Trigger Warning: The report contains mentions of rape and sexual violence. Reader discretion is advised.

On the morning of August 9, two days before lakhs of students were going to take the <a href="https://indianexpress.com/article/education/neet-pg-2024-checklist-nbems-exam-day-guidelines-admit-card-details-reporting-time-9500798/">NEET PG exam</a> for a postgraduate seat, a woman postgraduate trainee doctor was found murdered in the seminar room of the emergency medicine building <a href="https://www.shethepeople.tv/news/kolkata-rg-kar-medical-college-hospital-trainee-doctor-sexual-assault-murder-6845821">of RG Kar Medical College Hospital in Kolkata</a>. This was exactly a week before India celebrates its 77th Independence day.

The autopsy report concluded that the victim had been sexually assaulted, severely injured and strangled to death.&nbsp;

On the night of the murder, the trainee doctor had been posted on a 36-hour duty in the emergency department. After she had finished dinner with her colleagues and watched Neeraj Chopra&rsquo;s silver-winning javelin throw at the Olympics, she had sought out the quiet of the seminar room to rest. The hospital does not have duty rooms for doctors working in the emergency department.

The principal of the medical college, Sandip Ghosh, initially attempted to dismiss the murder as a suicide, while also maintaining that &ldquo;it was irresponsible of the girl to go to the seminar hall alone at night&rdquo;. The Calcutta High Court while <a href="https://www.ndtv.com/india-news/hes-so-powerful-principal-sent-on-leave-in-doctor-rape-murder-case-6326618">criticising</a> the role of the West Bengal government in the handling of the case &ndash; Ghosh was appointed the principal of the Calcutta Medical College and Hospital after he resigned from the RG Kar Hospital &ndash; ordered him to &lsquo;go on a long leave&rsquo;.

Responding to the incident, the Silchar Medical College and Hospital in Assam has, in an order issued on August 13, asked its women doctors, students and other healthcare workers to &ldquo;avoid isolated, poorly lit and sparsely populated areas&rdquo;.

Women healthcare professionals in India, doctors, nurses, paramedics and administrative staff who work in shifts, have always been vulnerable to violence given the poor infrastructure and security systems of the medical facilities where we work. &quot;It could have been any of us&quot; that is what most women doctors or indeed any female&nbsp; healthcare worker would say of this tragedy.&nbsp;

Many women health workers I know walk through abandoned corridors, empty and unlit roads, and attend to patients in darkened buildings at night. Many of us, especially those working in public hospitals, have slept in seminar rooms, unoccupied OPD rooms, and inpatient beds in the wards because we could not find unoccupied duty doctor&#39;s rooms. Many of us have also had to share these rooms with male health workers. All this while working for inhuman hours between 24 and 48 hours, forgoing food and sleep. Now that I look back, I wonder why we found it acceptable to not have a place to rest our heads in the midst of a punishing schedule.

This incident has also brought the focus back on women&rsquo;s safety and safe workplaces in India. Cases like this and Jyoti Pandey&rsquo;s rape and murder (known as Nirbhaya case in the media) in 2012 tend to gather mainstream attention while countless women, especially from marginalised communities like Dalits and Adivasis, routinely face violence from upper and dominant castes as a means of control.&nbsp;

In 2022, more than 4 lakh cases of crimes against women were reported per the National Crime Records Bureau. Of these, 31,516 were rape cases&ndash;averaging to one every 16 minutes. And these are just&nbsp; cases where women have reported them and the police have filed an FIR. The latest data from the National Family Health Survey (NFHS-5) indicates a higher prevalence of violence.

As many as 30% of women between the age of 18 and 49 have experienced physical violence since the age of 15 years, while 6% have experienced sexual violence in their lifetime per data from the <a href="https://dhsprogram.com/pubs/pdf/FR375/FR375.pdf">NFHS-5</a>.

Everyone Is At Risk

Violence against doctors and other healthcare professionals such as nurses and paramedics has become a <a href="https://www.bmj.com/content/382/bmj.p1803">common issue</a> in India, and being a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5198359/">woman</a> in healthcare deepens anxieties around safety issues.&nbsp;

At night, when the likelihood of this violence is at its <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10693911/">peak</a> especially in remote areas, there are several women at work in hospitals and health facilities. Nursing staff (of which 80% are <a href="https://www.hindustantimes.com/columns/valuing-nursing-can-transform-health-care/story-7Ivc4wuNXQ554iTO78aj7K.html">women</a>), women lab technicians, billing clerks, pharmacists and sanitary assistants too are busy at work in public hospitals at night. This vulnerability in healthcare workforce goes back to the&nbsp; brutal rape of <a href="https://www.theguardian.com/world/2015/may/18/raped-indian-nurse-dies-after-42-years-in-coma">Aruna Shanbaug</a> at Mumbai&rsquo;s KEM hospital which left her with brain damage in a vegetative state&nbsp; in 1973.

There are several reported incidents of assaults by relatives of patients whose condition may have worsened or who may have died during treatment. But the violence is often internal too. The existing power dynamics and heirarchical nature of the medical profession has created multiple layers of oppression - doctors above other healthcare workers and men above women. Women healthcare workers often find themselves at the bottom of the ladder and at the receiving end of verbal, physical and sexual harassment from coworkers and seniors as well, according to reports.

For example, studies mention that around <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7324991/">43.5% of female nurses</a> have faced harassment at the line of duty from various stakeholders. ASHA workers, India&rsquo;s frontline community healthcare workforce have routinely faced different kinds of violence, emotional, physical and sexual violence from their co-workers to beneficary families but there are few studies on this. A 2021 <a href="https://www.joghr.org/article/24351-investigating-violence-against-_accredited-social-health-activists_-ashas-a-mixed-methods-study-from-rural-north-karnataka-india">study </a>from North Karnataka reports that 88% of ASHA workers reported economic violence, 73% reported emotional violence, and 32% and 26% reported sexual and&nbsp; physical violence.&nbsp;

Infrastructure, Work Hours, Security&nbsp;

As a duty doctor in a secondary hospital in Chittoor, I used to transfer critically ill patients who needed specialist care to the tertiary hospital in Vellore. There were times when, as the duty doctor, I was the only woman in the ambulance with a male driver, patient, and their male relatives.

These transfers often used to take place in the middle of the night and looking back, I realise the risks involved in doing such duties. It is clear that the existing guidelines do not reflect the real world problems a healthcare worker would face while transferring patients. A single doctor would anyway not have been able to manage any emergency during this transfer so why not enforce regulations on hospitals to have a trained team of an EMT or a nurse to accompany the doctor?&nbsp;

In public hospitals, toilets are sometimes not gender segregated and mostly out of maintenance, say women doctors. &ldquo;The toilet we had didn&rsquo;t have a latch,&rdquo; says one. &ldquo;We had to put a board saying &lsquo;do not open without knocking&rsquo; and then keep the door closed by parking some object in front of it.&rdquo;

Another female doctor recalls that the door to the duty doctor&rsquo;s room did not have a sturdy lock. &ldquo;I had to place a chair or something in front of it to keep it closed and even then it would be opened by ward boys and so on,&rdquo; she adds.

A doctor tells me on the condition of anonymity that the Government Hospital at Royapettah in Chennai has only about 20 security personnel, and most of them are elderly and frail. &quot;I have always wondered whether they could protect anything if needed,&quot; he adds.

In emergency situations many security guards throw their hands up, says another doctor. &ldquo;There have been times when a security guard would come to me and say &lsquo;I tried controlling the crowd of angry relatives but they are not listening, ab aap dekhlo (now you handle this)&rsquo;. I was shocked &ndash; shouldn&rsquo;t they be calling a senior or police or something?&rdquo;

However, a security guard at the Pentland Hospital in Vellore told a doctor I know that being a guard at a government public healthcare facility is not seen as a desirable job because they take the first impact of an attack by angry relatives of patients. Most of these offenders also get bail within a few days and come to harass the staff again, he says.

No Political Will

Violence against healthcare workers (VAHCW)&nbsp; essentially boils down to very structural issues that underpin the healthcare system in its entirety. India&rsquo;s public health system is underfunded and understaffed. As per the latest available <a href="https://hmis.mohfw.gov.in/downloadfile?filepath=publications/Rural-Health-Statistics/RHS%202021-22.pdf">Rural Health Statistics</a> from 2021-22, there are not enough primary and secondary health centres. And in the existing centres, there are significant staff shortages. &nbsp;There is an 80% shortfall of specialists in community health centres.

While the situation calls for increased funding to improve health infrastructure, the central government&rsquo;s allocation has seen a <a href="https://timesofindia.indiatimes.com/business/india-business/centres-health-expenditure-down-as-share-of-gdp-or-total-budget-since-2018-19/articleshow/111737183.cms">decrease</a> in real terms, despite the introduction of a health cess in 2018.

Underfunded healthcare is the one of the biggest reasons behind most cases of VAHCW, Parth Sharma, physician and my colleague at Nivarana wrote in TOI. Staff shortage leads to long working hours and limited communication and healthcare workers are not trained in communication or conflict management.

Moreover, existing power dynamics that place doctors above the patient, lack of trust in doctors due to over medicalisation and privatisation and lack of redressal mechanism and accountability are also factors influencing VAHCW.

At the institutional level, mandated structures like the&nbsp; internal complaints&nbsp; committees under the Prevention of Sexual Harassment Act (POSH) are mostly filled with doctors themselves and occasionally they are those accused of unethical practices. Secondly, these senior doctors do not have any formal training&nbsp; in administration or human resource issue management. This means that even without any conflicts of interest, they will be unable to skillfully manage such complaints. The cost of dissent is also high for healthcare professionals, especially junior doctors. There are worries&nbsp; that the college or hospital administration could be vengeful and there could be repercussions &ndash; exams failed, thesis kept unsigned, job loss or transfers. A urologist from Tamil Nadu told me how he was threatened with repercussions, from withholding his pension to firing him from his job, after he gave evidence in the sexual abuse case of his female colleague.&nbsp;

&quot;When I speak about women&#39;s issues in any of the doctor&#39;s association Whatsapp groups, people are completely uninterested,&quot; says another doctor. &quot;The reason is that women are not represented&nbsp; well in health leadership and associations. The leadership in organisations like Indian Medical Association (IMA) and Federation of Resident Doctors Association (FORDA) is all male. And these doctors are genuinely uninterested in matters such as women&#39;s safety until an incident as large and as gruesome as this takes place.&quot; He suggests including women doctors in leadership and associations and pushing quotas and incentives for them to do so.

