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The doctors navigating covid-19 with no internet

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1417 (Published 07 April 2020) Cite this as: BMJ 2020;369:m1417

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Re: The doctors navigating covid-19 with no internet

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From one lockdown to another, doctors in Kashmir continue to struggle, this time facing a huge health emergency.
We commend the author on highlighting the challenges doctors in Kashmir face in tackling the Coronavirus pandemic under restricted telecommunications. Here we write to provide a further insight into the difficulties of tackling COVID-19 whilst only just recovering from a 7- month communications lockdown.

Consequences of communications lockdown pre COVID-19 pandemic

As Puja Changiowala correctly highlights, doctors in Kashmir are navigating a global pandemic on the background of decades of conflict and civil unrest rendering the healthcare system severely under-developed as result of repeated communications blockade ) and restrictions on movement in and out of the state which has lead to lack of investment.1 The most recent clampdown on telecommunications and free movement within and in/out of the state imposed by Indian authorities lasted 7-months with severe repercussions for doctors.2
Following partial restoration of communication in January 2020, accounts from Kashmiri doctors demonstrate a compete disruption of the healthcare system with doctors stating they have been unable to treat patients in a timely and adequate manner. One such story is that of a cardiologist working at a hospital in Srinagar, who, when faced with a patient with myocardial Infarction requiring specialised intervention, found himself driving to a technician’s neighbourhood in the pitch darkness of a night time curfew, unable to contact the technician otherwise due to lack of mobile connection services.3 Lifesaving emergency services have been inoperative since the lockdown including an emergency ambulance service ( KASHMEIR ) running in parts of the valley just started in July 2019 , and ‘Save Heart Kashmir’ a revolutionary initiative enabling 1200 doctors working in remote, poorly-connected areas of the Kashmir valley to seek advice and guidance from cardiology specialists via WhatsApp instant messaging. The initiative successfully ran for 500 days, handling over 19,000 cardiac emergencies prior to the lockdown, the service has rendered defunct since then.4 Free health programmes funded by government insurance schemes that are run primarily online, such as a free haemodialysis scheme for chronic kidney disease patients also came to a standstill meaning those unable to afford upfront payments for treatment have been unable to access this during the time.5. “People have died because they had no access to a phone or could not call an ambulance,” said RA, one of more than a dozen Indian doctors who signed a letter urging the Indian government to lift the restrictions.6
In addition to this, junior doctors completing their Internship training (similar to UK Foundation Year 1) at a leading hospital in Srinagar (Kashmir’s capital) told us in January 2020 that their training had been severely affected. They recall spending hours travelling, by ambulance between hospitals in order to communicate with senior doctors. The internet blackout also had a detrimental effect on medical education in the Kashmir valley. We spoke to a postgraduate doctor in Kashmir in January 2020 after partial restoration of internet. The doctor, planning to write his research during the internet ban recalled travelling 800 KMS to the capital of India, New Delhi, to access medical journals. Clinicians active in research have been unable to submit findings or access papers from medical journals for 7 months, with no medical research emerging from the Kashmir valley during this period. IK a research scholar in Kashmir University missed an opportunity to collaborate with a university in Estonia, as he couldn’t file visa applications in time. 7 In addition, prospective medical students have been unable to sit entrance exams to medical school due to a lack of adequate internet.
These are just a few of the stories giving a glimpse of what has been going on in Kashmir in the past few months, and doctors are only just recovering from it. Puja Changoiwala rightly points out that despite a lifting of the blackout, communication is still severely hampered by a lack of restoration of full access to social media and adequate 4G internet speeds. Episodes of civil unrest, communications black out etc. such as the one starting on august 5th have occurred repeatedly over the past 30 years and have left the healthcare system in tatters. Kashmiri doctors now face the new battle of a pandemic whilst their healthcare system has only just emerged from the recent events of the past few months let alone decades of unrest.

Current issues during COVID-19 pandemic

A senior healthcare advisor in Kashmir issued a statement stating that Primary and even secondary care hospitals are not capable of handling the COVID-19 pandemic. They neither have infrastructure nor the resources for this, said Q B a health inspector. The doctor-patient ratio in the state is one of the lowest in India (1:3866) as against 1; 2000 in the rest of India. The support for intensive care is poor with just over 112 ventilators for the whole valley with a population of 8 million.8,10 Various organisations have been supporting the public health for a number of years, they say there is a huge dearth of N95 protective masks in the valley for front line healthcare workers, and situation will get worse than better as number of corona virus infected cases are beginning to increase, 333 cases now reported as on April the 17th.8 As a result of lack of supplies due to current lockdown lot of non-government organisations are finding it difficult to place orders for PPE’s ( personnel protective equipment ) from other parts of India due to inadequate internet service. SK a communication coordinator who works for mental health and women’s empowerment, says we have to travel to the office and document everything on hard copies and submit these documents physically to our donors.9
As already highlighted by the author, when science about coronavirus is fast changing, there are hundreds of instances of Kashmiri doctors expressing their concern over the difficulties in accessing important information in a crisis like this. Their practice is being restricted due to the low internet speed and failure to connect to live webcasts, guidelines from leading professional bodies, or keep pace with the latest developments regarding coronavirus. Even in this time of need they are unable to communicate with their peers overseas for advice.

