We are witness today to a democratic country violating multiple rights of an entire state of its own citizens. Starting from August 5, 2019, it is now over two months that the state of Jammu and Kashmir has been under a lockdown, and there was also a communication blockade. Initially all modes of communication – landline telephones, cellphones and the internet were blocked, and there were severe physical restrictions on the movement of civilians, with concertina wire barricades manned by soldiers every few metres. The Central Government put these measures in place along with thousands of additional troops brought into the state, in addition to the troops already deployed there, as it abrogated Article 370 and 35A of the Indian Constitution, and downgraded the state into two union territories (1). A further precautionary step was deemed necessary – the house arrest and subsequent imprisonment of thousands of political leaders, activists, lawyers, civil rights workers – anyone seen as having the ability to command a following. Leaders of mainstream political parties have also been under arrest since August 5. These restrictions and arrests were supposed to be necessary to maintain peace and avoid the loss of life.

As of today, landline phones have been restored in almost all areas and mobile telephony in Jammu. Post-paid mobile phone connectivity was restored in Kashmir on October 16, 72 days after it was blocked (2). A third of mobile phone users (about 20 lakh) who use prepaid phones still do not have access. Political leaders in Jammu have been released from house arrest, but most from Kashmir remain in detention. Daytime restrictions of movement of people in the Valley have been officially lifted, but are put back in place whenever there is a protest somewhere. Internet connectivity is still blocked across the state, and prayers at the main mosques in Srinagar are still not allowed (3).

As a result, the citizens of Jammu and Kashmir have been unable to communicate with anyone not in their home or immediate neighbourhood. The only news they get about what is happening in the state is what is portrayed in the mainland news channels, or in foreign news media that is accessible to those with satellite TV. Since local journalists are not able to move around freely to gather news, the publishing of local news and newspapers has been severely affected.

An unspecified number of citizens have been detained, including children, and news channels like the BBC and Al Jazeera report allegations of beatings and torture by the security forces (4, 5), though these have been officially denied.

Impact of the prevailing situation on the health of the citizens

What is most evident in Jammu and Kashmir is the lack of information about the health situation. The only information that we have is from press reports. There is no independent information from the medical community in Kashmir or from non-governmental organisations. In the context of the information blackout, press reports which provide information about the health situation assume greater significance. The lack of information also impairs our ability to articulate an informed response.

How has all this affected the health of the residents of Jammu and Kashmir? We shall focus on Kashmir as the restrictions have been most severe in the Valley and most available reports are from there. Our information sources are press reports and some teams and individuals who have visited and written accounts of their experiences there. Two groups of physicians (6, 7) who have sought official permission from the Home Ministry to visit and make an independent assessment of the health situation have not had a response from the Ministry even after a month.

Living in a conflict area has already resulted in a disproportionately high burden of psychiatric morbidity and post-traumatic stress disorder. A study by Medecins Sans Frontieres (MSF) in 2005 (8) in two rural districts of Kashmir found that nearly two thirds (62.7%) of the adult population suffering from high levels of anxiety, such as nervousness, tension and excessive worrying*. A third of the population had entertained thoughts of ending their life. In such a situation, to have a prolonged communication blackout and restrictions on movement, when people cannot meet or speak with friends and family except those in the immediate neigbourhood, must only increase stress levels (9). Children and family members of Kashmiris living outside the Valley too, are anxious about the well-being of their relatives in Kashmir.

There have been many reports of problems with access to healthcare. During the 72 days that citizens were without mobile phone connectivity ( as a third of the population with pre-paid phones still is), physical access was difficult when an ambulance could not be summoned (10). Unless one walked to where an ambulance was available and got it for the patient, it was not possible to use its services. Even if one had access to a vehicle, negotiating the numerous barriers put up by the army and answering their questions at each barrier meant delays in reaching a hospital (11).

Since the national health insurance scheme (Ayushman Bharat) depends on internet connectivity to verify the credentials and avail of the scheme, it has stopped functioning across the state in the absence of internet access (12). Patients undergoing expensive treatment like dialysis or cancer chemotherapy have had to borrow money for this in both public and private facilities, or have stopped seeking treatment.

Difficulty in travel has also meant that patients living in rural areas have not been coming as usual for treatment like dialysis and cancer treatment, and doctors have no way to contact them (13). In one instance, a linear accelerator (a machine required for cancer therapy) was out of order. Till it was repaired, many patients who had turned up for their appointments, had to be turned back as they could not be informed in advance not to come on that date (14).

Patients with severe pellet gun injuries are brought to the larger Government hospitals, but those with serious but not life-threatening injuries stay back at home, fearing arrest from the hospital itself (15). Hospital records may therefore, underestimate the number of pellet gun injury victims or those treated (16).

Doctors, too, have been under stress in this situation (17).

We have no information about the situation in rural areas and regarding primary care. Are maternal and child care and immunisation services being provided as before? Are patients with tuberculosis getting their medication and monthly food subsidy regularly? Are malnourished children getting the extra care they need?

Constitutional rights and the right to healthcare.

