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How do medicine and violence interact in Kashmir? This book explores their disorienting world

An Excerpt From ‘The Occupied Clinic: Militarism And Care In Kashmir’, By Saiba Varma.

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Kashmiris waits to receive counselling from a doctor (C) at Kashmir's psychiatry hospital in Srinagar, 2007. | Fayaz Kabli / Reuters.

Back in the crowded OPD, meaning slips through my fingers like water. Patient after patient – or more precisely, one kin group after another – enters. The flow is relentless. A doorman attempts to maintain order. He guards the door, a thick stack of medical cards on a stool in front of him.

Every time the door cracks open, more faces peer inside, hoping for their turn. He calls out names, Ashraf Hussain! Irfana Maqbool! Another family shuffles to the front and edges inside. The doorman hands them their white medical cards, many of them worn and palimpsestic. The door slams shut.

Inside, I watch Dr Manzoor, patients, and kin engage in rapid-fire ex- changes in Kashmiri and Urdu. There are a dozen people in the small room at any given time – one family being attended to, the next on standby. Their presence lingers long after they depart.

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I smell a warm, musky hearth, pine trees, rose water – an earthy, smoky, and floral bouquet – signalling winter’s approach. Some exchanges are wordless, consisting only of scrawls of “CST” – continue same treatment – which will be exchanged for psychiatric drugs (if available) at the hospital’s pharmacy or from one of the more ex- pensive pharmacies that opportunistically exist outside the hospital’s gates. Most patients know pharmaceuticals cannot cure them, but something is better than nothing.

The psychiatric hospital is almost 70 years old, and it would soon be upgraded to a National Institute of Mental Health, giving psychiatrists access to resources and prestige. Yet this transformation would largely be lost on visitors, who will still see it as the pāgal khānā, the asylum.

Patients are haunted by the knowledge that, until very recently, patients living in the long-term wards were chained to their beds. For these reasons, they still worry about being “locked up” here. Most want their prescriptions filled and their most adverse symptoms alleviated. A short, quick exchange. Unfortunately, the long lines mean that a quick hospital visit remains a fantasy.

A woman – perhaps in her forties – enters with her daughter and son-in- law. She tells Dr Manzoor that three of her sons are dead. One, who was thirteen months old, died after a fall. Another died of pneumonia. She is vague about how the third died, but it sounds like he was a “militant,” the name given to those who took up arms against the Indian state.

Three of her daughters are alive. She says her husband doesn’t believe she is sick and did not let her come to the clinic for two weeks because it is the harvesting season. She has been experiencing dag, a Kashmiri word meaning restless pain, for the past eleven years. She’s been on Fludac – a generic version of Prozac – and another generic antidepressant for most of that time. Like most patients at the hospital, she does not know her diagnosis and does not ask. She’s here because she’s out of medication.

During their interaction, Dr Manzoor turns to me and says in English, “Her multiple somatic features are characteristic of trauma victims.” He emphasises the word “characteristic,” making it crackle. He occasionally translates these encounters for me, especially those related to trauma and PTSD. His explanations are terse, the result of years of giving case presentations as an intern and junior doctor. His statement contains a twofold translation: a physiological sign, dag, is converted into an English-language psychiatric diagnosis.

Psychiatrists like Dr Manzoor believe that Kashmiri patients lack knowledge of the psyche and express psychiatric symptoms as physical symptoms because these are more culturally acceptable and less stigmatising.

In other words, Dr Manzoor is saying that, though this woman thinks she is suffering from dag (physical pain), she is actually suffering from psychological trauma. Psychiatrists call this process “somatisation.” However, Dr Manzoor does not have the time nor the inclination to explain any of this to his patient. He scribbles another round of Fludac, and she’s gone.

Next, an elderly woman enters. She has come alone, which is unusual. She’s wearing a face-covering veil (burqā), but it is casually tossed over her head, in the unfussy way many elderly women wear it. Dr Manzoor asks how long she’s been ill. She’s on the verge of tears. She says she has been coming since “the English lady” was here.

She is referring to Erna Hoch, a Swiss psychiatrist who was a professor of psychiatry and served for some time as the head of the department (HoD) of psychiatry in Kashmir. Hoch retired in 1980, so this woman’s distress is also chronic. She speaks rapidly, trying to maximise her time with Dr Manzoor. In the middle of her soliloquy, Dr Manzoor’s phone beeps a loud and obnoxious melody, a text message received. She pauses, midsentence, while he clumsily punches a response. A precious moment slips by.

When he’s done sending his text, Dr Manzoor looks up and, to my surprise, asks if she will switch to Urdu so I can better follow her story. Her eyes dart in my direction; she seems uncomfortable but reluctantly agrees. She has been coming to the hospital for a long time, she repeats. She has one son. Two of her brothers were killed by “unidentified gunmen.”

This term is a code word for ikhwāns, Kashmiri armed fighters who were turned into counterinsurgents by the Indian military and who committed some of the worst atrocities during the conflict. She is a widow, she says. She lives with a persistent body ache.

Dr Manzoor tells me, in English, that she hasn’t come to terms with any of these deaths. “She’s unlikely to improve,” he says. “Another typical trauma case.” He prescribes a benzodiazepine, another illegible scribble.

As she’s about to leave, Dr. Manzoor suddenly asks if I want to ask a question. Caught off guard, I struggle to formulate something. I ask if she prays. She says she tries, but she can’t. In a patronizing tone, Dr. Manzoor encour- ages her to pray. I am annoyed at myself for asking this question, but also at Dr. Manzoor for turning my question into a critique of her behavior.

The next few hours pass like this, smudges of anguish, blurs of medical cards, and muted grief, like a steel-gray ocean registering the coming of a storm. Soon, my field notebooks will be filled with similar, fleeting, dream-like encounters between doctors and patients, aid workers, and recipients. This fragmentary archive both frustrated and fascinated me. Too much left unsaid, festering disputes glimpsed through flashes of life.

Abruptly, at 3 pm, the hospital empties out. Many patients are from rural areas and must start on their journeys so they can be home by dusk. The habitus of military occupation dictates that people do not stay out after dark, though there is no official nighttime curfew. Dr Manzoor gathers his belongings.

He will now go to his private clinic, where he consults with patients until 8 pm almost every day. Although Dr Manzoor and other public-sector employees are technically forbidden from private practice, he tells me it is a necessity: the salary from the public hospital is a “pittance.” When I ask when he takes time off, he chuckles, “every other Sunday.”