Acknowledgements
We wish to thank members of the Citizen's Initiative, ANANDI, SAHAJ, SAHRWARU, and PUCL - Shanti Abhiyan for the generous help and cooperation they extended to us during various phases of the investigation. We would like to thank Vinay Mahajan, Sejal Dand, Sheba George, Bhushan Oza, Dr. Rajesh Mehta, Bina Srinivasan, Ashok Bhargava, Dilip Mavalankar, Poonam Katuria, Bhavna, Renu Khanna, Sudarshan Iyangar, Dr. Hanif Lakdawala, Dr. Bashir, Dr. Shujat, Dr. Sadiq, Dr. Makwana, Dr. Patel, Dr. Ishaq, Dr. Chhaya, Dr. Kasbekar, Dr. Bharat Amin, Dr. Vijay Bhatia, Dr. Amit Mehta, senior officials of state health department, Ahmedabad Medical Association and Al Amin Hospital, who spent time in discussing various issues with us.
We are grateful to the camp inmates, organisers and the volunteers working in the relief camps for all the information they shared with us.
We would like to thank friends Sandhya Srinivasan, Nandita Bhatla and Ranjan De for their help in the process of editing, layout, cover design and final production of the report.
“Some 20-25 men gang-raped the young girls in this area, and then burnt all of them to death. I watched my own son and daughter-in-law being slaughtered. I have a grandson to look after, I don't know how I will cope with that responsibility.”
The mob attacked his wife who was nine months pregnant, and killed her. “Her womb was slit open by a sword and the baby was removed and thrown into the fire,” say the people gathered around this man. He himself is silent, in shock. He does not respond to anything.
“That little girl witnessed the death of her father and brother in front of her eyes. When the mob left, she tried to put out the flames with a blanket, but could not save them. She carries the same blanket in her hand and lives in her own world.”
“On February 28, we were taken to the fields,
stripped naked and gang raped. The next day, we somehow covered themselves
with the sheaves and dried leaves in the field and went to the police station.
But we did not get any help.
“But please don't ask us questions, we don't want
to talk about what happened. We don't want our names to appear in newspapers.”
Twenty-year-old A.A was shot in the abdomen by the police. He was operated upon twice. During the first surgery his perforated intestines were repaired but no bullet was found. A subsequent x-ray showed a bullet lodged in his vertebral column. A second operation was then performed to remove the bullet, which had injured the spinal cord and AA is paralysed from the waist downward. He also has severe and continuous pain in both legs. He will require systematic and life-long physiotherapy and rehabilitation as a paraplegic.
“...A youth was stabbed right inside the V. S. Hospital, run by the Congress-controlled Amdavad Municipal Corporation, in the presence of police. The youth was stabbed when he alighted from an ambulance carrying a patient stabbed in Juhapura locality when some Sangh Parivar volunteers were demonstrating against the alleged 'partisan attitude' of the hospital authorities against Hindu patients.”
The Hindu, May 8, 2002.
Introduction
Starting with the Godhra train massacre on February 27, Gujarat has been engulfed in unprecedented violence. Since then, in systematic and gruesome attacks unleashed against the Muslim community, some 2,000 people have lost their lives and an even larger number have been seriously injured. Over a lakh continue to live in relief camps. In a context where the entire state machinery stands implicated (reports by the National Human Rights Commission, Citizen's Initiative, and National Women's Panel), the issue of timely, appropriate and non-discriminatory medical care assumes crucial importance.
In any disaster, the response of the health services determines the quality of care provided to affected people. And in a natural disaster, medical care automatically becomes one of the first priorities of the relief effort. However, in such a crisis, social institutions break down and extraneous pressures are generated, threatening the provision of medical care.
Several fact finding teams went in and reported on the failure of state agencies to prevent violence. They also documented the complicity of various state agencies in perpetuating the communal blood-letting. However, there was very little information about how the health profession had responded. Disturbing news about the outbreak of epidemics in the camps, and descriptions of the appalling living conditions there, suggested that not enough had been done to provide relief to those who were forced to seek refuge. Hence, as an organisation working on health issues, Medico Friend Circle (MFC) felt the need to investigate the adequacy of medical relief efforts by the public health system.
Medical professionals are expected to perform their duties within an ethical framework that is above religious and political affiliations. The failure to do so can mean the difference between life and death. Communalisation can have serious repercussions on a society that has already been so deeply fractured.
On the other hand, in such a crisis, medical professionals could become particularly vulnerable because they must venture out and work in an atmosphere of violence. They may find themselves targeted by communal elements, both as members of a particular community and as medical professionals helping victims.
While individual professionals may have little control over events, the medical profession as a whole has a responsibility to show solidarity towards all its members. It must protect them from any pressures that prevent them from performing their professional duty in an ethical and humane manner.
In the context of the violence in Gujarat, there was little information on the impact on health professionals. As a body of socially concerned health professionals and activists, MFC saw the need to document the experiences of health professionals forced to work under such pressures, and to express solidarity with them.
The medical profession must also involve itself in the long and painful task of rehabilitation. In this context, it must be remembered that justice is an integral part of rehabilitation. Doctors have a duty to do their utmost to ensure that justice is done, by accurately and completely documenting information on the people they examine and treat. Post-mortem records, medico-legal complaints and doctors' statements all provide vital support to victims seeking compensation and filing cases against the perpetrators of violence.
Those who suffer physical disability, and the large numbers who suffer from mental trauma, also need the support of the medical profession to rebuild their lives.
Finally, health professionals have an additional ethical and social responsibility, as close witnesses of the effects of violence. They must play a role in documenting what is happening and informing other sections of society, in analysing the causes of violence and suggesting both immediate responses and long-term preventive measures. Indeed, there are many such instances of health professionals taking on this task.
In the current situation, where there is a deep threat to secular and democratic values, the medical profession must reflect on its own role. It must defend itself from external pressures, and also fortify itself from within. It must ensure that it upholds the humanitarian traditions of the healing profession and desists from becoming an accomplice to human rights violations.
It was against this background that MFC decided to conduct an investigation into the health impact of the unrelenting and horrific violence in Gujarat, and the role played by the public health system.
A. Specific objectives of the MFC investigation in Gujarat
This investigation is an attempt to document the experience of survivors as well as health practitioners. The specific objectives are:
We hope that this report will contribute to the discourse on people's right to health care in conflict situations, and the ongoing debates on medical ethics. This could also contribute to the development of protocols for medical treatment and examination in conflict and crisis situations.
B.
Visits by the investigation teams
Team 1 : Dates of visit:
April 15-18, 2002
Members : Ritu Priya, Sarojini N.B.,
Srinivasan S.
Team 2 : Dates of visit:
April 25-29, 2002
Members : Abhay Shukla, Dhruv Mankad,
Jaya Velankar, Neha Madhiwalla, Sunita Bandewar
Three of the MFC team members were medical professionals. The others were health researchers or health activists.
CAMPS
Amdavad:
Dariyakhan Ghummat(Jamalpur);
Shah Alam (Shahi Bag);
Jahangir Nagar (Vatva);
Jai Ambe Yuvak Mandal (Lathi bazaar);
Madhav Mill Compound camp (Gomtipur)
Vadodara
Khureshi Jamaatkhana (Mughalwada)
Panchmahals
Godhra;
Kalol village;
Dahod; Fatepura village
HOSPITALS:
Sheth Vadilal Sarabhai Hospital, Amdavad;
Civil Hospital, Sola (on the outskirts of Amdavad);
Al Ameen Hospital, Amdavad
OTHER LOCALITIES: Juhapura (Amdavad) and Khamasa (Amdavad)
C. Methodology
Relief camps: Teams of two or three persons, including at least
one doctor, conducted visits to the camps. On starting, we met the camp
organisers and recorded basic details about the camp. Later, one or two
persons met groups of women in the camps, and asked them to speak about
their health problems, and experiences with the health facilities. Team
members asked specifically if the people had experienced any discrimination
on communal grounds. In each camp, the teams interviewed all present, who
were specifically involved in providing health care, including volunteers,
doctors and paramedics. They were asked to give information on the services
provided, the types of health problems encountered, and their own experiences.
On being informed that state medical relief teams held daily 'vigilance meetings', team members obtained permission to attend one of these meetings, held at Civil Hospital, Sola.
Hospitals: Team members introduced themselves to hospital administrations as researchers conducting an epidemiological study on riot victims. They gave all details of their personal affiliations, as well as those of MFC.
They went to the various wards (such as general, orthopaedic, burns) where riot victims were admitted, and interviewed patients, reviewed medical records, and spoke to doctors and other hospital staff. Patients were asked about the incidents which resulted in their injuries, and about the quality of care they received. Health personnel were asked about the environment in the hospital, and the problems they faced. In addition, verification of reports of intimidation and attacks within the hospital was sought from the concerned doctors.
Riot-affected areas : Despite curfew restrictions and the on-going violence, the team made some attempts to interview residents in predominantly Muslim areas, to get an idea of their health-care related problems in the current environment.
Interviews were conducted with:
A. Development and organisation of the camps
Immediately after the outbreak of violence on February 28, people fled
to areas where their own community was in a majority, to safe public spaces,
mostly dargahs, madrassas and some schools, and sought refuge there.
These locations were converted into relief camps. New camps were set up
as the violence continued and spread to other areas.
In some cases, the camps themselves are transient, and repeated uprooting and resettling adds to the feeling of insecurity. In one rural camp, the team learned that the entire Muslim population of two villages fled across the border to Rajasthan to escape the mobs. While three people had been killed in the violence itself, one small child was crushed to death accidentally during their escape. This group stayed in two different locations in Rajasthan for nearly 10 days before returning to their village and setting up a camp there.
As of April 25, there were more than a hundred camps all over Gujarat. Official figures mention 68 camps in Amdavad alone, of which four reportedly have inmates entirely from the Hindu community. The team visited nine camps spread across Amdavad, Vadodara, Panchmahals and Dahod districts, including two rural camps. Of these, seven camps housed only Muslim families, one had both Muslim and Hindu inmates and one had only Hindu inmates.