Fundamental rights guaranteed by the Constitution of India include the “right to equality” (Art.14), the right to freedom of speech and expression (Art.19), and the right to life and liberty (Art.21) which guarantees not only the right to life and liberty, but also the right to health, right to a safe environment, right to live a life with human dignity, etc. All persons have the right to immediate medical aid in case of injury or in an emergency to be treated in government hospitals. Additionally, the Constitution guarantees protection against arrest and detention to all persons (Art.22) and lays down certain rights of people being arrested or detained too, as one of the Fundamental rights.

Though the Constitution does not explicitly spell out the right to health, the Supreme Court has read the right to health as a part of the Fundamental Rights chapter in the Constitution and has relied on the Universal Declaration of Human Rights, and the International Covenant on Economic, Social and Cultural Rights while discussing the rights of workmen and healthy working environments. The apex Court held that the right to health does not mean a mere absence of sickness but complete physical, mental and social well-being (CESC Limited and others v Subhash Chandra Bose and others, 1992 SCC 1, 441). The Supreme Court has also stated that providing adequate medical facilities is an essential part of the obligations undertaken by the government in a welfare state, and the failure of a government hospital to provide timely medical intervention to a person in need of treatment results in violation of fundamental rights (Paschim Banga Khet Mazdoor Samity and Ors v State of West Bengal and Anr, AIR 1996 SC 2426). The guiding Directive Principles of State Policy in Part IV of the Constitution, mention the right to health “The State shall regard raising of … the improvement of public health as among its primary duties” (Art.47), while other provisions are for the promotion of welfare, to remove inequalities, to ensure that children are given opportunities and facilities to develop in a healthy manner and in conditions of freedom and dignity (Art.39).

Today access to the internet, mobiles and computers have become essential not just for communication but also for learning and getting an education. The High Court of Kerala recently passed an order (Faheema Shirin RK v State of Kerala and Ors, WP No. 19716 of 2019, judgment dated 19.9.2019) stating that the right to have access to the internet has become a right to education as well as right to dignity under Art.21 of the Constitution of India, and thus, blocking the same for months is a violation of not just freedoms but also fundamental right to life, dignity and education. In today’s age, ability to access the internet often determines access to health services, as in utilising the Ayushman Bharat Scheme.

Reactions of the medical fraternity

What has stood out has been the lack of a strong response from doctors and health professionals to the situation in Kashmir where there has been a glaring lack of access to health care.

In mid-August, both The Lancet and the British Medical Journal voiced their concern about the situation in Kashmir. The Lancet in its strongly worded editorial dated August 17 (18) voiced concern for “the health, safety and freedom of the Kashmiri people”, highlighting the high levels of stress people there are living under due to the prolonged conflict. The Indian Medical Association (IMA) reacted sharply to this editorial, asking the medical journal not to interfere in the internal affairs of another country, and stated it had withdrawn the esteem it had for the journal (19).

The British Medical Journal on August 19 has also published a news item expressing concern that the lockdown in Kashmir would adversely affect access to healthcare (20).

A few groups of doctors in India have also expressed their concern regarding the healthcare crisis in Jammu and Kashmir caused by the current restriction of movement of its citizens and the ongoing communication blackout (21, 22, 23). They have stated that the current situation in the state is a denial of the right to health and life.

What else can be done?

Are we as medical professionals doing enough in this situation? And what is our responsibility here? Narratives vary between the “all is well” claim of the Government and “a health crisis” reported by a few Indian and foreign reporters. How do we establish the truth and do we need to? By and large there has been silence in the medical community, with most going about their business as usual. An unspoken atmosphere of fear prevails. It is for multiple and perhaps valid reasons that even those medical professionals who are concerned have not been more vocal about it. Should we be silent bystanders when fellow citizens in an entire state go without unrestricted access to healthcare and health services? Even professional bodies have been silent about the healthcare situation in Jammu and Kashmir. Our lack of response has led to a normalisation and acceptance of the governmental action as being morally and legally correct.

A statement on public health and healthcare in Jammu and Kashmir by a group of doctors (24) offers a direction. It calls on professional bodies to co-ordinate with the Government to form teams to assess the actual situation in Jammu and Kashmir, and specifies areas of concern: maternal and child health services; emergency care; chronic disease care; child nutrition; disease outbreak prevention; medicines and supplies at health facilities, and last but not least, the issue of pellet gun injuries. The statement urges the Government to ban the use of pellet guns by security forces and calls for the immediate lifting on any curbs on communication and movement of people in Jammu and Kashmir. It urges professional bodies and the health system to prioritise citizens’ right to healthcare above all else, in keeping with the principles of medical ethics.

As a group of medical professionals, we also need to make our concern more visible to the lay public through writing in newspapers and magazines, and to our local elected representatives. We need also to organise ourselves to put pressure on the Government of India to acknowledge that health is above politics and to remove all restrictions on movement and communications that hamper unrestricted access to healthcare, as a first step. This will not be easy with the Government insisting that hospitals are functioning normally and that people have no difficulty in accessing health services. More direct support can be to provide professional support to Government institutions at district and sub-district levels based on consultations with the healthcare providers of Jammu and Kashmir.

As health professionals, it is our moral and ethical responsibility to speak up for and on behalf of fellow citizens in Jammu and Kashmir whose right to health and healthcare is being affected.

Ignoring the situation there, or being indifferent to it, is not an option.