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 

A criminal silence

World Hepatitis Day is celebrated every year on the 28th of July, on the birthday of Nobel Laureate Professor Blumberg who discovered Hepatitis B.  It was in 2010 that the World Health Organization made World Hepatitis Day one of only four official disease-specific world health days.  Previously an International Hepatitis C Awareness day was celebrated by the patient groups of the European and Middle Eastern regions on 1st October in 2004, but some other groups were having different dates for the same. World Hepatitis Alliance declared 19th May as the first World Hepatitis Day in association with the patient groups in 2008.  The date was finally changed to 28th July after the adoption of earlier declaration in the 63rd World Health Assembly in the month of May 2010. It was titled as the World Hepatitis Day with an aim to focus on raising awareness at the national and international level. 

Millions of people across the world have been taking part in the World Hepatitis Day, with an aim to raise awareness about viral hepatitis, and to call for access to treatment, better prevention programs and government action.  The theme for World Hepatitis Day 2015 is ‘The prevention of viral hepatitis’ with a campaign strap-line ‘Prevent hepatitis: It’s up to you’.

There are more than 400 million people living with hepatitis B and C worldwide, about 1.4 million die due to these infections every year. Unfortunately many more get infected at the same time. Prevention of further spread of the viral hepatitis is possible through better awareness, services that improve vaccinations, blood and injection safety and infection control training of health professionals. 

It is surprising that in a country like India with huge proportion of such cases, not many awareness programmes have been arranged to mark the Day.  Apart from the health secretary of Maharashtra directing health institutions in the state to organise awareness events on the day, rest of the country seems to be in a slumber including Jammu and Kashmir.  

Kashmir valley is one of the places worst hit by Hepatitis C infection, already declared as an epidemic by experts. One often reads about hundreds of positive cases in some villages of Kokernag area like Magam, Sonabarie, Sagam, Zalangam and list goes on. Unfortunately in some villages, more than 50% population has tested positive. Similarly many villages have been tested positive in Shopian, Kupwara, Lakdakh, as are some areas in downtown Srinagar.  Recent screening done in Sagam village in Kokernag has revealed more than 11% positive out of 400 samples taken.  Strangely, the results are being covered up had it not been for a dedicated journalist who broke the news. The SKIMS also collected samples in village of Sonabarie few months ago. It is alleged that the results are being covered up and not made public for unknown reasons. It is feared that more than 80% of the sample may be test positive.  Similarly it has also been alleged that SKIMS covered up the results of screening done in Zalangam village few years ago and hence those testing positive were kept in the dark and not provided with any treatment leading to complications in many.  

In spite of commendable media pressure, apart from some damage control exercises, the health authorities have completely failed to take any proper action on ground.  Tall claims were made of releasing crores of rupees for the treatment of those already infected but no one knows what happened to the money.  Recently few hundred patients from village Magam were offered treatment but nothing is being done about rest of the thousands of positive cases or to prevent people getting infected on daily basis. No work whatsoever has been done by the health department to find the reason for the epidemic or how to prevent further spread of the infection. Doesn’t it look like another scam which is being covered up? 

Since the change of the government in the state, a criminal silence has been maintained by the new health ministry.  The minister of state for health did visit Kokernag constituency   but did not care to utter a word about the ongoing epidemic of Hepatitis C. Similarly the new director health services Kashmir has either not been updated about the problem or has decided not to bother.

The World Hepatitis Day could have been used for creating awareness about spread of infection and also seek help from various national and international organisations to deal with this hopeless situation.  Instead of organising awareness campaigns, health authorities are busy stigmatising people who have been infected.  While going door to door in Sagam village few months ago, the health workers were patronising people by suggesting that screening and seeking help will affect the marriage prospectus of their daughters. Surely health workers were directed by their superiors to create fear, so that poor villagers do not demand any help.  Subsequently when a screening camp was organised under media pressure, people were hesitant to come out for screening, fearing stigma.  Allegedly another reason for cover up was that highlighting this epidemic can affect the tourist rush to Kokernag, hence poor lives are less important than non-existent tourist flow to Kokernag garden. Similarly the doctors working in the area are being discouraged to get people tested, supposedly it brings bad name to the health department.  So here are we preventing hepatitis by denying the facts for false pride…….Prevent hepatitis: It is up to you? 