Public Health Education

Whilst social media campaigns in India educate the public on how to protect oneself from coronavirus, this has not been possible in Kashmir. It has been impossible for healthcare professionals to educate the public en masse via the internet e.g. WhatsApp, regarding the virus leading to reports of huge amounts of unopposed misinformation regarding the pandemic, social stigmatisation of those infected, unscientific practices amongst the population and an increase in hysteria and panic due to the population being unable to access information online. Lack of education surrounding the virus, hand hygiene and social distances will undoubtedly have catastrophic consequences for the health of the population and put unbearable strain on doctors. 11

Effects on mental health

The COVID-19 crisis can be a huge burden on the mental health of the people already anxious over lack of inadequate healthcare as well as poor awareness of the disease. People are vulnerable to exacerbation of their pre-existing mental health conditions (from 2015 survey by Medicines San Frontiers, 41% of Kashmiri population suffer from mental health disorders) warns WHO. There have been reports that the spreading of fake news and myths have exacerbated mental health conditions. 12

Importance of being able to connect with loved ones

There are quarantine canters set up by the government for people who are found to be infected with the virus after contact tracing. This has caused social unrest, as people are sceptical about these moves due to their previous experiences in lock downs and lack of trust in authorities. It makes it even more important that if people’s loved ones are admitted or quarantined in hospitals and care homes, their families can stay in touch with them if there is adequate internet. Similarly healthcare workers are staying away from their families while at work for days and weeks together in order to protect their families, would be equally susceptible to isolation if they can’t stay in touch with their loved ones.

Conclusion
An internet connection especially in a pandemic is like eyes to the emergency physician, said one doctor rightly, kindly don’t blind us. As evident from the rest of the world, the outcome of this outbreak will ultimately depend on the efficient and timely communication with the public. An unfamiliar public health emergency surely leads to anxiety both in public and healthcare workers due to fear of unknown. Before that fear can do more harm than the virus itself, authorities in Kashmir need to relax the internet lockdown to save lives. In times of health crisis like COVID-19 pandemic, access to internet and information is a necessity not a privilege. It is still not too late, history will acclaim the benevolent not imperceptive. With the high court of Kashmir seeking report on restoration of efficient internet facility, further reinforcing the Supreme Court order dated January 2020, we hope that this blinding veil or eclipse is lifted soon, allowing healthcare workers to protect this already vulnerable society.

References
1. Covid-19: doctors in Kashmir express concern over inadequate infrastructure, shortage of manpower. Deccan Herald. 30 March 2020. www.deccanherald.com/national/north-and-central/covid-19-doctors-in-kash...
2. BBC New. Inside Kashmir's lockdown: 'Even I will pick up a gun'. https://www.bbc.co.uk/news/world-asia-india-49294301

3. Sameer Yasir and Jeffrey Gentleman. In Kashmir, a Race Against Death, With No Way to Call a Doctor. https://www.nytimes.com/2019/10/07/world/asia/kashmir-doctors-phone.html, Dated: October 7, 2019.

4. Hannah Ellis Peterson, Sun 5 Jan 2020 the Guardian.com
5. Ubeer Naqushbandi, Internet gag thwarts Ayushman Bharat healthcare scheme Underprivileged patients unable to avail free treatment, Greater Kashmir, Srinagar, Dated: December 13, 201
6. Kashmir communications blackout is putting patients at risk, doctors warn. BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5204 (Published 19 August 2019) Cite this as: BMJ 2019; 366:l5204
7. Athar Parvaiz, Kashmir valley braces for coronavirus with years of lockdown experience, Poor internet speed and abysmal healthcare facilities are the real threats, people say. doi,10.1038/nindia.2020.49 published online 23 March 2020
8. Syed Amjad Shah, Jammu, 208 ventilators in J&K, Bandipora has none, Greater Kashmir, April 17, 2020,
9. Muddasir Ali, Majid Maqbool. Lockdown hits access to healthcare in besieged Kashmir. https://www.thenewhumanitarian.org/news/2019/09/19/Kashmir-lockdown-heal...
10. Majid Maqbool. Jammu and Kashmir hospitals ill-equipped to deal with coronavirus pandemic.https://www.firstpost.com/health/jammu-and-kashmir-hospitals-ill-equippe... deal-with-coronavirus-pandemic-ut-has-180-ventilators-for-1-25-cr-population-8185591.html
11. Apr 01, 2020 | Dr Murtaza Rashid / Dr Mudasir Firdosi, Covid-19: Stop shaming patients, patients need respect, care, and treatment and demand full dignity, http://www.risingkashmir.com/article/covid-19-stop-shaming-patients-5002...
12. Covid-19 | Govt issues advisory for mental health, psychosocial support for children, families, GK News Network, Srinagar, April 13, 2020

About the Authors
Sehar Farooq, IBSC
4TH Year Medical Student
UCL School of Medicine, UK
Dr Farooq A Wandroo, MD,FRCP,FRCPath
Consultant and Senior Lecturer NHS, UK

Competing interests: No competing interests

18 April 2020
Farooq Sehar
iBSc, 5th year medical student
Dr Farooq Ahmed Wandroo MD, FRCP, FRCPath (NHS consultant and senior lecturer)
University College London
London