Arun Bhaiya[1] –Ramesh, I am giving you these medicines.  Count them and tell me how many tablets do you have?

Arun Bhaiya throws the seven medicine strips towards Ramesh, standing nearly one-feet away, a printed cotton mask on his face, with hands wide open, sort of like a ball-catching position.  The medicine strips slip through his outstretched hands and fall on the floor, scattering everywhere.  One strip falls near my foot.  I move my feet away as Ramesh bends and quickly starts grabbing them.  His movement is hurried as he counts the strips and responds to an impatient Arun Bhaiya. 

Ramesh  – 70

Arun Bhaiya – Good, so after how many days do you have to come now?

Ramesh – 10 days

Arun Bhaiya – Okay. Do not come before your due date. I will not give you these medicines before.  You eat seven tablets of Buprenorphine daily.  Come only when these medicines are over. Do you understand?  Go now and send the next person in.

Ramesh walks out, and Suraj walks in with his mother, then Sandeep walks in with his wife, then Seema comes for her brother, and so forth.  With everyone, a similar interaction repeats.

Nearly a year ago, COVID-19 hit the globe and severely impacted healthcare facilities worldwide. While nations across the globe grapple with the novelty of living life with the coronavirus, a small community of injecting drug users in Jammu City, Jammu and Kashmir (J&K), India is struggling in a shifting ecosystem of care to access the various state-sponsored rehabilitation services (known as “de-addiction”) for substances users. Before COVID-19, the individuals recovering from injecting drug use would visit Jammu City’s state-sponsored Psychiatric Hospital for different kinds of treatment and care. Some were registered at the Opioid Substitution Treatment (OST) Center that would dispense Buprenorphine (a medication used to assist drug addiction treatment) daily. Others would be admitted to the detoxification ward or sought outpatient treatment from the psychiatrists at the hospital. 

However, when India went into lockdown on March 22, 2020, the Health Secretary of J&K ordered the only psychiatric hospital in Jammu City to discontinue its services and reconstitute itself as a 70-bed, asymptomatic COVID-19 patient’s isolation unit. This emergency order created rush and panic as patients and doctors were forced to vacate the hospital premises on a terse notice. It also led to the indefinite displacement of psychiatric services and substance use recovery programs at the Hospital. 

But even before COVID-19, I observed the hospital undergo significant metaphoric and infrastructural changes as it responded to a rapidly changing socio-political and regional context. In the past year, the hospital has come to be (a) seen as a publicly known haven for substance users; (b) an Indian government-led and managed Armed Police Force’s residence center, and finally, (c) an impromptu COVID-19 isolation and testing center. These shifts have significantly impacted the state-sponsored de-addiction services and left the injecting drug users’ community in Jammu scrambling for care and recovery. This article details how the psychiatric hospital shifts between being a site of care and recovery to a site of armed occupation, thereby redefining the imagination about a hospital and impacting the horizon of care for substance use recovery clients.

Jammu and Kashmir: An Introduction

The Muslim-majority Indian territory of Jammu & Kashmir (J&K), located within the conflicted borders of Pakistan and China, is one of the most militarized regions of the world, with a “state of emergency” operative in the region since 1989 (Duschinski et al. 2018; Varma 2016a). Territorial claim about Indian military occupation and demands for self-determination in Kashmir have frequently led to widescale violence, demonstrations, state-imposed curfews, and travel restrictions in the entire J&K (Duschinski et al. 2018; Varma 2016b). Characterized by distinct ethnic, cultural, religious, and linguistic groups, the Jammu region and Kashmir region differ significantly. However, they remain inextricably intertwined through the civil and bureaucratic apparatus of the Indian state.

