Kashmir’s ill-equipped health system and government’s push for tourism led to a COVID crisis

In the first week of May, Qazi Idrees, a 29-year-old government employee, was making desperate calls to get a ventilator supported ICU bed for his father, Qazi Aftaab. Aftaab was admitted at JVC Medical College and Hospital in Srinagar, which was severely understaffed and under-resourced. “When my father required high-flow oxygen, they kept him on low-flow,” Idrees told me. “They asked us, as our father’s attendants, to give him injections,” Idrees said. “How could we? It’s a sophisticated set-up and what if we did anything wrong, who would be responsible? They even asked us to do suction by ourselves, how could we do it, what are the doctors there for?” Qazi Aftaab died of COVID-19 on 17 May, along with 73 others in Jammu and Kashmir. His case is emblematic of the critical shortage of oxygen, drugs, healthcare staff and hospital beds of Jammu and Kashmir’s health systems.

Amid this public health crisis, as COVID-19 cases and deaths have been rising dramatically in the region, the territory’s administration has been creating hurdles for local NGOs and civil-society organisations that have been filling in the gap, providing essential oxygen and drugs. Several doctors and local leaders told me that the current spike in cases in Kashmir was, at least in part, because the administration encouraged an influx of tourists in an attempt to portray Kashmir as having returned to normalcy. On 4 May, when Aftaab was admitted at JVC medical college, 4,650 people tested positive for COVID-19 in Jammu and Kashmir.

Idrees told me he had initially been glad when they had been able to find a hospital bed for his father, something that became increasingly hard as cases in Kashmir surged up. But as he discovered, the hospital was struggling with its limited resources, and said that the doctors were using the same amount of oxygen in regular oxygen beds and in intensive-care unit beds. “Initially they moved us to a bed, which they said was an ICU bed, but they used the same 60-litre oxygen machine. They even told the district commissioner, who had called them on our behalf, that we were provided an ICU and the patient is stable. It was a lie. No care is being given to patients.”

Idrees also learnt that families were expected to procure the drugs and manage the patients themselves. He said that when his father was finally admitted to an actual ICU, it had only two nurses, who did short shifts, and had no doctor after 9 pm. “They provide no care as they are supposed to,” he told me. “This is a wretched disease. It affects you mentally even if it is your kin who has it. If somebody were sick normally, your relatives and others would come to the hospital, we’d get some moral support. That’s not the case with COVID; you worry about your father, then about yourself, about catching the infection, and then you realise that you are on your own, nobody is coming to help.” Shafa Deva, the medical superintendent of JVC medical college did not respond to queries.

There has been a historic lack of medical infrastructure in the region, where the Indian government’s concerns over security have often outweighed its concerns over public welfare. In April 2020, medical professionals voiced concerns about the capacity of the region’s medical infrastructure to manage a crisis such as COVID-19. The same month, the Jammu and Kashmir directorate of health services published a circular threatening prosecution against outspoken doctors.

Over the past year, the Kashmir health directorate has been increasing the number of beds, oxygen and equipment necessary to handle rising COVID-19 cases, but several doctors told me that the current spike in cases dwarfed what they had prepared for. “The Kashmir valley has 2,459 oxygen-supported beds, only 752 of which could handle high-risk patients,” Mir Mushtaq, the spokesperson of the directorate of health, told me in the last week of April.  However, the administration has lost crucial time in equipping hospitals with ICU care facilities. According to the government’s daily bulletin on COVID-19, on 16 May there are only 133 ICU beds available in Kashmir. On 31 May, Mushtaq told me, Kashmir had 2,035 oxygen-supported beds, 67 ICU beds and 112 ventilators. However, there seems to be a discrepancy in the government’s data, because just a day earlier the government bulletin noted that Kashmir had 154 ICU beds, 83 of which were vacant.

