Amid the COVID-19 pandemic and inadequate public health infrastructure, private hospitals in India hiked up their prices, while both COVID and non-COVID patients desperately ran from pillar to post to access primary, tertiary, and emergency services. The bizarre phenomenon of Indians clanging pots and pans, yelling “Go, Corona, go!” at the behest of a senior minister, offers a glimpse into the possible pathologies that exist among communities, societies, and governments. Between this and the showering of flower petals over hospitals across the country by no less than army fighter jets, the middle class and elite of the country were sent into rapturous paroxysms of nationalistic pride.
These superficial gestures, however, camouflage a murky underbelly of the healthcare situation in the country laid bare by the pandemic. On March 24, 2020, a devastating lockdown was imposed by the government of India that lasted twenty-one days, following a fourteen-hour test run. There were hardly any support systems in place for the vast majority of people, while existing social security schemes for health, education, food, and pensions became even more dysfunctional. Many faced job losses overnight and were denied wages for work already done. The arduous and perilous journey home by foot made by thousands of poor migrant workers was documented across the country.
Marginalized and vulnerable communities bore the brunt of the pandemic’s fallout in disastrous ways. Muslim communities, as is the norm with the then regime, became the target of hatred, discrimination, and irrational accusations of being responsible for the pandemic. Unscientific and bizarre allegations of “corona jihad” were heaped upon the community, even by the so-called educated elite, including doctors.1 In Karnataka, this translated almost immediately into economic boycotts of Muslim-owned businesses, denial or discrimination in access to healthcare, and extreme forms of harassment and bullying—this toward a community that was at the forefront of providing essential rations, ambulances, oxygen cylinders, and even burial services for the dead during the worst part of the lockdown. It is crucial to note that some people refused to handle the dead bodies of their own community members.
Apart from the deplorable targeting of minority communities, the pandemic exposed many other disconcerting issues: discrimination based on caste and gender within and by the healthcare system, exorbitant and unethical costs in private hospitals, and incompetent public health policymaking, to name a few. Physical distancing was intended to prevent the spread of the virus from one person to another. However, “social distancing,” reflecting deep-rooted casteist hierarchies and prejudices of “them versus us,” “pure versus polluted,” and “touchable versus untouchable” became readily legitimized as “good public health practice.”2 Some doctors called for use of the term “physical” (rather than “social”) “distancing”—since caste already makes us pretty adept at the latter!
Around this time, use of teleconsultation and telehealth services in India increased. While they can add value to a well-functioning healthcare system and did serve a crucial interim purpose during a rigorous lockdown, they also need to be critically assessed in the Indian context. Telemedicine gives doctors and other healthcare workers the accessibility to consult and treat patients over the internet using interfaces such as WhatsApp, Zoom, and other teleconferencing technologies. Having worked with communities both in person and through telemedicine widely during the COVID pandemic, I have seen firsthand how the critical introduction of technology in the doctor–patient relationship has been well received by some but has woefully failed others.
Telemedicine practice guidelines published by the Indian government in March 2020 clarify the legality of teleconsultation, which is often hailed as a remedy to the disproportionate distribution of health services between urban and rural areas. The National Telemedicine Service of India, known within the country as eSanjeevani, was piloted by the Ministry of Health and Family Welfare in 2019 and launched in 2020 as part of the Ayushman Bharat Digital Health Mission, offering online outpatient consultations that link specialist doctors with the Ayushman Bharat Health and Wellness Centers. It operates as a central hub complemented by spokes “routing patients needing more intensive services to the hub for treatment” and “strives to provide an alternative via a digital platform to the conventional physical consultations.”
Pressing Concerns Remain Unresolved
A review of telemedicine guidelines in Southeast Asia finds that although the practice has expanded over the last few years, it has yet to address concerns related to cybersecurity, including data theft, phishing, and ransomware attacks, as well as digital literacy, among other ethical and legal issues. Five servers of the All India Institute of Medical Sciences faced a cyberattack in November 2022 that compromised the records of an estimated 30 to 40 million patients and interrupted services for fifteen days.