Jammu City is the Jammu region’s cultural, economic, and administrative center and home to the only state-sponsored psychiatric hospital in the region. I have been living in Jammu City since August 2019, conducting fieldwork at the hospital and observing its shifts and responses to the ongoing demands of the Indian regional and national politics. The start of my fieldwork coincided with an historic decision by the Indian government, which changed the cultural, social, and political landscape of the J&K region forever. Until recently, a constitutional provision had allowed the residents of J&K to live under a separate set of laws from other Indian citizens. This provision was the hallmark of J&K’s accession to independent India in 1947. However, on August 5, 2019, the Indian government revoked its state’s semi-autonomous status and split it into two territories: Jammu and Kashmir, and Ladakh. This decision led to a chain of events causing political turmoil, fear, hope, and fundamental uncertainty about the region’s future.  Within hours of this decision, militarization began: J&K state leaders were arrested in the middle of the night (Zia 2019), the government deployed police, imposed curfew (Gupta 2019), sent thousands of security forces to the region, and shut down the internet and phones on the day of the announcement (2019 Report on International Religious Freedom). Within a week, nearly one million military and police personnel were stationed at every corner of J&K. Among them was the Indo-Tibetan Border Police Force (ITBP), an Indian government-led and managed armed unit that was re-directed from patrolling the India-China border to J&K.

The Occupied Hospital

When ITBP personnel began arriving in August 2019 at Jammu City, the J&K Police (JKP) officials contacted the hospital management to accommodate one battalion. The hospital administrators readily agreed because, for months, they had been requesting JKP for increased security, especially for the staff at the OST center to manage the substance use recovery clients who sometimes misbehave with the clinicians. Hospital management and JKP officials agreed to turn an unused canteen area into the residence and commanding center for one ITBP unit. In return, the ITBP personnel would provide 24/7 security to the hospital. The hospital staff informed me that the canteen had been lying defunct for over two years due to financial strain. Eight months after the Indian government’s declaration, the ITBP personnel and their ammunition such as AK-47 assault rifles, sniper rifles, tear gas rifles, batons – were still here and had become a part of the hospital space and routines. ITBP men patrolled the hospital corridors, supervised the clients at the OST center, and interacted with doctors, patients, caregivers, and me, the researcher. 

When ITBP personnel converted the canteen into their shelter, they thoroughly cleaned the area. In the process, they found an abundance of broken needles, syringes, cotton, spoons, cigarette butts, paper, tin foil, and lighters: the drug paraphernalia of injecting users. They told me they had collected multiple bags of these materials and were shocked at the extent of substance abuse in the Jammu city and especially within the hospital premises. They questioned the hospital’s responsibility towards the care and recovery of substance users. On discussing ITBP personnel’s disbelief with the hospital clinicians, I learned that they were aware of the abuse of heroin, buprenorphine, and other illegal substances on the hospital premises.  It was publicly known that the hospital canteen, the parking lot, and areas around the hospital were hubs for these activities. Daily sale and purchase of illegal substances would occur in the late afternoons and evenings on and around the hospital premises. The doctors and nurses in-charge of dispensing Buprenorphine told me how clients would either miss their dose, cleverly hide the medicine in the folds of their shirt or at the back of their mouth and then inject it behind the hospital building. Even though the authorities were aware of this practice, general helplessness prevailed due to the lack of police security. According to staff and clients, incidences of violence and assault on medical staff ensued whenever a complaint was lodged against a client or their buprenorphine dose was suspended. Moreover, the OST staff was also under the National AIDS Control Organization’s responsibility to retain clients and ensure their compliance with buprenorphine despite the slippages and ruptures in treatment, which only formed a clients’ path to recovery.

However, these activities had tarnished the hospital’s reputation in the Jammu population. The hospital was seen as a bad place by the local residents and often by caregivers and clients. In this place, the substance user does not heal but returns addicted to other potent substances. A return that is multi-layered for it is a return to using heroin or any other substance and a return to the hospital either for detoxification or admission to the OST center and returning to the very dynamics of “endlessness” (Garcia 2008) of substance abuse and recovery.

