Monday 16 October 2017

Braid chopping- Acceptance and not accusation is the way forward

Kashmiri women, once again, are on the receiving end of the long-standing conflict and war.  Decades of living in fear of losing their loved ones, insecurity, abuse and day to day violation of their dignity have made them no more than scapegoats of the political conundrum.  As per police reports, there have been more than hundred cases of alleged braid chopping.  People more so women are living in perpetual fear of being attacked. Women of any age group are afraid to leave home, are sleeping with multiple layers around their heads and often waking up in panic even by a ticking clock. Vigilante groups have cropped up who are indiscriminately attacking anyone they feel responsible of braid chopping and as a result, many innocents both local and from outside the valley ended up black and blue.  Common people have turned into lynch mobs although the braid chopping incidents are going on without a break and no amount of vigilantism is having any effect.  Many women have reported that men are using braid chopping to make fun of them.  There is nothing funny about it even when joking.  Sadly this is another sad reality of the patriarchal society we live in. 
People are divided as to who is behind all this, with most believing that this sinister game is being played to harass the local population as part of psych-ops.  Some believe that this is due to an epidemic of mental health problems and women who allege braid chopping are doing it to themselves.  Few are blaming the wayward in the neighbourhood trying to have some fun, trying to get a hold on valuables, and what not.  The protest demonstrations by the opposition parties and potential flaring up of the cause make some believe that they may be paying off their agents to become nocturnal barbers.  Last but not the least, the deep mistrust of Indian state and current regime makes them the prime perpetrator of the heinous act for most Kashmiris.  Let us not forget that the rumour mill, fear, and hypervigilance make it impossible to let reason make any sense of the situation.  After months of violent political turmoil, this braid chopping epidemic has diverted the attention of people from the core political issues and impending Article 370 abrogation pending in the courts.
With the top cop of the state openly declares that it is all because of ‘depression and attention seeking’ and proposal to do narco-analysis or lie detector test of the women reporting such trauma, this is no more than treating the victims of this travesty as criminals of the lowest order.  The argument that cases of braid chopping have been reported from Nepal to Delhi and then Kashmir points to hysterical nature of the act, but one could argue that compared to rest of the places, the epidemic number of incidents in Kashmir are beyond reasonable proportions.  Although we may never know for sure what is causing the braid chopping and even if we assume all the cases are because of psychological reasons, how do treating the victims as offenders help the situation.  This is making the state of fear worse leading to further mayhem.  This is no way to reassure the population that the state machinery is there to protect them.  If it is being suggested that this whole menace is a product of fear and heightened response from a subjugated population, no steps are being taken to make them feel safe.  It is hard to think of a person or a political party on any side of the divide who has the power or aura or command to reassure the masses.  The Chief Minister of the state has already lost all credibility and whatever she may say, would probably mean nothing to the general public, but if she had acted sooner, maybe there would have been some impact.  Same is true for the opposition parties and even the Hurriyat camp. This is not the time to play politics or to use the poor victims as a trophy to prove a point.
If the authorities are certain that these incidents are due to psychological reasons or what they call in common language ‘mass hysteria’, would it not have made sense that people were reassured and not threatened further.  With the authorities claiming there is an epidemic of emotional disturbances in the population; one could ask the question, who is responsible for that?  There is no dearth of data suggesting that most of the population have experienced trauma in one way or the other.  Not a single day goes without news of killing in some part of the valley. Hundreds have died in last few years and many more have been brutalised, blinded and maimed. When the whole population is living in an open prison, under the shadow of a gun where life can be taken any minute and no one is sure of the safety of themselves or their loved ones, how does the State expect people not to suffer? Isn’t there an abject hopelessness and lack of certainty in masses with no one knowing what is in store for them?  The occupation not only controls physically but also mentally.
No matter which hand holds the scissors to cut the braid, the ultimate responsibility still lies with the State.  The brutal conflict and draconian laws have over the years made people vulnerable, and it is no surprise we may see them coping by methods which may mean self-harming at times.  But rather than supporting them through their pain and suffering, if the State wants to put them through denigrating lie detector tests, why would they trust the state machinery or police forces for a minute. However, the age-old method of victim shaming and shunning the responsibility is hardly surprising. The victims are traumatised and need support than accusatory fingers.  Again it does not matter who cuts the braid, another person or their own hand, the trauma suffered by the victims is same.  The genius who is proposing the lie detector test needs to understand that if this is happening in a dissociative state, the victim would not remember the event anyway hence there is no scope of lying.
Victims need to be supported, listened to and not interrogated.  The mental health professionals have a duty to educate people, offer training and support to local doctors, community leaders and voluntary workers.  It is not late for the state to own the responsibility, reassure people and give up the accusatory tone and the ridiculous plans to torment the victims by further interrogation.  The culture of fear, suppression, draconian laws, undue use of force, pellet guns etcetera needs to go to prevent such mayhem in future.  Just blaming mental health issues is not good enough when nothing is being done to address the problem.  War zones are ugly places to live in and can bring worst out of people, however, compared to the rest of the world, Kashmiris have proved to be more resilient and not to succumb to the viciousness.
It is prudent that civil society takes charge to ease the suffering.  Community leaders, Imams, and volunteers can play a major role in educating people; control the mobs so that any violence is prevented.  There is no room for vigilantism and lynch mobs to deal with this situation.  The attacks on innocents need to stop as this is not going to end someone’s hair being chopped.  Reassuring masses and controlling the general fear is the solution and not the other way round.

