Editorial
Fear and uncertainty around Kashmir’s future
REUTERS/Akhtar Soomro
For the human rights report
see https://www.ohchr.org/
Documents/Countries/IN/
KashmirUpdateReport_
8July2019.pdf
For the Medact Blog on War,
violence and the mental health
crisis in Kashmir see https://
www.medact.org/2019/blogs/
war-violence-and-the-mental-
health-crisis-in-kashmir/
For the Médecins Sans
Frontières study on mental
health status of Indian
Kashimiri population see
https://www.msfindia.in/sites/
india/files/research_summary.pdf
Joel Carillet/Getty Images
See Comment page 549
For the Aid Worker Security
Report 2019 see https://www.
humanitarianoutcomes.org/
sites/default/files/publications/
awsr_2019_0.pdf
542 www.thelancet.com Vol 394 August 17, 2019
Last week in a controversial move, India revoked the auto­
nomous status of Jammu and Kashmir, allowing India
greater authority over the state’s affairs. The announce­
ment fanned tension with Pakistan, which also claims the
region and has fought India over it for more than seven
decades. At least 28 000 Indian security forces have been
deployed; in the capital city Srinagar, a lockdown has
been implemented that suspended communication and
internet links, and a strict curfew has been imposed. The
militant presence raises serious concerns for the health,
safety, and freedoms of the Kashmiri people.
Since the insurgency of Kashmir in 1989, the state has
experienced bloody conflict from both sides, resulting in
more than 50 000 deaths. According to a report by the
UN High Commissioner for Human Rights, published last
month, gross human rights violations by state security
forces and armed groups have occurred, including cross-
border firings, sexual violence, enforced disappearances,
and acts of terrorism. The report emphasises continued
use of excessive force against civilians—for example, the
use of pellet-firing shotguns has led to 1253 people being
The gender plight of humanitarian aid
World Humanitarian Day, which takes place on
Aug 19 each year, celebrates the efforts of humani­tarian
aid workers operating in war-torn, resource deprived,
or disease-affected settings to sustain human life. This
year, special tribute is paid to the unsung heroes of
humanitarian health—women. Whether they are at the
forefront of an international crisis or operating within
local communities, their long-lasting and stabilising
impact makes them true peace keepers of humanitarian
health.
In the past few decades, the number of major attacks
on aid workers in hostile environments has soared.
According to the Aid Worker Security Report 2019
update published in June by Humanitarian Outcomes,
2018 was the second worst year on record for aid
security, with 226 separate attacks involving 405 aid
workers, of whom 131 were killed, 144 wounded, and
130 kidnapped. South Sudan continued to surpass Syria
and Afghanistan in the number of major attacks on
aid workers, which also put the Ebola response in the
blinded between 2016 and 2018. Both India and Pakistan
have largely dismissed the report’s recommendations to
end the abuse.
Despite decades of instability, developmental indicators
suggest that Kashmir is doing well compared with the
rest of India. In 2016, life expectancy was 68·3 years
for men and 71·8 years for women, which are greater
than the respective national averages. However, the
protracted exposure to violence has led to a formidable
mental health crisis. A Médecins Sans Frontières study in
two rural districts affected by conflict stated that nearly
half of Kashmiris rarely felt safe and of those who had lost
a family member to violence, one in five had witnessed the
death firsthand. Therefore, it is unsurprising that people in
the region have increased anxiety, depression, and post-
traumatic stress disorder.
Prime Minister Narendra Modi vows that his decision
to revoke autonomy will bring prosperity to Kashmir. But
first, the people of Kashmir need healing from the deep
wounds of this decades-old conflict, not subjugation to
further violence and alienation. n The Lancet
Democratic Republic of the Congo at risk. The report
focused on the variance in risk between male and
female aid workers. Men were more likely to be victims
of shootings and aerial bombings, whereas women
were more likely to be physically attacked, kidnapped,
or involved in complex attacks such as bombings.
Sexual violence had the highest gender variance,
comprising 8% of all attacks on female aid workers since
1997. The report calls for the risk of sexual violence to
be re-examined in humanitarian operational security.
Multiple reporting pathways and a higher degree of
decision-making autonomy offered to survivors would
improve case identification and analysis of security risks
and needs. Governments need to recognise the female
plight in humanitarian aid. Applying a gender-focused
lens to the identification, assessment, and management
of the security needs of humanitarian responders is a
good place to start. As humanitarians, women are often
first to respond in a crisis and they should not be the last
to be considered. n The Lancet