Victim assistance

As mentioned above, the Ottawa treaty requires that international assistance be provided to mine victims, with the specific possibility of channelling such assistance through the components of the International Red Cross and Red Crescent Movement. No one knows exactly how many mine victims there are already in the world, though estimates run into the hundreds of thousands.

THE HUMAN IMPACT

By using data gathered by ICRC hospitals and limb-fitting centres in several countries, referring to internal reports, and extrapolating from published epidemiological studies, the ICRC estimated in 1995 that, on average, 24,000 people were being killed or injured by landmines every year worldwide. However, no one really knows the total number of casualties.

Statistics gathered by the ICRC in 1997, in Afghanistan, paint a bleak picture. The ICRC admitted over 1,900 mine-injured patients at seven of Afghanistan’s hospitals in one year alone. Bearing in mind that only a minority of victims would reach these hospitals in Afghanistan, and that Afghanistan is just one of the many countries affected by mines, the number of people killed or injured by landmines every year must be far greater than the 24,000 previously suggested.

In Bosnia and Herzegovina, another severely mine-affected country, in the six months immediately after the war ended, an average of 50 people were killed or injured by mines every month. Since mid-1996, this number has gradually decreased. From August 1996 to August 1997, the ICRC estimates that there were 30 to 35 casualties per month. The typical mine victim in the post-conflict period is the male farmer.¹¹

¹¹ The silent menace Landmines in Bosnia and Herzegovina, published by the ICRC in collaboration with UNHCR, Geneva, 1998

The aim of direct assistance for mine victims is to enable amputees to become fully integrated and productive members of society once again. To meet this challenge means providing the requisite transport, first aid, surgery, safe blood for transfusions, prostheses, psychological counselling and social services.

Mine victims cannot receive the care they need if basic health facilities and social structures are inadequate, have been disrupted or have collapsed altogether owing to poverty or war. A strong commitment must therefore be made to multilateral and bilateral partnerships aimed at funding community-based reconstruction programmes in post-conflict societies.

PROFILE OF A MINE VICTIM Name: Dervisa Covic Age: 51 Sex: female Status: civilian and displaced person Place of injury: Grivici, Bosnia and Herzegovina Figure (Ian Woodmansey/ICRC) Dervisa’s house on the outskirts of Sarajevo was badly damaged in the war. During a visit to the ruined house on 18 August 1996, Dervisa was picking plums in the garden when she stepped on a blast mine. Neighbours who witnessed the accident rushed to her rescue. Hearing the explosion, her husband, who was in the house at the time, told his son: “Don’t worry, it isn’t your mother; I walked that way yesterday and there are no mines”. Fully conscious, Dervisa applied her headscarf to her leg as a tourniquet and shouted over to her neighbours: “I’ve lost my leg”. They rushed her by car to the nearest health centre where she received first aid. She was then transferred by ambulance to Kosevo hospital in. Sarajevo, where she was operated on within 20 minutes of arrival. Her lower leg was amputated. After four days her wound was closed and within two weeks she left hospital. She received no further treatment, rehabilitation or therapy. In May 1997, Dervisa bought an artificial leg from a prosthetics company in Sarajevo. Having tried unsuccessfully for months to get a prosthesis, she was eventually promised one through a personal contact. However, it soon became clear that it would cost her US$ 1,200. Dervisa and her husband turned to friends, relatives and former colleagues to raise the necessary funds. Her artificial leg has changed her life. At first, she found it painful to wear, but now she declares that she couldn’t live without it. She doesn’t suffer from any flashbacks or nightmares, but does have terrible phantom pains in her leg when it rains. At times they are so bad she cannot stop crying. Prior to her accident Dervisa used to work a lot in the garden and the fields. Now she can no longer participate. She receives a disability benefit of US$ 9 a month. She feels strongly about the use of mines in her country: “They must all be removed. I’ve been injured but others shouldn’t be. If I could, I would pay deminers myself to remove them all”. Printed with permission.

MEDICAL CONSEQUENCES

Anti-personnel mines cause severe injury. The injuries resulting from mines can lead to death, amputation, severe disability and psychological trauma. Treatment of mine victims requires rapid evacuation, the effective application of first-aid measures and time-consuming surgery. ICRC surgeons who treat such injuries daily consider them to be among the worst of war injuries and the most difficult to treat.

a) Diagram showing how an injury, apparently confined to the foot, is associated with proximal compartmental muscle damage.

b) Diagram of explosive injury with traumatic amputation of the lower leg. The mechanism of proximal compartmental injury with skin and gastrocnemius preservation is shown.

c) Diagram showing how, when the skin has returned to position, the extent of proximal damage is hidden.

MOST COMMONLY OBSERVED PATTERNS OF INJURY12 · Pattern 1: caused by a blast mine, results in the foot or leg being blown away (traumatic amputation), with varying degrees of injury to the other leg, genitalia, arms or chest. Very few survive blast mines with a larger explosive charge. · Pattern 2: caused by a fragmentation mine, or wounds similar to those caused by other fragmentation devices (grenade, mortar shell, etc.); can affect any part of the body. · Pattern 3: caused by accidental detonation whilst handling a mine, results in severe wounds of the hands, arms and face and, in some cases, blindness.

