A Medical College with two principals- mockery or politics! Who is to blame for the cock-up?

Medical College is the highest seat of education when it comes to the training and teaching of future doctors and other allied health professions.  Worldwide, most medical colleges are deemed universities and enjoy an independent status which helps them to grow and excel both academically and clinically.  Government Medical College, Srinagar has the prestige of being the oldest in the state and once upon a time used to be ranked among the top ten medical colleges in India.  But, one does not have to explain the current state of the health system in the state or of the esteemed Medical College, Srinagar.  For a long time now, it has been in the news for all the wrong reasons, from the death of infants, administrative cock-ups, violence against doctors, poor academics to almost no research.  The very same college and its allied hospitals were the victim of fake drug supply by the very health department which is supposed to run it safely.

From the last few weeks, the issue of the principal medical college (PMC) has become very contentious and one fails to understand who is running the institution? The current PMC (ex-PMC as per some) Dr Rafiq Pampori went on a protest leave few weeks ago alleging bullying and undue interference from the current health minister Lal Singh.  Dr Rafiq Pampori is a well-known ENT surgeon of the country and is highly respected by his colleagues and students alike for his integrity, honesty and humility.  He has been a role model for many newcomers to the medical profession.  But, when it comes to the administrative abilities, many people are sceptical about his role and to what extent he is able to deliver.  Going through the social media debates, everyone is united in vouching about his professional capacity and integrity, but there have been many voices questioning his extension as principal Medical College.  As it stands now, it has been reported that due to the direct intervention of the Chief Minister, Mufti Muhammad Sayeed, Dr Rafiq Pampori decided to join back as the PMC.  Meanwhile, the health minister, Lal Singh has appointed Dr Kaiser Ahmad as the in-charge PMC.  It is still unclear who is running the Medical College, as both have the claim of being the official PMCs. This speaks volumes about the disarray and mismanagement of the health sector in the state and it is not rocket science to figure out who is responsible for the mess!

While submitting his protest leave, Dr Rafiq Pampori alleged that the current health minister is interfering constantly into the day to day work of the medical college and the post of PMC has been rendered impotent.  It is no secret that Lal Singh has been bullying professionals openly and has been in the news repeatedly since he has taken the charge, from almost man-handling senior doctors to publicly harassing female doctors.  He has humiliated Dr Pampori publicly on many occasions, which comes as a surprise in current day and age.  Why Lal Singh got the health portfolio again, is a mystery?  This is, in fact, his second term as health minister and everyone knows his regressive tactics for allegedly improving the health sector in the state.  With the current PDP-BJP coalition, the situation is worse as it is hard to say if there is any coordination between the chief minister’s office and departments headed by BJP ministers.

Like all other departments, the health sector has also been the victim of centralisation of power.  Every decision is made in the secretariat with institutions like the Medical College having no powers to run its own affairs.  We all know why the powers are centralised and how the mafia for nepotism and corruption makes sure that even a small decision like transfer of a class fourth employee is done by the minister.  The hospitals cannot even buy their own medicines and equipment which ultimately led to the fake drug scams with central purchase committees directly under the control of the health minister.  The scandal of the postings and transfers in the health department has made sure that people continue to pay a high price for everything and in this process, the institution has been left to the dogs.  If a doctor has to go outside country for leisure or academic reasons even for few days, it is mind boggling to know that they have to take permission from the chief minister of the state.  Does the government have no better things to do than to micro-manage everything from the secretariat? Is the government for the people or against the people?

Should the medical colleges not be autonomous institutions? Who is responsible for the failings of the Medical College and its allied hospitals? Can we blame the PMC and the faculty for everything? What about the accusations of Dr Rafiq Pampori against the health minister?  Why is no one talking about the allegations he has made?  In any civilised society, a written note by a person of his standing will be entertained as an official complaint and investigated to get to the facts before taking further action. But as we are talking about a minister, it would be blasphemous to consider such an idea as VVIPs are above the law in the current age.  How can elected representatives and more so cabinet ministers be wrong?  Whistleblowing is almost unknown in our setup and anyone who speaks the truth is humiliated and punished in various ways may it be forcible retirement to the threat of transfer to far flung areas.  With the ongoing conflict in the state, people even fear for their safety and lives.  Few months ago when the Doctors Association of Kashmir (DAK) protested against the excesses of the health minister, immediately one of the doctors was transferred hundreds of miles away and the Doctors Association almost disbanded.  There is no space for questioning the coercive methods of the people in power.

That said the senior doctors and faculty of the various medical colleges cannot shy away from their responsibility and role in the degradation of the health education in the state.  There is a culture of yes-manship for various reasons and highly qualified professors can be seen lining the corridors of the secretariat for petty favours. The medical colleges are in bad state academically, clinically and hardly fulfil the role of a university- as the hub of teaching and research.  There are no simple reasons why this has happened. One of the main reasons one can argue is the centralisation of power.  The government should have no role into the day to day running and management of medical colleges and they should be allowed to set their own rules and regulations with short and long term goals. The PMC should not just be a caretaker and always under threat of getting sacked for no reason. Of course, there should be checks and balances but not by the government but by an independent body set for the purpose.

There should be regular appraisal and accreditation of the faculty and not merely by the outdated system of annual reviews (APRs). The promotions of the faculty should be based on their performance than automatic. Becoming a professor, for example, should be based on actual contribution to teaching and research and not just time in the job.  The entry criteria for the faculty posts should be revised and people with academic or research background should be offered the posts and not any doctor with a postgraduate qualification.  Ideally, people need to have a Ph.D. or an additional teaching qualification to qualify for the faculty post, so that they have the drive and passion for training, teaching and engage in fulltime academic work. This would cut the dead wood out and let people chose their paths early on.  

Finally, the government should seriously revisit the portfolio of the health minister and who should run the department.  I am sure there are many highly qualified MLA’s and even doctors in the current government who can run the department more sensibly in the greater good of the state rather than for their personal obsession of bullying medical professionals.  The state has already lost many doctors who are leaving left, right and centre due to unfriendly work culture, bullying, humiliation and lack of job satisfaction.  There is still time to save this (once upon a time) prestigious institute from the further debacle and prevent putting further lives at risk.  It would also mean saving the careers of many efficient brains who decide to become doctors after toiling for years.  The coalition government should rise above the petty politics and appoint someone with experience and qualifications to run the Medical College and not merely the one who is senior on the list.  Decentralising the powers and restoring the dignity of the PMC’s chair cannot be excused if the government is serious to improve the state of healthcare. 
http://www.risingkashmir.com/news/medical-colleges-should-be-autonomous-institutions/ 

Violence against women

This year the United Nations Secretary General’s Campaign “UNiTE” called for the ‘16 Days Activism’ to end violence against women by organising “Orange Events” worldwide held between November 25 (International Day for the Elimination of Violence against Women) to December 10 (Human Rights Day).   

