The former head of GMC, Srinagar’s Psychiatry Department, Prof Mushtaq A Margoob has contributed immensely in managing the massive load of mental illness at the peak of mass fear in the 1990s while battling with policymakers to create the required infrastructure. In this detailed interview with Khalid Bashir Gura, Dr Margoob flags the highs and lows of mental morbidity and the infrastructure while locating the deficits and gaps that require attention
KASHMIR LIFE: (KL): What is mental health and what are the problems related to it?
DR MUSHTAQ A MARGOOB (DMAM): WHO defines mental health as a state of well-being in which an individual realizes his or her own abilities, copes with the normal stresses of life, works productively and is able to make a contribution to his or her community. Multiple social, psychological, and biological factors determine the level of mental health of a person. For example, persistent socio-economic pressures and violence are recognized risks to mental health. Rapid social change, stressful work conditions, gender discrimination, social exclusion, unhealthy lifestyle, physical ill-health and human rights violations are also associated with poor mental health. Specific psychological and personality factors as well as biological risks like genetic factors also make people vulnerable to mental health problems.
Mental illnesses refer collectively to all diagnosable mental conditions involving changes in emotion, thinking or behaviour (or a combination of these). They are associated with distress and/or problems functioning in social, work or family activities. Mental illnesses refer collectively to all diagnosable mental health conditions involving significant changes in thinking, emotion and/or behaviour. They are common and are treatable like most physical problems. The vast majority of individuals with mental illness continue to function in their daily lives.
KL: Why is the stigma attached to mental issues?
DMAM: Mental illness is a medical problem, just like heart disease or diabetes. The stigma associated with mental disorders is a global public health problem. The fight against this discrimination is a complex process, with multifaceted implications, and must be examined from multiple perspectives to increase knowledge and experience about the best strategies to combat stigma. Research evidence suggests that crucial components of stigma consisting of difficulties of knowledge (ignorance or misinformation), attitudes (prejudice) and behaviour (discrimination) and can be tackled only with a focused, determined and sustained approach. A passing reference to the historical background of this unrelenting annoyance to innumerable innocent sufferers and their families is important to recognize the grip and the sway this abhorable process has had on the collective psyche of people over the centuries. Stigma primarily comes from the misguided views that these individuals are “different,” from everyone else.
Mental issues were earlier attributed to demonic or spiritual possession, which led to caution, fear, and discrimination. In Britain and most of Europe, France, and their colonies, the mentally sick were ostracized and isolated. The misconception that the mentally ill were “wild beasts” that needed to be dealt with accordingly shaped treatment practices for centuries. By the later eighteenth century, there was a shift in this attitude following which the nineteenth-century asylums gained popularity as buildings where the “insane” could be nursed back to health and replaced “mad-houses,” institutions that functioned as prisons and showed little regard for patients’ quality of life.
World War-I was a significant turning point in public understanding of mental health. The common diagnosis for soldiers having suffered emotional trauma on the frontlines was “shell shock” (much later as PTSD), a name that derives from the detrimental effects of explosive shells. In early 19th century America, care for the mentally ill was almost non-existent: the afflicted were usually relegated to prisons, almshouses, or inadequate supervision by families. Treatment, if provided, paralleled other medical treatments of the time, including bloodletting and purgatives.
On the contrary physicians of the medieval Muslim period (that had become an intellectual era for science, philosophy, medicine and education), including Ibn Sina, rejected such concepts and viewed mental disorders as conditions that were physiologically based. This led to the establishment of the first psychiatric hospital in the world in Baghdad by al-Razi, who was one of the well-known ninth-century physicians respected for his revolutionary contributions to medicine and psychiatry.
It is unfortunate and agonizing that sections in Muslim societies, including Kashmir, have adopted the miserable medieval western viewpoint about the cause and treatment of mental problems. This is perpetuating the stigma and enabling fraudsters to exploit and subject mentally unwell people to barbaric practices like branding with hot iron rods, or de-nailing in the name of expelling ghosts and evil spirits.
KL: What is the evolution story of mental health care in Kashmir?
DMAM: The process of establishing lunatic asylums in British India had first started during the later eighteenth century and by around the mid-19th century the British began to establish “Native-Only” lunatic asylums in India in Bengal Presidency. Subsequently, a chain of lunatic asylums came up at different places. Till then, there was no practice of confinement of the mentally ill.
