Urgent appeal for intervention/assistance of WHO in Jammu and Kashmir

Urgent appeal for intervention/assistance of WHO in Jammu and Kashmir

Response to WHO India’s MISLEADING & MISINFORMING communication to UN-WHO and International Community on the health crisis in Kashmir during and after floods.

To: Dr. Margaret Chan

Director General, United Nations World Health Organization [WHO], Geneva, Switzerland

October 4, 2014

Re.: Urgent appeal for intervention/assistance of WHO in Jammu and Kashmir

Dr. Chan,

1. We write to you today as concerned civil society representatives, including members of the medical fraternity, from Indian-administered Jammu and Kashmir.

2. In the first week of September 2014, Jammu and Kashmir was affected by the worst floods in its recorded history. There are now an estimated 8, 00,000 internally displaced persons [IDPs] in Jammu and Kashmir.

3. The extent of damage of the September 2014 floods, a disaster of international magnitude as stated by the Government of Jammu and Kashmir itself, has been compounded by Indian State policies of a complete lack of disaster management including in terms of preparedness, response, relief and rehabilitation. There has been a complete breakdown of an already overburdened healthcare system, which has been further aggravated by willful hindering/restriction of humanitarian work and aid. Government of India has sought to minimize the loss of life and property before the international community by misinforming the international community, including WHO. Various individuals and organizations internationally have expressed their willingness to provide financial aid, but Government of India has refused to accept aid and placed severe restrictions on voluntary donations.

4. On 29 September 2014, WHO India submitted a one page response to six questions posed by a journalist [copy of the same is attached]. This response, attributed to Dr. Nata Menabde, WHO Representative to India is the official position of WHO India on the present health crisis in Jammu and Kashmir. The responses, apparently entirely based on Ministry of Health and Family Welfare, Government of India inputs, are factually incorrect, and a complete misrepresentation of the dire situation on ground. WHO India concludes by incorrectly stating that: “The government has been intervening to tackle the potential adverse public health consequence of this disaster especially as related to water and sanitation and control of communicable diseases”.

5. A point by point response of WHO India’s present position and findings is as follows:

i. “58 mobile health clinics have been set up in Srinagar and 4 mobile hospitals have been pressed into service”: Firstly, reports from the ground suggest that the 4 mobile hospitals referred to do not exist. Further, while teams of doctors have been sent from India – and are perhaps part of the mobile health clinics referred to – it is clear that they are extremely few in number and with no effective reach on the ground. Secondly, there is no shortage of well-trained and skilled local medical man power on ground. The issue is that neither mobile health clinics nor mobile hospitals can be a substitute for permanent, well-equipped hospitals and a functional health care system.

ii. “Maternity hospital in Srinagar has been functional and the bone and joint hospital has re-opened a week ago”: Lal Ded [LD] Maternity Hospital, the only specialized maternity hospital in the Kashmir valley, was not functional as of 29 September 2014. A temporary arrangement was made with the Sanat Nagar Maternity home in the form of an Out Patient Department [OPD], with no in-patient or surgical facilities. LD Maternity Hospital only began functioning at a very minimal level on 3 October 2014. Even today, there is no continuous electrical supply and the blood bank and oxygen supply are extremely limited. Bone and Joint Hospital, Barzulla, the only specialized trauma and orthopedic centre, was barely functional as of 22 September 2014 [a week prior to the 29 September 2014 WHO response]. There were acute shortages of medicine, blood, oxygen and surgical, medical equipment.

Surgeries were being deferred. In fact, on 22 September 2014, 66 patients who had been stranded at the hospital were being sheltered in the Kashmir Nursing Home, Gupkar. To date, the functioning of Bone and Joint Hospital is extremely limited. Further, both LD Maternity Hospital and Bone and Joint Hospital have not been disinfected as per necessary standards.

iii. “Many district hospitals have been functioning”: Firstly, the Kashmir Valley, a 70, 00,000 population, is entirely dependent on the government hospitals in Srinagar. The district hospitals are incapable of handling tertiary care. Tertiary care in the Kashmir valley is completely handled by Shri Maharaja Hari Singh Hospital [SMHS] and associated hospitals and Sher-e-Kashmir Institute of Medical Sciences [SKIMS], Soura, of which, SMHS, the single largest facility is completely non-functional as of date. Secondly, specialist hospitals are only available in Srinagar city, for example, the GB Pant Childrens’ Hospital and the LD Maternity Hospital.

