WORK A Journal of Prevention, Assessment & Rehabilitation

ELSEVIER

Work 8 (1997) 299-304

Global health issue

Anti-personnellandmine injuries: a global epidemic Donna McIvor Joss* Occupational Therapy Department, Worcester State College, 486 Chandler Street, Worcester, MA 01602, USA

Accepted January 1996

Abstract Injuries and fatalities caused by anti-personnel landmines have become a global epidemic. Over 250000 people alive today have been injured by landmines, many of whom required amputations. Civilians, including a large percentage of women and children, are injured at least as frequently as are military personnel. An estimated 10 000-100 000 additional people are killed or injured by landmines each year. There are presently in excess of 100 million active landmines buried or scattered throughout the world, and every day, an additional 5000 are put in place. The majority are in poor, underdeveloped, war-torn countries whose populations are already traumatized by conflict. At the cost of $300- 000 per mine, the governments of these countries can not afford the process of de-mining their land, nor can they provide adequate emergency medical care and rehabilitation for landmine victims. The presence of mines in agricultural fields, near water supplies, along roadways and around villages, prevents the use of these essential resources, severely impacting on economic development. Health professionals are urged to support national and international legislation to completely ban the manufacture, sale and use of anti-personnel landmines. © 1997 Elsevier Science Ireland Ltd. Keywords: Landmine; Anti-personnel landmine; Amputation; Rehabilitation; De-mine

'But the war goes on; and we will have to bind up for years to come the many, sometimes ineffaceable, wounds that the colonial onslaught has inflicted on our people.' (Fanon, 1963 p. 203)

* Corresponding author. Tel.: + 1 508 7938119; fax: + 1 508 7537305; e-mail: [email protected] Sources of additional information: Physicians for Human Rights, 100 Boylston Street, Suite 702, Boston, MA 02116, USA and International Campaign to Ban Landmines, c/o Vietnam Veterans of America Foundation, 2001 S. Street N.W. Suite 740, Washington, D.C., 20009 USA.

'Already, huge regions of our earth have been horribly transfonned by landmines. What were once rice fields in Cambodia, savannah in Angola, mountain passes in Afghanistan and soccer fields in the former Yugoslavia are now unfit for habitation or cultivation for centuries. Will landmines be the mad inheritance we bestow upon the world's children?' (Goldfeld, 1996)

My first experience with the effects of a landmine explosion started when a 9-year-old boy was admitted to the Bethlehem Arab Society Rehabilitation Centre in the West Bank town

1051-9815/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved. PH S 1 051-9815(96)00250-7

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of Beit Jala, where I worked as an occupational therapist in 1990. Nazar and his sister had been playing outside their home in the Palestinian refugee camp of Ghan Younis in Gaza, when a small plastic object fell from a helicopter passing overhead. With childish curiosity, the two ran to examine the toy-like object. It exploded at their first touch, destroying Nazar's right leg below the knee, his right arm below the elbow, and half of his left foot. His sister was also seriously injured, and required amputations, but I never learned the exact nature of her injuries. By the time he was admitted to the Rehabilitation Centre, Nazar had already received extensive medical treatment which began after a frantic ride in a borrowed car to the local government hospital. As is usual with landmine injuries, the explosion had ripped and burned the flesh of Nazar's limbs, had forced dirt, bits of bone and clothing into tissue far above the major wounds, and had damaged blood vessels through the force of the explosion. Extensive debridement had to take place before the amputations could be performed, to eliminate the possibility of future infections. The amputations were necessarily much higher than the actual major wounds, to give the surgeon clean, even stumps with adequate innervation and vasculation that would eventually be able to allow the use of protheses. Nazar's stumps were beginning to heal by the time of his admission to the Rehabilitation Centre, and he quickly became adept at self-care and wheelchair mobility. What was most needed were prostheses. The Centre did not have the capacity to manufacture prostheses of the level of sophistication that would give this child the opportunity to continue to develop in a normal and positive fashion. Nazar's family, Palestinians living in one of the poorest, most crowded refugee camps in Gaza, had neither the financial resources nor the mobility to properly provide for the rehabilitation, including prostheses and therapy, for their two injured children. Nazar alone will require not just one but a series of possibly 20-25 different prostheses for each amputated limb as he outgrows them and as the devices wear out. At a cost of only $125 for each prosthesis, the cumulative costs over Nazar's lifetime could be more than

