In India’s healthcare ecosystem, abuse and marginalisation feed off each other

The rape and murder of a 31-year-old postgraduate trainee doctor at R.G. Kar Medical College and Hospital in Kolkata, has exposed a pervasive culture of abuse and harassment that has been entrenched within medical institutions across India.

In an interview with SocialStory, Dr Sylvia Karpagam, a public health doctor and activist, lays bare the grim reality of sexual harassment in medical institutions by sharing her own experiences of witnessing and reporting several such incidents during her medical education. 

“I began doing my postgraduate studies in 1989 when I saw multiple incidents of harassment by senior doctors, and when no conversations took place around the issue,” she recalls.

In one case, after reporting a doctor who had a history of inappropriate behaviour, Dr Karpagam was warned by the dean, as the accused wielded power.

“The general culture was, and continues to be protective of the institution's reputation rather than addressing the issue,” she notes, reflecting on the responses she received from her peers and superiors.

Dr Karpagam says despite filing complaints, she was mostly met with resistance and attempts to silence her. 

Power dynamics lead to impunity

From the time she was a young doctor to now, Dr Karpagam says incidents of senior doctors using their authority to exploit female students and patients, often under the guise of medical examination or mentorship, are common. 

"There was a doctor who, during rounds, would choose female patients with breast conditions and inappropriately touch them under the pretext of examination. When I raised this issue, the doctor was quietly asked to leave, but there was no formal acknowledgement of his misconduct," she says.

While Dr Karpagam is most vocal about the prevalence of crimes against women in medicine and ancillary fields, she is also among the few voices talking about the complicity of the medical community in perpetuating the culture of silence. 

"When I went public with my experiences during the #MeToo movement, I was removed from WhatsApp groups and received messages accusing me of tarnishing the institution's (in question) name. There are protocols for handling these cases, but they are often ignored or manipulated to protect the accused," she notes.

Abuse and marginalisation 

The intersectionality of abuse is such that marginalised groups of women like junior staff, and those from lower socio-economic backgrounds are more vulnerable.

Dr Karpagam says that in many such cases, the response to abuse is often influenced by the social status of the victim and the perpetrator. 

"There is a pervasive idea that rapists or molesters are from a different class or category–often portrayed as poor or outsiders. This justifies the exclusion of certain groups from accountability and perpetuates a cycle of discrimination and violence within the larger issue of gender-based violence, which in itself is complex," she says.

Dr Karpagam imagines that the Kolkata doctor’s case would have been handled very differently had the accused been a senior doctor rather than a civic worker. 

“There is a good level of impunity for those higher up in the hierarchy,” she says. “Even after movements like #MeToo and cases like Nirbhaya, a significant gap in how justice is served based on one's position of power exists.”

Implementing practical measures like CCTV cameras, strict regulations on work hours, and empowering women in the workplace to set boundaries without fear of repercussions are fundamental, she says. “This will not only protect women but also hold perpetrators accountable, creating a more just and supportive workplace for everyone,” says Dr Karpagam.

Furthermore, she calls for a systemic overhaul of how institutions handle safety. 

“Institutions often create environments where certain groups, especially those from marginalised backgrounds, are systematically excluded, even if unintentionally. These exclusions can be based on class, caste, or language barriers, leading to toxic environments for those not fitting into the dominant social circles,” says Dr Karpagam.

This selective silence or inaction becomes a form of complicity, where the perpetration of harm is allowed to continue as long as it doesn't disrupt personal convenience. 

Poor women are most preyed upon

This dynamic plays out starkly in institutional settings, where those at the bottom, particularly women from marginalised communities, face the harshest realities with the least support.

In the healthcare sector, for instance, even though women constitute a significant portion of the workforce, those in lower-tier positions, such as cleaning staff and nurses, face dire working conditions. These women often come from economically and socially disadvantaged backgrounds, and their roles within the healthcare system further exacerbate their vulnerabilities. They lack access to the resources and protections available to those in more senior positions, leaving them more susceptible to exploitation and abuse.

A study conducted by Dr Karpagam and her team during the COVID-19 pandemic highlighted the occupational hazards faced by these "invisiblised" frontline workers. These ranged from physical injuries and exposure to harmful chemicals to inadequate protection against infections. 

The lack of separate facilities for women, such as duty rooms or toilets, further compounds their vulnerability. “A hierarchical structure within hospitals means that while senior doctors receive benefits and protections, lower-tier workers are left to fend for themselves, often at great personal risk.

The situation is particularly dire for ASHA (Accredited Social Health Activist) workers, who, despite being crucial to the healthcare system, are paid on an incentive basis, making them vulnerable to exploitation by those who control their income,” says Dr Karpagam.

When abuse or harassment occurs, Dr Karpagam says these women have little recourse, she says. Their precarious employment status, combined with the absence of a supportive system, means that their safety concerns are often ignored. Speaking out could potentially jeopardise their livelihoods.

India has over 10 lakh ASHA workers.

Some steps towards redressal

In today's age of heightened social media presence, activism, and public scrutiny, the likelihood of a senior figure being swiftly brought under investigation in cases like the Kolkata doctor's death, is significantly higher than it would have been in the past. 

The rapid dissemination of information and the power of collective voices, especially when fueled by online platforms, means that cover-ups or delays in accountability are much harder to maintain.

In the ongoing investigation in Kolkata, the scrutiny faced by senior figures and the involvement of bodies like the CBI reflect the pressure that public awareness can exert on the justice system. It forces a quicker response and potentially challenges the sort of institutional silence that might have protected those involved in the past.

However, it also raises questions about who gets left out of these spaces and whose voices are prioritised or ignored in the process.

Dr Karpagam's compelling perspective on preventing such crimes includes a focus on supporting victims and holding perpetrators accountable, regardless of their position or status. 

The most important action, she says, lies in fostering solidarity among women. 

“Women across power structures and institutional hierarchies need to form stronger bonds within their institutions, breaking down the barriers that keep them in silos. This solidarity would enable them to support each other and challenge abusive behaviors more effectively, including those perpetrated by powerful individuals within the hierarchy,” Dr Karpagam adds.