitment to work is questioned. The attacks are vehicles for articulating popular concerns against these licensed and authorized experts who failed to care for a patient sufficiently. It is the corrupt alliances of this professional class with the money economy–with a monetary calculus–that the attacks (at least partly) aim. This is why even the police sympathize with the loss and anger of the protesters and are seen to be complicit in allowing these forms of popular action supplant official forms of justice. It is also worthwhile to add here that the attacks on hospitals and medical personnel occur not just in response to the medical judgments of staff but also in response to attempts to isolate the patient from relatives and other close companions. It is individualized forms of medical treatment that are being resisted by relatives and friends seeking to be involved in the treatment process. Attempts to isolate the patient from relatives and friends are viewed with suspicion. It is the social nature of illness in Kerala which is being affirmed in opposition to individualized forms of allopathic patient care.
The violence in Kerala’s healthcare domain bears ample testimony to the fact that health-seeking behaviour is intermingled with many other social factors. Hospital attacks invoke the complex ways in which Kerala’s healthcare is connected to state processes. The rational political language of the state is folded back on itself by the population because the promise of total scientific care is not being fulfilled. The scientific rational language of medicine and the legitimacy of medical professionals are being questioned by the population. There is a suspicion that the commercialization of medical care is preventing the state from fulfilling its obligations to foster and protect the life of its citizens.
What the attackers ultimately seek is efficient and accountable medical services. Such collective anger encodes more than just personal grief; it is partly an expression of the population demanding a larger and more efficient healthcare system and personnel. Hospital attacks are calls for the state to improve its competence, effectiveness and management of patient care, and for it to hire and regulate its staff more efficiently. They are demands for a (Foucauldian) bio-politics that operates smoothly, effortlessly and according to need. The expansion of the scientific medical model and its rationalization of everyday life is not a simple one-way process of seeking health care services but involves complicities and participation of the population in a democratic politics that demands more and more forms of bio-power. These assaults predominantly articulate a collective suspicion and distrust of medical professionals as not participating fully in the enlightenment project that they espouse and are meant to articulate. However, such tensions are rationalized and voiced within the framework of demands for bio-political security. A long-standing welfarist tradition has democratized a demand for bio-political security so much so that the population feels justified to attack the state when it fails to provide that security. The hospital attacks–though often associated with strong emotions– demand a more rational and responsible state, one that provides adequate resources and personnel, and that regulates the medical system in a more efficient manner.
(Dr Sajan Thomas is an Assistant Professor of Political Science and Public Administration at St.John’s College, affiliated to the University of Kerala. Previously, he was Fredrik Barth–Sutasoma research fellow at the University of Bergen, Norway and a Supra visiting scholar at the Nordic Institute of Asian Studies, Copenhagen, Denmark. He can be reached at sendsajan@gmail.com)
An interesting piont that seems to emerge from my recollection of such reports is that almost all such attacks have happened on hospitals of modern medicine, and few if any on Ayurveda, Siddha or Homoeopathy hospitals. Would be interesting to find out why. Is it because most hospitals follow modern medicine? Is it because attacks on them are reported more often? There has to be some reason, unless my observation is wrong.
Your article is indeed very valid doctor. It cannot be ignored that Kerala is immune from mob violence and mob justice contrary to the popular assumption. With fake news and fake science spreading, people who practice medicine recieve threats that rise from lack knowledge and surety of muscle power. News reports about doctors receiving death threats often go unnoticed. But it cannot be ignored that out doctors have worked so hard to get to the position they are in today and like you said, the health would not have improved had it not been for the doctors. People should remember that doctors are not infallible Gods, but human beings.