The state has also been unable to utilise ventilators well. A report from April 2020 showed that Kashmir had only 93 ventilators for a population of around eight million. On 21 February 2021, the local newspaper Greater Kashmir reported that the union government had allocated 908 ventilators to Jammu and Kashmir of which 892 were installed. However, a senior official with the health department told me that many ventilators were lying unused. “These are sophisticated machines,” he told me, requesting to remain anonymous. “To properly function each ICU requires at least a specialist doctor, that is an anesthetist, a trained technician for ventilator maintenance, a nursing orderly to cater to the patient’s non-medical needs, and a nurse, who all are to be supervised under a registrar who will in turn report to a consultant. The government had not used the time between the last wave and now to recruit the necessary manpower. As a result, at several places, ventilator facilities lie unused. Belatedly, the government has resorted to contractual recruitment through the National Health Mission.” On 24 April, Mohammad Yasin, the mission director of the Jammu and Kashmir wing of the NHM, issued a notification inviting applicants for 30 posts for anaesthesia consultants through walk-in interviews on 28 and 29 April. “But even that is woefully inadequate,” the health-department official told me.

Alongside ventilators, there has also been a lack of drugs commonly prescribed for COVID-19. On 20 April, AG Ahangar, the director of Sher-I-Kashmir Institute of Medical Sciences, Srinagar’s biggest hospital, said that Jammu and Kashmir was suffering a shortage of remdesivir. The same day, Atal Dulloo, the financial commissioner of the territory’s health department said that there was no shortage in the state. However, both doctors and relatives of patients told me that this was an absurd claim.

Two doctors I spoke to, one from SKIMS and another from Shri Maharaja Hari Singh Hospital in Srinagar, both of whom wished to remain anonymous, confirmed to me that since mid April, the hospital had lacked sufficient stocks of remdesivir. Idrees, too, told me that he struggled to get the drug. “The consultant had recommended remdesivir injection, but my father wasn’t given the medicine for his first two days in the hospital,” Idrees said. “The doctors ticked that column recording that they did provide it. I figured they didn’t have it in the stock. The consultant told me the administration wouldn’t say so, even if it was true. Finally, I got them from the market. They cheated the treatment sheet for a steroid medicine in the same way as well. On one night they didn’t even have paracetamol.” Dulloo did not respond to questions emailed to him.

On 17 May, the Hindustan Times reported that, despite a lack of oxygen for hospitals and homecare in Kashmir, five oxygen-generation units meant to be deployed in hospitals in Kashmir were diverted to Hindu-majority Jammu. Two days later, The Wire, reported that it was three oxygen-generation units that had been diverted. Abdul Rashid Dar, the chief executive engineer of the mechanical engineering department in Kashmir was quoted by the Hindustan Times report as saying, “Only two plants of 1,000 LPM capacity have been diverted.” Despite me pointing out his quote, Dar denied that any diversion had taken place to me.

A senior Kashmiri journalist who has covered the region for over two decades and wanted to remain anonymous, told me that the diversion of the oxygen-generation units was part of a larger pattern. “Allocation in health sector is almost at par in both regions, if not skewed towards Jammu,” he said. “In the past twenty year all health ministers have been from Jammu and they were all very powerful. Obviously, the BJP has a vote bank there. Jammu, Kathua, Udhampur districts have always been one of the bastions of the RSS. The diversion of the oxygen units makes Kashmiris feel they are expendable any way. I think there was a lot of anger on Kashmiri social media”

The lack of oxygen has severely hit families in the region. On 2 May, Faizan, a 29-year-old resident of Srinagar’s Kalashpora locality, saw his uncle’s oxygen saturation falling below 90. When he went to the city’s Chest Disease Hospital, he was told that his uncle could not be admitted. “They said that they wouldn’t admit him because none of us could qualify as a by-stander, because all of us were COVID positive,” Faizan told me. “So, we were forced to take care of my uncle at home, but there was no way we could get oxygen.” Late that night, an imaging and diagnostic centre which was conducting COVID relief work, reached out to Faizan and delivered an oxygen cylinder to his house. “They didn’t want any money either, but because of them my uncle’s condition is improving,” he told me.

