TRENDS OF VIOLENCE AGAINST HEALTHCARE

WORKERS AND FACILITIES

SYED UMAR AHMED

April 26th, 2019

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ABSTRACT

The study is mainly concentrated on the exhaustive illustration of violence factor associated with

the provision of health care assistance by the Health Care Professionals (HCP’s), including

doctors, nurses, medical staff, ambulance staff, paramedics etc. The study is aimed at uncovering

the root causes of such incidents that instigate the masses to lose their cool and adapt themselves

to violent behaviors instead, with due focus given to pointing out the factors that are instrumental

in such incidents. A detailed analysis has been conducted involving such trends of violence in

Pakistan. Facts and figures of past reports by WHO, International Committee of Red Cross

(ICRC) have also been considered. Later on, the violent incidents affecting HCP’s duties, have

also been debated upon. It was found in one of the reports, that around 65% of HCP’s had faced

verbal abuse, whereas the ratio of physical abuse was found to be considerably lower in Karachi

and Peshawar cities. 51% of HCP’s had faced verbal abuse while around 30% of the medical

providers had to experience physical abuse by different group of enraged people in Peshawar

city. Interventions initiated by International Committee of the Red Cross-Pakistan (ICRC),

Ziauddin Medical University, Appna Institute of Public Health of the Jinnah Sindh Medical

University, Jinnah Postgraduate Medical Centre (JPMC), Khyber Pakhtunkhwa Health

Department, Khyber Medical University in Karachi and Peshawar cities have also been

highlighted, that have proven to be truly favorable for the eradication of occupational violence

trends in Pakistan largely affecting health care workers. Types of violence, their repercussions on

the emotional well being of HCP’s, projects initiated by Government of Pakistan for de-

escalation of such violent incidents have also been addressed. Occupational violence, involving

barbaric assault and verbal abuse has become a disturbing experience, not only for the HCP’s as

they face hindrance in the provisioning of adequate medical aid to the sufferers, but it may also

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prove to be much hazardous for the recovery of the patients, as they might become devoid of

adequate medical assistance in case of any chaos developed due to the unwanted aggression

shown at the HCP’s by the people.

INTRODUCTION

We are living in an era where apprehension has superseded calmness and tranquility. The

notion is well believed all amongst a notable sector of masses. It is generally believed that such

angst has developed just because of lack of empathy amongst the masses. People, nowadays,

generally have apathetic perspective for others. This has become a true, yet a harsh reality.

The topic of concern today, is the ongoing prevalent trends of violence against the

Healthcare professionals across the globe. It is surely a matter of serious perturbation, not only

for the health-care professionals, who have been the victim of such violence since ages, but also

for the common man, who tend to cease such dreadful attitude by large.

Workplace Violence, has woefully seen a substantial rise during the past decade. Here we

will be shedding light onto the factual details pertaining to such intemperate acts, that cause

considerable harm or injury to the healthcare workers in the Metropolis City of Karachi,

Violence is a characteristic behavior in humans, that should be averted at all levels.

Violence brings vast ruination within the society and its people, both physically and mentally,

since it involves acts of barbarism, abuse (physically or verbally) and intimidating events that

leave indelible influence within the society. Violence doesn’t necessarily entail vast physical or

social destruction, but the emotional scars, left behind on the minds of victims of violence,

cannot be healed so straightforwardly.

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 Violent behaviors tend to cause the victim to suffer both physically and emotionally. In

an event of intense verbal abuse, the violent act committed by the person, truly jeopardizes the

emotional and mental well-being of the other party, subjected to his violent behavior. Not only

this, if a person is continually subjected to such violent and vicious behaviors, he gradually

begins losing his self-esteem, resilience and starts becoming the victim at the hands of such

disturbing events. World Health Organization (WHO) has always been focused in eliminating

the causes, repercussions, involving such violent incidents, and it has established its consolidated

programs for combating the menace of violence.

