Dignity in Mental Health

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

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

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

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

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

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

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

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

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

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

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

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

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

Personal reflections of doctor starting psychiatry training in Kashmir

Personal reflections of a doctor starting psychiatry training in Kashmir

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Suicide prevention needs State intervention

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How Stress Affects Health

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

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

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

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

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

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

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

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

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

Orphans of Conflict: Forgotten by Society and the State

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

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

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

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

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

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

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

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

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

So what can we do? 

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

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

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

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

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

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

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

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

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

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