Like the diagnostic centre, several NGOs, volunteer networks and civil-society organisations have been at the forefront of providing oxygen and drugs to those in Kashmir who cannot find hospital beds. A doctor who has been working in COVID-19 care at Srinagar’s Shri Maharaja Hari Singh Hospital since last year, who wished to remain anonymous, told me that despite the lack of beds and facilities, the death rate in the Kashmir valley has been lower than Jammu primarily because of the work of these civil-society organization. “If you look at the figures, the daily cases, we are already under strain,” he said. “But if you look at deaths, Kashmir has lesser deaths than Jammu because a large number of patients and their requirements are managed at their homes by NGOs. Take them out of the picture, and things would look a lot worse, at least in terms of deaths.” The data bears this out too. Between 28 April and 7 May, there were 161 deaths in the Kashmir valley, while 255 COVID deaths have been reported from Jammu. 

Bashir Ahmad Nadvi, who works for a Kashmir-based NGO called Athrout, told me that the condition in Kashmir was dire. “We get almost 30 or 40 calls a minute, and almost all of them asking for oxygen cylinders or concentrators,” he said. “Last year it was different. People would ask for medicine or food kits, this year it is all about oxygen.” Nadvi told me that besides helping people in Kashmir with food kits, and medicine, they have about 400 concentrators and 40 mini-ventilators spread across Kashmir, helping those who cannot arrange oxygen through government channels.

“We however can provide oxygen cylinders only at one facility, the Srinagar Hajj House which was converted into a COVID care facility in collaboration with the District Disaster Management Association,” he said. The equipment at the Hajj House facility, including oxygen and ventilators, was donated by Athrout. In mid May, Newslaundry reported how Athrout largely went unmentioned in government statements and press releases. The report noted that after the facility began gathering press attention, members of Athrout were asked to remove their uniforms and banners, so the initiative seems like it is entirely managed by the Jammu and Kashmir administration.

Nadvi told me that thirty years of conflict had helped build strong civil-society organisations that could step in when the government failed to provide for its people. “Naturally, Kashmir is far behind places like Delhi,” he said. “However, a network of NGOs working in Kashmir have been able to fill the gaps, where the administration could not, helping keep the death rate low. Our situation, the conflict of 30 years, helped us prepare better.”

However, the Jammu and Kashmir administration has been posing challenges to NGOs doing relief work. On 6 May, Mohammed Aijaz, the district magistrate of Srinagar issued an order which stated that “all oxygen manufacturing units within the jurisdiction of District Srinagar shall supply oxygen only to the designated hospitals/ clinics and will stop supply to any private society/ NGO with immediate effect.” It further stated that any private hospital would need to “register their genuine demand Nodal Officer COVID-19 War Room … with the copy of the communication to Director Industries Kashmir.” The order was widely criticised by civil-society organisations and journalists for restricting access to home care and further add pressure to already overwhelmed hospitals.

A senior functionary at an NGO that works with marginalised communities in Kashmir, who wished to remain anonymous, told me that home care had become even more essential because hospitals had begun discharging patients who still required oxygen. “Let’s suppose hospitals across Kashmir discharge 400 people every day who require some level of oxygen support at home to create vacancies to help other critical patients,” he told me. “But they in effect wash their hands off as far as the discharged people and the responsibility of their oxygen needs is concerned. Where will these people go? If we, and all other NGOs don’t provide oxygen, food, medicine to these people, won’t they die or come on the road?”

A project manager at an NGO that has been responding to COVID related SOS calls and delivering oxygen cylinders to patients told me that Aijaz’s order had created a panic when it came out. “The day that the order came, our vehicle wasn’t allowed entry into the factory for refilling even,” he told me. But his organisation, along with other prominent NGOs, got in touch with the administration to discuss the issue. “It was an exhaustive meeting attended by various officials,” he said. “They tried to convince us to follow the order. But when we put forward our points of view, they listened, and thankfully understood our concerns.” The Twitter account of the Srinagar administration has since taken down the tweet in which the order was published. As of now, NGOs have to file papers to the administration every week to be allowed to refill oxygen cylinders for patients.

Many local doctors and activists told me that the Jammu and Kashmir administration had not only failed to address the current COVID-19 crisis, but were largely to blame for the virus’s spread in the first place. “Jammu and Kashmir is a place of all seasons and we are planning festivals in every season for the locals and tourist alike,” Sarmad Hafeez, Jammu and Kashmir’s secretary of tourism, said in Srinagar, on 4 April. “We started with almond blossom (Badamwari festival) and now Tulip Festival and many more events are coming in summer. The tulip festival is an open invitation to all the people from all over the country and from all over the world to celebrate the beauty of Jammu and Kashmir.” According to the government of Jammu and Kashmir’s department of information and public relations, the two-day Tulip Festival had 32,000 visitors. Nearly the entirety of the state’s senior administration was at the event too, from the secretaries of various ministries, police heads and Manoj Sinha, the lieutenant governor of the union territory.