None of the camps visited by the team was set up at the initiative of the government. The first source of support was from volunteers from the neighbouring areas, and individuals among the victims themselves. Official recognition of the camps came from March 6 onwards. The process by which the state government recognised camps took several days in many cases. Only then was the supply of provisions and medical care initiated. Till that time, the neighbouring community would supply food, clothes, medical aid and other necessities.
The camps continue to be organised and managed by volunteers, most of whom are young people with no previous experience of managing such a large-scale activity. The relief camps have been a crucial, and perhaps the most important, support for survivors fleeing from violence.
In the context of the camps, the present role of the state is limited to the provision of rations, water and medical care. The government has also set up rudimentary sanitation facilities in some camps. In many camps, these have been augmented by international organisations such as UNICEF. The Indian Red Cross also provided some relief material and medical aid. Other than this, in general, the team did not find a noticeable presence of voluntary organisations in the management of the camps. The local volunteers were largely left to their own devices.
The camps have been extremely important for the survival of those affected by the violence. Many of these people have lost their homes, all their belongings and even several members of their families. Apart from providing shelter, the camps supply food and access to basic amenities for bathing and washing. The camps give inmates a sense of security because they allow survivors to be together and support each other. However, the government has provided minimal or no security. Its attitude seems quite clear: victims' sustenance, and even safety, is the responsibility of the Muslim community itself.
In general, living conditions in the camps are extremely poor. In fact, the inmates do not even have adequate shelter. Whenever possible, those who need special care – the sick, injured, and those women who have just delivered or are in the last stages of pregnancy – spend the day with relatives and acquaintances in the neighbouring areas, and return to the camps at night.
General living conditions in the camps
Shelter : Most camps are located either in open grounds, with
usually minimal cover to protect from sun and exposure, or in community
buildings (such as wedding halls, madrassas or masjids),
and there is significant overcrowding. Though this basic problem was recognised
by Dr Makwana, chief medical officer, Amdavad Municipal Corporation, the
government has taken no action in this regard.
As the situation fails to improve, people continue to stay in the camps through the hot months of April and May. The facilities in camps are not equipped to deal with the scorching sun and heat. The cover in camps located in open spaces is often totally inadequate, exposing the inmates to the danger of dehydration and heat strokes. There are only a few durries to sleep on (usually not sufficient for the number of people), and no mattresses, in most camps. There is a need for sheets and bedding in most camps. In several camps, groups of small children were found on the bare ground in dusty, unhygienic conditions exposing them to the risk of gastrointestinal and skin infections.
The Kalol camp is housed in a compound of an abandoned primary health centre. Before the violence started, this compound was being used as an open toilet.
Even though the camps are recognised by the State, basic amenities have come from the local community. Thus, of the State-recognised camps the team visited, only in the Godhra camp were there comparatively adequate arrangements, with several large pandals, and even fans.
Water for drinking and bathing: In the five urban camps visited by the team, water was often provided from large tanks, which were refilled daily by the Amdavad Municipal Corporation. Chlorine tablets are supplied for disinfecting the water. The water is stored in plastic tanks, becoming quite hot during the day, and is very difficult to drink. Also, the quantity of water is not always adequate for bathing and cleaning. Bathrooms or bathing spaces are either inadequate or not available, and there is no provision for soap.
Toilets: In most camps visited by the team, toilet facilities were far from satisfactory. Even according to official figures for camps in Amdavad, as of April 25, 2002, there were only 573 toilets for 55,186 inmates – or just one toilet for 96 persons. Further, existing facilities were fewer than what was provided for on paper. For example the Jehangir Nagar camp was supposed to have 15 toilets, but on inspection the team found only six. Some toilets and bathrooms have been erected by UNICEF in camps in Amdavad. Again, in the Godhra camp, the toilet and bathing facilities were found to be comparatively better.
Rural camps often did not have any toilets at all; if they were available, they were not utilised, people preferring to use the open fields.
Overall, living conditions in camps were abysmal, without basic infrastructure, and with no privacy.
Food for camp inmates
In Amdavad, the government has issued cards to inmates, to receive the following daily rations per person: 400 grams of wheat flour, 100 gm rice, 50 gm dal, 50 gm sugar, 50 gm oil, and 50 gm milk powder. Similar rations are being supplied in other areas as well. The government has also sanctioned a daily allowance of Rs. 5 per family, for fuel, spices, cooking charges, etc. Rations are supplied weekly, in bulk, for the entire camp.
However, team members heard some complaints that the food rations being supplied were of poor quality. In the Shah e Alam camp, several inmates reported that the quality of rations given was very bad initially; the dal had worms, and the grain was rotten. The camp organisers left this inedible food outside the camp and managed meals on their own. At the Godhra camp, the team was told that organisers sold the wheat provided by the government, and then purchased better quality wheat at a higher cost.
In most camps, food is cooked in the open, in large cauldrons. Meals are usually cooked only twice a day, lunch and dinner. Tea is provided in the morning.
There is usually no provision for special food for children, pregnant or lactating women, or those who are sick. There is also no provision for food in between meals - something which is very necessary for children. In some camps in Amdavad, anganwadis have been functioning and providing some supplementary food to children under 6 years of age. No anganwadis are functioning in the rural camps.
III. Health conditions in the relief camps: a general crisis
Direct impact of violence: the team's interactions in the camps corroborate the evidence of massive brutality and systematic use of rape in the pattern of violence. Those who have survived are recovering from serious injuries such as gunshot wounds, extensive burns, stab wounds and lacerations. Many survivors are left with permanent disabilities resulting from paralysis, amputation of limbs and contractures. In addition, psychological trauma poses a serious problem with far-reaching consequences.
Threat of a larger epidemic: A number of outbreaks have been recorded, of measles, chickenpox, typhoid, and bronchopneumonia. Thousands of children have been affected by acute respiratory infections and diarrhoea. Drinking water and sanitation facilities are grossly inadequate, and there is no active state health service response to improve the camp situation and prevent an epidemic of a greater magnitude.
Government reports that six people died from typhoid in a single camp in April give some indication of the health conditions there. Although medical relief teams from the public health system had been visiting most camps regularly, the quality of treatment did not seem to be adequate. The team came across a high prevalence and large range of health problems among inmates. The team conducted treatment sessions at the rural camps (Kalol and Fatepura) and was overwhelmed by the number of patients with various kinds of health problems. The prevalent health problems are both physical and psychological. Some were a direct consequence of the communal violence; others were due to the unhealthy living conditions imposed on inmates in the camps. Some of the major health problems are described below:
Injuries and burns
The team came across several people with unhealed burns and injuries.
Even one and half months after the acute violence, these conditions
had not received adequate care or had not healed completely.
Similarly, the team came across people with embedded pellets from gunshot wounds and other partially treated injuries. Fear of further exposure to violence if they venture out of the camp to seek treatment in a hospital was one of the major factors responsible for such inadequate care.
Many narratives show the helplessness and fear that grips the thousands of people who have had to suffer the consequences of the violence in Gujarat.
Public health issues
Given the state of living conditions in the camps, with overcrowding,
exposure and inadequate sanitation and drinking water, it is not surprising
that there have been outbreaks of person-to person-transmitted and water-borne
diseases. General under- nutrition and low levels of previous immunisation
contribute to the problem.
Outbreaks of infectious diseases: The government has consistently held that there has been no epidemic in the camps, in support of their claim that it is providing adequate health services. However, in addition to the government's own admission of typhoid deaths, there have been numerous outbreaks of other infectious diseases.
As of April 25, there have been 27 cases of measles in the Jehangir Nagar camp. Two special tents were erected by the municipal authorities to isolate children after this outbreak.
There have been at least 46 cases of measles in the Godhra camp. When the team visited, nine cases of bronchopneumonia resulting from the measles epidemic were being treated by medical teams from the public health department and UNICEF.
There have been six cases of infectious hepatitis, (transmitted by faecal contamination of food) in the Jehangir Nagar camp, two cases of which were seen by the team. There had been four cases of jaundice in Fatepura camp as well.
At a broader level, official data also indicated the high prevalence of communicable diseases in the camps. In the official vigilance committee meeting attended by the team, six deaths from typhoid were reported from one of the camps.
Sixty cases of post-measles complications had been reported at the rural camps, as confirmed by the director of the Directorate of Health Services.
As of April 25, 2002, medical teams had treated 11,820 new cases of diarrhoea / gastroenteritis and 16,690 new cases of acute respiratory infection in children under the age of five, according to state health department records for patients seen in relief camps.
The health services have tried to respond to such outbreaks by immunising children and in some cases arranging for the isolation of children with measles, though this is difficult to provide in camp conditions.
Another, perhaps greater, imminent threat is that of an epidemic of water- and food-borne communicable diseases. These can be prevented only by a dramatic improvement in water supply and sanitation, along with better surveillance and preventive health care, especially in the rural camps.
Further, camps are important, but they can only be a short-term arrangement. Urgent and immediate efforts are needed, to create conditions enabling inmates to move back to their homes in safety. Eventually, they must be able to move out of the camps. The longer people stay in the camps, the greater the likelihood of a bigger health crisis.
Profile of illnesses
The team gained an idea of the profile of general illnesses among camp inmates, based on its treatment of over 100 patients at Kalol and 80 patients at Fatepura, both rural camps. Most patients seen were children and women.
The common health problems encountered among children were: diarrhoea, cold and cough, viral fever, conjunctivitis, amoebiasis, scabies, dermatitis, infected small wounds and ear infections. There were many cases of bronchopneumonia, a common sequelae of measles.
Among adults, the common general illnesses encountered were: headache and body ache, anaemia, backache, asthma and chronic bronchitis, piles, constipation, eczema, conjunctivitis, loss of appetite, amoebic dysentery, acidity and stomatitis.
Special conditions seen by the team, such as psychological problems and problems related to women's reproductive health are described in the separate sections on these problems.
Discontinuation of treatment of chronic diseases: According to Akil Ansari, the volunteer taking care of medical relief at Dariyakhan Ghummat camp, there are over 20 cases of TB in this camp, who have previously been under DOTS and other treatment. Similarly, the Shah-e-Alam camp is reported to have more than 50 TB patients. However, there is no follow-up of people on DOTS, because most houses are burnt, and so are the DOTS registration cards. The on-going violence also prevents people from trying to get anti-TB treatment.
