Sunday, 24 April 2011

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Health and HIV in Jammu and Kashmir

In Jammu, people fleeing a conflict situation survive in congested refugee camps. In Kashmir, the population is under siege by the army and by militants. Their common ground: vulnerability to sexual abuse, abysmal healthcare, and the absence of any public awareness programme. This is the perfect breeding ground for epidemics of all sorts - including HIV. Anju Munshi reports on how conflict and displacement impact health

Since 1990 more than 4 lakh men, women and children targeted by terrorist violence have fled their homes in Kashmir. They have emerged as a new community of refugees, the Internally Displaced. Nineteen years after the exodus started, militancy continues to engulf Kashmir and the refugees remain trapped in camps. In the absence of basic facilities like education, hygiene, medical infrastructure, and health awareness, Jammu and Kashmir confronts a threat as ugly as militancy itself – HIV (Human Immuno-deficiency Virus).

Nearly 1.8 lakh of this internally displaced population stays in 11 camps in and around Jammu city. The rest live with their relatives and friends or in rented accommodation. The camps are the very definition of discomfort and misery.

To these families who have lost their homes and all their possessions, the government gives a ration of nine kilos of rice and one kilo of sugar for each member per month, and a monthly relief payment of Rs 500 per person per month, with a maximum per family of Rs 2,400. This paltry amount forces almost every migrant to look for some kind of work elsewhere, however poorly paid it is. This can make them vulnerable to HIV infection.

Jyoti Thussu (name changed), an inhabitant of the Muthi camp in Jammu, found an alternative to “undignified living” in the camps as she puts it, by taking to prostitution. Asked if she understood what HIV was, she replied: “Two of my friends in the Mishriwallan camp got themselves tested. They have HIV and they seem to be fine. They are on antibiotics.” Thussu is misinformed. Antibiotics have no effect on HIV infection though they treat opportunistic infections associated with HIV. Without special anti-retroviral drugs, her friends’ uncontrolled HIV infection will progress, leading to a fatal end.

The Muthi Phase I and Muthi Phase II camps are about seven kilometres from Jammu city. “There are about 500 Kashmiri Pandit families in each of the Muthi camps,” says Chaman Lal Kaul, manager of these camps. Of the other camps in the region, the camp at Mishriwala about 15 km from Jammu city, is the largest, housing about 1,500 families. Nagrota, about 25 km away, houses another 1,000 families and Purkhu, 12 km away houses 700 families. There is a camp at Udhampur too, about 60 km from Jammu on the national highway to Srinagar.

All these camps are wanting in hygiene and other civic amenities. Up to three generations of a family live in a single room of about 10 feet by 12 feet without even basic facilities like water, electricity and attached toilets. These makeshift rooms have common brick walls and galvanised iron roofs which absorb heat and make living here unbearable in summer when temperatures reach 45 degrees Celsius. Water is scarce, and when available, it is often filthy. It is common to see long lines of people waiting for their turn to collect water from community taps and use the toilets. Sweepers do the rounds once every two days, but the lack of water makes this exercise difficult. With such poor hygiene and sanitation, outbreaks of hepatitis, gastroenteritis and skin disorders are common in summer. Public toilets with no electricity or security are unsafe for women who have to venture out in the dark to use the toilets where outsiders have easy access.

Neerja Mattoo and Dr Shakti Bhan, both associated with Daughters of Vitasta, a women’s wing of Panun Kashmir (Our own Kashmir), a body committed to restoring and preserving the cultural identity of the Kashmiris, said that the camps are unsafe for women.

Vulnerability of the displaced

Why fear AIDS when hepatitis, gastroenteritis and cholera and diabetes also lurk around the corner? There are two reasons: First, there is no public awareness on issues related to HIV. Second, it is well known that displaced people get exploited sexually and economically. The London-based human rights organisation Survival International points out: “Vulnerability in displaced people is high, due to increased contact with outsiders and dramatic social change.” This situation can lead to spreading the virus on a large scale.

At a recent World AIDS Day meeting, Survival International’s director Stephen Corry declared: “Tribal and displaced people die because they succumb to outside diseases they never knew before. Increasingly, now, we can add HIV/AIDS to the list of killers. It is striking the most vulnerable peoples of all – those who have no grasp of the risks of unprotected sex, no access to condoms, no appropriate treatment, and whose numbers are already small.”

