Antipersonnel mines: why a ban?
The effects of antipersonnel mines are relatively new concerns in the medical literature. Until recently these injuries were considered the same as any other injuries caused by conventional weapons. It is only when faced with the surgical task of treating large numbers of such injuries that the true situation is realised; these weapons inflict much more severe injury and are specifically designed for this purpose. This subject has been brought to greater awareness through the surgical hospitals of the International Committee of the Red Cross (ICRC), especially those hospitals which have dealt with the wounded of the conflicts in Cambodia and Afghanistan.
Injuries from antipersonnel mines
There are three patterns of injury seen in those victims who survive long enough to reach hospital. The first relates to standing on a buried antipersonnel mine; there is usually traumatic amputation of the foot or leg with severe injury of the other leg, genitalia and arms. This first pattern tends to be the most severe. The victim only survives to reach a hospital because the severe injury is concentrated on the extremity. The second pattern is seen when the victim triggers a fragment mine. If he or she is not killed immediately there are wounds as expected from any other fragmentation device; such wounds can affect any part of the body. Bounding mines which explode at waist height carry 100% mortality among those who trigger them. The third pattern relates to accidental detonation whilst handling a mine; it is seen among de-miners, those planting mines or curious children who pick up or play with mines. This pattern inevitably inflicts severe wounds of the hands and face, and the victim is often left blind.
Those injured by antipersonnel mines may be far from a hospital; first aid and rapid evacuation by ambulance is needed for the victim to benefit from surgery. The earlier that the patient receives intravenous fluids, antibiotics and surgery the better. In most countries affected by mines, the transportation time to hospital may be days or even weeks and, even then, only for those who can afford it.
The ICRC surgical experience
In the last ten years, hospitals of the ICRC have treated about 15,000 mine injured patients. This represents a very small number compared with the total from the conflicts concerned.
The surgery required to treat severe limb wounds effectively is difficult and many surgeons are unprepared or untrained for this kind of work when they first encounter mine injured patients. The central role of the surgeon is to remove all dead and contaminated tissue; this can be a difficult and time consuming operation. Recently, the Division of Health Operations of the ICRC has developed surgical amputation techniques that are appropriate for mine injuries and a mine injury database.
The key to successful management is the use of myoplastic amputation techniques for both above and below knee amputation combined with complete and careful excision of the wounds of other injured parts. Both the surgical amputation and the wounds must be closed after a period of four or five days – a technique known as ‘delayed primary closure’. Trying to take a short cut by suturing the wounds at the first operation always results in disaster; the wounds become infected, break down and result in the patient staying for a longer period in hospital and with greater residual disability. (The ICRC has produced teaching videos and books on this subject).
Mine injured patients in a hospital require intensive nursing care; there are always many dressings and the patients may stay in hospital for months.
Mine injured patients also require more blood for transfusion than other war wounded; providing safe blood in sufficient quantities needs a full laboratory service, otherwise there is a high risk of transmission of infective diseases such as hepatitis B and HIV.
In addition to the physical trauma, the psychological trauma of loss of limb, especially for young adults, is considerable. A reaction equivalent to a grief experience can frequently be seen. When the patient leaves hospital after successful surgical treatment, his or her problems of rehabilitation and, with this, reintegration back into society, are only beginning.
Rehabilitation of a mine victim who has lost a leg involves fitting a prosthetic limb. Each such prosthesis must be individually fitted, has a limited life and so must be replaced after some years, especially in children. In most countries affected by mines there is neither resource nor expertise to establish the specialised workshops that are necessary. The ICRC has 15 prosthetic projects which together manufacture 12,000 prostheses per year.
The problem of rehabilitation is more difficult if there is associated eye injury.
Economic and social consequences of mines
The presence of mines in a country affects every aspect of life there. Farm land may be inaccessible. It may be too dangerous to collect firewood in the forests. Roads or tracks may be impassable. A community dependent on agriculture can be devastated. Normal points for collecting clean and safe water for drinking are frequently mined.
Victims of antipersonnel mines who survive injury and treatment are usually left with severe disability; this can lead to unemployment, divorce, poor prospects for marriage and often becoming outcasts (avoided by other people). All such situations have been witnessed but have not been quantified. The full social and financial implications of thousands of amputee’s in a country are unknown. Studies are presently being undertaken to determine the full impact of mines on a country recovering from war.
To put this on a global scale, a country such as Afghanistan is said to have 8-10 million unmarked mines. Each mine costs about five dollars and, using current techniques of mine clearance, about US$1,000 to remove. At the current rate of clearance it will take hundreds of years to make the whole of Afghanistan safe. This problem is repeated in Cambodia, Angola, Mozambique, Kurdistan and Northern Somalia. It is present in a lesser form in Rwanda, Bosnia, the Caucasus, Laos, El Salvador and more than 50 other countries. In most of these countries there is no longer a war. Another estimate is that there are more than 100 million mines laid worldwide. It is then understandable that the President of the ICRC has called for a total ban on the production, export and use of antipersonnel mines.
Why a ban on mines?
The international campaign to ban antipersonnel mines, also stressed by the ICRC, has focused on the fact that they injure combatants (e.g., military personnel) and civilians alike without discrimination. The ICRC data shows that a significant proportion of people injured by antipersonnel mines are non-combatant women and children. This focus on non-combatants is of great importance; however, it has stolen attention from another group of potential victims of war, that is, soldiers, who are provided protection by international humanitarian law.
Article 35 of Protocol I additional to the Geneva Conventions of 1945 restates an accepted (customary) rule of humanitarian law: ‘It is prohibited to employ weapons of a nature to cause superfluous injury or unnecessary suffering’. This rule is intended to protect combatants. It is understood to prohibit the infliction, by design, of more injury than is needed to take a soldier out of combat. Would not most people, including soldiers, describe the effects of mines as superfluous and excessive to the military need?
There are many parallels between the epidemic of mine injuries that the world is witnessing now and other global health issues. Health professionals must not focus only on the treatment of a particular injury; they must also consider who is injured by mines and how these weapons inflict injury. For this reason, it is imperative that professional medical and surgical associations, as well as humanitarian agencies, call for a ban on antipersonnel mines.