Kashmir Heaven on earth

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					     Medecins Sans Frontieres Holland




    Kashmir. Heaven on earth?
Psychological consequences of a chronic emergency


                  Kaz De Jong



                     2000
                                       Abstract

This report summarises the findings of a short visit by the MSF Holland team to the Kashmir
valley in September 2000. The aim of the visit was to conduct a preliminary assessment of the
psychosocial problems in this area and of the resources available for dealing with these
problems. A survey of existing health systems and structures was undertaken, as well as the
various projects that are run by local organisations. The report also reviews the psychiatric
literature and information available on mental health problems such as anxiety, depression,
post-traumatic stress disorder, suicide and substance abuse in the region. Individual, community
and cultural coping strategies are discussed. The report concludes with a discussion of
suggested psychosocial interventions that could meet the mental health needs caused by the
chronic violence in the region and identifies some of the gaps and unanswered questions in the
assessment.
                                         Contents

Introduction                                          6

Health systems and structures                         8
       Mental health services                         9
       Volunteer Health Association                  10
           Background                                10
           Programs                                  10
       Other (national) organisations                11
           Psychological Foundations                 11
           Village system                            11

Scientific data on mental health needs               11
       Anxiety disorders                             13
       Depression                                    13
       Post Traumatic Stress Disorder (PTSD).        13
       Suicide                                       14
       Substance abuse                               14

Stressors and needs                                  14
      Expression                                     15

Coping and self repair/help mechanisms               16
      Individual                                     17
      Community                                      17
      Cultural/traditional                           17
      Acceptance of counselling                      18

Suggested interventions as defined in the workshop   18

Gaps                                                 21

Conclusions                                          23

Recommendations                                      26

Notes                                                31

Appendices

Appendix 1: Additional literature                    32
Kashmir. Heaven on earth?




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                                            Introduction
Kashmir has been regarded by many as heaven on earth. Its beauty and hospitable population is legendary.
Unfortunately beauty is often not undisputed. Both Pakistan and China have occupied large parts of the
former independent state forcing it to give up its independence and become part of India. Over the past
decades Kashmir became associated with violence. Three wars between Pakistan and India have resulted in a
stalemate between the two nuclear parties. The last ten years militant groups of Muslim fighters falsely claim
to represent the wishes of the Kashmir population through violence. Most Kashmiris have but one wish:
peace. For further information and background on the situation of Kashmir I like to refer to the MSF
(Medecins Sans Frontieres) country policy India and trip report of earlier missions.

This report describes the findings of a short visit of one week organized for MSF (Medecins Sans Frontieres)
by the Voluntary Health Association (VHA) in the Kashmir valley. The VHA (Voluntary Health
Association) is the Kashmir partner of MSF that will implement a physical health and income generating
project (training of Village Health Workers on mother-child care, identification of pregnant women, passing
on health messages and women self help groups) in two areas of Kashmir.

MSF suggested to organize an assessment on psychosocial problems. Both VHA (Voluntary Health
Association) and the mental health specialists of Srinigar were in favor of a visit. The VHA arranged most
contacts and facilitated logistics. Their involvement has been instrumental in the success of this mission.

At the onset of our mission the team introduced themselves to relevant authorities (Division Commissioner,
(previous) Minister of Health). They displayed high interested and supported the joint VHA and MSF
initiative.

During the visit project field visits of villages in the Budgam and Vakharman areas were completed. In
addition a two day workshop on mental health in the Kashmir valley was arranged. A mixed group of twelve
male and female representatives (mental health authorities, specialists, educational representatives and 4
VHW's (village health workers) from the VHA project ) discussed the psychosocial needs, ways of
expressing distress, existing positive and negative coping mechanisms. After their conclusion that needs are
high and the expressed desire to address them, time was spent on the description of a possible project (project
purpose, activities and a possible time frame). The attitude of the conductors of the workshop was focused on
listening, allowing the participants to define themselves what they wanted. Due to the active involvement and
the mixed composition of the participants of the workshop, we are confident to have avoided culture pitfalls
and refrained from imposing our ideas on the people of Kashmir. We like to stress that this attitude should be
continued in a possible future project. It will avoid doing harm and is eventually the sole way of creating a
support health service (physical and psychosocial) that addresses the problems of those in need.

Often explo or assessments missions are a unilateral process. We have tried also to give something in return
during our visit. A seminar of one afternoon has been organized for the local medical doctors to increase their
knowledge on violence related psychosocial problems. A similar seminar for field health workers was
canceled due to circumstances beyond our power.

The findings of the explo mission as described in this report should not be regarded as final. A week in such
a difficult and complex area is not sufficient. Much still needs to be learned. Fortunately the mental health
specialists are already surveying the problem of mental health and violence related psychosocial problems,
for various years. The outcomes are described in various publications and do clearly indicate high
psychosocial needs expressed through high rates of depression, anxiety disorder, suicide, increase of
substance abuse and prevalence of Post Traumatic Stress Disorder (PTSD). In addition our observations, the
outcomes of the workshop and focus group discussion have made us conclude that the physical health
support should be extended with activities to improve the psychosocial well being. A project should aim at
providing psychosocial support to people at community level. Helping them to cope with their daily (violent)
reality in a better way. Given the complex situation, difficult working circumstances and our basic
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understanding of the culture the project proposal should be modest and restricted to a pilot area.

The team shared the outcomes, the conclusion and features of a possible program with the Division
Commissioner who invited MSF to support VHA in the implementation of the psychosocial component its
program.




