Wounds of war
NIRUPAMA SUBRAMANIAN
Living from moment to moment in a conflict zone can exact a heavy
price. Kashmir today has an alarming number of mental health patients,
bereft of traditional support structures or modern mental healthcare
facilities… Will they ever get the chance to heal?
It is noon at the Government Psychiatric Diseases Hospital in
Srinagar’s Rainawari neighbourhood. In a clinic at the hospital, Dr
Mushataq Margoob is sitting at his table at one end of the room.
Flanking him on either side are two junior doctors.
A saga of silent suffering... Picture by Nissar Ahmad |
The rest of the room is packed with people. Outside, more people are
waiting. The doctors’ assistant will open the door a crack to let a
couple of people in, but only if someone inside is preparing to leave.
Unfazed, the three doctors work their way methodically through the
crush of patients, speaking softly with each person to find out what is
wrong, asking for the symptoms, a background about the family or
significant episodes in the life of the patient before proceeding to
prescribe medicines.
The rush never ends at this hospital, the only government mental
health hospital in J&K. People come here from all over the state.
Established as a mental asylum in the mid-1950s, it has stood a lonely
witness over the last two decades to the terrible wounds that the
conflict in the Valley has left on the minds of those who have lived
through it.
Despite the stigma that is still attached to those afflicted by
mental health problems, the numbers attending the hospital have risen
exponentially.
The increase began around the same time as the troubles in the State.
In the 1980s, it saw 1,500 to 1,700 patients annually; in 1994, five
years after Kashmir plunged into militancy, the numbers rose to 19,000;
by 2002, more than 40,000 people were seeking treatment at the hospital
as outpatients.
Today, that number is close to 1,00,000. The World Health
Organization has predicted that by 2020 depression would rank as the
second biggest contributor after cardiovascular diseases to “disability
adjusted life years”, the sum of years of potential life lost due to
premature mortality and the years of productive life lost due to
disability. Dr Margoob says that has already happened in Kashmir.
“Here it is the direct impact of moment-to-moment living, for more
than two decades,” he says. Nearly 19 per cent of Kashmir’s adult
population, Dr Margoob says, currently suffers from depression. A
dishevelled-looking man from Pampore has come to renew a prescription
for his wife’s medicines. Dr Marghoob asks after his wife as he writes
out the medicines.
Seven years ago, she saw a child getting shot in an exchange of fire
between militants and security forces. “She has not been able to forget
that incident,” the man says later outside the OPD, before shuffling off
to collect the medicines. “She remains sad all the time. The doctor says
she has an illness in her mind”.
Back in the clinic, a woman has been waiting patiently. Her flaming
red cheeks hardly look like a sign of good health. She has been a
regular at the clinic since her husband disappeared 10 years ago. The
woman told the doctor that some unidentified men, often a euphemism for
militants, took him away. She has a daughter who is now 19 years old.
“She suffers constantly from aches and pains. She has a gloomy and
pessimistic picture of her life. In addition, she is also suffering from
hypertension. Because she has no money, she keeps missing her medicine
doses,” Dr Marghoob said.
For more than 20 years, militancy, the overwhelming presence of the
armed forces, bomb attacks, untimely deaths, disappearances, curfews,
protests have all had an adverse impact on individuals as well as on the
social fabric of communities.
Not all cases of mental ill health have a direct link to the volatile
situation in Kashmir. But, says Dr Margoob, even such patients who would
have fared better had it not been for the overwhelming conditions of
stress in the environment.
A study by Medecins Sans Frontieres (MSF) conducted between June 2005
and August 2005 in the two districts of Badgam and Kupwara, published in
2008, found shocking levels of exposure to violence.
Nearly 86 per cent had been exposed to crossfire; 82.7 per cent had
been exposed to round-up raids; almost three-quarters had witnessed
physical or mental ill-treatment. Over two-thirds had seen someone being
tortured. Over 40 per cent had witnessed a killing, over 13 per cent had
witnessed rape.
The study found over one-third of the respondents were suffering from
psychological distress, and one-third had contemplated committing
suicide. The most common ways in which people coped were by withdrawal,
isolating themselves from the people around them, or with displays of
aggressive behaviour.
For all this, J&K has abysmally inadequate mental health facilities.
The state has not more than 16 psychiatrists, most of them working out
of private clinics in the capital.
A private mental health hospital opened three years ago with
in-patient facilities. But professional mental healthcare in rural areas
is unheard of, and most people who want help must make the trip to the
capital city.
With increasing awareness about Kashmir’s mental health issues, the
postgraduate Institute of Mental Health, the teaching facility attached
to the hospital that Dr Margoob heads, is now engaged in training
psychiatrists, clinical psychologists, psychiatric nurses and social
workers. He points to the two junior doctors working alongside him in
the clinic.
One of them is last year’s topper from Srinagar’s government medical
college, the other is from a family of opthalmalogists in Jammu. “They
have willingly chosen to take up psychiatry. It is an encouraging sign,”
he says.
According to Dr Margoob, family and religion have played a big role
in compensating for the inadequate professional mental healthcare
facilities in helping people cope with their trauma.
But even these have limitations. Of the tens of thousands of orphans
in the state, a large number have no family support, ditto for the
widows, and the “half-widows”, women whose husbands have disappeared
after being taken away either by security forces or militants.
He cites the example of a patient, a 23-year-old girl, who saw her
father being killed by a notorious counter-insurgent when she was only
nine years old. Some years later, her mother also died of a kidney
problem, leaving her brother to look after the family.
Even after the passage of 14 years, the girl, who comes to see him
once a fortnight, continues to get seizures. The attacks could be set
off by anything that triggers a memory of the killing, such as a knock
on the door.
Recently, she has developed keratoconus, a degenerative disorder of
the eye, which can be corrected with surgery. She has no money for this,
and feels let down by her extended family.
“She tells me that as long as her father was alive, the house always
seemed to be full of aunts and uncles, but they are nowhere in the
picture now. There is no one to help her,” Dr Margoob says. “Once the
immediate incident is past, people move on, they vanish, and the
affected persons are left to fend for themselves”.
In this summer’s unrest in the Valley, the youth who made up the bulk
of the stone-throwers all belong to a generation that was born and grew
up in the shadow of the gun in Kashmir.
Children are daily witness to the helplessness and inability of their
parents to control the circumstances around them, and have internalised
the older generation’s feelings of insecurity. |