$3000 for each amputation, or over $6000 for protheses for just his leg and arm (Garachon, 1993). Returning to the refugee camp without prostheses, and in a wheelchair, even if he had access to one, would mean isolation, dependence, and exhaustion of the family members' energy as they took care of him. There are no wheelchair-accessible schools in Ghan Younis, so the formal education of this bright child would be terminated. His ability to eventually help support his parents, a traditional role in Arab society, would be limited, as would his potential to marry and support a family. Instead, he and his sister would drain the family resources, pushing them from poverty to destitution. Rather than helping his society move from occupation to independence, and from underdevelopment to developed status, the children would grow up to be impediments to social, political and economic progress. Up to this point, Nazar's story is a common scenario for the more than 250000 landmine disabled people in the world and for the 26000 that are newly injured every year by land mines (International Campaign to Ban Landmines, 1996). These grim numbers only begin to describe the global disaster created by these insidious devices. Deaths from landmine explosions are approximately twice as frequent as injuries (Doucet, 1993). The data are incomplete, however: many incidents (deaths and injuries) are never reported. Landmines were originally designed to be used by the military against enemy forces, targeting foot soldiers and military vehicles. Now civilians, especially women and children, are commonly their victims; in many countries as frequently as are military personnel. The landmine epidemic has devastating effects on the poorest, underdeveloped nations, those which are least able to protect their citizens from them. These nations are typically not at all equipped to deal with the complex aftermath of their use, including mine removal and rehabilitation of individuals injured by mines. Ironically, the only societies that profit from landmines are the rich, industrialized nations where most landmines are manufactured. Landmines came into widespread use during World War II, first as large, buried bombs strategically designed and placed to detonate when run

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over by tanks. These early mines were so large and easy to find, that it became common for opposing forces to unearth and relocate enemy mines into the paths of the armies that originally planted them. In order to discourage this practice, smaller anti-personnel mines were developed that would detonate when stepped on by a human foot. Anti-personnel mines were placed around anti-tank mines to protect them from enemy demining activities. They proved to be so inexpensive and effective in killing or disabling individual soldiers that their use has become ubiquitous for large as well as small nations and factions entangled in civil and international wars. Many variations of the original anti-personnel mine have been developed since World War II. Most are buried by hand in areas likely to be used by enemy personnel, but some, like the device that injured Nazar and his sister, can be dropped by aircraft. Others can be launched in clusters from artillery shells, a safe and efficient method of mining from a distance. The United States, France and the United Kingdom used this technique to spread over 1 million mines along the Kuwait-Iraq border and around the ancient and historic city of Basra in Iraq during the Gulf War (Webster, 1994). Initially, anti-personnel landmine use targeted military personnel. Their impact on civilian populations, which was accidental at first, and their ability to drain the enemy's resources, have not, however, gone unnoticed by opportunistic warring factions. Now, anti-personnel mines are used to punish refugees for attempting to re-occupy their home villages, and to prevent civilian populations from safely using farm, pasture or wood lands, water sources, roads, playgrounds, or beaches. As noted by Webster (1994), anti-personnel landmines have taken the place of human soldiers, blocking the flow of humanitarian aid and refugee populations. There exist today as many as 360 types of anti-personnel landmines produced or formerly produced by manufacturers in developed countries (Velin, 1995). China, Czechoslovakia, Italy, the United Kingdom, the former USSR, France and the United States have all been home to the landmine industry (Webster, 1994). The cost of

