Kashmir communications blackout is putting patients at risk, doctors warn

Dear Editors

Kashmir Medical Crisis

Thank you the BMJ for publishing the letter raising concerns about healthcare delivery in a conflict zone like Kashmir. It has been more than two months now that Kashmir remains under communication blockade with restrictions on people’s movement. Although there are claims that some landlines are working, practically it is very hard for people to connect. Internet and mobile phones remain suspended.

Since 5th August 2019, many scientific journals including Lancet1 and the BMJ2 published editorials and letters warning about the impending humanitarian and health disaster if the situation does not improve. It is difficult to ascertain the true scale of suffering due to lack of information via local media. Any news highlighting healthcare crises by international media is questioned by the administration. Hence, it is difficult to gauge the true extent of Kashmir Medical Crisis3. It is deeply worrying that a manmade health disaster is on its way and nothing is being done to prevent it. Many people are reported to have died because of lack of access to urgent medical care and difficulty reaching hospitals.4

Having worked and researched in Kashmir as psychiatrists, it is deeply worrying that in the current day and age, a population of 8 million people is being subject to collective punishment. With a community prevalence of trauma exposure to more than 60%5 and increased rates of anxiety and depressive disorders6, the ongoing blackout is likely to worsen the mental health of the besieged population. A recent article reports 1 in 5 people in conflict areas have mental health problems, including depression, anxiety and Post Traumatic Stress Disorder7. Conflicts involving killings, disappearances, rape, torture, collective punishment, arrests, and lack of access to healthcare are known to increase physical and psychological morbidity and mortality8. There are numerous publications from the United Nations, human rights organisations, and local doctors, about the scale of physical and psychological sufferings of Kashmiris9-10.

If the situation remains the same and nothing is done in the near future, many more people with chronic medical problems are likely to die undocumented when in reality such deaths can be prevented. It is time the medical fraternity and global organizations around the world raise concerns and demand that international aid and fact finding teams are sent to Kashmir at the earliest to prevent the disaster from going out of hand.

Dr Mudasir Firdosi & Dr Afifa Qazi

References

1. Editorial: Fear and uncertainty around Kashmir’s future. Lancet 2019; 394: 542.
2. Mahase E. Kashmir communications blackout is putting patients at risk, doctors warn. BMJ2019; 366: l5204
3. Naseer Ganai. Many May Have Died At Home': Amid Communication Blackout, Heart Attack Cases Rise In Kashmir. https://www.outlookindia.com/website/story/india-news-many-may-have-died...
Date: September 12, 2019. Date accessed September 12, 2019
4. Sameer Yasir and Jeffrey Gettleman. In Kashmir, a Race Against Death, With No Way to Call a Doctor. https://www.nytimes.com/2019/10/07/world/asia/kashmir-doctors-phone.html Dated: October 7, 2019. Date Accessed October 08, 2019.
5. Margoob MA, Firdosi MM, Banal R, et al. Community prevalenceof trauma in South Asia-experience fromKashmir. JK-PractitionerSupplement, 2006; 13 (1): 14-17.
6. Margoob MA and ShiekhAjaz A. Community Prevalance of Adult Post Traumatic Stress Disorder in South Asia: Experience From Kashmir. JK practitioner 2006; 13: 18 – 25.

7. Fiona Carlson, Mark van Ommeren, Abraham Flexman et all (2019) "New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis" The Lancet Volume 394, June 2019.

8. Muller LRF, Buter KP, Rose R, et al. (2019) Mental health and associated stress factors in accompanied and unaccompanied refugee minors resettled in Germany: a cross-sectional study. Child Adolesc Psychiatry Mental Health Jan 30:13:8

9. Housen T, Lenglet A, Ariti C, et al. Prevalence of anxiety, depression and post-traumatic stress disorder in the Kashmir Valley BMJ Global Health 2017;2:e000419.

10. ActionAid (2016) Mental Health Illness In The Valley: Community-based Prevalence Study of Mental Health Issues in Kashmir. A report 2016
https://www.actionaidindia.org/wp-content/uploads/2018/06/Mental-Health-...

Dear Sir,
I read this article along with the responses that has been submitted till now. Let me kindly enumerate my opinions:
1. The conflict is Kashmir is going on for decades. There are numerous reports of genocide by militant groups in th 1990s. Sadly, did not find so much attention of the medical community at that time.
2. Cannot comment regarding the actions taken by the Indian government other than what the UN has said "it is an internal matter" and possibly only our Supreme court can say whether it is correct or not.
3. With regards to patients movements and treatment. With total communications blackout, I wonder how our authors could get information from Kashmir. That leaves 2 possibilities: either the blackout is not as absolute as is being claimed by media (in which case there is nothing preventing doctor to doctor communications) or else people are just assuming what is going on and commenting accordingly.
4. People are afraid to go out. That is a really a problem if people do not fear terrorists who kill indiscriminately but fear security personnel (who are there to protect the general public). It is a mindset that has to be changed.
5. Finally, all government hospitals are open 24×7. And even the army medical units are willing to assist in all medical emergencies.
To conclude, all I can say to the people of Kashmir, please do not hesitate to seek medical assistance from the nearest center just because of the current situation.
Thanking you.
Sincerely,
Dr. Ambarish Bhattacharyya
MD, MRCP, FRCP, FACP