Killing of women by their in-laws is common in the Indian subcontinent with India, Pakistan and Bangladesh trying to outdo each other.  Reports suggest that bride burning accounts for death of at least one woman every hour in India. In most cases, fire is set by their nearest family and in some cases they set fire to themselves out of desperation. Official figures from India’s National Crime Records Bureau revealed that 8233 young women were killed in so-called dowry deaths in 2012 and 8083 such deaths in 2013.  Similarly in Pakistan, around 3000 women have been burnt alive since 2008, and 300 women are burnt by their families every year. Unfortunately, Kashmir too has been in the news lately for cases of domestic violence, throwing acid on girls and burning women alive.

One wonders why such gruesome acts are committed by civilised people. Many theories have been proposed talking about the historic practices of burning woman, inferior status of a woman in the society, patriarchy, women being treated merely as objects and disposable items, sexism, misogyny etcetera but none of this can explain exactly why simply divorcing or leaving her does not suffice and why people have to go to this extreme brutality. Despite being a criminal act, inhuman and surely prohibited by any religion why do we still have such cases? Is it akin to the corruption that no amount of religious teaching or fear of God would make it not doable?

Recently a friend argued that such acts are happening in Kashmir because men are feeling powerless and emasculated due to the ongoing conflict situation and have lost control on their lives. Targeting females starting from domestic voice to and such brutal acts somehow gives a vent to their frustration and they get some sense of control. One may accept this theory but it does not answer the basic question. Also in most of the cases, it is not men in isolation who set fire to a woman; it is usually women who run the mafia. Hence, the case that men are solely responsible for this brutality is not entirely true. It is usually the extended family including mother, sisters, aunts who float the idea that the daughter-in-law has not done enough or brought enough and she deserves to suffer or die. 

One could think that this could be due to poor education, illiteracy and poverty as we often blame everything wrong in society on such factors. But, again most cases happen in allegedly respectable, well-educated middle-class families, who have no financial crisis or starving due to poverty. It would not be wrong to say that every mother-in-law is a mother of a daughter and every husband is a brother or a father as well.  But then why does the same mother, mother- in-law, husband or brother find it so easy to set someone ablaze just because she is not a blood relation? I am not sure what the answer is, are you?

It is fair to argue that people who indulge in such acts/homicides are not suffering from an impairment of mind and they are perfectly able to understand their actions and its consequences. In fact, the inhuman and criminal mind-set makes them cunning and they plan the brutality with a cold heart. They usually get away with covering up the incident and in most cases the victim is blamed for her death, may be suicide or some other reason.

Talking of the Valley, we come on roads protesting for issues which can be as trivial as the installation of electric meters or the ongoing acts of brutality due to the conflict situation. We invoke religion on every aspect of life and criticise people when there is an occasion of happiness or celebration, alleging people are not mindful of the ongoing conflict and there is no fear of Allah in their hearts. We close down roads for days when an innocent is burnt to death by communal forces (I am not trivialising the incident and no amount of protest would suffice), but we do not react when a woman is burned alive by one of our neighbours. There are no strike calls, no agitation on roads as if nothing has happened. There are no sermons by religious leaders and self-styled moral critics on social media do not find such acts that interesting. Even the wazwan and singing on weddings finds more space when it comes to moral policing. I am not arguing whether all those acts are right or wrong. I am just trying to say that surely those acts are more important to us than when a woman is brutalised, violated or burned alive. This speaks volumes about the cultural acceptance of such gruesome practices against women compared to the other often trivial issues.

Despite there being laws in place, like a ban on sex determination, we still see female foeticide and worsening sex ratio. The core beliefs that females are a burden and inferior are so ingrained and deep rooted that even females themselves have become the victims of same thought process and ultimately often the perpetrators of such crimes. What can help to change such mind-set? Presumably religion, education, prosperity, laws, morality so on and so forth would be the answer. But aren’t those factors already there and instead of improving the situation, why has it gone worse? Are we deeply hypocritical and misogynistic? Domestic violence against women is rampant in all forms may it be emotional, sexual and physical, usually accepted as fate and often the victims don’t realise that they are being maltreated. Ultimately burning alive of a woman is the final expression of such mind-set.

What would it take to stop this cruelty and menace? Are we using religion selectively to further compromise the position of woman in our society when it should have made them safer and more respectable? Are we inculcating a type of slave mentality in female children from the time they are born? Are we giving them constant reminders that they are not equal, dependent and somehow there to please the men may it be their father, brother or husband? Are we talking about morals only when  women doesn’t agree with the current social regime or does something not considered right by the society but then somehow passively agree with what men do or demand? After all, why is it acceptable in broader terms that one can burn his wife or daughter-in-law just because somehow they are not happy with her?

Do we consider divorce worse than burning alive?

The answer is yes, there is more shame in breaking a marriage than killing.

So what is the solution? I am not sure, but probably it will start by considering woman as equal, as human and as worthy of living as are men. The culture of subjugation, dependence and inferiority needs to change and it will need much more than education and sermons. It needs a practical change in the way men feel entitled for special treatment in their own homes. Why do we feel humiliated or even shy in helping our women in the kitchen even though both partners may be working the whole day in full-time jobs?

Surely men are not more special and do some wonders which woman can’t. It is time that men change their mind-set than teaching daughters that they need to adjust every time something wrong is done to them. Surely, if women are confident and aware about their rights and somehow don’t feel they have to oblige no matter what; they would not put up with a family who is ultimately going to burn them alive.

The law needs to get stringent and fair and any family which is proved to have engaged in domestic violence or such heinous crime, need to be monitored and punished. Domestic violence in a broader sense needs to be discussed and women need to be mindful when to say no and raise their voice and seek help. 

Confidential helplines for women suffering from domestic violence could be of great help and may encourage many to seek help before they reach the point of no return. There are always tell-tale signs and if we are aware, many cases can be prevented. The government has to take responsibility and provide adequate alternatives when women are subject to domestic violence so that they don’t feel there is nowhere to go but to accept their miserable existence. 

Finally, it is women themselves who can change this status quo as without them men would not be able to stand a chance, so it is time to break such collaborations and refuse to be the victims of gas-lighting.

http://www.risingkashmir.com/news/violence-against-women-new 

The Price of Parental Neglect

There is no simple definition for neglect, more so when we are talking about the neglect of children by their own parents.  The fact is that most parents love and look after their children, at the cost of their own health, comfort and go to any length to make sure that their children are safe and do not come to any harm.  But unfortunately, that is not a rule and one comes across cases where children are neglected and maltreated.  Why it happens, is both complex and worrying.  Neglect is hidden, unlike abuse which can be visible and noticeable to others.  Hence in such situations the children feel helpless, trapped and unsure of what’s happening. 

A simple definition of child neglect is the failure to provide needed age-appropriate care. This encompasses the obvious physical needs of food and shelter to the subtle emotional needs of love, compassion, recognition, sense of safety and validation.  Failure in providing overall compassionate parenting can lead to serious adverse consequences both during childhood and adult life.  When it comes to the provision of physical needs, a family ought to live within its means and this does not mean neglect. A poor family may not be able to provide the same luxuries compared to a well off family.  But the difference is in the way children are provided and cared for, an excess of money and toys apparently sounds good but if there is little personal supervision and emotional care, it can prove counterproductive and harmful in the long run. 

