The nature of civil conflicts and wars is changing, with civilian deaths far exceeding the number of military fatalities.  The effect of weapons on civilians is widespread in ways that pervade civilised society.
In Kashmir, we are witnessing an epidemic of pellet gun injuries for the first time and at a scale previously unknown in the world. Protests have been met with a ruthless response from Indian security forces, who fired into crowds of civilians. Reportedly, 17 000 adults and children have been injured and there have been 94 deaths. More than 1000 people, most of them young, sustained injuries to their eyes and about 600 people sought treatment after their eyeballs were ruptured by metal pellets. There is no recorded instance of a modern democracy shooting at people with the stated risk of blindness. [2,3,4,5,6]
The long term effects of lead poisoning due to pellet gun injuries have received less academic attention than the long terms effects of mustard gas and other chemical weapons.  However, the cumulative effect of lead as a toxicant impacts multiple body systems and is particularly harmful to young children. According to the World Health Organization (WHO), there is no known level of lead exposure that is considered safe.
There have also been reports that ambulance drivers have been injured by pellet guns in violent clashes while they were transporting patients.  Doctors and healthcare workers should be allowed to practise medicine without discrimination and they must not be attacked or persecuted for doing so.
The magnitude of the health effects—both direct and indirect—of these non-lethal weapons being used for crowd control during civilian demonstrations means it is essential that health expertise is brought to the fore when discussing how and when weapons are used, as well as what weapons can be legally manufactured, sold, and distributed. Furthermore, the specific knowledge of doctors about these weapons’ effects—on both individuals and the structures of support that their use may demand—creates an ethical duty to use that knowledge to prevent health damage. Indeed, the issue of health risks due to weapons was recognised and adopted by the World Medical Association’s 48th General Assembly in 1996. 
The medical profession has to deal with the immediate effects of pellet gun injuries, as well as the potential long term public health hazards, including lead exposure. The profession should therefore, alongside other humanitarian organisations, directly seek to influence the government and raise public awareness about health related human rights, with the goal that these weapons are not used for civilian crowd control.
The situation in Kashmir cannot be met with ambivalence, silence, or inaction. There is an urgent need for specialist medical facilities in the state to treat the effects of pellet injuries. At the same time, the government and civilised society should also help to rehabilitate the victims as they will need care for life.
Altaf Hussain is a retired former NHS consultant orthopaedic surgeon. He did his
initial medical training in Kashmir, and completed his training at the University of Liverpool. He worked in the NHS for many years as a surgeon and also as a tutor for the Royal College of Surgeons.
Upon his retirement, he was elected to the National Assembly for Wales as regional AM
for South Wales West. He also served as shadow minister for social services in Wales, and as a
member of the Health Committee of the National Assembly. He was a parliamentary candidate in
the 2015 general election. In May 2017, he was elected as a councillor for Bridgend County Borough
David Francis Jenkins comes from a legal services background. He is a freelance
journalist and blogger, and has a specific interest in health policy, as well as in international affairs.
He is a former Welsh Assembly candidate.
Competing interests: None declared.
1. Lives and statistics: are 90% of war victims civilian? Adam Roberts, Survival, Vol 52, Issue 3, 2010.
2. India’s crackdown in Kashmir: Is this the world’s first mass blinding?
Mirza Waheed, The Guardian, 8 November, 2016
3. What are Pellet Guns and why are they so lethal.
Adil Akhzer, The Indian Express, 22 July 2016.
4. An epidemic of ‘Dead Eye’ in Kashmir as India uses Pellet Guns on protestors.
Ellen Barry, The New York Times, 28 August 2016.
5. Jammu & Kashmir: Three months, 1000 eye injuries by Pellets.
Sofi Ahsan, The Indian Express, 13 October 2016.
6. Pellets generally used in hunting animals: Gun Manufacturer.
Sofi Ahsan, The Indian Express, 7 September 2016.
7. What are the Lead Poisoning Risks of a Lead Pellet, Bullet or Shot lodged in the body. Elizabeth O’Brien, Manager, Global Lead Advice and Support Services. Australia, 17 March 2002; updated 2 January 2013.
8. Kashmir: Ambulance driver fired with pellets while ferrying patients to hospital.
Sofi Ahsan, The Indian Express, 20 August 2016.
9. The World Medical Association declared: “In considering the role of physicians in the control of weapons-related injuries, suffering and death, the WMA recognises that the effect of weapons can be viewed as a public health issue.”
Adopted by the WMA 48th General Assembly, October 1996.