Thursday 10 August 2017

Mental Healthcare: Time to change

With the President’s assent, The Mental Health Care Bill 2016 became law as the Mental Health Care Act 2017. Under the new law, every person shall have the right to access mental healthcare and treatment from services run or funded by the government. As such, a patient with mental illness will be able to access services and facilities such as: the provision of essential psychotropic medications, free of cost; insurance coverage for mental illness; funding for private consultation if a district mental health service is not available. The law further ensures that treatment and rehabilitation will be available in the least restrictive environment and will respect the rights and dignity of patients, including those from disadvantaged socioeconomic backgrounds. The outcome of these recommendations is that the financial burden, as well as the psychosocial burden, placed upon carers, will be reduced to a large extent.
The bill requires the establishment of central and state mental health authorities. Also, every mental health establishment will have to be registered with the relevant central or state mental health authority. The act provides right to confidentiality to patients suffering from mental disorder. Patients have a right for an advance directive and say in their treatment when they lose the capacity to decide for themselves.
Significantly the new law decriminalised attempted suicide as a criminal act and assumes the act as a result of severe stress and mental disorder. However, this is more as a stop-gap arrangement, by creating a presumption of mental illness in every case of attempted suicide unless proved otherwise. Suicide should be completely decriminalised, without any conditions attached, which would help reduce stigma, create openness and make it easier to seek help.
Overall, the Mental Health Care Act 2017 is a significant improvement over the Mental health Act 1987, bringing about protection and empowerment of persons with mental illness. Effective implementation will require a substantial change in the system currently in place and will need an extensive input of staff and finance. The average number of psychiatrists in India is only 0.2 per 100 000 population, compared with a global average of 1.2 per 100 000 population. Similarly, the figures for psychologists, social workers and nurses working in mental healthcare are 0.03, 0.03 and 0.05 per 100 000 population in India, compared with global averages of 0.60, 0.40 and 2.00 per 100 000, respectively (World Health Organization, 2005).
 With a meagre overall health budget, India spends only 0.06 percent of its health budget on mental healthcare, which is almost nothing compared to even poor nations in the world. This law will only become a success when its financial implications are taken seriously and provided for, or else it may become another tool for corruption and nepotism for many involved in its implementation.  As per a WHO report, most developed nations spend more than four percent of their budgets on mental health research, infrastructure, frameworks and talent pool.
There are certain ambiguities in the new law which question its applicability and meaningfulness for the Indian population. As admission procedures, treatment options and decision-making would become legalised and bureaucratised, certain experts are apprehensive that the bill will likely increase the stigma and hesitation to seek treatment from mental health professionals, due to cultural, educational and social factors, particularly in rural India. But at the same time, the revised legislation could mark a start of a new era for anti-stigma campaigns; it could lead to greater allocation of resources to mental health, and the training and retention of mental health professionals, including psychiatrists, psychiatric nurses and other allied professions. Hence, if appropriately implemented and financed, in addition to improved access to mental health services, the human rights of people who are mentally unwell could be safeguarded to a greater extent by the new act when it comes into power.

