Author: Dhara Patel
Conflict Origins
Kashmir is a long-disputed territory between the nuclear powers of India and Pakistan. The region, nestled in the Himalayan mountains, is home to over 111 ethnic minority groups, with the majority of the occupants being Muslim. The major industries in the area include agriculture and sapphire mining. Tourism contributes to a significant part of the economy, with many Hindus traveling to the sector on religious pilgrimages. The average literacy rate is 68%, and 38% of households in the region live under the poverty line. Before the Jammu-Kashmir conflict, Hindus and Muslims lived in harmony for hundreds of years.
The Kashmir conflict is one of the longest-running border and ethnic conflicts in the world and began with the Partition of India in 1947. The Indian Independence Act split Pakistan and Bangladesh off of British India and allowed the state leaders of Kashmir to choose whether to join India or Pakistan. Although the state belonged to India, the monarch created his own constitution and by-laws, ultimately deciding to join India and name the region Jammu-Kashmir. Border wars between Pakistan and India soon erupted and lasted sporadically through 1971. After the Indo-Pakistani War of 1971, Indian and Pakistani leaders decided to sign the Simla Agreement, which established a legal Line of Control in Kashmir. The state's northern half joined Pakistan as "Azad Kashmir," while the state's southern half remained with India. The ceasefire only lasted about fifteen years. In 1987, rumors of a rigged election of Kashmir pushed Pakistani insurgents to violate the Simla Agreement and cross the Line of Control. An extremely violent conflict ensued during which Islamic militant separatists from Pakistan, known as "mujahideen" or "jihadis,” committed massacres, robberies, kidnappings, and rapes against Hindu Kashmiri Pandits, an ethnic minority group in Muslim-dominated Jammu-Kashmir.
Furthermore, these insurgents infiltrated Jammu-Kashmir and began to ethnically cleanse Hindus. The Pakistani military soon involved itself in the conflict by supporting and training the insurgent groups. Pakistan's former President, Pervez Musharraf, finally admitted Pakistan's involvement in supplying and arming the insurgents in 2015, confirming the effort was called Operation Badr.
Tipping Point
The tipping point of the conflict occurred in the 1990s when the Indian government passed the Armed Forces Special Powers Act in 1990. Until then, the border conflict exhibited sporadic insurgent violence. Under the Act, Indian forces had permission to arrest insurgents for up to two years without processing charges. Indian forces exploited the Act and began to capture innocent Muslims and torture detainees without pressing charges. Human rights activists across the world highlighted human rights violations from Pakistan and India. In 1999, the Indian government called Pakistan to end the insurgency and border terrorism and restore peace on the UN stage. India decided to launch a purge mission in the Kargil district, which lies on the Line of Control (B. Patel, personal communication, October 22, 2021). The mission, named Operation Vijay, used India's Air Force and Navy to clear out insurgents and Pakistani soldiers. Pakistani trade routes were obliterated, and about three-quarters of the Indian-owned Line of Control was rid of Islamic militants. This show of force by India highlighted the true war power of the Indian military and underscored the chance that a nuclear war may ensue and affect the region's citizens. India has officially declared that they no longer wish to follow their nuclear policy's "no first use." Meanwhile, Pakistan used the situation to further its nuclear proxy war with India.
Internal Displacement and Refugee Situation
As the conflict between the Indian military and Pakistani insurgents raged on, many Kashmiri Pandits living in Azad Kashmir fled to Indian-controlled Jammu-Kashmir. Conversely, Muslims living on the Indian side escaped to the Pakistani side due to fear of detainment and torture (B. Patel, personal communication, October 22, 2021). As a result, the Kashmiri Pandits are now the largest internally displaced group in India. According to the CIA World Factbook, the mass exodus of Kashmiri Hindus out of the Kashmir Valley includes almost 400,000 people as of 2020. Refugee camps set up in Indian-administered Jammu and New Delhi housed the internally displaced Pandits.
