FACE the VICTIMS

All the above people have been injured by a landmine.
Click on their faces to get the full picture.
All photographs by Tim Grant

Over the past decades there have been hundreds of thousands of people who have been injured by landmines. The majority of children injured die from the results of the blast - mainly because of their small bodies and closer proximity to the centre of the blast. Those people who survive the initial blast of a mine will most likely require amputations, long hospital stays and extensive rehabilitation.

Countries that have a significant landmine problem are usually also suffering many other major problems. They mostly have a poor economy; their social and economic infrastructure has been torn apart by the ongoing fighting; educational programmes have mostly ceased and professional people have long since left.

Military hardware is in the hands of armed gangs, poorly trained soldiers or even children. Among the weapons that remain when the war ends there may be thousands, if not millions, of anti-personnel mines. Health care is largely dependent on a variety of foreign aid agencies whose work is also hampered by the presence of mines. The local medical personnel is usually not well trained and the and supplies are lacking, limited or stolen and sold in the markets. When an area is too dangerous for the agencies to visit or work in people must then rely on their own resources to transport the injured to a nearby hospital, which in some cases may be days away. They are then expected to pay for their medicines and treatment, which most rural people cannot afford.

In Cambodia alone there are more than 35,000 people who have been injured by landmines. They estimate that the same number of those who survive actually die in the fields from loss of blood.

Many victims are alone in isolated locations when they are injured. They may have been collecting wood or thatch or herding animals. They can lie for hours waiting for help, with shattered bones and severe bleeding. First the rescuers must negotiate the minefield before they give any support to a victim. Once basic first aid has been applied evacuation may then involve a bumpy ride through mountains or jungle that may take days. ICRC statistics claim that only 25% of mine victims arrive at hospital within 6 hours of being injured with 15% having to travel for more than 3 days before they reach a hospital.

From an epidemiological perspective, landmines precipitate not only physical, but frequently mental illness as well. Landmines, just by their sheer number alone in a particular area, can influence the population's behaviour. This in turn may result in an overall deterioration of pubic health and other aspects of social well­being. Farmers with mines, or even only "perceive" the presence of landmines on their land will not be able to cultivate the land. This will lead to food scarcity and eventually even malnutrition.

A mine victim, besides suffering a physical injury, may also develop post­traumatic stress disorder (PTSD). There are three main symptom clusters in PTSD; (a) Intrusions, such as flashbacks or nightmares, where the traumatic event is re-experienced. (b) Avoidance, when the person tries to reduce exposure to people or things that might bring on their intrusive symptoms. (c) Hyperarousal, meaning physiologic signs of increased arousal, such as hyper vigilance or increased startle response. The onset of PTSD follows the trauma with a latency period which may range from a few weeks to months (but rarely exceeds 6 months). If treated a victim could recover in the majority of cases. In a small proportion of patients the condition may show a chronic course over many years and a transition to an enduring personality change.

If this boy had been injured by someone or by any other means there would be some sort of investigation. But because he was injured by a landmine there was no investigation and no-one will be brought to justice.

CHARACTERISTICS OF HIGH RISK PERSONS

According to the ICRC, those at highest risk of mine injury are the rural poor. Villagers foraging for firewood and food, herding cattle, or tilling their fields are particularly at risk. Similarly, when refugees and internally displaced persons return home they are at a greater risk because they are now less familiar with their former home environment which is now changed. In the case of some countries, young men and women are returning who were actually born in refugee camps and have never seen their parents' homeland before.

Young adult males make up the majority of people killed or injured by landmines. In Cambodia, 87% of surviving landmine victims are males over 15 years old, with a mean age of 28 years. In Afghanistan, 73% are males between ages 16 to 50, and 20% of the victims are male children. However, the age and sex distribution of mine victims who did not survive, is not clear from the studies reviewed because this information is rarely gathered in the field.

The ratio of death to injury is considerably greater in children, perhaps because their vital organs are closer to the blast and comparatively less protected, and their bodies are less able to withstand blood loss. Those at highest risk of the indirect health consequences of landmines (i.e., waterborne diseases, malnutrition, childhood infections, etc) are again mostly the disadvantaged poor, especially children.

NATURE OF MINE INJURIES

There are three main patterns of injury seen in those landmine victims who survive for long enough to reach hospital. Some mines, by design, kill the person who triggers them; this is the case for the bounding mines which will explode at waist height. Therefore, the proportion of wounded who die or who suffer amputation depends on the type of mine.

BASIC INJURY TYPES

1. The first injury type relates to stepping on a buried anti-personnel mine; that usually results in a 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.

2. The second pattern is seen when the victim triggers a fragmentation mine. Their bodies are peppered by hot razor sharp metal fragments. If he or she is not killed immediately they suffer from horrific wounds which can affect any part or all of the body.

3. The third relates to accidental detonation whilst handling a mine; it is seen among mine-clearers, those planting mines or curious children who pick up or play with mines. This pattern inevitably involves severe wounds of the hands and face.