Saturday 8 April 2017

Kashmir Floods-Then and Now

Kashmir valley is famous for its beautiful landscapes; its majestic mountains, rivers that snake through this landscape, lakes which are homes in themselves and the lush green floating paddy fields.  Kashmir is also equally known for its disasters, both natural and man-made.  From the perpetual conflict situation to earthquakes, snowstorms and floods, there are hardly any disasters left, it has not seen.  In the September of 2014 Kashmir valley witnessed the worst ever floods of last 100 years.  The floods were so sudden and severe that for a few days there was no government in power, as everyone including the then Chief Minister of the state was trapped.  All means of communication including the mobile networks went dead.  Even the emergency numbers and wireless system of the security machinery could not stand the assault.  The sudden drowning of the capital city led to the total collapse of the state administration.  It was not that there were not enough warning signs- the incessant rains in upper reaches for days, the hiccups of the meteorological department to offer any proper forecast and advice and finally the failure of the Irrigation and Flood control department to manage the situation, lead to utter devastation.  Even on the day when the Srinagar city lost its defences to the rising waters and the banks of river Jhelum breached, the administration kept reassuring the inhabitants that there was nothing to worry about.  By this time, the south of the valley was already under water for days and it did not take long for north Kashmir to submerge.  The worst hit areas included Srinagar, Anantnag, Kulgam, Pulwama, Shopian and Bandipore in the Kashmir province.  Some areas of the Jammu province were also hit by heavy rains and consequent floods especially Poonch and Rajouri.
Millions of people were trapped, displaced, unsafe, and worst of all at the mercy of the missing administration.  People volunteered, innovated and used whatever means they could, to help and save each other.  Srinagar, a city of million people slipped under water and even those high up in the corridors of power, were not able to get any help.  Many people were rescued by their distant relatives, coming down from far off villages, days after they found themselves trapped under the  rooftops, living on dry rice and whatever they were able to stock, in that moment of  chaos.  Panic gripped the inhabitants of the valley and their relatives and loved ones living outside Kashmir. The situation was made worse by the lack of communication and the abundance of rumours, as there were hardly any credible sources of information.  The water reached up to 18 feet in some areas, flooding the 2nd floors of the houses and drowning and washing away essentials, valuables, cherished memories – anything that stood in its path.
There was social media frenzy, rumours, and a severe criticism of both the state and the central government, for not doing enough to save and help the people in time.  Kashmir being a conflict zone, the outcry was worse.  Even though the Army and National Disaster Rescue Force (NDRF) claimed to be helping people, there was a severe disquiet from various quarters. Allegations of favouritism and selective rescue and relief were hard to ignore.  There was a total lack of coordination between agencies claiming to be working in the rescue operations.  Even the Chief Minister went on record in the Supreme Court that the situation was under control and no further help was required in terms of boats and other essentials.  Obviously, that was a far-fetched claim and people remained trapped for weeks.  The media especially the tabloid news channels went to great lengths making heroes and villains depending on their loyalties, ignoring the actual victims and their suffering.  Sometimes they didn’t even spare people who had just been rescued after days of entrapment and trauma.  Some had lost their loved ones in the flood, but one could see the microphones being thrust into their faces, followed by insensitive questions like ‘How do you feel now?’   
The state government announced estimated loss of Rs1 trillion due to the floods, with housing sector losses of Rs30 000 crore and business losses of Rs70 000 crore.  The death toll after the floods was 280, more than 2500 villages submerged and around 2.53 lakh houses damaged1.  More than 550 000 people were displaced.  People lost everything from businesses, crops, livestock, vehicles, houses and other infrastructures.  The city remained submerged under water for more than 10 days due to the lack of necessary machinery to pump the water out, leading to severe damage to houses and buildings. 
Like other essential services, the health infrastructure totally collapsed with most hospitals remaining submerged under water.  Some hospitals were able to continue minimal services but they were left with no means to transport the sick and the injured.  The inpatients, most of whom were very unwell and some in critical condition were at the mercy of nature had it not been for the local volunteers who along with the on duty medical staff helped the patients to safety.  There was a looming risk of diseases worsened by the lack of clean drinking water, food, essential medicines and cold weather.  The situation became even grimmer when the bodies of dead animals started decomposing in the open and in the water bodies.  Even human bodies surfaced at many places.  The threat of water borne and contagious diseases loomed over the valley, just as the dark clouds continued to do so.  Death, decay and disaster were the only things clearly visible.
A lot has been written about the devastation, failure to manage the disaster and lack of appropriate response once the calamity was over.  Was this tragedy preventable by a proper forecast and warning system?  Was the state’s response and preparedness anywhere near adequate?  What caused such floods and devastation? Many people suggested that the floods were a manmade disaster for various reasons. Had the climate change even taken this picturesque valley into its grips? There are so many questions but hardly any answers.  Even after a year or more since the great flood, there hardly seems any change, reflection or preparedness for future disasters.  People are still living in constant fear and even a day’s rain reminds them that they may have to flee without any official warning.  Finally, the relief and rehabilitation of those worst affected, is still a mystery. When the physical rehabilitation is distant and people are still longing for the safety of their homes, it would be pointless to talk about psychological rehabilitation of the traumatised population.
