On October 18, as part of its autumn 2023 seminar series on APEC in advance of the organization's meeting in San Francisco in November, Shorenstein APARC and its Asia Health Policy Program (AHPP) presented the series' second event, Asia-Pacific Digital Health Innovation: Technology, Trust, and the Role of APEC. The featured panelists were Kiran Gopal Vaska, Director of the National Health Authority of India, and CK Cheruvettolil, the Senior Strategy Officer, Digital Health and Artificial Intelligence, at the Bill & Melinda Gates Foundation. Siyan Yi, the Director of the Integrated Research Program at the National University of Singapore and a former AHPP fellow, moderated the conversation.

While India is not an APEC member, Indian initiatives are examples of leveraging technology to better the health of the most vulnerable citizens in low- and middle-income countries (LMICs). Kiran Gopal Vaska gave an overview of the Ayushman Bharat Digital Mission (ABDM), India's latest health initiative that focuses on the interoperability of health records, services, and health claims. He stressed that ABDM was built on previous digital infrastructure, like Aadhaar, the national digital identity system, and Digilocker, a digital storage scheme for citizens' health and other records.

The approach India has taken is for the government to build the rails—the infrastructure of the system—and create a space where the private sector can develop applications integrated with that space through application programming interfaces (APIs), avoiding the siloing that can hamper the interoperability of data.

Regarding health data, privacy is a crucial concern at the patient level. ABDM addresses this concern through the use of a consent artifact. Individuals decide whether hospitals or other medical service providers have access to their data, and this access has levels of granularity: you can share specific portions of 7 different data types, like immunizations or prescriptions. You can limit that sharing to a particular period, like one day.

Also participating on the panel was CK Cheruvettolil, who discussed strategies by the Bill & Melinda Gates Foundation in leveraging the power of mobile phones to augment the work of Accredited Social Health Activists (ASHAs), the more than one million female frontline health workers in India. ASHAs can use mobile phone cameras, sensors, and streaming data to better care for low-birth-weight babies and other patients. 

He explained the critical role of taking local context into account when developing software by using the example of pregnant Indian women in their third trimesters. The custom for Indian mothers, especially in rural areas, is for the child to be born in the maternal grandparents' home. If software were to store only the mother's address, healthcare workers in the grandparents' jurisdiction would not know that a pregnant woman in the critical third trimester would soon be giving birth at a local address.

Kiran Gopal Vaska noted that India had solved the technological issues, and now the task was to push for adoption. He emphasized that the technologies underlying India's digital health stack were created as public goods for the world, and for LMICs to support each other in advancing digital health technologies, the key was interoperability, "using standards that are accessible and acceptable worldwide."

Gandhi reminisced about the ‘Unite India March,’ a democratic-inspired walk he led across the country that started with 125 people in September 2022 and ended with millions of people joining the 2,540-mile journey. And, although the ruling government had all the “force,” the instruments of control in society, the marchers were never stopped, he noted.

“This was a question that just kept rotating in my mind,” Gandhi said. “They have the force, but they don’t have power, and I realized that force and power are two completely different things. Most politicians confuse force and power, and they think they're the same thing. They’re completely different things. Power is an act of imagination, always in the present, and it is not linear. And power comes when you go close to the truth. That’s why we could not be stopped by force.”

He compared this to other moments of “power” in history, such as when President Kennedy said, ‘let’s go to the moon,’ or when Mahatma Gandhi stood up to the British Empire colonial powers in India, and when the American colonists created the Declaration of Independence to start separating from Britain.

Gandhi said acts of “force” did not drive these historical turning points; rather, they revealed the magnitude of the power of imagination that potentially exists among people to create a better, more just, and visionary world.

Such visioning needs to also inspire and transform the U.S.-India relationship, he believes.

“We already have a bridge between us, and it’s important that this bridge is not simply a bridge based on force, but that it is a bridge based on understanding of the realities of both our people,” said Gandhi, noting the software and technical skills of the Indian people in general match up extremely well with the leading-edge technology systems and markets in the U.S.

U.S. Relationship, Manufacturing, China

After his remarks, Gandhi engaged in an audience Q&A and conversation with Dinsha Mistree, an affiliated scholar with CDDRL. Gandhi elaborated that the political disconnect in India is attributable to a concentration of wealth, inequality throughout society, the current political system, and technology that’s outpacing the ability of social systems and people to digest and manage all the connectivity.

“With social media and technology, there’s a bit of a lag between the political system and technological progress, and I think democracies are struggling with that. I think evolution in the systems is going to take some time, but it’ll happen,” he said.

On economics, Gandhi said that while China’s Belt and Road Initiative, a massive infrastructure project that aims to stretch around the globe and seems to promote prosperity, it’s ultimately a non-democratic and authoritarian vision of the world. More visioning needs to be done by leading democratic countries on what prosperity entails for societies that may not be as wealthy as others.

“What’s the counter vision? So that’s where I see the gap. Of course, there is military cooperation (with the U.S.). That’s important. But it can’t just be military cooperation,” he said.

As for China, their top-down manufacturing policies are a challenge for democratic countries like India. Gandhi recommends that India follows a more decentralized manufacturing process.

“You cannot simply ignore the manufacturing might of China. You have to compete with. I don’t think it’s an option. So, what does that competition look like? I’m not talking about conflict, I’m talking about competition. How do we create an alternative vision?” he said, adding that it was a “fatal mistake” for the U.S. to parcel out its manufacturing in recent decades to China.

In response to an audience question on India’s position of formal neutrality in the Ukraine-Russia war, Gandhi said, “We have a relationship with Russia, and we have certain dependencies on Russia. So, I would have a very similar stance as the government of India. I mean, it might not be popular, but it is what it is. At the end of the day, we have to also look out for our interests.”

Democracy and Political Opposition

Mistree shared in an email prior to the event that Gandhi believes that India and the U.S. could work together in better ways on trade and economics.

For example, Gandhi’s view is that India could become a manufacturing powerhouse, which is a departure from the current ruling party’s position, while the U.S. continues to innovate and turns to India for more of its manufacturing needs, Mistree said.

“There’s a lot of space for these two countries to work much more closely together,” he said, adding that the Indian diaspora in America represents the second largest immigrant group in the country right now, and both countries share common security challenges in Asia.

Larry Diamond, Mosbacher Senior Fellow in Global Democracy at FSI, noted that Gandhi is the leader of the most important opposition party in India.

“You can’t have a democracy unless you have a political opposition that is free to criticize the ruling party, and contest for power. He has also been questioning directly the concentration and abuse of power by the current government,” Diamond wrote in an email prior to Gandhi’s talk.

Diamond added that U.S. and India have important, economic and strategic interests that should move forward in partnership based on their own logic.

“We need to hear and take seriously the concerns of political opposition and civil society in India, and we need to make clear to the Indian government that violations of basic democratic standards present obstacles to the deepening of U.S.-Indian ties,” Diamond said.

Gandhi was on a six-day visit to the United States to interact with the Indian diaspora and express his party’s commitment to democratic values in India and across the world.

He said, “There are difficult times, but there are also times of opportunity. I think there are times when acts of imagination and acts of true power will resonate and can transform the way we think of ourselves.”