On January 25, the Indian government restored partial internet access in Jammu and Kashmir, granting access to 301 select websites and bringing some closure to an internet shutdown that was imposed on August 5. Social media remains off-limits, internet service on mobile phones is running on antiquated 2G connections on the lowest possible speed, and broadband connections in households remain off.
The restrictions were imposed following the federal government’s decision to abrogate article 370 of the constitution, thus revoking Kashmir’s autonomy and statehood. What followed was a swift crackdown on the area, with internet shutdowns, increased troop presence, the detention of thousands of people, and the arrests of politicians. The government claimed such actions were necessary in order to prevent violent protests and militant attacks.
Such shutdowns have become commonplace under the BJP, who use internet shutdowns to both preventively and reactively silence political dissent. There have been 357 internet shutdowns in India since 2014, with 6 in 2014, 14 in 2015, 31 in 2016, 79 in 2017, 134 in 2018, and 106 in 2019. In fact, India imposes more internet restrictions than any other country.
Internet shutdowns have financial, interpersonal, and political costs. A TOP10VPN report suggests that India lost in excess of $1.3 billion in 2019 due to internet shutdowns, second only to Iraq and Sudan. They also place a heavy toll on interpersonal relationships by restricting one’s ability to communicate. Moreover, they severely limit access to political capital by denying access to information. For instance, during a 15-day internet shutdown in Jammu and Kashmir in July 2016, several newspapers and cable television channels were suspended, thus leading to underreporting on the issue.
However, one of the less considered aspects of internet shutdowns is their profound repercussions on the healthcare industry.
The internet has become synonymous with the healthcare industry, with medical facilities relying on online servers to maintain patient records and entire medical databases. Furthermore, drugs, instruments, and equipment are all ordered online. Not being able to access medicinal supplies, or specialized information search portals and patient records, impedes doctors’ ability to diagnose health conditions, develop treatment plans, and prescribe medicines.
Moreover, these shutdowns often extend to telephone services, as well. For instance, during a 2016 shutdown in Jammu and Kashmir, a Srinagar hospital was unable to contact a specialist to repair their CT scanner, thus leading to a delay in providing life-saving procedures.
In addition, patient influx is higher in conflict zones. Without internet connectivity, it becomes difficult for medical practitioners to be prepared as they are not able to communicate with those on the ground or access information that would give them an indication of the severity of the problem. As a result of this “vacuum in information”, they are not able to adequately stock medicine or tend to their patients.
Doctors also rely on each other to “discuss treatment plans and operative procedures” through e-mail, Whatsapp groups, and messaging and fax services. This problem is particularly acute in smaller towns, which lack specialists and within which doctors and patients alike contact doctors at hospitals in bigger cities for diagnosis and treatment suggestions. For example, the Save Heart Kashmir Whatsapp group is used by 1,200 doctors in the state to study ECGs, detect heart attacks, and suggest treatment and medicines.
The shutdowns affect not only practitioners and medical facilities, but also patients. It leads to a less personalized style of healthcare as doctors are unable to access the unique concerns of each patient and must thus treat each of them in a more uniform manner.
The advent of the internet also ushered in an era of patient-centered care, wherein consumers can access medical information themselves and communicate directly with care providers, health plan administrators, and other consumers. In the United States, for example, medical error is the third leading cause of death. By limiting patients’ ability to challenge their doctors' judgments and seek alternative options, the agency of consumers is greatly diminished as they must accept whatever information they are given at face value.
In the new ‘Digital India’, in which the government is trying to create digital profiles of all its citizens, internet shutdowns disproportionately affect the poor. For instance, the Ayushman Bharat scheme ensures free medical care for poor people using an online golden card. However, without the internet, hospitals haven't been able to verify patient details on the Ayushman Bharat website, and have therefore been turning patients away.
It was perhaps in response to such concerns that wired broadband internet service was restored to 80 government hospitals in Jammu and Kashmir on January 05. However, while that allowed hospitals to restock supplies and process Ayushman Bharat scheme patients, doctors were still unable to access the internet for medical research, academic material, and communication with other hospitals and practitioners. While the partial restoration of services on January 25 somewhat addresses this, doctors are still unable to access the majority of the internet or vital communication tools, such as Whatsapp.
This begs the question: does India’s healthcare industry need to become less reliant on the internet under the BJP? The BJP’s onslaught on political dissent at the expense of India’s and Indians’ economic, physical, and mental security shows no signs of slowing. These roadblocks become even more difficult to overcome when doctors themselves take political stances, as in the case of The Indian Medical Association (IMA). The IMA is a lobbying group with 78,000 doctors in 1,274 local branches across the country and is India's largest association of physicians and medical students. When The Lancet, a peer-reviewed medical journal, published an article titled "Kashmir communications blackout is putting patients at risk, doctors warn", the IMA "withdrew the esteem [they] had for the Lancet".
As the nation succumbs under the unrelenting pressure of the BJP’s Saffronisation, the doctors not indoctrinated by the IMA or the ruling party must devise contingency plans for internet shutdowns.
The question then becomes whether this is financially and logistically feasible. Practitioners and medical facilities can theoretically overstock medicines in anticipation of an internet shutdown that would prevent them from ordering supplies. They can plausibly routinely upload all of the information stored on their online servers, such as patient records, onto offline databases. However, even in the unlikely scenario that this is financially and logistically viable, there still exists a vast number of services that would remain inaccessible. Doctors still can’t communicate with one another, which inhibits their ability to access information to provide the optimum treatment. Additionally, doctors can’t communicate with patients, and vice versa, which curtails the quality of care received by patients–particularly those living in remote areas–who can’t visit a hospital on a whim.
The government is increasingly eroding the democratic foundations of India by using the internet to purchase silence and obedience. Thus, it falls on the healthcare industry to devise contingency plans for when, not if, the government turns off internet services. As the industry advances, so too does its dependence on the internet. Unfortunately, this also makes it virtually impossible for the healthcare industry to disentangle itself from this dependency. That being said, why would it want to? Greater information and resources have led to an unprecedented level of medical care. Internet shutdowns force India’s healthcare industry to become less reliant on the internet whether it wants to or not. Ultimately, there is no way to provide optimal medical care in the absence of the internet, and so it makes little sense to reduce one’s reliance on it unless extenuating circumstances, such as internet shutdowns, force the industry to develop contingency plans.
Does India's Healthcare Industry Need to Become Less Internet-Reliant Under the BJP?
There have been 357 internet shutdowns in India since 2014, more than any other country.
February 2, 2020
IMAGE SOURCE: ATUL LOKE / THE NEW YORK TIMESThe advent of the internet also ushered in an era of patient-centered care, wherein consumers can access medical information themselves and communicate directly with care providers, health plan administrators, and other consumers.