Bullet in the Eye

It is hard to keep a count of people maimed by the purportedly nonlethal pellets.  From the skull, chest, abdomen to the precious eyes, nothing is spared.  The victims are of any gender and age, from young children unaware of what just hit them, to the older ones who probably sense that their sight has been snatched away forever.  The 32 bedded twin wards of the ophthalmology department of SMHS Hospital Srinagar had to cope with a flood of patients most of whom need urgent intervention.  The doctors and other allied staff in the department have been working without taking a break, beyond their working hours and under hostile conditions to help the fallen and thus deserve all our commendations.  The situation has been made even more difficult by the unceasing assaults and interruptions by security agencies within the hospital premises, for obvious reasons.

Due to the eye being a very delicate balloon shaped organ, the pellets not only perforate but ricochet inside the eyeball causing severe damage to the cornea, lens, vitreous, and retina thereby destroying the whole eye from within.  In some people, the pellet goes through and through completely destroying the globe of the eye. In some cases, even the optic nerve is damaged.  We have seen horrible looking X-ray images of pellet victims doing rounds on the social media, and one does not have to be an expert to know what damage pellets can do. 

Although classified as a nonlethal weapon by the Indian state, ophthalmologists of repute have unequivocally agreed that the pellet guns are very lethal, blinding most people for life. Dr Tariq Qureshi, Head of the Ophthalmology Department at Government Medical College Srinagar went on record calling for an immediate ban on the further use of pellet guns.  In the past 3 weeks, doctors at the SMHS Hospital have performed 552 operations on those injured; out of which 211 were primary eye surgeries on the pellet victims. 58 further eye surgeries were performed out of which 48 were performed by a visiting surgeon working with an NGO. The surgeries are done to keep the eyeball intact and most patients will need multiple secondary surgeries.

The local ophthalmologists perform urgent surgeries trying to salvage the eyeball with whatever facilities they have.  There is no doubt that they have developed great expertise over the years to treat such patients but one cannot claim that they are able to treat everything locally keeping in view the complexity of the damage caused by the pellets.  The assertion by the Principal Government Medical College Srinagar that full treatment is available locally and “We are equipped as per international standards” is, in reality, the misleading rhetoric of yesmanship, probably articulated to please higher-ups or possibly under political pressure.  Barring few tertiary eye centres in the whole of India, even places like AIIMS are not fully equipped to deal with such complicated injuries. I am sure our ophthalmologists are fully aware of this and have been voicing their concerns.

Treatment of the posterior chamber of eye and retina needs specialised tertiary care facilities. The valley lacks an eye bank, so how are corneal repairs even possible in such a scenario? The team of doctors which was brought from AIIMS by the state government did nothing to help with the grim situation. They parroted the state narrative to keep the media busy, thereby misleading people by creating a false sense of security.

Even if some have chances to regain eyesight with appropriate treatment, they become blind because of the deliberate and forced negligence by the authorities.  There is a sense that any whistleblowing would not be tolerated by the authorities.  The simple narrative of 'all is well' and we have everything to deal with the situation sounds out of place keeping in view that our heath sector even struggles during normalcy let alone a war like situation.  But this is not the first time medical professionals have been used to cover up political failures and state aggression. 

I am not suggesting that everyone should be referred outside the state as the treatment is prolonged and the outcome is usually not good.  The government should officially bring experts from outside the state along with the necessary equipment so that they can work in collaboration with the local ophthalmologists, treating patients and also empowering local experts with the necessary training for future cases.  The hospitals would need to be funded properly and appropriate infrastructure developed to deal with such injuries on urgent basis. There is an urgent need to start an eye bank.

Most of the pellet victims come from poor backgrounds and cannot afford to travel outside of the state.  But patients, who need further treatment, which is not possible locally, need to be referred to appropriate centres and not just any hospital for mere eyewash.  If some patients want to go outside, they should be appropriately referred rather than denying them that chance by giving vague excuses. Medical professionals cannot ignore the limits of their expertise or the facilities available, when dealing with lives and someone’s chance at seeing the world again.  If people are not appropriately guided, they end up at wrong places, where they are not only looted but harmed further.  Even if the NGOs volunteer to help, they should work under the supervision of local Ophthalmology department and referrals to them should be done by doctors.  It is important that right patients are identified for right treatment at the right time.

The use of pellet shotguns was first introduced in Kashmir in 2010.  During the 2010 unrest and subsequent years, hundreds of people received pellet injuries with eyes being a common target. Sadly, most of these poor victims were lost to follow-up. The common reason for not coming back to the local hospitals seems to be the fear of authorities. This has meant that many people who have some hope of recovery did not come back to get further treatment.  Some of them sold everything to get treatment outside of the state on ill-founded recommendations, ending up losing both vision and money. This holds true for the recently injured who are likely to face similar consequences.  There are also allegations that doctors are being forced to discharge these patients from the hospital and many volunteers helping them have been roughed up as well.

There is hardly any research when it comes to the treatment of eye pellet injuries and long-term prognosis in the local context.  A study published in 2012, reported 198 patients with pellet gun injuries attending Sheri-Kashmir Institute of Medical Sciences between the months of June and September 2010.  Another study published in 2012, included 60 patients seen at the ophthalmology department SMHS Hospital Srinagar for various eye injuries between June and September 2010.  The study concluded that the prognosis for pellet gun eye injuries remains very bad.  A study published in 2014, which looked retrospectively at the pellet gun eye cases from 2010 cohort, suggests that visual prognosis remains grim despite adequate treatment at the time of actual injury. Half of the cases were blind with visual acuity of less than 3/60.