When we come to collecting facts and figures, we learn that around 470,000 homicides

take place each year. As a result of such brutality, a large number of people not only suffer with

physical ailments, but mental and emotional distress is yet another aspect of concern, when we

talk about the violence sufferers. People who manage to save their lives due to any kind of

violent incident experienced by them, cannot unfortunately getaway from the bitterness of

mental and emotional distress which occurs as a result of the aftermath of such incidents. Many

of the violence victims are seen to get inclined towards a path of destruction, a path that gets

them straight to miseries. Those victims may become drug addicts, may experience fit of terror,

may become socially isolated and also may adapt a self-harming approach. All this is because of

the fact, that they slowly and gradually begin losing interest in life, they tend to develop an

intense fear within their minds, they aren’t able to wipe off the horrendous sight of that brutality

that they had experienced, as a result they start developing socio-psychological issues. In such

situations, it is the duty of their loved ones, to help them fight with such complications, morally

and emotionally uplift them, so that they once again start believing in themselves, and are able to

let go of that violent event episode from their minds.

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 The sufferings caused by such volatile acts have to be discouraged at all levels.

Government of Pakistan has launched various initiatives in the past, aiming at the culmination of

such horrendous approach. Health-care personnel has the noble responsibility of serving the

humanity so that their sufferings could well be minimized and cured. It therefore seems to be

pretty strenuous for us to believe in the fact that such noble cause workers have also been

compelled to face torture/violence at the hands of some people. The study aims at unearthing all

the possible causes that lead to the occurrence of such disturbing incidents.

The composition of this study is based upon a better comprehension of violence, its

perceptions, types of violence, reasons for such violent attitudes, repercussions of such dreadful

events, ways to prevent such unfortunate events, steps taken by the Karachi Administration for

the eradication of such practices.

The Health Care professionals constitute of different staff, dedicated for various

responsibilities. During the past many years, it has been noted that trends of violence against

these professionals have considerably increased. It has been reported that verbal abuse is more

common as compared to physical abuse. In the event, where a patient is under uncertain medical

condition, where he is facing life critical situations, it is quite natural for his loved ones to get

emotional and perturbed, for the sake of his loved one’s well-being. These are the situations

where people often loose their cool, and start indulging in verbal fights and even physical abuse,

in some cases.

Violence- A Peril to be Abolished

a. Perceptions: It is generally believed that medical healthcare workers don’t

actually look after the well-being of the patients vigilantly, in the event of a

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 sudden adverse happening. For instance, when there is an event of a bomb

explosion, a sudden quick mayhem development is witnessed at the unfortunate

site. People begin to lose their cool, become anxious about saving their loved ones

lives. Such unfortunate events, not only give the common people a testing time,

where they feel at loss and helpless, yet at the same time, they develop the

feelings of agitation, which gets overwhelmed easily enough. The event under

debate, also tend to become quite an exigent situation for the health-care

professionals. A prodigious amount of pressure is therefore developed at the

minds of these healthcare professionals, who need to save the lives of the

sufferers, while keeping the site’s tranquility intact. It is therefore indispensable

for the people to realize the incapacitated situation of the medical workers in such

testing times, where they can’t do much about it. They are trying hard to save the

lives of the sufferers, yet at the same time, they have the additional responsibility

of keeping the site’s placidity intact. During these times, the sufferer’s kindred

have to control their nerves, they need not to react viciously, they need to stabilize

themselves well before the situation further aggravates.

b. Types of violence: As discussed earlier, there may be two kinds of violence. One

being the verbal abuse, and the second is the physical abuse. The latter is more

commonly experienced by the medical professionals. Many a times, situation

arises, where the patient is critically ill, and he has not been provided with

adequate medical aid, whatever the reasons might be, for e.g. lack of latest

medical equipments, lesser number of ambulances for the patients, wrong

diagnosis by the doctors, patient’s ailment overlooked.

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c. Reasons for Violent Behaviors Under no circumstances should a violent

behavior be accepted. Violence, as explained earlier, has many forms. Here we

are specifically discussing about the Work Place Violence (WPV). WPV has its

own impacts on the mental well-being of the victims as well as a lasting effect on

their emotional stability. Under no condition, workplace violence could be

justified, however there are certain reasons that tend to provoke such behavior, for

instance, incautious approach by the medical workers while handling the patients,

inadequate medical facilities, non-cooperative attitude of the doctors with

patients’ kindred and many more. One of the objectives of this study is also to

explore the ways through which the prevalence of such violence could be

minimized.

