Political Unrest and Mental Health in Srinagar N A S I R A L I A N D ...
Political Unrest and Mental Health in
Srinagar
N A S I R A L I A N D S U R I N D E R J A S W A L
This paper reports on the impact of the on-going political unrest in Srinagar on
the mental health of low-income urban people in Srinagar. The Kashmiri transla-
tion of the Self-Reporting Questionnaire 20 (SRQ-20) was used to assess current
psychiatric morbidity in the respondents in Baramulla. The SRQ-20 was validated
against the ICD-10, which was used as a gold standard. A cut-off of 11/12 was
arrived at by testing for sensitivity and specificity. The findings of the study
indicate high mental health morbidity in the respondents, especially in homemak-
ers and in unskilled workers as a result of the on-going long-term unrest and the
consequent trauma in the region.
Dr. Nasir Ali is a Health Administrator, currently pursuing further studies in
Australia, and Dr. Surinder Jaswal is Reader, Department of Medical and
Psychiatric Social. Work, Tata Institute of Social Sciences, Mumbai.
INTRODUCTION
The World Development Report (World Bank, 1993) estimates that
minor psychiatric morbidity (mainly anxiety and depression) consti-
tutes 90 per cent of the mental ill health in community settings in
developing countries. Moreover, mental health problems are grossly
underestimated in these countries not only due to lack of reporting of
their prevalence, but also due to underplaying of the significance of
these diseases (Harpham and Blue, 1995).
There is increasing recognition that mental ill health is a problem
in developing countries and that it causes a great deal of suffering and
places a considerable burden on national budgets. A review of a
cross-section of studies from developing countries, recognising in-
creasing mental ill health associated with, among other things, urban-
isation, has advocated more attention to mental ill health in rapidly
urbanising developing countries (Harpham and Blue, 1995).

Political Unrest and Mental Health in Srinagar 599
Recent literature on mental health in developing countries (Blue,
Ducci, Jaswal, LedermirandHarpham, 1995;Ekblad, 1995;Marsella,
1995; Srinivasa Murthy, 1997; World Health Organisation, 1992)
highlights the vulnerability of the low-income communities to mental
ill health. The studies conclude that the cause of illness in the respon-
dents is due to the socio-political environment in which they live. The
environment is responsible for mental health deterioration rather than
misconceived biological factors. The fears experienced by low-income
groups include losing esteem, income, love and employment. These
fears cause insecurity and incapacity to deal with everyday problems
(Blue and others, 1995).
The relationship between mental health and chronic conflict situ-
ations, such as political unrest, is poorly researched in developing
countries (especially in low-income urban groups). This paper reports
on the findings of a study which explored the impact of political unrest
and mental health in low income urban households in Srinagar by
studying the prevalence of minor psychiatric morbidity in the people
and by seeking to understand the experience of the on-going political
unrest on peoples' lives. The study also explored the peoples' response
(coping) to minor psychiatric morbidity.
Violence has become an integral constituent of Kashmiri life. The
reins of terror are in the hands of gunmen. Through kidnappings,
bombings, assassinations, religious blandishments and press censor-
ship, the secessionists have virtually achieved administrative and
psychological severance of the valley from India. The indiscriminate
killings and the panic and fear gripping the hearts of Kashmiris has
become a way of life. More than 90,000 Kashmiri Pandits have fled
their homes due to fear and the threat of impending danger and political
unrest (Ali, 1997).
The low-income urban community in Kashmir is perhaps the most
vulnerable not only in terms of overall economic deterioration but also
in terms of social security and the constant threat they face from both
the militants and the security forces by becoming 'soft targets' of
various atrocities (Ali, 1997).
THE STUDY
The study was conducted in the Baghat Barzulla area in Srinagar district.
This area has a population of around 10,000 and is situated at a distance
of 3 kms. from 'Lalchowk', the heart of the city. The area is primarily
residential with people from both high and low income groups living here.