One wonders whether the health authorities are there to safeguard people’s health or play politics with appeasement policies at the cost of poor lives.  One would have expected that the department will organise awareness programmes not only within the health department but also involve schools and other departments. It is amply clear that most people are acquiring this infection from the health facilities run by state due to lack of training of staff, poor accountability and lack of sense of responsibility.  Infection control and sterilisation practices are rare and same instruments and syringes are being used on multiple patients.  Unfortunately there are allegations that even hospitals like Government Dental College which is seat of learning for budding dentists and treats thousands of patients each day, does not follow any sterilisation procedures and same is the case with other hospitals around the state, not to speak of private dental clinics and peripheral health facilities. 

Health is a serious issue and cannot be done away with being irresponsible, may it be doctors, nurses, allied staff or health officials and administrators.  There is still time that this epidemic can be checked before it is too late. Acceptance of the problem, awareness of general public, training of staff and accountability of concerned are some of the steps required to curb further spread of this epidemic.  Creating a stigma among people just to shun away from responsibility is criminal and surely not a solution.  Let us pledge on this World Hepatitis Day to work towards controlling the further spread of hepatitis C infection as prevention is always better than cure. The state and health authorities need to take appropriate steps to help those who have already tested positive and stop further spread of infection. #worldhepatitisday 

http://www.greaterkashmir.com/news/opinion/a-criminal-silence/192736.html

AIIMS: A solution or another gimmick

We want AIIMS.  This is a common slogan from every region and district of Jammu and Kashmir these days.  I am not sure whether it is about health, politics, regional hegemony or keeping people distracted from the lack of basic health care facilities in the state.

 It has led the civil society of Jammu to unite and do whatever they can to claim the proposed AIIMS.  

Every political party is trying to take credit, doesn’t matter which region it goes to.  The Jammu faction of the ruling BJP-PDP coalition has given in writing that they will get an AIIMS for the region and the Panthers Party is marching to Delhi to demand its own.  It has also become a tool for furthering the regional divide in the state.  I wonder why people from Ladakh region are still silent. 

Similarly every district of the Kashmir valley wants AIIMS.  Social media is full of debates why it should be in south Kashmir, why not in central Kashmir and how north Kashmir best deserves it. People from Chenab valley are making similar demands.  However the question remains whether AIIMS is really the answer for poor health care delivery in the State?

 I am not against the idea at all and do believe it will help a good percentage of patients with life threatening and long term illnesses and there is a need for more tertiary care hospitals. 

What is wrong with the institutions we already have like GMC, SKIMS and the super-speciality hospital in Jammu? How do you think AIIMS would be any different from SKIMS? What happened to the four proposed medical colleges which were starting in the State? Was that promise also a political gimmick for attracting the vote bank.

 The Children’s Hospital is again in news for increased death rate of neonates and so is the lone maternity hospital for overcrowding and related issues. 

Before projecting AIIMS as the magical cure for all our health problems more needs to be done to improve the peripheral health service.  

Otherwise it is like starting a new university as a substitute for failure in primary education and replacement for primary schools. The notion that the tertiary care hospitals should treat every condition while ignoring the primary health sector, defeats the very purpose of AIIMS like hospitals.  

Would people not queue there with minor ailments like tummy ache and running nose? Would the super-specialists be able to treat those with terminal illnesses, rare diseases, life threatening conditions , organ transplants , do open heart surgeries,  cancer treatment just to name a few ? Or do you want them treating common cold, flu, itch, loose stools and subsequently turning it into another over crowded health facility.  

Hospitals like AIIMS or SKIMS are meant to treat only those patients who have been seen in the primacy care and are in need of specialist help.  Or those who cannot be treated locally and need specialist intervention for a life threatening conditions.  

That means people who are referred by the doctors from the primary care ought to be seen and treated.  We cannot have walk-in OPDs as is happening currently and then expect these institutions to deliver.  But here also we cannot blame the poor patients for queueing at tertiary care hospitals.

 If the appropriate services are made available at the primary care and referral system is streamlined, then only will it be possible to let these tertiary hospitals to work optimally and help those who actually need such kind of facility.  But are we ready for such a system, keeping in view the lack of accountability, mismanagement, corruption and nepotism? Would it cause poor patients further suffering, would they have to go from pillar to post to get referred? 