Corry supported his argument with an example from Kalahari in Africa. The virus was unknown among the tribes of Botswana's Central Kalahari before the tribespeople were forced from their homeland by the government. “In the new resettlement camp in 2002, at least 40% of Bushman deaths were due to AIDS.”

Healthcare in the camps

Dr Kundan Lal Chowdhury is an activist of the Shiriya Bhatt Mission hospital in Jammu, chairman, political affairs, Panun Kashmir, and president of the Displaced Doctors Association. He says that the camps’ inmates are deprived of even basic medical care. “The families cannot travel to places like Chandigarh and Delhi for treatment. They live on a measly dole of Rs 500 per head per month with a maximum of Rs 2,400 whatever the number of family members.” He also laments the fact that in the last 20 years no NGO has bothered to come and sensitise the camps’ inhabitants on various health issues. “Counselling, discussions, open forums, NGOs visiting the camps – all this could stir up things and set the stage for a new start,” he says.

When asked if he had figures on the numbers of people with HIV in the camps, Dr Chowdhury says, “Even if there are cases, they don't get reported for lack of awareness. People need to be educated about the dangers of unprotected sex, unsafe blood transfusions and recycled syringes." Hospitals in the state do not have proper facilities to test for HIV, he added.

There is no information on HIV in the migrants' camps. Nor is there counselling or dissemination of information of any kind, says Imtiaz Parrey who is associated with the AIDS Prevention Society in Jammu. Clearly there is a great need for an aggressive health awareness drive by way of mass campaigning and public service advertising on the dangers of unprotected sex, unsafe blood transfusion, reusing of needles, etc.

In the Kashmir valley

The state has a huge concentration of military and paramilitary forces that are high risk groups – for infecting and being infected. They live away from their families and may have sex with local men and women, including sex for money. Equally important, as people are injured in militancy, growing numbers of people need blood transfusion. HIV infection can be transmitted through unsafe blood transfusion.

A majority of the HIV infections detected in the Sher-e-Kashmir Institute of Medical Sciences and the SMHS Hospital in Srinagar were among the Border Security Forces (BSF) and the Central Reserve Police Force. These were found during routine tests of security personnel. The BSF has now started conducting workshops on HIV/AIDS at the basic unit level and further up in the Northern Command Hospital to educate officers, jawans and their families. It has also introduced a bi-annual health check-up for its doctors.

The political upheaval of recent years has exacted a heavy toll on the youngsters of this state. Many boys and girls are reported to have been sexually abused and forced to join terrorist outfits. It is believed that many of them are HIV-positive, says Imtiaz Parrey. “They live in poverty and are easily recruited into predatory terrorist organisations for prostitution.” Girls who live in camps close to the borders are particularly vulnerable to such abuse.

The Jammu and Kashmir Aids Prevention and Control Society (JKSAPCS) has made a feeble attempt to educate people on HIV by roping in religious leaders like Muslim imams, Christian priests and Sikh granthis in the state to speak to their communities. “The initiative draws inspiration from Uganda and Indonesia, where such messages are being propagated through imams,” says M A Wani, project director of JKAPCS.

However, Jammu-based immunologist Anil Mahajan is not impressed and calls the campaign “transferring your load on someone else’s shoulders”.

False promises

NGOs in the state have not conducted any awareness programmes, either by themselves or in collaboration with the state government.

In West Bengal, AIDS prevention has an ambassador in Buladi (di is a short form of didi or elder sister), a cartoon character who educates on how drug abuse, unsafe sex or blood transfusion could lead to HIV infection. In Mumbai film stars like Ashley Judd, Richard Gere and Bollywood’s Shilpa Shetty have helped spread the message. In Chennai the Red Ribbon Express did the same.

There has never been any such effort in the state of Jammu and Kashmir, leave alone in the camps. The task is made more difficult by the fact that several languages and dialects are spoken in the state – Kashmiri, Urdu, Dogri, Punjabi, Ladakhi, Pahari and Gujjari. So it’s even more challenging to accomplish minor tasks like developing video films, songs and posters, says Mahajan.

We see huge amount of funds being released to bring awareness but nothing comes to the Valley. On January 17, 2008, the union cabinet approved the creation of a joint secretary post to oversee the multi-billion rupee National AIDS Control Programme (Phase-III). The minister of state for health and family welfare, Panabaaka Lakshmi, said Phase III would focus on controlling the spread of HIV by scaling up targeted interventions among high risk groups. There is no evidence of this scale-up in the camps in Jammu. JKSAPCS’ Wani agrees that NACO should be implementing a targeted intervention for migrant labourers, the second highest risk group in Jammu and Kashmir but admits that “this isn’t being done.”

