The provision of assistance to mine victims
OAU conference on a landmine Free Africa. Presented by Dr Chris Giannou, Health Operations Division, International Committee of the Red Cross, Johannesburg, 19 May 1997.
Algeria, Angola, Botswana, Burundi, Chad, Congo, Djibouti, Egypt, Eritrea, Ethiopia, Guinea Bissau, Liberia, Libya, Malawi, Mali, Mauritania ... No: this is not a roll-call of the member states of the Organisation of African Unity. Morocco, Mozambique, Namibia, Nigeria, Rwanda, Senegal, Sierra Leone, Somalia, Sudan, Swaziland ... This is a list of regions of the African continent which are or have been polluted to a varying extent by landmines. Tanzania, Tunisia, Uganda, Western Sahara, Zaire, Zambia, Zimbabwe. Many of these mines date back to World War II, others to the struggle for independence and the wars of decolonisation, yet others to post-independence conflicts. It would be simpler to mention the handful of African countries not affected at some time in their history by the scourge of landmines.
The eras involved in these examples may well be different; the circumstances different; the politics different. The appalling humanitarian cost is the same, a legacy of lost and broken lives and limbs: soldiers and combatants, farmers and shepherds, women and children, lose an arm or a leg; are physically, psychologically and socially scarred and mutilated. Entire societies, all too often already poverty-stricken, have become economic invalids struggling for rehabilitation and reconstruction. Communities remain impoverished and malnourished, fields and villages empty. The normal activities of life -- work, travelling and play -- become fraught with danger because of the presence of anti-personnel mines.
War is ugly. War wounds particularly so. But there is something especially horrendous about wounds due to anti-personnel mines. A colleague of mine, a surgeon working in an ICRC hospital o n the Thai border of Cambodia, put it succinctly: " Whenever we were called in for an emergency case, we prayed that it would not be a mine injury, not another child or woman or peasant terribly mutilated " . It was the war-hardened ICRC medical staff who prompted our organisation to adopt its public stance against anti-personnel mines, a stance unprecedented since shortly after World War I and the ICRC position against poison gas as a weapon of war.
We have come to describe the present situation as a world-wide epidemic of anti-personnel mine injuries. This is a classic example of a pathology which is not simply biological in scope; like all epidemics, in their causes and consequences, it is a social, economic, health and political event which particularly targets the innocent, the weakest, and the least prepared.
Environmental prevention includes the political will to decide to ban anti-personnel mines, as well as marking mined areas and humanitarian mine clearance. Public education to change high-risk behaviour involves mine-awareness campaigns. Curative therapy for the victims extends from the evacuation of the wounded all the way to the discharge from hospital. Rehabilitation and social reintegration involves physiotherapy, the fitting of an artificial limb when necessary, and vocational training. Most important: it is anti-personnel mines which must be stigmatised and not the victims.
The needs are great, and the costs greater still. The task of clearing the world of the existing tens of millions of landmines is already daunting, and many more are being laid than are being cleared. But mine clearance is essential and the international community can undoubtedly do a great deal more to clear the scourge of mines from afflicted societies and communities. In addition, at a local level, mine awareness programmes -- equipping individuals and communities with the information and skills they need to minimise the risk of injury - can help to reduce mine casualties while allowing people to get on with their daily lives but these injuries will still occur. Fields must still be cultivated, water drawn and firewood collected, even if that sometimes means entering a mined area.
Thus, for the foreseeable future, the global number of mine injured and mine amputees will continue to increase. The ICRC database of mine incidents has registered more than 9,000 victims since January 1995 in more than 40 countries. For African countries alone, 234 separate incidents (representing 36% of the total number of incidents in the database) were registered, causing 330 killed and 749 injured. It is impossible to know what proportion of all victims are registered; they are certain to be only a small minority; many will die in the fields and mountains before they can reach a health facility. Access to the injured thus remains an important obstacle to their receiving assistance. Mine-injuries remain a large-scale, scattered and largely unattended problem. Accurate collection of data is therefore the first step in addressing the mines epidemic. Improving the availability and flow of reliable data is crucial not only to helping to meet the needs of the victims but also to determine priorities for mine clearance and community mine awareness activities.
Survivors of mine incidents typically suffer from three patterns of injury. Those who step on blast landmines usually lose a foot or a leg and suffer severe injuries to the other leg, genitalia and arms. Survivors of explosions of fragmentation mines, on the other hand, receive wounds similar to those from any other fragmentation device; such wounds can affect any part of the body. The third pattern of injury occurs where mines are accidentally detonated, either by deminers or by children mistaking mines for toys. This pattern inevitably involves severe wounds to the hands and face.
The medical and social management of landmine injuries taxes the public health system in every respect and at every level. Once a person has been injured by a mine the first priority is to get him or her safely out of the minefield -- the rescue effort puts the rescuers in danger -- and to stop the bleeding. This'first aid'can usually be achieved by the application of a firm dressing, but a traumatic amputation may require some sort of tourniquet which must be applied as low as possible and released at regular intervals. 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 more than six hours.