Additionally, potential mismatch between the skills and understanding of the treating doctor, the frontline healthcare worker, and the patient poses all possible dangers of misdiagnosis and potentially unnecessary prescriptions. As Dr. Budhaditya Gupta and Professor D. V. R. Seshadri write in a 2022 article, “City-based doctors are embedded in a vastly different socio-economic context compared to that of the local practitioner and the rural/semi-urban patient … This makes effective communication a challenge.” They suggest improving on existing intelligent matching algorithms, which would not only appropriately match the doctor for their clinical abilities to a patient but explicitly “consider socio-cultural factors, location proximity, language, gender, religion, and past patient experience.”
Data protection laws do not offer adequate safety, especially in maintaining confidentiality. Digital healthcare might be marketed as a symbol of India’s “progress,” but such self-congratulation ignores inadequacies and fails to address the question of access and protection. If a healthcare provider is casteist, Islamophobic, transphobic, or a sexual abuser, they are likely to misuse this private space to humiliate the patient, ask triggering questions, or offer advice laced with prejudice. How can India’s healthcare system ensure the safety and prioritize the well-being of the patient under such conditions?
An inability of the doctor to communicate in the local dialect and an inadequate understanding of common diseases, norms, values, behaviors, and diets of different communities can further impede effective communication. Telemedicine guidelines recommend that the doctor should maintain “the same standard of care during teleconsultation as during in-person consultation.” This, however, leaves the question of whether in-person consultations, as they occur now, can be held up as such a standard.
Although crucial, technology cannot be a standalone measure of India’s “greatness.” It is important to assess who benefits from it and, crucially, who it leaves behind.
A Struggle against Ingrained Prejudices
Unfortunately, many Indian healthcare providers readily rationalize embedded prejudices that cannot be dismantled with only a few sensitization training sessions. Moreover, regulatory bodies can sometimes themselves be afflicted with the same issues that they set out to monitor, often resulting in a culture of impunity and narrowing of safe spaces for individuals from vulnerable and marginalized communities. The culture of tolerating and enabling discrimination, bullying, and harassment seems to be more pervasive than a culture of inclusiveness, fraternity, and equality. How can coldness, meanness, disconnectedness, and apathy be regulated? How can healthcare personnel be trained in kindness and inclusivity? Discrimination and harassment have been normalized both within and by the healthcare system.
One way to at least partially change this is ensure diversity by introducing, at all levels of the healthcare system—and specifically policymaking—what is known in India as reservation. Reservation, a constitutionally mandated system of affirmative action for “socially and educationally backward communities,” aims to ensure representation in education, employment and politics. However, resentment against reservation and affirmative action is visceral and “unreserved.” Doctors from oppressor caste groups make little effort to hide, and even publicly share on social media platforms, their prejudice and sheer ignorance of this system meant to address generations of caste-based discrimination.
Dr. Kiran Kumbhar, a medical professional and PhD in the history of science, rightly points out that distrust of Indian doctors isn’t a new phenomenon, and that class and caste bias have always ruled the medical profession.
Thus, the relationship of the medical profession with the privileged public was vastly different from that with underprivileged people: the extent of doctors’ camaraderie and courtesy in the former often matched the amount of indifference and disrespect in the latter.
The 2019 suicide of Dr. Payal Tadvi, a postgraduate student of gynecology and obstetrics at Mumbai’s BYL Nair Hospital and member of the Tadvi Muslim Bhil Scheduled Tribe community, might be better described as institutional murder. Tadvi’s death reveals the grim truth of institutional prejudice, bullying, and discrimination as well as an equal measure of apathy when such violence is reported. All three accused doctors have been released on bail, and a government-appointed panel reported that there was “no conclusive evidence of caste-based harassment”—despite other reports showing that she had been a victim of extreme harassment and casteism. The tendency to blame the victims is the most common response, as if most of them are responsible for their own deaths. The mechanisms to identify institutional or structural casteism and to hold those who operate in the lens of casteism accountable are primitive at best. Responding to the claim made, ad nauseum, that reservations have “encouraged mediocrity” in our country, Dr. Kumbhar counters, “Reservations are—wrongly—blamed for encouraging mediocrity in the medical profession. The historical record shows that the floundering foundations of the profession were laid by doctors who came purely through merit.” He explains how abuse and bullying do not invite any major corrective action from the leaders of the medical profession, who turn a blind eye to the dominance of such damaging ideas and myths. He reiterates that there is a need for the medical profession to collectively act on workplace abuse as well as casteist harassment, before it is too late.