 

Even a baby that is a few days old reciprocates to your body language; they laugh, make eye contact and get scared depending on how a parent is playing with them. They respond to an angry or smiling face, and it is not difficult to note how they change their body language mirroring the parent.  They may not be able to talk, but all these small things make a huge difference in their overall personality development. A child whose behaviour and feelings are not noticed, acknowledged and are interpreted wrongly by their parents receive a powerful message that they are not wanted, their feelings do not matter or whatever they are trying to convey is not acceptable.  Such neglect and acts of omission by parents can lead to serious adverse consequences. 

 

Unlike in the West where the common factors which can lead to child neglect are illicit drug use, unsupported single parent, a breakdown of the family, poverty etcetera, the situation is quite different in the Asian context due to different cultural and local customs.  Some other risk factors which can lead to neglect are family conflict, unemployment, violence and conflict situation in the community, physical and mental illness in the family and acute life stress to name a few. 

 

In our culture, the differential treatment of children based on their gender is another grave issue.  Boys get all the attention and girls are left to fend for themselves and are given an impression that they are mostly a burden and liability.  The discrimination starts even before birth and some people choose to kill them in the womb.  We have seen time and again the cases of domestic violence, mostly directed towards females, which at times ends in brutal and violent acts like burning alive. It is fair to say that the acceptance of such behaviour, at a cultural level, starts subtly decades before the actual heinous act.  Hence, female foeticide continues and culminates in the murder of a grown up woman.  I am not trying to say it is only men who are responsible for such mentality and acts; women are equally responsible and often drive the process. 

Children can be neglected due to the ongoing conflict and dispute between their parents.  Parents who argue in front of their children and physically abuse each other in their presence; put the young minds in severe emotional and ethical dilemma.  Children in such cases become withdrawn, develop a sense of guilt and somehow feel responsible for the actions of their abusive parents.  This leads to a sense of insecurity and children can start acting out, become truant from school and often take on drug addiction.  Some parents are too busy with their work and personal ambitions that they knowingly or unknowingly ignore the needs of their children.  This not only leads to emotional deprivation but can become dangerous when the children are left unsupervised.  Leaving children with others is not always safe and can lead to potential harm.  Cases of physical and sexual abuse are common in such situations and children are caught up in the vicious cycle of neglect and abuse.  This is worsened further when the parents deny or ignore the child’s plea that they are not safe or have been actively harmed. 

 

Children who grow up in problem families as described above find it difficult to adjust to life and are at increased risk of developing psychological problems.  That means difficulties at home, poor schooling and ultimately not being able to live a productive and fulfilled life. Sometimes children can take on similar traits and engage in antisocial or harmful behaviours. Feelings of poor self-esteem, isolation, lack of trust and low self-worth are not uncommon. They also feel insecure and are not able to cope with day to day pressures of life.  They are at high risk of falling into the trap of bad company and drugs.  In some places, such children find refuge in criminal gangs which gives them a sense of purpose and belonging.  Suicide and self-harm is also common in such children.  It is very important to realise that children are highly sensitive about happenings around them and the way they are cared for. 

 

There is no simple answer to the problem, but the solution does come from common sense and from treating children with dignity, respect and love. This gives them the essential feeling of safety and security which is the right of every child.  Treating children partially based on their gender is morally and religiously wrong and harmful to the child and society at large.  Children look up to their parents as role models and if parents do not treat them with honesty and care, the children are unlikely to do well.  It is like teaching a child to speak the truth but acting and behaving otherwise, which not only confuses the tender souls but also sets them in the wrong direction.  Similarly, if the parents behave differently in their public and private lives, it worsens the situation and creates a sense of doubt and disillusionment in children.  

 

Finally, parents have the duty and responsibility to safeguard their children from any abuse or neglect and in no way should be the perpetrators themselves.   It becomes more pertinent in our current age when children are at additional risk due to factors like social media, excessive pressure to achieve, easy access to drugs and vulnerability from people who target children.  If parents are not coping due to any reason or feel they are in a strained relationship, they need to make sure that their children are not trapped in the middle and used to score points against each other.  It is better to seek help and advice than ruin the life and happiness of children.  Unfortunately, there are no safeguarding mechanisms in our society and it is very difficult for neglected children to get any respite.  Society at large also has a responsibility to help end the evil cultural practices which put children at risk, like partial treatment based on gender, female foeticide and dowry etcetera.  It is easy to fell prey to denial and refuse to accept what is happening within the family, but it is never too late to make a fresh start and give children their life back. 

 http://www.greaterkashmir.com/news/opinion/story/203673.html 

Dignity in Mental Health

Every year the World Mental Health day is marked on 10th October.  The theme of this year's World Mental Health day is ‘Dignity in Mental Health'.  Worldwide, various organisations including WHO, celebrate the day to raise awareness to fight stigma.  As per the World Health Organisation, millions of people with mental health conditions are deprived of their basic human rights.  Apart from being discriminated and marginalised they are also subject to emotional and physical abuse in their own homes, community and even mental health facilities.  This is further worsened by the lack of infrastructure, dilapidated facilities, poor quality of staff or lack of an adequate number of professionals.  Failure to treat people with respect and dignity often worsens their condition further, by having a negative impact on the recovery and long-term prognosis.

In Kashmir, the number of people suffering from psychological problems has increased exponentially.  With the ongoing conflict, mass exposure to trauma, worsening socioeconomic conditions and the prevailing day to day uncertainty, people are more prone to develop psychological problems.  Psychiatric Diseases Hospital, Srinagar is the main facility catering to all the districts of Kashmir, Ladakh and adjoining areas like Banihal, and Kishtwar.  The hospital has been under tremendous pressure over the years catering to huge demand due to the absence of other psychiatric facilities in the region.  The department has expanded and developed over the years and has become one of the Centres of Excellence in the country, meaning that increased number of doctors and allied staff are being trained.  This was only possible due to the sustained efforts of doctors working in the hospital, who at times spent money from their pockets to attend meetings around the country, to get the funding and upgradation status, without any help from the State administration.  The psychiatry department has its own facility at the SMHS Hospital, which provides daily OPD services and treatment to drug abuse patients.  Lately, many psychiatrists have joined at various district hospitals though there are still no inpatient beds available.  

The attitude of young doctors has changed towards psychiatry and even toppers in the entrance examination are choosing to become psychiatrists.  This is surely progress when it comes to the acceptance of psychiatry as a career by doctors in spite of opposition from families and society at large.  Mind you, they could easily join other specialities like medicine or surgery.  It is worth noting that psychiatry has improved academically in the Valley compared to many other parts of India. 

When it comes to the stigma and general treatment of people suffering from mental illness, we are not doing any better, both in the community and at the professional level.  There is huge stigma related to any kind of mental illness and often people find it difficult to even talk.  There are various myths and stereotypes associated with it and people prefer to take advice from anyone but a psychiatrist.  People would often go to neurologists and cardiologists and undergo multiple unwarranted investigations and end up on a cocktail of unnecessary medications.  Faith healers are often the first port of call, where few find respite and most get into further trouble.  I am not blaming common people here, it is due to lack of awareness and more so because of the stigma. 

