Confronting caste, hierarchy and fear in India's hospitals

A brutal killing inside a Kolkata hospital exposed deep fault lines in India’s health system. From junior doctors to sanitation workers, many say caste-based discrimination, rigid hierarchies, and job insecurity have created a culture where abuse thrives.

Rigid hierarchies in India mean trainee nurses and doctors are vulnerable to abuse. Photo: ILO

On the morning of 9 August 2024, the eastern Indian state of West Bengal woke up to a horror that shook the country’s medical fraternity to its core. A 31-year-old trainee doctor was found brutally raped and murdered inside the seminar hall of RG Kar Medical College and Hospital in Kolkata—one of the city’s oldest and most prestigious institutions—where she had gone to rest after a 36-hour shift.

Not since 1973, when a young nurse named Aruna Shanbaug was brutally raped and strangled and left paralysed and with brain damage at the King Edward Memorial Hospital in Mumbai, had such an attack shocked the medical fraternity on this scale.

The brutality of the Kar Hospital crime, and the fact that it occurred within a major public hospital, triggered nationwide outrage. Within days, doctors across West Bengal walked out in protest. Soon, the movement spread across India. In keeping with India’s policy of not publicly naming rape survivors and victims, the young doctor came to be known by protesters as “Abhaya”—the fearless one.

Junior doctors in West Bengal went on strike for 42 days, demanding a credible investigation and stronger workplace safety. As the protests unfolded, many health workers and researchers warned that the case was not an aberration. Abuse of doctors, and other health workers, is far more common than many realise.

“We were not just protesting for one colleague,” says Dr Reema Singh, a junior doctor who participated in the Abhaya protests in Delhi. “We were protesting because every woman doctor has felt unsafe at some point. Hospitals are supposed to be healing spaces, but for many of us they are deeply hostile workplaces.”

Across India’s public health system, workers describe a rigid hierarchy, often mirroring social inequalities that persist outside hospital walls. Doctors sit at the top; nurses, paramedics, and administrative staff follow. At the bottom are sanitation workers, ward attendants, and community health workers like Accredited Social Health Activists (ASHAs), and anganwadi workers, community-based workers monitoring pregnancy and early childhood care.

What binds these layers, many workers say, is not teamwork—but abuse.

Juniors and women doctors vulnerable to abuse

Dr Abhay Shukla, lead author of a forthcoming national study on the rights of frontline doctors in medical institutions, says that among doctors, residents or trainees are treated “the worst”.

“They are made to work continuously for up to 36 hours, spoken to rudely, and made to do all kinds of running around. Senior doctors sometimes misuse their authority to make residents do personal errands—getting groceries or doing tasks for their family,” he says.

According to Shukla, the problem is systemic. “From among more than 200 doctors we studied, most claimed that they had faced major work overload, or had encountered verbal, physical, or sexual abuse in their institutions. Add caste and religious discrimination, and the situation becomes far worse.”

“Women from marginalised backgrounds of religion, caste, and tribal groups are often more vulnerable due to the existing power hierarchies in our societies.”

The RG Kar Medical College and Hospital case, he argues, exposed what many insiders already knew: India’s hospital workplaces can be deeply unsafe—especially for women and those lower in the hierarchy.

Shifana Yasmin is a third-year medical student at Government Erode Medical College and Hospital in the southern state of Tamil Nadu. On the night of 21 August 2025, she was subjected to severe harassment by her seniors in the workers’ hostel where she was living.

It all started with their demand that she change her room out of turn. Yasmin agreed, even though the demand was unreasonable and she did not want to move. However, she needed to bring a room fan with her to shift to another room, as Erode is hot and sweltering for a good part of the year, but at that hour of night it was not possible to buy one.

The seniors kept arguing with her and bullied her into moving repeatedly between different rooms. Yasmin has a vertebral disc prolapse, which often causes intense pain. Despite being aware of this, the seniors forced her to sit for long hours and repeatedly move around the hostel—activities medically inadvisable for her.

Such harassment, often referred to as ragging, remains common in higher educational institutions—particularly medical and engineering—in India, where abuse of juniors is justified in the name of “tradition”.

