New Delhi: Expressing concern about the state of public health and healthcare in Jammu and Kashmir, a group of doctors have urged Indian professional bodies to coordinate efforts with the government and ensure that there are no gaps in service provision.
The healthcare situation in the region, under a lockdown ever since its special status was revoked on August 5, came into focus this week after The Lancet published an editorial on the issue. The British journal said it was concerned about the health and safety of the Kashmiris, to which the Indian Medical Association retorted that the former had no “locus standi” on the issue.
The group of doctors who issued the statement said it was unfortunate that the IMA reacted in this manner, calling for it to instead put together a team of doctors, paramedics “to address any possible health crisis and make recommendations for preventive, curative and rehabilitative measures”.
The statement calls for a focus on healthcare aspects such as immunisation, preventing an outbreak of diseases, maternity ward services, transportation facilities among others. The doctors also touched upon the use of pellet guns by security personnel. Because the guns can cause permanent damage, the statement said “use of pellet guns by the army against civilians has to be completely stopped”.
The full statement has been reproduced below.
Statement on public health and health care in Jammu and Kashmir
We are a group of doctors concerned about the public health and healthcare situation in Jammu and Kashmir. The Government of India has cut off communication from the 4th of August 2019 including internet, landlines, mobiles, cable television etc. People have found it difficult to access basic health care and emergency services. We request that Indian professional bodies of Medicine, Surgery, Gynaecology & Obstetrics, Pediatrics, Critical Care, Chest medicine, HIV, Tuberculosis, Psychiatry etc. co-ordinate with the government to put together teams of doctors to understand and address current issues in Jammu and Kashmir to ensure that there are no gaps in service provision. It is unfortunate that the Indian Medical Association (IMA) has only put out a statement to critique the Lancet article instead of putting together a team of doctors, paramedics etc. to address any possible health crisis and make recommendations for preventive, curative and rehabilitative measures.
Public health concerns in Kashmir
In the current situation where mobility is restricted and communication is blocked, various public health issues are likely to arise. These include
In most situations where services are disrupted, preventive services like immunization get affected and outbreaks of vaccine preventable diseases are known to occur. Vaccines, cold storage systems and more importantly communication systems, are crucial. Children in these circumstances, who may also be vulnerable to other infections and malnutrition, require immunization against potentially life threatening illnesses such as measles, rubella, tuberculosis, polio, diphtheria etc. Mechanism have to be put into place for uninterrupted immunization, ensuring that vulnerable children, pregnant women and those in hard to access areas are not left behind.
Many medical conditions such as hypertension, diabetes, thyroid deficiency, cardiac conditions, renal and liver conditions etc. require patients to have medications on a continuous basis, with fluctuations in dose and frequency leading to life threatening consequences.
As experts repeatedly stress, diseases such as HIV and tuberculosis require proper treatment and follow up. Discontinuing or irregular supply of these drugs lead to real risk of multi-drug resistance, not only at the individual level but even at the level of the population, necessitating stronger drugs with more side effects. Most of these diseases also require regular follow up to rule out drug side effect and complications.
Facilities for mental healthcare and counseling have to be made available, keeping in mind that mental health has already been found to be fragile because of the current conflict situation. Mental healthcare professionals, keeping with the learnings from other countries facing man-made or natural disasters, have to be sensitive to the issue, without undue dependence on medicines and medicalization. Mobile medical units with adequately trained staff and drugs have to be made available for hard to reach areas.
The Federation of Obstetric and Gynaecological Societies of India (FOGSI) is well aware that obstetric emergencies can be rapidly fatal requiring urgent intervention and follow up. Good communication facilities are required to ensure that both mother and neonate have access to blood bank, ICU and neonatal facilities. Women may deliver at home or be forced to walk long distances to access health facilities. Women who develop pregnancy related complications such as obstructed labour, fetal distress, antepartum hemorrhage, premature labour, ectopic pregnancies, twins etc. often have to be carried to health facilities by relatives in the absence of functioning transport and healthcare. This increases the risk of morbidity and mortality in both mother and baby.
Referral and transport
In the absence of functional ambulance systems, people are often forced to take private vehicles which are often treated with suspicion. Unless there is a functional ambulance system, there will be loss of life and delayed access to treatment can lead to disability and morbidity. Even those who have to access healthcare on an emergency basis are stopped at the check-posts and some are even arbitrarily denied access as decided by the army personnel. Seeking medical care seems to be a life threatening activity by itself. This is not how healthcare should operate in any state. All levels of healthcare personnel need free
access to the hospitals to allow for proper functioning.