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                             Health systems and structures
The health system is organized as elsewhere in India. A sub-center, coordinated by Family Welfare, (serving
max. 500 -1.500 persons) monitors ante and post natal care, provides vaccinations and health messages. It is
staffed by 1 multi purpose worker. The public health care center (PHC), serving approx. 5.000 persons, is
staffed by a medical doctor, lab-technician, a pharmacist and an all round worker. On this level regular OPD
(outpatient department ) activities are available, referrals are made and a final responsibility for
immunization is assumed. Attached to the PHC (public health center) are the Block Extension Services.
These are staffed by block extension educators and male health assistants. The sub-district hospital caters for
approx. 30 - 40.000 persons and has an in-patient department of 30 beds, a modest OT (occupational therapy)
and specialist facilities, managed by a block medical officer. District hospitals cater health services to a
population between 500- 700.000 and have specialist services available. It is managed by the Chief Medical
Officer. The last level of healthcare is the provincial or division hospital, which is connected to the
government medical college and offers extended specialist services as well as education and training of
doctors and specialists.

The system is largely dysfunctional. The public health services do run at a basic level. A lack of qualified
health staff both on general practice and specialist level, is reported by all health authorities. The Srinigar
medical college had over the past 10 years two graduation sessions for medical doctors. The few graduation
sessions resulted in a shortage of young medical staff. The older medical doctors have left the public health
system to start private practices.

The lack of qualified doctors is very obvious in the rural areas. Due to the violence, the difficult working and
living conditions no medical doctor in public services likes to work there. On community level people
depend mainly on private medical services for which they need to travel long distances (often finding out the
doctor is not there). The drugs that are prescribed are expensive.

However, the ineffective health care is not only due to the lack of services. High levels of somatisation
further cause a towering strain on the staff. The functional complaints often result in unnecessary and
expensive follow-up procedures (both in the public and private system). To compensate its large absence in
the field health camps are organized. During these events the population can make appointments with a
selection of specialists to have a check-up, receive a diagnosis and prescription.

The majority of the population can not afford the private system and neglects its medical condition. This
results at best in unnecessary suffering and at worst in a late hospital visit. The tertiary level (hospital and
specialized facilities) are overburdened with patients that should have received medical treatment much
earlier.

                                       Mental health services
Mental health staff is scarce. The state of Jammu/Kashmir (population 8 million, of which half live in the
Kashmir valley) only has 8 psychiatrists in public service and no clinical psychologists. All of them heavily
overburdened and exhausted. To their own dissent they have reduced their services to handing out drugs. The
absence of services on primary and secondary level do not only cause a heavy strain on the tertiary level.
Many clients that are seen by the psychiatrists have developed serious complaints and disorders because the
early warning and support system is absent. All psychiatrists who are well trained and updated on modern
psychiatry, express a deep frustration of the unnecessary suffering. They suggested us in the workshop to
strengthen the first line of intervention through general counseling and early referral. In addition they also
proposed to organize a mobile clinic to master emergency situations. Through scientific publications they
have tried in the past to raise awareness for this approach.

A visit to the psychiatric hospital was not possible. However, during our stay the newspapers did report
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Kashmir. Heaven on earth?



extensively on the dire conditions patients are surviving. The building is largely destroyed by a fire.

                                Volunteer Health Association
Background
The VHA has branches all over India. They work in 24 states implementing community based health
programs. They are funded by both government and international organizations (development) and generate
their own funding. Although there is a close cooperation with the state government it is an independent,
critical organization. The Headquarters has extensive knowledge and provides trained specialist services on
request to the branch organizations. The young Jammu/Kashmir branch is able to organize projects with the
specialist and training back-up from of the Headquarters. The VHA in Jammu & and Kashmir is recently
founded. When MSF visited the Kashmir valley (November 1999) they had one project in Chadura. During
the visit it was suggested to start another one in Wakharman block together with MSF. During this first visit
high psychosocial needs have been expressed. MSF offered support to address this topic.

A proposal to offer project support to the VHA has been submitted in April 2000. It included the provision of
basic outpatient health services, immunization (utilizing government facilities), ante-natal care and a
psychosocial component. The program is to be implement through VHA, MSF provides finance, monitoring
and evaluation input. The target population is a remote area of 5 villages with a population of each 3000.
Prior to the start of the project a baseline health survey has to be executed. It is suggested to include basic
psychosocial questions. The proposal is currently under discussion by the MT (management team), pending
the time needed for decision the VHA is allowed to spend a certain amount of money.

Programs
1. Chadura Project.

The five villages each have 2 Village Health Workers (VHW) and 20 Traditional Birth Attendants (TBA) for
the area, totaling to a staff of 33. The VHW's (village health workers) are trained to distribute health
messages, identify pregnant women and provide Folic Acid to them. The TBA's (traditional birth attendants)
do deliveries and provide basic gynecological support. The staff has weekly meetings in which they discuss
ongoing issues. In the future they will receive training on basic health (managing coughs colds, skins
diseases and diarrhea) and reproductive health. The VHW's and TBA's (traditional birth attendants) receive a
renumeration from the VHA. The group is very motivated and expressed a high interest in learning more on
psychosocial needs (see also the paragraph on 'Acceptance of counseling').

The income generation project organizes knitting and tailoring for women. The groups are arranged as
self-help groups (SHG) that finance themselves through monthly contributions of its members (30 rupees
(1$= 43 rupees)). The money is put on the bank and those that need money for a new income generating
activity can have a loan with permission of the whole SHG (self-help groups). This principle of 'Green
Banking' has been successful in other parts of India. The teacher that gives the skill training is paid by the
VHA. The income generation project is an excellent addition to a possible psychosocial project. It is our
perception that this well established project and motivated people provides a good basis for a psychosocial
pilot project.