Among the past IMA presidents, there is only one woman among the 94 names listed on the <a href="https://www.ima-india.org/ima/free-way-page.php?pid=20">website</a>. In the <a href="https://imatn.com/state-office-bearers-2024/">state lists</a>, women only occupy the two token posts allotted to women doctors. A <a href="https://pubmed.ncbi.nlm.nih.gov/39133694/">study</a> published this week assessing women&rsquo;s leadership in professional medical associations across the world reveals that only 9 out of 46 associations are currently headed by women. They also reveal dismal representation of women in sub chapters of associations as well.

We need to demand for a gender just healthcare policymaking and safe workplaces for women in the healthcare sector.

<hr />
This report was first edited and published by <a href="https://behanbox.com/2024/08/14/why-the-kolkata-hospital-crime-could-be-the-story-of-any-healthcare-worker/">Behanbox</a>

Image by Gayatri Sharma

This article explores the widespread prevalence of violence against women in the healthcare sector and argues that the Kolkata hospital crime could have been the story of any woman healthcare worker.

Why The Kolkata Hospital Crime Could Be The Story Of Any Healthcare Worker

4th June 2024 in India saw not only the declaration of the much-awaited Lok Sabha election results but the results of the NEET UG medical entrance exam as well. This exam, attempted by around <a href="https://www.pw.live/exams/neet/how-many-students-appeared-for-neet-2024/#:~:text=The%20NTA%2C%20which%20released%20the,compared%20to%202023's%202%2C038%2C596%20examinees.">23 lakh students</a>, was highly competitive and is likely to provide only admission to around <a href="https://www.vedantu.com/neet/mbbs-seats-in-india">1 lakh students</a> nationwide. Amid allegations of several perfect scores from the same exam center, paper leaks, and mathematically impossible marking irregularities, the #NeetScam2024 scandal has erupted, casting doubt on the integrity of the National Testing Agency (NTA). Protestors claim the NTA is sabotaging the futures of aspiring doctors, potentially crippling India&#39;s already strained healthcare system. But the real question is: Is the NEET system truly designed to meet India&#39;s diverse healthcare needs, or is it setting up future doctors to fail?

The urban-rural divide in healthcare

When we talk about Indian healthcare and our doctor-patient ratio, most of us forget that the numbers are more complicated than they seem off the bat. Sure, India has achieved the WHO recommended standards for the doctor-patient ratio, standing currently at <a href="https://www.google.com/amp/s/m.economictimes.com/news/india/doctor-population-ratio-in-country-stands-at-1834-mansukh-mandaviya-tells-lok-sabha/amp_articleshow/107561323.cms">1:834,</a> compared to the standard 1:1000 (however, this includes AYUSH practitioners).

But this does not translate to quality healthcare for all, because most doctors are concentrated in a few <a href="https://www.google.com/amp/s/m.economictimes.com/news/india/india-builds-more-hospitals-as-population-surges-but-doctors-in-short-supply/amp_articleshow/100124282.cms">urban hotspots</a>. This leaves large swathes of areas in rural India woefully under- or unserved. A <a href="https://www.google.com/amp/s/www.business-standard.com/amp/article/current-affairs/80-of-indian-doctors-located-in-urban-areas-serving-28-of-populace-report-116081900640_1.html">2016 article</a> says that 80% of doctors are concentrated in cities serving 28% of the Indian population.&nbsp; This is the problem that should take priority as we try to achieve efficient and quality universal healthcare delivery.&nbsp;

But this also indicates that increasing the number of medical seats is not the solution for doctor shortage. We need to look at why the urban concentration of doctors is happening and address that.

Sprint or marathon

&ldquo;The nightmare that is preparation for NEET UG, NEET PG and the grueling requirements of the PG course ensures that many of us are burnt out at the start of our careers,&rdquo; says an internal medicine consultant who wishes not to be named. &ldquo;I have not met one colleague who has been through this system and says I am willing to put in a few more years of effort in an underserved area. Doctors tend to prioritize having an easy life as soon as they get to the stage of independent practice and they start focusing on earning money to facilitate that.&rdquo;&nbsp;

Everybody who runs long distances knows that you do not use up all your strength and speed at the start of running a marathon. The energy you conserve by pacing yourself through the race is what allows you to be able to run long enough to finish it. However, the NEET examinations- both UG and PG- require mammoth efforts and preparation. The MBBS and PG courses that follow also work on the arduous principle of trial by fire, which leaves doctors completely <a href="https://mecp.springeropen.com/articles/10.1186/s43045-021-00129-1">burnt out</a> by the time they can start working independently. An urban location offers them more opportunities for socialization, leisure and fun along with easier set ups and better facilities for practice, which they may then easily embrace.

Return of investment

The other problem is the cost of entry to medical education is too high. This might not even include the <a href="https://economictimes.indiatimes.com/industry/services/education/the-money-one-needs-to-shell-out-to-become-a-doctor-in-india/articleshow/87389789.cms?from=mdr">sky-high fees</a> that are charged by some private colleges (60 lakhs to 1 crore on average). Indirect costs such as the time spent in coaching, the time taken as drop-years and mental health issues brought by pressure&nbsp; serve to ensure that doctors want to &lsquo;earn back&rsquo; all that they have &lsquo;spent&rsquo; on the route to becoming a doctor.

Sure, NEET exams have done away with the malignant problem of <a href="https://inmathi.com/2022/02/11/neet-got-rid-of-capitation-fees-but-private-colleges-still-squeeze-students/40871/#:~:text=NEET%20got%20rid%20of%20capitation%20fees%20but%20private%20colleges%20still%20squeeze%20students,-Arockiaraj&amp;text=The%20Supreme%20Court%20verdict%20that,NEET%20will%20help%20prevent%20that">capitation fees</a>, but they have introduced more silent and insidious financial losses in their stead. When one has to spend this much money to become a doctor, the only rational reaction from their end seems to be to use that degree to earn more money.

Competence and cultural competence

The second issue with the NEET examinations is that it is drawing people away from meaningful clinical learning and practice and making them spend their time solving MCQs. The MBBS curriculum aims to produce doctors who can function competently as primary care physicians in areas of need.

However, students these days are found to be bunking practical classes and internships to watch coaching videos for PG preparation. This results in them not learning basic skills such as inserting an IV line or doing an ECG. By the time they get their degree and could be starting an independent practice, many of them have critical deficiencies in important lifesaving skills such as performing CPR or vaginal deliveries.&nbsp;

A survey was done by Dr Srimathi, an independent health researcher and Dr Anand Zachariah, a professor of internal medicine at CMC Vellore among medical students and they found that only 44% of medical students they surveyed felt that they would be able to function competently as a primary care physician after their MBBS degree. In the survey, they also noted a significant perspective shift among these students who have now started perceiving MBBS as just a stepping stone towards postgraduate medical degrees and have begun replacing their textbooks with PG coaching material. This problem has also been highlighted by a previous Nivarana article <a href="https://nivarana.org/singleBlogDetails/The-Pathophysiology-Of-Declining-Medical-Education-In-India-6618b422279d5">here</a>.

&ldquo;The other issue is that these MBBS graduates might initially try to work and study for NEET at the same time, but if they do not qualify once, their reaction is to quit their jobs and study full time. This too takes doctors in large numbers out of the workforce,&rdquo; says another Internal medicine consultant. &ldquo;It is truly amusing that a country with a dire need of working doctors in rural areas has designed a system that would produce people who will not be able to fulfill that need.&rdquo;

Cultural competence is another thing that is found lacking among doctors thanks to the current system. Seat distribution via NEET ensures that states are not completely in control of their seats. The 50% of seats in control of the central government can be filled by candidates from the same or different states. When candidates from different states come to study in a particular state, they may have issues connecting to the local populace and attaining cultural competence (understanding the motivations and history of the people one is working with). This might also lead to people who do not care enough about the people they are working with to help in their upliftment.

The <a href="https://www.news9live.com/state/tamil-nadu/north-indian-medical-students-at-aiims-madurai-complaint-of-tamil-nadu-patients-not-speaking-hindi-2499671">recent complaints</a> of North Indian MBBS students in AIIMS Madurai (Tamil Nadu) that their patients do not know Hindi and that they aren&rsquo;t getting a holiday for Holi is an example of how seat allocation via NEET puts up a barrier towards cultural competence.

The principle of exclusion

NEET in its current form is a highly exclusionary exam which is designed to keep underprivileged and marginalized people out of the system. Though operating on the myth of merit &ndash; it allows private college seats to be accessible to lower-scoring students who can pay large amounts of money while a student who has scored higher but cannot pay is left without a seat.&nbsp;

In fact, a <a href="https://pubmed.ncbi.nlm.nih.gov/38074236/">mathematical analysis</a> of NEET counseling and seat allocation systems reveal that luck and probability play far too much a role to ascribe NEET victories to merit. The amount of money required for coaching and the concentration of coaching centers in cities also ensures that it is gatekept from students from poor backgrounds. This too has been instrumental in weakening the public health systems of the country.

