It is estimated that over 2,000 adults and children have been killed in the Gujarat carnage since February 27, 2002. Over one lakh have been forced into relief camps, severely testing the medical community and health services. The state government failed in its duty to protect its people; numerous reports have documented the state´s complicity in the bloodshed, and its reluctance to provide adequate relief to the affected.
It is against this background that the Medico Friend Circle, a national voluntary network of health professionals and activists, conducted an investigation into the health impact of the carnage in Gujarat and the role played by the health profession.
Dr Ritu Priya, JNU, Delhi; Ms Sarojini NB, SAMA, Delhi and convenor of MFC, Delhi, and Mr S Srinivasan, LOCOST, Baroda, visited Gujarat between April 15 and 18. Dr Abhay Shukla, and Dr Sunita Bandewar, CEHAT, Pune; Dr Dhruv Mankad, MFC, Nashik; Ms. Jayashree Velankar, Forum for Women´s Health, Mumbai, and Ms Neha Madhiwalla, editor, MFC Bulletin, visited from April 25 to 29.
Team members visited nine rural and urban camps, and two hospitals in Ahmedabad, Baroda, Panchmahals and Dahod districts. They interviewed officials of the state health department, Ahmedabad Municipal Corporation, medical officers in the relief camps, private doctors as well as doctors in public hospitals, office bearers of medical associations, and representatives of voluntary organisations doing relief work. They also interacted with inmates of the camps and people in the community.
Health conditions in the relief camps: a general crisis
Direct impact of violence: Our interactions corroborate other reports of massive brutality and the systematic use of rape. Survivors are yet to recover from gunshot wounds, extensive burns, stab wounds and other serious injuries. Many have permanent disabilities. Psychological trauma poses a serious problem with far-reaching consequences.
Threat of a larger epidemic: Outbreaks of measles, chickenpox, typhoid and bronchopneumonia have been recorded. Thousands of children have been affected by acute respiratory infections and diarrhoea. In the absence of active efforts to improve water and sanitation facilities, a serious epidemic could occur.
Health system´s response
The state and municipal services are working together to provide health services in camps and various hospitals. Their effort is commendable given the inadequacy of public health services even in normal times, and the additional constraints of the crisis and the communal environment. However, these efforts does not go beyond what is provided in normal circumstances and is therefore highly inadequate. Such services given in a perfunctory manner have further undermined the health services´ credibility.
Health services have not made efforts to reach out to people unable to come to them for treatment. At the same time, the continuing violence means that health professionals providing care at the camps feel vulnerable, further inhibiting an empathetic response to their patients´ needs.
The team did not see mobilisation of non-religious voluntary organisations of the scale evident after the 2001 earthquake in Gujarat. However, those involved in relief work have done extremely good work in the face of physical danger and intimidation by state and right-wing forces.
State public health services have not provided the necesssary comprehensive treatment. They give immunisation, some maternal and child care, and limited out-patient services. They have made no active efforts to provide proper water and sanitation facilities. A comprehensive approach must treat severe injuries, chronic illnesses, and the psychological trauma resulting from experiencing or witnessing brutal violence.
There is no acknowledgement of the need to provide treatment for post-traumatic stress disorder, a known consequence of such situations, and a concern of the public health services. The only emotional support is provided by camp volunteers with no training or support for this work.
Existing services do not acknowledge women´s health needs, and there is no effort to make them more accessible to women. Hundreds of women have given birth in the camps, assisted largely by local volunteers, and without any facilities. These women, as well as those in curfew-bound areas, are not in a position to seek health services.
The team´s report corroborates other investigations´ findings of large-scale and systematic sexual assault. There have also been many reports of women coming to hospitals in a condition which doctors would certainly suspect sexual assault. Yet doctors in hospitals visited by the team stated that no cases of sexual assault had been filed in other words obvious signs of sexual assault have been disregarded. As a consequence, there is no medical evidence of sexual assault, on which basis women could seek justice.
Public hospitals have been working under threat of violence against their Muslim patients. Mobs have attacked hospitals, prevented the injured from entering, moved around in wards, terrorising and attacking patients and relatives. The government does not seem to have tried to protect health services and maintain people´s access to them. Still, health professionals in the hospitals have functioned neutrally, providing treatment without discrimination on the basis of community. This is commendable.
Measures such as segregating patients on the basis of community, and giving sympathetic leave to Muslim staff, threaten the secular character of health institutions and will lead to further polarisation within the profession. Administrations may have acted thus because the state has abdicated responsibility to ensure patients´ and staff´s safety.
