Antipersonnel Land Mines, Hutson et al. 205

Antipersonnel Land Mines: Why They Should Be Banned H. Range Hutson, MD, Deirdre Anglin, MD, MPH, Jared Strote, MS

I Why has the issue of land mines reached center stage in the intema- tional community? This commentary discusses the historical background of land mines. the different types of land mines, the epidemiology of injury and death caused by land mines, the se- quelae of land mine injuries, and the socioeconomic and political ramifi- cations of land mine deployment. It further clarifies why it is essential to have a worldwide ban of the manu- facture, sale, and deployment of land mines, in association with the clear- ance (demining) of all existing mine fields in mined nations. We also sug- gest ways by which physicians can become involved in supporting the to- tal ban of land mines.

Due to the dedicated work of nu- merous nongovernmental and govem- mental organizations, the epidemic of injury and death from land mines in many developing nations has now reached center stage in the interna- tional community.'"

Historically, land mines were de- veloped during World War I to protect opposing armies from attacks by ar- mored tank^.^'^ Antipersonnel land mines were later developed to prevent the removal of antitank mines by rival combatants, as well as to protect the perimeter of an army from attacks by opposing soldiers.6.8 During World War I, land mines were developed from modified hand grenades that were buried; however, they were rel- atively ineffective.' The development of the explosive trinitrotoluene (TNT) brought about reliable, effective, and efficient land mine deployment and detonation." Land mines were exten- sively used by both the German and Allied forces during World War II."." In modern-day war, mines are now being deployed by nonconventional combatants such as guerrilla and ter- rorist organizations." They are now used to deny large areas of territory to opposing combatants and to cause

fear and terror in the opposition, as well as the local population. Land mines are commonly laid along roads, footpaths, bridges, river banks, and rice paddies, and around Land mines of today are designed to mutilate and maim, rather than to kill an opposing soldier, thus requiring the use of more human and technical resources by the opposi t i~n. '~ . '~

Antipersonnel land mines are eas- ily manually planted and mapped. They can also be scattered by air- planes, or by artillery fire, thus im- pairing the mapping of their exact lo- cation." Even when appropriately mapped, weather conditions and the type of soil, over time, can vastly al- ter a planted antipersonnel mine's lo- cation. Some planted mines may travel kilometers, if washed from their initial location by heavy rains.'.' I

How long mines remain active after deployment is unknown. However, some have been documented to kill, injure, and maim decades following their deployment and long after the termination of armed conflict^.'^

There are 2 basic types of land mines: antipersonnel (the vast major- ity) and antitank mines. Two basic types of antipersonnel land mines are manufactured: blast mines and frag- ment mines. Blast mines are usually buried and triggered by foot pressure. Only 5 kg of foot pressure is neces- sary to detonate most buried antiper- sonnel mines." This commonly leads to the loss of the foot and the distal aspect of the lower extremity, as well as injuries to the opposite lower ex- tremity and the genital region.".'5 Or- ganic debris, clothing, metal, and other foreign bodies further trauma- tize the injured extremity. Fragment mines are located above ground and are triggered by a trip wire. usually requiring a force of 3.6 kg to 20.4 kg for detonation."' Fragment mines are commonly ejected into the air and af- ter a 3-second delay explode at waist

height, propelling metal fragments that kill the individual who triggered the blast and injure others in the im- mediate ~icinity.~' ' ' . '~ Antitank mines are larger than antipersonnel mines, contain more TNT. and require a foot pressure of 150 to 350 kg to deto- nate.'

The technologic development of antipersonnel land mines has vastly exceeded the ability to detect a planted mine with any precision. Many of the land mines deployed in the 1990s are made entirely of plastic as opposed to metal and therefore completely escape detection by metal detectors."' Mass production has reduced the cost of modem land mines to about $3 to $30 e a ~ h . ~ . ' ~ ~ ' Currently, there are approximately 340 variations of blast and fragment antipersonnel mines, manufactured by both private industry and government agencies in 48 nations."

