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Damned if You Do, Damned if You Don't (A Point of View on the Resident Doctors' Strike) Man From Matunga "Man from Matunga" lives in Mumbai, India and expresses his angst and pleasures through words

The resident doctors are again going on an indefinite strike from Monday, 22 November. History as usual repeating itself.

Since the early-80s, there have been at least five strikes by the resident doctors, at a consistent rate of one strike, every three-four years. The issues are always the same: more money, better working conditions and better accommodation. Only one strike was for another issue - a protest against the setting up of capitation-fee medical colleges - and, that strike failed, miserably. As have all the strikes. Each time, every time.

The bottom-line is this. To succeed, a strike needs to affect people who matter or those who can make a noise. For example, a strike by the Municipal Mazdoor Union gets resolved within a day or two, because no one wants their garbage not to be picked up or other essential services, like water, affected. Strikes by the electricity or railway employees also get resolved within days if not hours. A resident doctors' strike however, does not affect routine, middle-class public life, does not affect the rich and powerful and does not particularly affect the economy. Ergo, the authorities care a damn. And so eventually, the strike fails. Who are these resident doctors?

They are the ones who are training for their specialty MD and MS degrees in the various University colleges in the country, after having finished their basic MBBS and internship. These colleges are affiliated to various hospitals, which invariably are large public hospitals, run by the government. In proper Mumbai, for example, J J Hospital is run by the state government, whereas the other three, KEM, Nair and Sion are run by the BMC (Bombay Municipal Corporation). These hospitals are responsible for the health-care of more than 50% of the city's population (7 million people). This health-care is provided virtually free of cost or at negligible cost, in most instances, to whoever comes to these hospitals - even establishing a Mumbai domicile is not necessary, to get treatment. The residents, as part of their training, are required to work in these hospitals to get practical knowledge - in reality, these public hospitals function mainly because of the resident doctors, who do most of the work, most of the time. These doctors are supervised and trained by lecturers (Ls), assistant professors (APs) and professors (Ps), who are usually full-time employees of the BMC or the state government. The amount of work put in by the Ls, APs and Ps, on a daily basis, is usually inversely proportional to their seniority. When the resident doctors go on strike, these hospitals virtually stop functioning. The Ls, APs and Ps are too few in number to be able to shoulder the burden. Along with these hospitals, the so-called peripheral hospitals such as Kasturba (opposite the Arthur Road jail), Rajawadi (in Ghatkopar), Bhagwati (in Borivli), etc, also stop functioning, because they depend on residents posted in rotation from the central hospitals. In effect, more than 50% of the city's population is suddenly deprived of basic and essential medical services. You would think this would be enough reason to make the authorities negotiate with the doctors to resolve the strike.
But think again.

Who are the people affected? It is those people who cannot afford private doctors and hospitals, those who earn less than sustenance level and those who live in slums or on the roads or wherever.

The authorities do not care, since these poor people affected by the strike don't really matter. The lower middle-class, which might have mattered and does use these public hospitals at times, however, has the private sector to turn to. Moreover, the resident doctors are eventually doctors, who after a few years are going to be in the top 10% income bracket in the country - the authorities know that with this background, public and press sympathy, even if forthcoming will be muted and transient. So they wait, wearing down the patience and enthusiasm of the resident doctors, who after all are doctors and not politicians or bureaucrats used to pushing files and giving excuses. At the end of a month or 40 days (the usual length of a residents' strike), the strike ends, the residents accepting whatever few sops the authorities are willing to give. And the authorities magnanimously tell the striking doctors that they will not penalize them for not having worked for one month and will allow them to keep terms - one of the worst fears resident doctors have, is of losing a six-month term. Threaten them with this loss and half of them start thinking of capitulating.

Why don't the residents learn from the past? Because, every three years, a new crop of residents is in place. And the lessons of the past are forgotten.
The anatomy of the strike, thus remains the same.
First week - enthusiasm, rallies, hunger strikes, street plays
Second week - some of the less enthusiastic residents go home, some default, some start
studying for their exams on the sly
Third week - government threatens loss of term. Enthusiasm dips.
Fourth week - most residents want to get back to work.
Fifth week - strike is over
With each successive strike, the press has been giving more and more coverage to the plight of the residents. But it is always the same story. They are supportive in the first two weeks. Then, some journalists start posting horror stories of patients who have died because they were denied treatment - the tone of the articles suggests that the reason is the intransigence of the residents. The sympathy sours and by the fourth week, public and press sympathy is gone. This year, the senior doctors have decided to support them. Maybe they are sympathetic and mean well, but by supporting the strike and insisting that they will look after only very dire emergencies, the Ls, APs and Ps are also making sure that they will not have to do much donkey-work.

Should the residents strike?

Think about living, four to a 150sq feet room, with bed-bugs, poor ventilation, terrible food, unclean water, a 24-hours a day, seven-day a week schedule and the constant threat of work-related diseases such as tuberculosis, HIV and hepatitis B. For around Rs. 4000/month (<100$). When doctors with similar backgrounds get Rs 17,000 in Delhi and Aligarh, which is more than what a professor earns in Mumbai.

Now think how you would feel if the resident doctor were you, or your son or your daughter. Are the residents morally justified in striking, considering the problems it creates for the patients? I don't know, but I do know that most residents have trouble wrestling with this demon. Many however eventually justify this action by transferring accountability onto the government, which they consider to be the cause of the strike, in the first place.

The funny and tragic part is yet to come. After all this, even if an agreement is finally struck, the state government does not always fulfil the terms of the agreement. Follow-up by MARD (Maharashtra Association of Medical Doctors), after a strike, is extremely poor due to two reasons; the doctors are busy working and learning and they are extremely mobile - on an average, the maximum, one resident would be in any one place, is around three years. The government knows this and can play around with the terms and conditions any way it wants until the ground is laid for the next strike about three years later. The second problem is that in Mumbai, the major employer is the BMC, not the state government. The negotiations are held however with the state government, since this is an all-Maharashtra strike. The BMC is supposed to be a party to the negotiations, but invariably there is a large gap between promises made and kept. Thus the majority of Mumbai's resident doctors still get screwed.

Is there a better way out? I don't know. Everything has been tried, nothing works. If the government however was proactive and tried to solve the residents' problems in time, things would not come to this. Expecting this to happen however, is obviously a pipe dream. Maybe, the residents could go to court, and file a public interest litigation. But from where will the resident doctors get the time, energy and money, required to fight a court case on a daily basis? Obviously, it is much easier for them to go on strike, for which there is at least some concerted and determined effort, manpower and time, if not money, available. Damned if you do, damned if you don't.