The Lancet and the Kashmir conflict: A counter point of view

I had read the open letter and the subsequent prolonged correspondence on the Gaza conflict in The Lancet in 2014.¹ It was an unusual topic for a medical journal. The open letter predictably led to reactions from the medical fraternity, Western as well as Middle Eastern, both supporting and opposing Israel. Further, most of them opposed the move by The Lancet to comment on an apparently political subject and a few supported it. Many used the opportunity to make critical personal comments against the editor. And so, I expected criticisms by individual doctors when The Lancet published the editorial on the Kashmir conflict.² However, I was surprised by the emotional outbursts from the Indian Medical Association, Association of Surgeons of India and Indian Academy of Pediatrics. The article in the Indian Journal of Psychiatry³ is equally critical. The controversy revolves around two issues: (i) Is The Lancet partisan in its criticism? (ii) Should a medical journal comment on these contentious international conflicts?

To be fair, The Lancet has not been selective in commenting on international conflicts. It has published editorials on conflicts in other parts of the world, e.g. the Gaza strip in 2009,⁴ Sri Lanka in 2014,⁵ refugees in the Mexican border of the USA in 2019.⁶ The editorials have been even-handed on all the occasions, concentrating on the toll the conflicts have taken on human health—physical and mental. I went through the editorial on Kashmir again. Nowhere has it accused Indian forces alone, although it felt they could have exercised more caution. The reference to ‘armed groups’ probably included the militants too. It has also pointed out that the indices of physical health have improved more in Kashmir than in other parts of India.

I agree it is not for others, including The Lancet, to sit on judgement about the responsibility for the conflicts. One has to remember that the soldiers too work under severe stress, particularly in a situation where they are not able to distinguish the enemy from ordinary citizens and the unpredictability of attacks on them. While the actions on battlefields have some amount of predictability and it is possible to prepare for the battle in advance, the guerrilla type attacks on soldiers in these conflict zones require them to be on the alert all the time. The pressures on the local populace too are equally heavy. Even if many of them do not want to get involved in the conflict, they may not be allowed to remain neutral. However, the soldiers should not only avoid irreversible damage like pellet injuries on the face, they should also appear to make every effort do so because they are part of a law-abiding society and cannot simply copy the insurgents.

The Lancet has been accused of ignoring the ethnic cleansing of Pandits. In fact, this group has suffered a lot from fellow Kashmiris going by the individual accounts.⁷ I agree I would not have had the courage or stamina to endure such suffering for long. The narratives are vivid, and nauseating at times in the description of cruelty inflicted, especially on women. However, they are not the same as publishing figures with clinical diagnoses in a medical journal. No one prevented us from studying and publishing the health consequences of ethnic cleansing of Pandits so that they got the publicity they deserved. We, the medical fraternity in India have failed to do so except for some sporadic attempts.

Should a medical journal comment on these issues? There are no easy answers. Wars and small-scale but prolonged conflicts do not achieve any purpose—there are ‘wars to end all wars followed by a war to make the world safe for democracy, followed by a world full of military dictatorships’, as put by Marvin Harris in his history of humans.⁸ Medicine is increasingly concentrating on the social causes of illnesses and the ways to prevent them. There was once the hope of preventing wars, but the development of nuclear weapons has altered the picture. The nation or the group which uses them first is likely to destroy others as well as themselves. The only way wars can be prevented now is by ending the ‘tyrannical anarchy of unlimited national sovereignty of nations and replacing it with a principle of a global community’, as noted by J.W. Fulbright in his preface to the classic work by Jerome D. Frank.⁹ If at all any groups of professionals are well suited to initiate this process, it is doctors of all nationalities (and especially psychiatrists who are close observers of human nature and psychological causes of violence)––with their avowed ability to rise above narrow interests and to view the whole suffering humanity as one. It is from this perspective that The Lancet is right in doing what it did. One can argue that it is a too idealistic stance, and we, doctors, are too small a group to make any impact. However, The Lancet has not shied away from making an attempt, and we have a responsibility to support it.

However, there is one glaring omission by The Lancet. It is reported that in the recent years, 192 vaccinators, many of them women and some were between 23 and 27 years age, who have been killed in Pakistan, for attempting to vaccinate children against polio.¹⁰ Refusal of vaccine, even by the educated as in the USA, is a known fact. However killing the unarmed vaccinators––that too women––is a much more heinous act than the armed conflicts.