In Women, Healthcare and Violence in Pakistan, Sara Rizvi Jafree estimates that there are about one million female healthcare practitioners in the country. These include doctors, nurses and lady health workers (LHWs). Although there are no official figures for Pakistan, it is estimated that 90 percent of females in healthcare in the developing world face daily violence: verbal, physical, psychological and sexual.

Jafree, an assistant professor of sociology and gender at Forman Christian College, Lahore, has made a timely contribution. Women, Healthcare and Violence in Pakistan is an in-depth study of a neglected topic based on extensive literature review, interviews with relevant stakeholders and use of the World Health Organisation’s standardised surveys. Extensive quotes give voice to Jafree’s informants who describe violence, popular perceptions of female healthcare workers and the attitude of male colleagues. Although there is growing acknowledgement of how pervasive domestic violence is in Pakistan — and growing visibility of the #MeToo campaign — violence against women in the healthcare sector has been ignored. Jafree’s work is an important step towards addressing this lacuna.

Jafree describes rampant violence against female healthcare workers. Women from lower socio-economic backgrounds, mainly LHWs and nurses, face more violence than doctors. They are abused by patients, attendants and male practitioners. They are reluctant to complain to superiors or confide in their families. When they do, they are not taken seriously or told to accept the violence as part of their job. When a nurse tried to complain to her supervisor that she had been physically pushed by a “VIP” patient’s attendant, she was told, “I apologise on behalf of men [such as] this, but many nurses face such problems. This commonly happens in the hospital. You are very sensitive. You must stay calm and handle such incidents better and try not to upset the entire hospital.”

An in-depth study brings healthcare workers into the discussion about violence against women in Pakistan

Why is violence against women so pervasive in the medical profession, when — as Jafree points out — there are ample examples of how women caregivers were celebrated in early Muslim history? In part, the answer lies in gender imbalances embedded in society. Women are treated inferiorly to men in Pakistan. Most women grow up accepting this imbalance, restricting their ability to report violence. As a nurse said, “We [women healthcare practitioners] have a silent pact never to report victimisation. We try to push the memories of abuse and beatings, the language and the behaviours to the back of our minds and not talk about it much.” And this is what a female doctor added: “Remaining silent is in our favour because reporting violence only ruins our reputation and the team dynamics in the hospital. The victims are labelled troublemakers and no one wants to work with them.”

As Jafree argues, females in Pakistan are often encouraged to study medicine because female physicians are thought to have better marriage prospects. Likewise, women are encouraged to pursue “female-friendly” specialisations such as gynaecology-obstetrics or paediatrics. In this patriarchal society, women who opt for other specialties are more vulnerable, where they are considered “secondary professionals.” As Jafree also observes, male physicians are “doctors” while females are “lady doctors.” (I likewise consider the term “lady doctor” for myself discriminatory, tacitly underscoring a division between doctor and lady doctor).

Women, Healthcare and Violence in Pakistan draws on scores of interviews with male medical practitioners as well and Jafree found many hesitant to discuss violence against their female colleagues. Although accepting that violence against their female colleagues is rampant, most men opted to remain quiet. Otherwise, as Jafree points out, shifting blame on the victim is often the easier recourse. As one senior registrar — a trained doctor who has undergone years of specialty training — said, “Have you seen how some of our women doctors and nurses dress? Those living in hostels and from upper-middle class families wear inappropriate or Western attire and this provokes men. Wearing their hair loose and using makeup is another contributory factor. Men then believe it is acceptable to harass and catcall women practitioners as they are inviting such attention. Also, the knowledge that they [women healthcare practitioners] will not and cannot retaliate makes the men even more aggressive and persistent.” This is a recurrent theme, where the victim is blamed. Male colleagues are ready to turn a blind eye and accept it as a cultural norm, adding the women should “try to avoid such events.” Crucially, men are usually the ones in positions of administrative power; if they are unsympathetic to the plight of women who report to them, is it surprising that women are reluctant to report violence?

Pakistan is not the only country where violence against female healthcare workers exists. Legislature exists internationally to protect the rights of practitioners (and patients) in the form of the International Code of Medical Ethics, formulated by the World Medical Association. However, it is not specifically geared at protecting women from abuse by the public or their male co-workers. Nor is there any focus specifically on women in South Asia. In Pakistan, there is no official reporting body for this purpose and where a complaint-registering system might exist, the offices are manned mainly (or solely) by men. Men — and women — are not trained to deal with reports of violence, making it easier to ignore the issue. As one practitioner said, “The thing is that, in our society, we cannot tell off perpetrators, we cannot tell their relatives or ours and we cannot report to the police. Men know this and that is why women are vulnerable to such behaviour and harassment.”

Jafree’s work covers an important aspect of violence against women in Pakistan; she brings healthcare workers into the discussion. Here I do want to add that given the systemic violence that polio workers — most of whom are LHWs — have been facing, it would have been a valuable addition to see a more extensive segment on the extreme violence against this vulnerable section of healthcare workers. Harassment is not only men harassing women; there is room for broader discussion on women harassing other women, as this also contributes to a hostile work environment.

Jafree concludes her book by underlining the rights that female practitioners should have: the right to professional respect, to patient consent and trust, to co-worker support, to breach of confidentiality when women patients are at risk, to report errors in a non-punitive culture, to a learning-based culture, to report violence and to withdrawal of services.

The author concludes with important recommendations: that there should be regular standardised monitoring of violent episodes; formation of unions headed by senior female practitioners; budget allocation for safety, staffing and resources; a reporting office for violence and harassment; learning-based training and cultural competency and error-reporting culture and systems. Religious leaders should advocate the importance of women medical practitioners in Islam and there should be public prosecution of perpetrators. There should also be gender-equal quotas for women to involve women practitioners in governance.

The reviewer is a specialist in paediatric infectious diseases practising in Lahore

Women, Healthcare and Violence in Pakistan
By Sara Rizvi Jafree
Oxford University Press, Karachi
ISBN: 978-0199406067292pp.

Published in Dawn, Books & Authors, May 27th, 2018