2. Wakharman project.

The population (Shia -religious background) is in general lower developed then the population in the first
project. Women have a low status and generally do not receive education. The development of this project
depends on MSF funding. Four health workers are selected and two self-help groups of 30 people are
organized (knitting, tailoring). A complication factor is that MSF initially aimed its psychosocial activities in

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this area. Whereas our visit does suggest to start the psychosocial activities in the Chadura block.

3. Ophthalmology.

The high needs for ophthalmology services has been acknowledge and an eye camp was organized in the
Wakharman project.

                                Other (national) organisations
Psychological Foundations
This is a small organization of women clinical psychologists that work as a peer support group. To promote
clinical psychology they distribute a journal and organize every 4-th Monday of the month. They have
extensive training and varied clinical experience. They are willing to support MSF in establishing its network
and to give training or clinical supervision. However, we suggested to do in addition to do more networking
to identify training and supervision resources.

Village system
Every village has a village committee. Mostly consisting of elderly males. The village committee needs to
approve the new activities first. When approval is granted an implementing committee is assigned. Due to the
security situation many of these village committees are forbidden or discouraged. Its dysfunction has serious
consequences for the community. The (morale) leadership is gone, new initiatives are not supported and the
stimulation from this group evaporated.

Traditionally every village has its own cultural folk group (Band Pathre). The group is used to spread
messages, mock situations and tell stories. This popular medium is used to distract people and to educate
them. This medium can be used in a psychosocial program to spread program information and to raise
awareness.




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                        Scientific data on mental health needs
PTSD (Post Traumatic Stress Disorder) is in general public most often associated with violence. Despite its
clear relation violence does have more mental health consequences: anxiety disorders, depression, in some
extreme cases suicide is an indicator as also substance abuse often is.

                                           Anxiety disorders
Statistic data are available from 1972. Client files of the first 60 patients of the years 1972, 1984, 1996
(N=180) from the Outpatient department of the Psychiatric Hospital of Kashmir have been retrospectively
studied (Margoob, Singh, Ali, 1997 (1)). In comparison the incidence of anxiety disorders is nearly doubled
over the years (from 1972: 11.5% to 1996: 21%). The rise is even more pronounced when compared to the
year 1984 in which only 6.3% accounted for anxiety disorders.

After treatment normal functioning is restored in majority of cases. However, the effect seems to reduce after
1972 (75%, 70% and 1996: 64%). The study further indicates drug treatment (benzo-diazepines) as the sole
and major intervention method. Psychotherapy is not given.

Another study in 1995 (Margoob, Singh, Ali, 1997 (2)) shows similar high levels of anxiety disorders of
patients admitted in the general hospital ( 26% (N=556)) and a general private practice (18% (N=507)). The
most recent update is given by Khan et al (2000) whose study describes a prevalence of 13% on anxiety
disorders in a private setting (N=85).

                                                Depression
A similar retrospective study as for anxiety has been conducted for depression (Margoob, Beg & Dutta,
1993). Over the decades studied the percentage of depressive disorders is increasing (1971: 16%, 1980: 14%
and in 1989: 32%) among the patients (N=3486) admitted in the Outpatient department of the Psychiatric
Hospital of Kashmir. When a sub-division is made according to ICD 8,9 criteria 1 , especially the neurotic
depression type increases.

The authors explain the increase of depressive disorders by an augmented awareness and acceptance among
the patients. They explicitly do not rule out the possibility of the elevated stress in daily life as possible origin
for the increase of depression. Especially because the relation between stress and increased of neurotic and
reactive depressive disorders is common.

In a follow-up study in 1995 (Margoob, Singh, Ali, 1997 (2)) the number of patients admitted in the
Outpatient department of the Psychiatric Hospital of Kashmir with depression is decreased (23% (N=941)).
The authors attribute the decrease to the possibility that depressed persons turn to the private general practice
for treatment. The study registers that in this setting 44% (N=507) of the people suffer from depressive
disorder.

A similar high prevalence is described by Khan et al (2000). 35% of the visitors of a private clinical practice
(N=85) was diagnosed as suffering from major depression.

                            Post Traumatic Stress Disorder (PTSD).
The first signs of the occurrence of PTSD (Post Traumatic Stress Disorder) (15% of the patients in the
outpatient department of the Kashmir Psychiatric Hospital) are found in 1996 (Margoob, Singh, Ali, 1997
(1)). A study among visitors of a private psychiatric clinic (N=85) showed an occurrence of 11% (Khan et al.,
2000). Those who qualified for PSTD and somatoform disorders did initially presented their problems to
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physicians. The ones diagnosed with other disorders (like depression, dissociative disorder) did have made
initial contact with psychiatrists. The importance of this finding is that at both levels (patients and physicians)
awareness on the origin of the complaints (traumatic experiences) should exist. Otherwise appropriate
treatment is difficult or in the best case essential elements of the client's symptoms are not addressed.

                                                   Suicide
The present population of the Kashmir valley is predominately Muslim. The Islam religion and culture
strongly condemns suicide. According to mental health specialists suicide was rare in Kashmir. In the first
months of 1995 however, a sudden suicide increase at the Outpatient department of the Psychiatric Hospital
of Kashmir is observed. In a publication Margoob et al (1997 (3)) describe 41 cases. Most of them women
from rural areas in the age group of 21-35 years, 87% of them without any earlier psychiatric disorder.
According to the authors the sudden increase is caused by a generation conflict and change in life style. Most
of the cases attempted suicide because they were not permitted to marry with the one they love but were
forced to follow the predominate culture of arranged marriages.

