When I say mental hospital, the auto-rickshaw driver looks at me and, to my surprise, nods with recognition. I climb in. The formalized name of Srinagar’s mental hospital is the Government Psychiatric Diseases Hospital. The hospital is located on the margins of the city of Srinagar, in an area known as KhÄtti Darwaza. To get there, one crosses the Jhelum River and its decrepit houseboats. The rickety rickshaw then goes racing through the narrow, meandering alleyways of the Old City of Srinagar, past piles of red chilies and rows of pink and blue buckets roasting in the morning sun. In spite of its geographical obscurity, the hospital is well known to most residents of Srinagar, who will, depending on their mood, refer to it either as the pagal khÄna(literally, ‘mad house) or simply as the mental hospital.
The Government Psychiatric Diseases Hospital was established in 1957 as an asylum for mentally ill prisoners. In recent years, the hospital and its six psychiatrists have gained a certain amount of fame or notoriety depending on your perspective due to widespread reports by local, national, and international human rights organizations over an epidemic of trauma in Kashmir, the result of more than two decades of conflict and systematic human rights violations by the Indian state and insurgent forces. The 2006 annual report by the human rights organization, Human Rights Watch, for example, is entitled Everyone Lives in Fear. The report reads:
Suspicion and fear continue to pervade the Kashmir valley. A knock on the door late at night sends spasms of anxiety through households, afraid that a family member will be asked by the security forces or militants to step outside for a minute and then never return. Psychological trauma related to the violence has been enormous, as life itself is constantly under threat.
The report and others like it have drawn national and international attention towards an epidemic of trauma in the Kashmir valley, which has, in turn, led to a range of institutional responses, from formal to informal, from both state and non-state actors. In other words, mental health has emerged as one of the most pressing public health concerns in contemporary Kashmir. The Psychiatric Diseases hospital is thus a key ethnographic site where the mediation of ‘trauma’ is being played out. The hospital’s own history is a history of increasing awareness of, and incidence of, mental health problems in Kashmir. In 1990, for example, the hospital only had 1,700 visitors; last year, this number grew to over 100,000. 60,000 Kashmiris committed suicide last year alone. And according to a recent study, more than 15% of Kashmiris are thought to suffer from symptoms related to post-traumatic stress disorder (PTSD). Yet in recent years, the hospital has seen fewer patients suffering from ‘trauma’ and more who are suffering from a constellation of symptoms that may be the effects of symbolic or structural violence, interlaced with incidents of real, physical violence.
In this paper and in my future dissertation research, I will explore the mushrooming mental health complex in Kashmir, from the different vantage points of human rights organizations and the Psychiatric Diseases Hospital. I am interested in how the ‘suffering’ or ‘traumatized’ body has emerged as a site of both legal and medical intervention in Kashmir. How is suffering transformed into mental illness, and what is at stake in this transformation, or professionalization of suffering? (Kleinman and Kleinman 1991)
Medical anthropologists have produced an impressive body of literature on the effects of violence on knowledge, subjectivity, and experience. Drawing on post-structural practice theory and phenomenology, medical anthropologists have attended to the generative or formative processes through which illness and other dimensions of medical reality are formulated. To quote Byron Good, Rather than belief and behavior, the focus is thus on interpretive activities through which fundamental dimensions of reality are confronted, experienced, and elaborated (Good 1994: 69).
In taking my cue from this body of work, my observations at the Government Psychiatric Diseases Hospital in Srinagar have led me to argue that the session between the psychiatrist and his/her patient is a heteroglossic space, where ‘cultural work’ is required to reconstitute the person who is the object of medical attention. While I do not contest the empirical reality of ‘mental illness,’ I am interested in how the language of psychiatry is itself a rich cultural language, linked to a highly specialized version of reality and system of social relations.
I hope to illustrate this more clearly with what Kamala Visweswaran might term an ‘ethnographic fragment,’ a glimpse of a day I spent at the Psychiatric Diseases Hospital this past summer. In particular, through this fragment, I hope to show how the dialectic between ‘care’ and what I will call ‘technique’ by which I mean the technocratic management of illness emerges through ethnographic attention to psychiatric practice. At stake in this session, then, is not just the transformation of the ‘suffering body,’ but the very (dis)locatedness of suffering itself, from the body of the ‘ill’ into the heteroglossic space of the clinic.
Dr. Azad has been busy all morning, yet he has a calmness about him. He is dressed casually in jeans and a polo shirt and everything about his appearance is extremely neat. He furrows his brows when he talks to patients, and he forms his questions slowly and deliberately even though he has asked them time and time again.
Dr. Azad had just finished a session with a patient when Dr. Leila, one of the other psychiatrists, bursts into the room. She asks Dr. Azad if he can see one of her patients.
It’s a difficult diagnosis, Ayesha says.