According to the International Committee of the Red Cross (ICRC) and the State Department of the U.S. federal government, approximately 90 to 120 million land mines are de- ployed in nearly 70 countries world- ,+,ide. 1.10.1 1.19.20 One third of all an- tipersonnel mines are deployed on the continent of Africa, with 18 Af- rican nations having a total of ap- proximately 18 to 30 million land

The heaviest mined coun- tries throughout the world include Angola, Afghanistan, Cambodia, Mo- zambique, Bosnia, Sudan, Somalia, Iraq, Laos, Zimbabwe, Vietnam. Nic- aragua, Burma, and Ethi~pia . ' " ,~ .~~' ' ' .~~

Though the exact number of vic- tims of land mines is unknown, it is estimated that each month 800 people are killed and another 1,200 sustain nonfatal injuries.'2.20 Individuals most at risk for injury and death are rural peasants, refugees fleeing one country for another, and internally displaced pe0p1e.I~ More than 70% of individ- uals injured or killed by land mines are civilians.'

According to the ICRC, there are 3 injury patterns associated with an- tipersonnel land mine

206 ACADEMIC EMERGENCY MEDICINE MAR 1998 VOL 5/NO 3

Type I injuries (30%) involve the foot and lower extremity and are com- monly secondary to a blast mine. Type I1 injuries (50%) mainly result from a fragment mine, which typi- cally causes shrapnel injuries to the chest, face, and abdomen. 5 p e I11 in- juries (5%) commonly occur when the mine is being handled and usually result in injuries to the hands and face. The remaining 15% of injured patients do not fall into any of the 3 injury patterns.6"6

Worldwide, the mean age of a ci- vilian injured or killed by a land mine is 29 years, with 85% being adult males, 7% being adult females, and 8% being children under 15 years of age." In Cambodia and Afghanistan, 25% of individuals injured by land mines are children.' The ratio of death to injury for children from ex- ploded antipersonnel mines is much higher than that for adults. This is be- cause a child's vital organs are closer to the blast, therefore causing a greater degree of bodily injury.I4 It has been shown that women sustain a greater severity of injury than do men from land mines, which is also likely secondary to their smaller body m a s z 2

Although the best outcomes from land mine injuries occur in patients arriving at hospitals within 6 hours of injury, only 28% of injured patients arrive within 6 ho~rs .~ . ' 1~16321*23 The major obstacle facing most patients following their injuries is the distance from the site of the explosion to the nearest hospital.23 Since most victims arrive in excess of 6 hours, they are at risk for the development of hem- orrhagic shock and severe infection, including gangrene and tetanus."

After detonation of a planted an- tipersonnel land mine, an estimated one third of injured victims require amputation of the distal lower ex- tremity and 3.4% require bilateral lower-extremity amputations.' Many individuals require an amputation due to delayed arrival at the hospital and perhaps due to a lack of periodic loosening of the tourniquet on the

wounded extremity while en route to the hospital. While 35% of all mine- injured patients require blood trans- fusions, approximately 75% of all amputees are in need of a blood trans- f~1sion.l~ Amputees from land mines require approximately 3 times as many units of blood and 4 times as many surgical procedures, when com- pared with individuals who have other war The in-hos- pita1 death rate of victims of land mine injuries is 3.7%. while those presenting with or requiring an am- putation have a death rate of 6%.14

In 1995 it was estimated that Cambodia had approximately 36,000 amputees, with 1 in every 236 Cam- bodians being an amputee, and the majority occurring from land mines." Many of the antipersonnel land mines causing amputations in Cambodia to- day were deployed up to 20 years ago." Further, in Angola 1 in every 334 individuals is an amputee sec- ondary to an exploded antipersonnel mine.' In contrast, 1 in every 22,000 individuals in the United States is an amputee.2L

