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Landmine-Related Injuries, 1993-1996
During 1980-1993, the incidence of landmine-related injuries doubled, resulting in an estimated 2000 deaths or injuries each month (1). Approximately 120 million landmines are buried in 71 countries throughout the world, and 2-5 million new landmines are planted each year. Some countries, such as Afghanistan, Angola, and Cambodia, have approximately 10 million landmines each (2). Landmines can have profound medical, environmental, and economic consequences, particularly for the civilian populations of those countries burdened with landmines. However, the consequences of landmines extend beyond the borders of those countries. Health-care workers and nongovernmental organizations are increasingly asked to assist emergency-affected, displaced, and refugee populations in regional conflicts, resulting in their increased exposure to landmines. This report describes three cases of landmine-related injury and illustrates the public health consequences of those injuries and the potential role for public health workers in preventing those injuries. Case Reports
Case 1. On December 13, 1993, a 31-year-old relief worker with the International Rescue Committee in Somalia suffered traumatic amputation of the right foot and blast and shrapnel injuries to both lower legs after his vehicle struck a landmine. The patient underwent emergency surgery in Kenya, where a below-the-knee amputation was performed on the right lower leg. He suffered profound blood loss, requiring 16-17 units of transfused blood. He was evacuated to Switzerland and subsequently to the United States, where he remained hospitalized for 2 months. During 1994-1996, he underwent seven surgical procedures to save his lower left leg. In February 1997, a below-the-knee amputation of his lower left leg was performed. Total medical expenses have exceeded $300,000. The patient is undergoing rehabilitation.
Case 2. On October 29, 1995, a 53-year-old nursing coordinator with the American Refugee Committee working in the Democratic Republic of the Congo (formerly Zaire) was traveling in a vehicle that struck a landmine. The blast hurled the vehicle approximately 25 feet, and the patient suffered traumatic amputation of both lower legs, a broken jaw, and shrapnel wounds to the trunk and face. She was evacuated to Kenya, where she underwent bilateral below-the-knee amputations and multiple blood transfusions. The patient has since undergone several surgical procedures for reconstruction of her face. Total medical costs have been approximately $1 million.
Case 3. On March 16, 1996, a 38-year-old resident of Afghanistan working for CARE/Afghanistan was driving a vehicle that struck a landmine. He suffered facial lacerations and a fracture of the left upper arm and lost an estimated 1500 cc of blood. The patient remained hospitalized for 6 weeks. He experienced profound memory loss and has been under psychiatric and neurologic care since his injury.
Reported by: K Rutherford, Landmines Survivors Network, Washington, DC. J Hersman, A Kozlowski, American Refugee Committee, Minneapolis, Minnesota. P Giannone, CARE International, Atlanta. Div of Violence Prevention, National Center for Injury Prevention and Control; International Emergency and Refugee Health Program, National Center for Environmental Health, CDC.
Editorial Note: Both combatants and civilians, such as the local resident and relief workers described in this report, are at risk for landmine-related injuries. In many countries, most victims of landmines are civilian men, women, and children (3,4).
The health consequences of landmines include deaths, injuries, subsequent disabilities, and investments in health-care resources they require. An estimated 800 persons die each month from landmine-related injuries, and 1200 persons are nonfatally injured (1,2). Approximately one third of surviving landmine victims require amputations and often require a disproportionate amount of health-care resources (5). Compared with patients with other war-related injuries, amputees require nearly three times as many units of blood and four times as many surgical procedures (6).
Environmental health consequences in areas with large quantities of landmines include limited access to safe drinking water and arable farmland, which can result in increased waterborne diseases and malnutrition (7). In addition, persons leaving landmine-contaminated rural areas can lead to overcrowding in urban areas, increasing the risk for transmission of infectious diseases. Finally, as health-care resources are directed toward the care and rehabilitation of landmine victims, they are diverted away from other public health priorities (e.g., vaccination, sanitation, nutrition, and vector-control programs), possibly resulting in higher death rates, particularly for women and children, through increased malnutrition and decreased vaccination coverage (7).
In addition to their health consequences, landmines also exact an economic toll. The most serious economic issues include the treatment and rehabilitation of landmine victims, their loss of productivity and quality of life, and the clearance of landmine-infested areas. Treating a landmine survivor costs an average of $3000-$5000, a substantial amount in developing countries (1). Treating all landmine victims worldwide would require $750 million. Although landmines are relatively inexpensive to produce, ranging from $3 to $30, clearing a single mine can cost $300-$1000 (1,8). Many of the countries contaminated with landmines cannot provide for the costs of victim rehabilitation and mine clearance and have become increasingly dependent on the international community.
Because clearing all existing minefields is unlikely in the near future, efforts also should focus on preventing the devastating medical effects of existing landmines. Landmine-related injuries can be prevented by adapting health strategies that have been successful in decreasing the number of other injury-related problems (e.g., deaths caused by motor-vehicle crashes) (9).
Some prevention efforts are already in place, such as mine-awareness programs, in which residents are taught to identify landmines and to avoid areas that are known or suspected minefields. These programs should be supported and expanded by the public health community. For example, high-risk areas and populations can be identified through hospital surveillance and cluster surveys, thus facilitating the allocation of limited resources and the development of effective prevention strategies. Once these strategies are developed, health-care workers can assist in evaluating them and replicating those that are most effective.
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