¹² The worldwide epidemic of landmine injuries The ICRC’s health-oriented approach, ICRC, Geneva, 1995

Evacuation

Many victims are alone and in isolated places when injured. They may be collecting wood or fetching water, working in a rice paddy or herding sheep. Victims lie for hours with shattered limbs waiting for help and many die before help can arrive. When help does come, the rescuers must take care not to put their own lives at risk. Evacuation may involve transport without treatment or anaesthetics, and may mean a bumpy ride in a truck or horse-drawn cart through mountains, desert or paddy-fields. Based on data gathered by ICRC hospitals, it is estimated that only 25% of mine victims arrive at hospital within six hours of injury; 15% travel for more than three days to reach the hospital.¹³

¹³ R. M. Coupland, Assistance for victims of anti-personnel mines Needs, constraints and strategy, ICRC, Geneva, 1997

The most ordinary of activities may put civilian lives at risk.

Stefan Trappe/ICRC

First aid

The most effective way of preventing later complications, disability and death is the application of prompt first-aid measures: stopping the bleeding by applying a firm dressing, immobilizing wounded limbs and relieving pain. Care must be taken not to misuse first-aid measures: a tourniquet applied too high on a limb or left on for too long can mean that a traumatic amputation of the foot results in a surgical amputation of the whole limb. Most of the ICRC’s hospitals are served by first-aid posts where local employees and soldiers receive basic first-aid training.

Surgery

Mine wounds require skilled surgery, large amounts of blood for transfusion, antibiotics and other drugs, and prolonged hospitalization. The surgeon’s task is to remove dead and contaminated tissue, as well as any foreign materials (dirt, plastic casing from the mine, bone) that may have been driven into the wound, and in many cases to amputate severely damaged limbs. Few surgeons in civilian practice have experience and skill in dealing with mine injuries, as they are rarely seen. The ICRC has produced teaching videos and brochures on the proper surgical management of war wounds for interested surgeons.

SURGICAL DATA · Anti-personnel mines account for a disproportionate number of amputations amongst war-wounded: 82.5% of all amputations performed in ICRC hospitals are for victims of landmines.14 · The average hospital stay for patients with bullet wounds is 18.1 days; for a patient having sustained injuries from a buried mine it is 32.3 days.15 · While patients with a bullet wound will require on average 1.9 operations and 0.5 units of blood, patients with a blast mine injury will require 4 operations and 3.2 units of blood.16 · The cost per patient per day in an ICRC hospital is around US$ 120 (excluding salaries of expatriate staff). Therefore, the average cost of treating a mine injured patient is between US$ 3,000 and US$ 4,000.17 A young woman with blast injuries is admitted to Kompot Hospital, Cambodia. Serge Corrieras/ICRC Double leg amputation at an ICRC hospital in Kabul. Robert Semeniuk/ICRC

¹⁴ A Molde, H Samnegard, Med. Orth. Tech, “Amputationen unter Knegsbedingungen - Erfahrung des Internationalen Komitees des Roten Kreuzes”, 1997, Vol. 117, pp 205-208

¹⁵ R.M. Coupland FRCS (ed), The SIrUS Project Towards a determination of which weapons cause “superfluous injury or unnecessary suffering”, ICRC, November 1997.

¹⁶ R.M. Coupland, Medicine and Global Survival, “The effect of weapons: Defining superfluous injury and unnecessary suffering”, 1996, Vol. 3, p A1.

¹⁷ Ibid.

PHYSICAL REHABILITATION

Many mine victims do not have access to physical rehabilitation facilities. Prostheses are expensive and the cost of the technology used in wealthier countries to manufacture them is beyond the means of war-disabled victims, and of the authorities, in most post-conflict countries. Each prosthesis must be individually fitted and replaced every three to five years; a child’s artificial limb must be replaced every six months. The cost of a prosthesis varies greatly from country to country. In countries where average per capita income is about US$ 10-15 a month, it is easy to understand why crutches are all people can afford.

Since 1979, the ICRC has been assisting mine victims by establishing and providing support for prosthetic workshops and training local technicians in the production of artificial limbs. The ICRC’s main goal is to set up rehabilitation programmes tailored to each country’s social and economic needs, which can in the long run be taken over by a local organization or a governmental body. To eliminate the need to import expensive ready-made components from abroad, special moulds have been developed for the local or regional manufacture of prosthetic components using polypropylene, a thermoformable plastic. The advantage of this system is that it gives the amputee a light and individually-fitted artificial limb. It is cheap and can be readily replaced or repaired. Polypropylene is also easy to transport and work with, and can be recycled.

Through the use of polypropylene, amputees are given light and inexpensive new limbs.