Children who require an amputa- tion encounter a number of additional complications. As they grow, the bone of the amputated stump contin- ues to grow faster than the surround- ing skin over the stump, necessitating multiple stump revisions. Penetration of the stump through the soft tissues leads to pain, infection, and addi- tional stump revisions, which may render the stump incapable of sup- porting a prosthesi~. '~.l~ A prosthesis for a child requires replacement every 6 months, in contrast to adults, who require replacement every 3 to 5 years. For example, a 10-year-old with a life expectancy of another 40 to 50 years will require 25 prostheses over his or her lifetime.I0 Each pros- thesis must be individually fitted. Specialized workshops are necessary for the manufacturing and fitting of prostheses.' In many countries there are not enough prostheses manufac- tured for all amputees, with a recent article reporting that in Cambodia,

only 1 in 8 amputees had a prosthe- s~s .~ '

A large percentage of individuals with land mine injuries suffer from psychological sequelae secondary to their injuries, with 30% to 40% ex- periencing post-traumatic stress dis- order (PTSD).14

The effects of antipersonnel land mines far exceed their ability to injure and kill inhabitants of-a mined region. Land mines result in decreased avail- ability of agricultural land, with large areas rendered unsafe for farming." The inability to cultivate agricultural areas leads to malnutrition, starvation, and the inability of a nation to meet its food requirements. Access to safe drinking water is also limited, result- ing in the use of other sources for wa- ter that may be contaminated. This has led to an increase in water-borne diseases such as hepatitis, dysentery, and poli0.4.'~ Transportation within a mined country is severely limited.'* This hampers the ability of relief workers, mobile vaccination workers, and other public health teams to reach the population inv01ved.I~ Due to the increased transfusion requirements as well as the limited blood transfusion capabilities of some nations, victims of land mine injuries are at increased risk of acquiring blood-borne diseases such as hepatitis, trypanosomiasis, malaria, and HIV infection.14

Land mines cause a tremendous drain on the economy of a mined na- tion due to the cost of treatment and rehabilitation of victims, the loss of productivity secondary to a large number of amputees, the cost of mine clearance, and the inability to culti- vate and export cash crops.' The forced exodus of refugees and dis- placed people into neighboring coun- tries due to wars and the planting of land mines has resulted in overcrowd- ing of urban areas and the develop- ment of a global refugee crisis.21 These issues further impede the abil- ity of developing nations to recover and rebuild following war, which re- sults in continued economic and so- cietal upheaval, leading to further po-

Antipersonnel Land Mines, Hutson er al. 207

litical instability.'.'8.2' Measures to prevent antipersonnel land mine in- juries have been initiated on numer- ous fronts. Public health programs for the prevention of land mine injuries include: 1) land mine awareness and education programs consisting of the placing of graphic posters depicting types of land mines and patterns of injuries, as the illiteracy rate in af- fected nations is extremely high4*26; 2) mapping of mined regions based on injury/death cluster surveys followed by the targeting of these areas with prevention programs; 3) training of villagers in first-aid techniques; 4) ex- peditious transportation of land mine victims to hospitals; 5) an increase in the number of facilities for treating victims of land mine injuries; 6) de- velopment of mobile health care teams for rural areas; 7) an increase in the number and location of facili- ties manufacturing prostheses; 8) ed- ucation regarding clean drinking wa- ter; and 9) safe access to agricultural and grazing land.I4

Demining is the most immediate preventive measure, as mines are ac- tually removed and safely detonated. However, demining is labor-inten- sive, time-consuming, expensive, and extremely dangerous.6 For every 5,000 antipersonnel land mines removed, 2 deminers are injured and 1 deminer is killed.' Although land mines are in- expensive to purchase, it costs $800 to $1,000 to remove each deployed land In Mozambique, it took one year to demine 2,000 kilometers (1,250 miles) of main roads at a cost of $30 million.'E For every antiper- sonnel mine removed, 10 to 20 ad- ditional mines are depl~yed . ' .~ . '~ If the deployment of antipersonnel land mines were to stop immediately, at the current rate of demining, it would take 1,100 years to remove all exist- ing mines.I4 The cost of clearing all deployed land mines worldwide is es- timated to be $30 billion to $100 bil- Iion.4

In 1977, a United Nations confer- ence negotiated an additional protocol to the Geneva Convention, which

placed substantial restrictions on the use of antipersonnel land mines due to their indiscriminate and long-last- ing effects.' However, in the early 1990s, it became very apparent that these restrictions were inadequate.