Shadows of Abuse and Care at the Occupied Hospital

Interacting with the ITBP personnel, I noticed their desire to save Jammu’s youth from ruining its future. They expressed a moral compulsion to oversee the hospital’s everyday activities, protect the doctors and staff, and supervise the daily client flow at the buprenorphine dispensing unit. ITBP personnel began checking the client’s ID cards at the entry gate. They adopted the militarized technique of knowing and identification. They stopped every incoming person at the hospital gate and asked for their identification. Clients at the OST center were now allowed entry only if they furnished proof of registration and enrollment at the center. Family members were permitted to accompany clients if they could convincingly demonstrate their relationship to the client through a piece of government-approved documentary evidence or by calling the OST staff to validate their kinship ties. Client’s access to substance use recovery was now dependent on their approval and consent by ITBP men. ITBP personnel also actively engaged with caregivers to positively reframe the hospital’s narrative and improve its local reputation. Over time, they befriended clients and informally mentored them by sharing life stories of surviving physically and mentally tough situations with grit and determination. However, in the initial few weeks of ITBP’s presence at the OST center, their personnel would scream and verbally abuse the clients for not standing in the queue while waiting for their buprenorphine dose. Clients were threatened with wooden sticks if they spoke loudly to each other or argued with the dispensing staff. Above all, clients were constantly reprimanded and humiliated for their habit of drug use. There was minimal intervention from the OST staff and the hospital administration to stop this. Instead, strictness was perceived as an important lesson that these young men needed to improve their living ways and interact with the clinicians. A few clients tried to stand up for themselves, but they were admonished and silenced by ITBP personnel for their bad habits. Thus, the ITBP unit at the hospital reproduced the perpetual state of siege that subjects the entire population of J&K to everyday conditions of surveillance, punishment, and control (Duschinski et al. 2018). As Saiba Varma (2020) writes, the siege’s effects are psychological, not just physiological – wearing people down, testing their willfulness, and eroding their dignity.     

While the clinicians felt grateful for the security and support provided by men-in-uniform, they also expressed feeling surveilled and limited in practice by the dominant presence of ITBP personnel at the hospital. They remarked that it was becoming increasingly difficult for them to assert the clinical understanding of addiction.  The boundary between recognizing substance abuse as a disease versus substance abuse as a social malaise and substance user as a victim versus substance user as a criminal was blurred in everyday hospital life. New relationships of dependencies had begun to emerge. The hospital, which espouses itself as a non-judgmental space of care, recovery, and treatment, was now occupied by ITBP personnel due to a sudden political decision by the Indian government. ITBP’s impromptu arrival at the hospital and the discovery of drug paraphernalia at the canteen forged an unexpected relationship of dependence between the public health, police, and the state. The state-sponsored hospital’s smooth functioning was now dependent on the state-appointed armed personnel’s presence and participation, filling the long-standing absence of J&K Police at the hospital. While this unit was deployed to maintain peace and harmony in the region, they found themselves confronted with a moral choice of saving the youth from the drug menace and simultaneously advancing the Indian state’s agenda of winning the hearts and minds of the people at J&K (Duschinski et al. 2018, Varma 2018) by producing psychic, social, and political-economic dependence on the Indian state (Varma 2020) in order to integrate them into the national discourse of oneness and unity especially after the sudden removal of J&K’s special constitutional status.  For ITBP personnel, assuming the responsibility of cleaning the hospital’s reputation is an expression of care about the place and the people. Even violent shouting, screaming, and policing is a form of care because once they were embedded in the same social and local moral worlds as the clinicians and the clients (Kleinman 2006), they could not delink care from their role as security personnel. Thus, military and medical infrastructures, care and violence were co-imbricated, physically, and symbolically (Varma 2020). The language of care in the hospital was now entangled with the language of violence and moralization at the hospital.

