Doctors under siege: Making sense of the rising incidence of violence against doctors in India.

Society grants medical professionals' status, respect, and a privileged position with the expectation that physicians would be competent, altruistic, moral, and would conscientiously address the health care needs of individual patients and society. A well-functioning social contract and a harmonious relationship between the medical profession and the people it serves is essential for a country's health system to fulfill its mandate - in India this social contract seems to be breaking down. While across the world, many societies have seen major transformations in their social contracts with the medical profession, in India, we are seeing a violent unravelling of this historically stable social contract - with a dramatic rise in violent attacks on doctors in the last ten years. Is it that Indian society has changed to become more critical, assertive and aggressive? Or is it that while the Indian society has changed, the medical profession hasn't and that doctors are sticking with the more traditional paternalistic relationship with patients? Or does the violence somehow reflect Indian society's rejection of the growing commercialisation and managerialisation of healthcare provision? Or is the issue broader, and that society sees the medical profession as not keeping their end of the social contract, and no longer wants to accord them the same privilege, status, power, and wealth as before.
We contend that this social phenomenon of rising incidents of violence against doctors in India deserves a critical examination to understand what might underpin and explain this trend -this is the overall objective of our study. Exploring the identities, relational configurations, beliefs, and biographies that create the imagined spaces for violence to be justified is vital to improve our understanding of evolving power relations and status accordement in society. Further, understanding the less tangible atmospheres of violence and the less visible socio-economic-political structures that may underpin these acts, is similarly vital. We argue that such an understanding is a critical first step to inform reflection within the profession and ultimately to enable the reconfiguration of the medical profession's relationship with Indian society.

Insights from our study will be of interest to social and health policy makers, and to the medical profession in India and beyond. We will share our insights widely within the medical profession with a view to trigger conversations and critical reflections about the state of social contract. We will also use study insights to work with stakeholders in India to inform the development of innovative and practical health system interventions. Specifically, we will develop a two-day accredited continuous medical education (CME) course jointly with the Indian Medical Association (Maharashtra State), the Academy of Family Physicians of India, and Government agencies, based on our findings. The course will be geared towards getting doctors to critically reflect on the state of their profession and will be aimed at triggering conversations about the need for a new design archetype for the medical profession and to nudge the medical profession to meaningfully engage with the changing expectations of Indian society. We recognise that the study's direct impact will be slow and difficult to assess, however, to enhance long-term impact, we will actively work with our collaborators (the Indian Medical Association, the Academy of Family Physicians of India) to find resources to subsidise the CME, and to ensure that it is widely subscribed and implemented across the country.

Society grants medical professionals' status, respect, and privilege with the expectation that physicians would be competent, altruistic, moral, and conscientious. A well-functioning social contract and a harmonious relationship between the medical profession and the people it serves is essential for a country's health system to fulfill its mandate - in India this social contract seems to be breaking down. Globally, many societies have seen major transformations in their social contracts with the medical profession, however in India, this historically stable social contract is unraveling with a dramatic rise in violent attacks on doctors. We contend that this unraveling deserves critical examination to understand what underpins it - we argue that this understanding is an essential first step to inform changes to the nature of the medical profession's relationship with Indian society. This is the objective of our study.
We will conduct an exploratory, qualitative study using in-depth interviews with purposefully selected participants to unpack how various societal actors experience and understand these acts of violence. Through comparing the understandings and experiences of different actors we will reveal the cleavages and disconnects in the current social contract, and the implications going forward. While the inquiry will be inductive, it will be guided by theoretical understandings around social conflict and foregrounded by the socio-economic-political processes shaping the society and the medical profession in India.
Insights from our study will be of interest to social and health policy makers, and to the medical profession in India and beyond. We will share our insights widely within the medical profession with a view to trigger conversations and critical reflections about the state of social contract. We will also use study insights to work with stakeholders in India to inform the development of innovative and practical health system interventions.