In Kashmir, the first asylum was established by the Prisons’ Department in 1903 in the backyard of the Central Jail Srinagar. It had the provision of keeping few individuals in a few barracks. Subsequently, the hospital, still housed in barracks of the Central Jail, was delinked from prisons and established as a mental health facility under the Directorate of Health Services. Over the years it got transformed into a 100-bedded Psychiatric Disease Hospital and attached to Government Medical College, Srinagar, initially as its undergraduate and subsequently as postgraduate teaching department.
During this period, most of the clinical work was being carried out from a three-room single-storyed building. Till recently, this hospital would cater to the mentally unwell people of Kashmir, Ladakh and adjoining areas of Jammu. Till the late 1960s, the hospital was rendering services to severely disturbed or mentally deranged individuals mainly as a custodial care institution without OPD services. In the 1970s, it was the Swiss lady psychiatrist Prof Erina Hoch who worked here as the first Professor and Head of the undergraduate department of psychiatry in GMC, Srinagar and significantly contributed to creating awareness among the people about mental disorders and their management.
Prof KS Dutta succeeded her and his small team opened the Post Graduate training department of Psychiatry in 1983. During the mid-1980s to mid-1990s, late Prof Abdul Ahad Beg made an outstanding contribution to Kashmir’s clinical psychiatry and got it a decent place like other branches of medicine. This marked the beginning of people coming openly for psychiatric treatment to the Hospital. His sad demise in 1996 coincided with the beginning of new challenges to psychiatry.
KL: Kashmir witnessed a serious mental crisis in the 1990s?
DMAM: Prof Dutta’s retirement and Prof Beg’s demise happened almost simultaneously as a result of which the PG department shrunk to a status of negligible faculty strength comprising only two consultant psychiatrists, both lecturers. There was no professor, no clinical psychologist or psychiatric nursing staff or psychiatric social workers available.
It was an era when Kashmir was exposed to intense stress arising out of mass destruction of life and property, crushing fear and uncertainty, the astounding increase in the number of people visiting OPD starkly reflected Kashmir’s harsh ground realities.
The data revealed the frightening impact of the man-made disaster on every segment of society and every aspect of life. Against a total number of 1762 patients in 1990, the hospital exploded with 17584 patients in 1994. Soon, the number crossed 100 thousand persons seeking help in a year.
It was at the peak of this crisis that a devastating fire nearly destroyed everything in the hospital area in March 1996.
It is so gratifying to see that almost all of the consultants who are managing the show now are the products of this space that was the most stigmatized place and was on the verge of a collapse in the mid1990s when the Government had declared its inability to rebuild the hospital for lack of finances. Tragically, some lawmakers actively contributed to reinforcing the stigma by resorting to demeaning references to the hospital.
Finally, post-graduation in medical education was started in 2000 and the department got a batch of three very brilliant students.
In 2001, the international medical humanitarian organization, Doctors Without Borders (MSF) also started working in Kashmir and rebuilt a portion of the gutted structure of the hospital. Subsequently, a SAWAB initiated PIL in the High Court pursued and vigorously fought by a young dynamic advocate without any financial gains or claims. It led the state government to start constructing the remaining portion of the hospital almost on the same previous pattern and outlay.
There was a tragedy that helped mental health care eventually. On August 6, 2001, 28 chain-bound inmates of a faith-based mental asylum were charred to death in Erwadi (Tamil Nadu). The Supreme Court of India took cognizance of the prevailing inhuman conditions of the mentally unwell in India and ordered that each state must establish and upgrade at least one mental health hospital with modern facilities and basic amenities and asked the central government to earmark a separate budgetary provision for it.
This marked the beginning of the change at the Kathidarwaza Mental health service centre. The work started with a Rs 2.5 crore grant from the Union Health Ministry in 2007 which eventually altered the face of the hospital. In 2010, the Ministry under the National Mental Health programme granted Rs 30 crore for upgrading the hospital as one of the 11 centres of excellence. Within few months, the Centre was adopted as the model for North Indian states and all the directors and health secretaries of the respective states were asked to attend the specific Regional Training and Sensitization Workshop of the National Mental Health Programme by Union Health Ministry at Srinagar on June 14-15, 2011. The centres of excellence in Chandigarh, Rohtak, IHBAS Delhi and Rajasthan were eventually set up on similar lines. Rest is history.