                                           Substance abuse
The use of alcohol has never been socially approved in the Kashmir valley (whereas in the rest of India this is
the most common abuse). The use of Cannabis and Charas is more accepted. In a study (Margoob & Dutta,
1993) over 8 years (1980-1988) 2% of the cases admitted in the Outpatient department of the Psychiatric
Hospital of Kashmir (N=9726) is diagnosed with substance abuse. Since 1990 drug addicts report less
frequently at the Outpatient department due to the ongoing disturbances. The authors stress that this does not
indicate drug addiction is decreasing.

Although these data are relatively low and represent the years prior to the conflict, the authors are alarmed.
During the last 4 years heroin addiction which was before 1984 unknown in Kashmir, rises rapidly to become
second after Cannabis. The current daily arrests and seizure of large quantities of heroin and Charas indicate
an upcoming problem, according the authors.




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                                     Stressors and needs
This paragraph describes an inventory of stressors and needs as has been expressed in the workshop, during
interviews and focus group discussions in the villages. To avoid unnecessary duplication the needs as
described in the above paragraph are not repeated.

The violence in the Kashmir valley has a devastating effect on the economy. Un-employment is very high
and nearly everyone reports this, having debts or outright poverty as the most important stressor. Especially
widows and females who are divorced are affected. Despite the tradition that a sum of money or land (called
Meher) is set aside for the woman before her marriage in case she might divorce. The dire economic situation
has resulted in the introduction of the practice of dowry although previously not common in Kashmir. The
acquirement of the dowry causes a lot of stress and disharmony. In other parts of India the payment of dowry
is associated with female fetus-killing.

Also the poor health conditions is commonly seen as stressor. Many ailments are not addressed to save
money. The lack of accessible health care is another reasons for the poor health.

Peace and mental health is seen by many Kashmiris as interconnected. The threats and continuous
intimidation of the (para)military and militants is reported as a major stressor. People are afraid to go out,
women get touched, males arrested or beaten, sometimes houses burned. This results in a strong restriction of
females to have perform their traditional outdoor duties (getting fire wood, washing, working on the land).
These tasks have an important social function for women. The (threat of) violence bars big social happenings
(Sunday outings, picnics) and certain rituals. An example of an important community ritual that is seriously
affected is marriage. Before the violence the party went on all night. Nowadays, the party and all the rituals
can only take place in broad day light for security reasons. The possibility of the community to enjoy, to
define and to vitalize itself is hindered for all major gatherings are regarded as security risk.

The family structure is suffering due to the ongoing violence. Many respondents report that the violence
seems has triggered a generation conflict. Women seem to claim more rights and privileges. Some situations
(like fury of 'mother in laws') is not tolerated anymore. In the past one person (the oldest male) was
responsible for the family. Due to the bad financial circumstances, the killings, the disappearances, arrests
and emigration the traditional role settings are changed. Everybody who can is making money. The income
allows youngsters to start their own life. When married the financial independence (and a big dowry helps
also) often lead to living separate from the extended family. The loss of previous hierarchies and family
structure is for old people hard to accept. Family disharmony or conflicts between parts of the family system
is by many mentioned as a major effect of the violence.

Moral values are closely associated with family structure. Kashmiris see overall changes in family values
(e.g. living with extended family), respect for elderly (e.g. smoking in the presence of elderly) and arranged
marriages (more forbidden love affairs and disregard of previous marriage arrangements).

Both authorities and village elders complain about the passivity of the community. Helping capacity is
reduced, initiative to start new activities is lacking and dysfunction greeted with submission. On community
level hardly any (local) NGO's are discovered (see also village system above).

                                              Expression
The local language (Urdu) has an expression that covers all variations of psychological stress and
psychosocial complaints. 'Tension' has a negative connotation. It also includes psychological symptoms
caused by and associated with violence. The word: 'tension' is very well understood by common people
(including non-educated). Both during the workshop and the interviews in the rural areas it became clear that
other words like depression, bad mood, anxiety etc. is not understood.
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Common ways to express distress do not differ much from Western ways of expression: worrying, praying,
closing one self of from its environment, distraction and sharing with close people (family, friends). Temper
attacks (aggression (physical), verbal shouting, abusive language) are reported to be a common way for
males to express 'tension'. Restlessness and continued excitement is more associated with those who have
been confronted with violence. More specific ways like: fainting, fits and shared mourning (sometimes with
loud screams and pulling out hair), are used to express serious stress and psychological pain. Among
youngsters it is noted that the tendency 'to live for the day' and a focus on immediate satisfaction, is
augmenting.

According to the health officials somatization (headaches, palpitations) is widely used to express 'tension'.
People look for immediate cure and when the treatment does not have immediate success the patients returns
the same day. It is reported (and confirmed by people interviewed in rural areas) that because of the ailing
health system most of the people suffering from 'tension' will visit a faith healer. There is not an official
registration system (like in some African countries).




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                     Coping and self repair/help mechanisms
Despite the dire status of the health system, the clear needs as shown by the specialists and village health
workers, it is possible that individuals, communities and the culture may provide very effective coping
mechanisms. In this way the increased needs can be balanced by the coping mechanisms. During our field
visits and the workshop however, it was frequently stated that the coping and self repair mechanisms are
under severe pressure.

Currently the coping mechanisms are studied by Dr. Shah (head of psychiatry department, medical college in
Srinigar). The results of this study are not yet available. Below, we have described what coping mechanisms
are found during our visit.