In most of the developed world, primary care system manages most of  the ailments from hypertension, diabetes, depression, anxiety, pain, asthma etcetera and people are only referred to tertiary care if not manageable locally.  

But unless we have a functional peripheral health system, no matter how many AIIMS are opened up, they are likely to have the same fate as the existing hospitals. One then wonders why nothing is being done or said about the peripheral health sector. 

We often hear accounts of deaths in various hospitals leading to beating of doctors and ransacking of property.  At times professionals are randomly arrested to calm down the situation.  Anyone from a village headman to a revenue officer feels entitled to boss around and order dismissal of staff, which speaks volumes about the actual disarray in the system and lack of seriousness from the authorities. 

There is no health policy and every new government bins the plans made by previous regime like the four proposed medical colleges.  Would it not be worth reviewing the current peripheral health structure and upgrade the facilities according to the needs of the area than how influential the local MLA is?  Is it not time that all the district hospitals are upgraded so that no patient is referred to tertiary care hospitals unless there is a real need and cannot be managed locally?  

By upgradation, I do not imply constructing oversized buildings, which our ministers are good at for reasons you know better.  Upgradation means appropriate allocation of adequate resources, recruitment of staff and doctors, creation of specialised units and starting of well-equipped accident and emergency sections at every district hospital.  There are enough trained and specialist doctors in the state to fill in these roles. 

With the ongoing neglect and failure of providing basic healthcare in the state, we surely need more AIIMS like hospitals in coming years. There is an epidemic of hepatitis C in the valley which has been completely ignored by the authorities.  People are being infected on daily basis and majority have no access to any treatment.  

If nothing is done sooner, within a decade or two, there would be thousands of people with terminal liver disease who would need AIIMS like hospitals and much more. Similarly the uncontrolled use of antibiotics, fake drugs, unhealthy lifestyle, obesity, drugs and alcohol addiction, environmental pollution, adulterated food products and road-traffic accidents leading to debilitating injuries etcetera would lead to conditions which will need more specialised hospitals. 

 But if there was any political will and demand from the civil society, most of these conditions could be prevented and treated locally.  Communicable and infectious diseases like hepatitis B and C could be curbed if department of Public health  (community medicine) is utilised beyond the borders of medical colleges so that they can conduct proper epidemiological studies on local population and come up with appropriate preventive strategies based on the resources available.

To conclude it is important that people demand equitable, safe and dignified health care first at primary and secondary level and then dispute about AIIMS type of facilities and its location.  So while the politicians play with your emotions using the issue of AIIMS and new medical colleges, it is time to demand a proper upgradation and necessary review of the current hospitals and peripheral health system.  

If there is a functioning primary health system, proper referral structure and the walk-in-clinics are closed down; even the existing facilities at SKIMS can do wonders for those who actually need them.  But surely there is need for more tertiary care hospitals to cater to the growing population and a health policy based on facts and needs than whims of political parties for vote bank politics. 

http://www.greaterkashmir.com/news/opinion/aiims-a-solution-or-another-gimmick/191834.html 

The health sector in Kashmir is an organised mafia

Recently the honourable minister for health came up with another genius plan to overhaul the health department.  A three tier roster for the doctors working in the health department was proposed.  The doctors working in the department reacted sharply questioning the very basis of the plan.   The doctor bodies even threatened industrial action if the plan was forced on them.  I am still to hear from anyone if the proposal is workable and it seems that even the common sense has been kept at a distance.  I am not advocating that doctors should not work, or work less or run way from on call and night duties.  But it would be interesting to know who came up with this idea. Was it the health ministers himself or his clever advisors? Surely whosoever it was does not seem to understand the basic problems or does not care to know.

One must be either naïve or idiotic to conceive the idea of starting a shift at twelve in the midnight where by a new doctor is supposed to come in and relieve the doctor on duty.  What about the prevailing situation in Jammu and Kashmir, conflict, insecurity, poor roads, lack of resources to mention a few? Would the authorities be kind enough to explain where a lady doctor will go if she has to leave the hospital at twelve midnight?  Who would be responsible if any doctor is harmed in the process? Is there a proposal of constructing staff quarters at every hospital? Are there plans to provide transport and security to doctors when they go home?