The fate of our establish the need-based Centre of Excellence in Kashmir would have been no different from the other five centres of north India, which had failed to make any headway despite having received the grant five years prior to us, had the then Health Commissioner, GA Peer not extended his extraordinary support to the plan during the crucial initial stages of the process. Equally commendable was the role of the then GMC Principal Prof Shahida Mir for agreeing to allow us the prime piece of land for constructing the community centre of IMHANS-K in SMHS premises.
Since then, psychiatry witnessed a fast spread – a PG department at SKIMS, undergraduate departments at the two newly set-up medical colleges at Anantnag and Baramulla, district level mental health care centres; all run by able professional and dynamic psychiatrists.
KL: What is SAWAB?
DMAM: SAWAB is the acronym for Supporting Always Wholeheartedly All broken-hearted, is the innovative voluntary psychosocial community care and research outreach initiative in Kashmir started in early 1990. It was a one-man mobile mental health service delivery process consequent to escalated psychosocial stress and a shocking increase in mental health disorders in Kashmir.
Over the years SAWAB has been very silently striving to fight stigma, enhance awareness about mental health problems, provide access to counselling and deliver expert psychiatric treatment and free medication to the needy at their doorsteps. It has also been focusing on and facilitating the training of the budding trainee mental health professionals in the community over the years with very promising results. It has also been a source of developing and testing innovative socio-culturally appropriate evidence-based promotive, preventive and treatment intervention models to bridge the prevailing gap in these areas of mental health.
KL: Is there any connection between mental health and spirituality?
DMAM: Apart from a state of complete physical, mental, and social well-being, WHO also suggests spiritual well being as a fourth dimension to health. The universality of spirituality extends across creed and culture. At the same time, spirituality is very much personal and unique to each person. Spirituality produces qualities such as love, honesty, patience, tolerance, and compassion, a sense of detachment, faith, and hope. Spiritualism in South Asia and Africa is recognized as a way of life with eternal joy and bliss beyond the realm of sensual pleasures. That is why mental health professionals in Eastern cultures must propagate the bio-psycho-socio-spiritual model in their approach in psychiatry so that treatment technique likes Spiritually Augmented Cognitive Behaviour Therapy is formally incorporated in the management of the patients with mental health-related issues.
KL: What has been the role of faith in healing? Have not in past faith healers become causes of abuse?’
DMAM: In spite of the advances made in various fields of medical science, traditional healing practices continue to be used widely all over the world especially in Eastern societies. Spiritual healing has got a pivotal role as far as mental health is concerned because traditional faith healers are usually the first contact in the event of sickness.
Our widely quoted research paper Pir, Faqir and Psychotherapist – role in the psychosocial intervention of trauma published in 2006 provides many insights into the phenomenon. A genuine faith healer and a psychotherapist share in the community similar experiences of balance between inner and outer life. The trend and percentage of patients visiting clergy or faith healers before seeking psychiatric help have continued almost unchanged over the decades in Kashmir.
In 1996, 73 per cent of the psychiatric patients would visit a faith healer before seeking psychiatric help (87 per cent in rural and 59 per cent in urban areas). In 2005, it is 68.5 per cent (84 per cent in rural and 53 per cent in urban) of patients seeking treatment visit faith healers first. The pattern seems unchanged even today or might have gone higher following the prolonged lockdowns and Covid19 pandemic induced multiple psychosocial stressors.
Reinforcing spirituality can be a powerful tool to boost resilience not only for manmade disaster stressors but even in the face of calamities and catastrophes. It is getting robustly authenticated. Because of these factors, the trend to compete and cooperate to a certain extent between mental health professionals and the indigenous spiritual healers is continuing the same way as four decades back.
In the majority of cases, there is peaceful co-existence as the traffic runs both ways. Patients under the treatment of professionals, wishing to make use of the local resources, are hardly objected to except for instructions not to fall prey to pretenders, fakes using injurious practices and the imposters. Faith healers in turn continue to refer cases to professionals. So collaboration with traditional healers is encouraged in Kashmir. However,
KL: How can the stigma attached to mental health problems be fought successfully?