600 Nasir Ali and Surinder Jaswal
The majority of the low income groups are small-scale businessmen
and daily wagers. Some of the residents are teachers, others govern-
ment employees and some are unemployed. In order to study the
impact of political unrest on the mental health of the community, men,
women and children as well as young adults and older people were
included in the study. A total of 25 households were selected for the
study.
Households, which had at least four members across three age
groups (children, young and older adults), a monthly income of Rs.
3000/- or less and were willing to participate in the study, were
included in the sample. Respondents were further selected only if they
had faced no major life event in the previous year, that is death in the
family, accidents, trauma, and so on, as these factors could contribute
to mental ill health and, hence, act as cofounders in the interpretation
of the results (mental health and political unrest).
Thus, respondents were selected purposively based on the above
criteria. A rough map of the whole area was prepared and the area was
surveyed so as to select the households based on the criteria outlined
above. A total of 100 respondents, across 25 households, were selected
for the study. Of these, 27 were children and young adults in the age
group of 12-19 years, 51 were adults between 20-49 years and 22 were
older adults in the age group of 50 years and above (see Table 1).
The study was conducted in two phases using a combination of
quantitative and qualitative methods. As no data was available on the
current prevalence of minor psychiatric morbidity in Srinagar, a quan-
titative study was initially undertaken to assess the prevalence of minor
psychiatric morbidity in the low income urban households.
The Self Reporting Questionnaire 20 (SRQ-20) was used as a
screening instrument or more precisely as a case finding instrument
for minor psychiatric morbidity. In the framework of a collaborative
study on strategies for extending mental health care (coordinated by
the World Health Organisation), the SRQ-20 was developed as an
instrument designed to screen for psychiatric disturbance in primary
health care settings, especially in developing countries (Harding, De
Arango, Baltazar, Climent, Ibrahim, Ladrigo-Ignacio, Srinivasa Mur-
thy and Wig, 1980). In recent years, the SRQ-20 has been used in some
30 studies from which its psychometric properties can be assessed. The
SRQ-20 is an instrument with proven reliability and validity consisting
of 20 items which question the respondent about symptoms and
problems likely to be present in those with neurotic disorders. The SRQ

Political Unrest and Mental Health in Srinagar 601
20 consists of 20 close ended questions which have to be answered by
a 'yes' or 'no'.
The SRQ-20 was translated into the local Kashmiri language and
the questions put forward to the respondents. An attempt was made to
translate the questions in Kashmiri as accurately as possible so as to
retain the validity of the data. Each respondent in the household was
interviewed separately. A cut-off score of 11/12 was arrived at after
measuring the sensitivity and specificity of the tool in the Kashmiri
community. The sensitivity and specificity figures for the validity
sample were calculated for various cut-off points using the decision
matrix advocated by the World Health Organisation (WHO)( 1994). A
sensitivity and specificity of 84 per cent and 100 per cent were obtained
using 11/12 as the cut-off point. The sensitivity figure (84 per cent) for
the study is high indicating that the probability of testing positive if
the disease is truly present is good. Specificity for the study (100 per
cent) is very good and indicates that the probability of screening
negative if the disease is truly absent is high.
The responses from the SRQ-20, were validated against the Inter-
nationa] Classification of Diseases-10 (ICD-10) using it as gold stand-
ard. The ICD-10 was applied by a trained psychiatrist in the field on
the respondents selected by the researcher. The psychiatrist was blind
to the SRQ-20 score of the patients, so as to avoid researcher bias.
In the second part of the study there was purposive selection of
households, based on their willingness to participate in the study,
experience of mental ill health by at least one member in the household
and the respondents' ability to reflect and communicate on the subject.
The interviews were conducted in the homes of the respondents with
the help of an interview guide.
RESULTS
Socio-Demographic Profile of Respondents
The table below shows that most of the respondents (52 percent) were
in the 20-50 years, followed by those in the 12-19 years age group (27
per cent) with 21 per cent in the older age group. Among the men, 69.6
per cent had studied beyond matriculation, with some of them being
even graduates and post-graduates. Thirty per cent were not able to
complete their education up to the tenth class and 30 per cent of the
respondents had not received any formal education. The last group
comprised mostly the older male population.