What is the current staffing level and doctor patient ratio in the state?  Can the current number of doctors cope with this kind of rota? If a doctor has to work whole week without any break or rest, how safe is it for the patients being treated? There are only questions and no solution. This has caused further unrest in already overburdened doctor fraternity.  It seems that such orders or rhetoric is deliberate to mislead common people from the basic issue of lack of appropriate health service in the state.

There are so many other examples of such orders since this government took charge.  Humiliating doctors seems part of the plan, should it be the senior most doctors working as Principal Medical College Srinagar or a female psychiatrist in Jammu.  Sadly the honourable health minister was seen physically pulling a doctor’s collar recently.   I wonder does law of the land permit anyone to behave like this.  In another example, it was ordered to arrest a doctor and other staff members of a hospital who had been on a picnic, probably to please the local headman.  Also hefty fines are being imposed on the staff for not doing their job, which not only speaks about lack of vision but also regressive approach to improve any system.  Is there no legal framework in that state?  Surely there must be some rules and regulations.  If someone is not attending duties properly, action needs to be taken after proper fact finding than following an appeasement policy.  As an elected representative, how can one think and behave like a dictator is amusing.

Similarly an order was passed making prescribing by generic names mandatory for doctors without thinking about how that will work on  ground. When there are no regulated pharmacies in the state, anyone can sell and buy medication, how was the policy supposed to make any positive impact and not do more harm?  If this is about fooling people, surely there are other ways to do that.  But let’s not forget health is a serious issue and how long can one fool the voters by polarising and rhetoric.  The issue of private practice by doctors is another favourite past time brought up often to cover the failings of the system without any proper alternative whatsoever. Huge threats are made in media without any action or a plan of action.

In another bizarre statement the health minister came up with the impractical idea of mandatory five year service for doctors.  Apparently he wants to pass an order to prevent any doctor leaving the state to curb the shortage of staff.  Let us not forget that Jammu and Kashmir is the only place where doctors are jobless and if he actually wants to improve the staffing levels, why not recruit?  He actually reduced the number of posts in the department by recruiting allied professionals on the assistant surgeon posts.  None of the announcements or policies made so far seems practicable and every time there is a U-turn for obvious reasons.  So apart from making some news, nothing changes in practice.

There has been too much centralisation of power and posts like Principal GMC have lost its worth and effectiveness. There are no significant decisions which can be taken locally and everything is managed from the secretariat, making sure that one has to be either a yes-man or corrupt to remain on any post. This has a significant negative effect on the delivery of health care and morale of doctors. There is no room for whistle blowers and people who strive to improve the service.   Is this the fault of our ministers and bureaucrats or top doctors in the department is open to debate?

There are often allegations that the senior doctors are hand in glove with the administration when it comes to corruption and current miserable state of health care delivery in the state.  Whenever there is a question of improving services, queries about lack of facilities, lack of manpower, the in-charge bosses always take one stand  of ‘nothing  being wrong’.  It is confirmed in writing that everything is hanky dory and there is no room for any error whatsoever. They presumably do all this to keep their bosses happy in the secretariat, either to acquire a position, remain in the chair or get further undue extensions.  Are they doing so in compulsion or not, I leave you to judge that.

The selection of doctors for various administrative posts from BMO to Director Health has always been a contentious issue. There are no set guidelines and even if there are any, surely none is followed.  Posts are allocated by a process better known to the health secretariat and the minister.  One does not have to be a genius to know how it works.  There are rampant examples of partiality and corruption.  Same people who are initially attached to department on corruption charges are later awarded higher posts.  How on earth are these officers going to be effective and upright when they are toothless and only in-charge till the ministers are happy with them?

Doesn’t it look like an organised mafia which actually does not care what happens to poor people? If there were any real intensions to help people and alleviate their suffering, surely something meaningful would have been said and done by now. The doctors involved in corruption and malpractice get away with it, so does the administrators and ministers who benefit.  Common man and an average doctor are made out as scapegoats in the process.

In a civilised set up, any representative tries to understand the shortcomings of the department first and then resolve the same. It is prudent that few expert committees are framed to review the current health infrastructure and failings to come up with appropriate recommendations which can be acted upon.  Nothing will improve by mere tactics of threats, bullying, humiliation and corruption to name a few. But as the African proverb goes, ‘a wise man never knows all, only fools know everything’.

