“When compassion bows to connections, healing becomes another injustice”
By Shah Mohammad Abaan
“I will not permit social standing or influence to come between my duty and my patient.” This line from the Hippocratic Oath is meant to guide a doctor’s hands. Yet in Kashmiri hospitals, patients see its integrity constantly questioned. There, they endure agonizing hours of waiting, only for someone from an influential background to bypass the queue and receive treatment first. There, they are exploited in emotionally vulnerable states, being asked to pay staff for services they are already paid to provide. There, they are wronged and made to suffer because of the vested interests of those who claim to be their caregivers.
Sifarish is an Urdu and Kashmiri word that every Kashmiri knows. Though its literal meaning is “a recommendation,” it often goes far beyond that. The sifarish culture is a euphemistic facade of an influence-driven system that has permeated the public sector, where the ordinary citizen struggles to access services they rightfully deserve. Within healthcare, the consequences of such a culture are devastating, yet there is little systematic data on its effects. This article will discuss four indicators that prove its impact: unethical referrals, shorter waiting times, quicker access to diagnostics, and the stories of patients left to suffer. These patterns reveal how social standing and connections determine who receives timely and quality care.
In recent years, there has been a significant rise in patient referrals across Kashmir. More than 30,000 patients every year are sent to tertiary-care hospitals in Srinagar, with SKIMS Soura managing over 18,000 alone. Lal Ded Maternity Hospital reported 38,013 referrals from 2020 to October 2023, over 40 percent of which were deemed unnecessary. This increase is not entirely due to medical need; in many cases, it reflects doctors’ personal interests. For influential patients, referrals provide clear advantages. First, they allow access to cheaper in-house care, while ordinary patients are directed to expensive private clinics. Second, referrals ensure that connected patients are sent to renowned specialists and the best-equipped facilities even when their conditions could be treated locally. This points to the rise of an unfair two-tier healthcare system, where preferential treatment is increasingly seen as socially and morally acceptable.
Kashmir’s government hospitals face the longest waiting times in the country. At Lal Ded Hospital, patients wait an average of six hours for a consultation. At the Sher-i-Kashmir Institute of Medical Sciences (SKIMS) in Srinagar, more than 2,000 outpatients are processed daily, overwhelming its resources. It is common to see patients writhing on the floor in pain with their medical files clutched in their hands. Yet in the same corridors, a connection can move someone straight to the front of the line. These waits are not mere inconveniences; they are inhumane. In such conditions, desperate patients often resort to paying staff unofficially to speed up the process. The fact that sifarish can erase protocol highlights how fairness is systemically undermined.
This unfairness extends to diagnostics. Lifesaving scans and tests like MRIs, ultrasounds, and CT scans are routinely delayed for days for ordinary patients. Yet those with influence are given short-notice slots, sometimes securing MRIs within hours. Access that should be determined by medical urgency is shaped instead by connections. What should be the first step toward healing has become another site of inequity.
The hidden hierarchies in healthcare are felt in countless patient stories. Consider a young man who waited alone for hours for an MRI until his father arrived and called a doctor he knew, after which the scan was arranged within minutes. Or a patient whose surgery was delayed for weeks, only to find that the same doctor was performing multiple procedures at a private clinic during that time. Or the parents who waited endlessly for discharge papers, until a staff member recognized their surname and suddenly everything moved swiftly. Each of these moments reinforces the same point: once fairness can be negotiated, fairness belongs only to the influential.
With each occurrence, sifarish becomes more accepted. Patients enter hospitals expecting bias. Personnel openly and frequently show favouritism. What should spark outrage does not draw resistance. Hospitals, which are meant to be healing places, become arenas in which social hierarchies adjudicate the suffering and privilege of patients, depending on their status.
In order to disrupt this cycle, there needs to be intervention at social, cultural and policy levels. Socially, silence needs to be broken; surveys indicate that almost 40 percent of Kashmiris securing medical attention admitted that they had made informal payments to facilitate treatment. Communities need to reject Sifarish culture and insist on equity and not favoritism. Culturally, it is time to re-center the Kashmiri cultural values of justice and compassion onto medical practice. Healthcare must remind our medical providers that their duty is to their patient and not the beneficiary.
At the policy level, the need for change is dire. Grievance cells must be truly empowered to ensure a process that is conducive to resolution. The processes to secure referrals must also be transparent, treatment queues must be digitized, and audit must be independent and continuous. Doctors and health care practitioners should be rewarded for ethical practice. If reforms aren’t made, hospitals will soon reserve care for the privileged, while vulnerable patients will be disregarded. This reality will corrode both public health and public trust.
The Hippocratic Oath states that no patient should be judged by social standing. Yet in Kashmir, the ill are still judged by influence. Hospitals must not become another agent of injustice. Fairness in healthcare is not just a policy; it is a moral obligation. Every patient, rich or poor, powerful or powerless, deserves to be treated with equal compassion. Only then will Kashmir’s hospitals live up to their purpose, and only then will doctors be trusted healers once more.
(The author is a student. The views expressed in this article are personal and do not necessarily reflect the editorial stance of Kashmir Despatch.)