Although stigma is inherent with mental illness in most societies, the delivery of care has made the problem worse in Kashmir.  The Psychiatric Hospital at Kathidarwaza originally a part of the central jail was initially started as an asylum.  Later, it was converted into a Mental Hospital and ultimately became part Medical College Srinagar.  Recently, it was renamed as Institute of Mental Health and Neurosciences.  But when it comes to the perception of common people, probably the status of the place has not changed much and is still considered merely as a mental hospital and often called by derogatory names.  Often, young women would request if the prescription is written on a paper which does not say Psychiatric Hospital.  Sometimes they will carry an additional prescription slip from SMHS to show to their family, fearing stigma, shame, being judged or even fearing that visiting here may cost them their marriage.  Most people are usually comfortable to see a psychiatrist at SMHS OPD but would refuse to go Psychiatric Hospital citing obvious reasons. 

Once accompanying a young man from downtown Srinagar, his old mother innocently narrated how she tried to bribe a policeman to get him arrested, explaining that it is more respectful to be in prison than to be admitted to this hospital.  Sadly, such cases are not rare. Many believe that by receiving treatment from this place, the prospects of future relationship and marriage could be bleak for both boys and girls. 

There are families even from well-educated background who lock up their loved ones, fearing stigma and shame. We still see incidents when people are being chained and treated inhumanely.  There are also some patients who have been admitted to the Psychiatric Hospital decades ago, but for various reasons have never been claimed back.  

With the opening up of new wards at SMHS and open ward at Psychiatric Diseases Hospital, the care and treatment for many patients has improved.  Unfortunately, same cannot be said about the patients treated in the closed wards. The wards are not in good condition and remain locked without any direct nursing supervision.  The hospital has a limited area of land, where ongoing construction has meant that it has lost the only garden space and looks more like a construction site.  There is no place for patients to have some free air or get any physical exercise. 

The Mental Health Act 1987 is in force in Jammu and Kashmir to safeguard the care and treatment of mentally unwell.  Sadly, the Act is on paper only and none of the state machinery including the medical fraternity abides by it.  When admitting or treating patients against their will, no consideration is given to their basic human rights and end up essentially locked up.  Sometimes people are admitted under court orders without a review date meaning prolonged admission.  Police has an integral role in the care and safeguarding of mental health patients, but most families have to either beg or bribe the cops to get help for transferring an uncooperative patient to the hospital.  With no training and knowledge of the mental health legislation, patients are transported in very inhumane conditions, often tied and bundled up. 

The Jammu and Kashmir State Legal Services Authority has published guidelines in 2010 for the care and treatment of the mentally ill persons, which if followed would have greatly improved the services.  It argues that as India is a signatory to the UN Convention on the Rights of Persons with Disabilities (CRPD), 2008, making it obligatory for legal system to ensure the human rights and fundamental freedoms of people with mental illness and mental disabilities are protected on equal basis with others.  It also advises to ensure that they get equal recognition before the law and equal protection of the law.  The Convention further requires ensuring effective access to justice for persons with disabilities on an equal basis with others.  But again this has remained limited to paper.

There is a need for education and awareness of the general public and particularly of professionals involved in care and treatment of mentally unwell. This would include the health professionals, police and legal services.  Mentally unwell people should be treated with dignity and respect as anyone else in the society. This includes treatment of both mental and physical health. Those who have been abandoned by their families or have no families need to be rehabilitated in the community so that they don’t live a life of imprisonment just because they have a mental illness.  

Finally the government should relocate the Psychiatric Diseases Hospital to a suitable location and allocate adequate land so that a world class Institute of Mental Health is developed with appropriate space and wards manned by psychiatric nurses, and separate wards for children and old age patients. Many like-minded psychiatrists tried to get the hospital relocated after it was granted the status of the centre of excellence, but no headway was made due to red tape and unending bureaucratic apathy.  A new hospital will surely ease the stigma and improve the basic facilities so that people are not treated in asylum-like conditions anymore.  

 http://www.greaterkashmir.com/news/opinion/dignity-in-mental-health/198198.html 

Personal reflections of doctor starting psychiatry training in Kashmir

Personal reflections of a doctor starting psychiatry training in Kashmir

 

It was my third year in medical school and we were excited to be out of the classroom and with real patients at last.  My first clinical posting was in surgery and within few weeks I had made up my mind, ‘I am going to be a surgeon, maybe a neurosurgeon’.  

This continued till I passed the final year examination.  During my twelve month internship, I had a ten-day posting in psychiatry.  Apart from a few lectures and a random question in the medicine paper in the final examination, these ten days are the only clinical psychiatry experience most doctors will have during medical training in India.  Hence, psychiatry has no identity of its own in undergraduate training.  I do not remember having much interest in psychiatry during my medical school days that is, until I started the ten-day psychiatry rotation as part of the internship in Government Psychiatric Diseases Hospital, Srinagar.

I think it was early winter, there was a chill in the air and the sky was invisible under a shroud of clouds.  The Psychiatric Hospital is old; historically it has been part of a prison, an asylum, a mental hospital and finally ended up as being part of the Government Medical College Srinagar. This led to the establishment of a postgraduate department of psychiatry in the hospital responsible for training doctors as future psychiatrists.

The hospital shares a wall with the Central Jail of Srinagar, in an area which was once within the confines of an old fort called Hari Parbat. One can still see the huge walls and the entrance to the area, called Kathidarwaza.  To my surprise, most of the hospital was in ruins due to a recent fire, the cause of which remains a mystery to this day.  A few old wards were still standing and the outpatients department was being run from a temporary building.  A new small structure, rather better looking than the rest was the office of the Médecins Sans Frontières (Doctors without borders) who had constructed that recently with their own expenses.

Patients were seen in two small rooms.  In one room, there was a consultant psychiatrist and his registrar and in the other room a few post graduate trainees and SHOs.  The corridor was full of patients, mind you there is no appointment system and patients walk in to be seen.   Each room had a small table, a few chairs and a coal heater in the centre.  There was no room to move and one can see people in a range of moods, holding the hospital cards in trembling hands waiting for their turn. There was no privacy and I was surprised how the psychiatrists were able to listen to personal stories and make sense of it all.  A few helpers were trying to man the door to stop everybody from pushing inside at the same time.  There was a strange aura around probably from burning coal heaters, overdressed patients and their attendants, some silent as if they were not there and some indifferent and lost.  It was rather hard to make sense of it all at the time.

As an intern, I was supposed to shadow and watch the psychiatrists seeing their patients.   I think it was my second or third day when one of the registrars asked me to take a history from a patient.  The patient was probably in his fifties traditionally dressed in Kashmiri Phiran (traditional gown) and a round cap.  He was sporting a short beard and looked like a village elder.  But once he started talking, I could not make much sense and my curiosity increased further.  He told me a long story which is hard to recollect in full detail now, but I still remember that he was on the moon, had attended a wedding there and was planning his next trip.  For a minute, I was confused, not sure any Indian has been to the moon let alone a village elder from Kashmir. But his story fascinated me, he was talking to unknown people and seemed perfectly convinced of what he was saying and I was not sure whether I doubted him.  He was happy and full of energy.

