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Hepatologist and
Head Gastroenterology
& Liver Transplantation


                                           My Journey Back to Kashmir
                                               from Caprice to Classic

(A personal note: This account of “My Journey back to Kashmir” has been written with a purpose. Before defining that I want to make a few comments. In this article, any reference to a system, department, or individual should be taken only coincidental and not with any feelings of disrespect or hate or ill will. I have no ill feelings or disrespect to any system or more respect for another when I tried to glorify one system or depicted the difficulties in another system or abused it as some may say. After even appreciating both systems I would yet love and like to be in my people and with my society should I have another chance in life. This account is a reflection of many hundreds and thousands of Kashmir’s who leave their motherland for other parts of India and the world. Everybody leaves for a purpose and with a motive. However, all of them want to come back to their home at one time and another, and I have given a small opening to that struggle. Continued stay away from home is not certain due to the fat pays they receive after each month but due to the enormous difficulties they face in disengaging themselves from that system and engaging back in the system at home. Many do complete “journey back to Kashmir”, many “cannot” and some do and then do “complete journey back to foreign lands”. However, one thing should be certain that all expatriate Kashmir’s have an intense feeling of their homeland and suffer intense pain and anguish whenever any calamity or suffering occurs back home.)

When the Delhi-Srinagar bound flight landed at Srinagar airport on March 6th, 2005 at 12.25 PM, I had finished my 10 years of “forced” exile and completed “my journey back to Kashmir”. While on the flight several thoughts passed my mind. Once the plane approached the Valley, I had a gorgeous view of the snow-covered Himalayas. In few movements, I saw a thick layer of gloomy clouds over the Valley and I felt that these were placed there to block all the “in- and out-lets” to the region. Once the plane sheared through the clouds I had a glimpse of the villages bordering the snow-covered mountains and the plight of the people of this region from a recent mini-tsunami like tragedy went through my mind. I pondered in my mind why this tragedy should happen to us? A recent well-debated program on the BBC depicted the enormous destruction of the Aceh district of the Island of Sumatra, Indonesia, and in that, all the mosques were completely intact, untouched, and not damaged by the tsunami. The head clergy of the region announced that tsunami had come to punish the “Believers” for their sins and God has maintained his places of worship. This program was underplayed by the western media; however, all of us who viewed this show loudly versed “Allah-o- Akbar” for we were appreciating the presence and will of the Almighty. While viewing the villages which had been affected by the recent snowfall in Kashmir, I remembered and repeatedly prayed to God to pardon us for our sins, show us the righteous path and rid this land from the natural calamities of disease, epidemics, disaster, poverty, and economic backwardness.

The last ten years has been a transformation in my career. Throughout my early career days, I had held a strong belief that I shall stay with this society and among my people. That is why I returned to Kashmir after educating myself outside the State and India. I surrendered many opportunities of working outside the State and India during my early career and afterward when I was trained. I followed this in my career firmly because of 2 reasons namely my internal zest to work in my society and a promise to my father that I shall work for my people. In late 1994 conditions in my life made fast changes and it was extremely difficult for me and my family to cope up with the situation. I remember the day when my father walked into my house in the most security-bound zone of the Valley and appreciating the conditions he said “Son, Now I advise you to move out of the Valley”. I knew I was ready for the action which I had held back for several years. That night I called a friend (a former student of mine) and gave him a go-ahead for which he was advising me for a long time. He did not believe and wanted to know whether I am OK. When I confirmed that I was awake and in myself he dropped the phone. Within one week a courier was delivered to my home address when I was at work and the envelope was opened by my family and when I returned from work I disclosed my intentions. With this, I along with my family reached King Faisal Specialist Hospital & Research Centre Riyadh Saudi Arabia on 16th of Ramadan, 1415, corresponding to 15th February 1995. We knew the place on earlier occasions but had never thought to be there for permanent. So that day the place for us looked different. For several weeks and months to come, we appreciated how much tired, exhausted, and frightened we had been. However, we were humbled by the love, affection, and respect given to us by the system and slowly we accommodated ourselves in the new environment. We had a plan to make this trip as short as possible but the bonds with the system became so intense that it took a decade and a lot of courage on my part to disengage myself from it and even after that many of my friends were not sure whether I did the right move.

I was to work in dual positions at King Faisal Faisal Hospital & Research Centre, one with a large American team of physicians and surgeons to establish a liver transplant unit in the Kingdom and second as a consultant to the Gastroenterology, Department of Medicine. I could have easily turned down one of the offers but thought to experience both in the new system. I had been in this hospital 2 years back for an invited locum job for 3 months and at that time I have contributed my bit in drafting the liver transplant unit document and had joined the Western team in many interdepartmental meetings. When after 3 months of that locum job I had to come back to Kashmir, I was advised by the head of the American team against it, the advice which I brushed away silently. My involvement in dual positions created many new issues in my career. The jobs were demanding, had to perform with IPPRs (Internal Policy Procedures Regulations) as per North American guidelines and with a strict excellent internal and external quality control. To make the situation even more intense, the Head of Gastroenterology (Dr. Jean Cronstedt, a senior respected Swedish Gastroenterologist) told me and wrote to Administration that he was to step down and recommend me for this position of Head Gastroenterology. I resisted but his comment “I shall feel proud to have Prof. Khuroo heading the team” left no option for me. In the next few months, I was in the driver’s seat as Head of Gastroenterology at the most prestigious apical institution of the world, a position which I held for nearly a decade.