                                                Individual
Religion is a very strong coping mechanism. Many people report to gain strength through praying. Denial by
keeping yourself busy (working on the land, visiting others) or pretending nothing is wrong is also a very
excepted way to cope. Expression of the worries and disclosure to trusted people is regarded as helpful for it
re-assures people. The number of people who medicate themselves is high. Due to the intense security
regulations and the vulnerability for violence especially families in the rural areas tend to regroup
themselves. It was not possible to identify the most effective coping mechanism but especially praying seems
to be effectual.

                                              Community
Previously, social outings (e.g. picnics) were a common way to express harmony and to stimulate bounding.
Every village has its own festival days in which males and females gather to sing, dance and party till the late
hours. Due to the security conditions this tradition is largely disappeared. People do not bother to organize it
anymore 'to protect themselves for another disillusion'.

NGO's or other ways of self organization are very poor. Although some report during the workshop on the
presence of activities for women and schoolchildren (indoor youth happenings), it has not been observed by
us (except for a self started school). When it is decided to start a program a thorough examination of past and
present existing community (group) activities is necessary.

A positive exception are the SHGs (self-help groups) organized by the VHA (see above). These groups
attract many women and seem to foster a very positive anti dote against apathy reported by many people.
Once started these activities seem to sustain themselves. The male population accepts the existence of the
groups and even allow women to pay their monthly contribution.

                                         Cultural/traditional
Common activities for women (washing, getting fire wood, working on the land) are traditionally the sole
way for women to ventilate, discuss and support each other. Especially in the rural areas these self help
activities are under pressure.

A visit to the faith healers is common and accepted. Among some younger people disbelief has been noted.
They denounce faith healers as money makers. Traditionally the faith healers are requested for: mental health
problems, marriage problems, pain, fits & 'tension' (in addition to many physical complaints). In the dealing
with Djinn related disorders (mind you: 'tension' is not seen as Djinn related disorder), anxiety, hysteria and
many PS problems faith healers seem to be quite effective. The effectiveness of faith healers for these
disorders is also reported in some Western countries. Some Kashmiri psychiatrists do refer some of their
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client to them. Mental health disorders however, can not be cured by the interventions of the faith healers.

Some parts of Kashmir are populated by Shia Muslims. A special Shia-ritual is held once a year to remember
the death of the brother of the Prophet who was killed with his whole family. The celebration to remember
his martyrdom lasts for 14 days. The daily rituals in which people mourn the death of the martyr are also
used to express frustration and grief for their own deaths. The ceremonies guide the expression of grief, anger
through praying, reciting verses, screaming, crying and self beating. The use of knives or whips is banned
because it has been judged by religious leaders that the blood should be used in a positive way: it is now
donated to those in need. This is the sole event in which males are allowed to cry without being judged as
weak. The Shia event that has a Kashmiri version (called Marcia) is a regarded by many people as an
effective way to ensure public hygiene through ventilation of personal emotions and frustrations. In high
security areas this ritual is impossible.

Another way to mourn is paying a weekly visited to the grave yard. This is an organized event. It has a set
time (every Thursday) and fixed place to meet. Another tradition is to cook the favorite dish of the deceased
and to distribute it among the poor. This ritual is believed to clean the spirit of the deceased.

A special ritual that seem to provide an effective coping mechanism are Sufi-rituals. During our visit we
could not obtain sufficient information but it seems that during these rituals the acceptance of the presence is
stressed. Hope is generated through rituals that emphasizes that lives goes on.

                                   Acceptance of counselling
Counseling as method or technique is not known on village level. However, variations and elements are used.
The first requirement is trust. Women and also man only disclose to those they trust and have proved their
confidentiality. The TBA's and the VHW's we met are trusted and do give also psychosocial support. They
advice women to unburden themselves and disclose what is pre-occupying them. They allow the person to
cry and give advice to share their problem with others, visit the faith healer, to distract themselves, change
environment or to come back again. In a number of cases the person comes back for more advice and
unburdening.

The TBA's and VHW express a desire to acquire more skills to support people in their relief of 'tension' for
they feel often insufficient. Their special role and already established position qualifies a selection of TBA's
and VHW's for more training on counseling. They suggest to include counseling in their daily home visits
and regular house to house visits. The services can be coordinated through the sub centers of VHA.




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         Suggested interventions as defined in the workshop
The participants of the workshop agreed on the necessity of a psychosocial intervention to meet the
psychosocial needs caused by the chronic violence. We used the mixed group of specialists and VHW's to
define the frame work of such an intervention.

The project should be named 'Sukoon' (Peace of mind) which is associated by Kashmiri people as the
opposite of 'tension'. The project name 'Sukoon' makes people immediately aware of what support is
provided. After field testing the name (on: is it indeed generally understood and is providing 'Sukoon' not
culturally the role of religious leaders or faith healers) it can be adopted and serve as a speaking name for the
project and its services. It was strongly suggested not use anything associated with mental health for this
would be associated with psychiatric disorders.

The project's overall objective was defined as: To provide support to people suffering from 'tension' to help
them cope with the daily realities in a more effective way. The participants defined five specific objectives
which are discussed below.


1.   Definition of a pilot project area. It was suggested to choose the project site of VHA in Chadura (5
     villages: Zoohama, Hanjoora, Dadampora, Nawhar, Surasyan). The system of VHA's is working. A field
     visit proved they were also enthusiastic to learn more on counseling skills. In a later stage the project
     can be extended to the Wakharman block (Wakharman, Benderpora, Badriwan, Renzipora).
     An intense cooperation with significant people is necessary at the start and during the pilot program. An
     advisory board of local people should consist of the Moqdam (village chief), imam, teacher (or
     headmaster), (respected) faith healers, members of the village development committee, representative of
     self help groups/NGO's and the village Chowkidar (the Chowkidar is the caretaker). The village board
     will support the implementation, awareness raising and provide the acknowledgment for the initiative.
     In addition, the pilot project should also be supported by a professional board consisting of at least one
     psychiatrist, representatives of ministry of health and social affairs, the medical college, the educational
     system and others involved. The board will provide advisory support and net work capacity. The project
     should aim at a general public but within this group especially to women, children and adolescents.