There are similar cases of hypertension and diabetes, where treatment has been discontinued because of lack of access to regular sources of health care. No efforts are being made to restore this access. Most camp inmates have been living there for more than two months, but the authorities' approach is that of a short-term problem.
Nutritional deficiency: Almost half of the population of Indian children under five is malnourished, and Gujarat is no exception. The department of health, Gujarat government, conducted a study on malnutrition in one of the camps in Amdavad, and found that 48 per cent of the children were malnourished.
Such pervasive nutritional deficiency reduces resistance to disease. The problem is worsened in the abysmal sanitation conditions in the camps, and the qualitatively limited dietary intake available to the inmates. The frequency and quality of meals is inadequate for children. The situation was illustrated by the team's treatment sessions at Kalol camp and Fatepura camp, when it found that many women and children were clearly anaemic.
Such malnutrition, along with poor living conditions, will increase morbidity and mortality.
Health problems specific to women
While interviewing women in each of the relief camps, team members specifically asked them about their own health problems. These discussions demonstrated that existing services did not acknowledge women's health needs. Also, the lack of privacy in camp health services prevents them from seeking such treatment. In one of the rural camps, women told us that many Muslim families had fled to Rajasthan for first few days, and received medical treatment in the hospital there. However, several women reported moderate to severe RTIs to the team – because the hospital had not treated these problems.
Women expressed a strong demand for a woman gynaecologist to visit them. However, there is no effort to make existing services more accessible to women.
Hygiene related problems: Hygiene-related problems are noticeable among women. Especially, in the rural areas, many women have reproductive and urinary tract infections. Several cases of polymenorrhea (shortened menstrual cycles), dysmenorrhea (painful menses) and menstrual irregularity were encountered among women inmates in the camps which visited by the team. The onset of these problems seemed to be related to the violence and shifting to the camps. The severe psychological and physical stress which women have undergone is likely to be responsible for such changes. Chronic vaginal discharge (vaginal infections) was also reported by several women. Women also require sanitary napkins.
Pregnant and lactating women: Hundreds of women have given birth in the camps, assisted largely by local volunteers, and without any facilities. These women, as well as those in curfew-bound areas, are not in a position to seek special health services. Although there is official provision for supplementary food for pregnant and lactating women, the team did not see any such provision in the camps it visited. A few women who had delivered recently were residing in the camps. Camp volunteers informed the team that it was extremely difficult to care for them in the open camps while living in tents. Milk powder supplied to families was used for children, infants as well as pregnant women. A dai expressed her concern for the pregnant and lactating women. She had assisted in many of the deliveries. In fact, people from the neighbouring areas prepare sira, a healthy diet for mothers. However, they cannot not sustain it for long, because they too are not earning these days. The dai felt that more nutrition and vitamins ('shakti ka botal') were needed.
There is no provision for bathing in the tents itself and pregnant women and new mothers must use the bathrooms used by the rest of the camp. One can only imagine how difficult it must have been to care for newly delivered mothers and neonates. In one camp, the team was told that the tent used to house new mothers had become overcrowded because several women delivered at the same time.
Long-term rehabilitation needs
Given the massive scale of physical and psychological injury inflicted upon the victims of violence, there is an urgent need to plan and implement rehabilitation measures. Some issues which emerged in this regard are outlined below.
Physiotherapy, disability prevention and prostheses: During the visits to the camps and hospitals, the team met several persons with sequelae of injuries. It met people with amputations of the hand or foot, burn victims and persons with post-fracture disabilities.
Such persons suffering from various forms of disabilities obviously need regular physiotherapy from trained specialists, which is currently largely unavailable. Those with burns require physiotherapy to prevent disability due to contractures. Those with amputations and orthopaedic disabilities may also require prostheses.
Counselling, psychological and social support: The scale and depth of psychological trauma undergone by the victims of violence has already been described. There are clear indications of the prevalence of post traumatic stress disorder (PTSD), especially among women and children who have suffered or witnessed horrific physical violence and sexual abuse. Such victims need sensitive counselling and psychological support, and for a sustained period of time. The survivors of sexual assault, and traumatised and bereaved children, need special professional support. attention. Families and community volunteers in the camps are informally counselling victims, in an extremely difficult situation. However, there is a definite need for training and continuing support to such volunteers, so that they can assist in the counseling process more effectively.
Continuing fear and anxiety also compounds the mental trauma already undergone by the victims. Keeping this in mind, there is a need to create definitive and effective safety mechanisms for victims and their families, so that their lives may return to normal as soon as possible.
Victims' psychological trauma is aggravated by their feeling that injustice has being perpetrated on a massive scale. This underlines the need for legal and social assistance to the victims, to get redressal and justice.
Justice: While the team concerned itself primarily with health issues, it could not ignore the larger context in which all rehabilitation must take place. Assistance to survivors of violence should integrate medical care, provision of security and legal investigation, towards rehabilitation. However, this has not happened in Gujarat. There is some medical care, but this is of limited use as there does not seem to be any intention to control the violence and ensure justice.
In conversations with the camp inmates and volunteers, it became clear
that there were many obstacles to any real rehabilitation. First, people
cannot go back to their homes unless they are assured of security. There
does not seem to be any sincere effort to enable people to file complaints,
take action on those complaints, and punish those found guilty. In sum,
there is no sense of any law and order in the state. Second, a completely
pauperised community, which has not been able to earn money for the last
two months, was not in a position to return to living outside the camps.
Finally, people didn't want to go back their homes. On many occasions,
camp inmates asserted, “After what has happened, we can't live in the same
areas, we will have to live separately.”
IV. Mental health issues
Post-traumatic stress disorder (PTSD) is a well-known sequelae of any disaster, and is accepted as a public health issue to be tackled by the health services in such situations. However, the only emotional support to victims of violence is being is being provided by camp volunteers, who have no training for this kind of work.
Because the team visited the camps nearly two months after the beginning of the violence, it could observe that a certain routine had been established. Survivors of the violence have made efforts to restore some normalcy in their lives. Still, the team also found pervasive psychological stress and trauma. Those who had witnessed killings and/or lost members of their own families were the most severely affected. Many broke down while recounting their experiences. Many suffered from the more visible symptoms of psychological distress: bouts of crying and complete withdrawal. They also reported insomnia and nightmares.
In general, stress and trauma among survivors manifested in both physical and psychological symptoms. People expressed feelings of frustrations, helplessness and fatalism, agitation, anger and depression.
Certain attacks, like those in Naroda Patia and Chamanpura, were so brutal that that they have become part of collective memory. Even those who have not witnessed those episodes refer to them again and again. Survivors are always conscious that they could be once again subject to violence of that scale and brutality. Many live in constant fear of what can happen to them as insecurity and earlier memories haunt them.
Another manifestation of stress was in an increased level of reporting of non-specific symptoms. This may be compounded by the fact that, in most camps, people are living out in the open, exposed to the heat. They complained of headache, body ache, palpitation, stomach ache and disturbed sleep. Among women, in many camps, team members found instances of disturbances of the menstrual cycle, such as polymenorrohea (frequent menstrual bleeding) and dysmenorrohea (painful menstruation), which were concurrent with the outbreak of violence. There is a strong possibility that these problems are stress related. Women were very concerned by these changes. They were also distressed by the difficulties of managing menstruation without adequate water and bathing facilities.
It was equally disturbing to see children with various stress-related problems. Women reported that their children would wake up at night crying, and get agitated on hearing loud noises. Children were afraid of anybody in police uniforms; they expressed fears that they would be killed or burnt; they did not want to leave the camp. Some were deeply disturbed and clearly needed professional help for their psychological problems.
The UNICEF study: UNICEF had conducted a training programme for Medical Officers deputed to provide medical care at the camps. Using a structured protocol, they screened 723 children for signs of mental trauma and found that 239 children required counselling (according to the protocol). This need was rephrased as 'parental support' in the interim report data. In addition, 12 children required referral to a psychiatric specialist.
These findings seem to underestimate the extent of trauma. There was no information about whether the symptoms recorded in the protocol were probed or only recorded if reported spontaneously. Also there were no details about which children were screened. (see appendix for the UNICEF report)
No assessment has been made of the mental state of adults. However, the experiences of heinous attacks, and a prolonged period of unabated violence, have taken a heavy toll. The extremely hostile and insecure atmosphere prevents people from moving out to look for work. This has led to feelings of depression and anger. Uncertainty about the future, and a loss of faith in civil society and the State, has led to a feeling of desperation.
Medical professionals and camp volunteers had strikingly different attitudes to people's mental health needs. The MOs providing medical care at camps consistently undermined the importance of dealing with psychological trauma. Any sign that people were returning to a routine was taken as proof that they were not traumatised. This was illustrated when the team attended a vigilance meeting of medical officers deputed to the relief camps. When a team member mentioned that disturbed appetite could be a sign of PTSD, an officer immediately retorted, “Oh, they eat very well...”
At the same meeting, medical officers repeatedly cited the UNICEF study to indicate that the scale of the problem is very small. It was quite clear that they did not want to get involved with providing counselling; they wanted to limit their intervention to treating physical ailments. There is a strong reluctance even to acknowledge that a problem exists.
A senior official commented doctors attending the camps were 'not capable' of assessing or treating symptoms of psychological distress. This indicates that no attempts has been made to orient medical teams to look for and address psychological trauma. At the same time, it suggests that authorities look upon psychological trauma as a distinct problem to be treated, rather than a pervasive problem, which will affect all other health problems as well.
Even more disturbing was authorities' general disdain for the suffering of those whom they treat. A senior government health administrator opined, “The camp inmates do not have brains to understand that they are suffering from stress and mental trauma.”
On the other hand, camp volunteers are extremely concerned about the mental state of survivors. They spend several hours talking to people and listening to them. In several places, they have organised makeshift schools for the children, and also games. Their role in providing emotional support to survivors is very important.
However, volunteers have already spent more than two months providing support, and they themselves are mentally exhausted. They would benefit from some training inputs and appropriate referral support for the seriously disturbed. They need to be able to discuss, with others, the mental health trauma, which they are witnessing and counselling on a daily basis.
