© 2022 Marina Vladimirovna BAKANOVA
2022 – № 1(23)
Bakanova M.V. (2022) Fenomen agressivnogo otnosheniya patsientov k lecheniyu i profilaktike COVID-19 v Pakistane [The Phenomenon of Patient Aggression Towards Treatment and Prevention of the Covid-19 Epidemic in Pakistan]. Meditsinskaya antropologiya i bioetika [Medical Anthropology and Bioethics], № 1(23).
Chief Physician of the International Medical Care Center “Dua Hospital”
Keywords: doctor-patient conflict, patient aggression phenomenon, Pakistan, COVID-19 epidemic, medical anthropology.
Abstract: The problems of the “doctor-patient” relationship have recently attracted more and more attention from specialists. The phenomenon of aggressive behavior of a patient towards a doctor is recorded in all countries of the world, including in Pakistan. The country’s government is not making the slightest effort to legally solve it. It is worth noting that the COVID-19 pandemic has only exacerbated this problem, increasing the number of either verbal and physical attacks by patients or their relatives against medical personnel. Many doctors suffered moral, material and physical damage as a result of this, which was reflected in their departure from the Pakistani understanding of international concepts of prevention and treating patients in the context of the coronavirus epidemic. At the same time, many of the doctors would like to receive state guarantees of protection in conflict situations, but at present, they are forced to rely more on the strength of the hospital walls, private security and their own self-defense skills.
The quality of work of any person is affected by working conditions: both physical and psychological. However, doctors are in special conditions: interaction with the patient and his relatives, emergency cases, damage to the psychosomatic profile, etc., which lead to original phenomena of interaction within the framework of the “doctor-patient” concept.
The phenomenon of aggressive behavior of a patient towards a doctor occurs in all countries of the world, and often ends badly in relation to one of the participants in the conflict. However, exploration of the phenomenon from a professional point of view and the development of methods for solving it began quite recently. [Deryushkin, Gatsura et al. 2021] The deformation of the doctor-patient relationship is becoming more and more relevant and is being developed in the research field not only of medical sciences, but also of sociological, legal, economic and psychological sciences [Gatsura, Deryushkin et al. 2019]. Many researchers consider the current situation to be dramatic and see the reasons for the deepening of the crisis in the excessive “technicism” of medicine, the dehumanization of the “doctor-patient” relationship, the increasing demands of the population for the quality and accessibility of medical care, and the imposition of a negative image of a medical worker, including by the media. This problem is acute in all countries of the world, although there are certain regional particularities. [Kowalczuk, Krajewska-Kulak 2017]
It is also worth noting that physicians are subject to aggression from patients or their relatives much more often than is commonly believed. Despite the fact that the main objects of violence in most cases are specialists in emergency services, resuscitation, surgery or obstetrics, other doctors also encountered manifestations of aggression in practice. At the same time, most doctors prefer to hide such incidents, often considering aggression as a manifestation of a patient’s somatic or mental illness, his inadequate response to the fact of his illness or treatment method, or a psychological breakdown in response to the loss of a relative. The COVID-19 pandemic, on the one hand, led to the glorification of doctors (not always and not everywhere), and on the other hand, it increased aggression towards them when the harsh conditions for providing medical care during a pandemic directly affected them or their relatives.
The problem of the patient’s trust in the doctor is quite acute in Pakistan. This is due to the system of organization of medical care and the low level of state resources aimed at supporting both doctors and patients, as well as the legal insecurity of both participants in the treatment process. At the same time, the problem itself is relatively new for Pakistan and is associated with an increase in the general level of education in the country, with an increase in the share of critical thinking and debunking myths about the “infallibility” of a doctor and a violation of absolute trust in “one’s own” specialist. In addition, local media (usually the yellow press) began to actively interfere in the doctor-patient relationship, especially in cases of a negative outcome of treatment. Thus, Pakistan is clearly in trend with the world system, where there is also a crisis in the doctor-patient relationship. At the same time, the country has rather weak control over the use of weapons, which makes the doctor’s position extremely vulnerable.
The COVID-19 epidemic, not accepted and not understood by the population of Pakistan, only exacerbated the process of misunderstanding and intensified the phenomenon of patient aggression in relation not only to the treatment and prevention of the infectious disease itself, but also directly to medical workers. [Bakanova 2021a]
Thus, the aim of the study was to determine the existence of the phenomenon of aggressive attitudes of patients towards doctors in the context of the COVID-19 epidemic in Pakistan.
Based on the goal, the following tasks were set:
- Determine the number of physicians who have encountered the phenomenon of verbal or physical aggression of patients
- Identify the main causes of patient aggression
- Determine the level of protection of doctors from aggression
- Outline the circle of “wishes” of doctors to organize a system for protecting doctors from the aggression of patients
The study of the problem was carried out by analyzing information from medical social networks in Pakistan. The number of doctors participating in the surveys ranged from 54 to 73 people at different stages with a sex ratio of approximately 35% women to 65% men. The main medical specialties represented are general practitioners, pediatricians, surgeons, obstetrician-gynecologists, resuscitators. It is worth noting that the country is actually deprived of infection specialists and doctors of all specialties had to work with patients with COVID-19.
