Politics

In Kashmir, Doctors Bear Witness

From treating pellet injuries to navigating the tension between political strife and the urge to maintain neutrality, Kashmir’s doctors share their experiences from the unrest in the Valley.

Que at the opthalmology ward in SHMS hospital in Kashmir. Credit: Shome Basu

Que at the opthalmology ward in SHMS hospital in Kashmir. Credit: Shome Basu

Warning: This article contains graphic imagery

Srinagar: The corridors of the Jhelum Valley Medical College (JVC) in Srinagar were tense with dread. The medical superintendent had received word on WhatsApp from some district hospitals and volunteers about pellets and bullets being fired in Baramulla and Shopian. “This means there will be a surge in patients, so we have the whole staff on standby,” said Dr. Shafa D.W. Deva, medical superintendent at JVC. “Since July 9, not a single day has passed without injured patients coming in. On some days, 40 or 50 arrive in just this small hospital.”

Two months ago, the all-too-familiar cycle of violence began again in Kashmir when popular Hizbul Mujahideen militant Burhan Wani was killed by armed forces. The state-imposed curfew and the separatist-recommended strikes have been ongoing for 58 days across the Valley. Frustrated residents are part of stone-pelting protests but also peaceful rallies and funeral processions; the Central Reserve Police Force (CRPF) and Jammu & Kashmir police have cracked down on these with pellet guns, batons and tear gas shells. Over 10,000 have been injured and 73 killed, with more than 700 people, including teenagers, being hit in the eyes. At least 60 of them have been entirely blinded – nearly one every day since the uprising began. Thousands have been riddled with the red pock marks of tiny blood clots all over their body, each a lead pellet that they will have to live with for the rest of their lives.

The ongoing unrest in Kashmir has competing narratives, especially on the indiscriminate firing of pellets and bullets. There are the ‘chicken and egg’ arguments about provocation by stone pelters and security forces. The CRPF and the government might continue to justify the crackdown, blaming separatists and Pakistan for instigating young men, but as in any violent conflict, some undeniable, unvarnished truths can be found where all politics must take pause: in hospitals. Doctors have been working round the clock and bearing witness. They say unequivocally that going by the nature of deaths and injuries, security forces have not only violated protocol, but also targeted people. Speaking to patients and their families during diagnosis and post-operative care, the doctors find that the collective experience of loss and gross injustice has fuelled more rallies and clashes.

Dr. Raashid Maqbool Wani is a consultant in the ophthalmology department of the Sri Maharaja Hari Singh (SMHS) Hospital. On the second day of protests, while walking near the Emergency ward, he saw a young man, with a sprinkling of a beard, with two bullets in his abdomen. He died as Wani stood watching. “To me, that was a sign this was going to be massive. I burst into tears.” At first, he thought they would do “marathon operations” to handle such mass trauma and the influx of patients with injuries of varying complexity. “We hoped the numbers would fall after one week, two weeks, a month. But after almost two months and staggering numbers, I can’t help but see patterns and meanings.”

SMHS is the biggest government hospital in Srinagar, most pellet injuries – especially to the eyes – are treated there. By the 56th day of unrest, the ophthalmology unit had admitted 550 patients with eye injuries – an average of 10 patients a day. Doctors assert that Indian forces have not reduced their use of pellet guns. “The numbers are not going down. In just one day, August 31, I treated 18 pellet cases – all of them [with injuries] in the eye,” says Wani. He has seen patients coming from all over the state – north, south, Pulwama, Kupwara and Anantnag. Most cases are from the hinterlands where the presence of the Indian army and paramilitary is deeply embedded in everyday life.

Atul Karwal, inspector general of the CRPF, told The Wire that his force “always follows the standard operating procedure” of giving warnings, shooting with rubber bullets and lobbing tear gases before shooting pellets below the waist, “unless it is a life and death situation”. But doctors testify that this does not appear to be the case. “If the CRPF is supposed to shoot this supposedly non-lethal weapon below the waist to control the crowds, they are hardly following this rule,” says Wani. “In a majority of cases, the pellets are lodged above waist. When I’m doing an eye surgery, I see that all the pellets are on the chest, back, neck and face. This continued even after weeks of knowing it was blinding people.”

The government apparently lifted curfew after 51 days, but in the week after, more than 1000 have been injured and 3 killed in clashes across Kashmir. A week after home minister Rajnath Singh said the forces would minimise the use of pellets and set up a committee to recommend alternatives, the CRPF reportedly received a new consignment of 1 lakh pellet cartridges, each containing 635 metallic balls.

Dr. Adil Ashraf, registrar of medicine and the president of the SMHS Doctors’ Association says, “Not every pellet firing or beating seems provoked, it just cannot be. The age and nature of injury is on record.” Most of his patients were in the 17-25 age group, but he has also treated an 82-year-old woman who was brutally beaten all over and a three-year-old girl with pellets lodged all over her body. In another hospital, a 22-year-old ATM guard was found to have 362 pellets in his guts, which is only possible from being shot at close range. He was killed on the spot. “These people did not participate in stone pelting,” says Ashraf.

