A quantitative assessment on violence, the psychosocial and general health status of the Indian Kashmiri population.
The Kashmiri population living in India has been both witness to and victims of violence, involving a number of groups with different aims over the past few decades. Since 2000, MSF- Holland has been working in the region, providing mental health care and support in the management of medical waste disposal in the capital Srinagar and outlying rural areas.
To identify needs and support project planning, a survey consisting of 510 semi-structured interviews was executed in two violence-affected, rural districts in Indian administered Kashmir during mid-2005.
The period of violence considered was defined by the local population as starting in 1989, continuing until the time of the survey. At the time of interview, almost half (48.1%) of the respondents said they felt only occasionally or never safe. In the period 1989-2005, people frequently reported crackdowns (99.2%), frisking by security forces (85.7%) and round-up raids in villages (82.7%). In the same period, damage to property (39%) or the burning of houses (26.3%) was considerable. Interviewees reported witnessing (73.3%) and directly experiencing themselves (44.1%), physical and psychological mistreatment, such as humiliation and threats.
In addition, people were forced to perform labour (33.7%) or to give shelter to combatants (18.4%). In the same period, one in six respondents (16.9%) were legally or illegally detained. A shocking finding is that torture appears to be widespread among those detained (legally or illegally): 76.7% said they were tortured while they were in captivity. The high levels reported suggest a strategy of intimidation and fear employed by the warring parties.
Violence is associated with human loss. In this period nearly one in ten people (9.4%) lost one or more members of their nuclear family because of the violence. A third (35.7%) indicated that they had lost one or more extended family members.
Violence or the threat of physical violence seems to have had a significant effect on the mental health of people in this region. In the past 30 days one in ten (9.6%) people mentioned mental problems as their primary health concern. In the past month the respondents suffered from high levels of anxiety such as nervousness, tension, extensive worrying (62.7%); using a self-reporting survey tool that has been validated for use in India, 33.3% suffered from psychological distress in the past 30 days. Just under half of those interviewed reported that they were unhappy to the extent that a substantial number of people interviewed admitted to having thoughts about ending their life (33.9%). Such a high percentage of suicidal ideation, within a population holding strong religious beliefs that condemn the act of suicide, is a worrying indicator of the level of despair and hopelessness.
Physical health is also affected; a substantial number of the people reported their physical health as being bad (22.7%) or very bad (7.1%) in the 30 days prior to the survey. Over a similar period high rates of physical complaints including headaches (23.5%), body pains such as joint and back complaints (20.5%), and abdominal complaints (16.9%) were mentioned. Such high levels of non-specific health complaints suggest high levels of stress and psychosocial problems.
Poor health placed a substantial burden on the area’s health facilities, with most people saying they visit health clinics frequently (63.9%); some even four times or more in the past 30 days (15.3%). Medicine consumption was also high, with over one-third taking six or more medicines in the previous 30 days (37.9%).
Poor physical and mental health clearly affects daily functioning. Nearly half (49.0%) of those interviewed report being unable to carry out their usual activities for four or more days in the past 30 days; a similar number (49.8%) reported having to cut back or reduce their activities or work in the past month because of ill health.
Sexual violence is a common strategy used to terrorise and intimidate people in conflict, but in Kashmir it is an issue that is not openly discussed. Nevertheless, 11.6% of interviewees said they had been victims of sexual violence since 1989. Almost two-thirds of the people interviewed (63.9%) had heard over a similar period about cases of rape, while one in seven had witnessed rape.
In children, the major effect of the violence reported in this survey is fear (24.6%). School-related problems also scored highly, such as being unable to attend school (15.5%) and having problems studying (16.3%) due to the lack of professional teachers and study material.
Respondents tell people deal with stress by isolating themselves (22.3%) or becoming aggressive (16%). These dysfunctional coping mechanisms are reported often as a consequence of exposure to violence. While people think that talking confidentially to someone they trust is helpful when confronted with tension (89.4%), over two-thirds (68%) do not know what counselling is.
The findings of the study are of considerable concern. While the level of violence has decreased since 2004, the events reported here were still occurring in mid-2005 when the survey was done, indicating an ongoing and unacceptable continuation of violence. Kashmir remains caught in a cycle of violence despite efforts by governments to break the cycle. Further, our findings indicate that mental and physical health needs are high, while the coping mechanisms of individuals are predominantly dysfunctional. Even with a definitive end to violence, it could be expected that a substantial number of people would need support to overcome their problems. This assumption is confirmed by our findings of high mental health needs despite the decrease of violence since 2004.
Mental health problems in Kashmir need to be addressed with urgency. In areas where MSF works, we have implemented community based mental health services. In all other Kashmir districts community-based mental health services are non-existent, despite the intentions set out in the Indian Mental Health Policy. Based on the findings of this survey, MSF calls on the health authorities to implement their stated policies and to prioritise the immediate implementation of community based psychiatric and counseling services in Kashmir.