Due to lack of a register for such patients, it is hard to know how many young blind people are suffering in silence. If this brutal weapon continues to be showered on the civilian population, we may have another cohort of ‘deliberately blinded’ people in thousands, adding to the list of half widows, orphans, and waiting mothers.  Such weapons were used by the West in the Gulf war but the world’s largest democracy using these weapons against the civilian population can only be described as shameful.  The use of such brutal weapons needs to be stopped immediately as no amount of justification makes them nonlethal under any international law.
http://www.risingkashmir.com/news/bullet-in-the-eye 

Pellet injuries - terrible fallout

During the last 3-4 weeks, an estimated 317 people have received pellet gun injuries in the Kashmir unrest, with half of them being shot in their eyes.  The two sixteen bedded ophthalmology wards in the SMHS Hospital Srinagar had to cope with around ten times the patients they have capacity for.  The use of pellet shotguns was first introduced in Kashmir in 2010.  During the 2010 unrest and subsequent years, hundreds of people received pellet injuries with eyes being a common target.

The eye being a very delicate balloon shaped organ, the pellet not only perforates but ricochets inside the eyeball causing severe damage to the cornea, lens, vitreous, and retina, destroying the whole eye from within.  Although classified as a nonlethal weapon by the police, the medical fraternity, especially the ophthalmologists, have unequivocally agreed that the pellet guns are very lethal blinding most people for life. Even after multiple surgeries, the prognosis remains grim, with majority becoming totally blind.

The local ophthalmologists are able to perform emergency surgeries trying to salvage the eyeball with whatever facilities they have, but the hospitals are not equipped to deal with the type of injury the pellets cause to the inner structures of the eye.  Concerns have been raised that treatment of pellet eye injury is not available locally, with the state being complacent; the victims are not referred to the appropriate centres outside for unknown reasons.  The valley even lacks an eye bank.  Most of the pellet victims come from a poor background and cannot afford to travel outside of the state for specialised treatment. Hence if some have chances to regain eyesight with appropriate treatment, they become blind because of the negligence of authorities. There is a sense that any whistleblowing would not be tolerated by the authorities for political reasons.

There is hardly any research when it comes to the treatment of eye pellet injuries and long term prognosis in the local context.  A study published in 2012, reported 198 patients with pellet gun injuries attending Sheri-Kashmir Institute of Medical Sciences (SKIMS-MC) between the months of June and September 2010. Another study published in 2012, included 60 patients seen at the ophthalmology department SMHS Hospital for various eye injuries between June and September 2010. The study concluded that the prognosis for pellet gun eye injuries was bad.  A study published in 2014, which looked retrospectively at the pellet gun eye cases from 2010 cohort, suggests that visual prognosis remains bad despite adequate treatment at the time of actual injury. Half of the cases were blind with visual acuity of less than 3/60.

Western literature suggests that people who lose their eyesight late in life are worse off emotionally that those who are blind from birth. Even people losing their eyesight due to medical reasons are highly likely to develop depression and other psychological problems.  This is thought due to the fear of unknown, fluctuating ability to see and rather being on an emotional roller coaster.  Losing vision is akin to a grief reaction where the loss is mourned by the person. More than 30% of people who develop blindness due to medical reasons develop depressive symptoms.

In comparison to medical conditions, people who lose their eyesight due to a traumatic injury inflicted on them, like the pellet guns, are highly likely to develop severe psychological problems. This is due to the trauma they experience and their final memory of seeing the world shattered by a pellet. The visual loss also happens within seconds of the injury, giving the individual little time to get used to the change in comparison to the loss of vision due to medical reasons. Suddenly young people find themselves blind, maimed and in pain facing a very bleak future. The uncertainty around recovery, multiple surgeries, inadequate treatment and subsequent poor prognosis further worsens the emotional health.

Such victims of the brutal blinding violence are likely to develop post traumatic stress disorder, depression and other anxiety disorders.  The sudden loss of functional life, almost negligible prospectus of future and inadequate support systems, in the long run, makes their situation more miserable. The victims get some attention in the immediate aftermath from doctors, their families and society.  But in the long run, they are forgotten and left to grieve on their own. They often become hostages in their own heads.  Sadly this is followed by stigma from their families and friends.

Apart from a lack of proper treatment in the acute aftermath, there are no support systems to help them to adjust to the change.  They not only need physical rehabilitation but also psychological rehabilitation and training so that they are able to adjust to the catastrophic change which has overpowered them without any warning.  Unfortunately, no such facilities exist in Kashmir valley. The local doctors, psychiatrists and civil society need to support the victims even after the acute phase is over, or else they may curse themselves wishing it is better to lose life than light. Counselling and rehabilitation services need to be established in all hospitals to help such victims cope with the loss of vision, life skills training and treatment of psychological problems.

The hospitals would need to be funded properly and appropriate infrastructure developed to deal with such injuries in future. For now, the state has a responsibility to fund their treatment in appropriate centres across India or even abroad if needed.   Finally, the use of such lethal weapons needs to be stopped immediately as no amount of justification makes them nonlethal.

http://healthanalyticsindia.com/healthopinion.php?id=221