In the early hours of the next morning, Yasmin took an overdose of an anti-anxiety medication and was hospitalised. As of today, she says, the college administration has still not provided any resolution to her mistreatment. “What happened has shaken me badly. I struggle to sleep. Constant stress is affecting both my health and my ability to interact with patients with the focus they deserve,” she says.

Women health workers continue to face harassment and abuse in India. Photo: Frederick Shaw

A 2025 study of health workers in southern India found 62.6% had experienced workplace violence at some point in their careers. Verbal abuse (62.1%) was more common than physical assault (13.6%). Younger, less experienced, unmarried, and female health workers are most vulnerable to workplace violence, according to the study.

“Women workers are the backbone of our health and care system; yet they continue to face harassment and abuse across the workforce. Women from marginalised backgrounds of religion, caste, and tribal groups are often more vulnerable due to the existing power hierarchies in our societies,” says Ananya Basu, health coordinator at Public Services International’s Asia Pacific team.

Caste-based harassment continues

For many in the Indian medical community, the death of Abhaya revived painful memories of another case that once gripped the country. In 2019, Dr Payal Tadvi, a young Adivasi doctor pursuing specialisation in obstetrics and gynaecology in Mumbai, died by suicide after months of alleged caste-based harassment by senior colleagues. Investigations later documented repeated humiliation, caste slurs, and professional exclusion.

Experts say the parallels between Dr Tadvi and Abhaya’s cases are disturbing, in the sense that foolproof safety protocols are still not in place. “There is what we call a toxic working environment, especially in medical college hospitals,” Shukla says. “Senior staff often treat resident doctors with humiliation and contempt, and this becomes worse for those from Scheduled Caste and Scheduled Tribe backgrounds.”

The Scheduled Castes and Scheduled Tribes are among the most disadvantaged socioeconomic groups in India. The 2012 Mungekar Committee, chaired by Dr Bhalchandra Mungekar, investigated allegations of caste-based discrimination against Scheduled Caste and Scheduled Tribe students at Vardhman Mahavir Medical College and Safdarjung Hospital in Delhi. The committee documented severe and ongoing harassment, including discriminatory grading practices, and the resulting mental trauma experienced by affected students.

It confirmed that students from Scheduled Caste and Scheduled Tribe backgrounds faced humiliation, abuse, and systemic bias from faculty members, particularly in practical examinations, oral examinations, and theory assessments, which adversely impacted their academic performance.

Despite convening multiple committees and issuing various sets of recommendations over the years, their implementation has remained weak.

Contracted workers fear speaking out

While the Abhaya protests were led by doctors, labour organisers say the deepest precarity lies further down the hospital chain among contractual and support staff.

Surya Prakash, Delhi state secretary of the All India Central Council of Trade Unions, which organises health workers’ unions in many Delhi hospitals, points to the widespread issue of contractualisation, where permanent jobs are replaced with temporary or contract-based employment.

“Contractualisation must end,” he says. “Whether hospital workers or primary health centre staff, many are on insecure contracts.”

“Contracts are renewed every one or two years. Workers live in perpetual insecurity and hence are forced to accept abuse without question.”

According to Prakash, sanitation workers and nursing orderlies are routinely pushed to go beyond their job descriptions. “Sanitation workers are supposed to clean the premises, but they are forced to handle biomedical waste without protective gear or training. Nursing orderlies do everything—changing sheets, shifting patients, even stitching work—but their wages are extremely low.”

He adds that the problem is compounded by fear. “There is no effective redressal mechanism,” Prakash says. “Contracts are renewed every one or two years. Workers live in perpetual insecurity and hence are forced to accept abuse without question.”

Few stories capture this insecurity more starkly than that of Sevak Ram. The 53-year-old joined Delhi’s Kalawati Saran Hospital as a sanitation worker in 2016. A Dalit worker—a community historically placed at the bottom of India’s caste hierarchy—he says he faced casteist slurs and verbal abuse from the start. “They pay low wages and make us do every kind of work,” Ram recalls. “We were made to move patients, carry samples to laboratories, even do porter work.”