A few minutes later, we are joined in the room by an elderly woman, probably in her late sixties. She is accompanied by her nephew, a young, athletic man who introduces himself as Imran. I notice that Imran is dressed almost identically to Dr. Azad: in jeans and a polo shirt. Imran’s cell phone seems attached to his body, grasped lightly in his left hand at all times.
The elderly lady wears a maroon salwar kameez and a head scarf; her body is rounded and soft. Her skin is pale; her lips down-turned as if in permanent displeasure. She does not look up. I sit at the back of the room. I am in her field of vision, but I am indistinguishable from Dr. Leila or Dr. Azad. This was true of many of the sessions which I observed. Most of the time, while speaking to the doctors, patients would make eye contact with me, as if asking me to corroborate their pains and ailments. Initially, I felt uncomfortable in this position, feeling ill-equipped as an anthropologist. It was only later that I realized that the telling of the story in this public way particularly in front of ‘educated,’ or ‘intellectual’ people was a socially efficacious exercise: it rendered the symptoms legitimate. I could either abet this legitimation by nodding sympathetically, or block it, by pretending to not understand, or feeling embarrassed. [Paul Farmer has discussed this in the context of Haiti].
Dr. Azad begins the session by addressing the lady, Qaalaa, or aunt (mother’s sister), a term that immediately establishes a close kin connection to her but also places her in a position of authority, vis-à-vis, him.
What has happened to you, Qaalaa? Dr. Azad asks, Why are you feeling bad?
Qaalaa does not respond. She stares at the ground for a long time. I notice that no one in the room seems impatient; no one jumps in and answers for her, breaking the awkward silence. It is only later that I realize the significance of this moment: the necessity to maintain the order of the everyday the norms of hierarchy even in this tense moment (Jean-Klein 2001).
Slowly, Qaalaa starts to speak.
I came here a few weeks ago from Pakistan and I have been feeling like this since then, she says.
After a moment of thought she adds, I don’t trust my sister. Her voice is shaky, but suddenly there is a glow in her eyes.
Dr. Azad moves through the timeline of the illness slowly by asking Qaalaa questions about her life in Pakistan, her move to Kashmir, her family. He is trying to piece together Qaalaa’s history, but more importantly, he is giving her the authority to speak. While this restores Qaalaa’s sense of normalcy, it is nonetheless still a dangerous tactic because Qaalaa’s memory is frail.
Only moments after telling us her ‘troubles’ (pareshani) began a few weeks ago upon her arrival to Kashmir, Qaalaa backpedals:
They [her sister’s family] are always talking behind my back. They are always conspiring. This has been going on for years! she exclaims.
Then, exasperatedly: Oh, I dont know when it started I don’t know when. All I know is this is how I feel I don’t feel like doing anything, talking to anybody.
At this point, Qaalaa burst into tears. I don’t know what’s happened to me, doctor! she cries.
We seem to be in what Michael Taussig would describe as a state of utter discordance. Everyone in the room is anxious: it seems science cannot whitewash Qaalaa’s existential uncertainty. What strikes me most about this moment is that far from being unfamiliar or strange, Qaalaa’s pain seems very familiar, very close.
Dr. Azad says, Insha’Allah [Allah willing], you will be absolutely fine [he uses the respectful aap]; there is absolutely nothing wrong that we cannot fix. He turns his attention to Imran, who is quietly sitting. He asks Imran more questions about Qaalaa’s history with biomedicine. Dr. Azad and Imran work like a bricoleurs,adding stories from other kin members and checking these against medical records. All the jigsaw pieces do not fall into place. Yet, I am suddenly in awe of Imran. He is able to recall Qaalaa’s medical history chronologically; he has been caring for her for some time now. He is able to remember why and when doctors switched her medication, why her diagnosis was changed from depression to paranoid schizophrenia. Yet Dr. Azad is not satisfied with this diagnosis.
At some point during the discussion, I ask Dr. Azad if something happened to Qaalaa before she left Pakistan. Was there an event? I wonder.
It is at that moment that Imran tells us that Qaalaa lost her brother in the Kashmir earthquake of 2005, that she had witnessed his death and has not been the same since. This had prompted her family to bring her to Kashmir. This piece of information, this fact as it were, transforms the entire narrative of Qaalaa’s illness, it situates her within a much longer and layered history of social suffering in Kashmir.
Dr. Azad finally decides on a diagnosis of psychotic depression, although he expresses his uncertainty.
Her symptoms are variable, he says, she has gone through many traumas.
Dr. Azad once again redirects his gaze to Qaalaa: Insha’Allah, he says more forcefully this time, you will be absolutely fine.
Dr. Azad’s intervention strikes me for its double movement: god and medicine are playing on the same side, he is saying to Qaalaa, on your side. He begins discussing with Imran the dosage and frequency of the new prescription. Imran asks questions and double-checks information; he is aware of how deeply implicated he is in Qaalaa’s treatment.