Impact on health professionals
As members of the BJP and the VHP, some medical professionals have been responsible for propagating hatred and perpetrating injury to Muslims in Gujarat. They have played a role that contradicts their professional calling as providers of care.
Medical associations have been partisan, and have made no attempts to mobilise relief. The condemnation of attacks on doctors followed only after Dr Amit Mehta was attacked by unidentified persons -- although many other (Muslim) doctors´ property had been destroyed earlier and they had faced physical attacks. (For the first time, doctors have not been spared during the violence.) The attack on Dr Mehta has been misrepresented to suggest that Hindu doctors are under attack by the Muslim communities they serve. This distorts facts and also does injustice to Dr Mehta´s sentiments.
The perceived significance of medical professionals´ religious identity is dangerous. The profession must be neutral and humanitarian -- and must be seen as such.
On the whole, doctors have acted professionally within a narrow definition of the word. While they have not actively discriminated against any community, they have not made attempts to safeguard the rights of their patients or their peers. By not documenting medical evidence, they have hindered the process of securing justice for survivors.
Medico legal issues
Several lapses in medico-legal documentation were evident, even without a systematic investigation. Post mortems were not conducted and medico-legal cases were not recorded in several cases; dying declarations were not recorded. We do not know if this was deliberate, because such lapses are common in normal times as well. However, in this situation, they have serious consequences for survivors in their attempts to get justice.
No comprehensive public health or rehabilitation effort in Gujarat today can be implemented or sustained without the restoration of peace and normalcy in the state or without addressing the issue of justice.
1. At no cost should relief camps be disbanded without survivors´ rehabilitation including medical care, compensation and housing, ensuring safety, and restoring their livelihood.
2. An independent health commission must be constituted. A detailed inquiry is needed to investigate health conditions in camps, assess rehabilitation needs, probe issues related to survivors of sexual assault, evaluate state health services´ response and the impact on health professionals, and examine medico-legal issues emerging from the carnage.
3. Attacks on health services must be publicly condemned, and the perpetrators punished, in order to reinstate their sanctity as inviolable humanitarian agencies.
4. Security must be assured of patients, hospital staff and camp residents. Safe transit to and from health facilities must be ensured.
5. Living conditions including water and sanitation facilities, in the camps must be improved. Pregnant and lactating women, and infants and young children, must be provided special nutrition.
6. Health services in the camps need to be strengthened to include resident health facilities effective referral facilities, and specialised services including gynaecology, mental health and physiotherapy.
7. Health personnel must be made sensitive to mental health issues and the health needs of women, including gynaecology and obstetric care.
8. Details of sexual assault must be systematically recorded. An investigation must be undertaken into the lapse in conducting medical examinations of women who approached hospitals in conditions suggesting sexual assault. Eyewitness reports and survivors testimonies should be considered for criminal prosecution. Medical care should be provided to the survivors of sexual assault.
9. The state authorities must acknowledge evidence of large-scale psychological trauma resulting from this man-made disaster´. Counselling support can be effective only if justice is obtained for the crimes committed against people.
10.The Medical Council of India (MCI) must take heed of the blatant violation of ethics and human rights by doctors who participate in violence (ref. Article 3 of the Code of Medical Ethics, MCI). It should de-recognise all doctors whose involvement in inciting or participating in violence has been proved.
11.Ethical guidelines in the context of communal situations must be developed. Communal attitudes within the profession and its associations are contrary to medical ethics (ref. Article 4 of the Code of Medical Ethics, Medical Council of India). The Indian Medical Association and other professional associations must condemn attacks on all doctors, regardless of their social background.
12.The systematic documentation of medical evidence is an ethical responsibility of the medical profession. (ref. Article 31 of Code of Medical Ethics, Medical Council of India). The National Human Rights Commission protocol for conducting autopsies should be followed. Dying declarations must be recorded in case of all seriously injured patients; Post-mortem reports should be audited, with sample post-mortem reports being reviewed by a team of independent experts.
13.Where evidence has been destroyed or is otherwise unavailable, circumstantial evidence and eyewitness accounts should be given paramount importance. The police should preserve unclaimed bodies for 72 hours under appropriate conditions.
14.We appeal to our peers among voluntary groups to respond to this humanitarian crisis and lend their support to the provision of care, rehabilitation, redressal of losses and injustice.