While clients reported feeling angry, they also expressed helplessness over their inability to stop ITBP personnel’s behavior. Culturally and relationally, abuse and disrespect have become familiar to them because they often receive it from their families, society, the hospital staff, or the local police. Nevertheless, at this moment, the client’s daily physiological dependence on buprenorphine and the nature of their reliance on de-addiction clinicians, they had no choice but to tolerate the behavior of ITBP personnel. Their compliance with the de-addiction regimen was monitored by the family, the clinicians, and the state’s agents: the police. Additionally, even the doctors depended on armed personnel to safely and securely conduct routine procedures at the OST center. Armed personnel alongside a clinician complicated the care experience for the injecting user because a shadow of policing and criminalization was always looming for the client. However, what happens when the armed personnel leaves? Will the hospital be able to sustain itself, or will it crumble back to old forms? The sudden shift in the status of J&K due to the revocation of Article 370 gave rise to a new inter-dependence among institutions, clinicians, and the state machinery that have since informed the routine care and recovery of a vulnerable population in Jammu City – until another sudden shift arrived.

The Occupied Hospital: Once Again

The novel coronavirus in China emerged in the doctors’ and hospital staff conversations in February 2020. While the disease was initially discussed with fascination and curiosity, worry and uncertainty were not far behind.  When it became evident that the virus would soon impact India, I suspended fieldwork and returned to New Delhi. The 15-bedded de-addiction ward, I learned at my departure, is becoming a COVID-19 isolation ward. According to one of the psychiatrists, the decision was made based on the crisis’s immediate urgency and because the detoxification ward was not a necessity. According to the clinicians, detox services could be administered at-home, supervision by a guardian and telemedicine, or a visit at the psychiatrist’s private clinic could be advised to the clients.

It has been five months since I left Jammu City. I interact remotely with doctors and the hospital staff. Coronavirus cases began rising in J&K, and soon the entire psychiatric hospital became a COVID-19 isolation hospital.  Psychiatric patients were ordered to leave by the health department, and alternate accommodation was made for those whose kin could not be reached on time. The hospital infrastructure and staff had to improvise in response to the global emergency. Amongst the five psychiatrists practicing at the hospital, one was retained to oversee the COVID-19 services, while the remaining four were re-adjusted into a different hospital building for providing psychiatric care.

Following the sudden closure of the psychiatric hospital, the daily dispensing of buprenorphine suffered significantly. When earlier 250 clients would visit the dispensing unit daily, the clinicians were now instructed to give take-home medicines only to the guardians of good clients, i.e., those who showed up regularly, did not misuse the medicine, and had no or few complaints against them. Meanwhile, clients who were deemed problematic or untrustworthy or who could not bring a guardian were advised to visit the new dispensing center daily for their dose. However, after the lockdown was declared on March 22, 2020, no locality in Jammu was willing to accommodate the buprenorphine dispensing unit. They feared that the clinicians’ or clients’ in-recovery would bring disrepute, the virus, and/or illegal activities to their locality. The stigma of being a substance user superseded the global pandemic. The doctors and nurses of the dispensing team were mistreated and forcefully expelled from various locations as residents’ mobs verbally attacked them and bullied them into leaving. The de-addiction clinicians negotiated with residents, police officials, and hospital authorities to secure space and regular care for their clients but to no avail. Within one week of the hospital’s closure, the dispensing unit moved to six different Jammu City locations, the farthest being 35kms from the hospital. Clients who did not own a private vehicle walked in the scorching summer heat with their guardians to these different locations as public transport was shut down. Finally, after a week of constant moving and eviction, the dispensing unit and their five-member staff were accommodated in one-room at the Anti-Retroviral Therapy (ART) Centre in Jammu City. New client intake, counseling, and clinical follow-ups of clients and family members suffered a setback. Due to lack of space and privacy, only dispensing of buprenorphine is prioritized.