602 NasirAli and Surinder Jaswal
TABLE 1: Socio-Demographic Profile of Respondents
Variable
Male
Female
Total
N=100
Age
12 to 19 years
13
14
27
20 to 50 years
20
30
52
50 years and above
18
3
21
Education
Above Matric
16
7
23
Under Matric
21
10
31
Uneducated
16
30
46
Marital Status
Married
37
32
69
Unmarried
16
15
31
In the female respondents, only about 15 per cent had passed
matriculation, 21.3 per cent had some sort of formal education, but
could not complete matriculation, and a large proportion of about
approximately 64 per cent had no formal education. This major group
comprised mostly middle-aged homemakers. About 69.2 per cent of
the respondents were married.
Further, six per cent of the respondents were skilled professionals
like tailors, craftsmen (carpet weaver), wazas (cooks), carpenters,
masons, shawl weavers, plumbers, and so on. Twenty per cent were in
the semi-skilled category: gardeners, bread-makers, teachers, cycle
mechanics, painters, caterers, and so on. The unskilled category com-
prised labourers, preachers, businessman, clerks, peons, daily wagers,
shop owners, and so on. Homemakers, students and the unemployed
contributed comprised 28, 15, and five per cent respectively.
Incidence of Minor Psychiatric Morbidity
Thirty-seven per cent of the respondents reported minor psychiatric
morbidity, on using 11/12 as the cut-off point. Table 2 shows that of
the 37 cases reporting minor psychiatric morbidity, 21 per cent were
in the 12-19 years age group, 62.2 per cent in the 20-49 years age
group and 29.7 per cent in the age group of 50 years and above.
Among the children and teenagers/adolescents (12-19 years) and
young adults, of the 27 members interviewed, 24 (that is 88.9 percent)
did not report morbidity, and three (11.1 per cent) reported minor
psychiatric morbidity. In the age group 20-49 years, a very high
incidence of minor psychiatric morbidity was reported. The total
number interviewed in this group was 52, including both males and
females of which 23 (that is, 44.2 per cent) reported minor psychiatric
morbidity. In the older age group (50 and above), of the 21 individuals

Political Unrest and Mental Health in Srinagar 603
interviewed, 11 respondents (52.9 per cent) reported minor psychiatric
morbidity, thereby indicating the presence of very high minor psychi-
atric morbidity in this age group.
Of the 53 males interviewed, 22 (41.5 per cent) reported psychiatric
morbidity. In females, 15 of 47 respondents (31.9 per cent) reported
minor psychiatric morbidity. Thus, males reported higher incidences
of minor psychiatric morbidity than females.
On looking at the marital status and the SRQ-20 score, it is evident that
in the married group, of the total respondents, 31 (that is, 45.6 per cent)
reported minor psychiatric morbidity. In the unmarried group, of 31
respondents, five (16.1 per cent) reported minor psychiatric morbidity.
One widow, who was interviewed, reported minor psychiatric morbidity.
Some respondents in the matriculation category were graduates
and post-graduates. In this group, the total number of population
interviewed was 23. Of these, 10 (that is 43.5 per cent) reported
minor psychiatric morbidity. In the below matriculation group,
consisting of mainly young adults, children and women, of the 31
respondents interviewed, seven (22.6 per cent) reported minor
psychiatric morbidity. In the group with no formal education, most
of the respondents consisted of the older persons and homemakers.
In this group of 46 respondents, 20 (43.5 per cent) reported minor
psychiatric morbidity.
It is evident from the above that both the respondents who had
completed their matriculation as well as those with no formal educa-
tion, the reporting of minor psychiatric morbidity was surprisingly
equal, that is 43.5 per cent, thus indicating that education was no buffer
for psychiatric morbidity or that the impact of political unrest was
similar on both groups. Reporting of psychiatric morbidity was lower
in the 'below matriculation' group.
Under 'occupation' homemakers and unskilled workers reported
the highest psychiatric morbidity. In the group where the approxi-
mate income was between Rs. 500-1,500, the SRQ-20 was admin-
istered to 18 respondents. Of these, five (that is 17.8 per cent) had
SRQ-20 scores of 11 and above, indicating minor psychiatric mor-
bidity. In the income group of Rs. 1,500 and above, a high incidence
of minor psychiatric morbidity was found. Of the 30 respondents
interviewed in this group, 15 (50 per cent) had a score of 1 1 and
above, indicative of mental illness, that is minor psychiatric mor-
bidity. Of the total respondents having minor psychiatric morbidity,
23.2 per cent were in the Rs. 500-1,500 income group and 71.4 per

604 Nasir Ali and Surinder Jaswal
cent were in the Rs. 1,500 and above income group. Thus, people with
comparatively higher incomes reported higher minor psychiatric mor-
bidity. Respondents with two or more children also had higher
psychiatric morbidity.
TABLE 2: Presence of Minor Psychiatric Morbidity
Variable
Absence of
Presence of
Row Total
Current
Current
Psychiatric
Psychiatric
Morbidity
Mobidity
(1-10)
(11 & above)
N = 63
N = 37
Age
12 to 19 years
24
3
27
20 to 50 years
29
23
52
50 years and above
10
II
21
Sex
Male
31
22
53
Female
32
15
47
Marital Status
Married
37
31
68
Unmarried
26
5
31
Widow
1
1
Educational
Above Matric
13
10
23
Qualification
Under Matric
24
7
31
No formal education
26
20
46
Occupation
Skilled
3
3
6
Semi-skilled
13
7
20
Unskilled
14
11
25
Housewife
16
12
28
Student
12
3
15
Unemployed
4
1
5
Income (in rupees)
Income Nil
1
1
500-1,500
13
5
18
1,500 and above
15
15
30
Effect on Mental Health
Respondents reported that the on-going political unrest affected their
mental health by impacting on their daily lives, on the children's
education and on the economic condition of the valley. Figure 1 shows
the cycle of deteriorating economic condition on the mental health of
the respondents.

