Kashmir communications blackout is putting patients at risk, doctors warn
BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5204 (Published 19 August 2019) Cite this as: BMJ 2019;366:l5204
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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-...
Competing interests: No competing interests
The Government of India (GOI) in a declaration before the Supreme Court, confirmed that the restrictions imposed in Jammu & Kashmir (J&K) concerning the abrogation of the Article 370 are temporary and are being relaxed in gradual phase. The GOI representative informed the court (1) that “the healthcare services have been functioning normally in J&K and from 5th August to 15th September 2019, over 1 million patients attended the out-patient department of various hospitals and 67,196 patients were admitted in the indoor departments in the government hospitals of J&K. Over 10,699 major and 53,297 minor operations were carried out during this period”. It was also reported that there is sufficient stock of essential drugs and other medical requirements across the hospitals, and 90% of the medical shops are open and functioning in J&K.
Reference:
1. Valley returning to normalcy: Govt. Hindustan Times, 17th September 2019: https://epaper.hindustantimes.com/Home/ShareImage?Pictureid=04a89472.
Competing interests: No competing interests
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
Competing interests: No competing interests
Dear editor,
I would like to thank BMJ for highlighting the lack of healthcare to the people of Kashmir due to the current ongoing lockdown by India`s government.
I would like to emphasize that besides increasing shortage of drugs, ambulances and staff due to communication and transportation blockade, the Indian security forces have been known to use measures like pellet guns, kidnapping, sexual violence and human shields from local population, as has also been reported by the Office of the UN High Commission for Human Rights (OHCHR) (July 8th 2019). Decades of turmoil have taken a toll on all aspects of health in Kashmir, including mental well being with rise in incidence of depression, anxiety as well as suicides (1-3).
Being born and raised in Kashmir, and having lived there through the unrest of 1990s, I can attest to the impact on all aspects of life of a common Kashmiri, with mental health being a casualty.
I would also like to congratulate the author of this article, Ramani Atkuri, for standing with the truth.
Regards,
Seema A. Bhat, MD
References
1 Naik AR. Impact of conflict on mental health with special reference to Kashmir Valley. Int J Indian Psychol 2016;4:76
2 Médecins Sans Frontières (MSF), the University of Kashmir, Institute of Mental Health and Neurosciences (IMHANS), 2016. Muntazar: Kashmir Mental Health Survey Report; 2015.
3 Bhat RA, Khan SM. Mental health issues in Kashmir valley: An overview. Arch Ment Health 2018;19: 96-6
Competing interests: No competing interests
Dear author and editor
It is heartening for bmj to comment on the human catastrophe that is Kashmir. We need to bring to light these humanitarian issues with lack of access to information and health care created by military might and not by natural disaster.
Being from Kashmir and having trained in Kashmir I have first hand reports from Srinagar, the busy hospitals that would normally be overflowing with patients are deserted, people have very limited access to medications, and not having worked for 2 weeks, most people have to choose between food or medicines. This is a disaster created by the authoritarian nationalist government of India and not due to natural disaster, you don’t have to be a genius to understand that people are dying at home since they can’t reach the hospital, a simple glance at the situation is enough to indicate that.
I urge the authorities in Kashmir to lift the information blockade, communication blockade and travel restrictions before we have the blood of innocents on our hands.
I am sure there will be a backlash from some in the Indian community who call themselves civilized and still condone repression in the name of nationalism.
I commend you to do this public service and respect your views
Dr. Khalid Ashai MBBS, FACC
Interventional cardiology
Chairman div of cardiology
Univ of Maryland,
Capital regional health system
Cheverly, MD USA
Competing interests: No competing interests
Re: Kashmir communications blackout is putting patients at risk, doctors warn
Dear Editors,
On behalf of the British Kashmiri Medical Association (BKMA), we commend the BMJ on raising concerns about the health and humanitarian crisis in Kashmir due to continued communication blockade, since 5th August 2019. We, the British healthcare professionals of Kashmiri origin are directly affected by this ongoing conflict. There is no access to internet, mobile telephones, and there is an ongoing restriction on the movement of people. Patients needing dialysis, chemotherapy, emergency surgeries, and pregnant women are unable to get timely treatment due to unavailability of transport, ambulance services, shortage of medical staff, and dwindling supplies of life-saving medications1.