DMAM: People struggling with mental illness, are burdened by the stereotypes and prejudices of stigmatization. This interferes with getting needed care and causes social isolation and alienation. People with emotional, cognitive and behavioural problems, regardless of whether the causes are external traumas or circumstances, internal events, or some combination, should be given the same respect and access to treatment as someone dealing with a mild sprain, the flu, or a life-threatening physical condition.
The saying ‘future germinates in the soil of present but has its roots in the past’ is very relevant here. In Kashmir, there was a positive impact of the successful campaigns on the issue using the mass media from the mid-1990s onwards. A similar collective effort is once again required.
In collaboration with the World Psychiatric Association, we are developing and testing an innovative model involving specifically grass-root level traditional and faith healers, children and adolescents and a component of citizen journalism. The work on this endeavour is successfully going on in Kashmir, Jammu and Ladakh under the supervision of a senior consultant psychiatrist at each respective place and we hope to have a socio-culturally relevant and evidence-based roadmap to fight the stigma successfully once the research is completed.
KL: There are reports of drug abuse increasing. How is the present scenario different from the past? And where are we heading?
DMAM: In the early 1990s, the majority of the people believed that the menace of drug abuse has almost completely been eradicated as a result of the ban and retaliatory measures by various militant groups. But, our research paper ‘Drug abuse in Kashmir, Experience from a provincial level psychiatric disease hospital’ published in 1993 in the Indian Journal of Psychiatry carried the clear warning in these words “the reduction in the number of persons reporting or seeking help for drug-related problems at the hospital OPD should not be misinterpreted as an indication of decreasing incidence of drug abuse in Kashmir. The almost daily reports of big seizures of substances of abuse like charas and heroin in the local press is a clear indicator that the menace is touching new heights and that the situation will eventually become explosive. Urgent steps must be taken to curb it before it is too late”.
The subsequent situation was also clearly reflected in a subsequent study based on the drug addiction scene in 2002, “Changing Socio-demographic and Clinical profile of Substance Use Disorder Among Patients in Kashmir”. The results were startling. Even young semi-educated women from far-off areas were using harder substances like opioids, and benzodiazepines at times intravenously. The abuse of the traditionally used drugs was being completely replaced by harder substances like heroin and over the counter drugs like opium preparations, combination injections, and codeine-containing cough syrups.
The large community-based study conducted by me from August 2003 to January 2005 across Kashmir districts (with the Department of Science and Technology logistic support) provided the first time with the most needed details about the magnitude of various types of substances abused by the general population in Kashmir’s urban and rural areas with appropriate representations.
The results were published in the book The Menace of Drug Abuse in Kashmir: Trend Tradition or Trauma and distributed free of cost in the conference organized as a SAWAB initiative in the University of Kashmir in November 2008.
The findings were disturbing. Overall the prevalence for use of a psychoactive substance is 47.77 per cent, out of which the major share is that of tobacco or nicotine abuse. An alarmingly high percentage of the population – 3.83 per cent abuse opium related substances with Anantnag having the highest rates (6.2 per cent) and Budgam the lowest at 2.1 per cent. Other districts sail in between.
Extrapolating the above prevalence estimates can be projected that there are 24.32 lakh substance abusers (including tobacco users) in Kashmir out of which 2.11 lakh people are opioid abusers, 1.37 lakh are cannabis abusers and around 38,000 abuse alcohol. Almost 2.5 per cent of the population abuse charas (cannabis) with Anantnag again hit worst. The abuse of Benzodiazepines and related tranquillizing drugs comes to 1.07 per cent, with the highest rates in Kupwara. The prevalence of Alcohol abuse is 0.7 per cent in the total sample population, with the highest rate again in Kupwara.
The unfortunate situation has further worsened over the years as is revealed by various latest studies reflecting most of the opium derivative preparation being now used as intravenous heroin coming via Line of Control.
The comprehensive drug de-addiction policy of the Jammu and Kashmir government needs to be implemented by all stakeholders in letter and spirit with every individual in Kashmir having a role to see it successful so as to save the young generation from complete devastation.
KL: What needs to be done to deal with the ever-increasing number of various mental health problems in Kashmir?
DMAM: Thankfully we now have a huge capital of very competitive dedicated and dynamic mental health professionals available to people in Kashmir at most of the places at institutional levels. There is, however, a huge gap as hardly 7 per cent of people avail proper mental health care as of now. We need to bridge this gap with evidence-based intervention methods and measures.