He has also noticed a spike in the number of incoming patients, in tandem with a rising number of cases of physical abuse by the Indian army. For instance, on August 17, Shabbir Ahmed Mungoo, a 30-year-old professor from the saffron-rich Khrew district, was thrashed to death by army men in his home. On that day, Ashraf says 33 patients were admitted, five from the same village of Shre-e-Shali. “The more the police pump protestors and bystanders with pellets and bullets, the larger the rallies have grown and greater the injuries.”

§

The pellets – balls the size of mustard-seeds – fly out of pump shotguns with ferocious velocity and rip through skin, nerve and muscle. Extracting the pellets and treating the wounds has been a harrowing experience for doctors, especially since few patients or doctors have experience dealing with this type of injury or have seen a injury and death toll of this magnitude before.

A pellet after being extracted from a patient's eye. Credit: Doctor at the hospital

A pellet after being extracted from a patient’s eye. Photo courtesy: A doctor at the hospital

Evenings and Fridays, every hospital staff member admits, are the worst. That’s when people come out to defy the curfew or to attend prayers and end up getting injured. Patients in rural Kashmir, where the unrest is most intense, are rushed to the primary health centre or district hospital for initial treatment. “Few [of these health centres] are equipped to handle pellet [injuries] to the eyes, so they’re (patients are) sent in ambulances to JVC or SKIMS,” says JVC medical superintendent Deva.

As soon as a patients arrive at the bigger hospital, they are wheeled into the X-ray room and if pellets are found, they’re taken straight to the operation theatre. At JVC, three doctors are on duty every night, with one assigned to do the primary repair – closing up the wound to prevent blood from flooding the eye cavity.

Dr. Hina, a postgraduate ophthalmologist at the JVC, works 36 to 40 hour shifts, takes a day’s break to sleep and is back on the job the next day. After three operations in the morning, she eats a quick lunch and sits down with a thick textbook, trying to catch up on reading. She is exhausted. “Not a single textbook tells me how to handle pellets lodged in someone’s eyes,” she says. “Even the senior doctors faced this for the first time. In a conflict zone, you learn on the job.” Since the protests began, she has operated on about 20 patients and assisted in 30 eye repair procedures.

After completing the initial suturing, JVC sends most patients to SMHS for a vitrectomy, a surgical procedure to fix detached retinas to improve vision. SMHS doctors have had to operate on these patients in addition to attending to their own incoming trauma patients. “It took us a few days, but in the middle of waves of patients, we put in systems and procedures,” said Wani. He went on to list a mind-boggling level of preparation: “We cancelled all leaves to all staff. We created teams for emergency, surgery, post-op care. We fumigated halls filled with families, shoes, food, blood, and all sorts of unhygienic stuff, as often as we could, to prevent infections. We called in NGOs to help with transporting patients because we didn’t have enough ambulances. We added trollies as operating tables in our theatres so that multiple surgeries could be performed simultaneously.”

Doctors have to take consent from a patient or his family before performing surgery but in this situation doctors have been receiving patients who are near-unconscious, blinded or younger than 18. Referring to past situations, Wani said, “People bringing them were also most often friends or strangers, not family, so we ended up having to get quick signatures from the kids themselves, while wheeling them into surgery.”

A senior doctor in the ophthalmology department at SMHS says the doctors in his department decide whether or not it’s possible to remove a pellet from the injured eye when a patient comes in. It takes doctors about 90-120 minutes to remove each pellet. “They really lodge themselves into muscle,” says the doctor.

A doctor explaining a pellet injury by looking at a CT scan. Credit: Shome Basu

A doctor explaining a pellet injury by looking at a CT scan. Credit: Shome Basu

This is the first time in Kashmir, and perhaps the world, that pellets have been used this extensively for crowd control. The CRPF has admitted before a Jammu and Kashmir court to firing 3000 cartridges in the first 50 days. “The world record is of 70 injuries in over a decade, in the seventies, largely from pellet guns used to hunt birds. We had hundreds of pellets by the second day,” says Wani, who has written a research paper analysing the use of supposedly non-lethal weapons in the 2010 protests in Srinagar. “The 2016 protests will be marked by pellets and even if withdrawn, they’ve already left an indelible mark on Kashmiri society.”

Acting out of academic interest, doctors have also been trying to understand the nature of pellets by taking pictures and videos. “In the 2008 and 2010 uprisings, we didn’t have vitrectomy facilities nor were pellets so widely used, so we didn’t have a chance for analysis,” says Wani. For instance, after conducting several surgeries, doctors have realised that pellets are almost hexagonal in shape with sharp edges, as opposed to spherical as they previously believed.

SMHS has now sent two sample pellets to a chemical lab for analysis. “We want to know why it takes 1.5 hours to remove pellets when it takes only a maximum of 45 minutes to extract other foreign bodies,” says the senior doctor. “Does it emit some chemical? How much dust and dirt does it gather from the ground or air before it hits the eyes? Why do some exit the body and some don’t?”