This was the first time I thought about the psychiatry as a speciality and what psychiatrists do.  Within the next seven days, I had changed my mind and decided to be a psychiatrist.  I still did not discuss this with any of my colleagues, friends or family.  After finishing my internship, I again joined Surgery as a house officer and nearly everyone thought I would make a good surgeon, not knowing I had other plans.

In those days, there were only 2 placements for psychiatry training in the entire state of Jammu and Kashmir, despite having four medical schools and dozens of placements in other specialities like medicine and surgery.  Out of the two places, one was reserved for “backward category” (those from impoverished backgrounds) meaning there was actually only one placement on offer and hence competing for this single place was not easy.  Thousands of newly qualified doctors compete with each other; a yearly entrance examination is conducted and merit list is drawn as per the score in the exam.  At the time of counselling, the top scorer is invited first and can cherry-pick any branch and rest of the candidates follow as per their scores, meaning those at the end do not have much choice.  Hence to get to this single psychiatry placement, one has to be at least in the top ten on the merit list.  Fortunately, after working hard for a whole year and revising all that had been taught in the entire MBBS, I scored well and was 6th on the merit list.

At the time the result was declared, I was spending time with my parents and was off work.  It was my brother who called late in the evening confirming my score and place on the merit list.  My father asked if I was going to be a cardiologist or a surgeon. I replied “I am going to be a psychiatrist” without any doubt or ambiguity.  Both my parents went a bit quiet initially, but then said "if that is what you would like, why not".  I have to say I have been lucky when it came to my parents; they always believed in me and let me make my own decisions. But I know other people in my place, whose families opposed their becoming psychiatrists and one doctor was even threatened with divorce by his in-laws if he chose psychiatry.  The stigma was very much there and it still prevails.
 

On the day of counselling, when I went to fill in my preference, there was a noticeable stigma.  I was asked to give two choices and when I mentioned psychiatry as my first choice, I remember all three-panel members stopping in time, with their jaws dropping.  They probably thought that with my score, I can take any branch, surgery, medicine, paediatrics, orthopaedics, why is he asking for psychiatry? They could not resist and finally the Chair asked why do you want to do psychiatry?  Obviously my answer was not for their understanding.  I still remember while I was sitting in the waiting area, all the doctors who were supposed to be there that day, came around to have a look at me. They were also surprised why someone would do psychiatry when he could cherry pick whatever he liked. I am glad; my decision did make a difference as next year, candidates with even better scores than mine decided to join psychiatry creating a positive ripple.

Hence, I started my psychiatry training in May 2004 at the very same burned and gutted Government Psychiatric Diseases Hospital Srinagar. I was awarded MD Psychiatry by the Kashmir University after passing the final examination in 2007.  Later, I worked as programme officer for the National Mental Health programme, trying to take psychiatry to the community and was able to establish psychiatry outpatient services at few district hospitals. I was also organising training programmes for general practitioners and health workers with the help of faculty from Psychiatric Diseases Hospital. 

When I needed to move to the UK, I contacted the Royal College of Psychiatrists London, who advised that I could apply under the MRCPsych equivalence scheme which would help me to gain the GMC registration and allow me to work as a psychiatrist in the UK. Unfortunately, the College decided that ‘I could not prove that my degree was equal to MRCPsych' and advised me to take the examination instead.  Although, it was not good news, I was not disheartened; neither did it change my desire to continue practicing psychiatry.  After passing the PLAB examination conducted by the GMC, I applied to London Deanery and they gave due weightage to my experience and degree from India and I started working at the South London and Maudsley NHS Foundation Trust.   I passed the MRCPsych membership exam and currently I am working as a specialist registrar in consultation liaison psychiatry at the famous Guy's Hospital, London. I am involved in teaching and training core trainees and medical students. I am also an honorary researcher at the Institute of Psychiatry, Psychology & Neuroscience King's College London.

Looking back at over 11 years of being a psychiatrist, I do not think there was ever a dull moment. Every new patient I encounter is different and the curiosity to know the human psyche never ends. Reflecting back on my six months in surgery, where things are fairly similar, i.e.  One tries to avoid the same artery while taking out a lipoma, being a psychiatrist means no two cases are ever the same. I am still fascinated with the same energy and intensity as I was in 2002 when I met that Kashmiri village elder who had just returned from the moon. The value of life is not only in its physical form but what drives us underneath. I am glad I made the decision to choose psychiatry. While I could have been treating organs and systems being a surgeon, treating someone as an individual is far more satisfying and fulfilling and that defines being a psychiatrist to me.

Finally, I am happy to say that the Psychiatric Hospital Srinagar, through the efforts of like-minded doctors has developed as one of the centres of excellence in mental health. It has been renamed as The Institute of Mental Health and Neurosciences Srinagar, with an increased intake of psychiatry trainees and has also trained allied mental health professionals in the last few years. The stigma among doctors is much less and for the first time in the history of Kashmir a few female doctors have qualified as psychiatrists.

http://www.rcpsych.ac.uk/discoverpsychiatry/overseasblogs/psychiatrytraininginkashmir/personalreflectionsofadoct.aspx

Suicide prevention needs State intervention

World Suicide Prevention Day is observed on 10^th of September each year to raise awareness and prevent deaths from suicide.  This year’s theme for World Suicide Prevention Day was ‘Preventing Suicide: Reaching Out and Saving Lives’.  As per the WHO estimates, more than 3,000 people die of suicide every day or more than 800,000 people every year.  For every 20 people who attempt suicide, one succeeds.  Sadly, suicide is the second leading cause of death in the age group 15-29.  More people die due to suicide worldwide, than due to wars and homicide combined, and around 75% of the deaths by suicide occur in low and middle income countries.

In India every year around 135,000 people end their life by suicide which is about 17% of the total suicides worldwide.  Some estimates suggest suicide rate of 10-11 per 100,000 of population.  As per a report by the National Crime Records Bureau (NCRB), Sikkim has the highest suicide rate at 29 per 100,000 of population and Bihar was at the lowest 0.8 per 100, 000.  Jammu and Kashmir has a suicide rate of 3.5 per 100, 000 as per this report.

Historically, Kashmir is known for low suicide rates and I am not sure if a word for suicide exists in the Kashmiri language.  Various factors have prevented serious escalation in deaths by suicide in spite of ongoing conflict and high prevalence of mental health problems in the Valley.  Being a predominantly Muslim population, religion acts as a protective factor.  The social structure and close knit families provide a protective environment.  People are also known for their resilience which could also be responsible for some protection against escalating suicide rate.

Lately there are frequent reports in newspapers about increasing rates of suicides in the Valley.  Some estimates have suggested suicide rate of around 13 per 100,000 in the Valley.  As per a study by Dr Arshad Hussain, 3-4 patients attend the SMHS emergency department daily, with attempted suicide.  In 2012, about 836 cases of attempted suicide by poisoning were treated at SMHS and more than a thousand such cases have been treated since 2013.  There is hardly any data available from other hospitals across the valley, neither is there any central suicide data base.  Recording suicide is difficult because of the tag of criminality associated with it.  Hence, the actual suicide rate can be much higher than we know. 