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these devices start at $3.00 for the Chinese types, 40 million of which are scattered around Afghanistan, Africa, the Middle East and South East Asia. An upgraded model from Thiokol Corporation in Shreveport, LA costs $27.47. Six million of these are deployed in Angola, Mozambique, Central America, and South East Asia. There are nearly 11 million French models, costing only $4.00 each. These can be found in Afghanistan, Iraq, Iran, Mozambique, Somalia and Lebanon (Webster, 1994). Worldwide, an estimated 110 million (Velin, 1995) anti-personnel mines are buried, waiting for the touch or footstep of an unwary victim. These numbers mean that there is approximately one mine for every fifty humans on earth (Webster, 1994). The horror does not end with mines already buried, however. Every day, 5000 additional mines are put in place, and another 10 000 are manufactured and stored for future use (Goldfeld, 1996). The cost of locating and removing just one of these mines will run between $300 and $1000, unless someone accidentally steps on it. Then the cost, in human suffering, will be incalculable and ineffaceable. The disastrous effects of landmines on the civilian population of Cambodia have been well documented and can illustrate the severity of this global crisis. Since the early 1970s, Cambodia has been the scene of international and civil conflict. Thousands of land mines have been placed by both government and resistance forces along waterways, roads and paths, rice paddies and around villages. Most are still in place, ready to add to the huge number of mine-related casualties already experienced by Cambodians. In the early 1990s it was estimated that of a population of nearly eight and one half million, 35000-36000 were amputees. This gives Cambodia the distinction of having the highest percentage of physically disabled individuals of any population in the world, exceeding even Afghanistan (Asia Watch, 1991). A study of the human suffering in Mozambique caused by landmines indicated 10 000 casualties and 8000 surviving amputees. In addition, mines have had a devastating effect on the social and economic status of the country. The report esti-

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mated that it would take decades to de-mine the country (Human Rights Watch/Africa, 1994). The details of the impact of landmine use in each area of the world will be different, but the lessons from these countries' experiences can help to predict and explain what other nations may also experience. One common factor for affected countries is that they have endured many years of warfare, usually internal conflicts involving guerrilla factions, or occupation by foreign governments. These countries are nearly all underdeveloped, with fragile or non-existent infrastructures. The years of warfare have already taken their toll on the resources of the government, resulting in inadequate education, transportation and health care systems. Medical services are usually particularly affected. Medical supplies and facilities are scarce or unavailable; personnel have been killed, injured or exiled. Even after the wars are over, the need for health services is far greater than in a country of comparable size which has not experienced war and occupation. , Continuing injuries caused by landmines place an added and sometimes unbearable burden on medical services which are already inadequate. A society at this level of development is not equipped to deal with a disabled individual, let alone provide educational or work opportunities. For example, Crawford and Amro (1996, p. 129-130) describe the present situation in Palestine: 'Occupied Palestine could be described as totally inaccessible to people with disabilities. Even the schools are not accessible; therefore thousands of Palestinians are denied education ..... For those students with disabilities who can manage to get to school, there are few qualified teachers with the experience or training to deal with them.'

Individuals in affected countries typically have had to endure refugee status, sometimes for many years. In many cases families have been separated and family members have been killed under circumstances that traumatized the survivors. They have lost access to their original homes and villages, their businesses or farms, their domestic animals and their formal and informal support systems, either permanently or for extended periods. Poverty, unemployment, undernourishment,

illiteracy and lack of educational opportunities, inadequate housing and unhealthy living conditions are the norm. These experiences and conditions would challenge even the most hardy and resilient individuals and societies. Add to the scenario an environment purposefully made so hostile and dangerous by hidden land mines that such normal activities as gathering wood, fetching water, herding cattle, planting a crop, walking to the market in town, or playing in one's own yard, as Nazar was doing, frequently results in instant death or dismemberment. The impact of landmines on the ability of individuals and societies to rebuild normal lives and reestablish basic infrastructures is disastrous. The presence in the society of thousands of disabled individuals who are often unable to contribute to their family's or nation's rebuilding efforts, and who frequently require assistance and services that consume scarce resources, exacerbates the disaster. De-mining is an obvious solution to the problem and threat of mines presently in place. Mine detectors can be used to locate land mines, and a de-mining expert can often safely disarm and remove a mine, one at a time. Mines that are buried in rice paddies, other wet lands, and jungles present special problems and dangers, and may require drainage or eradication of vegetative growth before they can be located and removed. De-mining personnel are expensive and scarce; local inhabitants may be willing to undertake the task for their local area, but often lack the equipment and training to be effective. Frequently, they become mine victims themselves. Countries which are most in need of de-mining services are least able to afford them. Clearly, the exposure of civilian populations to landmines grossly violates the most fundamental human rights. The use of land mines is far more effective in destroying the peace and security of a society or an individual than is a well-armed enemy, because there can be no peace treaties with landmines. They are not able to discriminate between an enemy soldier and a child, a grandfather, a pregnant woman, a relief worker or a priest. Landmines have the potential to outlive the men who planted them; they will remain in