What was next to come was a transformation in my life, family, and the way I practiced medicine. At home, I was used to working for nearly 18 hours per day, was available to system all days at any time, and had no days off, had to train many postgraduate students and few Ph.D. students. Some of my students writing their thesis or analyzing the data had become my family members and lived in my drawing-room by the side of a personal computer of mine and continued to do so till they finished the thesis or wrote manuscripts out of it. Also while performing advanced endoscopies and procedures I used to wait for hours for my assistants to pick up the art from me and I never had given them the feeling of my frustrations while they were practicing that art. For all the years for work at home, I had visited, interviewed, examined, and spoken to all my patients admitted under my service or referred to my service daily (irrespective of conditions) and I followed their concern in the outpatients after they were discharged from the hospital. At no time I told a patient that you don’t need to follow the system. I saw my family and children infrequently and had never thought intensely about the career of my children. The pay was meager and I had to borrow from my father to maintain the home services. With all this life was busy, interesting, productive, and rewarding. At no time I complained about any inadequacies in the system. During the last 2 years, I had taken as Director of Sher-i-Kashmir Institute of Medical Sciences Srinagar, I was in the driver’s seat to revitalize the system which had been crumbled by our actions (how sad!!). I had spent days and nights to bring some semblance to the Institution.

Coming out of this back home, the work at the new place at King Faisal Specialist Hospital & Research Centre Riyadh was orderly, regulated, and respectful. The work was 5 days per week with 2 days off (a forced vacation for me). Each day was divided into few sessions of work with enough breaks in the middle. The first time I realized that I had time to take lunch either by a visit to my home to join family lunch or to visit the cafeteria and have 5-star subsided lunch for 30 Saudi riyals. There was nobody in my house after 6 PM and I joined my family for a smooth and orderly dinner. In fact, during the ten years of my stay in Riyadh at no time did we have a visitor to our home without prior information and there was no question of the patient, patient’s relative, or any colleague visiting my house. It was different than my house in Kashmir which was free for all even up to my bedroom and those who visited (patients, patient’s relatives, and others) felt their right to do so. At King Faisal Hospital, I was to plan my vacations for the next year so that my clinics would be blocked for that period, a thing which I had never appreciated in the past. The eligibility department sends me medical reports of patients to see whether I need to see them or they can go to another hospital. I had to define how many patients I should see in my clinic. After each clinic, I was asked whether I need to discharge any patient from the system for another hospital or service to follow. For patients admitted under me, I was supposed to take only 2 ward rounds per week (by hospital policy consultant should see patients admitted under him two times per week) and speak to patients and family. Sick patients, needing continuous care were quickly admitted under the intensive care unit to be cared for by intensivists trained for the job. On endoscopy day I did a few procedures and for this also nurses had done all the groundwork and after the procedure nurses dealt with the patient and his family for future follow-up.

While these things were so, I quickly discovered that patient satisfaction with the system and the physicians were far more than we provided at home, and the image of the Institution was extremely high in public and the society. I asked myself why so? How come we the physicians in Kashmir put in so much yet cannot satisfy patients, the public, and society. I found a huge big gap in the system of our health care delivery system in India and particularly so in Kashmir which was being filled by the hard work of physicians and for which we are not meant for, not trained and because of which our basic job comes under tremendous pressure. The health care delivery system in King Faisal Specialist Hospital & Research Centre Riyadh was built on North American System with intense respect for local social and religious values and beliefs. I found that a huge amount of hard work had been done to make this system foolproof and was continuously being monitored for efficacy and any errors. There were multiple checks at each place to identify and correct errors. An orderly redressal system was there to complaints raised by the patient and his relatives (no newspaper complaints). An efficient social work department put in extremely hard labor to identify the needs of the patients and fulfill these. These included reservations, accommodation for the family, monetary support, and support to patients who were terminally sick to satisfy the religious needs of the family, and so on. Social workers educated patients about “Patients Bill of Rights” during their first visit and on an ongoing basis and patients expected that they shall be treated with dignity and respect as the system had repeatedly said “Patient First”. An extremely efficient, dedicated, and well-trained staff provided continuous care to patients and took care of all the minor complaints of patients by medication approved by physicians on phone and informed the patient and his family continuously about their health status after discussion with the physicians. They and social workers organized meeting between patient’s family and physicians for any questions which were raised by the family and we informed the family of how much we knew or did not know about their beloved one. Staff looked after the personal needs of patients including food requirements, medication, taking patients to toilets, cleaning the patients, transporting them by wheelchairs, etc to the laboratory and staying with them to allay their apprehensions and anxieties. There was no need for attendants and if somebody wanted to stay with the family because of the cultural background it was organized with respect and dignity. Staff was trained as they should be to identify emergencies of their patients and take steps to do first-line management and inform the physicians. I felt over 90% of the work which I and my physicians did at home was done by the system of dedicated staff and social workers. Besides, the place was clean, floors were continuously cleaned to maintain meticulousness, toilets never smelled and the air was never to smell except for fresh air. Hospital supplies were there always and we never had to bother ourselves for these as the system took care of these in advance and continuously. Any new drug or laboratory test I needed for the patient’s well-being was quickly addressed to and I never needed to break my head to make this available for my patient. Any hospital employee deviating from his duties was booked by an incident report and this report by his senior was reviewed and assessed by an inbuilt system. There were no strikes and no breaks because of any situations. We prepared the system for any eventualities insight like accidents, wars, etc. Nobody how big or small he may be in position could deviate from the IPPRs built by the system for running the hospital. Suddenly I found that we at home can only improve our patient care by building a strong system of IPPRs and unfortunately none of our hospitals has even the slightest idea of this important phenomenon in our health delivery system.