When it comes to the method of attempting suicide, use of pesticides remains the leading cause in most Asian countries, including India and same is true about Kashmir.  Hanging remains another common mode of suicide followed by overdoses with prescription and recreational drugs.  Attempted suicide is more common in women than men, but death by attempted suicide is more common in men.  Suicide is also common in urban, literate population than rural areas.

The common reasons for attempting suicide are mental health disorders followed by drug abuse and family problems.  India uniquely poses other reasons for suicide like poverty in farmers.  When it comes to Kashmir, we do not have any robust data to suggest the pattern and causes.  It is a well-established fact that there has been an escalation in mental health problems due to ongoing conflict and mass exposure to psychological trauma.  The rates of depression and PTSD have significantly increased.  Drug and alcohol use is common, making people more vulnerable towards attempting suicide and accidental overdoses.  

People are living in perpetual uncertainty.  There is an environment of fear and a sense of feeling trapped. This is worsened by poverty, little hope for future in terms of joblessness particularly in the youth.  Increased joblessness has also meant delay in settling down and getting married.  Many females are not able to get married due to poverty and huge social expectations.  The increased demands of a modern life coupled with a race to perform better increases the vulnerability of susceptible individuals.  Even children are under extreme pressure to outdo each other.  There is usually an escalation in the number of people attending hospitals for attempted suicides after exam results.  Relationship issues and breakdown in families is another reason.  Other important but hidden factors include domestic violence and sexual abuse. 

India is one of the last few countries in the world where attempting suicide is a criminal act. As per the Indian Penal Code 1860, section 309, ‘Whoever attempts to commit suicide and does any act towards the commission of such offence, shall be punished with simple imprisonment for term which may extend to one year 1 or with fine, or with both.  Even the wordings like ‘commit’ and ‘offence’ brings in shame and stigma. This archaic law was enforced under British rule in 1860 and has still not been amended in spite of repeated calls to abolish it.  The Mental Health Care Bill 2013, suicide has been partly decriminalised and a presumption of mental illness has been added, meaning people will not be prosecuted if they attempt suicide.  But this Bill is yet to be passed in parliament.

The issue of criminality around suicide has meant the shame, and stigma getting worse for someone who is already feeling low, hopeless, and worthless with no motivation to carry on. There is an immediate need to decriminalise suicide completely, so that people are able talk about it openly.

Robust registration and documentation of every case should happen, which can help to plan future services.  This is not always easy as the culture of registration and documentation in our hospitals remains weak.  Undertaking community studies on such a subject is arduous and almost impossible in our setup.

Early identification and treatment, training of health workers, follow-up care and community support, introducing alcohol policies, restricting access to means and lastly responsible media reporting are some of the strategies advocated by the WHO to prevent suicide.

Many lives can be saved if people get right support and help at right time.  Awareness of public and health workers with an acceptance that suicide is real but preventable can make a big difference.  Any patient of attempted suicide, who is brought to emergency department in any hospital, should not be discharged home unless seen by a mental health professional for thorough psychiatric assessment to assess further risk and formulate a management plan.  

In the SMHS hospital patients are referred to psychiatry OPD for such assessments during working hours, but there is no such provision during night time and holidays.  I am not sure other major hospitals in the Valley including SKIMS have developed any such protocol for dealing with suicide cases.  There is a need of developing close liaison between various departments and psychiatry.  Ideally, every emergency department should have access to a psychiatrist all the time.  In the absence of such facility, all cases should be admitted overnight and referred to psychiatry next day so that they receive appropriate treatment and have a safety plan before going home.  Some people do need inpatient treatment if severely suicidal, but unfortunately we do not have such wards or setup in the valley yet, and it is often families who have to deal with the crisis situation.

It is also important that people seek timely help for psychological problems and not let it go to the stage when one starts feeling suicidal. Non Judgemental support from family, and friends helps people suffering from depression and other such problems to recover, without feeling rejected and looked down.  Avoiding drugs and alcohol is another way of preventing suicide.  Improving ones spiritual wellbeing and faith is a great support and gives hope to many who are not able see any other way out.

Easy access to drugs and poisons is a problem in our society which is hard to tackle.  Some have suggested creating pesticide banks, which sounds appealing but rather impractical in our setup.  Here also, awareness of family and friends is important so that if they know someone is at risk of suicide, they can keep such articles under lock and key and supervise the person till they become safe.

In conclusion suicide prevention needs comprehensive multi-sectoral approach from the State, policy makers, and health services including psychiatrists, police, religious leaders and society in general.  It is important to take on board that none of us is immune to such difficult situations.  Anyone of us can fall victim to this hard hitting BUT preventable condition. 

http://www.risingkashmir.com/news/suicides-prevention-needs-state-intervention/  

Conspiracy of Silence- Childhood sexual abuse is a hidden epidemic withlack of recognition and safeguards

In 2007 Government of India authorised a survey into the childhood sexual abuse. The results were alarming describing ‘conspiracy of silence’ around the issue. Out of 13500 children surveyed in 13 states, about 20% were subjected to severe sexual abuse.

Around 31% of such assaults were by a neighbour or a close relative in family. Childhood sexual abuse is unfortunately common and usually perpetrated by someone known to the victim within or outside family. From scientific literature, it is evident that childhood sexual abuse is widespread in all cultures irrespective of religion, values, society, social class, geographical area and Kashmir is no exception. From our own clinical practice and research in the Valley, it is clear that childhood sexual abuse is a common occurrence and is not restricted to any social class.

Unlike other forms of physical or sexual abuse, nothing seems to be protective here as anyone can be the perpetrator. If a parent or guardian is the culprit, it makes this kind of trauma worse than any form of brutal torture. When someone is abused by a ‘person in trust’, the impact of the horrifying experience is profound and leads to lifelong psychological and emotional scarring which is hard to heal. Such children become confused as the boundaries of relationships get blurred and they struggle to comprehend the meaning of social norms. This shatters their core belief of depending on someone or finding emotional comfort. The victim loses all hope and is never able to trust anyone anymore. This gives rise to very complex situation for a child, who may not be able to understand what’s happening at the time.

As the trust is first causality here, children are afraid to approach anyone for help. If ever they do get some courage or in naivety do mention it to a parent, the outcome is not as you may be expecting. Sometimes it can take decades for them to come out if at all. One would assume that immediately the child will be made safe, reassured and the perpetrator brought to books, but that is not the usual outcome. After a brief phase of anger or frustration, the adults in most cases go into a denial mode and refuse to entertain the idea consciously or unconsciously. Children are even threatened with their life, to keep quite. The elders do not listen to their children in such matters and usually the allegation is out rightly rejected. At times their own mothers shut them up due to fear of stigma, guilt, shame and in a false belief to save the future, both of the child and family. This shatters the abused children of any remaining hope and sends them back into a state of perpetual fear, and at times exposes them to continuous and long term abuse. It also reinforces the feelings of rejection, guilt and belief that no one can be trusted.