Thirdly, many facilities, such as MRI facilities and a fully equipped oncology department, provided by SMHS, are not available at any district hospital. Fourthly, even the private hospitals in Srinagar city– which cannot be compared to the government hospitals in terms of infrastructure and expertise– were inundated by the floods. Lastly, the diagnostic centers have also been inundated in Srinagar city. Therefore, the district hospitals are not a replacement to the Srinagar city government hospitals.

iv. “106 medical teams of the army have been deployed in addition to 1 Base hospital and 4 Field hospitals”: Firstly, information about medical teams or hospitals by the army have not been made public, strongly indicating the lack of any seriousness in providing access to common people. Secondly, there are confirmed reports from the ground that there has been no effective healthcare provided by the army. Only limited first-aid was provided in some instances. Lastly, given the long history of violence of the armed forces against the civilian population, and the recent discriminatory rescue efforts of the armed forces during the floods, the civilian population does not prefer approaching the army healthcare units.

v. “2 Central Public Health Teams have been posted – 1 each in Jammu and Srinagar for rapid health assessment and response by the Ministry of Health & Family Welfare”: Firstly, if these teams have been posted, their reports must be made public. To date, there is no information about their assessment. Secondly, based on the abysmal situation on ground, it is clear that these teams have made no contribution whatsoever. The fact remains that even today the government is relying on local volunteers and donations for medical supplies.

vi. “A 29-member clinical team comprising of physicians, pediatricians and gynecologists has also been positioned in Srinagar”: As stated above, there is no shortage of well-trained and skilled local medical man power on ground. The issue is that the hospitals are not functional, stocks and equipment have been destroyed, causing an acute healthcare crisis in Jammu and Kashmir.

vii. “All medical supplies that have been requested by the state government have been provided”: This contention is refuted by the fact that local voluntary groups such as Athrout, Help Poor Voluntary Trust and others have been requested by government hospitals to arrange medicines as the government is unwilling to assist. Further, disturbing reports suggest that medicine that was provided by the army to SMHS recently was in fact expired. Confirmed reports suggest that as far as medical supplies are concerned, the hospitals are purely managing on voluntary contributions and supplies. These supplies are also in danger of being restricted by the government.

viii. “Clean up operations at hospitals in Srinagar have apparently started and once electricity and water supply is restored, these hospitals will also start taking on the patient load in an incremental manner”: Firstly, this statement contradicts with the earlier statement of how LD Maternity Hospital and Bone and Joint Hospital, Barzulla are open. Secondly, all cleaning that has taken place has been done by voluntary groups and NGOs. Further, while some fumigation has been done by voluntary groups, it cannot be considered a substitute to a proper process followed by the concerned government department. No certification has been provided by the Infection Control Committees, present in each hospital, charged with granting a certificate that the hospital is in a state to begin work. Absolutely no care or concern has been shown by the government on whether the actual hospital buildings, inundated in floods for weeks, are structurally safe for use. This is particular alarming considering that Jammu and Kashmir is listed in the National Policy on Disaster Management, 2009, as being in Seismic Zone V [Very high damage risk zone]. On 30 September 2014, it was reported in the media that while the Director, SKIMS, Bemina declared the hospital unsafe, the Public Works Department [Roads and Buildings] of the government dismissed the same. The government, in its own interests of portraying normalcy, minimizing the crisis and excluding international intervention, is willing to place the lives of numerous patients and staff at risk.

