The month of March witnessed the Pakistani public joining people across the world in showering unconditional praise for healthcare workers of Pakistan (HCW), the “warriors” who would save the nation from the ravages of Covid-19. There was much applauding, singing and banging of pots and pans from rooftops to salute the would-be saviours, the hapless doctors and nurses who suddenly found themselves on the proverbial front lines. But these people were manning the frontlines not because they were trained and equipped to do so; they were doing it because if they didn’t, who would?

Surprisingly, within a matter of a few weeks, the same HCWs are now falling from grace, as if they have let the nation down. Thirty-eight physicians have lost their lives, scores more are enduring the infection, and many more have brought the virus home and are suffering the guilt of having infected their loved ones, knowing the viral load they bring will result in a much more severe infection. Yet, this doesn’t seem to matter to the public at the moment.

Falling from grace

The end of April saw several incidents of hospital emergency departments across the country being stormed and ransacked by angry crowds. While such behaviour is by no means unheard-of in the country, in the context of Covid-19, two factors seem to stand out when it comes to the outrage towards doctors.

The most common reason fueling such attacks by enraged relatives is when literally gasping patients are refused admission and turned away from the threshold of a designated Covid-19 centre. This is despite the fact that the government keeps insisting that there is still a significant number of ICU beds and ventilators available across the country, with the green flags on the newly launched official mobile application testifying to this claim. However, the public is reluctant to take their loved ones to an unknown hospital in the periphery of the city and quite rightly question the quality of care available. With no faith in deliverability of these green flags on the screen, the public insists on being accommodated in the few prominent hospitals they are familiar with. Finding their doors shut because of no further capacity, the public vents the only way it knows how.

Another major reason behind enraged mob attacks is when reportedly dead bodies of patient who succumb to Covid-19 are refused to be handed over to relatives. This in itself is confusing since government guidelines on www.covid.gov.pk do not indicate that bodies may not be handed over to relatives. Instead, the guidelines describe very practical processes which are not difficult to follow. In light of this, any altercations that may be taking place between hospital staff and bereaved relatives is probably based on misconceptions, the hospital staff as liable to be misinformed as are the relatives. Handling the dead body, its cleaning and shrouding is not the responsibility of the physician, yet it is the doctor who is in the crosshairs in this instance as well.

In both scenarios where these broad causes that may be inciting the public, after destruction of any physical structures accessible to the mob, they turn their attention to doctors.

Doctors, more so than any other health workers, symbolise not only the healers, which they are, but also the system, which they are not. However, it is the doctors who find themselves on the frontlines of facing the wrath of the public for health systems failures.

Establishment of dependable Covid-19 related logistical issues like finding beds for admissions and managing safe transfers between facilities are primarily administrative matters. Similarly, in case of a patient's passing, taking care of the dead body and following defined SOPs is also an administrative matter. However, here as well, it is the doctors who are dragged out and beaten.

Assaults on doctors have gone well beyond just being pushed around, slapped or kicked. In one case, a doctor was made to perform cardiopulmonary resuscitation, a process which exposes the practitioner to maximal contamination risk because of the virus becoming airborne, without letting him put on protective gear. In another private health facility, when the emergency room physician explained that the patient may need a ventilator, and that the hospital had none, the relatives spat in their hands and rubbed them on the face of this 60-year-old doctor. This is the level of inhuman behaviour that doctors are having to face even as they try and help.

These incidents are probably still in the minority, but they are on the rise. And posting police in front of hospitals is not going to help. The root cause needs to be addressed.

The March bonhomie notwithstanding, erosion of trust in the medical community has been something that has been going on for a long time, Covid-19 just gave it a further nudge south.

Past feeding the future

A nonsensical rumour making the rounds and somehow shaping public opinion is that for every Covid-19 death, doctors or hospitals receive money from foreign agencies. The fact of the matter is that for every patient they see, doctors and other health workers are actually risking their own lives, as is so plainly demonstrated by the ever increasing death toll in the doctor community.

The medical profession has often been in the limelight for unprofessional and unethical practices in the past. The press has run numerous reports of unindicated surgeries, unreasonable fee structures, refusal of emergency care to critical patients just to avoid undue legal hassle, and even deaths due to wrong injections by inexperienced professionals.

The stage, therefore, was already set for the medical professionals to fall from their short lived grace as Covid-19 bared its teeth. At the heels of the pandemic has been unleashed an equally vicious pandemic of misinformation, further fueling misconceptions.