Digital Connectivity Does Not Break Down the Walls of Bigotry
Teleconsultations would be more effective if frontline workers, ideally qualified doctors, shared comprehensive details of the patient with the treating specialist, who would be able to offer emergency treatment or referral based on the patient’s condition. This suggests that telemedicine can only play a supportive role in an egalitarian, accessible, and affordable healthcare system, rather than as its replacement.
In India, the current primary focus of telemedicine seems to be on screening and referring patients to treatment in large corporate hospitals, rather than offering healthcare close to where they live. In Karnataka, the fact that most of the doctors and healthcare facilities are in the city results in more people traveling to the city to access even basic and essential services. A patient with a lung infection or a complicated delivery should not have to travel any further than their district hospital. Shifting patients further and further away from home increases alienation, compounds their precarity, reduces their agency, and causes out-of-pocket expenditure to skyrocket, even if state health insurance covers empaneled private hospitals.
While telemedicine served a purpose during the COVID pandemic, it has always been better suited to meet the needs of literate, middle-class, and urban patients who have access to their records, are comfortable using technology, do not face linguistic barriers, and inhabit less noisy and better-connected environments.
The unequal distribution of technology in India puts those in urban-deprived and rural areas, the elderly, and those with physical and cognitive disabilities at an even greater disadvantage. Difficulty in identifying patients in need of a physical examination or emergency care can lead to negligence and denial of appropriate healthcare as well as a breakdown of the doctor–patient interpersonal relationship, which depends on bonds of empathy, touch, and reassurance. Undue reliance on telemedicine can lead to a collapse of existing healthcare systems, which get reduced to referral outposts at most.
Against the backdrop of poor regulatory mechanisms and unequal access to healthcare, telemedicine can become a way of aggravating age-old practices of discrimination, while also reducing quality of care. In a country where caste-based and religion-based discrimination and denial of essential services are serious threats, telemedicine can exacerbate the social distance between marginalized communities and the health system.
The irony is that in India, many doctors working in person already depend heavily on lab tests and avoid touching patients, not dissimilar to how a doctor would interact with a patient through teleconsultation. Healthcare can be compromised in the absence of a detailed physical examination, including direct observation of the patient for their gait, body language, and speech, among other vital aspects. A person who has faced abuse, such as custodial torture or domestic or sexual violence, may present critical signs and symptoms that would alert a discerning clinician.
Ultimately, all healthcare systems are reflective of the larger social and political entities that govern them. In India, the sad reality is that whether it is a hospital visit or a teleconsultation, a privileged few benefit while the already vulnerable are left behind, dependent on the attitudes and ethics of healthcare providers who are themselves located within a larger society and institutional structure. Unless overt and covert practices of discrimination are recognized and addressed at every level, some people and communities will be “diagnosed” as being of “lesser value,” and left out as some form of “collateral damage.” Ensuring that the healthcare system is inclusive and accessible to all will build the necessary framework for value addition from telemedicine. It can never be a standalone intervention; it can never be a panacea.
1. Aarti Lalchandani, “Statement Condemning Abusive and Communal Hate Speech,” Kractivism, June 6, 2020.
2. See Vanessa Heaslip et al., “Caste Exclusion and Health Discrimination in South Asia: A Systematic Review,” Asia Pacific Journal of Public Health, May 24, 2021; Charu Gupta, K. Satyanarayana, and S. Shankarhttps, “The History of Caste Has Lessons on the Dangers of Social Distancing,” Wire, May 1, 2020; S. Harikrishnan, “Coronavirus, Social Distancing, and the Return of Caste Apologists,” News Laundry, March 30, 2020.