The doctors treating Kashmiris blinded by pellets

Two Kashmiri doctors describe treating pellet injuries and share their fears for the future of their patients.

by

    It is being described as the biggest uprising against Indian rule in Kashmir in two decades. Since the rebel fighter  Burhan Wani was killed on July 8, thousands have taken to the streets to protest .

    Over 80 people are reported to have been killed and 12,000 injured in clashes with the Indian armed forces that often involve running battles between heavily-armed riot police and young people throwing stones.

    The use of force against protesters isn't new. But the shooting of pellets as a way of controlling crowds has grabbed the headlines, as hundreds have been struck in their eyes, with many losing their vision as a result.

    The Indian government considers pellet guns to be non-lethal weapons, but at least 10 people have been reportedly  killed since July. Human rights activists have called for the weapon to be banned, alleging they have "neither been used proportionally nor in compliance with international standards on the use of force or domestic standards on crowd control".

    Amnesty International India has described them as "inherently inaccurate and indiscriminate" and said they have "no place in law enforcement". 

    In August, Naeem Akhter, A spokesperson for the Jammu and Kashmir government, told Al Jazeera that a decision had been taken to phase out the use of the weapons. "The use of pellets were inherited from the previous government ... we have always been against it," he said. 

    But, although Indian officials have launched an inquiry into the use of pellet guns, they continue to be used.

    The CRPF, an Indian paramilitary unit, revealed that it had used 1.3 million pellets in 32 days, adding that "it was difficult to follow the standard operating procedure given the nature of the protests". 

    Dr Rashid Maqbool and Dr Sajjad Khanday, two ophthalmologists at the Shri Maharaja Hari Singh Hospital (SMHS) in Srinagar * , where the majority of injured patients have arrived, spoke to Al Jazeera about the horrors the weapon can inflict.

    Al Jazeera: There has been a lot of focus on pellet injuries during the past two months. But this is not the first time you have had to deal with these type of injuries, is it?

    Dr Rashid Maqbool: Yes, this started in 2010 [during major protests of the summer of 2010]. I was a postgraduate student then, and we treated around 100-105 patients at that time. The pattern of injury at that time was very much less pronounced; some patients would have pellet injuries, some marble slingshot injuries, some due to stones, sticks, etc. Hardly 15 percent of patients were pellet related.

    Between 2010 and June 2016, we would receive perhaps around two or three patients [with pellet related injuries] every week, particularly on Fridays when most protests tend to take place.

    Since Burhan Wani's death, the nature of trauma has been altogether different in terms of the pattern of eye injuries we have received in our department.

    More than 95 percent of eye injuries are exclusively due to pellets. Sometimes it is a penetration injury - where the pellets remain inside the eye. On other occasions the pellets are going through the eye and exiting through the retina, reaching very close to the brain itself.

    Al Jazeera: How many people have been treated here with eye injuries from pellet guns since July 9?

    Maqbool: There have been around 780 patients who have been admitted, operated and managed by our department. However, this is not the exact figure of eye injuries we have received here. There have been others who received emergency treatment but were not admitted.

    Around 100 others have been to the SKIMS Medical College (in Srinagar) and I don't know how many were managed at district hospitals. Some others have gone to Indian cities like Hyderabad and Delhi directly without consulting anyone in [the Kashmir] valley. So there would be no less than 1,000 eye injury patients since July 9. 

    Khalid Arif, 19, a plumber from Budgam, was hit in the eyes with pellets on September 14. His mother, Taja, told Al Jazeera that he was distributing meat to family members around the town when he found himself in the middle of clashes [Shuaib Masoodi/Al Jazeera]

    Al Jazeera: Are you able to estimate how many people will suffer permanent damage to their vision?

    Maqbool: Since the retina is a very sensitive structure of the eye which forms the image, most of these patients have retinal haemorrhages, tears and detachments. I would say most of them have permanent damage to their vision. 

    There are those who have bilateral injuries - ie, injuries to both eyes. There are around 42 cases at this hospital. They have very little chance of regaining their vision. And the rest, around 700 or so, were hit in one eye. They too have little chance of regaining their eyesight back in that eye. There are a number of patients who cannot even perceive light in one eye.

    I assessed the situation in both eyes. The injuries were very grievous, and so I kept silent. He understood, and it was heartbreaking. He said: 'So I donate both my eyes to the people of Kashmir, particularly to those who can see, yet they are blind. I donate my eyes to the resistance.' 

    Dr Rashid Maqbool

    Al Jazeera: What happens during the operation when pellets are removed?

