Every time health workers go on strike, a battle is waged not only between strikers and their managements, but also between the right to strike and the ethics of not doing so (1, 2, 3, 4). The latter battle appears to be important, for it raises some controversial issues.

A strike is an extreme action, which threatens the livelihood of many strikers if it fails or is crushed. Therefore, at such times fence sitters and doubters are as disliked by strikers as by their opponents.

Debates at the time of a strike are often motivated by strikers' immediate need for survival and the state's resolve to crush the struggle. The former normally uses the language of rights while the latter of morality. Abstract morality usually projects strikers as oppressorsof unattended patients, and supports the real oppressor.

Ethics and union strategy
This extreme language has prevented a rational appraisal of the problems of health workers and their method of struggle. To say that such strikes are always immoral is unacceptable. On the other hand, the statement that strikers need not be concerned with patients who are suffering due to the strike, is difficult to accept, as good ethics as well as good trade union strategy.

The recent successful strike by nurses in Delhi has raised similar issues. Supporters of the strike have publicly asserted that nurses don't need a lecture on morality. (5)

Nurses' abysmal wages and working conditions have not been affected by the many committees on the subject (6, 7, 8). Nursing also occupies the lowest rung in the sexual division of labour in the health system. Inadequate professionalisation of nursing in our country has made this profession almost completely subordinate to the doctors' profession, so much so that in many states doctors are appointed as presidents of nursing councils.

Studies have shown that these factors promote a negative stereotype of women in nursing (9), one which has made them vulnerable, added to their job-related stress and made them the target of sexual harassment.

Interestingly, most nurses' strikes have been in the government sector, though in India the private sector holds an estimated three-fourth of hospitals and beds. The private sector must employ at least as many nurses as the government does, if not more. And their condition is much worse.

Studies show that a majority of nursing homes employ unqualified and unregistered women as nurses at incredibly low wages. Most of these nurses are not organised, and none will directly benefit from the Delhi nurses' struggle. Indeed, the organised public sector nurses and nursing councils have hardly done anything for these nurses.

Lastly, the schism between doctors and nurses in their struggles is clearly visible. The two have rarely supported each other's strikes; at times they have clashed, or worked at cross purposes. This reflects the relationship between different categories of health workers.

Under these circumstances, one would support any attempt by nurses to achieve better conditions in the health care system, and the recent strike may signal the beginning of such an assertion in other parts of the country.

A complex problem
However, the problems of nurses are not only those of wages and working conditions. While it is important to win a specific trade union battle, this will not provide a lasting solution. Since their problems are also rooted in the social status of nursing, their insufficient professionalisation and the neglect of their colleagues in the private sector, they will need wider social support to solve these problems.

For this, they will have to work out a long-term strategy, and ensure that each action they initiate is sensitive to people's needs. This strategic requirement,not a moralistic criticism,should prompt nurses to think of methods of struggle which are effective as well as sensitive to patient care.

In other words, a strike cannot be separated from its outcome for patients. Can one get broad social support for the strike in the short term and the profession in the long term without regard to patients' suffering? Can a strategy which ignores, even celebrates, such suffering be a correct one? Should health workers' trade unions blindly copy traditional trade union methods or should they look for equally effective methods consistent with their role as care-givers?

Sensitivity to ethical issues
In sum, one must strive to exercise one's rights while being sensitive to the ethical issues involved in the methods of struggle. Such sensitivity will help health workers be resolute in providing alternative care to patients during a strike. It will also help them further radicalise their struggle by moving from a strike (no patient care) to hospital occupancy (continued patient care under self-management). While the latter is difficult to achieve, unless groups consider their actions examining both the ethics and the needs of the struggle, they will never transcend their present constraints and achieve their larger goals.

References:

1.Naik Ajay, resident doctors on strike , Issues in Medical Ethics, 1996;4:(2):46-47.
2.Lokhandwala Yash, Should doctors strike work?Issues in Medical Ethics,1996;4(2):47-48.
3.Pandya S.K.' lter from Bombay Strikes in hospitals, Brtish Medical Houranl,1998:297:1278.4.
4.Jesani Amar, Medicos' strike :relevant issues, Radical Journal of Health (New Series);1995;(1):247-250.
5. Patel Tulsi, Nurses don'tnee a lecture on morality,The Times of India 1998:May25 , 6.
6.Government of India.Report of the nursingcommittee appointed by the Centrak Council of Health to review the condition of service, emoluments, etc,of the nursing profession;(Shetty Committee report);1955 New Delhi.
7.Government of India.Report of the high power committee on nursing and nursingt profession 1989 New Delhi.
8.Government of Maharashtra.Report of the committee appointed by the government to go inti the question of improvement of nursing services and nursing education in the state of Maharashtra 1975 Mumbai.
9.Iyer Aditi, Jesani Amar: Women in health care:Auxillary Nurse MIdwives.Mumba:Foundation for Rresearch in Community Health.1995 159 pages.

Dr Amar Jesani,Co-ordinator, CEHAT, 519 Prabhu Darshan, S. Sainik Nagar, Amboli, Andheri (W), Mumbai 400 058