The most definitive measure to prevent the epidemic of injuries and deaths from antipersonnel land mines is the complete and total ban of the production, stockpiling, sale, trade, transfer, and use of antipersonnel land mines worldwide. Along with the to- tal ban, there must be a clearing of all existing mine fields. To achieve this goal, the International Campaign to Ban Land mines (ICBL) was launched in 1992.'.2 The ICBL joined by the ICRC has spearheaded the campaign for a total ban of antiper- sonnel land mines.

In 1996, the Canadian govern- ment announced its support for a total ban on land mines. The Canadian government called for all nations to join in signing a treaty banning all mines in December 1997 in Ottawa, Canada, formally starting what is commonly referred to as the "Ottawa Process." Numerous international con- ferences were held to negotiate the terms of the treaty. For countries sign- ing the treaty it included: stopping production, use, and export of anti- personnel mines; destroying all stock- piled antipersonnel mines within 4 years; and mapping and clearing antipersonnel mines from mined areas in regions under their control within 10 years. One hundred twenty-two nations signed the treaty, including Canada, the United Kingdom, Swit- zerland, Angola, Mozambique, Cam- bodia, Belgium, and Norway. Coun- tries that are refusing to sign include: Kuwait, Russia, China, India, North Korea, Israel, Iran, Iraq, and the United States. The United States has demanded certain exemptions such as the right to continue the use of land mines in the buffer zone between North and South Korea to protect American soldiers in the event of war. The United States also wants an ex- emption for the use of certain types

of antipersonnel land mines. These demands were rejected by the Ottawa Process.

What can we as physicians do about the worldwide problem of an- tipersonnel land mines? We should increase the awareness about the causes and consequences of the land mine epidemic among our colleagues and in our professional organizations. We should support the total ban of an- tipersonnel land mines by all nations, as well as the demining of all existing mine fields, and encourage our pro- fessional organizations to support the ban. The American Medical Associa- tion (AMA) has already adopted a resolution urging the United States to support the total ban of antipersonnel land mines and sign the treaty.27 In addition, we should encourage our lo- cal, state, and federal leaders to sup- port the land mine ban. Fifteen former top military leaders in the United States, including General Norman Schwarzkopf, have urged President Bill Clinton to support the total ban and sign the treat^.^

The names of companies and countries profiting from the manufac- ture and sales of land mines should be made public, and they should be strongly encouraged to discontinue making these destructive, indiscrimi- nate, maiming weapons and help fi- nance the demining of mined nations. All nations, including mine manufac- turers, should help develop demining technologies.

Only by supporting the total ban of antipersonnel land mines and the clearance of all existing mine fields can the epidemic of antipersonnel land mine injuries be eliminated.

Dr. Hutson is at Harvard Medical School, Brigham and Women's Hospital, Boston, MA, Department of Emergency Medicine; Dr. An- glin is at Los Angeles County + University of Southern California Medical Center, Los An- geles, CA, Department of Emergency Medi- cine; and Mr. Strote is at Harvard Medical School. Boston, MA.

Dr. Hutson is an Executive Board Member of Physicians for a Violence Free Society.

~

208 ACADEMIC EMERGENCY MEDICINE MAR 1998 VOL 5/NO 3

Address for correspondence and reprints: H. Range Hutson, MD, Brigham and Wom- en’s Hospital, Department of Emergency Medicine, 75 Francis Street, Boston, MA 021 15. Fax: 617-264-6848; e-mail: rhhutson@ bics.bwh.harvard.edu

Key words: injury control; land mines; emer- gency medical services: EMS; prevention; land mine ban.

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