Materials, equipment and diagnostics for hospitals
To function effectively, hospitals require a steady supply of materials and drugs, which if affected may compromise care and may result in patients being turned away, inspite of reaching the healthcare facility with difficulty. In the instance that equipment malfunction, there should be systems in place to allow for immediate repairs or replacements. Adequate diagnostic facilities such as CT, MRI, laboratories etc. will ensure that patients receive correct and appropriate diagnosis and treatment.
It is well known that in situations as existing now in Jammu and Kashmir, children often become vulnerable to malnutrition. Additional measures have to be put in place to ensure that nutrition of children does not suffer. Many residents are unable to access basic foodstuffs and gas for cooking. These can have long term and/or fatal consequences in those with underlying medical illnesses such as diabetes, liver and kidney disease. Pregnant and lactating women without adequate nutrition stand to have a higher risk of maternal morbidity and mortality. The adverse effect on the newborn of maternal undernutrition is likely to be high.
The elderly are also prone to nutritional deficiencies. The government needs to ensure adequate supplies of milk, meat, poultry, vegetables, fruits, cereals, pulses, oils etc. Drinking water quality can be compromised when these kind of blockades take place. This further leads to gastrointestinal disease which aggravates malnutrition. The government has to ensure proper potable water.
When people are placed in situations of uncertainty and unrest, even fragile existing public health systems break down. Systems need to be in place to handle an outbreak or an epidemic which has the potential to spread rapidly and place vulnerable groups like pregnant women, children, the elderly and immunocompromised at particular risk. Gastrointestinal diseases like hepatitis and cholera can occur when public health systems are compromised. Not anticipating these and exposing communities to the risk of such outbreaks is a violation of natural duties of the government.
Pellet gun injuries
The use of pellet guns on unarmed civilians and sometimes even on children can cause permanent disability, is of grave concern and is against basic human rights. In the interest of public health, we call upon these professional bodies to demand that the use of pellet guns by the army against civilians has to be completely stopped. International groups such as Doctors against Torture have been vocal against capital punishment and government sponsored violence. It is unfortunate that professional groups in India have not been very vocal against pellet guns being used against citizens.
The rights of citizens of Jammu and Kashmir to healthcare and right to life is currently being compromised. The professional health bodies of India should affirm basic rights of the citizens of Jammu and Kashmir, to communication and access to all levels of primary, secondary or tertiary healthcare, both private and government.
Professional bodies should demand that the communication blockade in Jammu and Kashmir has to be urgently and completely removed. Healthcare personnel, drugs, lab reagents, surgical material, equipment etc. required for proper function of all levels of healthcare should be ensured. People should not be fearful for life just to access healthcare. Fully equipped and staffed mobile medical units should be made available at frequent intervals particularly covering hard to reach areas.
The Indian government should commit itself of the responsibility of healthcare and public health for the lakhs of citizens of Jammu and Kashmir. Right to healthcare of the citizens should be prioritized by professional bodies and health system over and above everything else, in keeping with the principles of medical ethics.
1. Dr. Amar Jesani, Independent consultant and researcher
2. Dr. Anoob Razak, physician
3. Dr. B.Ekbal, Kerala Sastra Sahithya Parishad
4. Dr. Chand Ohri, Medical doctor and academician
5. Dr David Goldberg, Retired Psychiatrist, St George’s Hospital, London
6. Dr. Haneen Bég, Kumudini Womens Medical College and Hospital, Bangladesh.
7. Dr. Imrana Qadeer, Distinguished Professor, Council for Social Development, New Delhi
8. Dr. Jammi N Rao MD FRCP, Visiting Professor in Public Health, University of Staffordshire
9. Dr. Jose Kunnel Paul, Neurologist, Trivandrum
10. Dr Kaaren Mathias, Public health physician, Uttarakhand
11. Dr. Mani Kalliath, Community health professsional, Karnataka
12. Dr. Mohan Rao, former professor, Centre of Social Medicine and Community Health, JNU, New Delhi.
13. Dr. Monica Thomas, Neurologist, New Delhi
14. Dr. Nafis Faizi, People’s Health Movement.
15. Dr. Prabir KC, Independent Public Health Physician, Kolkata
16. Dr. Shyama Narang, Obstetrician and Gynaecologist, Karnataka
17. Dr Sushrut Jadhav, Cultural Psychiatrist and Medical Anthropologist, University College London
18. Dr. Sylvia Karpagam, Public health doctor and researcher, Karnataka
19. Dr. Veena Shatrugna, Retired deputy director, National Institute of Nutrition, Hyderabad