The lockdown has entered the third month and ground reports suggest that the situation to access to healthcare continues to worsen.2-4 Scheduled cancer surgeries are being cancelled and people have no means to call an ambulance.4 It has become extremely difficult for doctors to seek urgent advice, liaise with others, or refer to other specialties. Junior doctors have to physically travel between hospitals in hostile conditions to seek such advice while compromising their own safety. Due to lack of internet, clinicians have no access to clinical guidelines, evidence base, and insurance details of patients which makes the delivery of healthcare extremely difficult.
Nearly 8 million people caught up in this blockade are being denied the fundamental right to healthcare. Numerous reports in international media have alleged several deaths due to exacerbation of chronic illnesses which could have been prevented if people were able to access urgent medical care5. Estimates suggest 20% (1.6 million patients) of the population that suffers from a chronic disease is at risk of poor outcomes due to the current situation6. There are widespread reports of blindness and physical injury due to the use of pellet guns 7-8. In addition to the obvious physical element, the psychological scarring of the population is unimaginable.9-10
The preventable healthcare disaster and communication blockade in Kashmir is affecting day to day functioning of Kashmiri diaspora and many have reported symptoms of severe anxiety11. With the situation becoming grave without any respite for over nine weeks now, Kashmiris residing in the United Kingdom are struggling to make contact with their families and have little knowledge about their safety and wellbeing. There is no clarity on how long this blackout is going to continue. We are concerned that many Kashmiris living around the world could end up having acute mental health crises as a direct consequence of the current situation.
We finish with the hope that the global medical fraternity and global organizations seek immediate relief for the besieged population, stress on the international agencies to support local healthcare system in Kashmir and also send fact finding teams to review the Kashmir Medical Disaster.
Lastly, as Kashmiri doctors, directly affected by the ongoing situation, we would like to thank the editorial team of the BMJ for the timely news article.
Yours sincerely
Dr Farooq A Wandroo President BKMA
Dr Mudasir Firdosi Vice-President BKMA
Dr Afifa Qazi General Secretary BKMA
References:
1. BBC New. Inside Kashmir's lockdown: 'Even I will pick up a gun'. https://www.bbc.co.uk/news/world-asia-india-49294301
2. Samaan Lateef. Kashmir crisis: Hospitals turning patients away as doctors fear ‘impending tragedy’. https://www.independent.co.uk/news/world/asia/kashmir-crisis-hospital-vi...
3. R. Prasad. In a letter, doctors urge government to allow patients in Kashmir to access health care. https://www.thehindu.com/news/national/other-states/in-letter-in-bmj-doc...
4. Aakash Hassan. Kashmir Dispatch 11 | Valley Running Out of Medicines With No Fresh Supply Coming, Say Doctors. https://www.news18.com/news/india/kashmir-dispatch-11-valley-running-out...
5. 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.
6. World Health Organisation- Noncommunicable Diseases ( NCD) Country Profiles, 2018. https://www.who.int/nmh/countries/2018/ind_en.pdf?ua=1 Date accessed September 9, 2019
7. Muddasir Ali, Majid Maqbool. Lockdown hits access to healthcare in besieged Kashmir. https://www.thenewhumanitarian.org/news/2019/09/19/Kashmir-lockdown-heal...
8. Office of the United Nations High Commissioner for Human Rights. Update of the Situation of Human Rights in Indian-Administered Kashmir and Pakistan-Administered Kashmir from May 2018 to April 2019. https://www.ohchr.org/Documents/Countries/IN/KashmirUpdateReport_8July20...
9. de Jong K, Ford N, Kam Sv, et al. Conflict in the Indian Kashmir Valley I: exposure to violence. Confl Health. 2008;2:10. Published 2008 Oct 14. doi:10.1186/1752-1505-2-10
10. Kashmir: Violence and mental health. https://www.msf.org/kashmir-violence-and-mental-health Report14 December 2006. Accessed online dated: 09/20/2019.
11. A. Qazi, M. Firdosi, F. Jan, A. Majeed. Psychological burden of the Kashmir Conflict on Kashmiris living abroad: damage caused from a distance. EPA 2020 Secretariat
Competing interests: No competing interests