During my ten years of work in this system, I enjoyed working and at the same time changed my concepts in the health delivery system. However, a few things always left me disturbed. The most important was that once I treated one Saudi patient with whatever expertise I had, I felt that several patients at home were devoid of this because of my physical placement. Also, I was aware that the tertiary care system which I had nurtured for so long could not be maintained for whatever reasons. This unease left me to visit Kashmir many times and sometimes even at short breaks and I wanted to study the changes which had happened locally over the past few years. I took pains to study it, made it widely known to the public, administration, and published it through media and journals. I titled the first report “Healthcare in J&K at Cross Roads”. Subsequently, I made a detailed report after consulting many International experts which defined the guidelines for improvement in our health care system and tilted it “Healthcare in J&K: A model for the Millennium”. I shall make no more comments on these because these are a part of the record. Every time I visited the valley, health caregivers, the public and the media felt that I have come back to join the system again. When I took a flight back to Riyadh, some were dismayed, some disturbed, some angry, and some happy. I received letters, phone calls, lawsuits, and e-mails from friends, the public, and angry patients. For this, I want to make a statement public. Throughout my stay in Riyadh, I made myself available to this health care system for any job where I could contribute to the system. This I did in writing and clear language and once the system of administration changed I renewed my availability by a fresh document. This I thought was the least I could do to respect the wishes of those who wanted me back and were eager for me to return.

Finally, in 2004 I felt it was time to go back home and I made it known to the administration at King Faisal Specialist Hospital & Research Centre. Appreciating this they took several steps for me to change my mind. It included personal sessions with the administration, reducing my workload and letting me take over medical hepatology of the transplant unit, extending my contract for 2 years at a stretch rather than one year, waiving off my retirement age limit, and opening many benefits for me not in the contractual obligations of the system. I was humbled by these and felt obliged to stay back and another 6 months passed. Finally, I had to hold my heart in hand and send a final letter of my clear intentions. Many of my friends who thought I had been only threatening them of my intentions were shocked and told me that I need another consideration for my decisions. On the Farewell “(Ma-Sallamah)” occasion I have presented a memento which read “Award of appreciation presented to Mohammad S. Khuroo, MD for 10-years of outstanding division, integrity, hard work, and loyalty extended to his patients, colleagues, students, and staff of the King Faisal Specialist Hospital & Research Centre Riyadh, Kingdom of Saudi Arabia”. On Feb 2, 2005, I found myself in a Saudi flight bound for Chennai, India, and then to Delhi and finally to Kashmir.

During my short stay in Delhi, I was humbled by the changes in the system which had happened in the last 10 years. On the face of it, everything looked the same as in India should look namely poor roads, poverty, poor methods of communication, and so on. But the system was efficient, professional, and on the move. A quick comment on the health care system, it had advanced and could be compared with many developed countries, of course, with the limitations which any developing country has. I am sure it shall catch the West in near future. While appreciating all this I made another prayer that we, in Kashmir, should move in the direction of peace and prosperity and have a society free of corruption and nepotism and of course, have a health delivery system that fulfills the expectations and needs of a common man -Ameen.

Prof. Mohammad Sultan Khuroo,
MD, DM, FRCP (Edin), FACP, Master American College of Physicians (MACP, Emeritus),
Former Director, Chairman Dep’t. Medicine, Professor and Head Gastroenterology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India;
Former Consultant and Head Gastroenterology, Hepatology and Liver transplantation, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia;
Director, Digestive Diseases Centre, Dr. Khuroo Medical Clinic, Srinagar, Kashmir, India.
Twitter: Mohammad Khuroo @mskhuroo