On the other side of the border, Muzaffarabad and Rawalpindi in Pakistan house several refugee camps for persecuted Muslims. The camps share common characteristics despite their opposing populations, including irregular school for children, unstable shelter structures, low compensation for food (55 USD), and nonexistent water sanitation. Heavy refugee movement across the Line of Control meant many lives lost as a result of armed warfare. As families continue to separate and migrants cannot hold jobs, the major industries in Kashmir have subsequently tapered out. Generational trauma has been passed down, and many have spent their entire lives as refugees (B. Patel, personal communication, October 22, 2021). The implications of the travel and curfew bans are devastating; access to healthcare in a limited area and during short operational hours makes it difficult for residents to seek care with the COVID-19 highlighting the discrepancies in healthcare access across the region.
Current State of the Conflict
In 2019, India's Prime Minister Narendra Modi announced the Jammu and Kashmir Reorganization Act, reclaiming Indian-occupied Jammu-Kashmir and declaring the region governed under the Indian Constitution. Pakistani Prime Minister Imran Khan cautioned the UN about potential terrorist threats to the area due to the decision; Khan also warned Prime Minister Modi that he would seek action against Modi through the UN Security Council and the International Criminal Court. As Jammu-Kashmir lost political autonomy, foreign humanitarian aid halted. Foreign aid workers are not receiving visas, and supplies have accumulated at the border, deeming them inaccessible to refugees. Those in the Indian-controlled region now live under a strict lockdown with stringent curfews and communications blackouts. Indian military forces continue to detain, torture, and kill Muslim men as political prisoners, and travel is limited in and through the region due to hundreds of Indian-manned security checkpoints. The Indian government has promised improved communication networks and pledged travel will resume, but the effort has been slow on their part. As a result, many still live with violence and in unsafe living conditions in refugee camps. Kashmiri Pandits and Muslims hope for peace; however, they are hesitant to return due to empty promises from both governments (B. Patel, personal communication, October 22, 2021). With many of their villages burned to the ground, natives to Kashmir are wary of returning due to decimated health and social systems. Many say that violence will increase once the lockdown lifts.
Although the physical conflict stays centralized at the Line of Conflict, the conflict has tremendous global implications. World powers have accused both India and Pakistan of human rights violations and ethnic cleansing. Pakistan reached out and asked the U.S. to assist in fighting terrorism on its Afghani border and reestablishing stability at the Indian border. On the other hand, the British Prime Minister views India as an economic asset. Therefore, it is in the best interest of Britain to assist in stabilizing Jammu-Kashmir. As India and Pakistan continue to quarrel, the rising threat of Taliban occupation remains imminent; the South Asian regional security remains vulnerable attack by Middle Eastern insurgent groups and China.
Additionally, agricultural exports of Kashmir, such as wheat and fruits, have dwindled; major global powers who import Kashmiri goods chose other exporters to obtain those goods. As a result, India and Pakistan suffered significant economic loss as a result of horticulture being the biggest source of income for the area. Therefore, restoring major industries will assist in reestablishing the region's financial security.
Mumps
Mumps has a worldwide incidence rate of 500,000 cases per year; however, the incidence rate remains grossly underestimated, as more than 90% of cases go unreported. In densely populated countries like India, the incidence rate could be higher, as mumps is neither a notifiable disease nor a priority in childhood vaccination series. India is one of several countries still reporting measles-mumps-rubella immunization after outbreaks occur. The mumps virus is a highly contagious, enveloped, single-stranded RNA virus in the Paramyxovirus family. Mumps spreads by close human-to-human contact via respiratory droplets, and humans are the only known hosts of the mumps virus. Once an immunonaive individual is infected, the virus replicates in the nasopharynx and surrounding lymph nodes. Once the virus spreads into the bloodstream, it can travel to the meninges of the brain, salivary glands, pancreas, and reproductive organs. The inflammation of these tissues leads to clinical complications known as parotitis and, in severe cases, meningitis. The infection passes within a 1- to 2-week period.
Swollen salivary glands best characterize parotitis under the ears. An infected individual will shed the mumps virus two days before parotitis sets in and up to five days after parotitis. Typically, the incubation period begins between seven days before the onset of parotitis to nine days post-parotitis; therefore, symptoms can present anywhere from 12-25 days post-infection. Before parotitis, patients can experience typical flu-like symptoms such as fever, headache, body aches, and fatigue. In addition, individuals can range from asymptomatic, mildly symptomatic (i.e., cold symptoms), to severely symptomatic, characterized by encephalitis and vital organ inflammation. In male adults, the most severe forms of mumps infection can lead to orchitis or severe inflammation of the testes (Marlow et al., 2021).