d. Repercussions of such dreadful events It is certainly a formidable experience

for the victim to forget those appalling memories, and get back to normal life,

whether or not, the abuse is a physical one or a verbal abuse, its repercussions

cannot be overlooked. Many people are of the view, that if a doctor or a nurse is

just verbally abused, pushed or pulled, it is such a severe attempt, they tend to

forget the socio-psychological impairment that the sufferer experiences under the

shadow of that horrendous act.

e. Ways to prevent WPV

Violence in any form, in any way, is not acceptable at all. Whosoever, is

subjected to such violence, be it doctors, nurses, medical staff, ambulance staff

etc., should be helped out in making his way back to normal life. It is really hard

to understand what the victims of WPV might be going through, yet it is certainly

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 not impossible to normalize their lives by employing some practices that prove

instrumental in the betterment of the lives of WPV victims. These mainly include,

imparting trainings to the individuals studying in different colleges, universities to

help them understand the importance and nobility of medical professionals,

training should focus on the motives of improved workplace environment, better

relationship with the medical workers, and most importantly anger management.

The lack of anger management as a pedagogy, has paved a way to numerous

social difficulties, WPV being one amongst them. Despite, countless incidents

that have occurred in the past, the training aspects has never been taken seriously

enough. The prevalence of WPV could well be curtailed, by spreading adequate

awareness about the negative effects of WPV.

f. Steps taken By Government of Pakistan to alleviate WPV

There have been various reported incidents of violence against healthcare workers

in Pakistan. In Karachi alone, a huge number of medical professionals have been

pushed to death during the past few years, major/minor injuries victims is a

separate debate. It is learned that such violence has seen a significant rise in the

recent years. In view of these factual details, the development of preventive

initiatives seemed inevitable. Here we take a quick glance on those initiatives that

have been aimed at averting such violent behaviors against health care workers

and facilities in Pakistan.

 A project named as Health Care in Danger was launched in the year 2014,

for safeguarding healthcare workers in Karachi. This project was launched

in collaboration with the Jinnah Postgraduate Medical Centre (JPMC),

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 Indus Hospital, the APPNA Institute of Public Health & the Research

Society of International Law (RSIL)

 World Health Organization (WHO) Violence Prevention Unit: The

WHO has always strived hard to ameliorate the consequences faced due to

the violent acts against the medical providers. The prime objectives of

WHO Violence Prevention Unit could be summarized as under:-

a. Formulation of training packages and relevant tools for

strengthening the violence prevention initiatives.

b. Aiming at getting enhanced financial assistance supplemented with

appropriate political support by the governments to appositely implement

the violence prevention schemes at a larger scale, as well as making the

common man abreast with the Do’s and Don’ts of violence prevention

against Healthcare individuals.

c. Identifying the measures that are deemed essential for an effective

cessation of violence trends against health-care workers, as well as

properly disseminating the evidences among the masses.

The Leading Causes of Violence Prevalence

i. Behavioral Violence: Such type of violence can be interpreted as having a direct

interrelation with human demeanor and their sentiments. Violence is a learned

behavior that is not agreeable to anyone, violent behaviors tend to leave adverse

impacts on the socio-emotional intelligence.

ii. Institutional Violence

iii. Socio-Political Violence

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Health-Care Infrastructure In Pakistan

Pakistan, being a third world country, is lagging far behind in the accessibility to medical

facilities. Recent reports have concluded that despite numerous efforts that have been made

recently, Pakistan would still need a thriving breakthrough into the medical field, such that the

provision of adequate medical facilities is made readily accessible to every common man.

Below, we present tables showing some of the renowned public and private hospitals operating

in Pakistan.

PUBLIC SECTOR HOSPITALS

Year of
S/N Hospital Nature Location
Establishment
1. Abbasi Shaheed Hospital Public Karachi 1974
2. Lahore General Hospital Public Lahore 1958
3. Civil Hospital Public Karachi 1898
4. Combined Military Hospital Military Rawalpindi NA
5. Nasir Hussain Shaheed Hospital Public Karachi 2010
6. Shalimar Hospital Public Lahore 1982
7. PNS Shifa Public Karachi 1956
8. DHG Hospital Public Mirpur Azad 1981
Kashmir
9. Jinnah Hospital Lahore Public Lahore 1996
10. DHQ Hospital Faisalabad Public Faisalabad NA
11. Military Hospital Military Rawalpindi 1857
12. Pakistan Institute of Medical Public Islamabad 1985
Sciences

