The cost of Kashmir conflict

An MSF staff member tends to a Kashmiri man at a health post in Kashmir’s Kupwara district. Photo: Giulio Di Sturco/VII Mentor

By Dr. Arshad Hussain

Kashmir has been the witness to one of the worst conflicts of modern era with huge human costs and mental health one of the worst casualty’s. Lifetime prevalence of major depression. Substance use disorder and trauma related disorders are at all-time high. The economic costs of this huge mental health burden are tremendous. Annualized work loss due to mental health issues in Kashmir is due to absenteeism and presentism is predictably huge.

In lower socioeconomic class, the costs are more gruesome. Mental health problems lead to economic depression which leads to inadequate treatment or no treatment which leads to perpetual and vicious circle leading to social drift hampering employment, relationship, and many other severe social problems. In urban areas the problem is compounded by lack of social networking leading to further social exclusion and stigmatization. There are no income tax benefits for most of the mental health problems even though World Health Organization (WHO) recognizes them as costliest diseases. Insurance doesn’t cover any mental health problem. Non-Governmental Organizations (NGO) and social groups don’t provide any long-term treatment benefits in form of drugs, investigations et cetra to mentally ill except for some initiatives by Action Aid. This is more serious because mental health problems in Kashmir are afflicting young productive age group furthering the economic burden.

Because of substance use and other mental health problems the indirect costs on criminal justice are also increased. Because of stigmatization the indirect costs on existing health system are too difficult to understand and estimate but everybody in Kashmir hospitals knows the maximum unwanted procedures- diagnostic and therapeutic. Subjects are people with mental health problems and with privatization the costs are even higher and sometimes cruel. Substance use and suicide seem to be consequences of hidden mental health morbidity in the community and are consuming our youth.

Kashmir lost its innocence long back in many ways and one of the nightmares we are living with is that our children are at increased risk of developing a substance related problems. When there was Opioids boom in whole subcontinent we were aloof as society except for few aberrations in tourist related areas and socially accepted Charas Takias. We as culture had beliefs and values which were protective and preventive and we sailed clear of Opioids epidemic. No more can I repeat this optimism as Opioids abuse along with other medicinal abuse has gone deep inside Kashmiri society. I know of rural areas were bus does not go but Opioids do, not only inflicting damage on the minds and souls of youth who consume it but breaking families and neighbor hoods and societies.

In the process causing irreparable damage to culture which is already scarred. Families after families are drifting into blind hole of poverty and alas we are watching thinking that my children, my brother can’t do it, not understanding that when flood breaks river banks then it does not obey laws it moves to destroy everything in its way and does not even spare mosques and temples that is what substance abuse is doing to our society it is going deep into culture and today’s substance abuser in Kashmir has no profile. He is rich and poor, employed and unemployed, traumatized and resilient, educated and illiterate, rural and urban, ghettoized and uptown; he is that all and much more.

In past two decades, suicide behavior has gained recognition worldwide as a serious problem. Suicide ranks ninth among causes of death in developed world. Whenever figures on suicide are presented or discussed there is always the question of their reliability. Since in some instances and for several reasons suicide as a reason for death can be hidden, thus real figures are higher. According to WHO estimates, based on current trends, for the year 2020 is approximately 1.53 million people will die from suicide and 10-20 times more people will attempt suicide worldwide. This represents on average one death every 20 seconds and one attempt every 1-2 seconds. A comparison of suicide rates according to the prevalent religious denomination in countries brings to light a most remarkable difference between Islamic countries and any prevailing religion. At 25.6/100,000 the blood suicide rate is markedly highest in atheist countries. Kashmir a predominantly Muslim society had lowest suicide rates in whole India at 0.5/100, 0005 comparable to Kuwait which has 0.1/ 100,0003 lowest in world. Past few years have shown spurt of suicides, Para-suicides and deliberate self-harm. The increase in Para suicides and deliberate self-harm are much more alarming, the suicide rates are also on rise. The present study was carried out with the back ground, that Para-suicides and deliberate self-harms are greatest predictors of eventual suicide, and thus warrants public health measures to decline mortality because of suicide, as better understanding of risk factors for suicide as well as of the magnitude of the effect of known risk factors in general population is crucial for the design of suicide prevention programmes.

Psychiatric Disorders have a substantial impact, globally accounting for 12 percent of all Disability Adjusted Life Years (DALY’s), and 31 percent of all years lived with a disability. [WHO 2001] In Europe alone, they account for 20 percent of all disability adjusted life years, and 43 percent of all years lived with a disability. Globally, they include 3 of the top 20 causes of disease burden in the general population, (unipolar depressive disorders, self- inflicted injuries and alcohol use disorders), and six in the 15-44 age group, (additionally schizophrenia, bipolar depressive disorder and panic disorder).

Furthermore the incidence of age related cognitive disorders in the next two decades is expected to increase markedly, and the proportion of DALYs attributed to mental health disorders are expected to increase to 15 percent by 2020. Poor mental health also has a significant impact on other aspects of health. The level of co-morbidities and (non-suicide related) mortality in people with mental illness has been observed to be significantly higher than those in the general population. In addition to the burden on overall individual health, mental health disorders generate substantial costs not only to health and social care services but also to many other sectors of the economy, including notably criminal justice. The social impact is also profound. The stigmatization and social exclusion of those with mental health disorders, can affect all aspects of an individual’s life limiting their access to employment and housing, hampering social relationships and reducing self esteem

Family relationships may suffer; relatives may have little choice but to provide substantial amounts of informal care, much of which is not valued in economic burden studies. Mental disorders that occur in childhood can also have a significant impact on educational attainment; depression has been shown to be correlated with poor school grades.  Those with untreated common childhood mental disorders may experience higher rates of unemployment, poorer relationships, and greater contact with the criminal justice system in adult life.

The impact on employment and productivity is substantial, e.g. one UK (United Kingdom) study estimated that depression alone accounted for a third of absenteeism from work. . In another recent study it was estimated that 86 percent of the total costs of bi-polar disorder (£2 billion in total) were attributable to lost productivity.  In the United States costs of lost productivity attributable to mental illness were estimated to be $76 billion in 1990. Those with mental health disorders may drift into poverty and are at greater risk of becoming homeless. The mentally ill may also be subjected to human rights violations, through inappropriate use of compulsory detention and involuntary treatment.

Mental health problem has announced its arrival in an unlikely sociocultural scenario and perhaps taking all health planners unawares. And preventive strategies at all levels from primordial to primary to secondary to tertiary need to be taken to address this problem. From early recognition to making mental health available and accessible we have a Herculean task on our hands. Cultural Cognitive reappraisal at community level  and preservation of culture at all costs of whatever little is left of it and not confusing modernization with abandonment  of culture and social values  looks to be an effective maneuver to combat this ever-growing mental health morbidity Multi-pronged strategy with role for everybody should be the goal ahead.

Dr Arshad Hussain is Assistant Professor, Department of Psychiatry Government Medical College Srinagar.

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