In an interview, Dr. Palanivel Thiagarajan, the minister of IT and digital services in Tamil Nadu points out that universities in the Global North have been decreasing weightage of marks scored in standardized tests for college admissions as there have been numerous studies which show that <a href="https://oxfordre.com/education/display/10.1093/acrefore/9780190264093.001.0001/acrefore-9780190264093-e-1123">standardized</a> tests have an<a href="https://journals.sagepub.com/doi/abs/10.1177/0895904815614916"> inbuilt bias</a> of favoring <a href="https://psycnet.apa.org/record/2016-00321-002">privileged</a> populations. His arguments are supported by multiple <a href="https://link.springer.com/chapter/10.1007/978-3-319-94724-2_26">studies</a> done from the Global North.&nbsp;

An <a href="https://www.newindianexpress.com/states/tamil-nadu/2018/Sep/01/finding-anitha-what-i-discovered-about-the-face-of-tamil-nadus-anti-neet-agitation-1866033.html">article </a>written in the New Indian Express about Anitha - the girl who spearheaded Tamil Nadu&rsquo;s opposition against NEET in the Supreme Court, who eventually died by suicide in 2017 talks about how Anitha had never used a computer in her life and had to be taught the basic functions using a friend&rsquo;s laptop. &ldquo;When she went to the center for JIPMER exams, she didn&#39;t even know how to switch on the computer as she hadn&rsquo;t seen a CPU before&rdquo;, her brother had told the reporters in that article. This reveals the stark reality of exactly how exclusionary the medical entrance exams are.&nbsp;

&nbsp;&ldquo;When I visited Mahabalipuram, I had the opportunity to visit the PHC. It was unstaffed,&rdquo; I remember a senior colleague telling me. &ldquo;The last time it was staffed was when a doctor from the area had come back after doing their MBBS course and served there.&rdquo; This is one of the most important reasons to provide opportunities for the marginalized &ndash; as they have an emotional attachment towards their communities and will hence come back to serve them. &ldquo;People from an area will also feel more comfortable availing care from a person they know and trust, so it&rsquo;s really important to ensure representation,&rdquo; added the senior.

Potential solutions

The states that make up India are unique and different from each other and hence decentralization of health as a subject is important. It allows states to make decisions that help in strengthening their public health systems and filling in the gaps. One of those decisions is whom to admit into their medical colleges and train to become doctors. A single entrance exam diminishes a state&rsquo;s ability to give representation to its underprivileged and marginalized populations and must be reconsidered. In the long run, decreasing the weightage of standardized testing marks in the admission procedure to colleges may be attempted.

Incentivising rural service &ndash; such as financial incentives, better housing and working conditions for doctors willing to serve in rural areas along with mandatory rural service postings for seats availed from the central government counseling could also be implemented.

Including a section which covers practical clinical aspects of medicine along with procedural skills and community awareness in PG entrance exams might also incentivize MBBS students to gain those meaningful skills.

The NEET exams, in their current form, prioritize rote learning and financial capability over genuine medical competence and commitment to serving the underserved. This systemic flaw leads to an urban-centric concentration of doctors, burnout, and a lack of practical and cultural competence among new doctors. The result is an exclusionary system that fails to meet the healthcare needs of India&rsquo;s diverse population. And this is the real NEET scam we need to be wary of.

Edited by Radhikaa Sharma.

Image by Gayatri Sharma.

It is truly amusing that a country with a dire need of working doctors in rural areas has designed a system that would produce people who will not be able to fulfill that need.

The Real NEET Scam: Is India's Medical Exam Failing Healthcare Needs?

&ldquo;Afsos Mukesh bach nahi saka,&rdquo; is a sentence all of us have heard more times than we can remember. In fact, as you read this sentence, you might have pictured the faces of Mukesh and Sunita or even heard the melancholy background music that is supposed to convey the tragedy of their story, in your head. This advertisement, conceived as a part of the campaign against smokeless tobacco in 2009, showed graphic images of cancer and was expected to make people consider the ill effects of tobacco and stop its use.

Following that, the COTPA Act of 2003 was amended in 2014 where the size of graphical warnings on tobacco products was increased from 40% to 85% percent. Every audio-visual campaign against tobacco is flooded with grotesque images of lung-shaped sponges soaked in tar. So all this fear-mongering should have worked, right?

Well, as an ex-smoker, I had continued to puff one after another as I sat through the tobacco warnings displayed in every movie, TV show, and billboard and wondered, &ldquo;If awareness is all that is required, then why do doctors like me smoke?&rdquo;&nbsp;

By then, I knew of doctors who smoked, while also working day in and day out with patients who suffered from horrifying diseases due to tobacco use. In fact, I knew doctors working with cancer patients and in cancer wards who used tobacco. The subset of people likely to have the most awareness about tobacco continues to use it. Why is that?&nbsp;

This question requires us to analyze the concept of &lsquo;awareness&rsquo; as it relates to the problem of tobacco consumption in various ways &ndash; namely, how effective is it, and how can it be made more effective?

&ldquo;<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6293941/#:~:text=In%20a%20review%20of%20GATS,message%20and%20willingness%20to%20quit.">Data</a> from the Global Adult Tobacco Surveys 1 and 2 show that people exposed to tobacco warnings did demonstrate an increased willingness to quit,&rdquo; says Dr. Dheeraj Kattula, an Addiction Psychiatrist. &ldquo;The problem, however, is that there is a massive difference between wanting to quit and actually quitting. Make no mistake, nicotine is <a href="https://www.sciencedirect.com/science/article/pii/S0376871618305313#:~:text=Conditional%20prevalence%20has%20been%20estimated,Lopez%2DQuintero%20et%20al.%2C">the most addictive substance</a> known to man!&rdquo; he adds.&nbsp;

&ldquo;Nicotine creates actual changes in the brain, causing intense cravings like nothing else. So much so, that a current smoker craving for their next hit will be able to look at the image of a grotesque tumor on the cover and still be able to light up without any worry for their own wellbeing. And the craving can last about 6 months to 1 year after stopping smoking, so a person remains in danger of restarting anytime.&rdquo;

So yes, these advertisements might put an idea of eventually quitting in one&rsquo;s head, but they fail to generate the urgency needed for that person to embark on the kind of Sisyphean uphill battle that is quitting tobacco.&nbsp;

Let&rsquo;s get back to Mukesh and Sunita for a moment. Is it just the addictive potential of nicotine that renders them unable to tug at our heartstrings, or is there something fundamentally wrong about the way their stories are being told?

To answer this question, all one needs to do is Google some permutation or combination of the words &ldquo;Mukesh&rdquo;,&rdquo; tobacco&rdquo;, &ldquo;ad&rdquo; or &ldquo;cinema&rdquo;. The sheer number of memes and jokes that show up on our feeds then makes one realize that these advertisements have been rendered powerless by repetition.&nbsp;

Mukesh and Sunita have become constant fixtures in our cinema experience, much like popcorn and cool drinks. And just like the way our eyes automatically gloss over the anti-tobacco warnings that appear in TV shows, our mind is now trained to not engage with the message anymore.

&ldquo;There is a need to tell new, fresh stories,&rdquo; adds Dr. Dheeraj. &ldquo;Tobacco companies constantly spend money on researching new ways to sell tobacco to people. Anti-tobacco campaigns are falling behind on this behavioral research aspect. We need to look at what pictures and what stories people relate to the most and keep shuffling them so that people stop becoming desensitized,&rdquo; he adds.

There is also a need to focus on problems caused by tobacco that are not heart disease or cancer. &ldquo;Most people perceive cancer as something that happens to a very few people, always to someone else and never to them. Not only that, most people also perceive all forms of cancer as deadly and terminal. So faced with that image, the overwhelming human instinct would just be to give up hope,&rdquo; says Dr Dheeraj.&nbsp;

How long do these alarming consequences take to appear? One or two decades at least. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428406/">Studies </a>show that people are simply not good at making decisions based on what is good for them in the long run. <a href="https://pubmed.ncbi.nlm.nih.gov/27818375/">Habit formation </a>(or in this case, habit breaking) cannot be affected by making people think about consequences they consider to be not highly prevalent and that won&rsquo;t affect them for a long time to come.

However, there may be several alarming effects of tobacco that if communicated well can stop people in their tracks and make them consider stopping. Erectile dysfunction is the obvious example. Smokers are<a href="https://academic.oup.com/smr/article/11/1/61/6985842?login=false"> three times</a> as likely as non-smokers to have erectile dysfunction, something that is not conveyed in any anti-tobacco campaign.

While having a good sex life is considered a very important need, in a son-preference patriarchal culture like India, the inability to perform sexually could potentially be damaging to a person&rsquo;s identity as a man. But this is not being talked about enough.

Say, we double down on this information and make more audiovisual ads explaining the association of tobacco with erectile dysfunction. The examples of Mukesh and Sunita show us that it is possible to saturate the public consciousness with a message. Then, would we be able to dethrone tobacco from its brand positioning as a &lsquo;masculinizing product&rsquo; if it was well known to be associated with an &lsquo;emasculating condition&rsquo;?

We don&rsquo;t know the answer. But, we do know that juxtaposing the image of a tobacco user with erectile dysfunction strikes at the root of one of the most important priorities a person has, his identity of being a man. And Indian men seldom like to do anything that makes them appear emasculated. And for that reason alone, it appears that this answer is worth exploring.

My last perspective on awareness is gleaned from my therapist&rsquo;s office, as I sat there seeking help for my own journey of quitting. &ldquo;Well imagine that your leg is broken and you are using nicotine as a crutch, Christianez,&rdquo; said my therapist patiently. &ldquo;If I remove your crutch without your leg healing, I will force you to go through unimaginable pain. My job is to help you cope in other ways so that you will stop needing this crutch eventually.&rdquo;&nbsp;

This awareness that tobacco is a crutch sold to the masses - <a href="https://www.thequint.com/opinion/tobacco-awareness-day-control-health-celebrity-endorsements-government-action-epidemic#read-more">an empty solution</a> for problems that aren&rsquo;t being solved well - is an important one for everyone to keep in mind while designing campaigns. People smoke or chew tobacco for various reasons - when education, healthcare, and social security are distant dreams, tobacco might be a guilty pleasure.&nbsp;

Laborers chew tobacco to keep themselves from getting tired, doctors smoke before night duty so that they do not fall asleep on shift&nbsp; - and this awareness of tobacco use as a coping mechanism in the face of broader socio-economic issues underscores the need for comprehensive support systems alongside awareness campaigns.&nbsp;

Ultimately, a multifaceted approach that combines innovative messaging with robust support for quitting could be the key to reducing tobacco use more effectively. As we redesign campaigns, we must ensure human behavior lies at the heart of our efforts. To truly make an impact, we must move beyond generic warnings and delve deep into the intricacies of what drives individuals to smoke. Only by understanding the psychological, social, and cultural factors at play, can we tailor our messages to resonate with diverse audiences. And only then, will our messages lead to any meaningful change.

Edited by Radhikaa Sharma.

Image by Janvi Bokoliya.

Tobacco use prevention strategies need to be reimagined in India.