6. The healthcare system of Srinagar city is almost completely comprised of and dependent on SMHS hospital and associated hospitals, as SMHS and associated hospitals include of a majority of departments and provide treatment to approximately 10,000 patients per day, from across the Kashmir valley. SMHS was inundated from 7 September onwards. Further, the other major hospitals inundated by the floods catered to vital specialty areas: LD Maternity Hospital, GB Pant Childrens’ Hospital, and Bone and Joint Hospital, Barzulla. LD hospital is the only specialty maternity care hospital in the Kashmir valley. It is also the only maternal, obstetric, and gynecological referral centre across the Kashmir valley. Similarly, GB Pant Childrens’ hospital is the only specialized pediatric hospital in the valley. The only functioning major hospital, with tertiary care, following the flood is SKIMS, Soura, which is now overburdened by having to serve a population of 70, 00,000.

7. None of these hospitals [or for that matter any of the government hospitals] had in place any disaster management plan. Further, no warnings or evacuations were carried out by the government at these hospitals at any point before or during the floods.

8. An illustrative example of the role of the government is that of SMHS hospital. The hospital premises were inundated from 4 September onwards. A boat had already been commissioned to ferry hospital staff and stock to the hospital. Yet, no emergency action was taken by the government until it was too late. When the water began to rise at 10/11:00 am, on 7 September in the hospital building, rather than evacuate SMHS, patients on the ground floor were moved to the first floor. This included critically ill patients in the Medical Intensive Care Unit. This led to the death of one patient. Further, at the same time, the oxygen plant, drug store, blood bank, electricity, telephone network, generator back up and hospital canteen stopped functioning, as they were all in the ground floor, which was flooded. Relief in the form of limited food and life saving drugs were also ferried into the hospitals by local volunteers on boats. As a result, local volunteers and hospital staff had to manage in extremely hazardous circumstances. There were a total of 13 deaths recorded at SMHS by the time patients could be evacuated, by local volunteers and hospital staff, out of the hospital on Monday evening. Reportedly, many patients died during the process of evacuation and shifting from SMHS. These deaths were all a direct result of the flooding and the lack of effective evacuation by government before the floods, and lack of any assistance in the final evacuation by government. The death toll would have been much higher if not for the work of the local volunteers and hospital staff. The government administration in charge of the hospitals, including the Chief Minister and Health Minister of Jammu and Kashmir should have, by the 7th, ordered evacuation of serious patients away from the hospitals in the low lying areas, such as SMHS, to SKIMS, Soura, the other tertiary care facility, which was not affected by the flood. Further, there were no rescues carried out by the government from any of the hospitals, including SMHS.

9. The omissions and acts of the government have led to significant mortality and morbidity across the city hospitals. Out of this, there have been atleast14 neonatal deaths at GB Pant Hospital due to power and oxygen failure. The government has failed to provide any official record of loss of life at the hospitals. There has also been monumental damage across the government hospitals. The government figure of 250 odd crores [2.5 billion INR] across SMHS and associated hospitals is a severe under-estimation considering the infrastructural damage to the hospitals. For example, at SMHS alone the following facilities have been destroyed: oncology department, oxygen plant, central blood bank, dialysis unit, ENT operation theatre, ENT emergency theatre, ophthalmology theatre, Medical Intensive Care Unit [along with all modern life saving equipment], echocardiography laboratory, neurology lab, radiology department with three CT scans, two MRI’s, USG machines, Doppler’s and x-ray plants.

10. In reality, despite a passage of one month since the floods hit Srinagar city, neither Government of India, nor Government of Jammu and Kashmir, have made any efforts to rebuild the healthcare system. On the contrary, Government of India, and the Government of Jammu and Kashmir, took no steps to prevent, prepare for, or manage the floods. The role of Government of India and Government of Jammu and Kashmir has been of criminal negligence in not anticipating the floods, and a willful intent adverse to the people, coupled with acts and omissions, in the work of evacuation, rescue and relief. No warnings were issued. No evacuations were carried out. Almost negligible rescue of the people of Jammu and Kashmir by the Indian State rescue forces [Indian army, Central Reserve Police Force and other units] was carried out. Hospitals, the highest priority in the time of disaster, were completely ignored by the government. Reports have emerged of military airlifting of their own personnel from bunkers/camps located adjacent to hospitals, while ignoring the appeals of patients stranded on the roofs of the hospitals in obvious distress. Rather than assist in the re-building of the healthcare system, the government has repeatedly sought to suppress the seriousness of the situation.