Currently, the psychiatric hospital is serving as a testing and isolation center for coronavirus cases. Routine psychiatric services have partially started, but the detoxification ward is barren and empty. OST center has not been relocated to the hospital from the makeshift one-room setup. Their space is being used by hospital security personnel and administration staff at the hospital. According to the clinicians, it is unlikely that the sole, state-sponsored psychiatric hospital will be fully-functional within the next year. The hospital leadership unquestionably accepted the decision to convert the hospital into an isolation unit in Jammu City as a medical response to the pandemic, just as they unquestionably accepted the arrival of ITBP personnel as a security response to the politically fragile and complex landscape of J&K. However, their colleagues in Kashmir refused to convert their psychiatric hospital for COVID-19 services. Instead, the clinicians advocated for decisive state actions to mitigate pandemic and economic distress’s psychological impact. Even though psychiatric services have resumed partially in Jammu City, clinicians remain under-resourced to provide regular care and access to state-sponsored de-addiction services to all substance user clients. Presently, the OST center operates from a one-room setting. The pharmacist gives away the medicine strips with the hope and warning that the client would not abuse them by selling or injecting. A new client in-take is suspended. Everyone is waiting for the psychiatric hospital to renew its functioning and resume the suspended de-addiction services. ITBP personnel left the hospital after it was designated as a COVID-19 unit. Their role was over. Their militarism was no longer needed; after all, the entire world was under the COVID-19 siege. The hospital leadership and administration has also changed. I was informed that the complaints about mismanagement and fraudulent activities prompted the removal of a long-standing hospital administrator and several staff members.

In less than a year of fieldwork, the hospital and its meaning has shifted as it is entangled with care, policing, and governance. At one point in time, the functioning of the psychiatric hospital is mediated by the presence of the armed police force because of their deployment to manage the longstanding conflict over the Kashmir region and the resulting sociopolitical crisis. This militarized occupation has dominated the cultural, social, and political landscape of the J&K region for decades (Duschinski et al. 2018). The arrival and sustained presence of armed force at the hospital signifies the extent to which the hospital had combined militarism and care (Varma 2020) and how their presence impacts and infiltrates the de-addiction regimen at Jammu City. Furthermore, the clinicians’ smooth functioning depends on the gentle yet firm presence of the armed police forces at the hospital. And, the recovery of a substance user client is dependent on the support of the family, clinicians, police, and the hospital infrastructure. These complex relationships and shifts illuminate the different scales and contours of the historical, social, cultural, political, and economic processes that inflect the administration and provision of de-addiction services in Jammu City. A post-COVID 19 moment is yet to be determined, but at present, the hospital is literally occupied by coronavirus and metaphorically existing as a scattered entity across Jammu City. 

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Sugandh Gupta is a PhD candidate in Sociocultural and Medical Anthropology in the Department of Anthropology at the University of North Carolina – Chapel Hill, USA. She is interested in studying mental health systems and access to care in areas of distress, socio-political conflict, and violence. Her Wenner-Gren funded PhD project focuses on the state-sponsored rehabilitation services (known as “de-addiction”) for injecting drug users in Jammu City, Jammu and Kashmir, India. She introduces the concept of “dependency” as an analytic shaping the experience and treatment of substance use in Jammu City. Drawing on ethnographic research, she argues that by examining de-addiction services in Jammu City through the analytic of “dependency”, one can develop an ethnographic understanding of: the impacts of regional and national politics on the administration of de-addiction services in Jammu City; the practices and relations of care among people, substances, and institutions in the provision of de-addiction services; and the multiple, overlapping, and distinct meanings of dependency as experienced in the everyday life, at the de-addiction clinic, and as a political-economic tool of governance. Her project aims to illuminate the links between the social, psychological and political aspects of being human and addicted in an environment of conflict with implications for clinicians, service users, their families, and for regional and national policy.  She is also a graduate of the Master of Psychology program at University of Delhi, India. Prior to her PhD, Sugandh worked in India in management sector and social sector conducting research, training, and organization consulting.

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Notes

[1] Bhaiya – a Hindi term used to respectfully address an elder male. The word originally means Brother.

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