2.   Raising education level and awareness on psychosocial issues of the public in general and health
     professionals in specific. The extensive knowledge and material available in India (for instance by the
     VHA Delhi) should be screened first. Special Information, Education and Communication material
     (IEC-material) is developed to support mass (psycho) education. The education should be focused on
     general psychosocial topics and issues (stress, grief, communication, conflict etc..) with the purpose to
     explain how it works, what can be done about it by themselves and by others. Suggested places and
     events for group and community village education are the mosque and Imam-Baras. The Imam Bara is
     the community building, which also serves as a mosque if there's non, as khuran school, as the setting
     for wedding ceremonies and as village meeting room. Before the conflict every village had its own
     cultural folk group (Band Pathre). The groups that still exist (in Baderwan, Renzipora) can be used in
     the psycho-education process. In addition to the above mentioned facilities special psycho-education
     activities should be done on schools, health and Anganwon centers (day care centers).
     The awareness of health staff should be raised through seminars. Proposed target groups for general
     seminars are general practitioners, village health workers, field doctors, nurses and medical students.
     The topics should include signs and symptoms of varies psychosocial problems (stress, traumatic stress,
     family conflict etc..), diagnosing and treatment of psychiatric patients. Despite the high level of training
     of the remaining psychiatrists more specialist training is needed. A link with the outside world is
     necessary to re-vitalize and re-open the Kashmiri mental health community.
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3.   Training of barefoot counselors with follow-up to junior and senior level. The participants agree on the
     fact that the training of barefoot counselors should be done on village level. The training has to be in
     local language (Urdu) and should be held regularly depending on the other duties of the volunteers. The
     focus of the training should be on practical skills rather than theoretical knowledge. The trainer should
     guide the counselors for some time after the training until they can function independently.
     Each village should have at least one barefoot counselor. They should be selected among people that are
     respected in the village. As in the villages has been suggested the workshop participants agree on the
     VHW's and TBA's for being the most likely to recruit. Other suggestions are the teachers or the village
     development workers or those working for NGO's. To generate dignity and respect the course should be
     certified. For follow-up, exchange visits between the village counselors should be organized regularly.
     Junior and senior counselors are trained later (from the existing group). The psychiatrists suggest they
     can be used for monitoring and consolidation of psychiatric patients.



4.   Services to reduce 'tension'. Barefoot counselors are the front line in the early management of 'tension'
     through psycho-education and crisis intervention. The participants stress that 'tension' should not be
     reduced to a simple set of symptoms. Consequences of violence affects people mentally, economically,
     spiritually and socially. The services should address these various levels.
     Regular house to visits should be used to identify people in need. It is stressed that the visits should not
     focus only on those suffering from 'tension' to avoid stigmatization. A regular visit to schools is part of
     the house-to-house monitoring. To identify 'tensioners' a good cooperation with local dispensaries and
     health workers (when present) should be established. Anganwon centers (day care centers) or sub
     centers can be used to provide individual and group counseling services. Target outreach is necessary to
     those that have been confronted with crisis (crack downs, army operations, militant activities). To
     re-establish the referral net work the psychiatrists suggested regular area visits and a PS mobile team to
     visit areas in crises.

     To reduce social tension the participants suggested that the counselors should facilitate a civil-army
     liaison meeting to discuss local problems. It was also stated the absolute suspicion and resentment
     towards the army would make this a difficult task. To re-activate the community social activities (sports
     events, folk music performances (Band Parti), picnics, recreation programs, debates etc.) should be
     organized.

     The economical needs are significant. The participants do not belief that a psychosocial program can or
     should solve this. However, through having strong cooperation with grass root organizations in the
     community suffering might be alleviated. Counselors can stimulate the organization of self-help groups,
     income generating initiatives, education/skill training activities and refer clients to these activities. In the
     suggested pilot area the VHA already started these activities.

     The participants reserve an important role for both religious leaders and faith healers. They should be
     informed about the activities and cooperate. When possible referral should also be discussed



5.   Establishment of a local NGO and village committees. The issue of continuation of the services is
     discussed. The participants advice to start a local NGO that has strong links with the village committees.
     This organization must be trained to become independent and generate its own national and
     international funding. A strong link with the VHA is logical. MSF should provide the technical
     knowledge/training and project implementation experience. Local specialists see it as their duty to
     establish the NGO and spend time on it. The NGO should not be a vertically organized, specialist
     organization. It should be able to address the mental health and psychosocial needs but in relation to the

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Kashmir. Heaven on earth?




     clients socio-economical and spiritual needs. A strong participation of village committees, grass root
     organizations and income generation organizations or self help groups, is vital.




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                                                  Gaps
The visit was short and more information should be gathered before starting a pilot project. Especially net
working is essential to support the preparation and implementation. More information is needed to map the
local initiatives (community NGO's, self help groups etc.).

Together with VHA the medical college should be visited and possibilities for mutual cooperation assessed.
Dr. Shah (head of psychiatry department, medical college) looks like a good contact. His study on coping
mechanisms of the local population is noteworthy.

In addition also bigger NGOs like needs to be contacted. Oxfam (Ms Sahba Husain) for more info on
community activities, the Indian Red Cross and Crescent Department of social and family welfare for survey
results on identifying families of militancy hit victims (for rehabilitation) and ICRC may give useful
information. In Srinigar the UN is present with an observation mission. But maybe also other UN agencies
are present.