Rethinking Anti-Tobacco Campaigns: Why Mukesh and Sunita’s Stories Aren’t Enough to Stop Tobacco

When Dr. Pearl Lal joined her training in General Surgery in 2015 at Christian Medical College Vellore, she was one of the two women in her batch of ten residents. That changed considerably in the following years with the 2020 batch having more women than men. &quot;Though we do not have the exact data, this seems to be the trend across all the medical colleges in India&quot;, says Dr. Pearl. &quot;These days, we see more and more women choosing surgical fields such as Orthopaedics and Neurosurgery in India, which is amazing.&quot;

&quot;But this trend was long-awaited&quot;, points out Dr. Eknoor, an orthopedic surgeon currently receiving super specialty training in hand surgery. Considering that Dr. Eknoor was only the second woman orthopedic surgeon in all of Rajasthan when she took up her course in 2017, what she mentioned bears weight. &ldquo;Women have always been surgeons,&quot; she adds, &quot;Haven&#39;t we seen women do very well in Obstetrics and Gynecology, which is predominantly a surgical specialty? Both the numbers as well as the performance of women surgeons in the fields of ObGyn, ENT, Ophthalmology, and even Dermatosurgery, reveal that women have always had the aptitude to be good surgeons. So, it is amusing to note that there are biases extended to them in other surgical fields such as General Surgery or Orthopaedics&quot;, she says.

&quot;I&#39;d been told multiple times as an undergraduate that women cannot make good surgeons&quot;, said Dr. M, who has recently completed her General Surgery residency. &quot;When I was a student in MBBS, I remember a practical class in Surgery, where I was supposed to sew two ends of an animal intestine together. I had done a pretty decent job, but the supervising doctor congratulated me by saying, you will be a great obstetrician someday. I was taken aback, at first, because the potential I showed was quickly boxed into the surgical specialty that he considered appropriate for women, but then I allowed it to fuel me into pursuing General Surgery with a passion.&quot;

Dr. M was able to take that biased comment and turn it on its head. Many other MBBS students, however, give in to the biased remarks and subtle intimidation. &quot;Many times, people tell us that women cannot manage the job with their family commitments. They also scare impressionable students by creating self-doubt about their aptitude for the subject. These things may have played a large role in keeping the number of women undergraduates choosing surgical specialties on the lower side.&quot;

Regardless of the bias, the current trend depicts that women are rightfully claiming their place in the operating rooms. But are their coworkers, seniors, and departments prepared for this change?

&quot;It&#39;s not the entire department, but a few people in the department who carry on the bias toward women trainees&rdquo;, says Dr. Eknoor. The Orthopedics department head she trained under in Rajasthan was very supportive and encouraged her to pursue the Hand Surgery course. &quot;He had trained under Dr. Poornima Patni, the only other woman orthopedic surgeon in Rajasthan at the time. Having a woman role model in his field greatly influenced the way he approached and educated me,&quot; she says. Her experience drives home a crucial point about why the representation of women in the surgical field matters. Having women role models helps educators unlearn their biases, in turn making them better mentors for their women trainees.

&ldquo;There are also a few other people who think that women lack the commitment to pursue surgery as a subject&rdquo;, says Dr. M, &quot;The reason for that could be that everyone views women as the glue that holds a family together. With such a view, everyone would automatically assume that a woman&#39;s priority will not be patient care.&rdquo; However, time and again, <a href="https://www.bmj.com/company/newsroom/study-finds-no-differences-in-performance-between-male-and-female-surgeons/">studies</a> have <a href="https://pubmed.ncbi.nlm.nih.gov/36332819/">shown</a> that across the board, women as surgeons perform equally well as men.&nbsp;

&quot;People hold women to higher standards compared to their male counterparts&rdquo;, adds Dr. M. &quot;I keep hearing from many senior women surgeons that we must always be the best versions of ourselves because otherwise, we will make all women surgeons look bad.&quot; The pressure to overperform is because of the phenomenon where one person&#39;s failure reflects on the entire group, especially for marginalized groups. For example, a man driving poorly is just a bad driver, but a bad woman driver is an example of why women are bad at driving. (Of note,&nbsp; there are <a href="https://www.hindustantimes.com/sex-and-relationships/women-can-actually-be-better-safe-drivers-than-men/story-oDVZo7s78BfbOPVJeS5QvI.html">more bad</a> men drivers compared to women drivers).&nbsp;

The occurrence of this phenomenon is quantified in the surgical specialties by economist Dan Zeltzer. In a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8581775/">2020 study</a> quantifying the role of gender in inter-physician referrals, he found that when a physician refers a patient to a male surgeon and the patient suffers a bad outcome, the physician continues referring patients to other male surgeons than that one surgeon. However, when a physician refers a patient to a woman surgeon and the patient suffers a bad outcome, the physician stops referring patients to women surgeons altogether. Hence,&nbsp; any and every woman surgeon, at all times, has to be at her best as all women surgeons are being judged by their behavior and performance. When this study was mentioned to Dr. M, she laughed and admitted that it did seem like a lot of pressure when put that way.

Another issue is that women opting for surgical training have to suffer from denial of their gender-specific needs. &quot;The department gets annoyed at the fact that women are not men. The fact that they have gender-specific needs that may require accommodations from the system inconveniences them&quot;, says Dr. Silvia, who went through a bad time during her maternity period while in Surgery. &quot;There are no accommodations because women are afraid to ask for them&quot;, she adds. &quot;They feel that being allowed a place at the table itself is too big a privilege to spoil by asking for their needs to be addressed. They do not want to be seen as a separate group with separate needs.&quot; This is called <a href="https://opmed.doximity.com/articles/fostering-gender-equity-and-inclusion-in-surgery-for-women-surgeons">camouflaging</a> - women pretend to not have needs to avoid retaliation. This allows them to defer the discomfort for a short period but consequently blocks important conversations that may translate into fruitful accommodations for women. &quot;Sometimes even senior women surgeons may not offer accommodations because they were not offered the same. My colleague worked herself almost into a pregnancy complication and people praised her for being very dedicated. It felt disturbing to see that&quot; she concludes.

&ldquo;I altered the way I carried myself so that people do not see me as a woman&rdquo;, says Dr. Madhuri Evangeline, a consultant urologist. &ldquo;In my outfits, my accessories, and even the way I look, I feel I have removed every trace of femininity.&rdquo; As she says this, I wonder if it was some instinctual understanding she felt that more traditionally masculine traits would be valued and appreciated in the department as compared to traditionally feminine ones.

Workplace hazards affect men and women differently in surgical specialties and there is little information about the same currently - A study was conducted in 2021 to assess the awareness of breast cancer risk due to radiation among women orthopedic surgeons after noticing that they were <a href="https://pubmed.ncbi.nlm.nih.gov/22432467/">2.9 times more at risk</a> for the same than the general population in a US-based study. This <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8854465/">study</a> revealed that most orthopaedicians were unaware of the risk and did not have a dosimeter to calculate their cumulative exposure.

&quot;Both partners need work-life balance, not just women&quot;, says&nbsp; Dr. Pearl. Her husband, a surgeon, is also a present parent to their two children. &quot;We took turns taking breaks from our respective careers to take care of our responsibilities at home and him being an equal partner allowed me to focus on my career well&quot;, she adds. It is the oft-ignored reality. Most surgeons who are men have families and children, but in the popular narrative, they appear to have been absolved of all responsibilities towards them in their pursuit of &quot;surgical excellence&quot;, which is unfair to everyone involved.&nbsp; Familial commitments need to be viewed as common to surgeons of both genders.

Dr. Asha Bakshi, a renowned neurosurgeon working in Moolchand Hospital, Delhi currently points out that whenever she felt guilt about not having time for her child, she reminded herself that it was the quality of time that was important and not the quantity. &ldquo;I was a present parent in whatever time I could spend with my daughter. I used the time to ensure she knew she was on the top of my priority list.&rdquo; She feels that her daughter appreciates that now and has turned out to be a wonderful person.

Dr. Asha also recounts the sexual harassment she underwent during the time she attended conferences. &ldquo;This is something that isn&rsquo;t talked about much, but neurosurgery was a very male-dominated field when I began my training in 1992. When I went to conferences, I sometimes found myself being the lone woman in the room. I used to get catcalled and had to fend off unwanted advances at an alarming rate and eventually decided not to go to conferences at all. It&rsquo;s been 12 years since I last attended one. I feel like I had to give up a chance at academic excellence in order to keep my dignity&rdquo;, she says. Closer to work, Dr. Asha has also been subjected to harassment by a colleague she was posted with. When she brought up the issue with a senior, she found herself being displaced to a different hospital while the situation was being dealt with. &ldquo;I almost regretted opening my mouth but then I saw that other women were also being victimized by him. That made me realize that speaking out was the right thing to do, even though it felt like I was being punished alongside him for complaining,&rdquo; she said. &ldquo;Having more women entering the field and the academic spaces will make them safer for every woman surgeon.&rdquo; is her opinion on this matter.&nbsp;

And there is the problem of remuneration - women surgeons are offered lower starting salaries than their male counterparts in private hospitals in India, government ones having a fixed compensation for both genders. &ldquo;The&nbsp; problem is also the lack of opportunity,&rdquo; Dr. Asha points out, &ldquo;When you are a private doctor, most of your cases come by referrals from a primary contact and if that primary contact for the patient is a male physician then he will almost never refer to a female surgeon, much less a neurosurgeon.&rdquo; And as bleak as that sounds, this too has been quantified by a study published in the <a href="https://jamanetwork.com/journals/jamasurgery/fullarticle/2786065">JAMA Surgery</a> where they note that a physician who is a man is 32% more likely to refer a patient to a male surgeon while a woman physician refers to both men as well as women surgeons. This gives the opportunity to perform more interesting and complex surgeries heavily towards male surgeons. This leads to a large gender-based pay gap in surgical specialties.

