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Received: 26 February 2021    Revised: 2 March 2021    Accepted: 2 March 2021

DOI: 10.1111/acem.14244

C O M M E N TA R Y - ­ U N S O L I C I T E D

Emergency medicine in India: Time for more than applause

Kevin Davey MD1  | Janice Blanchard MD, MPH, PhD1  | Katherine Douglass MD, MPH1  |

Ankur Verma MBBS2 | Sanjay Jaiswal MBBS2 | Wasil Sheikh MBBS2 |
Meghna Halder MBBS2 | Kamal Palta MBBS2 | Narendra N. Jena MBBS3 |
Venugopalan Poovathumparambil MBBS4 | Sajid Nomani MBBS5 |
Shweta Gidwani MBBS6
1
Department of Emergency Medicine, George Washington University, Washington, DC, USA
2
Department of Emergency Medicine, Max Super Specialty Hospital Patparganj, New Delhi, India
3
Institute of Emergency Medicine, Meenakshi Mission Hospital and Research Center, Madurai, Tamil Nadu, India
4
Department of Emergency Medicine, Aster DM Healthcare Hospitals, Calicut, Kerala, India
5
Department of Emergency Medicine, AMRI Hospital-­Bhubaneswar, Bhubaneswar, Orissa, India
6
Department of Emergency Medicine, Chelsea & Westminster Hospital, London, UK

Correspondence: Kevin Davey, MD, Department of Emergency Medicine, George Washington University, 2120 L Street NW, Suite 450, Washington, DC
20037, USA.
Email: kdavey0210@gmail.com

Supervising Editor: John H. Burton

Keywords: global health, health policy, international emergency medicine

As the COVID-­19 pandemic continues to rage across the United
States and Europe, attention has been diverted from the toll the
virus is taking in India. India is currently home to the second larg-
est COVID-­19 outbreak in the world, with more than 10 million
confirmed cases and over 150,000 confirmed deaths.1 Although of-
ficially reported numbers are down from a peak over the summer,
many experts believe that the true number of coronavirus cases in
2
India is much higher than reported. Throughout the pandemic there
has a great deal of focus on the role that emergency medicine (EM)
providers have played in the fight against COVID-­19, dutifully stand-
ing on the frontlines to provide compassionate care for patients
while exposing themselves to a deadly virus. The frontline providers
in India have shared in this sacrifice: more than 660 doctors in India
have died while caring for patients with COVID-­19.3 Despite their
sacrifices, many of these doctors are denied formal recognition as
trained EM physicians by the Indian government. While news media
has been flush with heroic tributes to frontline providers, India's
emergency physicians need more than appreciation. In a demoral-
izing fight against an invisible enemy, what many of these doctors
truly need is recognition–­–­recognition by India's government as vali-
dated, sanctioned, wholly competent, and legal practitioners.
Despite the need for a well-­trained EM workforce, infighting
between stakeholders, the slow pace of program development,
and onerous certification requirements have handcuffed the de-
velopment of EM in India. As a result, much of the emergency care
system in India remains in its infancy. In 2009 EM was formally
recognized as an independent specialty by the Medical Council of
India (MCI), and since that time EM training programs have been ini-
tiated in both public and private hospitals. Unfortunately, the scale
of this government-­sponsored training is woefully inadequate to
serve India's population. This year in India there are 196 recognized,
government-­sponsored training seats available in EM to serve a pop-
ulation of 1.324 billion people.4,5 For comparison, the United States
has 2,278 training seats per year and 57,000 active board certified
EM doctors for a population less than one-­quarter the size.6 The gap
is huge. To reach similar proportions, more than 130,000 trained
emergency physicians are needed in India today to provide adequate
access to emergency care.
Recognizing the insufficient numbers of graduates available from
government-­sponsored training programs, many hospitals have de-
veloped their own educational programs to address the EM physi-
cian shortage. These programs, commonly referred to as masters