When diagnosing an individual presenting with parotitis, a differential diagnosis occurs to determine the specific cause of parotitis. Other diseases that present parotitis include Epstein-Barr virus, influenza A virus, and HIV. Healthcare providers provide an RT-PCR test or oral/urine viral cultures to confirm mumps infections. Even with negative laboratory diagnostic results, an individual may still be infected with mumps. In developing countries, children receive the MMR (Measles, Mumps, Rubella) vaccine in two doses, with the first dose given at 12-15 months of age and the second dose given at 4-6 years of age. The MMR vaccine prevents severe mumps infection and is the primary method to prevent the disease. Mumps has no treatment; healthcare providers can only provide supportive care when the disease progresses to severe manifestation. Post-exposure prophylaxis (PEP) MMR vaccination has limited efficacy data, so healthcare providers usually do not resort to using PEP for treatment.
Mumps in Kashmir
Jammu-Kashmir yields the highest incidence of mumps of any state in India, with most of the cases increasing morbidity in children. From January through September of 2017, the Indian-controlled region of Kashmir, otherwise known as Jammu Kashmir, experienced 15 outbreaks within seven districts during severe blackouts and lockdowns. The Pulwarma and Shopians were the most brutally hit of the regions affected by mumps, with at least four separate outbreaks in a month and a half. At the conclusion of the outbreaks, 260 cases were confirmed, although many experts contest that number due to the government’s disregard for the burden of the disease. Mumps outbreaks began at government schools, such as the Government School Maloora in Srinagar. As school officials sent children home, the infection spread to unvaccinated parents, who travelled to various areas in the region to work. In addition, students were only allowed 4-5 days for sick vacation, so infectious students returned to school while in the contagious period. As health authorities allowed sick leave for students but never fully shut down, outbreaks continued to cycle for nine months.
Local health authorities such as Chief Medical officers (CMOs), Medical
Superintendents and District Health officers (DHOs), District Surveillance Units (DSUs) of all the districts of Kashmir Division, and the Strategic Health Operations Centre (SHOC) assisted in containing the disease. However, as government schools penalized children for missing more than 4-5 days of school, it proved difficult to keep social distancing measures in place. The Integrated Disease Surveillance Program (IDSP) of India provided surveillance data to district responders, and veterinary officers with the Animal Husbandry Department and scientists with the Water Quality Monitoring Programme remained on standby to assist, even though mumps is not zoonotic or spread through water systems. Due to faulty reporting regulations in India’s Ministry of Health and Family Welfare guidelines, many cases went unreported. The national government never sent out national health officers to manage the outbreaks. Although the 2017 outbreaks seemingly came to a conclusion and severe hospitalization cases were rare, many experts argue whether the cases indeed ended or the healthcare system deprioritized the reporting of mumps, as the national government decided mumps was not a burden worth tackling. The region also experienced strict curfews and communication blackouts, making it difficult for healthcare officials to access infected individuals. In most conflict areas, the first governmental provision lost is healthcare systems. Given the lack of physical and political safety and strict lockdown measures, the valiant efforts of Jammu-Kashmir’s district responders helped the region recover from the cyclic mumps outbreaks, but vaccination campaigns were beyond their capacities.
Prior to the 2017 outbreak, district officials reported significant mumps outbreaks in Jammu-Kashmir in 2007, 2012, 2013, and 2014. Specifically, between September 2009 and November 2014, the IDSP investigated 72 outbreaks nationwide. Throughout these outbreaks, the IDSP confirmed the mumps G and C genotypes circulating in the villages. The IDSP also reported that of all the mumps cases reported in Jammu-Kashmir from 2007 to 2011, all individuals were unvaccinated. Aside from reported outbreaks, mumps is endemic in Jammu-Kashmir, with children exhibiting parotitis year-round. Furthermore, the MMR vaccination is not listed on the free Universal Immunisation Programme (UIP) for children; therefore, all children born after 1957 are not required to receive the MMR vaccination series. Although several states, such as Uttar Pradesh and Punjab, have made MMR vaccination compulsory, states like Jammu-Kashmir do not have the same mandate. Like the U.S., each state in India has state and local health ministries that make the bulk of the public health decisions. Very rarely does the national government get involved in public health decisions.