Despite being prone to extreme weather, rains, floods and earthquakes, Jammu and Kashmir does not have any flood forecasting system or capacity for flood preparedness.  And the facts have not changed since the devastation of 2014.  Although, there was a nominal disaster management cell in the office of divisional commissioner Kashmir, once the floods took over, the cell went underground and has not since made any fresh claims.  The head of the meteorological department was the only source of news and somehow achieved celebrity status but was hardly able to address the worries and anxieties of people.  At times, he was used by the state administration to cover up its failures.
An analysis by the Centre for Science and Environment (CSE) suggests that the climate change and increased carbon emissions are responsible for heavy rainfall in the Himalayan region2.  The situation is worsened in Kashmir due to lack of appropriate drainage system.  If we talk about Srinagar only, the city has expanded beyond reason without any proper planning.  Most of the unplanned construction has taken place around river banks and encroachments are at its peak.  Huge buildings have come up in many flood-prone areas. Even many government offices like the Board of School education, State Hajj House, Police and Hospitals have been constructed in Bemina area of the city.  The area is actually meant to be the flood channel, which is supposed to divert the water in case of flooding in the Jhelum River.  One cannot help but wonder what were the clever city planners thinking, when they approved this land for the construction?   The corruption within the local administration means planning permission is hardly ever a problem and the alleged masterplan for the city has been dumped before it could have taken any practical shape.
As per the CSE ‘In the last 100 years, more than 50 percent of the lakes, ponds and wetlands of Srinagar have been encroached upon for constructing buildings and roads.  The banks of the Jhelum River have been taken over in a similar manner, vastly reducing the river's drainage capacity’.   Another research study undertaken by Directorate of Environment, Ecology and Remote Sensing concluded that, ‘During the past century, deforestation in the Jhelum basin led to excessive siltation in most of the lakes and water bodies of Srinagar and subsequent human greed brought about sustainable reclamation and land-use change in these assets of high ecological value’.  More than 9,119 hectares of open water surface and wetland have disappeared between 1911 and 2014 while only 6,873 hectares were preserved’3.  The encroachments and landfilling is an open secret.
The lakes like Dal, Nagin, Manasbal and Wular stand shrunk, invaded, and turned into a landfill by dumping the rubbish and excreta from the city and adjoining areas.  Mighty buildings, hotels and houses around the officially off-limits land have become part of the city’s identity.  The size of Dal Lake has shrunk from 22 square kilometres (8.5 sq mi) to the present area of 18 square kilometres (6.9 sq mi), and there is a concerning rate of sediment deposition due to catchment area degradation4.   Dal Lake has lost half of its water surface area in last forty years. The adjoining lakes like Gilsar, Khushalsar and Aanchar have all disappeared.  The feeding channels to these small water bodies have turned into landmass through heavy siltation.  Experts like Dr Shakil Romshoo of Kashmir University’s Earth Sciences department had recommended long ago that construction should be totally banned in this ecologically fragile area.  He had also suggested that measures like de-siltation of water bodies and afforestation programmes in catchment areas of the Jhelum should start on a war-footing.  "If the indifference of successive governments and the greed of the society at large has led to the degradation of our water bodies, we, at least, have to think of measures to save them from further degradation before it is too late,"5 But as usual, there are hardly any takers for such advice as the administration is working hand in hand with the land mafia turning the water bodies into a concrete jungle.
The Jhelum River with its origins from the Verinag spring in the Anantnag district passes through various parts of the valley before flowing into Pakistan.  With an increasing population and illegal construction boom encroaching on its banks, the capacity of the Jhelum River to carry usual amounts of water has significantly diminished.  This has meant even one day’s rainfall leads to water logging and potential risk of floods.  The other small rivers, streams and water bodies have suffered a similar fate. Some are at the risk of extinction and many have completely disappeared. 
It is no exaggeration to say that with the global climate change, increased risk of rainfall, lack of adequate drainage channels due to man-made encroachments, disappearing of wetlands and reduced capacity of lakes, Kashmir is at increased risk of flooding again, if necessary steps are not taken sooner.  There is a total lack of planning on the ground and buildings are popping up on any kind of land, from agricultural to forest. Who is responsible? Is it the civil society or the government? Why after so many disasters, nothing seems to change the public attitude or the State’s preparedness? Is the ongoing political conflict shadowing everything else in the state?
With the fragile political situation and the often mistrustful state-centre relationship, nothing much has been achieved as for the prevention and management of such disasters is concerned. Elections were called within few months of the devastating floods which led to regime change in the state.  That did not help matters either, as the administration got drawn into the conducting elections and poor flood victims were left at the mercy of no one.  The state government after preliminary estimates implied lacking enough resources to provide relief and rehabilitation of such enormous scale.  As the winter was approaching there was hardly any plan to house those living in makeshift camps.
There was a flood of non-governmental organisations (NGOs) during the deluge, both local and national. Many Kashmiris living outside India travelled back to help.  People worked hard all over the country to collect money and goods for the flood victims.  Here again, the effort was not organised and many people cried foul for various reasons.  Overall the NGO's were able to support, be it with clothes, medicine, money and other essentials. Many airlines agreed to carry the load free from Delhi and other major cities to Srinagar.  On the other hand, there were complaints that the administration is creating hassles in the process and not letting people work freely.  Obviously, it is hard to ignore the security concerns when it comes to the Kashmir valley.  Although there were many offers of international help, the Government of India did not accept that, claiming that the country was more than capable of dealing with the calamity.  Many in Kashmir felt that keeping away international aid was a step-motherly treatment to the people of Jammu and Kashmir and they were being taught a lesson for political reasons.
