22nd August 2019

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
Immunisation
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.
Chronic diseases
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.
Obstetric emergencies
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.
Nutrition
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.
Outbreak prevention
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.
Conclusion
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.
Signed
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. Srinivas Kakkilaya, Consultant Physician, Mangaluru.
17. Dr. Shyama Narang, Obstetrician and Gynaecologist, Karnataka
18. Dr Sushrut Jadhav, Cultural Psychiatrist and Medical Anthropologist, University
College London
19. Dr. Sylvia Karpagam, Public health doctor and researcher, Karnataka
20. Dr. Veena Shatrugna, Retired deputy director, National Institute of Nutrition,
Hyderabad