The members of the focus group discussions in the villages were only women. We suggest to extend the
information during the preparation with focus group discussions with males. Due to the limited time
available we could not visit some minority populations like Hindus, Pandits, Sikh migrant workers. Neither
did we visit the military authorities.




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                                            Conclusions
The health system of the Kashmir valley is clearly affected by the violence. The mental health services did
suffer equally. Lack of staff and a virtually absence of services on the primary and secondary level are
evident.

The data as reported by the studies of the mental health specialists do indicate an increasing negative effect of
the conflict on the mental health status. Most notably the high and increasing incidence of the depression and
anxiety disorders can be associated with the daily stress and lack of future perspective as caused by the 10
years of chronic violence. Substance abuse is believed to augment.

Conflict changes the social fabric of communities and often influences established social and cultural
patterns. The increase of suicides among a very specific group (rural women of 21-35 years) might be an
indication of a generation conflict possibly catalyzed by the situation.

Most of the studies have been done in tertiary facilities or private clinic settings. Therefor, one has to be
careful with drawing conclusions for only a selective (socio-economic) population has been studied (e.g.
those able to reach the hospital, having sufficient money). To be more conclusive surveys and qualitative
methods among a more representative group are required. The focus group discussions and the workshop as
executed in the cause of the visit do confirm the trend of studies.

Kasmiris indicate several stressors. The violence did seriously affect the economy. Everybody needs to fight
for its income. The health condition of the people is bad and many complain about the poor health facilities
and expensive drugs. Violence is seen as the root of all evil. It does not only dislocate the life of many
individuals also social and community life is affected for many rituals and events are banned for security
reasons.

A lingering generation conflict seems to be triggered by the violence. Family structure changes, habits
disappear and respect for tradition is diminishing. Some report on a loss of morale values. The protective belt
usually formed by family is eroded.

Especially in the rural areas all expressions of psychological suffering (violence and non violence related) are
summarized by the expression of having 'tension'. Most ways of expressing 'tension' are similar to the West.
Somatisation for expression of 'tension' is widespread. It is believed that many people seek help from faith
healers.

The resilience of individuals, community and culture is expressed through coping and self help mechanisms.
Most of them however, seem to have suffered from the ongoing violence. The many rich and protective
rituals are difficult to execute. On community level apathy is prevailing. The need for expression of 'tension'
is observed by the TBA's and VHW's. Their daily presence confronts them with many cases. But they lack of
skills is to provide support.

The participants of the workshop were in favor of an intervention to address the pressing psychosocial needs.
They suggested to call the program 'Sukoon' which means in Urdu 'Peace of mind'. The participants
suggested to define the overall objective as: 'To provide support to people suffering from 'tension' to help
them cope with the daily realities in a more effective way'. The participants defined five specific objectives:

1.   Definition of a geographical project area;


2.   Raising education level and awareness on psychosocial issues of the public in general and health
     professionals in specific;

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Kashmir. Heaven on earth?




3.   Training of barefoot counselors with follow-up to junior and senior level;


4.   Services to reduce tension including possible channels for referral; and


5.   Establishment of a local NGO and village committees.


Despite the short time and the evident gaps the final conclusion is that the psychosocial needs as identified
during our visit do justify a psychosocial intervention.




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                                       Recommendations
The intervention should be executed in close cooperation with representatives of the villages, mental health
specialists and authorities. During the workshop very valuable suggestions were given by the mixed group of
participants. These recommendations should be used as a basis for the program logical frame work (see for
details 'Suggested interventions as defined in the workshop).

The situation in Kashmir requires prudence and modesty. The indicators of the program should be realistic
and achievable. A flashy quick fix will not work in Kashmir. A program should be defined in various
achievable steps. A close cooperation between MSF and the VHA is necessary. The VHA should do most of
the implementation on the ground whereas MSF can provide technical knowledge, project implementation
advice and temporary on site quality supervision (as part of the training). The distribution of tasks and
responsibilities should be made clear in advance to avoid misunderstandings and wrong expectations. Each
new phase of the program should include an evaluation by MSF and VHA of the past phase. To promote
institutional learning lessons learned have to be drafted. Each new stage requires a new logical frame work, a
time frame and discussion with the VHA on who is doing what.

A first stage can be implemented before this winter. It includes three activities : organize a training for
VHW's in the Chadura block. The training should be short and focus on: knowledge and skills on
psycho-education, crisis intervention, basic counseling skills on listening, communication, conflict
management, problem solving and advising on self-help methods for people with bad mood, tension, grief
and aggression. The formal training should be followed by training on the job and supervision on the quality
of work for at least four weeks. At the end of the training (formal and on the job) the barefoot counselors
have implemented psycho-education activities and initiated basic counseling during their home visits.

A second activity is to support the local psychiatrists to organize a seminar for general practitioners and one
for themselves through the medical college. MSF can provide a trainer or lecturer. A third activity is
extensive net working to identify local organizations and key people needed for the composition of village
and specialist board of the program. A fourth activity can be the start of a radio program which gives
information and discusses psychosocial issues. Preferably this should be a life and call in program. The
program should be organized by the VHA and the Medical college jointly. The sustainability should be
guaranteed through local resources (MoH, MoS, Divisional Commissioner).

MSF can provide the trainer, facilitate technically the implementation of psycho-education activities and
counseling on village level. In Srinigar MSF can advice on the radio program. The MSF expat can give
lectures during the seminar (in addition to a consultant psychiatrist?). The VHA's input is essential for
advice, organizing logistics, establishing the seminar (with the Medical College) and organizing the radio
program. The net working is a joint operation. It is strongly suggested to link the MSF expat with a VHA
counterpart to promote a close cooperation between VHA and MSF. The VHA counterpart should be full
time available and have an interest in and a talent for psychosocial work.