Indian Prime Minister Modi visited the valley pledging his support and announcing special assistance of Rs1000 crore for relief and rehabilitation.  He declared the floods as ‘national level disaster’.  On a subsequent visit, Mr Modi announced a relief package of Rs745 crore out of which Rs 570 were earmarked for relief to flood victims and Rs 175 crore for renovation of the six major hospitals. Meanwhile, the state government asked for a relief package of Rs44 000 crores from the centre for rehabilitation of flood affected.  Subsequently, the state officials denied that any money was received from the centre.  It was also alleged that a bill of Rs650 crore was raised against the Jammu and Kashmir State by the NDRF for the relief and rescue work.  Locally with the administration and the revenue department caught up in the election preparation, it was hard for people to even get the estimates of the damages they had suffered.
Despite all these announcements, estimates, packages, the fact remains that people on the ground did not get much relief or help.  Many families spent the last winter with their relatives where possible, some rented on extortionist prices and some suffered badly in open.   When the estimates were finally done, it was equally distressing for people as someone with a 2-3 storey building costing more than Rs 75-100 lakhs or  more, was given a meagre sum of Rs50-70 thousand which was not even enough for demolishing and clearing the site.  People who were considered to have partial damage of their houses were given a paltry sum of Rs 2300, which some felt was an insult to their suffering.  Actually ‘partially damaged’ meant that the house can crumble anytime with minor shakes, that too in this volatile earthquake prone area. Most people chose not to collect the money from the district administration.  Ironically, the second winter has arrived and the relief and rehabilitation has yet to start.  The red tape and bureaucracy of the place did not spare the flood victims and people mostly elected to depend on their own means. With the change in regime and the coalition between PDP and ruling BJP, things did not go any easy.  The State and central governments still seem to be at logger heads when it comes to the rehabilitation of flood affected though the same party (BJP) is in power at both places.
In November 2015, Prime Minister Modi again announced another package of Rs80 000 crore for the state of Jammu and Kashmir. Out of this, Rs2000 crore were earmarked for relief and rehabilitation of the flood affected population.  As the state came under Governor’s rule due to the death of ex-chief minister Mufti Mohammed Sayed, one could guess that whatever plans coalition government had proposed over the months are essentially lost.  It is surprising to know that orders for dredging the Jhelum River had to finally come from the Governor in January 2016 than the two elected Chief Ministers.  It is again announced that some money has been released from the Prime Ministers fund to rehabilitate the flood victims of 2014, but will they actually get it, remains to be seen.  One wonders, isn’t it too little, too late? Kashmir was engulfed by the uprising in 2016 with hardly any government or administration on ground barring the security apparatus busy with killings and blinding people. The great flood of 2014 became a distant memory, though the flood risk is higher than ever keeping in view nothing has changed on ground and Kashmir has received the best snowfall in years which would mean the water bodies will be running high in summer and any climatic change can lead to an unimaginable disaster. The proposed dredging never happened and flood is back like a flashback and it is only April and not September.
The state has yet to put in place the Flood Early Warning System (FEWS) for the Jhelum River.  At least, this could give a timely warning and people can attempt to leave for safety within a reasonable time. But it is hard to understand why there is so much delay even after repeated warnings from the experts.  Coming to the prevention of future floods, nothing solid has been put in place. Writing in the daily Greater Kashmir, Dr Romshoo quotes that when the flood was it its peak, Jhelum was discharging around 120 000 cusecs of water5.  Suggesting using the strategy of Relief, rehabilitation, reconstruction and risk reduction (4Rs) to deal with the disaster, he sounds dismayed that nothing moved beyond political jargon.  It seems that the state government did not use any proper methodology for assessing the damage, and if that was done, the centre will have little excuse in releasing more funds.  Experts have warned that post floods, the state is highly vulnerable for further flooding due to the weaker defences of the river banks, higher underground water levels and reduced water carrying capacity of the Jhelum River and its tributaries.  The current carrying capacity of River Jhelum is around 35 000 cusecs and that of flood channel around 5000 cusecs.  Even if Jhelum is dredged fully, its carrying capacity would not be more than 50 000 cusecs and 10000 cusecs for flood channel. What about if the rain doesn’t stop with water levels cross 120 000 cusecs?
Hence, the risk of impending floods is looming on the population who are still awaiting rehabilitation.  It is worth mentioning that the state of Jammu and Kashmir with its water resources, is a leader in the generation of hydroelectricity, most of which goes to the NHPC limited.  Would it not be reasonable that in return, the State gets some financial assistance from the NHPC to strengthen the rivers and make them more useful to carry the ever increasing load of water?  This may in return help with generating more electricity and revenue.
To conclude climate change, deforestation, encroachments and unplanned construction are continuing at full speed. The rivers have little capacity to carry increased load of water while the risk of incessant rainfall looms over Kashmir more than ever.  The state government is still in slumber and hardly anything has been done to prepare for and prevent further such disasters. With ever increasing political uncertainty in the state, one wonders if there would be any sincere efforts to save the population from further floods, earthquakes and other manmade disasters.  There should be, in place some form of prevention and preservation plan, before it is too late.