By ignoring the importance of psychological trauma, health services are under-estimating the scale of damage, and undermining the need to rehabilitate the affected. There is no acknowledgement of the need to provide treatment for PTSD, a well-known sequelae of any disaster. The only emotional support is provide by camp volunteers, who have no training for this kind of work. Volunteers' own needs of support and sharing has not received recognition.
V. Survivors of sexual assault
The team's report corroborates other investigations' findings of large-scale and systematic sexual assault. There have also been many reports of women coming to hospitals in a condition which doctors would certainly suspect sexual assault. Yet the senior health officers interviewed as well as private doctors visited by the team stated that no cases of sexual assault has been filed. In other words, doctors seem to have disregarded obvious signs of sexual assault. As a consequence, there is no medical evidence of sexual assault, on which basis women could seek justice.
Profile of the survivors
Many Muslim women and girls have been the victims of most brutal forms of sexual violence in both urban and rural areas of Gujarat. Interviews conducted by women's groups have provided extensive documentation of systematic and brutal sexual violence as an integral part of mob attacks. As pamphlets circulated by the Sangh Parivar indicate, women's bodies were turned into battlefields in order to perpetrate hate and dishonour and assault the pride, dignity and integrity of the whole community.
There is, however, no official admission, either by police or by the health care machinery of the fact that sexual abuse was perpetrated at such a large scale. Nowhere do medical records of the dead or injured women mention sexual abuse. Also, there are no First Information Reports (FIRs) barring one or two cases. It is also likely that many incidents will never be made public, given the vulnerability of the victims.
There was a pattern in the sexual violence inflicted on the women. Accounts narrated by volunteers as well as women inmates of the camps indicate that women were beaten up, stripped naked, gang- raped, stabbed with iron rods, swords or sticks, and then burnt alive. The assailants cut open the abdomens of pregnant women and killed the foetuses. There were cases reported of mutilation and disfigurement – cutting off breasts, carving “Om” on foreheads, chopping of limbs, thrusting cricket bails / sticks or swords into women's vaginas. In some areas the abusers themselves stripped to further humiliate women.
The team's investigation corroborates other reports of large-scale burning of rape victims. The mobs were instructed not to leave behind any trace of evidence. They came prepared with weapons, petrol, kerosene, chemicals and gas cylinders. They shouted, “Jala do, saboot mat chhodo.” (“Burn them, don't leave any proof.”
Evidence of sexual assault was also destroyed in other ways. In some camps, volunteers reported receiving unidentified bodies without any medical records or post-mortem reports. They were forced to bury them as soon as possible.
Many women are still in a state of shock and trauma. Volunteers, as well as affected women, told the team that they were not willing to talk or complain to police. Even when some victims dared to speak out, no FIR had been lodged or arrest taken place. Hence women have lost faith in the police and other state machinery. Women also fear the adverse publicity their testimonies will draw. They are apprehensive about their names appearing in newspapers and on television. This prevents them from even complaining to health care providers.
In no camp was the team told of efforts to provide psychiatric counselling to women by government doctors or Auxiliary Nurse Midwives (ANMs). Any counselling and emotional support comes only from camp volunteers.
Assessment of specific health care needs
At one urban camp that the team visited, many women were still recovering from burn injuries. Some women who had healed only partially had gone to their relatives. All these women will need long-term care, essential for burn patients, particularly for morbidities such as deformity of limbs and other body parts. Volunteers reported that some women could not walk when they were brought to the camp; their genitals were torn as a result of gang rapes. Though many of them had received some primary treatment, there has been no long-term treatment.
Apart from the enormous pain, discomfort and psychological trauma resulting from the brutal assaults, sexual abuse can also result in Reproductive Tract Infections (RTIs), sexually transmitted diseases (STDs) including HIV and pregnancy. As the state has effectively denied that sexual assaults had even occurred, no measures had been taken for detection and further action. A strategy needs to be urgently worked out to assess the actual prevalence of RTIs/ STDs/ HIV and pregnancy. This will need the collaboration of different social action groups. Camp volunteers are overwhelmed by the overall task of running the camps, and cannot take any pro-active role in this matter.
The assessment of PTSD, and the actual provision of counselling, are the other crucial areas that have remained hitherto neglected. Women are traumatised not only by the sexual assault but also because of the killings and brutalisation of their family members, relatives and neighbours. There is an intense sense of insecurity and frustration. Many women broke down repeatedly while narrating their experience. Many were completely withdrawn, shaking and trembling, and showed symptoms like insomnia, nightmares, and lack of appetite. There is an urgent need for counseling women witnesses and victims alike.
The health care needs of survivors of sexual assault can be summarised as follows:
Treatment for the injuries of all kinds, genital as well as injuries due to stabbing, cutting, beating or burning
Assessment of problems such as damage to the genitals and other pelvic
organs and pregnancies,
RTIs/ STDs including HIV
Psychiatric care and counseling, in particular, for PTSD
Reproductive health problems were very prevalent among the women in the camps, and sensitive woman gynaecologist must be part of medical relief efforts. This would also enable women who have been sexually assaulted to seek treatment without fear of stigmatisation.
Availability of services to survivors
From all accounts, it is clear that in the first few days, volunteers from the community alone organised medical help along with shelter and food.
In Amdavad city, volunteers said women were brought in stark naked and a burnt condition. A woman volunteer, a dai by training, helped some women. She reported removing objects like cricket bails and sticks from vaginas of some women, and also stitching up vaginal tears in a few women. Some women had suffered mutilation of body parts. Inmates from camps that the team visited corroborated this fact. These women had been unable to access the health services for critical medical care.
In Amdavad, many women from the camps were sent to the Civil or VS hospital, mostly for the treatment of burn injuries. Volunteers said these women received some treatment for rape-related problems. However, no medico-legal cases for sexual assault were filed.
One Muslim woman doctor from a public hospital, whom the team met in one of the camps, stated that she was not aware of such atrocities. When asked about the need for assessment of morbidities and pregnancy as an outcome of rapes, she remarked that pregnancy was not a problem as the women were already married; none of them was virgin anyway!
Dr Makwana, Chief Medical Officer, Amdavad Municipal Corporation, did not have any information on the state of women who suffered sexual abuse or on what medical treatment they received.
Future efforts to give such medical assistance will be hindered by the fact that many women who were sexually assaulted have left the camps for the homes of relatives, and do not want to be traced.
VI. State response to health care needs of the survivors in relief camps
State and municipal services have collaborated in providing public health services in the camps and in various hospitals. These consist of immunisation, some maternal and child care, and limited out-patient services. The effort has been commendable considering health services are inadequate even in normal times, and there are the additional constraints posed by the crisis situation and the communal environment. However, services do not go beyond what is provided in normal circumstances - and are therefore highly inadequate for people's needs.
A comprehensive approach to health care in this situation would include the treatment of severe injuries, chronic illnesses and psychological trauma. Instead, the public health response consists of ad hoc measures to avoid the public outrage which would follow from complete neglect and deaths.
Injuries such as stab wounds, lacerations, abrasions, acid burns and gunshot wounds would normally be treated in hospitals. However, in the Gujarat violence, many people with serious injuries were brought directly to camps, because camps were perceived to be safer and more accessible; people were uncertain about their own safety while trying to reach hospitals for treatment. This insecurity has been reinforced by the continued violence in various localities and around hospitals.
This complex situation has placed a unique challenge before the health care system. Apart from providing quality health care services within the camps, it must also put in place a workable referral and follow-up system.
Organisational set-up
In Amdavad, interviews with government officials and official documents show that the Gujarat state health department and the health department of the Amdavad Municipal Corporation collaborated, with a clear division of labour, to provide health care services to inmates of relief camps. In the urban areas, special medical teams have been set up to provide out-patient services to camp inmates. In the rural areas, staff of the nearest public facility (primary health centre or community health centre) have been asked to make visits to the camps.
The situation in Amdavad camps
Under the supervision and leadership of one of the senior officials
at the Civil hospital, Sola, a unit of 88 government medical officers (MOs)
is meant to reach out to the relief camps. MOs from the government health
system are deputed in rotation to this unit. MOs may request a change of
schedule but may not abstain from this state-organised medical relief work.
The medical relief effort is reportedly being strengthened, with 20 more
MOs. According to official figures, another 21 MOs from the Employees'
State Insurance Scheme (ESIS) are involved in the relief work. The ESIS
also supports mobile vans for medical relief work.
The team was told that special funds of Rs 2 lakh per day had been budgeted for health services to relief camps. In addition, there are some funds available from international organisations such as UNICEF.
Composition of teams visiting camps: Teams, each consisting of 1- 3 MOs, 2-4 male Multi- Purpose Workers (MPWs) / nurses and a pharmacist, are deployed for visiting the camps. They are expected to visit the camps at least once in two days. Camps with large numbers of inmates are to be visited daily. The teams provide clinical services and referral.
Teams of officials for public health measures such as drinking water, sanitation, and immunisation have also been constituted. Immunisation services are taken very seriously. Vaccines for DPT, polio and measles are administered to children. Tetanus toxoid is given to pregnant women. MOs are instructed on the significance of maintaining the cold chain and the use of disposable syringes for immunisations. They are told to dispose of the vaccines if the cold chain is disturbed for any reasons.
In addition, 12 teams are available to respond to calls from Members of the Legislative Assembly, for providing services within their constituencies.
Planning camp visits: The entire relief team, along with its in-charge, meets daily at the Civil hospital, Sola, to review the work and assess the health situation. This meeting is also to discuss problems faced by MOs and others while engaged in relief work. Daily logistics are planned a day in advance. Schedules of team members, work schedules, and names of the camps to be visited are shared with members of this larger relief team.
Visits to the camps are decided on the basis of distance from Sola Civil Hospital, and the number of inmates in a given camp. Security is sought if needed.
Although there is an organised system put in place, we found certain crucial gaps in the provisions and the existing reality.
