Sometime in the summer of 2010, a decision was taking to add a wing to Srinagar’s SMHS Hospital, formally known as the Shri Maharaja Hari Singh Hospital. Spread over 10 acres of green, it is one of the biggest government hospitals in the heart of the city and a city doctor had just managed to convince the powers that be of the need to integrate mental health services within a general hospital setting. He wanted to take the stigma away from seeking care of mental health and drug abuse, both ever increasing in a city coping with conflict and human rights abuse. The lime-coloured building got a new additional wing in white.
Then one day, the city doctor decided to stop by to have a look at the four-storey white structure taking shape. He walked in to each floor, inspected the wards and then the toilets — still under construction — to realise there were just urinals. When he asked the architect why there wasn’t a facility for women, the architect asked with a confused look, “But you said this will be a de-addiction centre. Female bhi aayengi yahan ? (Will women come too?)” The question posed by the architect reflected the concern of the society struggling to acknowledge the incidence of drug abuse, considered haram in Islam.
Addiction and stigma
Here in Srinagar, you cannot have a conversation about mental health and drug abuse without being told, in every conversation, about the work done by Dr. Arshid Hussain. The 40-year-old is the kind of person who can fill a reporter’s notebook in the first 20 minutes of the meeting, leaving you reeling under the onslaught of information about the magnitude of drug abuse and mental health plaguing Kashmiri youth.
As a medical student interested in mental health, Dr. Hussain was overwhelmed by the sheer volume of patients coming in seeking de-addiction services. In a freewheeling conversation in his office, Dr. Hussain speaks about his first brush with female drug-using patients. “It was the graveyard shift and I was sleeping at my desk. I suddenly felt someone lift my hand, which was on top of a medicine box,” he says over tea, juggling three conversations at the same time — with a staff member who was done for the day, a patient wanting to assure him that some politician will bear his expenses, and a journalist who wanted his undivided attention. “The patient had been admitted after seizures. She was stealing pentothal injections from the pharmacy. From right under my nose.” Pentothal is an opioid analgesic, a common painkiller.
Doctors in Srinagar feel a majority of the women who use drugs in Kashmir tend to get addicted to painkillers. “She was the first patient I scientifically detoxed. It took five days,” says Dr. Hussain. Soon, he saw another girl, a classmate, also a case of medicinal opioid abuse. The patients kept coming — sometimes he knew the person from school, sometimes they were friends he played cricket with, sometimes he was related to the person. “It was everywhere I looked. And nearly 90% of female patients were not reaching the hospitals due to fear of stigma and shame,” he says.
A 2012 study by M. Mudasir Naqshbandi, a School of Social Work student of Indira Gandhi National Open University, titled ‘Drug addiction and youth of Kashmir’ revealed a staggering data that 75% women in the age group of 26 to 30 knew what ‘gateway drugs’ are. Gateway drugs, in common medical parlance, are substances that supposedly lead the user on to more addictive or dangerous drugs. Cannabis is considered a gateway drug. The percentage of men in the corresponding age group with the same information was just 22.22%. The study concluded that “overall female respondents from all age groups have better knowledge about gateway drugs than that of male respondents”.
The data sample was admittedly small, collected as it was from 250 respondents in Srinagar, Anantnag, Baramullah, Pulwama and Budgam, but with few community studies and lack of reliable data, the findings are indicative of the unacknowledged problem facing Kashmiri society. To the last question, “Do girls also take drugs?”, 70% of the women surveyed and 50% of the men said yes. The author concluded his study reiterating the “shocking” finding that “72.36% male and 57.14% female respondents revealed that girls also take drugs; so far hardly any study had been done about female and their addictive approach (sic).”
The girl with the fake name
For close to two years, doctors at SMHS have been treating a girl for Tramadol addiction, another painkiller. No one in the hospital knows her real name. They call her Nida.
To get her to come to the hospital for treatment was the kind of health outreach that makes people think of medicine as a truly noble profession. Now in its seventh year, the SMHS Hospital’s de-addiction centre still does not carry a board announcing what it is. A simple board hangs outside the two-storey structure saying, “SMHS Community Centre”.
The ground floor has a mental health OPD (Out Patient Department), the floor above has wards for men and women who are admitted on account of either mental health problems or drug use. The top floor has a rehabilitation centre, with a table tennis table lying unused, an eight-seater dining table with a television across the room. “It is for when the patient stays for long. These things help normalise the days spent in hospital,” says Mir Mohsin Rasool, a medical officer at the hospital.
I ask if women staying at the hospital for de-addiction ended up at the dining table, watching television with the rest of the patients. Dr. Rasool smiles and shakes his head. The next stop was the female ward. There was one patient, under treatment for depression. No drug abuse cases.
In a room with three doctors, a male patient, one must weigh the words carefully before asking how the hospital claims to be treating female patients, when there are none to be found. Immediately, the air tenses up, the doctors exchange glances and Yasir Hasan, consultant at the SMHS psychiatry department, says there is a girl, they don’t know her real name though. “She’s agreed to talk to you, on the phone.”