PRIVATE SECTOR HOSPITALS

Year of No. of
S/N Hospital Nature Location
Establishment Beds
1. National Medical Center Privat Karachi 1974 200
e
2. Liaqat National Hospital Privat Karachi 1958 700
e
3. Shifa International Privat Islamabad 1989 439
e
4. The Agha Khan University Privat Karachi 1985 542
Hospital e

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 5. Quaid-e-Azam International Privat Islamabad 2012 400
Hospital e
6. The Indus Hospital Privat Karachi 2007 150
e
7. South City Hospital Privat Karachi 2006 124
e

A study conducted in Karachi had reported that around 65% of Health Care providers had to

experience an unfair treatment at the hands of enraged mob gathered at the medical assistance

provision site, during a span of one year. It was also learnt that verbal abuse was found to be

most common mode of violence, such volatile behaviors were particularly noticed to happen in

the Emergency Care Departments as well as in Ambulance Vans.

Likewise, the trends of violence against health care providers have penetrated well enough into

the socio-economic frame of any country. People have become accustomed to it, yet they still

want this problem to be eradicated at all cost, for the sake of humanity, better patients’ treatment

resulting in his speedy recovery. Moreover, such traumatic happenings have an everlasting

impact on the socio-economic well being of the medical staff, who have been through such

horrendous incidents. The World Health Organization, as well as the International Committee of

Red Cross (ICRC), have always tried to play pivotal role in effective mitigation of this

undesirable trend. Below is mentioned, a set of information, showing that such violence trends

against the health-care workers are not only limited to Pakistan, but has been pervasive globally.

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 Karachi, a metropolis city, is by far the largest city when it comes to head count. Yes,

being the largest city by population, not only seems to be advantageous, but it also has some

major downsides. Karachi, although considered to be a city of opportunities, still cannot be

categorized as the city having best of the facilities. Here, we are peculiar about the Health-Care

professionals, who have the noble job of saving people’s lives, improving the well-being of the

suffering individuals and at the same time consoling their loved ones during the times of severe

ailment.

The prime objectives of this study are to dig out the main reasons of such violence,

determining the possible consequences of such occurrences, the intensity of such adversity, role

of current government to combat such menace, and at the same time spreading the word to the

masses with the motive of enhancing their cognizance and making them abreast with preventive

tactics against such volatile attitudes.

When it comes to trends of violence against healthcare professionals, adequate

trainings shall be imparted to common people so that they realize the significance of such

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workers and put themselves in their shoes, thus comprehending in a best way regarding their job

responsibilities, and ultimately causing such violent trends to be minimized to a greater extent.

Common threats effecting Health-Care Professionals in Karachi:

a. Extortion: Although this form of harassment has considerably been reduced in

number as of today, but history won’t lie in disclosing the seriousness of this

matter, that was prevalent widespread in the city since ages. Extortion is a form of

a ‘forceful fee’ taken from multiple entities within the city, be it traders, shop

owners, businessman, or even the doctors. Yes, to no surprise, that is a true but

harsh reality that even the doctors have to pay for extortion money. Usually, we

may think that such ‘forceful money’ should be taken from only those entities

who have some personal conflicts with the ‘that criminal mafia’, but that has not

really happened so far. For the past many years, the sudden escalation in the cases

of ‘extortion’ has led to the development of an inexorable atmosphere in the

metropolis city Karachi, a city which was once considered to be the ‘city of

lights’ was being dreaded badly in the past. As of lately, thanks to the effective

grand operation conducted by our Law Enforcement agency against such mafia,

the situation of the city is much better now, with the number of such extortion

cases reduced significantly over the years.

b. Target Killings: Like extortion, target killings have also been an issue of great

concern over the past many years in Karachi. One would think that target killings

should only involve people who have personal enmity with one another, but that

is not true in all cases. Over the years, many plots were developed at the hands of

foreign powers and traitors to suppress the prosperity of the nation, thus a number

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 of diabolical plans were devised to demolish the peace and progress of the nation,

special focus was given to Karachi by these mafia, as Karachi being the economic

hub of the country, holds the prime attention of such detestable entities. As a

result of which, an unrestrained wave of killings was seen by the Karachiites, that

involved all stakeholders, doctors also being in the list. Researches were

conducted to find out as to why anyone would kill a doctor, where substantial

evidence was also gathered that proved the fact that many doctors got assassinated

on account of cultural linguistics basis.