Lack of protection to the medical relief teams: It was reported that the department of police had offered security measures to teams visiting the camps. In the routine vigilance committee meeting that the team attended, MOs categorically stated that till date they did not feel threatened inside the relief camps while providing health care services. However, the intermittent violence in various localities in the city does affect the regularity of visits to camps. Curfews in areas on the way to the camps prevent teams from visiting camps according to schedule. On any given day, those camps near affected localities are not visited.
At the vigilance meeting, the in-charge asked MOs to inform him if any team felt the need to have security, and promised to make appropriate arrangements accordingly.
Health care service profile and record keeping: The team was told that each camp inmate had a Health Card issued by the health department. However, it could not get a sample of the health card at the Civil hospital at Sola. Also, such cards were not found with the camp inmates when visited.
ICDS - on paper: The team was told that pregnant women and lactating mothers were being provided extra food through the Integrated Child Development Scheme (ICDS). However, interactions with the inmates of the camps, in both urban and rural areas, indicated that these services were inadequate, and not all camps were benefited of these services.
No outbreaks? Medical Officers at the Amdavad vigilance meeting reported that there had been no major outbreak of communicable diseases among the inmates. However, team members came across a number of such outbreaks in the camps that they visited.
Need for women doctors: When the team attended a vigilance meeting of medical officers, it did not observe a single woman doctor in this reasonably large medical relief team.
An important issue that could not be covered adequately in this investigation concerned the health situation for those populations not in the camps, but living in curfew-bound localities. The team repeatedly heard reports of the serious ill, convalescents and newly delivered mothers being sent to live with families outside the camps.
Privacy: A simple issue, but of much significance to the users of services, was the question of privacy while getting examined. This was not taken account of in the camps. One wonders how women are examined in such overcrowded camps, without compromising on their privacy. During the team's treatment session, it tried to provide some privacy by putting up a bed sheet. However, the sheer number of patients and the absence of any facilities - even clean floor space - made it impossible to conduct even a physical examination for women.
Adequacy and regularity of medical staff
It is certainly commendable that a system had been put in place to
reach out to the camps. Teams can also refer people to hospitals when necessary.
The fact that 60-70 medical professionals have been assigned to this effort
does seem impressive. However, this number needs to be seen in the context
of health care needs of people affected by violence. For example, there
are 68 relief camps in Amdavad city alone, according to the records at
the health department of the Amdavad Municipal Corporation, with an estimated
70,000 people living in these camps.
With teams of two or three, it is possible to form 20-25 teams daily, visiting 20-25 camps - twice as many camps if two are visited in a day. This means that camps would be visited either daily or once in two days. There are no other health service providers, such as nurses or other paramedics based in the camps as part of the public health care service provision. This is a major gap in services, given inmates' fears about leaving the camps for anything. Between visits by teams, inmates are left to look after their own health care needs.
Another fact the team observed was that different camps provided differing levels of services. Certain larger or 'high profile' camps received more regular inputs. The rural camps were significantly under-served.
Perceptions of camp inmates about the services provided were varied.
People appreciated team visits as a regular service, especially since they could not move out. However, they also felt that staff spent too little time in the camp. The team was told that the mobile health team spent between one and two hours per camp visit.
Another complaint concerned the range of drugs for various conditions available with the teams. The Citizens' Initiative received several requests for various drugs because the state services did not provide them. Several emergency care medicines not available with the ambulatory care team.
On the other hand, inmates acknowledged that the staff's feeling of insecurity made their visits to sensitive areas like Juhapura irregular.
Records of medical teams indicate that 74,277 health cards were issued in Amdavad alone. Up to April 25, the teams had provided treatment in approximately 2, 70, 815 cases in Amdavad alone, of which 88,483 cases were of children and 1,03,554 were of women. (Each visit to the health services was recorded as a separate case, not a separate patient.) Of these, 2,13,659 cases were classified as 'others', whereas acute respiratory tract infections (among under 5 children) accounted for nearly 16,690 cases. There were 11,820 cases of diarrhoea / gastroenteritis. There were 15,640 new cases of fever. Surprisingly, only 569 cases were referred to a higher facility for treatment.
Some features emerge from these rather bare figures. First, the vast majority (almost 80%) of cases have been classified as 'other' with no further break-up. There is no way to ascertain what the majority of patients seen were suffering from. This points to a need for refining the recording system. Second, only 0.25% of the new patients seen were referred to a higher facility; this is an extremely low proportion, especially given the types of injuries and mental health problems suffered by the victims. This confirms the team's impression that referral linkages were poorly developed. Third, women are clearly the single largest category of patients, and women and children together constitute over 70 per cent of the new cases. Special services for these groups, including gynaecological and paediatric services, are clearly required.
Rural camps: Medical services were much more inadequate in both the rural camps the team visited. The team was told that government doctors visited very irregularly, if at all, and that the drugs dispensed were of an extremely limited range.
Specialised health care services: Outreach of, or follow up with, specialised health care services was unsatisfactory. This was evidently not a concern of the relief effort. While constraints and time pressures on the part of government officials are understandable, but the fact remains that inmates are virtually without attention for such essential services. For example, those who have been treated for injuries of brutal attacks may require physiotherapy and follow-up services to avoid permanent disabilities.
There is hardly any follow-up with specialist teams such as paediatricians, gynaecologists, psychiatrists and counsellors, and orthopaedic specialists and physiotherapists. Also, auxiliary services such as mobile laboratories and X-ray facilities were not found to be available.
Medical relief work in such a context would require a different approach, and also additional skills. For example, the team should be able to assess the mental health care needs of the violence affected. However, except for one training session conducted by UNICEF to assess mental health care needs among children (referred to elsewhere in this report), there were no efforts.
Credibility of health services
The team's interactions in the camps suggested that people are losing faith in existing health services; inadequate services, given in a perfunctory manner, without a sense of commitment to people's right to treatment - all of this has further undermined the credibility of the health services. The fact that the health professionals involved in providing health care at the camps feel that they are vulnerable (because the violence continues) further de-motivates them and inhibits them from responding to the needs of their patients with empathy.
VII. Voluntary response to the health care needs of camp inmates
Though relief work is the central responsibility of public agencies, voluntary initiatives have a critical, complementary role to play in providing relief in crisis situations. The team found that volunteers from within the Muslim community had risen to the occasion with commendable attempts to cope in a situation where they themselves are vulnerable. However, broader voluntary relief efforts from beyond the Muslim community have been strangely muted, with certain notable and exemplary exceptions.
Voluntary health care efforts from the Muslim community
In the initial days (February 28 to March 5), local volunteers provided the only medical care available to the survivors. The team heard reports of burns victims being treated in the camp itself. In one camp, stab and sword wounds had been sutured by a paramedic. The most seriously injured had to be shifted to hospital, often under difficult and dangerous circumstances. This too was largely organised by the camp volunteers.
In most of the camps visited by the team, one person – with some medical training — has been involved in providing medical care to the inmates. In some camps the team found one or more such persons. These included a pharmacist, an operation theatre assistant, a mid wife and a medical store assistant.
In the Godhra camp there is provision of 24-hour medical care provided voluntarily by a team of trained doctors from Godhra, working as a Rescue Relief Committee. There is a full-fledged medical unit in place here. In the urban camps, doctors (most of them Muslim, and including many non-allopaths) in the surrounding area have been providing free medical care to camp inmates who came to their clinics. In most of the village camps, there is virtually no health care available, except for the brief visits by the CHC staff made once a day. Women in the camps have conducted several deliveries without trained assistance, in some cases using dai delivery kits supplied by UNICEF and Red Cross.
In both Amdavad and Godhra, the team found that some hospitals and nursing homes belonging to Muslim trusts or doctors had made their services available free of charge for survivors. However, the continuing violence makes it even more difficult to refer patients for further treatment. In both rural and urban areas, patients are unwilling to venture out of the camps and travel to hospitals.
There does not appear to be any organised effort on the part of the public health services to tie up with such efforts from within the community. The public health system could have more effectively provided referral support and drug supply to help such initiatives within the camps. The exception is Godhra where the team found a level of collaboration between official and voluntary medical agencies.
Those not staying in the camps, but with relatives, also found it difficult to obtain medical care. The sudden imposition of curfew in different parts of Amdavad prevents many of them from reaching hospitals.
Health care efforts from the broader voluntary sector
Efforts by voluntary agencies from outside the Muslim community are
very inadequate, with just a few agencies standing out due to their committed
efforts. While, in the initial phase, international agencies such the Red
Cross and UNICEF have provided some services, it is surprising why other
many other organisations have not been involved in the relief work. This
situation is sharply in contrast to the
relief efforts initiated immediately after the earthquake in
Kutch in January 2001.
Large charitable trusts and non-governmental organisations (NGOs) within Gujarat, otherwise known for their charitable work, do not appear to have responded adequately to the humanitarian crisis. One major exception has been the Citizen's Initiative, a network of NGOs. In the matter of health care, it has played an important role in ensuring drug supply, providing transportation and establishing referral links with hospitals. It supplies drugs to camp organisers as and when requested. It is not in a position to provide actual medical care in the camps since it does not have medical experts as part of its network. However, it is playing an important role in sustaining the efforts of local volunteers, providing transport for those who need to be shifted to hospitals, and making arrangements for treatment, both at government and private hospitals.
Similarly, in rural camps in Panchmahals and Dahod, ANANDI, an NGO working with rural and tribal women, has been reaching out to relief camps and trying to make available referral support to those with serious health problems.
SAHRWARU, an NGO based in Amdavad, working with the urban poor, has been involved in intensive relief work with specific urban slum communities.
Although, we were unable to interact with them, SEWA has also undertaken relief and rehabilitation work in several camps in Ahmedabad.
Notably, the team found that the presence of such non-religious organisations was very important in establishing links with government institutions, and also in dialoguing with state officials.
The team would like to place on record the exemplary initiatives it observed, such as Citizen's Initiative and ANANDI, and logistical support for medical relief from Xavier's Social Service Society. Besides these notable exceptions, in the nine camps visited, and the large number of people interviewed, the team found that few developmental agencies, NGOs, membership clubs, community health organisations or medical associations had made organised efforts to provide humanitarian medical care to those affected by violence.