Having women surgeons is important for women patients who may feel<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9473674/"> uncomfortable</a> discussing certain aspects of their care with men doctors. These preferences for women surgeons<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5131538/"> increase</a> when the area affected in question is the breast or the pelvic region. &ldquo;I did not notice this much as a general surgeon, but as a urologist, I see the preference women patients have towards being treated by me as opposed to my male counterparts&rdquo;, says Dr. Madhuri, who is now seriously considering pursuing a subspecialty of urology that focuses on female urogenital tract after seeing the difference her presence made to them. &ldquo;Many women walk up to me almost every day to say how grateful they are that a woman doctor is available in my department.&rdquo; &nbsp; This impact on healthcare access is very important. In fact, the World Health Organization recognizes improving health worker gender parity as a critical component of<a href="https://pubmed.ncbi.nlm.nih.gov/24347710/"> improving the acceptability</a> of the health workforce. Patients from certain populations may also have cultural barriers to accessing help for their conditions in such cases and a woman surgeon is the answer to their problems. Women patients also tend to do better under women surgeons according to various<a href="https://www.houstonmethodist.org/leading-medicine-blog/articles/2022/feb/surgical-outcomes-worse-for-women-when-doctor-is-male/"> studies</a> which indicates how the representation of women in surgery is vital from the patient&#39;s perspective. <a href="https://jamanetwork.com/journals/jamasurgery/article-abstract/2808894">New evidence from Canada</a> based on 1 million patients suggests that not just women but all patients regardless of their age and gender across different specialties and procedures seem to have better outcomes in the short and the long run when treated by women surgeons.&nbsp;&nbsp;&nbsp;

Gender equity in surgical specialties is not as commonly discussed as it should be, at least in South Asia. There are unique barriers to professional growth and at times denial of gender-specific accommodations.&nbsp; These can profoundly impact the quality of life of women choosing to train in the field. It is important to initiate and continue the conversation to ensure a better workplace for every woman surgeon and surgical trainee. The bottom line is that women are as capable, if not more capable than men to be surgeons. Yet, centuries-long societal bias against women has also seeped into surgery. The bias has to go away.&nbsp;

<hr />
This article was originally published in August 2023.

Edited by Parth Sharma.

Image by Janvi Bokoliya.

About the authors:

Dr. Christianez Ratna Kiruba is a general medicine physician with a passion for medical ethics and patient rights advocacy.

Siddhesh Zadey is a co-founder of the non-profit think-and-do tank Association for Socially Applicable Research (ASAR) India and the Chair of the G4 Alliance Working Group for SOTA Care in South Asia.

&nbsp;

Male surgeons have dominated the medical field for ages. What role does gender bias have in this and are things changing?

Surgically Removing Gender Bias

Nearly a year ago, Sugirtha Selvakumar, a 27-year-old anaesthesia postgraduate, died by <a href="https://www.newindianexpress.com/states/tamil-nadu/2023/Oct/10/tn-pg-doctorwho-died-by-suicide-was-workingover-20-hours-a-day-say-friends-2622583.html">suicide</a> by injecting herself with a muscle relaxant in Tamil Nadu. In her suicide note, she mentioned having to work twenty hours a day under immense psychological pressure from seniors. Her death sparked outrage and dialogue, but the furor eventually died down without any fruitful action.&nbsp;&nbsp;

<a href="https://medicaldialogues.in/news/education/64-mbbs-58-pg-medicos-committed-suicide-in-last-five-years-reveals-nmc-data-125142">An RTI</a> filed in 2024 revealed that in the past 5 years, almost 58 postgraduate medical students have ended their lives. <a href="https://www.livemint.com/news/india/with-37-000-medical-students-giving-details-of-their-mental-health-illnesses-worried-nmc-plans-gate-keeper-programmes-11715494494888.html">A recent online survey</a> done by NMC reveals that almost 37,000 medical students have self-reported mental ailments with suicidal risk. How many students filled this form is unknown and therefore to tell what percentage of students reported poor mental health is not possible. And as an insider within the medical education system who has witnessed how it functions, I have reason to believe that these staggering numbers are just the tip of the iceberg.&nbsp;

Postgraduation, a high-stakes trap

A postgraduate seat, in essence, can be likened to a toxic relationship &ndash; in that, leaving could be just as dangerous as staying. Acquiring a PG seat gatekept by a single 3-hour exam is uniformly nerve-wracking, and the over-glorification of postgraduate medical education in Indian society leads to a situation where a student, once admitted to a medical college for their postgraduate degree, finds it hard to leave.&nbsp;

This situation is worsened considerably by the excessive seat-leaving fees levied on students who wish to exit. The <a href="https://www.edufever.com/statewise-bond-for-neet-pg/">fines</a> begin from 5 lakhs and can rise to almost 40 lakhs, something most students cannot afford. While NMC has <a href="https://timesofindia.indiatimes.com/india/do-away-with-seat-leaving-bond-national-medical-commission-tells-states/uts/articleshow/107093513.cms">now requested</a> states and union territories to do away with the seat leaving fees, no concrete measures have been put in place as of now.&nbsp;

Doctors forced to &ldquo;fill in the gaps&rdquo; in the system

For one, residents or PG doctors are not just doctors. They are a skilled labour pool that has been used to fill in the gaps, wherever they may be found. An average resident, along with their studies and patient care responsibilities, is invariably also responsible for umpteen odd jobs- carrying samples to the lab, ensuring radiology technicians get scans done, pushing patient trolleys around when paramedical staff isn&rsquo;t around- the list goes on. They may also take on some responsibilities for their seniors &ndash; helping with their research, covering their classes or presentations, and even attending to personal favours.

&ldquo;I feel my life would be so much easier if everyone else just did their job &ndash; from ward boys and lab technicians to assistant professors and professors,&rdquo; adds an internal medicine resident on the condition of anonymity. &ldquo;It just seems like everyone in the system knows that they can slack off and not be accountable because the PG doctor will come and pick up the slack anyway.&rdquo;&nbsp;

&ldquo;Leave is not a right,&rdquo; is a statement the average resident doctor is inured to. It is reinforced that their taking a leave would mean that they would be a burden on their colleagues who would have to do more work. &ldquo;Why don&rsquo;t the colleges then hire more doctors if there is such a deficiency in manpower?&rdquo; wonders another resident anesthesiologist. &ldquo;There are, after all, innumerable post-MBBS doctors looking for employment and exposure. Why can&rsquo;t there be more senior resident and non-PG resident posts?&rdquo;

Glorification of the mythological &ldquo;toughness&rdquo;&nbsp;

&ldquo;My seniors used to get upset if they found out that I had had breakfast that morning,&rdquo; says a general surgery resident. &ldquo;If they notice some sign that you have showered, or god forbid, a trace of eyeliner, they will make snide remarks about you having the luxury for personal care,&rdquo; she added. Unfortunately, this seems to be the attitude across the board. &ldquo;They expect you to be above basic physical needs like sleep and food. And they treat you as&nbsp; somehow less worthy just because you need those things.&rdquo;&nbsp;&nbsp;

It might be relevant here to note that residency as a method of training was introduced by <a href="https://pubmed.ncbi.nlm.nih.gov/31944636/">Dr William Stewart Halsted</a>, who was infamously known to have been able to work constantly without food or sleep, and expected his trainees to be the same way. However, after his death, it was discovered that Halsted was able to accomplish these feats as he was addicted to cocaine. One would then logically need to question the need to continue a system that requires doctors to overwork as though they are cocaine-addled.&nbsp;

&ldquo;I was made to feel extremely guilty for taking leave even when I was sick. A senior even told me to find a replacement for duty before I went on my sick leave. However, I was too sick and needed to go in for admission, so thankfully I resisted. I am glad I had that experience because it opened my eyes to how unreasonable all of this is,&rdquo; concludes an internal medicine resident.&nbsp;

An inefficient way to teach and a danger to patients&nbsp;

One of the myths perpetrated by people in the system is that the only way to adequately learn is to be ground through the mill of overwork. However, there is a lot of evidence pointing to the opposite. <a href="https://www.bmj.com/content/366/bmj.l4134">A large-scale study in BMJ</a> analysing almost 4,85,000 patient records reveals that internal medicine doctors trained for fewer hours treated patients just as well in their first year of unsupervised practice as doctors trained for more hours.&nbsp;&nbsp;

&ldquo;There is no structured learning in residency anyway,&rdquo; adds another internal medicine resident. &ldquo;We almost never have lectures. We learn through the caseload we have, if and when we have time to read about our patients. Most of our seniors are uninterested in teaching. What kind of learning can even happen when you have not eaten or slept for many hours?&rdquo; she asks. &ldquo;Sometimes, I want to scream, this is a course. I have paid money for you to teach me things, not for you to overwork me like a dog and leave me no time to sit down with a book.&rdquo;&nbsp;

&ldquo;As a resident doctor, I am required to assess my patients accurately, and at times I have to make life-saving decisions in the moment. Given how sluggish I feel when I have not slept well, I am 100% sure that my brain is not functioning well at all during those moments. Patients should insist on being treated by a non-sleep deprived doctor for their wellbeing,&rdquo; an obstetrics and gynecology resident adds. A <a href="https://qualitysafety.bmj.com/content/32/2/81">large-scale study</a> done in the US reveals that once physician work hours were restricted, patient adverse outcomes and human errors fell by a third.

Postgraduate students or staff?

The PG medical education suffers from the fact that the postgraduates are a group of people who are in the grey area between students and staff. A PG resident is expected to take care of patient responsibilities like a staff member, without any benefits that come with formal employment- such as a provident fund, bonuses and paid vacation leave, etc. Many postgraduate students are not even awarded free healthcare by their colleges and might have to pay out of their pockets to avail of the same.&nbsp;

They are also expected to take care of their commitments to their course, such as thesis and compulsory research work, while also managing what is essentially a full-time job. There is also <a href="https://www.edufever.com/statewise-bond-for-neet-pg/">variability</a> in pay scale across the states, suggesting that some medical residents receive very small stipends as compensation for their labour.&nbsp;

&ldquo;This is probably why there is a deficiency in manpower. Colleges are trying to minimise their investment in faculty. Why to hire someone formally for whom you have to provide benefits when you can exploit PG students?&rdquo; concludes the anaesthesia resident.