Recommendations to Prevent Future Outbreaks
The national government controls the UIP, which offers a list of mandatory childhood vaccinations for free. Measles and rubella vaccinations top that list, with pushes from the government to prevent those diseases. Due to substandard documentation and the relatively low manifestation of severe mumps disease, the government has repeatedly decided that the MMR vaccine is not an economically essential expenditure. It is not a lack of capability for India to control mumps; the Indian government pushed the measles vaccine in the 1990s as a part of the UIP requirements, which reduced up to 57% of expected measles deaths. Pediatricians in India see the morbidities of severe mumps infection that afflict children, leading them to fill the gaps in mumps research and show the national government that mumps is a serious public health concern, despite its overwhelmingly mild clinical presentation. Government officials also incorrectly use childhood vaccinations’ “waning effects” as reasoning against adding MMR vaccination to the UIP. Epidemiologists such as SM Kadri continue to fight against the government to add the MMR vaccine to the UIP and clarify that three doses of the MMR vaccine in high-incidence areas will solve the problem of waning immunity.
Education is not necessarily the primary blockade in distributing the MMR vaccine in conflict areas such as Jammu-Kashmir. As internally displaced persons (IDPs) move across territory lines, paying for vaccinations is not the top of their financial expenditures. Food, water, and shelter take up most of the IDPs’ expenditures. Unfortunately, MMR vaccines can be expensive for families with many children. Most IDPs in India will obtain crucial vaccines for their children if the local health departments provide them for free. If the MMR vaccine joins the UIP, children and adults who missed childhood MMR vaccines can obtain a vaccine that prevents encephalitis, parotitis, and orchitis. Since the 2017 mumps outbreaks, India’s government has made great strides in disease surveillance with the new Integrated Health Information Platform (IHIP), which provides real-time data to health responders. The IHIP will help document mumps cases better, and the WHO representative to India, Dr. Roderico Ofrin, is hopeful that the IHIP will assist with prioritizing diseases India previously sidelined. Closing the gaps in information and promoting the MMR vaccination series’ 95% efficacy will allow the government to listen to scientific experts and put the vaccine on the UIP. District health experts in Jammu-Kashmir eagerly anticipate MMR vaccination campaigns by the central government to relieve the region’s burden of mumps.
Future of the Conflict
Tensions have accumulated over nearly 75 years, and pressure continues to mount as India seeks to end lockdowns. Many failed negotiations and ceasefires have left innocent civilians discouraged on both sides. The conflict could have been prevented if there had been clear guidelines on determining statehood. For a region with different ethnic groups, creating a statehood with soft borders and a unique Constitution after a land partition can be construed to incite an ethnic war. For any country experiencing an event where land border disputes occur, it is essential for negotiating powers to understand the underlying sentiments of religious groups and to construct statutes that cannot be open to interpretation. When regulations cannot concur on both sides of a conflict, international players such as the UN should facilitate elections to provide an unbiased method of returning democracy to the region. Under no circumstances should warring governments strip political autonomy from an undisputed region. In Jammu-Kashmir's case, the way to begin re-legitimizing political power to the people starts with demilitarizing the area and providing cell phone service to the region.
Furthermore, journalists should return to the area to document the conflict and provide an outlet to the world to garner international attention. With international media attention, world leaders can be pushed to reengage in the crisis and restore regional stability. In February 2021, the Indian and Pakistani governments signed ad hoc ceasefires and claimed land by show of force. Unfortunately, no form of transparent diplomacy has occurred, with the ceasefire coming as a surprise to many. Moving forward, younger generations should elect leaders who have civilians' best interests in mind; the Kashmir conflict has been a power struggle between leaders with personal motives. As a result, ethnic groups in the region have served as a pawn in a political chess game.
This article was prepared by the author in their personal capacity. The opinions expressed in this article are the author's own and do not reflect the view of their place of employment.
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