In 2019, he filed a police complaint against his supervisor alleging caste-based abuse. Casteist slurs often involve the use of caste names as insults or remarks that mock a person’s caste identity, implying they are “impure,” “inferior,” or suited only for certain types of work. Ram says he was repeatedly abused in this manner, with his caste name used derogatorily. In India, sanitation work has historically been performed largely by Dalit communities, a reality shaped by deep-rooted social stigma and exclusion.

Sanitation workers receive low wages and are often forced to handle biomedical waste without protective gear or training. Photo: Sujeeth Potla

During the Covid-19 pandemic, sanitation workers at Kalawati Saran Hospital did not receive their salary for months. They protested, and in March 2022 all the nearly 400 sanitation workers were terminated. The legal case continues.

Today, Ram survives on irregular daily wage work in his native Baghpat, Uttar Pradesh. “I work as a porter whenever I can,” Ram says quietly. “But now that I am over 50, no one gives me work. I am hardly able to make ends meet.”

Fear of retaliation keeps many others silent. Babita, who is 48 and goes by one name, was terminated along with Ram and awaits justice. She is in touch with many men and women from her village who perform sanitation work at Kalawati Saran Hospital.

“They say that low wages, castiest abuse, and extra work continue in the hospital,” she says. “But they are too afraid to question the supervisor or raise issues legally. They don’t want to go to court. What we are going through scares everyone.”

Strong policy interventions are needed

For public health experts like Shukla, these stories are linked by “structural violence” inside India’s health system that is aided by severe shortages of health workers. “There is massive understaffing at almost all levels,” he explains. “For the work of two people, only one person is employed. In many states, community health centres have up to 60% specialist vacancies.” Community health centres form the middle tier between primary health centres and district hospitals, an important mainstay for primary care, especially in rural areas.

The consequences cascade: excessive workloads, inadequate infrastructure, digital reporting burdens, and public frustration directed at frontline staff. “They become the face of system failure,” Shukla says. “When services collapse, anger gets directed at frontline workers.”

Sexual violence, verbal abuse, and physical attacks, he says, must be seen within the context of this broader systemic stress.

If abuse is so widespread, why do so few health workers pursue formal complaints? The answer, workers say, is simple: precarity. Contract workers fear termination; women and junior doctors fear career damage; and Dalit workers fear retaliation.

“People are too afraid,” Prakash says. “Many lab technicians and support staff take second jobs quietly just to survive. Speaking up feels risky.”

“Internal complaints committees and anti-discrimination cells must actually function, with external oversight. Right now, many exist only on paper.”

Both experts agree that piecemeal responses will not work and the crisis requires structural reform.

“Precarious employment is a major driver of vulnerability,” Shukla says. “Large sections of the health workforce—ASHAs, contractual nurses, contractual doctors—lack social security and job protection.”

Prakash says that not paying minimum wages is nothing short of bonded labour. “Governments must regularise long-term contractual staff and ensure wage justice.”

Shukla emphasises that duty hours must be regulated. “Resident doctors should not be working 36-hour stretches. We need enforceable duty-hour norms, more duty doctors, and filling of vacant nursing and support posts.”

Both experts stress the need for a shift in medical training culture and independent complaint mechanisms. “Internal complaints committees and anti-discrimination cells must actually function, with external oversight,” Shukla says. “Right now, many exist only on paper.”

Experts say reforms of working hours, staffing levels, and contract terms are urgently needed to protect health workers in India. Photo: ILO

In 2013, the Indian Parliament enacted the Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, widely known as the POSH Act. The law raised significant hopes that workplace sexual violence against women would finally be addressed in a systematic manner.

“On the ground, however, multiple gaps remain,” Basu says. “In many places the Act is not implemented at all, and even where it exists on paper, serious shortcomings persist. There is no robust government mechanism to monitor or assess compliance, which means authorities don't really know if this Act is making any difference at all.” She says a key priority is to “ensure full and effective implementation of the Act”.

Ultimately, viable solutions to the crisis depend on adequate financing. Shukla advocates for an increase to public health spending of at least 2.5% of GDP. “It is a promise that was made in the National Health Policy of 2017, but has not been fulfilled yet,” he notes.

“Without this, understaffing and infrastructure gaps will continue to produce unsafe working conditions.”