Bhopal: With the discovery of the Delta plus variant and the threat of a third Covid-19 wave looming, junior doctors in government medical colleges, forced into the forefront of India's battle against the pandemic, are worried that they will have to return to an exhausting, stressful, unhealthy and insecure work environment, IndiaSpend learnt through extensive interviews.

If they have to be put on Covid-19 duty again, the junior doctors said they would like to be paid better and on-time salaries, allowed time to pursue their specialisation, and provided necessary medical infrastructure and mental health support at work. Junior doctors [JD], also called junior residents [JR], are postgraduate medical students pursuing an area of specialisation under senior doctors at hospitals.

To understand their grievances, IndiaSpend spoke to junior and senior doctors, hospital administrators and government representatives in state-run medical colleges in Madhya Pradesh, where 3,000 junior residents of six such colleges had collectively resigned from their jobs in protest on June 3. They were supported by junior doctors from 76 other government medical colleges in the state after the MP High Court order declared the strike that began on May 31 illegal. The doctors joined duty after the state government agreed to their demands on June 7 and raised their salary by 17%.

Young doctors and medical staff have had to protest during the pandemic for even basic rights: salaries, protection from assaults by patients' families, better staffing, poor quality hospital equipment and medical help. Some graduates have also resigned from their jobs in frustration.

Junior doctors at government medical colleges who were officially assigned Covid-19 work complain that their three-year postgraduate studies have been disrupted, putting a question mark over their career progression. For those who started their postgraduate studies just before the pandemic, two of the three years will have been spent on Covid-19 work. "This won't be useful for them," said Parag Sharma, associate professor of respiratory medicine at Gandhi Medical College (GMC), Bhopal.

At the GMC, for instance, every one of the 400 or so junior doctors was put on Covid-19 duty over the last two waves, we found. This included those who signed up for specialisations such as surgery, orthopaedics and ophthalmology with no links to Covid-19 treatment, doctors said.

Junior doctors also complained that their Covid-19 tasks were largely manual in nature. "A doctor's work is to prescribe and monitor a patient whereas we have worked like technicians, monitoring equipment, dragging ventilators across wards, and manually pumping the many ventilators that came through PMCARES but didn't work," said Mohit Pancholi, 24, who is doing his first year in a master of surgery (MS) course at the GMC in Bhopal. (The central government had placed orders for 60,000 ventilators worth roughly Rs 2,350 crore in March and April 2020 partially under the Prime Minister's Citizen Assistance and Relief in Emergency Situations Fund (PMCARES), a privately audited fund chaired by PM Narendra Modi and created on March 27, 2020).

'Forced into crisis with no preparation'

Junior doctors--along with nursing staff--are vital in the everyday running of hospitals because they are typically the most numerous. "In any medical college, the biggest section of people is JRs. A lot depends on them," said Sharma.

However, even established systems at India's health facilities collapsed during the pandemic and with acute staff shortage, high rate of infection among doctors and quarantine requirements, junior doctors were pulled into unfamiliar roles, leading to widespread discontent.

As many as 1,492 doctors have died of Covid-19 since the first wave, with the Indian Medical Association (IMA) flagging 800 deaths in the second wave alone. All doctors were asked to go above and beyond their duty during Covid-19 surges, working extended hours in uncomfortable protective gear and putting themselves and their families at risk of an infectious disease that has killed at least 408,792 in India as of July 11.

By June 25, 38 practitioners from Madhya Pradesh died while on Covid-19 duty (the list includes interns, junior residents, general practitioners and senior resident doctors at both private and government facilities), IMA data show. Hareesh Pathak, a junior resident at GMC, Bhopal and the regional president of the MP Junior Doctors' Association, estimated that during the second wave alone, there have been 173 casualties on Covid-19 duty among the MP medical community (modern medicine doctors, nurses, AYUSH doctors).

"We were forced into this without any preparation, stipend honours, or securities from the Madhya Pradesh government. Unlike Maharashtra and Uttar Pradesh where doctors' stipends were raised, we haven't even received our Rs 10,000 Covid-duty honorariums which CM Shivraj Singh Chouhan promised to us," said Pathak.

The usual trajectory for medical aspirants in India looks like this: Once they clear the National Eligibility Cum Entrance Test (Undergraduate) and qualify, they join a 4.5-year undergraduate (MBBS) course followed by a one-year stint as interns at a rural facility or at an urban public hospital. They can then go in for post-graduate studies to qualify as doctor of medicine (MD) or master of surgery (MS).

Postgraduate years are crucial for the medical community. After this, students spread out into different clinical and non-clinical practices in rural India for a year-long bonded engagement. Thereafter, they may choose to work or seek further specialisation.

Collective protest

Roughly two months after the peak of the second surge, on June 3, 2021, nearly 3,000 junior residents of six state medical colleges under the umbrella of the Junior Doctors' Association of Madhya Pradesh (JUDA-MP) collectively resigned from their jobs, as we said earlier. They had the support of nearly 3,500 senior doctors, said Pathak.