Emotional abuse: Unspoken but well known&nbsp;

While the systemic failures and lack of any form of labour protection are huge issues, what causes the most suffering is the emotional toxicity that exists within these departments. Seniors routinely engage in non-professional behaviour-&nbsp; insulting resident doctors in front of patients, calling them names, passing untoward comments, and bullying- all in the name of teaching.&nbsp;

&ldquo;A senior I worked with once told me that I wasted a seat and he wasn&rsquo;t sure how I got through the entrance,&rdquo; says an internal medicine consultant who ended up remembering this comment long after her residency period ended. &ldquo;I was shocked. In a professional environment, even senior colleagues must be held to a standard of decorum when it comes to communication. Expressing displeasure at mistakes must also be done courteously.&rdquo;&nbsp;

&ldquo;When we ask for breaks or for assistance from seniors, they make it sound like we do not care about our work or our patients. Some of us chose this field to help people, and the implication that we are shirking off work or actively harming our patients is a painful one to hear. Every single resident I know has been taken on this guilt trip by their departments,&rdquo; says the pediatrics resident.&nbsp;

&ldquo;They make us feel guilty for even personal milestones like getting married or having a baby. The entire department was icy when they realised I was pregnant and did not hesitate to bring it up every time I made a mistake,&rdquo; shudders the general surgery resident.

Then why not complain to the authorities?

If it is that bad, then why don&rsquo;t resident doctors complain? &ldquo;Well, because I am scared that my HOD or thesis guide will not sign off on my thesis, for one,&rdquo; says the anaesthesia resident. &ldquo;There is an environment of fear. People are scared that they may be failed in their internal exams if they antagonise some senior and will end up having to stay a year longer in an environment they already despise. The other fear is that the bullying will intensify against the complaining resident without any measures being taken against the person being complained about. The consensus is, do not complain because it will make life worse for you. Just keep your head down and finish the course,&rdquo; she adds.&nbsp;

&ldquo;The other thing is the glorification of this struggle. People see it as a rite of passage,&rdquo; says the obstetrics and gynaecology resident. &ldquo;If I complain, or even raise concerns, people will act as though I am the weak one for being unable to cope in the system. They will say I am not fit to do the PG course, and who wants to be thought of that way?&rdquo; she says.&nbsp;

What can be done?

While the problem is multifaceted and the collective traumatization of hordes of young doctors must end soon &ndash; measures to do so have not yet been conceived. The new <a href="https://timesofindia.indiatimes.com/india/do-away-with-seat-leaving-bond-national-medical-commission-tells-states/uts/articleshow/107093513.cms">PG medical education guidelines</a> released in 2023 have not addressed any issues regarding mental health problems and burnout among PG residents.&nbsp;

There are a few tangible steps that need to be taken urgently. Removing the seat-leaving fees seems to be the logical next step so that no one is financially coerced into completing a degree they no longer want. Other steps include hiring non-PG residents, senior residents, etc. so that there is no lack of manpower, and ensuring that employed staff performs their duties adequately.

Measures to strengthen infrastructure in colleges are essential to ensure that patient care systems in hospitals are not run on the backs of PG students. The systematic exploitation of resident doctors to fill in the gaps in manpower must be done away with completely. In the future, introducing some labour protection and making PG stipends uniform and adequate across states may be explored.&nbsp;

There is also a need to understand that a postgraduate degree is a service availed by the student from a college, having paid the stipulated fees. The college has a responsibility to provide a well-structured education to the students in a professional environment, without resorting to overburdening young doctors. Having disciplinary bodies at the level of the colleges, states and the centre is also necessary to ensure that students can safely raise their concerns without fear of persecution.

With work done on all these fronts, hopefully, post-graduate medical education in India can create not just efficient doctors, but better carers of health. If the healthcare system does not pay heed to the call of its students, who will?

Image by Janvi Bokoliya

Quality of post graduation medical education in India needs to reviewed to improve the quality of life of doctors and patient care.

The Untold Story Of Postgraduate Medical Education In India

In 2012, the second episode of <a href="https://www.india.com/viral/watch-aamir-khan-speak-about-child-sexual-abuse-in-satyamev-jayate-on-international-day-of-innocent-children-victims-of-aggression-69693/">Satyameva Jayate</a> aired on national television, bringing the conversation of child sexual abuse to India&rsquo;s living rooms. The episode featured a brave young man who spoke out about his experience of child sexual abuse in his family, thus challenging the notion that sexual abuse is a crime that is committed exclusively against girls and women. &ldquo;I did tell my mother something was happening&rdquo;, tells the young man on national television as the camera shifts to the parent, putting her on the spot. In reply to Aamir Khan&rsquo;s inquiry as to why she didn&rsquo;t do anything, the mother replies, &ldquo;I didn&rsquo;t know such things even happened. I did not know what I could have done.&rdquo;

Since then, <a href="https://journals.lww.com/ijmr/Fulltext/2015/42010/Child_sexual_abuse__Issues___concerns.1.aspx">India&rsquo;s child abuse statistics</a> reveal that more male children are being sexually abused compared to female children (55% boys as compared to 45% girls) in our country.&nbsp; Even though more and more men are coming out and talking about their experiences, most Indian families still struggle with the idea of boys being subjected to sexual violence.

A female child is subject to a lot of restrictions on freedom of movement in our country as she is perceived as being vulnerable to sexual violence from others. However, this lack of knowledge about the abuse of boys leaves them open to predators, as their increased freedom of movement is not supplemented with knowledge on how to protect themselves or how to ask for help if an untoward event occurs.&nbsp;

Just like female children, India&rsquo;s statistics reveal that male children too are subjected to sexual violence which nearly 95% of the time is by <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4311357/">known people</a>.&nbsp; &lsquo;<a href="https://www.blueumbrelladay.org/wp-content/uploads/2021/03/caring-for-boys-report_march.pdf">Freedom at a price</a>&rsquo; report from countries including India, reveals that in 2021 the experience of abuse for a male child was shaped by several cultural narratives that hindered them from availing help and healing optimally.&nbsp;

There may be a fear of societal ridicule, as patriarchal definitions of masculinity may categorize a child as being weak or &lsquo;not a man&rsquo; for having allowed sexual violence to happen to him. Additionally, in cultures like India where heterosexuality is the norm, the fear of judgement for having had a male&ndash;male sexual interaction with the abuser also leads to internalized shame for the child. The idea that a man must always enjoy sex has also led to the rebranding of events of male child sexual violence perpetrated by older women as a <a href="https://www.indiaspend.com/most-men-are-pressured-by-society-to-pass-off-their-sexual-abuse-as-a-rite-of-passage-73833/">rite of passage</a> in the journey toward manhood. This has allowed our society to erase many instances of male child sexual abuse from our collective consciousness.

Many studies also show that most male children do not disclose their experiences for fear of their experience being <a href="https://academic.oup.com/bjsw/article/52/8/4588/6570932">dismissed or minimized</a>, which would further invalidate their trauma. Studies show that men do not disclose their abuse for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9230611/">decades</a> after the incident has happened. A few anecdotal mentions in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5547862/">studies</a> also revealed that even on the odd chance of disclosure, families expect male children to be more resilient and deal with trauma better than female children.&nbsp;

Child sexual abuse leads to multiple long-term health-related consequences, both physical as well as mental. The victims are at very <a href="https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30286-X/fulltext">high risk</a> of developing depression, anxiety, dissociative symptoms as well as substance abuse tendencies. Across the board, males have the same chances of developing these outcomes as female victims. Furthermore, studies reveal that disclosure is an important part of the healing process. Disclosure and supportive response towards the same accelerate healing, while increased time to disclosure is associated with <a href="https://www.sciencedirect.com/science/article/abs/pii/S0145213413002512?via%3Dihub">worse outcomes.</a> The other predictor of worse outcomes is adherence to masculine norms, both in the individual and the society the child belongs to. High conformity to masculine norms is also associated with a <a href="https://pubmed.ncbi.nlm.nih.gov/23313078/">higher risk of suicide</a> in male victims of child sexual abuse.

These studies indicate that not only is it important to disseminate information among families but also among clinicians to help them look for and identify signs of abuse in children of both gender and not only female. As a positive response to disclosure is a crucial predictor of positive outcomes, sensitizing the clinician to respond adequately and affirmatively to a child who has disclosed is also very important. Social support provided by the family and society at large is extremely important as well. Dismantling existing harmful masculine norms would ensure that any male victim of sexual violence does not internalize the shame of having gone through that experience.

&lsquo;<a href="https://outoftheshadows.global/">Out of the Shadows Index</a>&rsquo; was developed to rank countries and their provisions to both prevent as well as respond to complaints of child sexual abuse. The United Kingdom which has been deemed to have the most robust response towards child protection ensures positive responses to complaints by children and also provides a sensitized environment for the child to seek justice in a manner&nbsp; that does not let them experience the trauma again and again. For example, the testimony of the child is obtained in a non-threatening environment with a camera so that the child does not have to face the person who perpetrated the crime in a courtroom full of strangers. India has a lot to learn in terms of providing all levels of care adequately for a male child.

Recently there is increased media exposure to this problem with short movies like <a href="https://www.youtube.com/watch?v=obN-cjvq0js">Candy Man</a> by Insia Dariwala winning awards and the 16th of April being declared as &lsquo;Blue Umbrella Day&rsquo; globally to spread awareness about protecting boys. These incidents happening on a daily basis show us that the male child is stuck in a patriarchal system that he must conform to at great risk to his own self.

However, Non-Governmental Organisations like Tulir and Butterflies are continuing to work towards a better future. <a href="https://www.thehindu.com/news/cities/Delhi/children-take-centre-stage-to-raise-awareness-about-sexual-abuse-of-boys/article66741922.ece">Workshops</a>, plays, and other educational events are being organized by these NGOs to educate parents on how to respond and how to help prevent child sexual violence. In 2018, the <a href="https://www.thehindu.com/news/national/govt-approves-amendments-to-pocso-act/article25850988.ecee-of-boys/article66741922.ece">amendment</a> to the POCSO Act also ensured that abuse against boys is taken as seriously as abuse against girls legally. These changes shine a ray of hope on what appears to be a long and winding road that the Indian subcontinent must walk to ensure that the future is safe for all its children, not just its daughters.

Edited by&nbsp;Parth Sharma.

Image by&nbsp;Janvi Bokoliya.

Sexual abuse is more common in male children than female children in India.

