Amongst the bleakest in the history of Jammu and Kashmir (J&K), these past 12 months beginning with the revocation of Articles 370 and 35A on August 5, 2019 have witnessed unprecedented violations of the human rights to health and life.
Decades of oppression and humiliation of the people of J&K were escalated further through indefinite curfews, unconstitutional arrests and detainment, unprecedented military presence, and the clampdown on democratic and public institutions. The imposition of an indefinite lockdown – among the longest in J&K, as early reports by media and civil society (August to December 2019) flagged – impacted every dimension of life in Kashmir. People were deeply affected by the arrests and detentions, shelling and pellet injuries, economic distress, health problems, and breakdown of public services including education and health. Inevitably, the impact on people’s physical and psychological health and access to healthcare was severe.
Life-saving medicines were in short supply and stock-outs were evident. The lack of transport caused pregnant women to travel long distances on foot for delivery and created barriers for reaching the hospitals in time. Patients suffering from cancer, those requiring dialysis were unable to reach hospitals or access healthcare, and
patients discharged from hospitals were unable to return home due to lack of transport. Roadblocks and the communications shutdown had also affected healthcare providers and frontline health workers like ASHA workers, and prevented them from providing regular health care services due to restrictions as well as fears with regard to their safety.
Hospitals had to use ambulances to ferry hospital staff to and from their homes because private vehicles were not allowed in some areas. Doctors were stopped repeatedly at multiple barricades for identity checking and interrogated about the purpose of their travel, delaying them from reaching health facilities. People’s experiences of severe distress, trauma and high levels of psychosocial stress were seen to worsen.
Despite narratives of “normalcy” that began gradually emerging, a visit to Kashmir in February 2020 by a group of activists and academics witnessed a far-removed reality of widespread experiences of distress, fear, anger and violations. Interactions with people in Kashmir during the visit exposed the facade of “normalcy”, reiterating the huge daily challenges including access to health services, particularly due to the continued restrictions on movement, curfews, absence of transport and communications, as well as the fear of violence.
The lockdown had precipitated a public health crisis – evident from, for instance, the significant increase in numbers of stillbirths, foetal distress and severe postpartum anaemia because pregnant women could not come for regular check-ups. Moreover, the exponential rise in mental health problems reported since August 2019 provided more clues about the effects.
Further, the shutdown of internet, landlines and mobile phones disabled the functioning of health systems and programmes for the benefit of people, especially for the poorest. The narratives of daily humiliation and distress due to the sway of absolute power, control and disruption of all aspects of their lives, was a constant refrain.
The COVID-19 pandemic and the health situation in J&K
By the end of March 2020, the feigned rhetoric of normalcy was further shattered by the imposition of a sudden and total lockdown by the Central government in all states as a response to the COVID-19 pandemic. While most parts of the country experienced this for the first time, for J&K, the pandemic lockdown deepened the implications of the pre-existing lockdown since August 2019.
The response to this unprecedented global health catastrophe of COVID-19 has been an authoritarian lockdown implemented by an aggressive state, creating an severe humanitarian crisis. For the people of J&K, this has further exacerbated the trauma and impact of the ongoing clampdown as well as the fractures in the health system, and its consequences for the health and lives of the people. The COVID-19 lockdown has provided legitimacy for further repression under the garb of a public health necessity.
The lockdown not only continues to limit movement but also suppress the ground realities, including conditions of work of healthcare providers and barriers to access healthcare in the pandemic. For instance, on April 1, 2020, the Directorate of Health Services in Kashmir issued a circular threatening ‘strict action’ against government servants who criticise the government’s efforts to combat the pandemic on social media or in the press. This was to challenge the prerogative of healthcare providers to flag concerns about the unavailability of personal protective equipment (PPE) during the pandemic, the lack of safe working conditions or the absence of response by relevant authorities.
Whether the senior cardiologist in Srinagar who was detained and beaten up by the police and later lodged in a police station in Srinagar, the three gynaecologists of the Lal Dedh Hospital who alleged harassment by the police deployed outside the hospital, or the ambulance driver who was beaten up by police personnel in Pulwama district while transporting patients, the harassment and violence against healthcare providers preventing them from carrying out their healthcare duties have raised serious concerns.
As has been seen in other parts of the country, the pandemic has exposed the inadequacy of the public health infrastructure and human resources even in J&K. Given the non-availability of primary health care, patients develop secondary symptoms and need advanced health care including critical care involving ICUs, ventilators and oxygen supply. With merely two multi-specialty hospitals in the Kashmir Valley, patients are deprived of timely treatment.
Doctors have also called for increased home quarantine and for the home quarantining of asymptomatic patients to reduce the burden on the healthcare system. ASHA workers, who were engaged in contact tracing and door-to-door surveys, also reported the non-availability of surgical masks and sanitisers.
Although the J&K high court, in April 2020, sought a report from the Department of Health and Medical Education on the availability of safety equipment for healthcare professionals and on the provision of care for the families of healthcare and government employees or officials engaged in the fight against COVID-19, concerns about safety of healthcare providers has been most visible in the context of the pandemic located in the larger context of surveillance, violence and control.
The prolonged blockade of 4G internet services is one such example. With only low-speed 2G services available, especially in areas of South Kashmir, the functioning of doctors and patients accessing healthcare have been severely affected. The absence of fast-speed internet can affect the health of the entire community in general and particularly in a pandemic context, where immediate communication and widespread outreach are critical public health imperatives.
Women in J&K continue to experience trauma because of their inability to access timely health services for delivery due to lack of transport, stigmatisation and delays and denial of maternal healthcare, which have resulted in morbidities or even in the death of women. There were reports about a full-term pregnant woman who was denied services, allegedly on the pretext of waiting for her COVID-19 test results.
In July 2020, a PIL was filed in the J&K high court, on the basis of which the court directed the health authorities of all districts to maintain separate maternity hospitals for pregnant women and children, equipped with all facilities and trained staff. This ruling mandates a magisterial enquiry into all incidents of medical negligence resulting in the death of a child or a pregnant woman, and compensation to be deducted from the salary of the employees guilty of medical negligence.
Furthermore, the anxiety and distress of day-to-day survival, financial uncertainty, job loss, isolation, fear of illness or violence, grief, inability to access health services, inability to pay medical bills, lack of communication with relatives outside Kashmir, and many other psychological effects are increasingly evident.
Undoubtedly, there is an urgent need to address these issues through immediate as well as sustained strategies, given their potential social and economic impact. However, despite the overwhelming current focus on the COVID-19 pandemic and its consequences, the narrative in Kashmir cannot be isolated from the more deep-seated, fundamental factors that determine the health and lives of the people here – clampdown and violence that have created constant fear and humiliation, surveillance and control of every aspect of their lives.
The “unlock” process in J&K limited merely to the pandemic would be a travesty of justice, public health and human rights. This public health crisis will eventually pass, but is likely to leave a trail of social and economic devastation. In Kashmir, this is linked to the violation of people’s health and their rights as citizens.
The author acknowledges Roshmi Goswami, Kalpana Kannabiran, Navsharan Singh and Pamela Philipose, who were a part of the five-member team that visited Kashmir during February-March 2020. A few parts of this essay has drawn from the report “Interrogating the ‘Normal: Report of a Visit to the Valley”.
Special thanks to Deepa V. and Ranjan De for their valuable inputs, and Abhiti Gupta for research support.
Sarojini Nadimpally is a public health practitioner and National Co-Convenor of Jan Swasthya Abhiyan.