Footnotes:
3.      Humayun Rashid and Gowher Naseem, ‘Proceeding of Taal2007’: The 12th World Lake Conference, 653-658.
4.      Dal Lake". International Lake Environment Committee. http://www.ilec.or.jp/database/asi/asi-38.html

Friday 7 April 2017

Depression in Kashmir: In The Heart

Kashmir is a picturesque valley wedged between India, Pakistan and China. I trained and later worked as a psychiatrist at the only psychiatric diseases hospital of the valley which is based in the capital city of Srinagar. I remember the walk-in clinics, where at times we had up to 300 patients waiting eagerly to have few minutes with a psychiatrist despite the huge stigma associated with mental illness. The number of people seeking help for emotional problems grew exponentially after the armed conflict started in 1989. One of our studies reported the lifetime prevalence of exposure to the trauma of about 59%[1]. A recent survey by Medicines Sans Frontiers (MSF) reported that about half of the population is suffering from some kind of mental illness, with 50% women and 37% men suffering from a depressive illness[2].  During my research on PTSD patients, depression was again the most common comorbidity in more than 80% of the study sample[3].
One can argue that the diagnostic criteria as suggested in the ICD and DSM may not fully hold true in the local cultural context for the diagnosis of depression or even other disorders.   Asking the golden question, ‘How is your mood?’ usually gets a blank response.  People often talk in the context of ‘heart’ when talking about their emotions and feelings, rather than the mind. Typically, someone with depression would come saying, ‘My heart is not good’, usually pointing to their chest.  I remember asking, ‘How is your heart?’ more often than ‘How is your mood?’ Even the people from middle class and educated backgrounds would find it hard to discuss mood.  The same is true about anxiety disorders with palpitations and other somatic symptoms often being taken as a symptom of physical illness. http://www.rcpsych.ac.uk/pdf/VIPSIG_Depression_around_the_world.pdf
People usually do not come to the doctor with an idea that they will get treatment for depression or even that they may be depressed. It is usually the physical symptoms like tiredness, pain, palpitations, memory difficulties, medically unexplained symptoms, and weakness in limbs and headaches that bring them to the doctor.  Conversion symptoms are the most common presentations to the A&E department, typically a teenage girl not able to talk, move a limb or being unresponsive. This has a great cultural significance and is protective. If a woman reports feeling low to her husband, she would hardly be taken seriously and probably get told off for being lazy. However, when someone reports pain or physical symptoms, it is often taken seriously and considered a valid reason to seek help from a doctor. 