According to the data obtained, almost every doctor faced verbal aggression in their practice (before the pandemic, the level of verbal aggression was about 70%), physical aggression has grown from 15% to 35%. It should be noted that in private clinics, manifestations of aggressive attitude on the part of patients are observed much more often than in public ones. This is primarily due to the fact that a state doctor is protected much better than a private one, and it is useless to complain about him to any authority.
Much of the verbal abuse that Pakistani medics had to deal with was verbal abuse and threats:
- Insults of a private and general nature, profanity
- Threats of physical harm against a doctor or members of his family
- Threats to call the media and disparage the doctor/clinic as unreliable
- Threats of complaints to high-ranking relatives or friends
Verbal aggression was mainly manifested by such facts as:
- Requirement for patients and accompanying persons to wear masks/special clothing while in the hospital
- Requiring patients and accompanying persons to regularly test for Covid-19
- Increase in prices for services of private clinics due to the increase in the cost of tests, overalls, sanitization, etc.
- Prescribing “heavy” drugs for treatment – the accompanying persons considered them “harmful”
- The rest of the facts remained the same as before the pandemic.
Nursing staff mainly experienced mild physical violence – holding hands, grabbing clothes, etc., when they tried to protect the doctor from communicating with aggressively minded relatives of patients. However, it was not always possible to build a barrier of inaccessibility of a doctor for patients or their relatives. In this case, the doctor often had to hide behind the walls of the office, operating room, leave the hospital through the evacuation rooms.
Actually physical violence – suffocation, pushes, blows, threats with weapons (up to the use of them) was not very important in statistics – about 35%, however, it increased by about 20% compared to pre-pandemic times. Quite remarkable was the fact that female doctors suffered from physical aggression no less than their male counterparts did. However, if both men and women could attack a male doctor, then men tried not to attack women doctors, but subjected them to verbal humiliation, physical attack in these cases came from women, and older ones. It is also worth noting that paramedical personnel were also subjected to physical violence, especially in cases when they tried to protect a doctor. There was no perceptible difference in exposure to physical violence between physicians of different specialties.
In addition to the above facts, the phenomenon of physical violence was caused by:
- Death of a patient, especially in case of an acute shortage of funds that could save life (for example, oxygen cylinders)
- Non-delivery of heifer-like patients with a confirmed infection, whose burial was carried out by special services without the possibility of relatives to say goodbye to the deceased, to perform rituals, in a special cemetery in closed plastic containers.
- Denial of hospitalization of hopeless patients in private clinics (doctors tried to transfer such patients to public hospitals so that they would not be subsequently subjected to aggression when they died), public hospitals often refused to accept patients in the absence of places or medicine.
It is worth noting that the facts of aggression did not go unnoticed for the doctors themselves. Most of them (up to 90%) point to tangible moral damages that cannot be compensated in the conditions of Pakistan. About 10% believe that moral damages to them were compensated in connection with the received apologies or material gifts. The blow to professional reputation was also significant (up to 65%), especially in cases where there was interference in the conflict by the media (20-25% of all conflicts). Some doctors (15%) were forced to pay significant compensation to the patient’s relatives in order to avoid publicity of the conflict in the press, even in cases where “the truth was on the side of the doctor”, about 25% of doctors were forced to cancel payment to the patient for the procedure (surgery, hospitalization, etc.) without payment of an additional amount of money. 35% of doctors also experienced physical damage: from mild forms (bruises, abrasions) to severe ones with forced hospitalization. In the framework of this study, such information was not confirmed, but in the whole country, there were several resonant (in the medical environment) murders of doctors during the conflict.
The Government of Pakistan and the Ministry of Health of the country have introduced very stringent standards and requirements for hospitals and doctors working in them to comply with the prevention of COVID-19 for both infected patients and patients admitted to a hospital with other emergency indications. [Ministry of Health of Pakistan 2020-2022] Requirements related to access to hospitals, isolation, not allowing relatives (both to visit and stay with the sick), testing, sanitization, requirements for the treatment of the deceased, etc., but in the general information field countries, these requirements were not commented on or explained. In this regard, doctors were placed in strict conditions for their observance, and patients and their relatives simply did not know about the existence of such requirements and tried to negotiate conditions corresponding to “pre-Covid times”. The radical-religious part of society treated most of the problems most acutely, considering the “unfair demands of the doctor” incompatible with the requirements of religion and not believing that they come from state norms and regulations. Thus, the state at the moment, by its actions, intensified the “doctor-patient” conflict, while not protecting doctors in any way. An additional catalyst was the religious factor, usually associated with the problems of burial of the dead. Only one relief was made for doctors (and medical personnel in general) – those who contracted COVID-19 while working with Covid positive patients and died from this infection, they were equated in status to “shaheeds” (those who died for their faith, which applies mainly to the Pakistani military who died during border conflicts or while participating in foreign military missions) with large payments and benefits to their families. The doctors who suffered from conflicts with patients (even specifically when fulfilling state requirements for the prevention of the spread of COVID-19) did not have such a status and the state did not care about them. Thus, often the implementation of state regulations was reduced to state hospitals or large private ones, where checks were carried out and in many respects, it was formal, so as not to inflate the conflicts that had arisen. Most private hospitals began to ignore many of the requirements already 6 months after their introduction, due to a decrease in patient flows and an increase in the degree of conflict.