The treatment of mine wounded people has become a speciality in its own right, although there are rarely specialised facilities available. The doctors work with a basic level of technology and are expected to provide a standard that is the absolute minimum for both effectiveness and safety. Landmine injured are not the same as any other injuries caused by conventional weapons. Mines inflict a much more severe injury owing to the specific design of the weapon with the victim suffering a lifelong disability.

The type of lifestyle an amputee will lead will depend on the severity of their injury. If they have only lost one leg below the knee (BK) then, with the proper prosthetic leg, they will be able to return and carry out most of the same psychical activities as they could do before the accident. This will include walking; running; climbing; planting rice; playing sport, etc. After they have practised their walking and manage to do so without a limp there may be little outward signs of the amputation.

A MINE INJURY
The diagram below graphically illustrates what can happen when
a person steps on a below ground antipersonnel landmine.
  1. The initial blast tears the foot apart, causing the foot and toes to peel away from the leg.
  2. The action of the blast forces dirt, mine fragments, bone and tissue to be driven deep up into what is remaining of the leg, the genitalia and torso.
  3. The outer leg skin returns into place and hides the full extent of the damage.

If they lose a leg above the knee (AK) or are a double amputee, then they can expect to be reliant on crutches or a wheelchair for the rest of their lives. This will be very hard, especially in countries like Cambodia, Angola and Mozambique where there are not many pathed roads or paths.

HOSPITAL PROCEDURES

The rescue and first aid procedure involves getting the wounded person out of the minefield and stopping the bleeding. Most bleeding can be stopped by a firm dressing or 'compress'. However, a traumatic amputation may require some sort of tourniquet which must be applied as close as possible to the wound. Many limbs are lost or have to be amputated higher than otherwise necessary because tourniquets are applied too high on a limb and left on for too long.


Many Landmine Awareness Programmes refuse to teach people to apply a tourniquet because of the large amount of victims losing more of their legs than necessary. NB. The more stump that's left provides more chances of leading a relatively 'normal' lifestyle.

Anti-personnel landmine injuries account for a disproportionate number of amputations amongst war wounded. Around 82.5% of all amputations performed in ICRC hospitals are for victims of landmines. The average hospital stay for patients with bullet wounds is 18.1 days, but for a landmine injury patient it is 32.3 days. Whereas a bullet wound patient requires on average 1.9 operations and 0.5 units of blood, landmine patients will require 4 operations and 3.2 units of blood.

The surgery of mine-injured patients can be a challenge to even the most experienced surgeon. Wounds caused by landmines are not seen in civilian practice and they do not correspond to any of the modern surgical specialities. They require skilled surgery, large amounts of blood for transfusion, antibiotics, other drugs and prolonged hospitalisation. All dead and contaminated tissue must be taken off, as well as any foreign fragments (such as dirt, plastic casing, bone, etc.) leaving the wound for four or five days before it is closed. A surgical amputation either of an entire limb that is beyond repair or at a point above a traumatic amputation needs to be carried out.



Cambodian landmine victims are usually smiling and ready to joke.

A NEW LIMB

After four or five weeks, when the surgical treatment has been completed, all the wounds are healed and the swelling of the stump has settled, the patient is ready to be fitted with an artificial limb (a prosthesis). The fitting of an artificial limb, which will be with them for life, is an essential part of the rehabilitation of a mine-injured amputee. In biological terms, it replaces that part of the organism responsible for locomotion and fulfils the same function as the lost part. It negates the need for crutches and thus frees the amputee's hands for the tasks of everyday living and helps in regaining some of their dignity lost.

Most limb-fitting centres rely upon "appropriate technology" as modern technology may not be workable in a country affected by mines. Initially they made use of locally available materials, such as wood, bamboo, leather and rubber, for the production of artificial limbs but discovered some disadvantages and problems. Some of these are a short life span, inferior quality materials, not comfortable and irritation of the wound. Nowadays most components of an artificial limb are made of polypropylene, a thermoformable plastic. The advantage of this system is that it gives the amputee a light and specially fitted leg. The new material is cheap; easy to transport; recyclable; has no waste; and can also readily be replaced or repaired.

For a young active person an artificial limb may need to be replaced every two years. Thus during one amputee's lifetime they may cost the community thousands of dollars. Of course a poor farmer, soldier or villager could not afford these costs, where a weekly wage may be as low of $10 US per week and must depend on international organisations to pay for and supply the materials and expertise.

The focus of rehabilitation has always been on the physical aspects of disability, which does go some way to supporting amputees psychologically. However, the need to furnish additional psychological assistance and help with finding a place in society is too difficult and has largely been neglected. Little is known about what happens to mine amputees after a fitting and then later in their lives. In some countries, amputees form gangs and turn on the society that has rejected them; in others, there is an unofficial family-or clan-based form of support that the handicapped people have to organise themselves.


According to data from an ICRC study in 1995, there are on an average 24,000 people being killed and injured by landmines every year world-wide.


References

Goliath: Landmines, the Invisible Goliath, Paul Hubbard & Joseph Wehland July, 1997, http://library.thinkquest.org/11051/history.htm

Coupland, Robin M., Assistance for Victims of Anti-persoinnel Mines: Needs, Constraints and Strategy. ICRC Geneva, August 1997.