Depression and other mental health problems form the biggest group of illnesses and burden of disease in the local population. With such a variable presentation of symptoms, patients often go to all kinds of specialists, quacks and faith healers. This results in unnecessary costs, inadequate or wrong treatment and, at times, iatrogenic harm.  There is a need for training doctors and other health professionals in better identification and treatment of depression and other mental health disorders.  There has been some awareness both among the doctors and the general public in seeking right help for mental health problems.  Finally, medication still remains the sole therapeutic modality, keeping in view the lack of allied professionals like psychiatric nurses, psychologists and therapists. 


[1] Margoob, M. A., Firdosi, MM, Banal, R., et al. (2006). Community prevalence of trauma in south Asia: Experience from Kashmir. JK-Practitioner, 13(Supplement 1), S14-S17.
[2] Medicine Sans Frontiers (Doctors without Borders) ‘’Kashmir Mental Health Survey 2015’’ https://www.msfindia.in/sites/india/files/research_summary.pdf
[3] Firdosi MM, Margoob MA. Socio-demographic profile and psychiatric comorbidity in patients with a diagnosis of Post Traumatic Stress Disorder–A study from Kashmir Valley. Acta Medica International. 2016;3(2):97-100

Depression: Let's Talk

The theme of the World Health Day 2017 is “Depression: Let's Talk”, which is being celebrated on the 7th of April 2017.  According to the World Health Organization (WHO) estimates, the number of people living with depression has increased by more than 18% between 2005 and 2015.  More than 80% of this disease burden is among people living in low- and middle-income countries.  Globally, it is estimated that more than 300 million people suffered from depression in 2015.  Nearly half of these people live in South East Asia, China and India to be specific. As per WHO estimate, around 56,675,969 people suffer from depression in India, which is 4.5% of the total population. The same report suggests that depression is responsible for 10,050,411 years lived with the disability which is around 7.1% of the global burden of disease. Depression is ranked as the single largest contributor to global disability.  Depression is also the major contributor to suicide deaths which is close to 800,000 annually. However, when it comes to the allocation of resources and funds to tackle this global epidemic and disability, depression or mental health, in general, is usually not a priority for the policy makers.
Kashmir is not foreign to the concept of psychological problems and many reports have been published in the last year alone about the high prevalence of depression and other mental health problems in the local population. The number of people seeking help for emotional problems grew exponentially after the armed conflict started in 1989.  One of our studies reported the lifetime prevalence of exposure to the trauma of around 59% with most people having suffered directly or indirectly from some traumatic incident. A recent survey by the Medicines Sans Frontiers (MSF) reported that, about half of the population is suffering from some kind of mental illness, with 50% women and 37% men suffering from a depressive illness.  During my research on PTSD patients, depression was again the most common diagnosis in more than 80% of the patients.  Another study published by Action Aid India showed a high prevalence of depressive illness, anxiety disorders and other mental health problems.
The burden of disease more so in the female population is huge although we do not have actual numbers. The number of patients coming to the hospital is just the tip of the iceberg and many more do not seek help or aren’t aware that they can be helped. The awareness about depression and other mental disorders has improved overtime; however, there is still a lot of stigma associated with visiting a psychiatrist. I know of cases where families would not allow members to seek help for emotional problems fearing they would be judged by the society which at times, is true. Some families still prefer for their children to be in prison than in a psychiatric hospital and some go as far as paying to get their loved ones locked up.
Depression can present in various forms and I believe that the Western criteria set by the WHO or the American Psychiatric Association (APA) to diagnose depressive illness, are not always applicable to our population. The core symptoms of depression are low mood and lack of interest in pleasurable and day to day activities.  When we talk about mood, and expressing it in words, apart from some highly educated people, most are not aware of what it means. Hence asking someone, ‘how is your mood?’ does not apply. Most of us think in terms of ‘Heart' and something not right with it. ‘Meh Haz dil pareshan (My heart is sad)', ‘meh haz weanijih rawan (my heart is missing beats/palpitations)', are the classical statements one hears when talking to someone with depressive symptoms in our cultural context. It is one of the reasons why people suffering from depression end up visiting cardiologists and at times undergo expensive and unnecessary investigations, when in reality nothing is wrong with their heart or its proper functioning.
The common symptoms for someone suffering from depressing in our cultural context are tiredness, difficulties with memory, stomach problems, aches and pains, headaches, back pain, weakness in arms and legs, inability to move an arm or leg, episodes of loss of consciousness, weight changes, irritability, tearfulness, and suicidal thoughts. People usually do not come to the doctor with an idea that they will get treatment for depression or even that they may be depressed.  It is usually the physical symptoms like tiredness, pain, palpitations, memory difficulties, medically unexplained symptoms, and weakness in limbs and headaches that bring them to the doctor.  Conversion symptoms are the most common presentations to the casualty department, typically a teenage girl not able to talk or move her arms or legs or being unresponsive.  This has a great cultural significance and is protective. If a woman reports feeling low to her husband, she would hardly be taken seriously and probably be told off for being lazy.  However, when someone reports pain or physical symptoms, it is often taken seriously and considered a valid reason to seek help from a doctor. It is important then to be mindful, when going to the doctor repeatedly and not getting better, even after undergoing multiple treatments – one should strongly consider depression or an anxiety disorder as a possibility of on-going poor health.
Hence if you are suffering from symptoms as mentioned above or someone in your family is, please do consider depression and seek help. Depression is a treatable condition at a much lower cost than one would spend visiting various specialists and undergoing costly investigations.  Sometimes your psychiatrists or doctor may request tests like thyroid function and blood sugar which can be associated with depression.  People who suffer from long term physical health conditions like diabetes or heart disease are at an increased risk of developing depression than rest of the population.  Treatment of depression is necessary in such patients as it can affect the physical health condition adversely and worsen the outcome.  In people suffering from diabetes, treatment of depression helps with better blood sugar control.
One cannot blame the general public for not knowing where to seek help as it is not always easy to make sense of the symptoms.  It becomes the duty of every doctor to identify depression, treat it if they can and refer if they feel it is beyond their capability or area of expertise.  Unfortunately, at times people are put through unnecessary investigations and even invasive tests, deliberately or unknowingly when the problem lies somewhere else. Some female patients typically suffering from vague pain symptoms are advised to have surgeries like removal of the uterus which not only deprives the woman of an essential organ but in long run, makes her depression and pain symptoms worse. It is an open secret that there is an epidemic of such unnecessary surgeries and even young girls who have even not conceived are deprived of their womb.  This can only be stopped when people are aware about their symptoms.  It is therefore imperative that patients seek a second opinion and rule out depression before going under the knife.
Lately, there has been a surge in the number of people, including doctors writing about depression, its causes, suicide and other mental health issues.  This may seem a harmless enough exercise to most people, but when doctors who are themselves uninformed write about such issues in a manner that causes more harm than good, the results can be devastating.  Many articles have been published which instead of informing, misinform the general public and increase the stigma already attached to depression and suicide.  Sadly, some have even gone as far as to suggest that depression and suicidality are due to a lack of willpower and go on to sermonise with threats of hell and wrath of God.  People who suffer from depression and suicidal thoughts are already under tremendous pressure from the illness and need treatment, not threats.  They need support and empathy.  To call people suffering from depression and suicidal thoughts as weak-willed or cowards or idiots is not only derogatory but deeply shameful and inhumane.  Such articles and misinformation can trigger or even push someone over the edge by worsening their feelings of guilt and putting them through shame.  Let's reiterate again that depression and other mental health problems are clinical conditions, mostly treatable and at times curable.  Like diabetes and high blood pressure, people suffering from depression need medicine and other help on an ongoing basis.  Hence it is better to seek the right help at the right time to reduce the disease burden and improve the quality of life.  Doctors have a huge role to play in reducing the stigma, identifying those suffering from depression and providing the right treatment.  The media houses also have a huge responsibility to check that what is printed is not misleading and ask expert opinion before publishing in public domain.