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place, active, ready to kill or maim, for decades after the wars they symbolize are officially over. Their presence negates the conditions of any cease-fire. The land mine crisis has not gone unrecognized by the international community. The International Campaign to Ban Landmines (lCBL) is a coalition of non-governmental organizations including the Handicap International, Human Rights Watch/Arms Project; Medico International; Mines Advisory Group; Physicians for Human Rights; and the Vietnam Veterans of America Foundation. The ICBL is waging a well organized campaign to collect support for a world-wide ban on anti-personnel landmines via a United Nations resolution. As of September, 1996, over 40 nations have indicated that they favor a total ban on anti-personnel landmines. Among these are Austria, Belgium, Canada, Denmark, France, Germany, the Netherlands, Norway, Portugal, Switzerland and Australia (Goldfeld, 1996). Unfortunately, neither the United States nor the United Kingdom is among those supporting a total ban, and without the support of the US, it is unlikely that the United Nations will be able to pass a resolution implementing such a ban. The United Kingdom has recently agreed to support efforts to reach a complete international ban, and to destroy half of its stockpiled anti-personnel mines, to have a complete moratorium on their export, and to use them only in exceptional circumstances. In the United States, Vermont Senator Patrick Leahy has led an effort to ban the use of anti-personnellandmines and prohibit the sale or transfer of US military equipment to countries that export landmines. Even with exceptions for anti-tank mines and for situations the President considers international emergencies, the US has been reluctant to agree to such a ban, or to ratify a United Nations resolution completely prohibiting the use of anti-personnel mines. Nevertheless, support for national and international bans continues to grow and in October, 1996, Canada hosted an international conference, 'Towards a Global Ban on Anti-personnel Mines'. The goal of the conference was to develop a strategy which

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would lead to a complete, international ban on the use of anti-personnel landmines. Many health professionals may never be confronted with the necessity of providing therapy for a landmine victim. Most of us work in western, industrialized countries where our practices are well insulated from the effects of war. On the rare occasions when we do treat a survivor of a landmine explosion, our primary foci are the physical and psychological status of the patient, not the arms industry and international law. Yet it must be argued that health professionals have the responsibility to be informed about the causes of the global epidemic of landmine casualties, just as we must be informed about the causes of the AIDS epidemic. And our responsibility does not stop with educating ourselves. Recognition of the global landmine crisis as an epidemic obligates the medical community to look beyond the treatment of individuals after they have been affected, since post-hoc treatment alone is not adequate to prevent future injuries. Indeed, the medical communities of affected nations, even with the assistance of the international medical community, can scarcely provide the rehabilitation required for those already affected, to say nothing of those who will be the future victims of landmines already in place, estimated to be between 15000 and 26000 each year. Clearly, prevention of additional injuries is essential, as is prevention of future HIV infections. Giannou and Geiger (1995), medical doctors themselves, are encouraging the medical community to adopt the public health model in respect to the anti-personnel landmine epidemic. This model might include education of the public about the severity of the problem and methods of prevention; appropriate treatment of those affected including proper evacuation and emergency care procedures; and rehabilitation for survivors including prostheses appropriate to the individuals' ages, lifestyles and environments, as well as therapy that addresses their psychological as well as physical problems. Since prevention is as much our responsibility as is acute care and rehabilitation, we as health care professionals must make it our responsibility to work for the prevention of the use of anti-per-