For six months, junior residents at Madhya Pradesh's government-run medical colleges had been asking for security in the face of possible assault by grieving families, a 6% annual increment in their salaries pending since 2018, a 24% stipend hike, reservation of Covid-19 beds for members of the medical community, reduction of college fees and dissolution of the mandatory year-long rural posting at the end of their studies. They were given various verbal assurances by the state medical education minister Vishvas Sarang but when these did not translate into anything concrete, junior doctors said they offered their collective resignation.

"We were forced into mass resignation," said Pathak of GMC, recalling what he called a "day of horror". He said the police visited his home and even tried to persuade or threaten his parents into convincing Pathak to call off the strike. "But we didn't budge… Doctors' [demands] were not given priority in the pandemic," Pathak said.

Madhya Pradesh's first Covid-19 patient landed up in a Jabalpur hospital in March 2020, and ever since, the state's junior residents and interns have been routinely transferred to emergency coronavirus duty.

The state's post-graduate students, along with undergraduate interns, had gone on strike earlier on May 6 but had resumed their duties after a few hours when the government issued various assurances. But all through this troubled period--marked by a chain of protests, strikes and resignations for over six months--junior doctors pointed out that they had not let patients suffer. They set up parallel outpatient departments outside hospital premises under tents, started blood donation drives after filing their resignations, and set up food distribution networks to show their "commitment" to their work, said Pathak.

Warnings of shortages ignored: doctors

Despite warnings from doctors, both waves of the pandemic caught India's healthcare governance unawares. There was an acute oxygen and staff shortage at hospitals, as we said earlier.

For example, hospital beds in Madhya Pradesh were completely occupied by July-August 2020, nearly two months before the first wave peaked. Observing this, doctors in the state had indicated to the government the need for better medical infrastructure and improved work conditions in January 2021, Pathak said, roughly three months before the second wave peaked. The suggestions were not heeded, doctors said.

The shortage of doctors too could have been anticipated, said experts. As per the World Health Organization's recommendations for India, the ideal doctor-population ratio is 1:1,000. India has just over 1 million modern medicine doctors (considering 80% availability), the health ministry told the Lok Sabha in March. This translates to a doctor-population ratio of 1:1,308. In Madhya Pradesh, this dips to one doctor per 2,630 people, IndiaSpend calculations show.

Thus during the second wave, with highly transmissible variants, hospitals found their human resources stretched beyond all limits.

Demands justified, not strike: Dean

Mohit Pancholi at GMC recalled the questions junior doctors were asked when they declared their intent to strike. "Why are you on a strike?" "Are you fighting at the borders like soldiers?" Young doctors, he pointed out, should not have been pitched into this unprecedented medical crisis, often described as a "war", and forced to take on responsibilities they were not ready for.

"They were wrong to assign us JRs to Covid duty. We did fulfil them, but they took us for granted," said Pancholi.

The new dean at GMC, Jiten Shukla, said he agreed with the grievances of junior doctors but these still did not warrant a strike. "Things have been going wrong since 2020 because all [medical] branches [at the hospital] were doing Covid-19 work. They (JRs) were not getting exposure to the branches they were specialising in, for example, surgeries, orthopaedics, even ENT. But the strike cannot be justified in any case," he said.

Doctors were working under tremendous pressure during the two waves and this may have added to their resentment over low stipends, Shukla said.

Shukla also pointed out that the government had conceded to the demands of junior doctors and increased their salaries by 17% as per the JUDA's demand. Orders on other demands would be released soon, and doctors have been assured that their requirements would be met at the earliest, he said, since "government procedures take a long time".

The second wave, which started subsiding last month, has left Bhopal's medical services in shambles. "The setup is clearly overburdened. Even in moments of crisis, we have to look to patients and their families to run [and get] basic things like medical gloves and injections. It is heartbreaking," said Pancholi.

Himank Agrawal, an intern posted in the casualty ward at Hamidia Hospital, the GMC's tertiary care centre, said that they only had 22 non-Covid-19 beds (as of June 20, 2021) because general wards have not been reassigned elsewhere. "Now, non-Covid patients are dying for lack of resources like oxygen because everything got used up during the second wave," he said.

Undergraduate medical students too supported the agitation. Aniket Pamecha, 22, an MBBS student at GMC, said they were frustrated with the state of medical education in Madhya Pradesh. "In the past 3-4 years alone, so many new medical colleges have mushroomed in the state. They should focus on building medical infrastructure in old established colleges, rather than race to open a medical college building with no hi-tech infrastructure in your constituency," said Pamecha. "Vidisha is just one hour away from Bhopal, but it is Shivraj Singh Chouhan's constituency, so he opened a college there." Since 2011, at least seven new medical colleges have been established in MP.