VIII. Provision of medical services to the survivors by public hospitals
Hospitals have an indispensable role in providing medical care to those with more serious or special health problems. In this regard, the team gathered information primarily in Amdavad city, focussing attention on the role of public hospitals. It obtained various kinds of information through discussions with camp inmates who had accessed hospital services, interviews of staff and patients in hospitals, and discussions with doctors working in various hospitals.
Amdavad is characterised by a fairly large number of government hospitals, both run by the Amdavad Municipal Corporation (L G Hospital , V S Hospital, and Shardaben Hospital) and two civil hospitals run by the state government.
Public hospitals have been working under a constant threat of violence against Muslim patients within the precincts of the hospital. There have been instances of mobs attacking hospitals, preventing injured persons from entering their gates, and even moving around in the wards, terrorising and even attacking patients and relatives. There is no indication that the government has made serious efforts to protect the health services, and maintain people's access to them. Despite this pressure, health professionals in the hospitals have functioned neutrally, providing treatment without discrimination on the basis of community. This is commendable.
On the whole, comments from almost all sources, including the camp inmates, indicated that individual doctors working in hospitals have worked strenuously, often around the clock, to deal with the large number of violence victims. This needs to be placed on record, and the efforts of many committed doctors, nurses and hospital staff to provide care to victims in a demanding situation needs to be appreciated.
However, there have been many larger forces at work, which have been responsible for restricting the effectiveness of hospitals in providing care especially to the minority community. The sanctity of hospitals as humanitarian spaces, where everyone should be able to receive treatment without fear, has been violated. In some situations, doctors are even pressurised or threatened for making efforts to treat minority patients. Based on the various interactions and observations, the team identified the following issues concerning public hospitals during this crisis.
Religion-wise segregation of hospitals
A senior medical consultant from a municipal hospital, told the team
that, informally, both hospital authorities and the common people have
to some extent segregated hospitals according to the religion of patients
to whom they generally provide services. He said that there was an unwritten
guideline that patients of the 'other' religion should be transferred to
a 'safer' hospital.
Such segregation, which has become accentuated during the recent violence, is partly related to the geographical location of hospitals and the ghettoisation within the city. This has contributed to the public perception of each hospital as being the preserve of patients of certain communities. Hospitals which are located in Hindu majority areas are not so frequently accessed by Muslim patients and vice versa.
On the whole, there is an impression among camp inmates that Vadilal Sarabhai hospital is a comparatively 'safe' hospital for Muslims. Muslims have not accessed certain other hospitals as frequently during the violence from fear of attack by Hindu mobs. There was a case in the L.G. Hospital during the 1992 communal violence, when a Muslim burns patient admitted in the hospital was thrown off the roof of the hospital. ('In Ahmedabad, even hospitals are divided along communal lines', The Times of India, Mumbai edition, April 8, 2002). The memory of that event inhibited many patients from going there.
It is also important to comment that several ad hoc measures, that have been taken to deal with emergency situations (segregating hospitals and patients on the basis of community, giving sympathetic leave to staff belonging to the minority community) may threaten the secular character of health institutions and lead to accentuation of polarisation within the profession. However, it must be noted that the responsibility of ensuring safety of patients and staff in the hospitals lies with the agencies such as the police, which have clearly been party to the violence themselves. It is apparent that while the hospitals have largely been non-discriminatory, they have been unable to mobilise support to protect their non-partisan and humanitarian role.
Mobs creating terror and Muslim patients being unable to access hospitals
Patients, hospital staff and doctors - all told the team of large mobs,
usually of the majority community, gathering in front of some hospitals
or in hospital compounds, especially during the initial days after the
outbreak of violence. The mobs intimidated Muslims trying to bring new
patients to the hospital. Such threats sometimes forced patients to retreat
from the hospital gates.
After the initial incidents, hospital authorities started providing security staff outside the hospital and even in some of the wards. This is not always sufficient.
Lack of access to hospitals was a problem encountered at various levels, even before patients could reach the hospitals.
In an abnormal situation, where there is a threat to people's safety and movement, the barriers to access to the institution has much worse repercussions. By depending on people to come to them for treatment, the services do not reach those who need them the most.
Threat of violence to patients within hospitals
The team also received reports of individuals and groups of 50 to 100
people, sometimes armed, circulating in certain hospital wards. These groups
would talk in violent language about people of the other community, and
create an atmosphere of fear. Even more serious, both patients and staff
reported incidents of attempts to inflict violence upon patients within
the hospital. Although such incidents were probably uncommon, the fact
that they could occur is a serious matter, concerning the security of patients
in the hospital.
There were many reports of violence by probable outsiders entering wards and attempting to harm patients.
Another issue regarding hospitals related to the premature discharge of Muslim patients in certain instances. While such decisions were apparently taken in order to ensure the safety of patients, they confirmed that even doctors perceived that patients and their attendants were not entirely secure within hospitals. The appropriate action by the authorities in such a situation would have been to ensure adequate security, rather than discharging patients.
IX. Impact on health professionals
The team examined the impact of the violence as well as its underlying processes on the health profession. It looked at three aspects: the participation of health professionals in violence and polarisation within the profession; the possibility of discrimination by health professionals against patients of the minority community; and attacks on medical professionals and other losses suffered by them. It concluded that on the whole doctors have acted professionally within a very narrow definition of the word.
While doctors have not actively discriminated against any community, they have not pro-actively made any attempts to safeguard the rights of their patients or even their peers. The medical profession has also not made any attempts to contribute to the process of securing justice for the survivors by documenting medical evidence or highlighting the problems that victims have faced.
Participation of health professionals in the violence and polarisation
within the profession
The team conducted several interviews with representatives of the medical
profession - doctors from both the public and private sector, paramedical
staff, and others associated with the health field. There were varied impressions
received from the interviews. While some senior doctors emphasised that
a certain section of doctors had definitely been drawn into right-wing
organisations, and openly espoused their ideology, the personal accounts
of affected doctors themselves indicated that they did not interpret attacks
on them in communal terms. However, it is clear that certain groups are
trying to mobilise professionals along religious lines, which could lead
to greater polarisation within the profession.
Unfortunately certain medical professionals have also been involved in propagating an ideology of hatred. As members of the BJP and the VHP these professionals have also been responsible, directly or indirectly, for perpetrating grave injury to Muslims in Gujarat. They have played a role that runs counter to their professional calling as physicians and are a blot on the medical profession.
Pravin Togadia (Vishwa Hindu Parishad, International General Secretary) Jaideep Patel (Vishwa Hindu Parishad, Joint Secretary, Chief), and Maya Kodnani (M.L.A, Naroda) are three medical professionals who were reported as being directly involved in the carnage. Apart from making incendiary statements and provoking violence, at least two of these have been reportedly named in police complaints as assailants in different incidents in Naroda and Gomtipura in Amdavad. Although such reports referred only to certain members of the profession, no cognisance has been taken of their actions; nor has have any of the medical associations taken action against them. Professional bodies, both statutory and voluntary, play an important role in safeguarding the integrity of their members. Their failure to even comment on the behaviour of members of their own fraternity is inexcusable.
However, the passivity of bodies representing the medical profession is indicative of much more deep-rooted polarisation within professionals. One doctor, who was earlier an office bearer of the IMA in Godhra, reported that after a change of leadership, the current office bearers had stopped inviting Muslim doctors to meetings of the local IMA. It is well known and openly acknowledged that certain medical associations have political affiliations with right wing groups (National Medicos Organisation, Amdavad Doctors' Forum).
It is noteworthy that the Amdavad Medical Association (which has 90 percent of the registered allopathic practitioners in Amdavad as its members) has not publicly condemned the attack on doctors during the violence. Any condemnation of attacks on doctors followed only after Dr Amit Mehta, a Hindu doctor, was attacked, although many other (Muslim) doctors' property had been destroyed earlier and they had faced physical attacks.
An AMA office bearer was asked by the team as to why the AMA had not participated in relief work in the camps - unlike after the earthquake when it had immediately sent a relief team. It was informed that there was a problem of safety.
The AMA office bearer reported that they had sent a letter to the state government asking for security for Hindu doctors practising in Muslim areas, and vice versa. Security would enable them to safely go to their workplaces and also provide services at the camps. He called for police pickets to be provided outside doctors' dispensaries.
The AMA office bearer asserted that 'no Muslim doctor has been attacked in Hindu areas.' When confronted with a report that establishments of some Muslim doctors had been destroyed, he replied that the clinics must have been damaged accidentally because they adjoined other Muslim establishments; no one would deliberately destroy medical establishments.
However, the team's own observations suggested that shops and establishments were quite systematically burnt. It is unlikely that medical establishments were accidentally destroyed, or that they could not identified as medical establishments.
The refusal of medical associations to even acknowledge that attacks had taken place on Muslim doctors and their property in mixed and Hindu dominated areas, is very striking. It is clear that these associations do not want to take a stand on an issue in which doctors of the minority community have been the main victims.
On the other hand, the attack on Dr Amit Mehta in a Muslim dominated area by unidentified persons has received substantial publicity. The Amdavad Doctors Forum promptly issued instructions to its Hindu members to stop practising in Muslim areas. It was only after the assault on Dr Mehta that the Indian Medical Association expressed concern for doctors' safety. Some medical associations have painted a picture of 'Hindu' doctors being endangered merely by venturing into Muslim-dominated areas. Dr Mehta himself has opposed this generalisation.
Possibility of discrimination by health professionals
During the team's investigation, it probed into some complaints of discrimination against Muslim patients immediately following the carnage, either while seeking treatment in hospitals or as patients in general practice. Every violence survivor interviewed was specifically asked about the treatment received, the institution where it was received and the experience. Team members interviewed survivors who had been treated immediately after the attacks, largely in the government hospitals - Civil Hospital, VS Hospital, LG Hospital, Amdavad and Civil Hospital, Godhra. Some interviews were also conducted of survivors who had received emergency care in Al Amin Hospital, Amdavad, and in some private nursing homes in Godhra.
The team did not find any reports of blatant discrimination or neglect. It was not able to conclusively establish discrimination on a large scale, though it is possible that there may have been instances by individual doctors.