Political Unrest and Mental Health in Srinagar 605
FIGURE 1: Viscous Cycle Of Deteriorating Economic Conditions and Mental
Health
DECREASED PRODUCTIVITY
Implications for Day-to-Day Life
Case Illustration 1
A 50 year old man, married with three children, with no formal
schooling and a waza by profession.
Difficulties! Our whole life has become one big difficulty. I swear
by God that since this gun [unrest] has come my life has become
chaotic. My work [earnings] is almost zero. I had to sell my small
piece of land in order to feed my family. I do not know what will
happen when that amount finishes. My daughter is no more a child.
I have to get her married. This is my concern. I am always preoccu-
pied as to how I will fulfill my responsibilities.
Tension is the only problem. I know it will kill me. I am not scared
of bullets whether of the CRP [Central Reserve Police] or the
militants; my own tension will kill me. When my children go to
work in the morning, I do not know whether I will see their faces
again. The whole day I have headache and when they come back I
feel relieved. Last year my neighbour's son was kidnapped and they
(militants) took 20,000 rupees for his exchange. I have told my
children so many times to go out of the State and work, but they do
not agree. When your life is like this how can they progress in life!
These problems are not only with us; my whole neighbourhood
feels like me. But whom to tell! Sometimes in a crackdown [by state
defense forces] we get beaten by CRP, sometimes militants threaten

606 NasirAli and Surinder Jaswal
to kill us if we do not provide space in our houses — we are caught
between two guns. You won't believe I just sleep 2-3 hours at night.
If there is a small noise at night I get shaken. I have to shift my
children to my room to provide them [defense personnel] space.
Even my youngest child is getting influenced by them. When he
sees guns and money with them, he wants to become like them. My
wife is a patient of blood pressure [suffers from hypertension] and
will definitely die if this continues.
The above views about the present political turmoil are expressive
of the difficulties people face in their day-to-day life in Kashmir. One
family in Barzulla, whose house is close to a bunker, said, 'We are
never sure what is going to happen next. The thought them firing at us
always hangs over us'. In a totally uncertain environment, these
helpless residents of Barzulla live under a constant threat. The prime
fear for women and people belonging to the older age group is for the
the well-being of their children. As a mother said, 'The whole day I
am on thorns as I do not know whether I will see the faces of my
children again when they leave for work'.
Bus travel is also an ordeal for working women. Militants and defense
forces stop vehicles and order the men to come down and start frisking
women. As some women reported, 'Search is only a pretext, they begin
fondling our bodies and we cannot do anything'. Women are also forced
to unveil themselves, as a female teacher reported this:
One day I was travelling in a bus. The army stopped it and ordered
the men to come down. Then they started frisking women and forced
them remove their Burkhas. I requested that they bring lady police
for searching women. But they turned down my request and un-
veiled me at gun point.
'The militants have used their increased militancy and political
power to engage in abuses against the civilian population,' reflected
an engineering student. 'We are crushed between guns. Our days begin
with fear and end with fear.'
'Pick' was a local term widely used by respondents to indicate
kidnapping. The word was used to communicate that somebody had
been kidnapped for a ransom by one group or the other. Respondent
stated,
Last year my neighbour's son was 'picked' and they (militants) took
20,000 rupees for his exchange. I have told my children so many
times to go out of the state and work, but they do not agree. When
your life is like this how can they progress. These problems are not
confined to us, our whole neighbourhood feels like this, but whom