11. Jammu and Kashmir faces a dire healthcare crisis that Government of India and Government of Jammu and Kashmir are unwilling to address. Legal action in the form of public interest litigations before the Jammu and Kashmir High Court, and criminal complaints against the government administration have been initiated.

12. In the present dire situation, the people of Jammu and Kashmir require the urgent intervention of the international community, particularly WHO, to:

i. Put pressure on Government of India to allow an international WHO team to visit and perform an independent evaluation of the magnitude of the health crisis in Jammu and Kashmir

ii. Put pressure on Government of India to invite WHO to work in Jammu and Kashmir and serve as a coordinating and consulting body in the rebuilding of the healthcare system in Jammu and Kashmir

iii. Put pressure on Government of India that all restrictions to financial and other aid, particularly for the healthcare sector must be lifted, and the international community must be allowed to play a direct role in the rehabilitation of Jammu and Kashmir, particularly that of the healthcare system

iv. Seek the cooperation and assistance in the instant matter of the: Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health and Independent Expert on the issue of human rights obligations relating to the enjoyment of a safe, clean, healthy and sustainable environment. Further, pressure must be put on Government of India to allow both the Special Rapporteur and Independent Expert to visit Jammu and Kashmir and assess the health crisis.

Yours Sincerely,

Doctors Association Kashmir (DAK),

Resident Doctors Association of SMHS and Associated Hospitals (RDA),

Kashmir Voluntary Doctors Organization (KVDO),

Association of Pharmacy Graduates of Kashmir (APGK),

Jammu and Kashmir Chemists and Druggists Association (JKCDA)

and

Jammu Kashmir Coalition of Civil Society (JKCCS)

ATTACHMENT:

Response from the WHO Country Office for India

For The Huffington Post and www.worldmedicaltimes.org

1. What are the main health risks during floods?

2. In the WHO’s view, what are the main risks in Kashmir?

Please refer to

http://www.who.int/hac/techguidance/ems/floods/en/

3. There is only one hospital serving 70 lakh people. What is the WHO’s view on this in terms of patient safety?

According to the information we have collected from various sources, in order to mitigate the impact on the functionality of certain major government hospitals due to the floods, 58 mobile health clinics have been set up in Srinagar and 4 mobile hospitals have been pressed into service. The maternity hospital in Srinagar has been functional and the bone and joint hospital has re-opened a week ago. Many district hospitals have been functioning.106 medical teams of the army have been deployed in addition to 1 Base hospital and 4 Field hospitals. If the standard precautions are followed in all these facilities, patient safety may not be unduly compromised. To prevent /control public health exigencies 2 Central Public Health Teams have been posted – 1 each in Jammu and Srinagar for rapid health assessment and response by the Ministry of Health & Family Welfare. A 29-member clinical team comprising of physicians, pediatricians and gynecologists has also been positioned in Srinagar and all medicines and medical supplies that have been requested by the state government have been provided. Clean-up operations at hospitals in Srinagar have apparently started and once electricity and water supply is restored, these hospitals will also start taking on the patient load in an incremental manner.

4. Does the WHO believe that UN aid/assistance should be given to Kashmir?

5. What is the WHO’s view on India’s refusal to accept UN aid.

As United Nations specialized technical agency for health WHO is mandated to assists the national government in the response starting from the early recovery phase to tackle the public health consequences of a disaster and not at the search and rescue / relief phase. When the country has sufficient resources and capacity to mount an effective response in a timely manner in accordance to the scale of the disaster, WHO assistance may be limited to normative guidance on technical issues related to the public health response. WHO has been in constant communication with the Ministry of Health and Family Welfare, Government of India and is cognizant of the response efforts. The government has been intervening to tackle the potential adverse public health consequence of this disaster especially as related to water and sanitation and control of communicable diseases.

6. Any other information in relation to this disaster would be useful.

Please refer to:

http://www.searo.who.int/india/areas/health_systems/JandK_floods/en/

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