© 2021 by the Society for Academic Emergency Medicine

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2      COMMENTARY – UNSOLICITED
in emergency medicine (MEM), have taken various forms, some in
partnership with international universities, while others partner
with local professional societies. Moving to fill the gap in EM train-
ing, MEM programs have flourished over the past decade, particu-
larly in private-­sector hospitals. As a result, hundreds more doctors
are trained in EM each year. Many of the doctors leading these pro-
grams have worked in the emergency department for their entire
careers, simultaneously providing valuable education and training to
students and providing lifesaving care to the people of India. Despite
their expertise and commitment, graduates of these programs are
not recognized by the Indian government as trained EM specialists.
Aggressive campaigns in the Indian news media threatening the legit-
imacy of these programs have only further demoralized these front-
line providers. As a result, graduates of these programs are faced
with a choice: to serve in their home country where their validity as
physicians and livelihood is under continuous threat or to leave. As
a former member of the British Commonwealth, the Membership to
the Royal College of Emergency Medicine examinations are given
throughout India every year. Doctors who pass this examination can
practice as recognized physicians in most commonwealth countries.
Faced with a choice, each year many MEM graduates leave India, as
bureaucratic pressure pushes them out, while better-­paying jobs and
formal recognition in places like Australia and the United Kingdom
pull them in.7
Given the current deficit of EM physicians in India, solely relying
on new trainees from recognized, government-­sponsored programs
to solve the physician shortage is unreasonable. However, there are
numerous steps that India could take to scale-­up capacity in emer-
gency care. Significant international precedent exists for the grand-
fathering of physicians trained in different specialties. Judicious and
deliberate use of grandfathering, in combination with additional
experience requirements, will enhance emergency care capacity in
India, while maintaining that only qualified doctors gain recognition.
Additionally, recognition of training pathways like MEM pro-
grams could prevent movement of India's EM physicians elsewhere.
This second step has other potential benefits. More than 70% of
India's population lives in a rural setting, yet access to trained health
care providers in rural areas is limited. Approximately 77% of all
qualified allopathic doctors in India live in cities, forcing many rural
Indians to travel great distances for medical care.8 By tying recog-
nition for physicians trained in MEM programs to a requirement to
spend time working in a rural posting, India could simultaneously
address its shortage of rural health care providers while retaining
manpower and scaling up its emergency care capacity.
Even before the pandemic, the need for emergency care in India
was immense. Injury is the second most common cause of death in
India after age 5, second only to ischemic heart disease.9 It is es-
timated that in 2016, a total of 415 people died each day in India
due to road traffic injuries.10 While the arrival of several promising
COIVD-­19 vaccines gives reason for hope, quantities are limited and
much of the existing supply has already been purchased by wealthier
countries. This, combined with the emergence of more contagious
and potentially more deadly variants, suggests that the state of the
pandemic in India will likely worsen. Increasing EM training pathways
in India must be a national priority. As precariously positioned and
underresourced as the Indian emergency medical system may be at
present, it would no doubt collapse entirely without the tireless work
of these unrecognized doctors. In the early days of the pandemic,
people across India cheered for health care workers as they re-
mained away from their homes and families to stand guard and care
for patients on the frontlines. The time is now to formally recognize
their contribution with more than a just round of applause.
C O N FL I C T O F I N T E R E S T
All authors are teaching faculty in masters in emergency medicine
(MEM) programs and are involved in regular teaching, curriculum de-
velopment, and program implementation of MEM programs in India.
AU T H O R C O N T R I B U T I O N S
Kevin Davey, Katherine Douglass, Janice Blanchard, Ankur Verma,
Sanjay Jaiswal, Wasil Sheikh, Meghna Halder, Kamal Palta, Narendra
N. Jena, Venugopalan Poovathumparambil, Sajid Nomani, and
Shweta Gidwani conceived and authored this piece. All authors con-
tributed substantially to its creation and revision.
ORCID
Kevin Davey  https://orcid.org/0000-0002-8350-4380
Janice Blanchard  https://orcid.org/0000-0001-7230-2583
Katherine Douglass  https://orcid.org/0000-0003-4730-571X
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