Political Unrest and Mental Health in Srinagar 607
to say this to. Sometimes in crackdowns which are there every
alternate day, we get beaten, our children get beaten and at the same
time militants threaten to kill us, if we do not provide space in our
houses. We are caught between two guns.
A Human Rights Report by Justice Tarkunde (substantiates the
terror and misery of the Kashmiris. According to this report, the people
in the Valley are terror stricken. In their daily life, they are constantly
haunted by the fear high handedness of the security forces and barbar-
ity and repression of the militants. Even the literate class and persons
of conscience who can raise a voice against the repression, cannot do
so for they fear reprisal.
Implication for Education
An old man related the segregation of the pen to segregation of Kashmir
from India as he argued that if their children remain uneducated, then
they cannot have access to reputed national institutes in the country
and blend with its (Indian) culture. Thus, they have no alternative but
to get entangled with the gun culture, which will remain their prime
source of income. On the other hand, some women even considered
the closure of schools a blessing in disguise as their children were safer
at home. But most of the parents, with some educational background,
said that the closure of educational institutions had crushed their hopes
of seeing their children prosper.
A school teacher revealed that the political turmoil had not only led
to increase in drop-out rate from schools, but had also degraded the
quality of education. While revealing his experiences, he expressed
that examinations were a mockery, 'Open market sale of question
papers has put forth a new challenge before us. If this trend continues,
a day will come when the edifice of educational system in the valley
will crumble. By remaining a mute spectator to this ongoing assault
on our educational set up, we will be pushing our future generation
into a whirlpool of agony and misery'. The implication of political
unrest on education and the vulnerability of the students to constant
stress and strain is clear from the high reporting (43 per cent) of
psychiatric morbidity in matriculates and above.
Implication for Economic Condition
Preoccupation with the economic crisis was an important issue brought
out by the respondents. The businessmen were of the opinion that ever
since the political turmoil, they had lost their zehni tamadan (mental

608 Nasir Ali and Surinder Jaswal
peace) as they were always preoccupied about how to sustain them-
selves. Among them, the businessmen who solely depended on the
tourist industry were the worst affected. A businessman who had a
carpet weaving business and who also owned a a little shop stated,
'Those who can afford have left and started business somewhere else,
but what about us, we are crushed. Even if we go out just to sell some
items we will be called 'Indian agents' and 'they' will kill us. I wish I
was a government employee who gets his pay even if he does not
work'.
On the other hand, government employees complained that as the
government machinery has collapsed, their day-to-day work and lives
were guided by militants and this had brought them to a stage where
some of them were even prepared to leave their jobs. The direct
influence of militants in terms of threats left them with no alternative,
but to quit their jobs. As one government employee said, 'A job is
meant for earning to live, not losing your life'.
'Money has finished', and 'how are we going to eat' were the
statements spontaneously stated by many respondents. A teacher ex-
pressed how, in the existing economic crisis, even students have
stopped paying the fees. 'You cannot stop teaching them. I have started
to spend what I have saved for my daughter's marriage. What will
happen next when it finishes? With this preoccupation, it is a torture.
It is better that they kill us once and for all, rather than dying a little
everyday like this'.
Implications for Mental Health
'We are forever ill', commented a middle-aged housewife. 'How can
we remain happy and healthy when our zehan is constantly worrying
for our men and children who go out in this turmoil. Money can come
again, but if a life is lost can it come again'? Constant recurring
symptoms like headaches and sleeplessness were reported very fre-
quently by the respondents. Local terms like pharat (fear/threat) were
commonly used. Complaints of 'sleeplessness were found not only in
adult men and women, but also in teenagers and children. On probing
for the possible reasons for such complaints, the researcher found that
the pharat of the midnight knock was reported as the main cause. Some
related their ill health to preoccupation with deteriorating economic
conditions, while others associated it with worry for children. How-
ever, the overall cause was enmeshed in the present political turmoil.

Political Unrest and Mental Health in Srinagar 609
Accessibility to health services was a major problem reported.
Some respondents reported that in case of sudden illness at night, no
health services were available to the patient until morning, as the
security forces did not let anybody come out of their homes at night.
'After evening, our life is a hell. It is not only physical torture for the
ill person, but mental anguish for all of us'.
Figure 2 clearly outlines the social and economic factors impacting
on the mental health of the respondents.
FIGURE 2: Effect of Political Unrest on the Mental Health of Urban Kashmiris
SOCIAL CAUSES
ECONOMIC CAUSES
Deteriorating children's education
• Tourist turnover nil.
• Infrastructure burned
• Close down of tourist dependent
• Increase in dropouts from school
business establishments like, hotels,
Social Isolation
shikaras, carpet sellers, shawl and
• Restricted movement of especially
so on
women
• Interference in government jobs
Increase in number of deaths of known
• Unemployment
persons
• Other businesses stagnant, poor inputs
• Mourning
from other states
• Fear
• Intrusion of money by one group or
Suspicion of each other
another
• Loss of trust
• Hartals, curfews
• May be an informant (mukhbir)
• Poor condition of daily wagers
POOR MENTAL HEALTH
Constant Tension
Sleeplessness
Headache
Detachment
Irritability
Depression
Constant Fear
DIRECT AND INDIRECT THREATS
Midnight knock at doors
Warlike environment — Increased number of bunkers, military operations,
crackdowns, interrogations, and so on.
Increased number of deaths of known or unknown people by unnatural causes: cross-
firing, interrogation centres, and so on.
COPING WITH THE 'TENSION'
To understand the people's response to the current political unrest in
Kashmir, the different coping strategies used by respondents were