    Dr Sajjad Khanday: The eye is composed of many parts. It depends on the impact.

    Sometimes a patient has a pellet lodged just in the front of the eye and everything inside the eye might be normal and we may be just required to remove the pellet. But sometimes the pellet has gone inside and ripped everything in its path, and created a hole or a defect in the cornea. Then it becomes rather delicate.

    There have been cases where pellets were lodged around the optic nerve. It's impossible to remove those. And there are pellets that have pierced everything and come out behind the eyeball. Again, it's impossible to remove those as well. 

    Al Jazeera: What has been the psychological impact on patients?

    Maqbool: It is very emotional. You have to remember, we are dealing with young kids. Some are 12 or 15 years old. They are often not accompanied by adults.

    It is a friend or someone else on the street who has brought the person to the hospital. When they reach us, we are supposed to ask for their consent, but the parents are not there, and we have to tell the young patient that we are operating and that there are no guarantees.

    So when they are told this, they become very perturbed.

    I received a patient from Kupwara [north Kashmir]. He was hit in both eyes, and we put him on a table to work on him. I gave him a local anaesthetic, and so he was very much aware of what was taking place.

    He asked me: 'Doctor, will I be able to see again?' I assessed the situation in both eyes. The injuries were very grievous, and so I kept silent. He understood, and it was heartbreaking.

    He said: "So I donate both my eyes to the people of Kashmir, particularly to those who can see, yet they are blind. I donate my eyes to the resistance.' That couplet has stayed with me. 

    And remember one important thing: Everyone in their family suffers. The whole family is shattered. They are now a burden to their families because someone has to look after them. Imagine a young man who is the sole breadwinner of the family and now blind.

     

    Al Jazeera: How are pellet injuries different from other foreign objects entering the human eye?

    Khanday : Since they come at very high speed, the impact on the eye and its various components is enormous. It shatters everything inside.

    Then, there are certain bodies which are metallic so that makes their removal relatively easier by using electromagnets, but these [pellets] are coated with lead, which makes it non-magnetic, and so their removal is very challenging.

    Once they are embedded within the retina, you need specialised faucets for their removal. So we had to customise. This makes pellet injuries different from other injuries which affect the eye.

    Al Jazeera: So the pellets are made out of lead?

    Maqbool: We sent them for a forensic report. It is mainly lead, but not pure lead. We thought that once it enters the eyes, it would just inflict mechanical damage.

    Now, we see it is not just the mechanical impact of the pellet.

    There are other reactions inside the eye. Extensive fibrosis, clot formation, lots of dense exudates ... These cause us a lot more grief and make it difficult to operate on patients. 

    Fourteen-year-old Insha Malik was hit by pellets when she had looked through a window of her parents' home [AP] 

    Al Jazeera: Are there case studies for you to refer to in dealing with these types of injuries?

    Pellet guns against protesters
    • Indian security forces don't use pellet guns anywhere else in the country and are now under pressure to stop using them in Kashmir
       
    • The Jammu and Kashmir High Court Bar Association has filed a petition at the state's High Court asking for the use of pellet guns to be stopped, saying they are a lethal weapon
       
    • Bashir Sidiq, the association's general secretary, led a group of lawyers in protest outside the High Court. He told Al Jazeera: "You can never expect a mob to be disciplined, but CRPF have to be disciplined"
       
    • At the end of July, the Indian government set up a committee to review the use of pellet guns. The army has recommended replacing them with less lethal weapons such as sound cannons, pepper shotguns and chilli grenades

    Maqbool: There isn't much literature. But to give you an indication of the scale of the injuries here: There are studies published I have read that looked at around 60 pellet-related injuries over one or two decades.

    And these are accidental injuries that have taken place while hunting for birds, not pellets, that were showered intentionally on protesters.

    In our case, we have had more than 750 eye pellet injuries over the past two months in our department alone. These are absolutely record-breaking numbers.

    No studies give us any clear-cut idea of how to manage these injuries. 

    Al Jazeera: How do you respond to the matter of lethal vs non-lethal use of force? 

    Khanday: Facts are facts. There are patients who have been killed by the use of pellets.

    There are statistics available which make it clear that pellets fired at very short range and in abundant numbers have the potential to kill. 

    Maqbool: We need to talk about how they are being used. And it is clear that those who are using it are not professionally trained because most injuries are from the chest up.

    Also, there are around 10 people who have been killed with pellets since July 9. So, if you are killing and maiming people, to me, it is a lethal weapon.