Child Abuse: Not Just India’s Daughters

After explaining that there was a high suspicion of stroke and convincing them to do a CT scan, I walked to the nursing station to enter my notes, where I heard a throwaway comment from a nurse - &quot;Why don&#39;t these people just die off instead of coming here and burdening us?&quot; Shocked beyond measure, I just stood there wondering whether this thought would have risen in her mind if the patient who had come with these same complaints was cisgender (a person whose gender identity corresponds with the sex registered for them at birth)

I suddenly realized that even after more than a decade in healthcare, this patient was the first and only transgender patient (a person whose gender identity does not correspond with the sex registered for them at birth) I had encountered. Many healthcare professionals I know have not treated even one person with a trans or non-binary (a person whose gender identity does not fit in the male-female binary) identity. India&#39;s transgender population is estimated at 4.8 million by the <a href="https://journals.plos.org/globalpublichealth/article?id=10.1371%2Fjournal.pgph.0002933&amp;s=08#pgph.0002933.ref004">2011 census</a> - a count of the number of people who have marked their gender identity as &lsquo;Other&rsquo; (a probable underestimation considering the stigma of disclosure and the fact that some transgender people may have marked the gender concordant with their identity), and it appears that their healthcare needs are significantly underserved.

Insights from Research

According to a recent <a href="https://journals.plos.org/globalpublichealth/article?id=10.1371%2Fjournal.pgph.0002933&amp;s=08#pgph.0002933.ref004">study</a> by Dr. Harikeerthan and colleagues in PLOS Global Public Health, people who do not subscribe to the gender binary face severe discrimination while trying to access health, both within and outside the system. This study attempted to analyze the barriers that transgender people face when accessing healthcare. The uniqueness of the study was the fact that the focus was not just on HIV-related or gender-affirming care but also on health-seeking for general complaints. The interviews conducted in the study with several persons holding transgender and non-binary identities revealed that access to health systems remains dismal.

The authors reported that many transgender people admitted to self-treating their ailments or waiting to seek healthcare until the illness progressed. Some even admitted that they would access healthcare only if they thought they had a life-threatening condition. The most common reason cited for this was the fear of being discriminated against and unfairly taken advantage of.&nbsp;

Similar findings have been previously reported. A <a href="https://pubmed.ncbi.nlm.nih.gov/38028887/">study</a> published in 2023 in the Journal of Migrant Health assessed the impact of the COVID-19 pandemic on the health of transgender women. The study revealed that many transgender women decided not to take the COVID-19 vaccine due to fear of hostility in the vaccine centers, thus exposing themselves to the danger of severe coronavirus infection.

&quot;Most people with a trans identity also end up going to a few doctors that they know are safe. They may know these doctors through friends who also go to them. However, they may not be the right specialist doctors for the condition that the patient has. This way, they end up not receiving the right kind of care that they need,&quot; adds Dr. Harikeerthan Raghuram.

Another <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5178031/">study</a> also suggests that the burden of mental health issues and suicidal ideation is very high among people with transgender identities. Social and financial marginalization also predisposes them to substance use and sex work which worsens their mental health. However, most mental healthcare services too,<a href="https://www.frontiersin.org/articles/10.3389/fgwh.2023.1126946/full"> remain out of reach </a>for transgender persons.

Discrimination in the healthcare systems occurs at various levels including at the mode of transportation used to reach the healthcare facility. In the study by Dr Harikeerthan and colleagues, transgender persons mention being stared at, commented upon, and joked about by all personnel employed at the healthcare facility starting from security guards stationed at the gates, nurses, and ward boys to sometimes even other patients and their bystanders. Outside of overtly hostile language and actions, they also feel subtle body language shifts that express to them that they are unwanted there.

Even after admission, nurses express discomfort in carrying out duties like giving sponge baths,&nbsp; if the patient holds a trans identity. They instead request the bystanders to administer such care to the patient, a transgender activist mentioned in the <a href="https://journals.plos.org/globalpublichealth/article?id=10.1371%2Fjournal.pgph.0002933&amp;s=08#pgph.0002933.ref004">study</a> by Dr Harikeerthan and colleagues.&nbsp;

A few other transgender folks in the study also expressed having to face gender dysphoria as hospitals addressed them by their deadnames (a name the transgender person was assigned at birth but isn&rsquo;t using anymore upon transitioning), refused to accept ID cards if they were not gender-conforming, and refused to provide professionals of their preferred gender for examination. Some even complained about being subjected to examination without consent by professionals. A few transgender people who could pass themselves off as cis people chose to do so at hospitals at the expense of their mental health as they felt they were being treated better when they appeared cisgender

Towards inclusive healthcare

I recount to Dr. Harikeerthan, an incident that occurred when we were on rounds and met a patient who decided to disclose their intersex (a person born with both male and female biological traits, an umbrella term which encompasses several biological variations) identity to the treating team. After hearing that, the consultant physician (in front of the patient) suddenly asked to add tests to screen for sexually transmitted diseases to the patient&rsquo;s evaluation. According to Dr Harikeerthan, people within the trans community are more vulnerable to sexually transmitted illnesses. However being intersex is not being trans, a common misconception among many people. Focused gender sensitivity training is needed to help physicians clarify their own misconceptions and phrase their concerns in a better manner.

&quot;While there have been changes in the MBBS curriculum, gender sensitivity training needs to be a part of the education of a wider range of professionals employed in healthcare - nurses, physiotherapists, occupational therapists to mention a few,&quot; says Dr. Harikeerthan. &quot;However in India, doctors are seen as the leader of the team in healthcare, so I expect that the changes made in the MBBS curriculum will also have a ripple effect in ensuring that the rest of the team adopts a more inclusive approach towards a patient with a trans identity&quot;, he adds.

Even structurally, hospitals and other centers that focus on health delivery are designed with the gender binary in mind. There may be gender-based separation in queues, restrooms, and wards which causes confusion as well as discomfort for the trans person accessing care. &quot;Eventually a redesigning of these places to make them inclusive is very important, however, a few clinics need to be established now everywhere where transgender people can access safe quality healthcare until those structural and systemic changes can be brought about,&quot; says Dr. Harikeerthan.

Solutions are possible - but must be multipronged and require concentrated effort. An expansive curriculum change that begins at the school level is necessary to ensure that all professionals in the healthcare industry are adequately educated on gender and sexuality. Collaboration with transgender advocacy groups and other community members is essential to redesigning hospitals and healthcare delivery areas to make them inclusive. Telemedicine services too can make healthcare more accessible for transgender people without subjecting them to the trauma of navigating a hostile system.

At last, there is a need to increase&nbsp; awareness in the transgender community as well as the medical fraternity about the laws that will punish discriminatory practices by healthcare institutions to safeguard the interests of transgender individuals. With the Transgender Persons (Protection of Rights) Act of 2019, the government of India has recognized the civic identity of individuals belonging to the transgender community. However, there is a long way to go before the practical realization of the community&#39;s right to health.

Edited by Parth Sharma

While aiming for universalizing healthcare, is our health system making sure to include everyone in this ambitious dream?

Beyond the Binary: Addressing Healthcare Disparities for Transgender Communities in India

&quot;I believed that I would have some pain in my leg immediately after having my hip replacement surgery and hence did not point it out to the doctor who came for rounds&quot;, said Mr Matthew (name changed). Mr Matthew was an active 70-year-old gentleman, whose goals after surgery included being able to independently do his daily activities. This required being completely pain-free, something Mr Matthew didn&rsquo;t believe was possible.

&quot;Eventually, people noticed that my heart rate was high all the time in the ward. They repeated some blood tests and wondered whether I had lost too much blood during surgery. They also said they were worried about infection. Only after some time, they asked me whether I had pain. When I said I did, they went up on the dosage of the painkillers. Just like that, as the pain disappeared, they noticed my heart rate normalised too. I wish I had known that the normal amount of pain after surgery was zero,&quot; he said.

Unawareness blocks access to pain relief

&quot;Doctor, how much will this surgery hurt?&quot; is probably one of the most common questions that any surgeon or anaesthetist will encounter in their office when counselling a patient for surgery. However, many patients and healthcare professionals alike carry many misconceptions about pain.

Dr Parul Raina, a consultant anaesthetist at Sharda Hospital, Noida, recalls an incident where a teenage girl was in tears because of the fear of her upcoming surgery. &quot;Her mother was consoling her by saying that some pain would be there during surgery and afterwards. She was told that she had to adjust to it,&rdquo; told Dr Parul. The fact that adjusting to the pain was considered to be the only option was shocking to Dr Parul.&nbsp;

&ldquo;Over the years, I realised this is a widespread misconception among people - especially those of low socioeconomic status. Since then, I have made it a point to explain to patients that they do not need to adjust to pain and they must insist on adequate and complete pain relief.&quot; - Dr Parul Raina.

Pain after surgery which is often considered &lsquo;normal&rsquo; can also suggest something sinister. However, the lack of awareness in the patient prevents them from seeking care. &quot;After tooth extraction, if pain persists for more than a day, it might suggest that there is an infection or a dry socket (where the jawbone becomes exposed). Corrective measures can make the pain go away,&quot; said Dr Madhushree Rao, a practising dentist from Assam. &ldquo;However, unaware of the problem, the patients often end up tolerating the pain.&rdquo;

Similarly, pain after eye surgery could be due to an increase in the pressure within the eye. &ldquo;This can be a potentially sight-threatening complication and hence, I take post-surgical pain very seriously&quot;, added Dr John Sangma, an eye surgeon serving the tribal Garo population in a Christian Mission Hospital in Babupara, West Bengal.

&quot;Sometimes patients take pain relief into their own hands,&quot; said Dr John. One of the issues that he struggles with is the widespread use of herbal juices and steroid eye drops to relieve pain caused due to eye injuries. &quot;Patients come to me after applying these home remedies which worsen their conditions and invariably lead to fungal ulcers.&quot; Dr Madhushree too, receives patients who self-treat their dental pain with tobacco and clove oil and has to extensively counsel them against the same.