The golden rule, ‘always believe the child whatever he or she is saying’ needs to be followed in all cases. Children do not lie is these matters and they do not invent stories. It does not matter whom they are referring to and how respectable and trustworthy the said person is in your eyes. He may be a highly respected social worker, religious leader, faith healer (peer), teacher, doctor, freedom fighter, village elder, politician, father, grandfather, brother, cousin or anyone. The child needs to be taken seriously and saved from any further trauma. In addition to ill formed beliefs, the adverse social and cultural pressures about sexual abuse in our society make it difficult to deal with this subject.

Children can display various symptoms and behaviours if they are being sexually abused within or outside family. Children can present withdrawn, aloof, depressed, angry, challenging, refusing school, start bedwetting, not eating, weight loss, always on edge and fearful, lose interest in activities which they usually enjoy, tearful, not sleeping, stop playing and the list goes on. Some children may start self-harming by head banging, cutting on their arms, or putting themselves in dangerous situations. Some fall into the trap of drug addiction and self-medication. It has varying long term consequences. The outcome is grave if child is not believed by their loved ones, breakdown in trust, and lack of emotional support, repeated and prolonged abuse. People can develop severe forms of post-traumatic stress disorder, personality change, dissociative disorder, depression, anxiety, panic attacks, phobias to name a few. Self-harm and suicidal attempts are common as people see little hope in future. There is severe lack of confidence with poor self-image which can lead to failure in studies leading to school dropout and inability to achieve professionally. They find it difficult to form long term relationships and may avoid marriage. In summary the whole life is shattered, leading to poor outcomes both in terms of health and quality of life, failing to achieve to their potential, may not be able to work and lead a miserable life for no fault of their own.

In our society, there is a strong taboo for any kind of sexual abuse and unfortunately the victims are on the receiving end. They are made to believe that somehow they are not equal or dignified anymore. There is no legal recourse and we do not have systems in place which can help such children. Suppose if a child somehow makes to police and narrates the ordeal, what are they supposed to do? What if a parent is involved, where would the child go? In a country where judges advocate that a rapist should marry his victim, there is little hope for such lonely children. There is no recognised system to deal with perverted people like paedophiles and neither are they identified. And let’s not be naïve they don’t exist in our society.

The Protection of Children from Sexual Offences Act (POSCO) was enacted in all states of India in 2012 except Jammu and Kashmir. It seems that nothing has been done in this matter by the Jammu and Kashmir Government till date and there is no legal framework or procedure in place to safeguard children from sexual abuse. The Jammu and Kashmir Juvenile Justice ( Care and Protection of Children) Bill was passed in 2013 which classifies sexually abused children as ‘child in need’ but does not say anything further about safeguarding or management of such cases and seems more interested in arresting juveniles who are allegedly involved in unlawful activities against the state.

There is a need to recognise the problem and help the victims than going into a denial mode. Work needs to be done on the stigma and social attitude so that when these children do seek help, they are taken seriously and not rebuked. It is better to keep the children’s interest at heart and not the family and society in such cases. One would be doing more disservice by not helping children in crisis and worrying about family name or the accused. It is time to come out of any false belief that such acts don’t happen in our society or culture. It can be happening in your house or the house next door. It is not uncommon in institutions housing large number of children, whether run for imparting mainstream or religious education, or the institutions which bring up underprivileged and orphan children. Unfortunately our state has hundreds of such institutions but there are no checks or procedures in place.

Parents and professionals (teachers, doctors, and police etcetera) should always keep abuse as a possibility if there is such presentation and explore actively to prevent any further damage and long term consequences. Teachers have got the bigger responsibility and should be concerned if a child has suddenly started showing any changes in behaviour or decline in academic performance. Doctors should always keep this possibility in mind while treating young people and children.

Training of professionals including doctors, police, teachers and social workers is needed to help such children with sensitivity, compassion and an effective outcome. Civil society has a big role to play in breaking the shackles, creating conducive environment and raising awareness. There is need of policy and procedure from the State for identifying, treating and safeguarding such children.

http://www.greaterkashmir.com/news/opinion/conspiracy-of-silence/195664.html 

How Stress Affects Health

Stress is a normal part of everyday life.  At times it is a driving force for us to achieve better and succeed.  It is not always easy to define stress and it has different meaning for different people.  Mostly stress represents a negative feeling or experience and rather than a positive one. People vary in how they react to stress; same event can be stressful to one and not others. Similarly some recover quickly where others may not be able to cope.  Stress can affect both physical and mental health if it continues for longer duration.   

Stress can be defined as the brains response to any demand or pressure.  Chronic stress changes the balance of neurochemicals and hormones in the body and one may feel on high alert all the time. Chronic stress can also lead to structural changes in some areas of the brain.

Stress has been broadly classified into three groups.  First group comprises of the routine stresses brought about by day to day life e.g. work, family and other responsibilities.  Second group of stress is more severe in nature such as sudden change or loss in life e.g. divorce, losing a job, illness, death of a loved one etcetera.  Third group is commonly known as trauma like major accident, war, disaster, rape.  There is severe threat to life or integrity of an individual and most people find this type of stress difficult to manage and cope with.

Physical effects of stress can come across as loss of sleep, tiredness, appetite changes, aches and pains, headaches etcetera.  Stress can affect the immune system negatively and people become more prone to infections.  Long term stress and strain can lead to serious health problems and people become predisposed to develop conditions such as heart disease, high blood pressure, diabetes, and other illnesses.  Stress can also worsen existing physical health problems like asthma, diabetes, ischemic heart disease etcetera.

Stress has numerous mental health or psychological effects and sometimes stress is seen as such a mental health problem.   Most people cope with day to day life stress but some find it difficult and can develop anxiety, irritability, insomnia, fatigue, poor concentration and forgetfulness.  Some find it hard to deal with other people or social situations and may become recluse.  Chronic stress can lead to something called adjustment disorder which can present as severe anxiety, agitation, irritability, tearfulness, and suicidal thoughts, self-harm, depression.  People change life style and can engage in harmful activities like smoking, use of alcohol and drugs in an attempt to self-medicate to get some relief.  This often worsens the symptoms in long run and ultimately leads to drug addiction. It is know if the stress is removed from the person’s life, there is usually good recovery. Chronic fatigue syndrome is one of the outcomes of modern age life style and stress.

In contrast, when someone is traumatised by an extreme kind of stress like disaster, war, rape, and torture it can lead to severe and enduring mental illness. People can develop acute stress disorder, post-traumatic stress disorder and other  mood problems.  Repeated exposure to such stress can lead to chronic posttraumatic stress disorder, change in personality and even psychotic symptoms. Dissociation is very common and people can develop dissociative amnesia to multiple personality disorder. 

It is very important to identify stress early on and make necessary changes if possible to avoid long term problems. Talking to friends and family helps to overcome routine and day to day stress.  Sometimes people need help by professional counselling and at times medication if symptoms are severe.  There should be no hesitation in seeking appropriate help as failure to address the problem can lead to long term physical and mental health problems in addition to poor quality of life.  It is important to realise that the sometimes the solution can be in making simple life style changes. If that does not work one should seek help from a mental health professional who can be a counsellor, psychologist and psychiatrist.  It is also important to seek the right advice than get caught up into a cycle of doctor shopping.  People often end with cocktail of medications after having multiple investigations which are not often warranted.  It is often stigma and shame which holds people back from seeking the right help.