The doctors tell me that Nida’s brother, also a user, was their patient. During his counselling sessions, they found out that his sister was abusing painkillers. It took three more sessions to convince him to bring her in. “She eventually came as her brother’s attendant and met us. It then took a few more counselling sessions with her to convince her to take the opioid substitution therapy (OST). Eventually, she agreed but told us she won’t give her original name,” says Dr. Hasan.
An anti-drug use campaign in which schoolchildren took part, in Srinagar in 2007.
It was November 2015 when Nida started seeking care as someone who accompanies her brother to the hospital, but she is not the only patient with an assumed identity. The SMHS Hospital treated nine female patients between April 2016 and March 2017 — each had a unique complication that had to be dealt with discretion by the hospital administration.
Nida was introduced to Tramadol injection because of a painful kidney stone episode. Before she knew it, she was shooting six-seven injections every day and still writhing in pain.
“Initially my family thought it is just a painkiller. Then we realised there was a bigger problem.”
‘Why did you give them a fake name?’
“I did not trust the doctors.”
‘Then why did you come in?’
“I heard nice things about them. My brother assured me ki baat bahar nahin jayegi (word won’t go out). But the doctors still had to earn my trust… I am not scared to come here anymore. I come over, collect my medicines and my brother’s but Kashmiri society is different.”
‘How?’
“I am very bold. But these things can ruin your future in Kashmir. Chehre pe daag ho toh future bigad jata hai yahan (A blemish on your face can can ruin your future).”
Eventually, the conversation turned to the pervasive gender bias in accessing health care and Nida said, “I pray for the women using substances and not being able to get care. I know so many women who are suffering alone. Because they are scared, for themselves, their families and most of all, from eternal damnation for this being haram.”
The epidemic of pain
Besides Nida, the doctors are seeing a teenage student who is addicted to cannabis. “That was a classic case of peer pressure. The patient came for a few sessions and then she stopped coming,” says Dr. Yasir.
From conversations with doctors, police officers and patients, it emerges that cannabis is a popular mood-altering substance being abused by Kashmiri youth thanks to the copious amounts being grown locally in villages in Anantnag and Pulwama districts; other favourites include solvents such as fluids, inhalants and nail polish. Women, however, tend to have iatrogenic addiction — drug dependency due to a medical treatment, usually of drugs prescribed to relieve pain.
Data regarding drug abuse among women in Kashmir are scarce. The most detailed study done so far was way back in 2008 when a United Nations International Drug Control Programme survey found that there are up to 70,000 drug addicts in Kashmir, out of which 4,000 were women. The survey also revealed that nearly 70% of the student community in Kashmir abuses drugs, including 26% of the female students.
At SMHS Hospital, 291 patients were treated for drug addiction in the hospital’s OPD in 2014; 119 were in-patients. The next year, numbers rose to 490 in the OPD & 226 in the in-patient department (IPD). In 2016, 535 patients came to the OPD and 224 in the IPD, and this year has already seen 584 OPD patients and 191 admissions for opioid substitution therapy. Currently, 70 are under treatment and nine of these are women.
There are currently two operating de-addiction centres in Srinagar — one is run by the Police Control Room at Batamaloo and the other is at SMHS Hospital. The police centre was created as an initiative to bridge the mistrust between the community and the police in 2008. Muzaffar Khan, in-charge of the PCR De-addiction Centre, likes telling the story as to how this centre came about. In 2008, the police got repeated calls from Anantnag about someone desecrating the Koran to stoke communal tensions. “One day we caught him. He was not trying to create any communal tension. He was on drugs. We decided to hold a three-day camp in the district and realised the magnitude of the problem,” says Dr. Khan. “We realised that the society was in deep denial about level of drug addition among young Kashmiris. We decided to set up a centre with Dr. [Arshid] Hussain as a consultant with us,” he adds. The centre, however, refused to share details of female patients currently seeking treatment at the centre.
According to data released by the State Home Department, between October 2014- 2016, 3,864 patients were treated for de-addiction in Jammu, Srinagar, Anantnag and Baramulla. The highest number of cases came from Srinagar (2,260), followed by Jammu (610), Anantnag (603) and Baramulla (391) districts.
The statistics — as seen in police records and hospitals OPDs — don’t tell the full story of drug abuse, Dr. Hussain adds. After three days of meetings, as the conversations started winding up, he spoke about a teenage patient he could not save. The patient was abusing drugs and his parents would routinely call the doctor. The boy eventually died from drug overdose. At the funeral, the parents’ grief was measured — everyone had been told that the teenage boy had a cardiac arrest and could not be saved. As the doctor began to leave, the parents asked him one more time, “How did he die?” Dr. Hussain assured them it was a cardiac arrest and left. “Dying from an OD (overdose) can get you eternal damnation while a cardiac arrest can comfort the grieving parents that their son is in Jannat (heaven),” is Dr. Hussain’s parting shot.