Should the Chief Minister think about changing the health minister or keep a check on his rhetoric to save further embarrassment?  Should the civil society respond and demand some actual change? Question remains who will bell the cat?

http://www.kashmirreader.com/the-health-sector-in-kashmir-is-an-organised-mafia/ 

Why is the health sector in shambles?

Have you ever seen any bureaucrat, politician (lets us call them VVIP) or their family being treated along with your loved ones in any of the hospitals of the valley?I am sure the answer is mostly no. If you ask any Kashmiri doctor working in Delhi, you will come to know most of our self-styled VIPs get themselves treated in costly and high end hospitals of Delhi and other parts of country.I am not in any way opposed to them going to Delhi or getting their loved ones treated at expensive hospitals. But there is a problem. Do you know who pays their bill?  

When there used to be any thefts in our villages, the only solution to the problem was to give the thieves responsibility of night watch and hold them responsible every time there was any incident. Similar is the story with our exchequer and tax payers’ money. Although you have given keys to them, you have no power to hold them accountable. In fact you don’t even know it is your money.  A blue eyed VVIP takes his family member for a routine surgery like removing gallbladder outside state. Surgery is done in a posh private hospital charging few lac rupees. Once back in the office, the VVIP sends his peon to the directorate of health services with the bill and instructs the in charge officers to process it urgently. What would they do, they cannot refuse, after all they are only in charge and they can be changed, transferred or dismissed any time. Somehow with in no time, note on note is written which essentially says that the VVIP was on official tour to outside the state and suddenly the family member became unwell and the doctors there advised emergency surgery.  And hence you pay the bill of few lacs from the state exchequer even without your knowledge, as the educated conman here is clever, entitled and above all VVIP.  

Even if the VVIP wishes to get treated locally, by a simple phone call they make sure they are either seen at home, or even if they come to hospital, they don’t have to wait, get a registration card or pay for anything. You will be surprised how the bills are adjusted. So if the VVIPs have no idea how hospitals work, how the long queues never end, how poor patients and their tired doctors manage the rush, how are they going to know what to do with the failing health care in state.

If we talk about the bureaucrats working in the department of health, what do they actually do? Sign files, transfer people from here and there, get special treatment if they are unwell and rush out of state to sort their health needs. Have you ever heard they come up with a policy, white paper or just some statistics about the current affair of health issues in the State? 

This raises an important question, why do some state employees (of course VVIPs are employees) get to treat themselves and their families wherever they want and why not you.  Are they paid less in their salary that they need extra help? Are they doing some great humanitarian work that you are obliged to shower them with the money, which the state even doesn’t have? Are they running the affairs of state so well, you feel like rewarding them? You all know that is not the case.  None of the departments can even claim they know actually what they are meant for, let alone be productive.  It is simple, the people who are supposed to be running the affairs and safeguard your health, resources and money, are obsessed  with the idea of being special and important than rest of  you. After all they know how to pass rules or bend rules to suit their needs.  But they are not the only one who believes for them being special; actually it is you who think they are above law with lives more precious than yours. 

There are endless examples of neglect and deliberate harm by the health department, which amounts to criminal offence in most countries in this day and age. Hundreds of neonates died in hospital, supply of fake drugs, thousands infected with hepatitis C both in tertiary care  and periphery, most women left without a uterus, overcrowded hospitals without any accountability for mortality rates, thousands dying in road traffic accidents due to lack of emergency service (ambulances and paramedics) and the list goes on. You all know the number of probes ordered but no one being held responsible for anything till date. 

There is not a day when a doctor is not assaulted, beaten or humiliated and mostly with no fault on his or her part.  The health ministry was awarded to a person who humiliates doctors, without actually having any idea about the health sector and its failings. It seems he is finding it hard to come out of the election campaign mode, that is why we hear regular impractical threats against doctors.  When few haemophilic patients got infected with hepatitis in United Kingdom, the British Prime Minister apologised in the parliament and all those people were compensated for failure of the state to provide safe health care. But I wonder if our health minister actually knows about basic health issues in the State or is he done with keeping people happy with his rhetoric.

Since he has taken charge, he has yet to talk about any meaningful policy to salvage the broken system. I wonder if his commissioner secretary health has any idea or real plans to reboot the system without blaming the professionals who are working day and night in difficult environment. But maybe it does not affect them as they get free treatment from best possible set up in the country and they do not have to even pay for it. Hence why should they bother what is happening to common people and to the health department they are allegedly managing.