Up until last year, GMC's annual fees for MS students was Rs 66,000 but this was hiked to Rs 1.18 lakh early this year--this too was a concern for JUDA, which says a government college should not be this expensive. During the protests, the fee was reduced to Rs 84,000 (including a refundable deposit of Rs 14,000).

Little time for specialisation

The Covid-19 crisis has kept junior doctors busy across the country but it has also been a setback for their careers. In a month, they were assigned to Covid-19 duties for 14 days--seven days in the ward followed by seven days of quarantine. They could spend the remaining days on their specialisation. But once the second wave got out of hand, they were directed to skip the weekly quarantine.

With fewer non-Covid-19 patients visiting hospitals, this also meant that junior doctors were getting very little exposure to their areas of specialisation. Pancholi, for example, said that with surgeries down he had hardly any engagement with his chosen field. This problem applies across medical fields, even to those who do not attend to patients directly--medical biochemistry (M.Sc) for example.

"It has been a sheer waste of my time. Had I wanted to learn medicine, I would have chosen MD. Of course, we have learnt some new things in Covid but it is not my specialisation," said Pancholi.

Parag Sharma, associate professor at GMC, said that the time spent in Covid-19 wards is a setback to JR education. "That's the biggest fear we now have, that the batch which is currently doing their post-graduation will not be as learned in their respective fields [as earlier batches]," he said.

Students preparing for the National Eligibility Cum Entrance Test (NEET) 2021 for medicine are in the dark about their future. There are chances that the exam might get postponed again with the third wave estimated to arrive between July and October. Pancholi joined his course after a delay of two months in the NEET 2020 counselling process (used to decide colleges and departments on the basis of scores). Final exams in the postgraduate and undergraduate courses were halted along with clinical postings.

Anger has been growing in the medical profession over the government's attempts to treat ayurveda on par with modern medicine, which doctors said would lead to "mixopathy". The Indian Medicine Central Council (Post Graduate Ayurveda Education) Amendment Regulations, 2020 authorise post-graduate practitioners in specified streams of ayurveda to perform general surgical procedures.

Trauma and its aftermath

All the JRs at GMC, around 400 of them, have tended to Covid-19 emergencies over the two waves, as we said. Most complained of exhaustion and emotional numbness at seeing one-two deaths every day. "We got used to it. I was emotional initially. But what can one do apart from numbing yourself to it? Even before you could recover from the last trauma, the next death would hit," said Pancholi.

Junior doctors were exposed to immense stress prematurely, said therapists.

"During the Kargil war, the Indian Military Academy graduated cadets earlier than usual to increase the strength of the army. [Similarly] JRs are being put to the job before they are ready to handle it. And a lot of these are ophthalmology students, skin doctors, who wouldn't have seen [much] death otherwise," said Aditi Saxena, a psychotherapist and psychologist who runs Adds to Life and Coffeeshop Counseling, both Bhopal-based organisations specialising in cognitive behavioural therapy and life skills training.

Her doctor patients, said Saxena, recounted witnessing extremely disturbing scenes at work during the pandemic. "They have seen very unfortunate deaths like pregnant women dying in their third trimester and piles of dead bodies in wards, which has put them in a state of post-traumatic stress disorder (PTSD)," she said. PTSD is often seen as a failure to get over a crisis even though it is a normal reaction to abnormal events, the therapist said.

At its peak between April 24-30, the infection claimed an average of 97 lives a day in Bhopal.

In the absence of any kind of therapy during the darkest days of the surge, Pancholi recalled the effort he and his colleagues made to cheer themselves up by exchanging stories about patient recovery. "It was always about bringing a patient back to life such as '65% saturation pe tha, hum 99 pe le aaye (their oxygen saturation level was at 65% and we brought it up to 99%)'," he said.

The pressure to constantly report numbers, monitor every minute change in parameters such as oxygen saturation levels in patients, the pressure to save lives and the burden of self-doubt can all turn into quick triggers for anxiety, said Barkha Bajaj, a trauma specialist and clinical director at Unalome Therapy, Pune.

"Doctors need to be trained to be in touch with their feelings and you can't do that when you're on autopilot," said Saxena. "The motivation levels are really low in such war-like situations, and everyone in the medical stream being highly underpaid presently also adds to that."

Both specialists contended that the medical community lacks an understanding of and empathy for mental health issues. "It is like, if I am a doctor, I know I cannot take an hour off for therapy. Their technical knowledge of the human mind and anatomy affects their appreciation of psychotherapy, almost as if their training of medicine comes in the way of their understanding of how talking helps," said Saxena. "They would rather take an anti-anxiety pill than talk about it."

Bajaj also suggested that hospitals should hire more trauma specialists and set up 'critical incident stress debriefing' groups--facilitator-led groups to mitigate the aftermath of a traumatic event.

(Ishita Patil, Prakriti Arya and Gokulananda Nandan, interns with IndiaSpend, contributed to this story.)

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