The spread of COVID-19 in the Kashmir valley has been alarming even in comparison to India’s poor management of the pandemic. On 20 February, Jammu and Kashmir had 700 active cases of COVID-19, but by 3 April, the first day of the Tulip Festival, the case count had grown five-fold to 3,574. The cases load only continued to climb over the next month, reaching 44,307 on 7 May. “The government-organised tourist fests could have been a major reason for the spread of the virus,” the doctor at SMHS told me. “They gave precedence to tourism, image-making and economy over people. Public health was delegated to second place.”

Several doctors told me that a key reason for the spike in cases in Kashmir was because the government failed to carefully test and isolate tourists. Syed Ghazala Nazki, a community-medicine specialist, who has been in charge of testing at Srinagar airport since May 2020, told me in late April this year that they test between 3,000 and 5,000 persons at the airport daily. “We mostly do rapid antigen tests and the results come within half an hour,” she said. “If a person is positive, he is contacted by authorities and monitored constantly. We do about 500 or 600 tests on average these days.” Nazki said the more efficient RT-PCR tests were reserved for travellers from outside India, and those who may show symptoms of COVID-19 upon arrival. Data accessed by the online news portal Citizen Matters showed that between January 2021 and the end of April, 1,26,076 tourists arrived in Kashmir, only 424 of whom were foreign nationals. When asked why such a distinction was made when a vast majority of tourists who arrived in Kashmir over the past year were Indian, Nazki said, “We have been advised to do so.”

The doctor from SMHS’s COVID-19 ward told me that merely sampling tourists at the airport and letting them travel around the state before their results came in could lead to a wider spread of the virus. “What is the point of testing and sampling even if we just let people go? We have had cases where people would deliberately hide their travel histories, so how does testing and letting go people make sense?” Nazki, however, argued that the burden of preventing this lay entirely with the tourists themselves. “The tourists are supposed to follow SOPs and keep in isolation,” Nazki told me.

The government’s policy of testing and quarantining those arriving from outside points to a double standard for tourists and Kashmiris. In the beginning of the pandemic, as people all across India scrambled to reach the safety of their home, Kashmiris, spread all across India and the world, flocked to their homes as well. On 23 May 2020, the Jammu and Kashmir department of information and public relations reported that 87,948 residents of the territory had returned since the start of the pandemic. Initially, all passengers coming through any mode of transportation were required to be tested and sent to mandatory quarantine at facilities set up by the government or paid for by the travelers. The travelers, at that time almost all Kashmiris returning to the relative safety of home, would be sent to their homes after testing negative in a RT-PCR test and completing the mandatory two-week quarantine period.

It was not until 30 October 2020, following restrictions being eased in other states that the administration in Kashmir also followed suit, and allowed home quarantine. This double standard is also clearly emphasised during the second wave of the COVID-19 pandemic in the Kashmir valley. On 30 March this year, two days before the inauguration of the Tulip Festival, the Jammu and Kashmir administration passed an order establishing a Test-Track-Treat Protocol. The order said that RT-PCR testing should be increased in Jammu and Kashmir. “The proportion of RT-PCR tests in the total mix should be scaled up, on best effort basis, to 70 % or more, excluding travelers.” In other sections of the document, the term “traveler” seems to refer exclusively to tourists. The order also specified that up to 25,000 pilgrims a day were allowed to visit the Vaishnodevi Shrine in Katra, while not allowing gatherings, assemblies or processions anywhere else in the territory.

Members of the Jammu and Kashmir administration also told me that even if tourists were sufficiently tested, they were often hard to trace after they left Srinagar airport. A senior official working in the administration’s COVID-19 control room, who wished to remain anonymous, explained that if a tourist or an incoming local tests positive, they are contacted based on the details they provide to government officials at the airport. “For incoming tourists, usually the only details noted are their cell phone number to the contacts of their travel agents and hotels,” he told me. “But the system has gaps, a lot more could have been done to prevent persons with viral load from entering the valley. Sometimes the phone numbers provided by tourists don’t work in Kashmir. Initially we missed some positive travellers. It wasn’t possible to gauge how many people those tourists might have in turn infected.”