610 Nasir Ali and Surinder Jaswal
probed (Figure 3). The responses varied and were not always clearly
defined. One reason for this could be that due to chronic stress faced
by the respondents in the last seven years, these coping strategies have
become a part of their day-to-day life and the respondents cannot
distinguish them as strategies to cope with the current stress.
FIGURE 3: Nature of Coping Strategies Used by Respondents
Respondents used mainly two types of coping strategies: internal
strategies (such as praying, crying, suffering in silence, emotional
breakdowns like crying and self-beating, thinking it over, day-dream-
ing, and fantasising); and external strategies (such as talking it over,
violent attitude, frequent quarrels at home, engaging in different
activities such as formation of mohalla groups, committees, "and so
on).
Apart from these strategies, some used a combination of both
external and internal strategies. Harari and Kaplan (1977) also sug-
gested that avoidant thinking is a way to cope with stress. People can
avoid uncomfortable situations by turning their attention away from it
or by thinking about other things. Coping, as a concept, is process

Political Unrest and Mental Health in Srinagar 611
oriented. Coping is directed towards what the Kashmiri actually thinks
and does within the context of the experience of political turmoil, and
how these thoughts and actions change as the experience unfolds itself.
Due to varied responses about the coping strategies used, no clear
coping strategy could be identified for specific situations by a particu-
lar group of respondents. However, various methods such as 'talking
it over', 'praying and crying' and 'suffering silently' were reported by
almost all the respondents. There was not much of a difference between
the number using internal methods of coping and those using external
methods.
Comparison of other variables like education with the coping
strategy did not reflect a difference between those who received formal
education and those with no formal education. This could be due to
the fact, that both the educated and uneducated are being exposed
equally to the impact of political unrest in their day-to-day life.
'Talking it over' was again a commonly used coping mechanism in
the educated group, but combination of other coping strategies like
'suffering silently', 'praying and crying' were also used.
Talking it Over
A majority of the respondents in the adult age group affirmed use of
the coping strategy which involved 'talking it over with others': the
'others' included close friends, family members and relatives. A point
to be emphasised is that in one of these 'talks' observed by the
researcher, the discussion revolved round the day-to-day incidences
related to political unrest like crackdowns, killings, bomb blasts, and
so on. This type of coping strategy was observed both in male as well
as female adults, irrespective of sex, education, and so on. These
discussions were confidential and only took place with utmost care
with close and trusted individuals.
Praying and Crying
This was another popular coping mechanism observed in a majority
of adult females and elderly respondents. Interestingly many of the
female respondents quoted, 'After we finish our household chores, we
sit on the Jai Namaz [prayer mat] the whole day, praying and crying
for the return of our men from work and for forgiveness of our sins
that has led to the present political turmoil'. ,:..:.

612 Nasir Ali and Surinder Jaswal
Suffering Silently
This was a response which could not be measured quantitatively.
Almost all the respondents reported that this coping strategy had been
used in the beginning years of political unrest, but now 'suffering
silently' was not possible as 'water had gone over their heads'.
To illustrate the combination of coping strategies used, a case study
of a middle aged Kashmiri woman is given here. Farida Begum, wife
of a daily wager, married for the last 20 years, and a mother of two,
living in a three room hut in urban Srinagar expressed her views
regarding the political turmoil and a reflection on the combination of
coping strategies used.
Tabahi [destruction] is the only thing we are seeing for the last seven
years in Kashmir. Kashmir is burning, we have lost our children,
our livelihood. So many lives have been destroyed. Those who are
living are in constant pharat and pain. I have seen a mother whose
four sons were killed by security forces. If this continues Kashmir
will be a desert, and not a single soul will survive.
I do 'cry' often on seeing what is happening. I 'pray' day and night
for the day when I see the military [security forces] going back and
Aman in the valley. Sometimes, I feel like 'bursting open'. I cannot
restrain myself, at times and 'cry and beat my chest' hours together
whenever I see faces of young boys who are massacred by the
security forces in the newspaper.
My husband is a member of the 'mohalla action committee'. There
they discuss whatever is happening and all of us have to contribute
25 Rupees per month, which is given every month to a family like
us on rotatory basis, because how else can we survive, if this
continues.
DISCUSSION
Measurement of Mental Health in Low-Income Urban Groups
It is currently estimated that at least 500 million people in the world
suffer from mental disorders and that only a small proportion of them
receive appropriate care. In Kashmir, in the present turmoil, various
reports published by social organisations like the People's Union for
Civil Liberties (PUCL) highlight the alarming rise of minor psychiatric
morbidity and their neglect in terms of non-identification, treatment
and referral.
In the current study, the cut-off point for minor psychiatric morbid-
ity by using SRQ-20 was found to be 11/12. This, in itself, reveals a