c. Kidnapping: It is obvious to see this problem here in this list, because it directly

relates with the above mentioned 2 issues. Kidnapping has by far been the most

fretful incident for the loved ones of the kidnapped individual. Specifically

speaking of the health-care workers, the city has witnessed an unbridled wave of

such kidnapping involving a great number of notable healthcare workers, doctors

and nurses. As of now, with the much-improved law and order situation

prevailing in the city, it is delightsome to learn that incidents of such nature, have

been significantly decreased due to the proactive and resilient tasks force and law

enforcement agencies, who have made it possible for the Karachiites to live a life

of peace and safety.

d. Harassment by Attendants Usually, it is hard to believe the fact that attendants

may also attack the health-care workers, but yes this happens in many cases. Here,

emotional upheaval plays a crucial role in compelling the patients’ attendants to

strike physically or indulge in verbal abuse with the health care providers, reason

being the immense distress that the patients’ loved ones are going through. This

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 act of barbarism still can’t be justified in any case, yet we may have soft corner in

this case, as the attendants are not terrorists, they do not have the intention of

harming the doctors, nurses etc., they are compelled to commit such act of

violence as they find themselves to be helpless at the hands of that emotional

upheaval that has slowly and gradually taken over their personality stability in

such diring situations that involves serious conditions of their loved ones and even

life-threatening cases where doctors cannot do much about it.

e. Police Cases It is very disconcerting, when an innocent person is attacked by

gun fire and he is rushed to the hospital and the doctors refuse to treat him,

doubting that it might be a police case. Many a times, many innocents lives are

claimed because of this wrong perception and fear the doctors have. In other

cases, a doctor is subjected to violence, if he is found to treat any suspect or

criminal. The doctors’ safety should be of prime concern at all levels, because

they are the savior of the humanity. They, in any case, shall never be treated

unfairly and shall always be safeguarded with the best possible protective

measures.

f. Anti-Polio Workers Targeting The workers involved in anti-polio campaign to

save the children from the Polio disease, have also unfortunately been victimized

by such violence. The reason for this violence against vaccinators is hard to

discover, but with the rapidly increasing incidents involving the killings of

number of polio workers, adequate protection measures have now been taken by

the Karachi Administration, to counteract this menace.

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g. Other Attacks: Besides the attacks on vaccinators, attacks on the healthcare

workers by attendants, kidnapping and target killing, one more issue that has

contributed much towards the deteriorating condition of safety measures against

healthcare workers in the past, is the random attacks on different hospitals,

bombing the ambulances and intentionally injuring the healthcare workers at the

effected site, to ensure that those workers aren’t left fit enough so that they may

easily perform their duties and help the sufferers with the speedy recovery of their

injuries.

FACTUAL RESEARCH ON VIOLENCE TRENDS AGAINST

HEALTHCARE WORKERS IN KARACHI

Violence against the Healthcare workers and facilities has been a topic of debate

since ages. Much has been said about it but unfortunately this menace has still not

been eradicated completely. Not only in Pakistan, violence against healthcare

professionals is a matter of concern in the entire world. Countries like USA, UK,

KSA, China etc. have all been facing this issue for quite some time. The need has

certainly arisen, that the effective mitigation of such volatile behaviors aimed

towards health-care professionals be encouraged more intensely at all platforms

such that the medical professionals embrace the idea of a violence free

environment whilst performing their duties, wholeheartedly, which in turn would

increase their effectiveness and motivation levels at the same time. In Karachi,

fortunately some of the measures have been initiated that have proven to be much

fruitful for the betterment of healthcare professionals and their safety.