These questions, in a way, are pulling and tugging at the claim that the pellet is a non-lethal weapon. An expert committee instituted by home minister Rajnath Singh to come up with an alternative to pellets has recommended using Pelargonic Acid Vanillyl Amide (PAVA) shells. PAVA shells are chilli-filled grenades meant to “temporarily immobilise the targets”. However, it is unlikely that pellets will be entirely banned on the basis of these recommendations; pellet use will probably be restricted to the “rarest of rare cases”. Like many other doctors, a casualty medical officer at JVC finds the recommendation laughable. “Who will define what is rare?” he asks. He believes it will only provide a ready excuse for misuse. “They’ve showered pellets indiscriminately, half a cartridge on 20 to 25 targeted persons that I have seen myself,” says SMHS general surgeon Dr. Yaqoub. He continues, “I also removed a pellet half a millimetre away from a boy’s carotid artery, which supplies blood to the brain. Pellets cause deaths and any doctor here will tell you it is not non-lethal by any stretch of imagination.”

§

In a room next to SMHS’ Ward 7, where doctors do marathon eye surgeries on four tables, is a narrow office stocked with pink and white files. About 200 of them are arranged neatly on the floor and a couple of desks. Wani points to them. “They have wrong names and wrong addresses,” he says. “By the first week, a message seemed to have gone around to patients that policemen were slyly profiling patients here.” This has led to scared patients – especially those under 25 – giving fake names and addresses to the hospital. Wani was annoyed at this rumour at first. But on a break one day, he caught a plainclothes “CID person” expressing sympathy to a young man still woozy from anaesthesia and taking down his name and address. The doctor realised that security was a real concern, even in the hospital. SMHS now assigns a number to each patient, so that records can be more accurate and the patients safer.

On August 11, the SMHS hospital staff, including doctors and senior faculty members of the Government Medical College, Srinagar, held a protest against the use of pellet guns. They stood in silence outside the hospital, wearing eye bandages in solidarity with pellet victims. “Stop killing innocent kids,” a placard read. Dr. Tariq Qureshi, head of the ophthalmology department, said they held the protest because his team was “deeply pained by the violence”.

A group of young physicians from the Government Medical College have also submitted a memorandum to the World Health Organisation. “Nobody can tell the tale of this horror better than a doctor who receives and treats the victims in the hospital and witnesses the agony of the patient and the suffering of his family members,” the memorandum reads. “[The] doctor community has been exposed to [the] worst kind of mental trauma, be it disclosing the news of a young victim’s death to his parents or the news of permanent blindness or handicapped to the victim himself.”

Hina says every few days she shuts herself in a room to cry. Wani says a fervent prayer before every surgery, “hoping for the patient to be able to see light again”. Ashraf says many of his colleagues have broken down while providing treatment. “When a doctor breaks down, that means all lines of humanity have been crossed,” he adds.

Victims of pellet injuries hold up pro-freedom placards in SMHS. Credit: Rohini Mohan

Victims of pellet injuries hold up pro-freedom placards in SMHS. Credit: Rohini Mohan

Talking to patients, these doctors have also registered the burgeoning rage among patients and their loved ones. “It’s exploding, this anger, it’s becoming uncontrollable,” says Yaqoub. On September 1, when a couple of casualties were brought in and a doctor declared one of them dead at the door, people thronged to the body. Lifting the dead man high above their heads, young men chanted slogans. Two women, one of them with a bloody head bandage, sang a high-pitched song about never forgetting this martyr. Dr. Wajeed, registrar of medicine at SMHS, describes another time when people chased out a policeman who’d come to the hospital to have his bleeding head bandaged. Thrice, he says, the CRPF has lobbed tear gas shells inside the wards to break up sloganeering and skirmishes. “It left so many infants, other patients with bronchial asthma or on post-operative care more vulnerable.”

Wajeed recalls an instance when M.K. Bhandari, the secretary of the health department, had a close shave with Kashmiri protestors. Bhandari was at SMHS to visit pilgrims who had met with an accident Amarnath. “It was some boys who were pelting stones elsewhere that brought many of the injured pilgrims to hospital,” says Wajeed. “Kashmiris have not lost their humanity. We too treat all patients equally. But we can’t help but notice the government’s obvious disregard for the thousands hurt in the protests.”

All the doctors that The Wire spoke to admitted experiencing the same frustration their patients do. “As doctors we usually feel neutral, we treat the wound, not the person,” says Yaqoub, sitting on a bench outside the medical college. “But when I see this extent of discrimination and heartless violence, I want to shun the neutrality and take sides.” A young Kashmiri himself, Yaqoub grew up in the nineties listening to the same “tales of loss and betrayal” as the youth protesting today, and seeing traumatic scenes of violence enacted against his friends and family. “For some reason, I became a doctor and banked on optimism,” he says.

But after the past two months, when injured protestors swear that they will rejoin protests even with one eye or bandaged arms, Dr. Wajeed feels shaken. “I’m too weak to go on the road and throw stones, I just don’t have the courage to face the army – that’s the raw truth. But inside me, I have the same feeling as the protestors,” he says, his voice rising. “That sense of injustice, that rage against an uncaring state…I feel it too, deeply. It is like white matter in the brain.”