When Qaalaa and Imran leave, Dr. Azad and I talk before the next session is upon us. Every home in Kashmir has a story like this, he tells me. There is terrible ache when you lose a sibling he is referring to Qaalaa’s witnessing of her brother’s death during the earthquake. Pills can’t help. I share this pain with my patients this pain is everywhere.
According to the French psychoanalysts, Françoise Davoine and Jean-Max Gaudillière, the psychotic is lost outside of history in the realm of what Lacan (1978) called “the Real,” a realm outside of symbolization. Davoine and Gaudillière note how social forces “tend to eliminate the subject (p. 25), such that narrating the story becomes a way of not only affirming one’s being but also one’s essential humanity. In this session, Dr. Azad carefully reconfigured Qaalaa’s suffering as no longer individual, but as social, as human. Interestingly, he situated himself in a social web of relations as well, as healer and sufferer simultaneously. In doing so, I would argue, Dr. Azad constructed a new reality in which Qaalaa is no longer the deviant individual or the abandoned, but is instead, the bearer of massive social suffering congealed on her body.
Doctors at the Government Psychiatric Diseases Hospital work for next to nothing. Many of them have worked in private clinics in Delhi and elsewhere in India, but all returned to Kashmir. Most of them joke about their pittance salaries. During a busy day at the hospital, when I told Dr. Azad I admired his work, he looked at me with a tired expression and said, I don’t do anything. This is nothing.
This is not a statement of modesty; it is a statement of failure. Dr. Azad has been transformed in his encounter with trauma, with the failures that are part and parcel of his everyday world. At the hospital, suffering does not seem to have any clear beginnings or ends it is impossible to locate it on any one body as such. I hope to illustrate this point with a final fragment.
Dr. Azad, who described his own work as doing nothing, was the same man who had told me a story, one year earlier, while we were sitting in his private clinic, drinking tea and eating biscuits in the afternoon. He had told me about a father who had come to the hospital seven years ago, carrying his five-year-old son in his arms. The man had walked four kilometers carrying his dead child.
It was as if he didn’t know that the child’s leg had blown off it was dangling off his body But I couldn’t tell him that his child was dead. I had just become a father myself at that time Instead, I put the child in a wheelchair and wheeled him inside the hospital. That memory still haunts me I have lost so many patients but that memory is still with me…that memory will not leave me.
Initially I thought this story was about identification, about Dr. Azad’s search for an echo. When I thought about it more, it seemed to me less about Dr. Azad empathizing with this other father. In other words, it was not a story about understanding per se; it was a story about transmission. It was Dr. Azad’s way of exerting his difference from this father, being respectful of the existential distance between them. It was his way of saying, just because I am a father, does not mean I can understand your pain. Yet, in wheeling the child into the hospital, Dr. Azad seemed to say, I cannot possibly understand your pain, but yes, I will go there with you: I am willing to accompany you into the unknown.
Davoine and Gaudillière note that as we come into resonance with another’s being, we encounter the prohibitions against knowing and in this way, we learn by our own experience to appreciate the enormity of the challenge of psychiatry (and anthropology as well, one might add). In Kashmir, as in other parts of South Asia, those suffering from mental illnesses are often labeled pagal, mad or crazy, characterized not by their lack of words, but by their generous use of nonsensical words, bakbak, which Lawrence Cohen has written about so eloquently in the case of Varanasi. Dr. Azad’s decision to take seriously what Qaalaa had to say about her own history reminded me of Joao Biehl’s work with Catarina, the mesmerizing poet in Vita: Life in a Zone of Social Abandonment. While I do not wish to make an argument about the liberating effects of narrative in all places and all times, both Qaalaa and Dr. Azad told their narratives in order to construct new realities, which profoundly transformed notions of mental illness into something closer to what anthropologists would call social suffering. In particular, the session with Qaalaa represented not just a transformation of pain into diagnosis i.e, psychotic depression but a double movement, from pain treatable illness social suffering. That is, there are two movements in this cultural work.
Not all the doctors at the clinic have the time, nor the perspective, that Dr. Azad has. Not all the patients who come to the clinic have an Imran to care for them. It takes particular familial and professional subjects to restore Qaalaa’s sense of authority by using norms of respect in a context where she is the least able. It takes Dr. Azad’s acknowledgement of his own ‘failure’ that makes healing possible and yet always incomplete. Dr. Azad cannot ‘save’ everyone he encounters, and his acknowledgement of his own failure is a way for him to cope with what is being transmitted to him on an everyday basis.
Saiba Varma is a doctoral candidate in the Department of Anthropology, Cornell University, Ithaca, NY. This paper was presented in the the Annual Conference on South Asia, Madison Wisconsin, October 16 19th, 2008. Saiba can be reached at firstname.lastname@example.org.