During a visit to one of the camps, the team heard of an incident in which patients were refused admission in a municipal hospital, but this could not be confirmed because the patients concerned were not present in the camp at the time.
The team also spoke to several individual doctors. One senior doctor
serving in a public hospital held that there had been complete polarisation
in the medical profession. He spoke of a 'schizophrenia' within a large
section of the medical profession, whereby though their political views
were in support of Hindutva, they would continue to treat Muslim patients
professionally. He felt that it was unlikely that in their professional
work, this would lead to any negligence or discrimination. He had not heard
of cases of overt discrimination against patients of the minority community
in any public hospital. He also commented on the fact that the health workers
serving in the public hospitals were 'frightened and confused' by the situations
in which they had been placed, especially the nursing staff.
Several other doctors, from both communities, felt that there may have
been delays due to the rush of patients during the height of the violence.
Delays could also have taken place when doctors tried to prioritise patients
on medical grounds. These may have been construed as deliberate acts by
patients and their relatives.
However, as noted earlier, the general atmosphere of terror surrounding the hospitals, as well as the presence of Bajrang Dal and VHP activists within the hospital premises, intimidated Muslim patients from approaching hospitals. There also may have been a process of 'self-selection' wherein Muslim patients actively avoided going to the hospitals or doctors who were known for their inclinations and might have treated them with discrimination.
An interesting insight came from one of the doctors interviewed, who had been associated with the RSS. He suggested that professionals may have drifted with communal forces because they enable them to promote and protect their interests. According to this doctor, it was commercial interest, rather than any political commitment, which guided doctors' actions.
Attacks on medical professionals
There have been several documented attacks on health professionals
and their homes, property and establishments in the early part of the violence.
Of these, only one attack, on Dr Amit Mehta, in the Juhapura area of Amdavad,
received publicity in the national press. The team received a press note
prepared by the Medicos Welfare Society, which condemned attacks on doctors
on behalf of doctors of the minority community. It had mentioned the following
attacks:
While Dr Amit Mehta was stabbed by an unidentified person in his dispensary, Dr Sadiq's car was destroyed by persons well known to him. He also had a narrow escape from a mob while driving to Al Amin hospital. The mob set fire to a couple riding on a two-wheeler just in front of him.
Both doctors blame individuals and not entire communities for the attacks on them. Dr Sadiq categorically blamed the authorities for letting the violence continue by not taking action against troublemakers from both communities. Dr Sadiq continues to attend the nursing home outside which his car was attacked, while taking many precautions. Dr Amit Mehta does not want to move his clinic from the area where he has been practising for many years, but he is too afraid to go back there because he may become the target of attacks by fundamentalists from either side. The danger to medical practitioners is real. However, there is no evidence that entire communities have turned against them and would like to drive them out.
The interviews suggested that doctors from both communities do not pay much attention to the religious background of the community among which they choose to set up practice. Their decisions are based largely on their assessment of the client base, and the prospects of a profitable practice. More Hindu doctors are working in Muslim areas because, in general, there are very few Muslim doctors. It is largely Muslim doctors who have been involved (voluntarily) in relief work. This fact has been interpreted as a gesture of solidarity to their own community. However, it is also true that at present, they are the only doctors available in Muslim-dominated areas. Other doctors, both Muslim and Hindu, live further away and are not able to reach their workplaces or the camps.
This was highlighted by the plight of Al Amin hospital, which lists 92 doctors as giving voluntary time. Only 14 are Muslims and the rest Hindus. However, after the riots, only four doctors are coming for duty - two of them were Hindu and two Muslim. The others are absent because of insecurity, a feeling that has been actively propagated by the communalists.
Other losses suffered by medical professionals
The violence has definitely affected the doctors economically. Several
doctors working in mixed communities reported that their patient load had
decreased substantially after the violence because their patients could
not reach them. On the other hand, the few doctors who lived and practised
in Muslim-dominated areas were overworked.
The fact that doctors have been targeted for attack based on their religious identity has changed the framework within which the profession articulates its interests. While the security-related problems of 'Hindu' doctors in 'Muslim' areas, and of 'Muslim doctors' in 'Hindu areas' may reflect the actual situation, formulating the issue in this manner also has long-term implications for the profession.
Sentiments of doctors who have been personally affected by the violence are being distorted. It is extremely divisive to portray doctors as either 'Hindu doctors' or 'Muslim doctors' and then explain their problems, actions and motives according to that definition.
Hospitals' (unwritten) policy of segregation on the basis of religion “for better management of security” severely damages the secular character of an institution dedicated to healing. Several Muslim doctors and other hospital staff serving in public hospitals were given sympathetic leave immediately following the violence of February 28 - even if they had not asked for it. One lab technician informed the team that when she reported for duty (in a public hospital in a Hindu-dominated area), she was pressurised by her colleagues to take leave. They felt her presence would incite trouble and pose a danger to herself as well as to other staff and patients.
The medical profession has largely stayed away from communal politics - whether for commercial reasons or otherwise. Since communalisation now directly affects them, a space has been created for religion-based politics in the profession as well. The profession's neutrality will be further damaged if communal organisations provide professionals opportunities to expand their business. This splintering process seems inevitable in the absence of a strong counter-force to prevent the co-option of professionals by communal forces.
Neutrality and humanitarianism are the founding principles of the medical profession. The team repeatedly heard these sentiments from the medical association representatives interviewed. However, in practice it did not find many attempts to uphold or re-assert these values. It is quite clear that doctors' decisions on where to situate their practices are based on pragmatic considerations — the scope for earnings.
Still, the right of all people to work wherever they choose to work, must be respected and protected. Any exodus of medical practitioners due to real or perceived dangers based on their religion will inflict irreparable damage to the profession. In this context, one cannot over-emphasise the role of medical associations in protecting the interests of all their members.
X. Medico-legal issues
Although the team could not conduct a systematic investigation into the quality of medico-legal documentation, it was evident that there had been several lapses. Post-mortems were not conducted in several cases, dying declarations were not recorded and medico-legal cases were not recorded in several cases. It remains to be seen whether these were deliberate because such lapses in documentation are common in normal times as well. However, in this situation, these lapses have serious consequences for survivors in their attempts to get compensation and punish those who inflicted violence on them.
During discussions with both survivors of violence and representatives of NGOs working for the victims, the team came across medico-legal issues which will affect victims' efforts to obtain justice. Some of these relate to the conduct of the police. In other situations, doctors may have been under pressure to 'modify' post-mortem reports. While these issues need a full-fledged investigation, some instances which came to the team's notice are mentioned below.
Inadequate medico-legal procedures followed
Legal volunteers involved in handing complaints of victims and their relatives referred to inadequate procedures followed by the police. Even though many of the deaths took place in hospitals (70 deaths in corporation hospitals in Amdavad as of April 25), dying declarations were rarely recorded. Most patients were victims of burns, stabbing or gunshot injury, and many would have been in a position to give a declaration after having received life-stabilising treatment. However, neither the police nor hospital authorities are pursuing this issue. A senior administrator in the municipal corporation stated that at the height of the riots, when there were many casualties, only identification of bodies was done, not post-mortems.
Another issue related to the police disposing of bodies prematurely, without waiting for relatives to claim them. The police is required to preserve the body for 72 hours, during which period they may be identified and claimed by relatives. However, the police has disposed of bodies as 'unidentified' within a day of receiving them. In such a situation relatives were often unable to see the body of their loved ones, gather any information on the cause of death, and otherwise follow up the case.
Finally, the National Human Rights Commission has laid down certain guidelines for conducting post-mortem examinations. There is also a provision for video-photography during the post-mortem, especially regarding custodial deaths. It does not appear that these guidelines have been followed in large numbers of cases.
Destruction or unavailability of medico-legal evidence
Eyewitness accounts of many of the rapes have indicated that many of the victims were subsequently burnt to death. This led to the destruction of all physical evidence. Other rape victims fled to relief camps immediately after the assault. The violence on the streets prevented them from approaching a hospital for a medical examination (and the recording of evidence), and the lack of facilities prevented this from being done within the camp premises. In such cases, physical medico-legal evidence of the assault no longer exists.
XI. Summary and conclusions
Health conditions in the relief camps: a general crisis
Direct impact of violence: the team's interactions in the camps
corroborate the evidence of massive brutality and systematic use of rape
in the pattern of violence. Those who have survived are recovering from
serious injuries such as gunshot wounds, extensive burns, stab wounds and
lacerations. Many survivors are left with permanent disabilities resulting
from paralysis, amputation of limbs and contractures. In addition, psychological
trauma poses a serious problem with far-reaching consequences.
Threat of a larger epidemic: A number of outbreaks have been recorded, of measles, chickenpox, typhoid, bronchopneumonia, and thousands of children have been affected by acute respiratory infections and diarrhoea. Drinking water and sanitation facilities are grossly inadequate, and there is no active state health service response to improve the camp situation and prevent an epidemic of a greater magnitude.
Health system's response: The state and municipal services have collaborated in providing public health services in the camps and in various hospitals. Considering that the level of functioning of the health services, even in normal times, is inadequate and the fact that there are the additional constraints posed by the crisis situation and the communal environment, the effort has been commendable. However, this does not go beyond what is provided in normal circumstances - and is therefore highly inadequate for people's needs. The approach seems to be not comprehensive treatment but some ad hoc measures to avoid the public outrage which would follow from complete neglect and deaths. State public health services provide immunisation, some maternal and child care, and limited out-patient services. A comprehensive approach to health care in this situation would also include treatment of severe injuries, chronic illnesses, and extensive psychological trauma resulting from experiencing or witnessing truly brutal acts of violence.
Mental health issues: There is no acknowledgement of the need to provide treatment for post-traumatic stress disorder - a well-known sequelae of any disaster. PTSD is accepted to be a public health issue to be tackled by health services in such situations. By ignoring the importance of psychological trauma, the services are under-estimating the scale of damage and undermining the need to rehabilitate the affected. The only emotional support and some kind of counselling is being provided by camp volunteers, who have no training for this kind of work. The camp volunteers' own needs for support and sharing has never received any recognition.