At the national level a number of programmes have been conducted to bring awareness about HIV/AIDS, but there are hardly any in the camps in Jammu.

It was good to see actor Shreyas Talpade go on air to inform people that the test for HIV is simple and free of cost. This message needs to spread far and wide, especially in the beautiful valley of Jammu and Kashmir. It is also time to educate the inmates of the migrant camps, for education is always an intelligent investment. Why wait for an epidemic to go out of hand to sound an alert?

(Anju Munshi is an activist from Kashmir and writes on conflict displacement, especially in connection with the state of J&K. She contributes regularly to several major newspapers)

Government estimates: tip of the iceberg?

According to National AIDS Control Organisation (NACO) surveillance figures, HIV prevalence in all groups in Jammu & Kashmir has stayed close to 0.0% ever since testing began in this region. NACO estimates that J&K has 14,600 people with HIV, with a sizeable number of these in Kashmir.

Little is known about HIV in the camps but some figures are available for the areas outside the camps. These are for reported cases of AIDS – the syndrome of illnesses that indicates a progression of HIV infection.

According to the Jammu and Kashmir Aids Preventive Control Society (JKAPCS), in 2007 the state reported 211 cases of AIDS compared to 34 in 2006 -- a six-fold increase in one year. The government also reported 42 AIDS deaths in 2007. The figures for the previous years were not available.

However, “AIDS” refers only to a collection of illnesses. People with TB or any of the other AIDS-related opportunistic infections may not be recorded as having AIDS. This is especially so when ignorance and the fear of being shunned by family and friends prevents most people from seeking testing and, if necessary, treatment. Doctors may hesitate to report AIDS fearing that the report will leak out and cause stigma to the person and family. So reports of AIDS cases provide limited information.

Estimates of HIV infection based on NACO’s annual surveillance can give a better idea of the extent of HIV in the state. In 2006, the annual surveillance had 16 ANC sites (antenatal clinics, which are meant to represent the general population).

  • All but one registered a prevalence of 0.0%;
  • Jammu had a prevalence of 0.5% (the all-India average of HIV in antenatal clinics is 0.36%).
  • Injecting drug users in Jammu had an HIV prevalence of 2.5% in 2006, up from 0.0% in 2005.

Source:NACO HIV fact sheets 2006

InfoChange News & Features, May 2009

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Ajay Bharti  - False and malicious report   |2009-07-13 11:40:08
The write up is malicious, outrageous and a deliberate attempt to malign the community particularly
those living in the camps.

I refute this with authority as totally false, baseless and pure

I, as a person belonging to the displaced community, am directly affected by the
I therefore request you to let us know the basis on which such defamatory content has been
published by you.

The report has been used by mentally sick people to tarnish the image of
helpless women who do not even know that they have been used for making the write up sound

I request you to publish the facts about the story in full if you think it is correct
or come out with a clarification.
Anju Munshi   |2009-07-13 11:58:18
Your comment actually vindicates my stand. Anything to do with women’s plight in Kashmir evokes
responses similar to yours. Anything to do with women’s health, sexual or reproductive, cannot be
spoken or written about as it is a forbidden subject and thus attempts to promote her welfare and
status are seen as a threat by the self-styled cultural czars of the community.

You are right
that the medical fraternity and the state AIDS cell are tight-lipped and said they were not aware of
any such cases for no data were available. Dr Chowdhury admitted that there is a serious lacuna on
the women’s health front but would not comment on the type of health disorders for no one has kept
any records, and testing centres for AIDS are unheard of in J&K.

Neerja Mattoo and Shakti Bhan
are well known for their endorsements of women’s causes and have time and again stressed the need
to make Kashmiri women aware about their own health. The problem lies not in what the women said but
in what they didn’t say, and that is the point of my article.

I do not deny you the freedom to
speak your mind. Your pride in the community culture is well placed but there are some real hard and
bitter facts that are crying aloud for attention.

I completely stand by what I have written on
the basis of interviews done with experts, teenage girls and reports by the National Aids Control
feroz  - the report needs to be cross and reverified   |2010-02-26 13:21:42

You have touched a vital issue, and I will not disagree with your write up, but their are some
grave mistakes too. You have written about the sexual abuse of females by militants which is not
100% correct, at the same time you have forgotten the fact that security forces have been sexually
abusing the females of Kashmir.
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