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a) In the past, some productive efforts have been made pertaining to the

prevalent violent behaviors against healthcare professionals & facilities in

Karachi city. International Committee of the Red Cross-Pakistan, Ziauddin

Medical University, Appna Institute of Public Health of the Jinnah Sindh

Medical University & Jinnah Postgraduate Medical Centre (JPMC) were

the main contributors to this initiative. These stakeholders had taken the

responsibility of launching schemes that resulted proved to be useful

enough in considerable mitigation of such absurd behaviors. Several

studies were conducted in this regard, to enlighten the aspects of

workplace violence prevalence, its causes and its consequences in the near

future. It was clearly reported, that plentiful incidents had taken place in

Emergency Departments, inside the Ambulance Van. Obviously, one

would infer that reasons of such behavior on those specific spots must be

directly related to non-cooperative attitude shown by medical staff, but

this is not always the case. Many a times, it has been witnessed that a mob

gathers down at the site, and intentionally tries to further jeopardize the

already disturbed situation. Those people, are not patient’s relatives or

friends, they are an unwanted group of people, who apparently have

nothing to do with patient’s well-being. They are a rabble, who have evil

intentions of creating chaos in their surroundings, such that a greater

number of people are affected by this disorderly environment.

b) Peshawar City:

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As discussed previously, it is much pronounced to say that the prevalence

of such violent acts against medical professionals are surely an unjust,

discriminatory and a deplorable matter. Many stakeholders have

intervened in the past too, for having this menace eradicated considerably,

and yes, they have been much successful in achieving this goal to a greater

extent, if not completely though. Karachi city factual details on such

violent incidents were detailed in the preceding notes, however here we

are about to shed some light on the prevalence of this volatile trend in the

Peshawar City.

Khyber Pakhtunkhwa Health Department, Khyber Medical University &

International Committee of the Red Cross (ICRC) had worked in alliance

to formulate a concrete report, depicting various aspects of the violence

trends, its consequences and ways to eliminate such trends.

When we talk about the factual details of such investigations, it became

evident that most of the incidents that had occurred were related to verbal

abuse as compared to physical assault, which means that verbal abuse was

found to be more common in the perpetrators, who solely had the

intentions of bringing in more discomfort to the already distressed site.

51% of the paramedics, doctors and nurses were subjected to abusive

behaviors while they were trying to serve the sufferers on site, a recent

report indicated, whereas almost 30% of the medical staff were subjected

to physical assault like pushing, pulling, beating by the enraged mob.

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 It is really sad and disheartening to see such behaviors, as they not only

hinder the process of patient recovery but are also quite detrimental to the

medical workers, as the medical workers tend to develop a feeling of

dismay and panic when they have to take care of the patients under such

risky circumstances. Not only this, many health workers lives including

doctors, nurses, polio team workers and other paramedic staff, have been

claimed at the hands of such enraged mob, that has been a huge set back

for the health care industry in Pakistan as well as the medical

professionals’ kindred.

CONCLUSION (150 words ): write this first

The notion of readily accessible, cost effective and comprehensive health-care system having

incorporated all the elements befitting the fundamental health needs of common man, could well

be implemented, given the random occurrences of inimical incidences during the provision of

medical assistance to the sufferers by Health-Care providers (HCP’s) be curtailed well enough.

Even though a surfeit of legislations does exist, yet the negligence in their implementation, on

part of City’s’ administrative authority cannot be overlooked, since the violence trends against

HCP’s have already proven to be quite detrimental. The alleviation of violent incidents affecting

a large number of HCP’s is deemed ineluctable as this would result in a much improved

environment for the HCP’s for the provision of adequate medical aid to the patients, counseling

them for their miseries, bringing a harmonized socio-psychological perspective in their minds to

help them stabilize themselves from their emotional ailments, which could only be realized once

the HCP’s are themselves free from any emotional or mental stress. Truly, HCP’s need to be

mentally relaxed before they provide any kind of medical treatment to the patients and this

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mental firmness could only be attained once there has been a considerable reduction in the

threatening incidents causing physical and emotional torments to the HCP’s. The projects in

future shall be developed with careful consideration of violence mitigation against HCP’s and

medical facilities. We propose a framework, that should include but is not limited to the

following attributes: -

 Prompt action to patients and their kindred queries.

 Improving Medical Staff competency by rigorous trainings, centric to latest industrial

trends.

 Eliminating ethno-political conflicts at large.

 Well-timed availability of emergency treatments, medicines, and functional equipments

to help diagnose and treat patient’s ailment instantaneously and efficiently.

The above are few suggestions that could certainly pave the way to better patient care

supplemented with better environment for HCP’s, for the provision of the same. Violence is a

menace, which should be squashed at all levels, HCP’s would be able to deliver their best if they

are assured of a violence free working environment, which would not only provide a sigh of

relief to them whilst they are performing their duties, but it also would cause the medical

assistance provision phase become much easier and advantageous.

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