Finally it is your chosen government and health minister, and it is your life and health. The responsibility is yours, whether you want to have safe and equitable health care or you are happy with funding their costly lifestyle and five star hospitals stays outside the state. The vote bank gimmicks of arresting staff, dismissing doctors and transferring officers is not going to change things on ground. Constructing huge hospital building is also not going to do much but make them richer.  Unless you demand an honest, dignified and safe health care system with adequate staff and resources the innocent will keep suffering. It is your right so take it or leave it but please stop beating doctors; they are bound to commit mistakes when their morale is shattered. There are inadequate resources and manpower to cater to the growing population. May be the Chief Minister should ponder if his voters deserve safe and dignified health care, seeing as it is after all a BASIC HUMAN RIGHT!  

http://www.greaterkashmir.com/news/opinion/story/188097.html

Faith and Mental Health

There is research based evidence that religion and spirituality help prevent many physical and mental illnesses, decreasing both symptom severity and relapse rate, enhancing recovery, as well as rendering distress and disability easier to endure. Religious and spiritual factors can significantly affect the presentation of mental disorders and its knowledge is of utmost importance for proper diagnosis and treatment.

In a country like India it is fair to say that the vast majority of the population believes in one or other religion with varying influences of local and diverse culture on the same. When it comes to the treatment of common mental illnesses in India, unlike West, faith healers and religion is the first port of call.

There is truer for rural population which comprises majority of the population. When a patient comes to see a psychiatrist, it is likely that the family has already exhausted a number of options including faith healers. Although there is no proper research data from India, from clinical practice, it is fair to say that religion and faith healers play a big role in the recovery of many common mental health conditions.

Conditions like dissociation, conversion, day to day stress, anxiety problems are managed by visiting holy sites, gurus and faith healers. They act as counsellors and religious places give a platform to vent emotions. Many people also turn back to religion in difficult situations to find solace. Some times this is the only hope in one’s life. There is evidence that suicide rates are lower in populations where religion prohibits suicide, and thus faith or religion becomes a protective factor.

Lately concept of spirituality has been introduced into psychiatry and is considered more inclusive and affecting everybody. Some consider the concept of spirituality better than religion, claiming that unlike religion it is not divisive and can be adopted by anyone.

Spirituality is also considered more secular, and applicable to the whole field of mental health care. There are advocacy groups who call for routine assessment of spiritual health in all mental health patients. According to the World Health Organisation, ‘Patients and physicians have begun to realise the value of elements such as faith, hope and compassion in the healing processes. The spiritual dimension includes these factors and goes beyond religious affiliation. According to the WHO, it may be categorised under four headings: transcendence, personal relationships, codes to live by, and specific beliefs.

In western psychiatry, there is emphasis on spiritual training and providing adequate resources and manpower. Chaplains, Imams and other religious leaders are regularly employed by the psychiatric and general hospitals for providing ongoing support to patients in need. Sometimes religious beliefs make people not to take certain kind of treatment and having a religious person to counsel the patient at that time proves a great help.

On the other hand, when many people do find religion and its practices helpful in recovering from common mental health conditions, there are times when it acts adversely because of the negligence and uncontrolled mushrooming of people acting as faith healers.

Some faith healers advocate stopping medication prescribed by doctors which can be risky and life threatening in conditions like epilepsy and mood disorders where medication forms the first line of treatment. Sometimes people with learning disabilities, psychosis and other conditions are treated in a very inhuman way and tortured based on ill formed beliefs around religion. People are sometimes chained at some places run on the name of religion and faith.  There have also been incidents of sexual and physical abuse by self-styled religious leaders.

India has unlimited resources when it comes to religion, spirituality and faith healers but there needs for some training and sensitisation so that people do not intervene beyond their capacity and untoward incidents are prevented. Psychiatric departments need to organise regular workshops for local faith healers for coordinated work so that people who need medical intervention are promptly referred.

There is also need to keep check on rogue people who tend to exploit people on the name of religion and more so mental health patients who may be more vulnerable when unwell. Engaging faith and spirituality will also enhance the experience of patients and help build trust in their treating psychiatrists. 

 http://healthanalyticsindia.com/healthanalytic/faith-and-mental-health.html

Hepatitis C and preventive measures

Kashmir valley is witnessing another disaster in the form of Hepatitis C epidemic. In some villages in Kokernag area the number of cases is around 40% of the total population. In spite of media pressure and demand from local population, authorities are still contemplating curbing the further spread of this infection. Similar scenario exists in other districts of the valley like Shopian, Kupwara, Srinagar and other areas of district Anantnag.