Thursday 5 January 2017

Dignified rehabilitation of orphans, widows and destitute

Kashmir valley has witnessed numerous disasters, both natural and manmade leading to an environment of insecurity.  This has changed the dynamics of social interaction creating a sense of urgency and uncertainty.  Poor and downtrodden have been the worst victims of this conflict, though every section of the society has been affected in one way or another.  The ongoing conflict has led to huge loss of life leaving behind orphan children and widows in dire poverty and state of helplessness.  This is further complicated by the indifference of the State, with blatant refusal to take any responsibility for the care and upbringing of these poor children.  In any civilised society, the State would have introduced systems and checks so that all these vulnerable people are supported and provided necessary access to basic amenities of life.  It is no exaggeration that the State has failed in performing this crucial duty and has condemned this vulnerable group to infinite misery.
The society stepped in, to fulfil the role of a guardian and a provider for these poor children and widows, but was the response timely, adequate and dependable?  Kashmiris became well known for their resilience and helpful attitude towards people in distress.  The response seems, by and large, adequate during the crisis phase.  But the question to think about is; are we able to maintain the momentum in the long run?  Do we stop visiting the widow’s cottage after few days of mourning?  Do we think who is feeding and protecting the vulnerable children?  The initial response is usually driven by emotions which ultimately fades off and hence does not last long.  As a society, after witnessing so much of death and destruction, probably our hearts have hardened - a common phenomenon in conflict zones.  People become indifferent to the ongoing suffering, as a means of carrying on and coping otherwise, the mourning never ends.  But can we afford to forget those who are worst hit by same violence?  What about our duty and social responsibility?  This may come across as a conflicting argument but on one hand we have countless NGOs and on the other there is not an adequate response from the society to look after those in need.  Have people lost faith in all institutions including those who look after the weaker sections of the society?  With more than 200 000 orphans and thousands of widows, have we done enough to help?  Have we left children in these institutions and are happy with few donations around the Holy Month?  Do we know how the widows struggle to raise vulnerable orphans in unfriendly times and circumstances? 
Voluntary organisations commonly known as Non-Governmental organisations (NGOs) started by like-minded people in various parts of the state became a norm and society at large has assumed these NGO’s to be solely responsible for ever increasing numbers of orphans and widows.  With time, we have even lost track of the actual number of NGO’s operating in the state and their modus operandi. Was there any method in the response?  It seems the response from society mirrored the chaos and conflict.  There is no uniform plan, policy or guidelines under which most of these organisations operate.  Should there not be a uniform code of practice and coordination among such various organisations? Having fewer organisations could deliver a more uniform level of care, better utilisation of resources and real accountability.  Is there any monitoring process?  Surprisingly, there is no such body or organisation in the State to make the NGOs accountable.  Ideally, it is the responsibility of the state to have an independent organisation or commission which should have the power to take on any unscrupulous NGOs.  This would also mean collaboration between various organisations and equitable distribution of resources depending on actual need and not merely chance.  Unfortunately, we have got an excess of such organisations in some areas with no help available in other places.  Would it be possible to create such a body in the voluntary sector which could formulate a uniform framework and various NGO’s could sign in to work and collaborate?  Can the smaller organisations merge with few bigger ones and create a uniform platform?  But that would demand serious understanding and humility to even ponder on the idea.  As a society, we have to create the checks and balances and it becomes imperative that the civil society takes charge to create the accountability process.
That said voluntary sector has played the main role in the rehabilitation of orphans and widows.   Some reports suggest there are more than 700 orphanages operating in the State. How are the orphanages doing? There is no standard against which the performance can be monitored.  With more than 200 000 orphans and thousands of widows, surely these NGOs have done a commendable job in making vulnerable children safe, housing and feeding them and providing them with basic amenities.  At least, they have provided a dignified alternative when the State has completely failed.  There are also allegations that some are using orphanages to keep their own businesses going and some have more staff than children being looked after.  Are we really happy to let these children grow up in orphanages?  Can we think of fostering or adopting them?
One cannot claim that NGO’s are immune to whatever is happening in the society.  As the number of such organisations has crossed all reasonable limits, many people have raised questions about their credibility and there are allegations that it has become merely business. This puts genuine and credible organisations in a difficult position and they have to keep defending themselves, wasting their time and valuable resources.  There is no simple answer to this problem.  Corruption is rampant in the society and it would be too ambitious to claim the NGO’s are somehow protected from this menace.  Unless there is some accountability and people are held responsible for their actions, it is impossible to weed out the fraudulent.  The civil society will have to rise above small differences and come up with a solution for this so that the genuine organisations are able to function and in the process the vulnerable are not neglected. 
The response of the society does seem ambiguous and at times critical towards the people who engage in social work.  Keeping in view the uncertain political situation in the state, most people have been struggling with the challenges of everyday life.  This has meant that only a handful have been actually left to fend for these orphans and widows.  At some level, we have unrealistic expectations from those who work in and run NGOs.  We want them to work for nothing and rather be super-humans.  But the reality is they have their own families to raise and look after.  Some may have enough resources and time to work for free, but most cannot afford to do so.  Then how do we make this sector attractive to credible and hardworking people?  We need honest people with real qualifications and passion in social work to take charge.  It is time to reason with compassion than just respond with emotions.  We have to devise methods for improving the sector than mirror the chaos around.
Work needs to be done towards building trust in voluntary sector so that more people choose to join hands.  There is a need for educating the masses about the magnitude of the problem and how their engagement can benefit the needy.  It does not have to be only monetary help but time, resources, expertise and knowledge is as important. We have a network of Auqaf committees in every nook and corner of the State, which can be engaged to spread the message e.g. by organising workshops and debates at various places. This again requires some central organisation and network for coordination.
It is evident that overall we do not have much zeal for charity or social service attitude though we may like to think otherwise.  NGO’s and orphanages are predominantly run by men when the vulnerable are mostly widows and orphan girls.  Involvement of women in such activities would mean better outcome bringing in traits of compassion, dedication and empathy.  Keeping in view our sociodemographic profile, men usually work and there are so many educated females with time on their hands who can take on the good cause.  But who is going to make that happen, are we too patriarchal a society or it is a general lack of interest? We need to encourage the involvement of women in such activities and make it easy for them to do so.  Involvement of women in voluntary sector would also help educate the children and youth to take on social work and create a more charitable society.  It would also help the widows living in their homes who may otherwise feel vulnerable and find it hard to trust strangers, particularly men.
We are also not sure about the actual numbers of widows and orphans who are suffering in silence.  Apart from few estimates by some international charities, there is no credible local register.  Here again, the state has failed to do its duty.  To formulate a proper long term plan, numbers are important, so are the estimates of current resources and people involved in such work. Organisations like J&K Yateem Foundation have tried to work beyond the concept of orphanages and expanded work in the community by helping widows, arranging marriages for poor girls, scholarships for  poor children for education, to name a few.  But a single charity or few charities cannot work everywhere and reach every destitute. It is the time that some order is restored in this sector and a mechanism devised so that NGO’s link and cooperate.  Sharing ideas and resources can make a big difference in how the help reaches the needy and those who deserve it most.  It would also increase the accountability and cut out those who are using voluntary sector for personal gains.
In the age of information technology and the internet, it is not difficult to have a database and link remote areas and organisations together.  It would help to keep track on performance, easy auditing, monitor the movement of children through the system, and compare performance and share resources etcetera.  The society has produced so many engineers and IT specialists who can bring in their experience and help to build the necessary infrastructure.  I think it is time for such professionals to come forward to help their society especially those who are weaker and worst hit by the ongoing conflict. Every professional can bring in the expertise from respective fields to make this possible.
Finally, it is hard to argue that there is something like an ideal social response. We as a society are going through a difficult phase in our history and whether we have fared well in looking after our orphans and widows will always remain debatable.  But certainly we can do better with same resources if we leave our differences aside and come together as a family.  We all need to be social workers, advocates and offer whatever we are good at. We have to inculcate the culture of compassion, social work and helping others, in our youth and coming generations.  It is time to reflect and act, as no action is too small, and after all, every little helps.


 ©EHSAAS, J&K Yateem Foundation 

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