On the one hand, the public seems to believe that physicians and health facilities somehow profit from labeling all patients Covid-19 and want to admit them ostensibly for personal gain, and even put them on ventilators for more profit, while on the other hand, the same public is up in arms against doctors for not admitting their loved ones. The obvious contradiction in this dual belief is confusing, to say the least.

Contradictions unfortunately define us quite often. Whether it's polio vaccination, or TB control, or family planning campaigns, misconstrued cultural and religious conceptions become a challenge towards implementation of globally proven public health interventions in our country, and often end up in violence on the providers. The practically universal disregard for pandemic SOPs regarding the use of masks and physical distancing are perhaps a reflection of the lack of faith the public has in governmental instructions or medical experts who share their findings backed by data. The inability of health planners in meaningfully engaging with communities in the past has been a root cause of failure of acceptance of these well-established public health measures. Compounding this of course is the politicising of each and every aspect of this pandemic.

While the virus is indiscriminate in choosing its victims, it is the poor who feel the greatest impact both when it comes to health as well as the economic fallout. The public-private divide has been further widened in the pandemic, with one health sector for the haves and another one for the have nots, only reinforcing the mistrust from the public.

Exploiting this already smouldering issue, TV anchors have started blasting doctors and private hospitals for charging hundreds of thousands of rupees for Covid-19 related admissions to ICUs and ventilators, which these hospitals insist are their usual charges for such facilities. Whether or not private medical facilities are making a profit on Covid-19, it is again doctors who are targeted as profiteering by anchors on television and in slanderous social media clips.

Those actually on the frontlines

A point has now been reached that every patient who walks in, for whatever ailment, is a potential Covid-19 source, since asymptomatic carriers are now responsible for transmission more than those who are showing symptoms. This means the proverbial frontlines are everywhere a doctor sees a patient, and the enemy cannot be identified by a thermogun. Covid-19 is attacking in stealth mode, and the doctor is the target, both from the virus and from those he strives to save from it.

Let us also examine who these warriors actually are. These are by and large young physicians who were never trained to do what they are doing, with public health usually treated as a minor component of most medical curricula. They are used to treating diseases that generally do not involve prospects of their own mortality in the process. While PPEs are more plentiful now, much of the health workforce, and certainly in the private sector, has had to purchase their own equipment. Far from making money off Covid-19, many doctors have had their pays cut for having to go into quarantine or isolation, since they were unable to report for duty.

In a situation where more than 60% of the population attends private medical providers for routine consultation, the rights of healthcare workers are not even covered by the labour law of Pakistan, or through the Factories Act or Industrial Act. Most of those working in private sector are on a contract without the benefits of gratuity or pension. The day their job ends is the day they are left with nothing but whatever they managed to save. Their contract can be terminated unilaterally in most cases, with no possibility of legal intervention. There is no mechanism to ensure their protection against occupational hazards and provision of safety gear is not a guarantee. They have no viable medical association that can fight their case.

Finding a way forward

The gulf between society and medical professionals is widening by the day. As the numbers skyrocket, resources already heavily strained, will collapse. But for this governmental failing, it is doctors who will bear the brunt, be beaten and maligned, and emergency rooms and wards ransacked.

This situation points to an urgent need of community engagement in the delivery of healthcare, defying the culture of “doctor vs patients”.

Measures need to be taken to build public trust. The vicious propaganda against doctors and the spreading of misinformation on social media must be challenged and countered through effective communication and with the help of designated bodies so that this additional burden on them is eased. The mental stress that this adds to an already deeply stressed professional body handling death and disease at close quarters can be paralysing, and is already taking its toll. They need mental health support more than ever but this is hard to come by because of a grave paucity of qualified mental health experts in Pakistan.

Healthcare journalism demands something more than sensationalising news. Incidents need to be covered in an unbiased manner, providing perspectives of all the parties involved, generating a dialogue between society and healthcare professionals. Only then can trust be fostered.

Healthcare workers need to be left to do what they are supposed to do, provide care as best as possible under trying circumstances. Public dealing and administrative measures is neither their domain nor their strength. Administrators need to come up to the front lines and take on their own responsibilities, relieving doctors of this added burden.

The government needs to respond to the needs of the healthcare workforce and take measures to enhance job security, benefits, and protection.

Imagine the pain of these doctors when they spend all their energies in trying to save a breathless patient, at personal peril and that of their families, only to lose him in few hours because of the ravage caused by this disease, and then to face the wrath of the relatives. And in the case of doctors who contracted the virus as they performed their duties and succumbed to the disease, they signed up to treat people, not to die as they treated them. Losing their lives and then getting a "shaheed" package is not the reward they had been hoping for.