Hepatitis C is not transmitted by routine personal contact and there needs to be an actual transfer of the virus via blood, blood products and body fluids, from one person to another. From the sociodemographic profile of the rural population, one can easily exclude intravenous drug abuse or sexual contact as the cause of the current epidemic in majority of cases. The unsafe use of syringes and instruments by health professionals, dentists, chemists and quacks does explain this explosive nature of the problem. The situation is made worse by the lack of training and accountability, unsafe sterilisation procedures or no sterilisation at all.  The reuse of disposable syringes is quite common and people are not used to questioning the unsafe practice. Stitching of common injuries at health centers is another common mode of infection. The practice of circumcision in our community puts children at high risk if proper precautions are not used. Unsafe dental practices and mushrooming of dental quacks is another worrying reason.

Use of injections is a common practice more so in villages. Even for minor ailments, people prefer to get medication by injection than by oral route. There is also a practice of using intravenous fluids in villages for no apparent reason. A large number of injections are superfluous and either due to the public, the patients, and erroneous beliefs in the superiority of injections compared to pills, or due to unscrupulous providers /quacks, who like to inject people because of greed for extra money.

People should take extra precautions when seeking help for any medical condition. When your doctor prescribes an injection, ask if you can get along without any medicine, or if an oral alternative is available. Many conditions, such as colds, flu, dry cough, and diarrhoea are better treated without injected medicines. Most drugs and other substances can be taken orally, and should be injected only in rare situations like if someone is unconscious, or vomits so much that oral medication will not stay down. Vitamins, glucose, paracetamol and other drugs to reduce temperature, most pain-killers, treatments to stop diarrhoea or vomiting, medicines to treat asthma, antibiotics (with a few exceptions, such as penicillin) should be taken orally.

Only new and disposable syringes and needles taken from a sealed package should be used. Syringes should not be kept at home for reuse even on the same patient because it is potential source of infection.  If for any reason syringe or needle has to be reused, ask if it has been autoclaved or boiled.

Single dose vial should be used as much as possible, which is a small bottle with medicine for one injection only, so that there is no need to reuse the medication on same or other patient. Multi-dose vials, with medicine for many injections, are often used by dentists and anaesthetists when giving local anaesthesia like during removal of a tooth. This can become a source of infection if both the needle and syringe is not changed between the patients.

If no single dose vial is available, see that your doctor takes medicine from a new multi-dose vial opened in front of you. This may not always be possible and many doses are taken out from same bottle. Some people have the bad habit to only change the needle (and not the whole syringe) between two injections for a same patient, (and only change the whole syringe in between patients), which contaminates the vials because of the reflux mechanism, and you are placed at risk of getting contaminated with the virus (HIV, Hepatitis B & C) or bacteria of the patients before you, including drug resistant bacteria.

Recent investigations in the USA on nosocomial epidemics of Hepatitis C showed that badly trained, unscrupulous care givers only changed the needle and not the whole syringe to re-inject a same patient from multiple dose drug vials. In the process of injection, when the needle is pulled out, microscopic quantities of blood (not visible with the naked eye), gets back up into the syringe. Thus when only the needle is changed and syringe is reused, multi-dose vial gets contaminated with the blood from the syringe possibly containing the infection. Then, when the vial is used for a new patient, even if a totally new sterile syringe is used, the new patient is at risk of getting infected with the virus/bacteria of the patient or patients who came before him for treatment (and many microorganisms remain viable for days in microscopic drop of blood). In 1996, even in North America, more than half of anaesthesiologists had those bad 'dirty' practices. Many health care givers are not conscious of the danger of this practice. So both needle and syringe should be changed with every withdrawal of medicine from the vial.

Another option is to take injections from pre-filled disposable syringes– which are disposable syringes combined with single-dose vials, or single dose cartridges.  ‘Smart syringes' which include a manufacturing system which makes them definitively non-reusable, but they are unlikely available due to cost issues.