Luz Luzemo/ICRC

ICRC PHYSICAL REHABILITATION PROGRAMMES · In early 1999, the ICRC was running 25 physical rehabilitation programmes in 13 countries: Afghanistan, Angola, Azerbaijan, Cambodia, the Democratic Republic of the Congo, Georgia, Iraq, Kenya, Rwanda, Sri Lanka, Sudan, Tajikistan and Uganda. Twenty-four ICRC projects in 12 other countries have now been handed over to local or NGO control. Many of these still receive financial and technical support from the ICRC. · Between 1979 and the end of 1998, the ICRC manufactured more than 130,000 prostheses, over 175,000 pairs of crutches and close to 9,000 wheelchairs. · In 1998 alone, the ICRC manufactured over 11,500 prostheses; of these, more than 6,500 were for mine victims. During the same year it produced over 17,200 pairs of crutches and more than 700 wheelchairs. · Many amputees find employment in ICRC limb-fitting centres. This not only helps them regain their dignity but also has a positive impact on patients who are still coming to terms with their disability, as they are able to see with their own eyes that life can go on. In the Kabul centre, 60% of the workers are disabled.

PSYCHO-SOCIAL ASSISTANCE

In most settings, psychological assistance and social integration of mine victims have largely been neglected. Many mine victims are unable to find employment after their accident and are forced to turn to begging on the streets to support their families. In most agrarian societies, the loss of a limb makes it impossible for a person to plough fields, carry heavy loads or help in other ways to contribute to the household income. Divorce and social ostracism may ensue, and in societies where cultural and religious stigma may be attached to amputees, young, female mine victims may have substantially reduced chances of marrying as a result of their disability. Child mine amputees may be prevented from going to school or may be at too shamed to leave the house.

Figure

There is therefore a need to reinforce community based support for the recovery and reintegration of the survivours of mine blasts of the survivors of mine blasts. Such support should include vocational training and psycho-social assistance, where needed, to help landmine survivors to become self-supporting and should aim to tackle problems of discrimination faced by amputees.

VOCATIONAL TRAINING IN CAMBODIA Banteay Prieb, or the Centre of the Dove, in Kandal Province, Cambodia, is a vocational skills centre run by the Jesuit Refugee Service for people disabled by landmines, war, polio and accident. It is a place where the disabled can tell their own story, gather strength and hope, and learn a new skill that will enhance their sense of dignity and self-worth and increase their chances of finding permanent or part-time employment. The underlying philosophy of the centre is that of normalization, focusing on abilities rather than disabilities. At the centre, students live together in small cottages in groups of eight and cook and care for themselves. Training in agricultural skills, carpentry, electronics, machine repair, sculpture, sewing, weaving and welding is provided. Wheelchairs and furniture are manufactured by the disabled. The centre runs a three-month intensive programme for students lacking basic literacy and numeracy skills. Shorter courses are held in agriculture and business management. Since the first students graduated in November 1992, an average of 70 people a year have completed the various training courses. On leaving the centre, some students have set up their own workshops, some have found full-time employment, others have returned to their rice fields equipped with new skills to mend and manufacture new tools for their work, and others have had to take whatever job has come along.

CONSTRAINTS

During or after a war, the treatment and rehabilitation of mine victims will in most cases reflect the general availability or lack of basic health and social services for all. Much needs to be done to reinforce these services in mine-infested countries, particularly where there are large numbers of victims, as the care of amputees places enormous demands on medical resources and often overburdens an already fragile health-care system. In other words, the rehabilitation of mine victims depends on the rehabilitation of the country’s health and social sectors. Security is another major constraint. Many organizations will not work in certain areas because they are unwilling to risk the lives of their staff. Lack of cooperation from the political and administrative authorities may further hinder the work of those wanting to assist victims. The availability of donor funds may be conditional on agencies working in one area rather than another, or on treating one specific category of victim. These are just some examples of the numerous constraints that may result in mine victims receiving inadequate care, an issue that must be addressed urgently and coherently.

A further obstacle to dealing with the human and socio-economic consequences of landmines is the lack of hard data available on the severity of the mine problem. The ICRC believes that there is an urgent need to standardize and systematize the collection of data by the various players concerned (UN agencies, non-governmental organizations, the ICRC and political and military authorities). To this end it has proposed an integrated approach towards the analysis of data, a “Mines Information System”, to allow for the planning of priorities in any country, one province and one district at a time, and enable operational programmes to be implemented effectively. Addressing these constraints is also a prerequisite for implementing effective preventive measures, such as mine awareness and mine-clearance programmes.

PRINCIPAL FACTORS DETERMINING THE SEVERITY OF THE MINE PROBLEM18
· Mortality and morbidity · Capacity of the health care system to deal with the needs · Extent of the civilian areas mined: residential, agricultural, industrial · Percentage of population affected in socio-economic terms · Public or community programmes disrupted because of mines	· Population density compared to density of mines laid · Transportation infrastructure affected · Indigenous demining capacity · Security concerns · Method of mine laying

¹⁸ The Mines Information System (MIS) and factors determining the seventy of mine infestation, ICRC, Geneva, 1997.

Figure

Teun Anthony Voeten/ICRC