Political Unrest and Mental Health in Srinagar 613
very high cut-off. Recent studies in India in low income urban groups
(Jaswal, 1995, 2000) have used 7/8 as the cut off point for measuring
minor psychiatric morbidity. The cut-off scores in countries such as
Brazil, Chile, Columbia, Ecuador, Ethiopia, Guinea-Bissau, Hong
Kong, Kenya, Malaysia, Spain, South Africa, Sudan, United Arab
Emirates, the United Kingdom and Zimbabwe, have been found to be
in the range of 3/4 to 10/11 (WHO, 1992). Earlier studies in India
which have used the SRQ-20 (Deshpande, Sundaram and Wig, 1989;
Dhadphale, Ellison and Griffin, 1982; Harding and others, 1980; Sen,
1987) have also used a cut-off of 10/11, 7/8, 5/6, and 7/8 and 1 1/12
respectively. The cut-off of 11/12, thus, signifies a relatively high
threshold for minor psychiatric morbidity.
Further, an overall morbidity of 37 per cent was reported by the
respondents indicating a high prevalence of minor psychiatric morbid-
ity. Jaswal (1995) reports a prevalence of 17.9 per cent in a general
population of low-income urban women in Mumbai. The prevalence
increased to 27.5 per cent for women reporting gynaecological mor-
bidity. Older women and women who were isolated reported the
highest psychiatric morbidity. In another study (Jaswal 2000), of
low-income urban women reporting to a health facility and facing
different forms of violence, 55 per cent of the women reported minor
psychiatric morbidity when 7/8 was taken as the cut-off point.
In the current study, amongst those reporting psychiatric morbidity,
respondents between 20-50 years reported 52 per cent of the morbid-
ity. Further, married respondents reported higher morbidity as well as
those without any formal education. It is also seen that homemakers
and unskilled workers report high psychiatric morbidity. Thus, respon-
dents in the employable age group with fewer alternatives (unskilled
workers and homemakers) and those with dependants (married) are
seen to report higher morbidity. Figure 2 clearly outlines the social and
economic causes leading to poor mental health in these respondents.
This profile of psychiatric morbidity is different from findings of other
studies in low-income urban groups in India.
Mental Health And Political Unrest
Srinivasa Murthy (1997) recognises that 'the need of the population
arises from the uncertain and threatening situation which changes from
day to day with associated decreased feelings of security and mental
tension'. He reiterates that 'the stress arises from lack of control day

614 Nasir Ali and Surinder Jaswal
to day activities and lack of predictability and inability of the individu-
als to take or initiate action at their own level'.
A renowned psychiatrist from Kashmir (Beigh, 1992) also
reports that the preliminary enquiry conducted by the PUCL
about tension related diseases, torture related mental imbalances,
militancy related deaths, and excesses committed by the para-
military forces presents a very gloomy picture. It reveals that the
turmoil in Kashmir, marked with brutal violation of human
rights, has injured a large number of Kashmiris, physically and
mentally. Beigh (1992) further reports that a large number of
patients can be seen queuing outside psychiatric clinics and the
social life in Kashmir is under the shadow of the militants and
Khaki clad men. This has made deep impressions on the minds
of people. The dances of death in and around the bunkers have
made life miserable for the people and many inhabitants of
'pressure areas' (where the military operations are carried fre-
quently) in Srinagar now complain of mental ailments.
An investigation by the PUCL into the rise of psychiatric problems
also reveals the severity of the problem in the valley. They reported that
in the last two years there was an increase in depressive disorders by 20
per cent, anxiety related disorders by 30 per cent and hysteria by 10-20
per cent. The cause of such an increase in minor psychiatric morbidity
was related with the political turmoil in the valley.
The PUCL explained that the causes of mental ill health are
either embedded in unnatural life events like untimely death of
a friend or a relative, loss of life and property in firing, constantly
perceived threats and fear in interrogations, crackdowns, and so
on. These findings are strikingly similar to the findings of the
current study. Beigh (1992) also reports that many people, young
and old, are found to be carrying sedative strips like valium and
calmpose in their pockets and complain of insomnia (sleepless-
ness), headaches and fatigue.
Striking similarities to the above study are found in the current
study. Respondents reported that pharat revolved around the survival
of oneself. Social isolation, in terms of restricted movements after the
office/work hours, was an important factor brought out by some of the
male respondents. 'We feel we live in jail' and 'Our life is tied by
a rope' were some of the analogies used by the respondents in
explaining the amount of stress and constraints they faced in their
day to day life.