With any stressful situation, it is helpful to take a step back and try to think rationally. Regular exercise, good sleep, balanced eating and quality time with friends and family are helpful. It is necessary to keep balance between work and other leisure activities. Faith and spirituality are good for reducing stress and better coping. Avoiding drugs, alcohol and smoking are helpful in long run though they may seem attractive at the time. The most important step that leads to recovery is recognising that there is a problem.  Once acknowledged, recovery can begin.

http://healthanalyticsindia.com/health/how-stress-affects-health.html 

Orphans of Conflict: Forgotten by Society and the State

Kashmir valley had just one orphanage in 1986, now there are more than 700.  An estimate by a UK based charity Save the Children; Kashmir valley has 215,000 orphans out of which more than 37% have lost one or both parents to the prevailing conflict. More than 15% of these children live in orphanages. Before 1990 most orphans were rehabilitated within extended families and adopted by relatives without any financial help from the State.  Due to the ongoing conflict, the number of orphans increased exponentially and families struggled to take care. Some had no extended families, some families were too poor to look after their relative’s children and others worried about their safety at home.  The traditional role of society towards orphans started changing and various Non-Governmental Organisations (NGOs) took over the role of extended families and homes got substituted by orphanages. Most of the orphanages are run by charities, NGOs and some by the State.  Reportedly most of these orphanages are not registered.  Let’s not forget though, 85% of these orphans are living within community without any help from the State.  

In orphanages, usual focus is on providing physical rehabilitation like food, clothing, and safe shelter but hardly any emphasis on the psychological wellbeing and over all personality development. There is no evidence that orphanages are helpful in the long run and are said to have negative influence. Institutionalised children have poor psychosocial development due to insufficient emotional stimulation. It has been proven beyond doubt that orphanages are an awful place to live in and most developed countries have shut them down during the early parts of last century. These children become ‘Institutionalised’ and are not able to blend in or perform in the society to their potential.  They are always reminded of being orphans, dependent and somehow not equal. They are not able to grieve and come to terms with their loss.  Often they are deprived of the normal childhood as they are expected to be mindful of the local rules twenty four seven. They are mostly devoid of any personal choice and have to do what is being told. This gives them a sense of rejection, worthlessness, low self-esteem leading to various emotional problems. Our own studies have revealed that more than 40% of the children living in orphanages suffer from various psychological problems with hardly any access to help. Having been victims and witnesses of severe trauma, Kashmiri orphans are at increased risk of psychological problems.

I am no way trying to criticise the good work these NGOs are doing or have done over these difficult times. It is fair to say that if these orphanages had not come to rescue, these children may have become victims of hunger, violence, exploitation and what not.  Most of these charities are working in good faith and have done a commendable job. At times, there have been concerns about poor living conditions due to overcrowding, lack of entertainment, regimental lifestyle, poor diet and access to education and health. Various forms of abuse do occur with institutionalised children and there are hardly any checks.  It is also alleged that some people are misusing the name of orphanages to keep their own businesses going. A meagre sum of 50 rupees a day per child is provided for the State run orphanages. 

These poor children have been neglected by society and condemned by the state.  Organising the longest Iftar party on the shores of Dal Lake for promoting tourism by using orphans as bait for sponsors is not exactly caring. Breaking fast with them during Ramadhan by police officers and posting pictures on social media does not heal their wounds. Let the cameras not focus on them with a judgmental eye, reminding them of their underprivileged status and horrible past. Do we have any right to cash in on their helplessness?

The J&K Rehabilitation Council was created in 1996 with one of the objectives to look after any orphans who are product of the conflict. Although, it claims to provide physical, psychological and economic rehabilitation, but no one has heard of it on ground. 

The National Commission for Protection of Child Rights had recommended to the J&K government to draft a Child Policy and set up State Commission for Protection of Child Rights back in 2010. It had made several other recommendations to ensure their rights including that “The orphanages should function instead as boarding schools, the state government should do away with the nomenclature of ‘orphanages’ or ‘orphans’ which could be stigmatizing as well as incorrect in many cases”. 

The State Government had signed a Memorandum of Understanding with the Ministry of Women and Child Development in 2013 for implementation of Integrated Child Protection Scheme in the State.  But I doubt any proposal was submitted for the release of grants. After all, orphans don’t have money for paying bribes to bureaucrats, so why should they bother? 

Have we become used to the growing orphanage culture? Is institutionalising these poor children been normalised and actively promoted?  Or do we need to cut down on the number of these orphanages to the minimum possible and ultimately aim to close them all? 

It is a shame that there is no policy in the state for rehabilitation or safeguarding of these orphans and neither did the state government bother to act on any recommendations.  Are these children not the responsibility of the State? Where is the State Commission for Protection of Child Rights?

So what can we do? 

Foster parenting or fostering has been adopted worldwide, wherein any family can volunteer to raise orphan children with regular financial help from the state to cover up the costs. Background check of the family is done by trained social workers to assess suitability.  Subsequently regular checks are carried out to prevent any abuse or engagement in child labour. 

Most extended families who had to give up these children because of poverty would be happy to have them back if due financial assistance is provided. Also State can give an option of adoption for families who want to come forward after a due process. 

Is not the foster parenting way of our beloved Prophet PBUH?  Was not this our way before this conflict started?  If we are able to look after 85% of these orphans within families, we can look after the remaining 15% as well with some planning and help. 

It is criminal if they are left at the mercy of orphanages for ever.  Social welfare department needs to wake up and utilise all resources from central schemes and NGO’s. A special department or even a cell can be started in the social welfare department to collaborate with various NGOs, orphanages and civil society to come up with a joint working plan. That would entail educating masses, advertising benefits of fostering and adoption. It should be made easy for people so that they can come forward minimising the red tape.

 Same money currently spent to run these orphanages can be pooled from both State and NGOs and used to support the families who are willing to raise these children. The state could also act on recommendations of the National Commission for Protection of Child Rights and try to manage these places as boarding schools wherever possible. The State needs to come up with laws and checks to prevent any kind of abuse of these children either in orphanages or in community. 

If State continues to fail, the civil society would have to take charge of this serious matter.  

Civil society has a major role in rehabilitating these children and utilise resources for integrating them in the community than promoting orphanage culture. Civil society can take on various stake holders including the State, NGOs, charities, international bodies’ etcetera to start the process. Imams of the mosques can help spreading the message to promote the change. The schools have a bigger role to play making sure these children are attending regularly and their academic performance is at par or at least not declining for any reason.

To conclude the state government needs to own these orphans and work with other stakeholders to rehabilitate them in community.   They are there because of the choices made by State and not because of their free will. They deserve to live in community with dignity and not neglected, used or institutionalised.

 http://www.greaterkashmir.com/news/opinion/orphans-of-conflict-forgotten-by-society-and-the-state/194021.html   #orphansofkashmir