Many patients also seem to complain of long-term pain several years post-surgery. It is a common phenomenon that physicians see in the outpatient department. &quot;It is important to validate the patient and evaluate the pain they are complaining about&quot;, says Dr Parul, &quot;Most doctors do not take it seriously as they feel that the correlation the patient has made between the pain and past surgery is irrelevant. However, doctors need to remember that there is always a possibility of nerve injuries during surgery which can cause longstanding pain. And even if the patient&#39;s correlation is not right, the pain itself must be evaluated as they have sought medical help for the same.&quot;

Inequitable access to pain relief

While pain relief during surgery is a right and a fundamental part of surgical healthcare, access to the same is not equitable. &quot;We do not have an anaesthetist in my centre, hence we cannot offer general anaesthesia for eye surgery,&quot; said Dr John. &quot;That means I cannot operate on children or patients who are uncooperative. And we are the only centre&nbsp; available for the Garo people who sometimes travel around 200 km to reach here.&quot;&nbsp;

As Dr John believes in offering robust pain relief, he uses nerve blocks instead of topical medicines. As he is a single doctor who performs dozens of surgeries per day, he has trained an assistant who administers the blocks.&nbsp;

However, when one speaks about inequitable access to pain relief, one does not need to look beyond labour analgesia to witness the stark reality. &quot;Epidural analgesia during labour is almost universal in developed countries but is hard to realise in the public health setups in India&quot;, says Dr Diana Terangpi, a senior resident in Obstetrics and Gynecology in Satribari Christian Hospital, Assam.&nbsp;

According to Dr Parul, most government setups do not practice epidural anaesthesia and the ones that do, do not offer it to patients routinely as an option. Epidural anaesthesia is a mode of injection of a pain relief drug in the spinal column that causes significant pain relief during childbirth. The inequity in access to this form of pain relief is similar to most other health services. &quot;Only rich people in private setups can access epidural analgesia,&quot; added Dr Parul.&nbsp;

The availability of the service also depends on the expertise present at these government institutions. While Dr Parul provided epidural anaesthesia to multiple patients in AIIMS Delhi, she did not get to do a single epidural while she was practising at Jammu Government Medical College. &quot;Epidural needs regular monitoring, good operation theatre set up as well as a duty anaesthetist at all times which is not possible given the infrastructural limitations of government hospitals. So in these areas, we tend to rely on injectable drugs such as opioids to provide some pain relief to patients,&quot; says Dr Diana.

Breaking the barriers to pain relief

The ultimate solution to poor access to pain relief, i.e. making pain relief affordable and accessible, lies at the policy level. However, healthcare providers can also contribute to making pain relief more accessible. Doctors need to not just be prescribers of care but also educate patients about pain relief and bust the myths blocking access to a pain-free life. &quot;I invest a lot of effort into creating awareness that the use of untested herbal medicines for pain relief can cause harm. I have noticed that more and more people now come to me to seek proper pain relief,&quot; said Dr John.

Not all pain relief is pharmacological according to Dr Diana. &quot;Motivating the patient, spending time with them, counselling them about what to expect, and teaching pregnant mothers breathing exercises are all ways to add on to pain relief which does not depend on medications&rdquo; said Dr Diana. Overcrowded government hospitals prevent doctors from dedicating adequate time to patient counselling. However, shifting this task to nurses and other healthcare providers can ease the burden on the doctors and improve patient care at the same time.

Often, the biggest barrier is the lack of a doctor&rsquo;s ability to use available drugs to provide relief from pain. Pallium India&rsquo;s <a href="https://palliumindia.org/essentials-of-palliative-care-india">online training program</a> makes acquiring this skill possible through distance learning. &ldquo;Our training program has enabled thousands of healthcare workers to be empathetic about other&rsquo;s pain. Our evaluation has shown us that our course has helped healthcare workers assess and treat pain confidently,&rdquo; said Dr Sreedevi Warrier, Head of Education and Skill Building Division of Pallium India.

It is high time we addressed the poor access to pain relief in India. Pain, tolerating which is often considered as the only option, should be actively addressed. Till policy changes improve the overall scenario, healthcare providers should make the best possible attempts to keep their patients pain-free.

&nbsp;

Edited by Parth Sharma.

Image by Janvi Bokoliya.&nbsp;

&nbsp;

Surgical care doesn't end at the operation but also involves provision of adequate pain relief. However, various barriers affect access to pain relief in India.

Pain Relief: A Crucial Yet Often Inaccessible Part of Surgical Care

India, the OG land of overpopulation woes, seems to have a curious approach to contraception. You&#39;d think a country crumbling under the sheer weight of its population would embrace anything (except genocide) that helps control it. But no, that would be common sense.

Recently, a girl dared to post a picture of her holding an i-pill (an emergency contraceptive) with the cheeky caption - &#39;girl breakfast.&#39; The response? A delightful torrent of negative comments! Some questioned her morality, some her health choices, and some even her future fertility. These comments loaded with misinformation and biases indicated that there is still much work to be done on this front.

But well, who can blame the &lsquo;aam aadmi&rsquo; when the people in power and people of science carry these very same biases themselves?&nbsp;

Not too long ago, the Drug Controller of Tamil Nadu, in a nearly comic move, made it incredibly hard for women to access emergency contraception. All emergency contraceptive pills vanished from pharmacies across the state, resulting in a <a href="https://www.thecitizen.in/index.php/en/NewsDetail/index/7/20438/Accessing-Contraceptives-Under-the-Shadow-Ban-in-Tamil-Nadu--">shadow ban</a>, so much so they were not even available in <a href="https://www.thenewsminute.com/premium/unsuccessful-hunt-emergency-contraceptive-pill-chennai-165554">government hospitals</a>. The reason? According to him, women would run wild if they had access to a pill that allowed them to have sex without constantly fearing the consequences. It makes perfect sense, doesn&#39;t it?

In India, the notion of women having control over their own bodies and reproductive choices is as unsettling as a horror movie plot. Even healthcare providers, the so-called people of science, are often found requesting spousal consent for procedures like <a href="https://behanbox.com/2022/07/24/why-indias-abortion-law-needs-to-be-rid-of-moralism/">abortion</a>, contraceptive prescriptions, and more, even when the law says otherwise. Because who cares about agency, right?

But let&rsquo;s dig deeper to see why this horde of well-meaning men is against women&rsquo;s access to contraception.

&ldquo;Women nowadays are irresponsible and engage in unprotected sex&rdquo;, says a large group of Indian members of the male persuasion. A whopping <a href="https://www.dw.com/en/why-are-condoms-unpopular-in-india/a-41453636">5%</a> of these well-meaning Indian men are willing to protect themselves and their partner by wearing male condoms during sexual intercourse with a <a href="https://www.dw.com/en/why-are-condoms-unpopular-in-india/a-41453636">52%</a> FALL in usage in the past decade. (Wait, what?!) <a href="https://www.frontiersin.org/articles/10.3389/fsoc.2021.689980/full">Studies</a>, (un)surprisingly, also reveal that most Indian men share their belief with the Drug Controller of Tamil Nadu, that women will go wild and start a promiscuous spree if they get access to contraception. However, more than <a href="https://www.thehindubusinessline.com/data-stories/data-focus/data-focus-fact-check-on-awareness-and-use-of-contraceptives-in-india/article66064786.ece">one-third of men</a> also believe that contraception is a woman&rsquo;s responsibility. The math just isn&rsquo;t mathing with this one.&nbsp;&nbsp;

According to another group, women do not understand or care about the health-related side effects of oral contraceptive pills. Luckily for us,&nbsp; <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10157918/">about 0.3% of Indian men</a> got us covered from these same side effects by getting vasectomies!&nbsp;

&ldquo;Why not get a tubectomy instead&rdquo;, said a testy Twitter user in a comment on the young lady&rsquo;s post. Of course, why shouldn&rsquo;t women want to get an invasive procedure that cuts into their abdominal cavity and carries the risk of various complications and even death? The only other option is for males to get <a href="https://embryo.asu.edu/pages/no-scalpel-vasectomy">vasectomies</a> - a procedure where a small hole, not even an incision, is made in the skin of the scrotum to ligate the tubes. Sounds scary right? This procedure has been available for Indian men for <a href="https://embryo.asu.edu/pages/no-scalpel-vasectomy">more than a decade</a>. However, the fear of this dangerous procedure which takes as long as 15 minutes, has prevented them from opting for it.

So what lies underneath this apparent Indian concern for female reproductive health? For that, we need to understand what contraception did for women across the Globe.

When we talk about women&rsquo;s empowerment, we often discuss education and employment. But <a href="https://www.forbes.com/2010/05/12/sexual-revolution-planned-parenthood-unplanned-pregnancy-forbes-woman-health-birth-control-pill.html?sh=4ff15fd62133">contraception or birth contro</a>l is one tool that truly liberated women and gave them time to pursue said <a href="https://www.pbs.org/wgbh/americanexperience/features/pill-and-womens-liberation-movement/">education and employment</a>. It gave them the <a href="https://www.journals.uchicago.edu/doi/full/10.1086/340778">freedom</a> to have lives beyond just popping out babies and helped them <a href="https://www.cfp.ca/content/58/12/e757.short">pursue careers and dreams</a>. It liberated them from being broken on the wheel of childbirth again and again.

So at the end of this mystery chase, we unmask our Scooby Doo villain and find that under the mask of concerns about morality, health, and fertility, lies the average Indian&rsquo;s need to control the lives of women. That is it. Plain and simple. That is why we expect one-half of the population to bear the entire burden of family planning while systematically stripping them of access, information, and agency. This Indian war on contraception is nothing more than a thinly veiled war on women.

If you are confused by the slew of conflicting information around contraception (especially emergency contraception) and want access to evidence-based information on the same, tune into our podcast - Public Health Simplified (in both <a href="https://podcasters.spotify.com/pod/show/nivarana">Hindi</a> and <a href="https://podcasters.spotify.com/pod/show/nivrana">Tamil</a>) this weekend and listen to us discuss scientifically proven information with qualified gynecologists! 
&nbsp;

Image by Janvi Bokoliya.

Edited by Parth Sharma.

&nbsp;

India has the most progressive contraception policies on paper. Yet women struggle to access contraception.

India’s Contraception Conundrum

Christianez Ratna Kiruba is a physician, patient rights advocate and the Deputy Editor at Nivarana.

Christianez Ratna Kiruba is a physician, patient rights advocate and the Deputy Editor at Nivarana.

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Christianez Ratna Kiruba

Christianez Ratna Kiruba

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