The COVID-19 control room official told me they had voiced these concerns to the Jammu and Kashmir health department. “We had also suggested a mandatory RT-PCR report of 72 hours as compulsory upon arrival for all tourists—we even did it unofficially for some time,” the official said. “But the proposal didn’t find favour with the administration for some reason.” I asked if the administration did not want to enforce stringent testing because they did not want the success of the Tulip Festival and other tourist events to be affected. “The less said, the better,” the official responded. “It’s obvious that doing such things at the time of a pandemic doesn’t make sense, but what can we say.”

It was not only in Kashmir that state administrations allowed for large religious or touristic events. Between January and April, the Uttarakhand government held a full-scale religious festival called the Mahakumbh, in which over 21 lakh people participated with minimal COVID-19 precautions. Experts have called it a super-spreader event. However, the tourist festivals in Kashmir differ from events like the Kumbh in that they were not backed by popular demand, or seen as religiously or culturally necessary.

The administration of Jammu and Kashmir has constantly tried to use tourism as a marker of normalcy returning to the region. Indian newspapers, too, routinely quote officials from Jammu and Kashmir’s tourism department who argue that the return of tourist following the abrogation of Jammu and Kashmir’s special status under Article 370 is a sign that the valley is peaceful. Amid the pandemic, the state’s tourism department was also bidding to hold conferences of international tourism leaders. News reports about the region routinely say that tourism is a key industry, arguing that its return will also create an economic recovery in the valley. In reality, the tourism industry only contributes an estimated 6.98 percent of the territory’s gross domestic product.

Kashmiris have constantly argued that the administration’s urge to increase the arrival of Indian and international tourists is not economic recovery at all, but rather an attempt to advertise that the region is peaceful. “In the case of the current BJP government, it has weaponised tourism, a recreational and commercial activity, to flood Kashmir with non-Kashmiri domestic tourists as a reminder to Kashmiris that they are insignificant in the face of the demographic power of India,” Siddiq Wahid, a historian who was previously the vice chancellor of the Islamic University of Science and Technology in Awantipora, told me. “So, the use of tourism as a political tool has to be understood in the context of the last seven years, not just the post-Article 370 political landscape. The government, both local and national, are entirely culpable for pushing tourism in the midst of a pandemic. In the context of the history of the Kashmir conflict, it leaves us wondering whether this radical promotion of domestic tourism by the government is not a political, rather than an economic, project.” Sinha, the lieutenant governor, did not respond to questions about tourism in Kashmir or the current health situation in the valley.

The doctor from SMHS who wished to remain anonymous told me that the administration had not learnt any lessons from the spike in COVID cases following the Tulip Festival. On 13 March, Sinha announced that the administration was going to allow the annual pilgrimage to Amarnath shrine in Kashmir’s Anantnag district. The pilgrimage had been halted in 2019 following the reading down of Article 370, and again last year because of the onset of the pandemic. On 1 April 2021, the Shri Amarnath Shrine Board had begun the registration for the Yatra. On 22 April, the board announced that the registration had been temporarily suspended, though it said they will re-open once the situation improves. Since then the Jammu and Kashmir government has not made any definitive statements whether the Yatra will take place. The 56-days-long pilgrimage was due to start on 28 June. “Allowing the yatra in present situation will be a disaster, bringing all variants of the virus to Kashmir,” the doctor told me. “It will be the next Kumbh.”

Wahid, too, argued that Amarnath Yatra might be dangerous. “Prima facie, there seems to be enough evidence to suggest that the government should suspend all such gatherings be they religious or political. But the government’s policies in Jammu and Kashmir are not necessarily governed by science as much as they are by politics. So, it is not surprising that it pursues a policy of ambiguity and of hope that it can continue to sponsor the yatra to continue to assert its domination in the former state.” He continued, “One should not be surprised if it is regarded here as a special political, demographic and ideological message to Kashmir.”