The introduction of a highly stringent vaccination system has not lessened the doctor-patient conflict. During the first 6 months, vaccination was carried out on the basis of hospitals and with the participation of doctors, which caused additional conflicts in cases where: patients demanded a certain vaccine, there were problems with age (the country started vaccination for certain age categories), with the amount of payment – some of the vaccines were initially administered only on a reimbursable basis, as well as with “imaginary” and “obvious” complications that arose, according to the patient, after the introduction of the vaccine. Naturally, the level of conflicts between doctors and patients has increased, although in view of the additional guards provided by the state to control the queues, it was precisely the physical manifestations of conflicts that were minimized. But, by the summer of 2021, when, after the May supply of vaccines in Pakistan, the situation with their availability for the entire population more or less normalized, doctors for the most part preferred to abandon additional workloads due to mass vaccination campaigns, including due to increased conflict situations. [Bakanova 2021b] From July 2021, the government was forced to open special vaccination centers, where staff worked with a minimum training course (documentation and intramuscular injection) and did not even have a secondary medical education. Doctors in this system occupied the positions of leaders or coordinators of the work of the center, without intersecting with the population.
- It should be recognized that at the moment the level of protection of medical personnel in Pakistan from aggression from patients and their relatives remains extremely low, and at the same time, it has also been aggravated in the context of the Covid epidemic.
- Most doctors are forced to solve the existing problems on their own, most often by paying monetary compensation, regardless of the proof of the doctor’s guilt.
- The most common are verbal abuse; however, attempts at lynching up to the murder of doctors are not so rare.
- Public health authorities evade solving this problem; the situation with Covid-19 caused a twofold situation: doctors were forced to follow the orders of the healthcare system, which were incomprehensible to patients and were not accepted by them; in addition, they significantly aggravated aggression towards doctors.
- Unlike Western and Russian sources, the glorification of Pakistani doctors in the epidemic did not happen, on the contrary, the conflicts that existed before only worsened. This may be due to the fact that most of Pakistani society denies the very fact of the pandemic and considers it either American propaganda or a fabrication of the government to further oppress society.
- Accordingly, the vaccination campaign, carried out under severe pressure from the state, did not lead to improvements in the doctor-patient relationship, most doctors decided not to take part in it.
In informal statements, the opinion was expressed that many doctors would prefer to have a legal state system for resolving possible conflicts, but at the same time, they now rely more on the security of the hospital itself, the strength of the nursing staff (nurses in Pakistan are usually strong young men) and guards. Some doctors – especially young ones – chose to take self-defense courses.
Biddison L.D., Berkowitz K.A., Courtney B., et al. Ethical considerations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014; 146: 4 Suppl:e145S-e155S.
Christian M.D., Sprung C.L., King M.A., et al. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014; 146: 4 Suppl:e61S-e74S.
Committee on Economic Social and Cultural Rights Twenty-Second Session, Geneva, 25 April-12 May 2000 Agenda Item 3, General Comment No. 14. The Right to the Highest Attainable Standard of Health (Article 12 of the International Covenant on Economic, Social and Cultural Rights. Available online at: http://docstore.ohchr.org/SelfServices/FilesHandler.ashx?enc=4slQ6QSmlBEDzFEovLCuW1AVC1NkPsgUedPlF1vfPMJ2c7ey6PAz2qaojTzDJmC0y%2B9t%2BsAtGDNzdEqA6SuP2r0w%2F6sVBGTpvTSCbiOr4XVFTqhQY65auTFbQRPWNDxL(accessed June 23, 2022).
Emanuel E.J., Persad G., Upshur R., Thome B., Parker M., Glickman A., et al. Fair allocation of scarce medical resources in the time of covid-19. N Engl J Med. (2020) 382:2049–55. 10.1056/NEJMsb2005114.
Guindo L.A., Wagner M., Baltussen R., Rindress D., van Til J., Kind P., et al.. From efficacy to equity: literature review of decision criteria for resource allocation and healthcare decision making. Cost Eff Resour Alloc. (2012) 10:9. 10.1186/1478-7547-10-9.
Kerstein S.J. Dignity, disability, and lifespan. J Appl Philos 2017; 34: 635–650.
Mushanyu J, Nyabadza F, Muchatibaya G, Mafuta P, Nhawu G. Assessing the potential impact of limited public health resources on the spread and control of typhoid. J Math Biol. (2018) 77:647–70. 10.1007/s00285-018-1219-9.
Vukoja M., Riviello E.D., Schultz M.J. Critical care outcomes in resource-limited settings. Curr Opin Crit Care. (2018) 24:421–7. 10.1097/MCC.0000000000000528.