Political Unrest and Mental Health in Srinagar 615
CONCLUSION
Strengthening of Mental Health Care Components in the Public
Health Care System
In India, in the public health care delivery system, mental health has
the least priority. This holds true for Kashmir too. Community mental
health or primary mental heath is not recognised as it may not always
elicit physical morbidity. In Srinagar, the main mental health care
delivery system has remained within the four concrete walls of the
psychiatric hospital run by government medical college. There is an
urgent need to reach mental health care services to primary health care
facilities such as urban health posts and clinics in various parts of
Srinagar as well as in the state as a whole. It is universally known that
in conflict situations, health professionals see people experiencing
distress more than any other group. Thus, sensitisation and training of
general practitioners as well as other health personnel to mental health,
particularly minor psychiatric morbidity is essential. Besides this,
specialised psychiatric services for those experiencing bereavement,
physical harm, terrorism, hostage and related experiences should be
available.
Social and Psychological Support
Since the Kashmiris are leading a life under constant threat and fear,
certain preventive measures need to be taken in order to stop further
social and emotional ramification in the present turmoil in the valley.
One of the most essential services that should be made available at
public dispensaries is that of a social counsellor. The researchers
realised this during the interview sessions, when the respondents were
sharing their personal experiences, that fear of their condition and
inability to express and share their feelings was an important factor
contributing to minor psychiatric morbidities.
. One of the most vulnerable groups in the present situation in
Kashmir are the unemployed youth and daily wagers. Due to the
on-going political unrest, labour intensiveness in the private sector and
other industries is receding leading to more unemployment. Instability
in day to day life has made the survival of daily wagers difficult. This
frustrating experience, along with the political turmoil, if allowed to
continue may not only lead to major psychiatric morbidities, but may
also lead to psychosocial problems such as drug addiction and alcohol

616 Nasir Ali and Surinder Jaswal
abuse. Social workers/counsellors are required, to counsel these youths
in vocational guidance as well as to provide information and support.
Social organisations need to provide support to the homemakers,
through formation of local support groups as they mostly spend the
whole day in mental anguish, waiting and praying for the return of their
husbands and children. Constant fear has become a part of the daily
routine of these women. To break this vicious circle of fear and despair,
self-help groups can be formed, which provide both psychological
support as well as some economic help. This would help to decrease
the feeling of helplessness and isolation and not being part of the larger
social situation.
Concept of Mental Health
There is growing evidence from both developed and developing coun-
tries that the prevalence of common mental disorders or minor psychi-
atric morbidity is high and that certain groups such as urban
low-income populations and women are particularly vulnerable. How-
ever, programmes such as Structural Adjustment Programmes and
other forces of globalisation have put the populations of developing
countries and particularly these populations at risk of mental ill health.
Increasing conflict between neighbouring countries and ongoing po-
litical unrest within the country are also putting more and more people
at risk of mental ill health. This study clearly highlights the impact of
chronic/long-term conflict on the mental health of the population.
In view of larger numbers of people requiring mental health serv-
ices, especially in the light of decreasing community and family
support (due to migration and decreasing resources), the need for
integration of mental health into primary health care is essential.
Further, the need to recognise and integrate the widening concept
of mental health such that illness related to conflict, trauma and
long-term stressors is identified and diagnosed by mental health pro-
fessionals is imperative.
NOTE
This paper is based on the M.A. Thesis of Dr. Nasir Ali (1997), submitted in partial
fulfillment of the requirements for the Master of Health Administration degree, Tata
Institute of Social Sciences, Mumbai.

Political Unrest and Mental Health in Srinagar 617
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