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sonnel landmines, which are the sources of this global epidemic. If the prospect of taking on this role seems daunting to you, if you feel unprepared for the task, consider the words of Elise Boulding (1988, p.75): 'We haven't yet realized the relevance of what we already know, and the possibility of applying it to the international order. All the traits that make our local and national communities work well - problem-solving competence, skills of coping with stress, confidence in our own integrity, respect for others, and the use of our imagination - are also traits that need to be developed and nurtured in our transborder interactions. These are craft skills. The future social order will require the best of human crafts and skill and will draw on everything we know in every sector of society, every profession, every specialization. We ourselves must bring the new forms into being.'

Nazar's case story, which began this article, is in many ways typical of the experiences of most landmine-injured civilians. He is a refugee, a child, who was engaged in normal non-military activities near his own home at the time of his injury. He suffered multiple injuries and has had multiple amputations. His family, although immensely supportive and devoted, does not have the resources to provide him with the most effective rehabilitation, prostheses and other medical equipment, nor does his community. His home and community environments are not designed to be userfriendly for handicapped individuals. There are also many parts of Nazar's story which are unique. It is unusual for a Palestinian in Gaza to be the victim of a landmine explosion. In my experience there, I have seen many spinal cord and head injuries related to the occupation, but Nazar was the only landmine victim I treated. Nazar was also very fortunate that the Bethlehem Arab Society Rehabilitation Centre was available for the first part of his post-amputation rehabilitation. In 1990 there were no rehabilitation facilities in Gaza, and only one other in the West Bank which served only spinal cord injured patients. In most underdeveloped, war-ravaged countries where land mine injuries commonly take place, rehabilitation facilities are primitive or nonexistent. Nazar was even more fortunate to have at-

tracted the attention of the head of an American organization which arranged to have him sent to the US, to be fitted for prostheses and provided with both rehabilitation and education. He was in the US for more than 2 years. At the last report I had of him, his rehabilitation had been very successful and he was a relatively happy, well adjusted preteen. He was sent back to the West Bank to continue his education in a residential school there, and presumably was able to see his family frequently. A relatively happy sequel, although obviously not the end of Nazar's story. He still has the challenge of being a young, triple amputee male from a poor refugee family living in an environment that is still very hostile. His road will be long and painful. Acknowledgements

The author would like to thank Rick Sollom and Gillian Webster of Physicians for Human Rights, Boston, MA for providing many of the references for this article. References Crawford, J. and Amro, Z. (1996) Violence, disabilities, and health care. Int. Relations J. XV, (2), 114-133. Doucet, I. (1993) The cowards' war: land mines and civilians. Med. War 9, (4), 304-316. Fanon, F. (1963) The Wretched of the Earth: New York: Grove Press. Garachon, A. (1993) ICRC rehabilitation programmes on behalf of war disabled. In: Report of the Symposium on Anti-personnel Mines. Montreux, Geneva: ICRe. Giannou, e. and Geiger, H.1. (1995) The medical lessons of land mine injuries. In: Kevin, M. and Cahill, e. (Eds.), Clearing the Fields: Solutions to the Global Land Mines Crisis. New York: Basic Books and the Council on Foreign Relations, pp. 138-147, Goldfeld, A. (1996) A weapon we can live without, The Boston Globe, September 22, 1996. Human Rights Watch/Africa (1994) Land Mines in Mozambique. New York: Human Rights Watch. International Campaign to Ban Landmines (1996) Anti-Personnel Mines Fact Sheet. Washington: International Campaign to Ban Landmines. Velin, J. (J 995) UN nations hit potholes on path to land mine ban, Christian Science Monitor, September 27, 1995. Webster, D. (1994) It's the little bombs that kill you, New York Times Magazine, January 23, 1994.

Anti-personnel landmine injuries: a global epidemic.

Injuries and fatalities caused by anti-personnel landmines have become a global epidemic. Over 250 000 people alive today have been injured by landmin...
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