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.

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.

Escalating numbers

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 Organisation 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.

Dwindling support

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. Peer groups offer a lifeline, and their collective attempts to fight the insecurity manifests itself in increased risk-taking behaviour. On the other side are parents, who want to hide their helplessness from their children.

“Here in Kashmir, the modes of communication and resolving age-related issues have broken down. How do you expect it not to be a challenge for a parent who has not lived normally for even a second of his life for the last 20 years?” asks Dr. Margoob.

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