Why Doctors And Medical Journals Are Fighting Over Health Care In Kashmir

The crisis in Kashmir has spilled over into medical journals.

In an editorial published this month, the Lancet had this to say about the 38,000 Indian security forces reportedly deployed to the region, which is hotly disputed between India and Pakistan: "The militant presence raises serious concerns for the health, safety, and freedoms of the Kashmiri people." And the British Medical Journal published an article with this headline: "Kashmir communications blackout is putting patients at risk, doctors warn."

The Lancet editorial has provoked a backlash from the Indian Medical Association, a lobbying group made up of medical practitioners. With headquarters in New Delhi, it has a membership of 78,000 doctors in 1,274 local branches spread all over the country.

In a letter addressed to Lancet's editor-in-chief Richard Horton (which was shared on Twitter), the IMA accused the Lancet of reacting to an "administrative decision" of the government of India under "a garb of concern for the health of Kashmiris."

The concerns about health care stem from the blackout on telephone and Internet communications imposed by India on Aug. 5, when India revoked Article 370 and 35A, laws that gave the state of Jammu and Kashmir greater autonomy. After Article 370 was revoked, that state was split into two union territories. Union territories are controlled and administered directly by India's central government. A military curfew was imposed on residents after this political move.

Under this curfew, educational institutions are closed. Public transport is suspended. The movement of vehicles on roads is restricted. Gatherings and public rallies are banned. People are asked to stay inside their homes. The curfew remains in effect today, 25 days after it was imposed, though schools have been reopened and communication has been restored in some areas.

While the public can access phones from some government offices, reaching these spots can be an ordeal. Once they do get there, they would need to wait long hours for their turn.

As a result of prolonged curfew, the medical journals argue, people are not able to get access to health care.

And it's not just because travel is restricted. There's a digital component as well. In this region of 14 million residents, 1.4 million people are eligible for the Ayushman Bharat National Health Insurance, a government-funded insurance plan for the poor and vulnerable. The system is completely paperless and operates with e-cards. Doctors need the Internet to check the national database to see if someone is eligible for care so they can dispense free medication and schedule routine and emergency surgeries.

According to media reports, the communications shutdown has prevented both patients and doctors from using the national insurance plan.

Though phone lines have been restored in some areas of Jammu and Kashmir over the past week, the curfew has not been lifted.

"As far as curfews go, this is one of the harshest restrictions we've experienced," says a doctor in a government-run hospital in the city of Srinagar in an interview with NPR. She asked for her name to be withheld because she was not authorized to speak to the media.

"Even though I live close by, it took me 45 minutes to reach the hospital today," she said on Friday. "There were many blockades, and I was redirected several times. Over the past three weeks, most patients who need our care have reached our hospital on foot, but if you're very sick or pregnant, this can be hard. And those who live further away are completely cut off. Ambulances are being allowed on the roads, but how do people call for them in case of an emergency?"

In addition, there have been reports in the media of severe shortages of life-saving medicines, although the Jammu and Kashmir authorities have denied that such shortages exist.

Shahid Choudhary, district magistrate/development commissioner of Srinagar, tweeted:

One doctor who publicly shared his concerns faced serious consequences. On Aug. 26, Dr. Omar Salim Akhtar, who last year won a gold medal for topping the National Board Examinations in urology, spoke to the BBC Urdu, a local channel, and said that in his view, the restriction on driving and communications would mean that patients needing dialysis and chemotherapy might be unable to get access to the treatments they need and could die. Shortly after the broadcast, he was arrested in his hometown of Srinagar, Kashmir.

During the interview, Akhtar had held up a paper that read, "This is not a protest, this is a request."

"His intention was to get a message across to the government that a major [health] crisis was looming and that this communication blockade needed to end," says his brother, Dr. Othman Salim, in an interview with NPR. Salim is a hematology and oncology fellow at Roswell Park Comprehensive Cancer Center at the University of Buffalo, New York.

Akhtar was released at night, a few hours after his arrest. His family is still shaken by the arrest, which authorities told them was "preventive custody."

"We had a brief conversation after his arrest," says Salim. "I felt a sense of great despair and disappointment in his voice, which is unusual. From a professional standpoint it has been frustrating for him and other physicians like him. His patients are unable to contact him, and he is unable to speak with them when they need help."

As in many parts of the world, smaller towns lack certain specialists, Salim notes — and that's why telephone contact is so important. It's often the only way a patient can speak with a doctor at a big city hospital who specializes in a disease. Frequent disruptions in telephone communication can leave a lot of patients without access to care, he says.

Before the current crisis, Kashmir's health care system had been making progress, says Salim, although he notes: "From living and working in Kashmir, I know there's still a long way to go in providing high quality preventive and primary care to people."

But many doctors from India do not share these concerns. In fact, some doctors took to Twitter to support the stance of the IMA.

The IMA has been unrelenting in its stance.

"We strongly condemn the Lancet editorial because this seems like an attempt to malign India," says Dr. Santanu Sen, national president of the Indian Medical Association in an interview with NPR. "The government is responsible for medical care of its citizens and no one outside the country has any right to meddle in our internal affairs."

But other physicians in India were critical of the IMA's letter to the Lancet, calling it unwarranted. "Whenever there is any conflict, when violence escalates anywhere in the world, health care is the biggest victim," says Dr. Arun Mitra, co-president of the International Physicians for the Prevention of Nuclear War. "We need to acknowledge this."

Kamala Thiagarajan is a freelance journalist based in Madurai, India, who has written for The International New York Times, BBC Travel and Forbes India. You can follow her @kamal_t.

Copyright 2019 NPR. To see more, visit https://www.npr.org.