The first stage requires one MSF expat who is able to train the VHWs and TBAs, and to give
presentation/seminars at the medical college. The expat must have MSF experience and extensive clinical
and training experience. In addition to the expat a consultant psychiatrist could be scheduled for a week to
give a seminar in Srinigar. To have MSF logistical back-up and guarantee MSF security guidelines a MSF
logistician for Kashmir should be considered. All contracts should be for about two months.

During the winter the activities in the Chadura block will dependent on the accessibility. Net working in
Srinigar, however should continue. The India CMT (country management team) (CM, Medco & Log Admin)
are responsible for maintenance of the net work. The radio program should continue on its own.

The second stage of the program can start in March. A new training for the barefoot counselors is organized.
The content of the training is based on the experiences, topics and cases the counselors have had during the
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Kashmir. Heaven on earth?



winter. The program needs further implementation and rooting in the community. During this stage which
will last approximately six months those who will qualify for a junior counseling training can be identified. It
will also become clear how the VHA project in Wakharman is developing and when extension of the
psychosocial component is feasible. At the of the second phase the program activities are established, further
training of the bare foot counselors is executed. The preparation for or start of the extension of the training
(junior counselors) and geographical area (Wakharman block) is in full swing.

The distribution of tasks between MSF and the VHA depend on the outcome of the evaluation and lessons
learned (especially the cooperation between the local VHA counterpart and MSF expat). A similar
distribution of tasks as described above is feasible. For the second phase a new logical frame work, time
frame and budget is required.

A third phase of the project can entail the follow-up training of counselors (junior). Probably, for senior
counselors (officially certified) a course can be organized on the medical college. The extension of the
project to the Wakharman area should be executed with the active help of the staff in the Chadura block.

In all stages of the program the issues of sustainability is key. As indicated by the participants the MSF/VHA
initiative can continue as independent NGO. I suggest contrary. The program should be part of the VHA
program in Kashmir for several reasons. First, the NGO should not become a vertical mental health NGO.
Second, the VHA is already established and has solid back-up in India. Third, it will take a long time to
register the NGO and if assistance in funding is needed, they cannot accept MSF money without an FCRA,
which will take years to get (the situation is so bad that there is a NGO especially occupied with this, since
the FCRA is used by the government to control what NGO's are doing; the NGO is named CAP).

When the VHA intends to take over the project after the third phase they should start securing funding during
the second phase. A possible third phase can then be financed by an external donor in addition to MSF. When
the strategy of fund raising of the VHA is not successful the decision for MSF to continue financing the third
phase of the psychosocial project has to be reconsidered.

I suggest to make a proposal for the first stage with an very likely option for the second (depending on the
outcome of the lessons learned). As described the logical frame work for these phases should be separated to
enhance learning and evaluation. Only based on the experiences of the first stage and the results of the net
working a second phase can be fine tuned and described in a new logical frame work.

The current proposal and budget of the VHA does not provide in funds for the psychosocial activities.
Training, education material, meetings, seminars, additional staff, translators, transport, flights for specialists
etc. cannot be paid from their current budget. MSF needs to write a separate proposal for this.

A last suggestion is to have a look at the Srinigar psychiatric institution which is destroyed by fire. It is
possible that MSF experience from Tajikistan is valid for Kashmir. When decided positively I suggested to
focus the activities only on reconstruction.




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                                            Notes

1.   Endogenous depression: a more severe depressive disorder usually episodic. It includes all
     entities like depressive psychosis, manic depressive psychosis (depressive type). Neurotic
     depression: a relatively less intense mood disorder which may run a continuous chronic
     course. It includes terms like reactive depression, depressive neurosis etc.




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                            Appendix 1: Additional literature
MSF country policy India

Kashmir Trip report of Country Manager and Medical Coordinator

Margoob, M.A. & Dutta, K.S. (1993). Drug abuse in Kashmir - experience from a psychiatric
diseases hospital. Indian J. of Psychiatry, 35 (3); 163-165.

Margoob, M.A. Beg, A.A. & Dutta, K.S. (1993). Depressive disorders in Kashmi; a changing socio-
demographic and clinical profile of patients over the past two decades. Jammu Kashmir
Practitioner, vol. 2 (1); 22-24.

Margoob, M.A. (1996). The pattern of child Psychiatric disorders in Kashmir. Jammu Kashmir
Practitioner, vol. 3 (4); 233-236.

Margoob,M.A., Singh, A. & Ali, Z.. All in Indian Psychiatric Society North Zone (1997):

1.   Prescribing practices and outcome in anxiety disorders over the past two decades- experience
     from a sole provincial level psychiatric diseases hospital outpatient department.


2.   Comperative study of patient profile in general hospital psychiatric clinic; private psychiatric
     clinic and psychiatric disease hospital OPD setting.


3.   A study of suicide attempts in Kashmir valley over the past six months (april-sept. 1997)
     experience from psychiatric outpatient population.


Margoob, M.A., Dar, M.M., Ahmad, M.M. & Wani, A. (1999). Non-psychiatrist clinicians training in
psychiatry, its perceived adequacy and modalities of treatment used. Jammu Kashmir Practitioner,
vol. 6 (4); 273-277.

Khan, W.A., Shah, H.S., Gliew, J. & Ali, Z. (2000). Trauma victims in psychiatric practice-need to
review current nosology. Jammu Kashmir Practitioner, vol. 7 (3); 174-176.




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