Many people give injections – not only doctors and nurses, but also pharmacists, traditional healers, family, and friends. No general statements can be made about who gives safe injections. If a trained provider respects your requests, uses a new syringe and needle, and takes medicine from a single-dose vial, you are probably safer with the trained provider. But if the trained provider will not do so, you may be safer with an untrained provider who will listen to you.

Finally health care providers need training around infection control and sterilisation so that this dangerous epidemic is put to a halt before it is too late. Every new case is a potential source and the only way to break the cycle of further transmission is to practice honestly and safely. It is your right to demand safe health care and question where ever you are in doubt. A five rupee syringe can save you money, can save your health and ultimately your life. 

http://www.greaterkashmir.com/news/opinion/hepatitis-c-and-preventive-measures/186152.html

The Collective Conscience

Why do the lives of some seem cheaper than others?
Dr Mudasir Firdosi

Thirteen years ago a drunk driver drove his car on a footpath crushing many poor souls, sleeping rough. One was killed and many injured. With more than a decade of lengthy court proceedings he was finally found guilty and awarded a few years prison sentence. While many were betting on the verdict, some were praying to their gods and goddesses for his alleged innocence and favourable verdict, no one remembered the victims of the crash.

India, where more than fifty percent population lives in poverty, one would have thought that majority will identify with the victims but the situation seems quite opposite. The social media is full of fury from elite to middle class to anyone using Facebook or Twitter, condoning the drunken driving incident. Some pleading that it was not his fault and people should not have slept on the footpath. Some stooped further declaring all those homeless worse than dogs. Most of the TV channels or media houses even forgot to mention about the plight of poor victims and ironically no one reported that a drunk driver was found guilty and hence appropriately sentenced. Some justify the action by quoting other elites who have killed people in similar manner and have never been questioned or arrested. Some talk about 2002 Gujrat riots and how even the convicted murderers got out on bail.  Some are worried about 200 crore loss to Bollywood and many are praising him as a philanthropist and saviour of poor, trying to influence the judicial process. Sadly one man tried to end his life in front of the court from almost same very social class as the actual victims in protest against the verdict. 

This begs a serious question, what has happened to the nation’s conscience. How do you call the country as largest democracy on one hand but want to impose princely rules on the other hand for select few. Why do the lives of some seem cheaper than others? Where did it get wrong?  Does it have to do anything with the prevailing post-colonial mentality and VIP culture? How much is the media responsible for shifting public perception and make anyone a villain or hero. Does the public sentiment have any bearing on courts verdict? Only few years back while deciding the case of Afzal Guru, even the Supreme Court of India mentioned in the judgement about ‘the collective conscience of nation’ and keeping it at centre of decision making. By that logic the court seems to have got it completely wrong after all it does not matter whether the evidence is there or not when it comes to what nation wants.

Surprisingly the higher court suspended the five year sentence till further hearing quite unlike the numerous cases where common people have to wait for months even to get a bail for petty crimes. Does that mean the judicial process is influenced by power, money and public opinion?

What else can be the reason knowing that someone has done a crime by taking an innocent life but people still feel sympathetic towards the perpetrator. Whenever, someone is considered superior for any reason, it becomes a breeding ground for injustice and lawlessness. People are even indifferent to some draconian laws framed by the state which provides impunity to ‘killers and rapists’. The deep rooted issues with inequality, racism, caste, communalism and elitism have been normalised and even the victims fail to see the injustice. The rampant corruption seems to have crept beyond the material world having been normalised at religious, moral and ethical level. 

The psychological state of ‘learned helplessness’, which results from prolonged use of coercive methods, either physical or mental, makes people to lose their free thinking.  When people feel that they have no control over their situation they may also begin to behave in a helpless manner. This inaction can lead people to overlook opportunities for relief or change. This phenomenon has taken over the majority. Even though apparently free to choose and act there seems to be a need to worship VVIPs and people in power and take their actions for granted even if it costs the life of common man. The mere acceptance of differential treatment depending on fame and power speaks volumes about the slave mentality and ignorance about basic human rights.

If celebrity goes to prison or is let go, probably does not matter much. But it is worrying when common man identifies with the offender and ignores the sentiments and rights of fellow citizens. Last but not the least; anyone can be a victim and it is never late to let the justice prevail.

http://risingkashmir.in/news/why-do-the-lives-of-some-seem-cheaper-than-others/