    On August 30, they [the government]  said they would use it on rarest of rare occasions. On August 31, we received 18 eye pellet patients.

    On September 1, we received 17. The next day we received 30. Don't they know what is happening to the people?

    They know it's maiming people, but still they are using it. 

    Al Jazeera: So, do you think the issue of lethal vs non-lethal use is a false question?

    Khanday: Exactly. This discourse cannot be actually converted into a question over the use of pellets. The protest on the roads are about something else. As far as lethality is concerned, if it impacts a teenager who has a long life ahead, whose career is at stake, whose family aspirations are associated with his development, and if he is blinded or maimed - I think the story is more grim than him being dead because death is a one-time shock.

    For many who have been hit in both eyes, chances of visual recovery are very bleak even with the most advanced and surgical interventions. So they are going to be blind; they are going to be a burden.

    Muhammad Ashraf, 19, from Budgam, told Al Jazeera that he was walking through paddy fields on September 14 when armed forces fired pellets at him from the highway. He says there were no protests at the time, and he was shocked when he was hit. On the way to the hospital, he says he was stopped at a checkpoint and beaten by police. He says he has taken part in protests and his village has seen many clashes between police and protests [Shuaib Masoodi/Al Jazeera]

    Al Jazeera: Considering that this is how the armed forces are responding to protesters, would you advise people to stay away from the streets?

    Fast Facts: The world's most militarised zone
    • India's offensive against the rebels between 1990 and the mid-2000s has seen the number of rebel fighters decrease from nearly 30,000 to around 200 now, according to Umair Gul, a scholar from Jamia Millia Islamia University
    • Indian-administered Kashmir remains the most militarised place in the world
    • Khurram Parvez, a Kashmiri human rights activist says there are more than 650,000 troops stationed in the region - that is one soldier for every 17 Kashmiris 
    • Independent analysts believe the number of Indian troops to be around half a million
    • The Indian government does not release official figures on the number of its troops in the disputed region
    • Human rights organisations have accused Indian forces in Kashmir of unlawful killings, disappearances, rape and torture
    • But the Armed Forces Special Powers Act , which was introduced in the state in 1990, gives security forces virtual immunity from prosecution

    Maqbool: We need to move away from this perception that only protesters are being hit by pellets.

    There is a four-and-a-half-year-old child here with pellets in the left eye. Do you think a four-year-old was throwing stones? Another lady was hit inside her home. There is Insha, a girl blinded by pellets. I call her the face of these eye pellet injury patients. She had just opened the window of her house to see what is happening outside. Then there are 50- and 60-year-olds hit in the eyes.

    And it is the same with gases. Here, I can narrate a personal story: During Eid, outside our house, tear gas and some other types of pepper gas were thrown at some protesters. I couldn't breathe at all. And I am 31 years old.

    My two-month-old daughter started vomiting milk through her mouth and nostrils. I started crying out of desperation because I didn't know what to do.

    I was sealing the rooms, and doing everything so that we can keep it all out. My other daughter - a three-year-old - was holding her throat saying that she is choking.

    When they started shelling again, I thought my two-month-old daughter had died. So I ran to the car, put on the air conditioner to try and help her breathe and drove off hoping the cool air would help her.

    As we drove, I again became emotional thinking about all the other children and families who can't escape. Not everyone has a car. I received a phone call from my cousin who lives next to me with his two-year-old son. He was saying: "You left, but what about us?" He was justified in saying so.

    Now, you are asking me about the guns they are using: Honestly, I don't know what is inside these pellets or the gases they are firing at us. What if my daughter develops some long-term reaction to it later on? What if she dies after a month. How do I know?

    I keep on telling my patients not to go back to the street to protest. If they go back, they may lose their other eye.

    If somebody else is going out to protest, I have said that people should use certain glasses made out of polycarbonate material or the ones used by welders. I have not done research on this, but it's the advice I offer.

    * Al Jazeera tried without success to secure comments on this interview from the Jammu and Kashmir police department, the state government as well as the ruling Jammu and Kashmir Peoples Democratic Party.

    Shakeela Sheikh, 30, from Baramulla, told Al Jazeera she had panicked when she heard that clashes had erupted in her neighbourhood on Friday, September 8. Her five-year-old son had gone to the mosque with her neighbours and, afraid, she ran out the house to search for him. She was hit in both eyes with pellets. She was also hit in the chest, neck and mouth. Her son survived, but she has lost her eyesight and now has no way to support him [Shuaib Masoodi/Al Jazeera]

    SOURCE: Al Jazeera


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