The earlier the wounded person reaches a competent medical facility the better. Transportation in many parts of rural Africa is inadequate at the best of times, during the rainy season it can be almost impossible. Again, many will succumb before reaching a clinic or a hospital.
Mine victims will often need an intravenous infusion. Early administration of simple antibiotics can help to prevent the onset of serious infection such as gangrene. In addition to antibiotics, measures must be taken to prevent tetanus. Active immunisation is not universal in Africa, especially in rural areas, and the presence of landmines can, and, in Mozambique and Angola, effectively has, hampered the work of mobile vaccination teams.
As soon as the patient reaches a hospital certain routines must be followed. The patient must be registered and, if possible, the details of the incident recorded. This is often the most important and most overlooked step in data retrieval. The patient will need to be washed with simple soap and water, if his or her condition permits, especially if injured by a buried anti-personnel mine. Blood tests should be taken both to estimate the patient's haemoglobin value and to establish the blood group. Befo re going to the operating theatre, the patient should be assessed by the surgeon and the anaesthetist.
The surgical management of mine-injured patients can be a challenge to even the most competent surgeon; it is difficult and time-consuming. The blast of the mine tears through tissues, it burns and coagulates; it drives soil, grass, gravel, metal or plastic fragments of the mine casing, and pieces of shoe and shattered bone of the foot, up into the leg, penetrating between tissue layers and causing irregular contusions and contamination of the muscles. This renders the required level of surgical amputation higher than is apparent to the inexperienced eye. Wounds such as these are not seen in civilian practice and they do not correspond to any of the modern surgical specialities. The surgeon should therefore have a solid background in general surgery, The effects of anti-personnel mines are a relatively new subject in the medical literature. Until recently, the injuries inflicted by mines were considered to be the same as any other caused by conventional weapons. However, mines inflict a much more severe injury owing to the specific design of the weapon; the result is specific medical needs. Thus, the treatment of mine victims in ICRC hospitals has become a speciality in its own right. As a matter of policy ICRC surgeons work with a basic level of technology and follow a number of well recognised basic principles of wound surgery.
All war wounds are considered to be dirty and contaminated. Dead and contaminated tissue must be excised, leaving the wound open under a secure dressing. Closure of the wound skin edges with sutures takes place only after four or five days (this procedure is known as delayed primary closure). Large wounds may require skin grafts. A wound with a fracture is managed in the same manner and the fracture immobilised. A surgical amputation either of an entire limb that is beyond repair, or at a point above a traumatic amput ation, should be carried out according to the same principles and closed after a delay. Certain amputation techniques, known as myoplastic amputations, are particularly appropriate for mine injuries. The ICRC has produced teaching material to pass on this experience to both military and civilian surgeons.
The severe nature of the injuries caused by mines and the lengthy time mine victims spend in hospital divert already limited resources from the needs of others. Moreover, the additional needs of mine victims may not be recognised by authorities or aid agencies because, compared with battle casualties, mine victims tend to arrive at a hospital in small numbers over a long period. These patients spend more time in hospital, require more operations, and greater quantities of blood transfusions. Blood is essential for the treatment of severe mine injuries. Those undergoing surgical amputation require the most. The ICRC has found that victims of blast mines require, on average, more than six times as much blood as those injured by bullets or fragments.
After any operation the patient must have at least 24 hours of close nursing supervision. Without this, surgery is dangerous. It is the nursing staff who are responsible for the efficient running of a hospital and who are most closely involved in patient care. To help other agencies, non-governmental organisations, and even Ministries of Health, the senior nurses who have worked in ICRC hospitals have written a book entitled " Hospitals for War Wounded " , to be published before the end of 1997.
The physiotherapy requirements of mine victims are unique. In the initial phase, the injured limb must be kept moving by passive movement and isometric exercises (though without interfering with the wounds). Patients must not be allowed to languish in bed, instead they must be up and about on crutches as soon as possible. As soon as the wounds are closed, active physiothera py should ensure a full range of movements and muscle strength, especially in the remainder of a limb above an amputation. A stiff knee, for example, may make the wearing of an artificial limb impossible.
After the surgical treatment and when all the wounds are healed and the swelling of the amputation stump has settled, the patient is ready to be fitted with an artificial limb. This is normally four to five weeks after completion of the surgical treatment. The fitting of an artificial limb is an essential part of the rehabilitation of a mine-injured amputee. In addition to ensuring mobility, it also constitutes the patient's first step in regaining their dignity, thereby facilitating the psychological recovery of the mine victim. There will be a life-long need for an artificial limb, and a for regular replacement.
The ICRC follows a policy of " appropriate technology " in its limb fitting centres. In many countries affected by mines, advanced modern technology may not be practicable or affordable. Thus, ICRC workshops now make artificial limbs out of polypropylene, a thermoformable plastic that is cheap, easy to repair or replace, and recyclable. In Colombia, for example, the introduction of polypropylene technology reduced the complete cost of an above-knee prosthesis from US$ 936 for the conventional method to US$ 390. The cost of physiotherapy, the prosthetic technician, psychologist and social worker remain constant in both cases; the difference in price is due entirely to the technique. Since 1979, the 45 ICRC rehabilitation projects in 22 countries have manufactured more than 100,000 artificial limbs for 80,000 amputees, as well as 140,000 pairs of crutches and 7,000 wheelchairs.