Women's health problems: Existing services do not acknowledge women's health needs. Also, the lack of privacy in camp health services prevents them from seeking treatment. There is no effort to make existing services more accessible to women. Hundreds of women have given birth in the camps, assisted largely by local volunteers, and without any facilities. These women, as well as those in curfew-bound areas, are not in a position to seek special health services.
Sexual assault: The team's report corroborates other investigations' findings of large-scale and systematic sexual assault. There have also been many reports of women coming to hospitals in a condition which doctors would certainly suspect sexual assault. Yet doctors in hospitals visited by the team stated that no cases of sexual assault has been filed. In other words, doctors seem to have disregarded obvious signs of sexual assault. As a consequence, there is no medical evidence of sexual assault, on which basis women could seek justice.
Credibility of health services: Further, the team's interactions in the camps suggested that people are losing faith in existing health services; inadequate services, given in a perfunctory manner, without a sense of commitment to people's right to treatment - all of this has further undermined the credibility of the health services. The fact that the health professionals involved in providing health care at the camps feel that they are vulnerable (because the violence continues) further de-motivates them and inhibits them from responding to the needs of their patients with empathy.
Voluntary efforts The team did not find a mobilisation of non-religious voluntary organisations of the scale that was evident after the earthquake in Gujarat in January 2001. However, the few organisations who have been involved in the relief work have done extremely good work in the face of physical danger as well as intimidation by the state and right-wing forces.
Response of the public hospitals
Insecurity in health institutions: Public hospitals have been
working under a constant threat of violence against Muslim patients within
the precincts of the hospital. There have been instances of mobs attacking
hospitals, preventing injured persons from entering their gates, and even
moving around in the wards, terrorising and even attacking patients and
relatives. There is no indication that the government has made serious
efforts to protect the health services, and maintain people's access to
them. Despite this pressure, health professionals in the hospitals have
functioned neutrally, providing treatment without discrimination on the
basis of community. This is commendable.
In an abnormal situation, where there is a threat to people's safety and movement, the barriers to access to the institution has much worse repercussions. By depending on people to come to them for treatment, the services do not reach those who need them the most.
Long term impact of ad hoc measures: It is also important to comment that several ad hoc measures, that have been taken to deal with emergency situations such as segregating hospitals and patients on the basis of community may threaten the secular character of health institutions and lead to accentuation of polarisation within the profession. However, it must be noted that the responsibility of ensuring safety of patients and staff in the hospitals lies with the agencies such as the police, which have clearly been party to the violence themselves. It is apparent that while the hospitals have largely been non-discriminatory, they have been unable to mobilise support to protect their non-partisan and humanitarian role. This is reflected also in the fact that they have opted to give sympathetic leave to their Muslim employees, probably because they feel that their safety can not be guaranteed.
Impact on health professionals
Participation in the violence: Some medical professionals have
also been involved in propagating an ideology of hatred. As members of
the BJP and the VHP these professionals have also been responsible directly
or indirectly in perpetrating grave injury to Muslims in Gujarat. They
have played a role that contradicts their professional calling as providers
of care.
Failure of the medical associations: The medical associations, which represent the medical profession, have been clearly partisan. They have made no attempts to mobilise any relief (again, in contrast to the earthquake). The condemnation of attacks on doctors followed only after Dr Amit Mehta was attacked, although many other (Muslim) doctors' property had been destroyed earlier and they had faced physical attacks. The attack on Dr Amit Mehta, too has been distorted and misrepresented to project that generally, doctors of the majority community are under attack by the Muslim communities whom they serve. The attempt to implicate the entire Muslim community in an attack by unidentified persons not only distorts the facts, it does injustice to Dr Mehta's sentiments as well.
The fact that the religious identity of the professional has become significant is a dangerous sign. The neutrality and humanitarianism of the profession is important, both in actual practice and also in the people's perception. If the profession is seen to be acting in a partisan manner, or it is observed that only a certain the section of the profession responds to a large scale crisis, it reflects the vulnerability of the profession to external pressures as well as sectarianism within.
On the other hand, doctors have, for the first time, not been spared during the violence. There are documented attacks on the property and person of at least 8 medical professionals. The lack of safety is a serious issue. However, ensuring their safety will not be enabled merely by providing security for them but is contingent on the return of peace.
On the whole, doctors have acted professionally within a very narrow definition of the word. While they have not actively discriminated against any community, they have not pro-actively made any attempts to safeguard the rights of their patients or even their peers. The medical profession has also not made any attempts to contribute to the process of securing justice for the survivors by documenting medical evidence or highlighting the problems that victims have faced.
Medico-legal issues
Although the team could not conduct a systematic investigation into
the quality of medico-legal documentation, it was evident that there have
been several lapses. Post-mortems were not conducted in several cases,
dying declarations were not recorded and medico-legal cases were not recorded
in several cases. It remains to be seen whether these were deliberate because
such lapses in documentation are common in normal times as well. However,
in this situation, these lapses have serious consequences for survivors
in their attempts to get compensation and punish those who inflicted violence
on them.
XII. Demands and recommendations
The team's investigation and analysis has strengthened its conviction that no comprehensive public health effort or rehabilitation in Gujarat today will be complete without addressing the issue of justice. Although the following recommendations specifically pertain to issues of health, health care and rehabilitation, none of these processes can be effectively implemented or sustained without the restoration of peace and normalcy in the state. This is essential for the effective operation of public health system and also to create conditions where civil society organisations can participate in the process of relief and rebuilding.
At no cost should the relief camps be disbanded without proper rehabilitation of the survivors.
An independent health commission should be constituted to investigate into the health conditions in the camps, assess rehabilitation needs, probe issues related to survivors of sexual assault, evaluate the response of the state health services to the violence and its aftermath and the impact on health professionals, and examine medico legal issues emerging from the carnage. The MFC team's investigation was an exploratory effort carried out within many limitations; a comprehensive investigation is essential.
Camps:
Living conditions and water and sanitation facilities in the camps
must be improved. Pregnant and lactating women, infants and young children
must be provided special nutrition.
Camps must be protected by an impartial security force. This force must also support volunteer camp organisers for transporting patients who need referral services or emergency care.
Health services must be strengthened with resident health facilities, since movement is severely restricted by curfew as well as the threat of violence. Referral facilities are needed as well as specialised services for gynaecology, mental health, physiotherapy, etc. Camp volunteers must be given training inputs, as they have been providing both physical and emotional support to camp inmates.
Health services
Better infrastructure is needed for medical facilities. This includes
more time to be spent by the health teams in the camps; better drug supplies;
transport facilities for patients; improved surveillance and screening;
and security to medical personnel.
The health personnel must be reoriented to mental health issues, and to the specific health needs of women, including gynaecology and obstetric care.
State authorities must acknowledge the clear evidence of large-scale psychological trauma, which is distinct from that which may result from a natural disaster. However, counselling and emotional support to survivors, can be effective only if justice is also sought for the crimes committed against them.
There is a need to reinstate the sanctity of health care services as inviolable humanitarian agencies. Attacks against health services must be publicly condemned, and the attackers must be given exemplary punishment.
Security of patients as well as hospital staff within, around and during transit to the hospitals must be ensured. A vigilance committee should be appointed for each hospital with representatives from all sections of civil society, which would monitor security mechanisms and provide support to the hospitals to function in a non-partisan manner.
The health authorities must explain why medical examinations were not conducted of women who approached hospitals in conditions where sexual assault would be very likely.
Medical care should be provided to the survivors of sexual assault.
Medical ethics
The Medical Council of India must take heed of the blatant violation
of ethics and human rights by doctors who participate in violence (ref.
Article 6.6; MCI notification of April 6, 2002, the Indian Medical Council
(professional conduct, etiquette and ethics) Regulations, 2002)
The Medical Council of India should de-recognise all doctors whose involvement in inciting or participating in violence has been proved.
Communal attitudes within the profession and its associations are not in consonance with medical ethics [ref. Declaration; MCI notification of April 6, 2002, the Indian Medical Council (professional conduct, etiquette and ethics) Regulations, 2002]
Professional associations such as the Indian Medical Association must condemn attacks on all doctors, regardless of their social background. There is an urgent need to draw up ethical guidelines for medical professionals working in communal situations.
The medical profession must not only provide treatment; it has an ethical responsibility to systematically and completely document medical evidence. [ref. Art. 1.3; MCI notification of April 6, 2002, the Indian Medical Council (professional conduct, etiquette and ethics) Regulations].
Medico-legal issues
Post-mortems: The National Human Rights Commission protocol
for conducting autopsies should be followed. Dying declarations must be
recorded in case of all seriously injured patients. Post-mortems must be
audited, with sample post-mortem reports reviewed by a team of independent
experts. The police should preserve all unclaimed bodies for 72 hours under
appropriate conditions.
Survivors of sexual assault: There is an urgent need to systematically record details of sexual atrocities. The testimony of relatives or eyewitnesses (if the victim was burnt to death) or the testimony of the survivors (where there was a delay in reporting forced by circumstances) should be given paramount importance in judging the case, keeping in view the context.
Rehabilitation
Compensation should be decided by an independent committee,
taking into account not only loss of property, but also the trauma suffered
by victims.
The state should allocate land to people who want to shift from camps into safe localities of their choice. As long as people do not want to relocate, they should be allowed to remain in the camps. For single women, the state should provide separate housing if need be, as was done after the anti-Sikh riots in Delhi, where single women got free flats. Telephone connections with a help-line should be made available to disabled persons to improve communications between the community and the external world and ensure security, trust building and referrals.
Shelter and livelihood: Rehabilitation must include various efforts
to restore livelihood to people who have been dislocated by the violence.
Livelihood programmes should be designed, keeping in account the concerns
and capacities of the affected community, and should facilitate the transition
from relief to rehabilitation.
Justice
To ensure complete safety of the people who want to return to their
houses and localities, the state must act to effectively control and inhibit
mob or individual attacks. Peace and security must be restored in these
localities, and anyone instigating violence must be given exemplary punishment.
Failing this approach, there will
be no real deterrent to violence, and no real rehabilitation.
We appeal to our peers among the voluntary groups and organisations
to respond to this humanitarian crisis and to lend their support to the
provision of care, rehabilitation, redressal of losses and injustice.