The ICRC puts great emphasis on the training of local technicians in the use of this technology; many mine amputees find employment in its limb-fitting centres. This ensures that the limb-fitting programme can continue on ce the ICRC withdraws. In recent years, partner organisations have been found to take over its programmes, the majority of them with some continued support from the ICRC. Most commonly, this is a governmental body in the country concerned, but some have been handed over to competent private foundations or to National Red Cross or Red Crescent Societies. Former ICRC projects include prosthetic centres in Chad, Eritrea, Mozambique, Sudan and Zimbabwe.
On-going programmes of the ICRC are to be found in Angola, and of the ICRC Special Fund for Disabled in Cameroon, Ethiopia, Ghana, Kenya, Nigeria, Mali, Malawi, Rwanda, Somalia, Somaliland, Tanzania, Uganda, Zaire, Zambia and Zimbabwe. The centre in Addis Ababa has become an important venue for training prosthetic technicians from African, Asian and Latin American countries, and a new, special prosthetic kit has been developed there comprising ready-made polypropylene components for 100 artificial limbs at a material cost of US$ 21 apiece.
Of course, appropriate medical interventions are not cheap. Hospital care, artificial limbs, lodgings, logistics and equipment must all be taken into consideration. The global cost each year of providing surgical care and physical, psychological and social rehabilitation to thousands of mine victims amounts to tens of millions of US dollars. All agencies, however, are chronically short of funds, and no one agency can attend to the needs of all.
An effective strategy for the provision of assistance to victims of anti-personnel mines -- to meet the needs of a maximum number of mine injured and mine amputees while allowing the rest of the population at high risk to feed, shelter and educate itself -- entails a decision-making process based on an accurate and objective assessment of the needs, available resources, and likely constraints. Priorities must be established. Needs are great, money is scarce. The mine-injured are one category of the wounded; the wounded are one category of all people needing assistance. There are many constraints and limitations to working in conflict areas. Access to the wounded and the needy is imperative; security, in a war zone, for the wounded and for health professionals is essential. In the last 12 months, the ICRC has experienced security-related tragedies in Burundi and in Chechnya; so, too, have other non-governmental humanitarian organisations and UN human rights observers.
Only a small proportion of the immediate needs are met by the ICRC and other agencies because:
- there is an obvious lack of funds for the projects already underway;
- the specific constraints, imposed in any given country affected by the mine problem, may be insurmountable;
- a comprehensive and co-ordinated approach to the problem of victim assistance with a long term view is lacking.
There are three reasonable and immediate goals for improved assistance for mine victims: first, that all mine victims should have access to adequate surgical care and rehabilitation; second, that the psychological and social needs of those injured and disabled by mines should be effectively addressed; and third, that the impact on the social and economic development of affected countries of the presence of mines should be measured.
As a first step towards meeting these three goals, the ICRC proposes a number of initiatives:
1) To be optimally effective, any concrete assistance in mine-affected countries must follow an integrat ed approach of possible measures: preventive, curative, rehabilitative. The ICRC believes that the key to improving assistance, to bringing more and higher-quality assistance to mine victims in the long term, is the structured flow and analysis of information about the entire mine problem in any given situation.
In each region or country affected by mines, there should therefore be a Mines Information System, to exchange data amongst governments and local authorities, the ICRC and National Red Cross and Red Crescent Societies, United Nations agencies and the network of international and local non-governmental organisations involved. Information gathering, pertaining to every aspect of assistance and prevention, and sharing, can then be used to better co-ordinate humanitarian activities and to best define needs and operational priorities: mine-risk education, mine clearance, access to victims, proper surgical care of the injured, rehabilitation and social reintegration.
A mine-afflicted society will go through various phases, of differing operational priorities, as it comes to grips with the challenges created by the presence of anti-personnel mines, as well as those created by the conflict and post-conflict reconstruction and reconciliation. Improved co-ordination will help to better define the priorities at any particular time, and allow for the most efficient allocation of resources, foreign and local, to the various aspects of prevention and assistance.
2) On a regional basis, regular training sessions should be organised for civilian and military health workers on appropriate treatment and rehabilitation measures for mine injured.
3) Greater efforts should be made to assess and then address the psychological and social needs of mine victims, aspects that are far too easily forgotten or ignored in the maelstrom of misery that permeates a post-conflict society.
4) All organisations, governments and agencies concerned with the mines issue should mobilise to improve access to mine victims and, where possible, to provide logistical support to victims so that they can be treated and assisted at appropriate medical and rehabilitative centres.
The ICRC is present at this conference not only to emphasise its continuing work and commitment to assist mine victims but also to establish how the necessary information exchange can take place in practice. No single agency or organisation can respond to the needs of the hundreds of thousands of mine amputees world-wide. But with better information, increased co-operation, greater resources, and the necessary political will, the provision and quality of assistance to mine victims will be greatly strengthened.
Ref. LG 1997-068-ENG